IMPACTS

A summary of select

research findings and impacts from

VA’s Health Services Research &

Development Service

VA Health Services

Research & Development Service:

I M P R O V I N G T H E Q U A L I T Y O F H E A L T H C A R E F O R V E T E R A N S
VA’s Health Services Research and Development Service (HSR&D) works to identify and

evaluate innovative strategies that lead to accessible, high quality, cost-effective care for

Veterans and the nation. One of four research services within VA’s Office of Research and

Development, HSR&D is an intramural research program funding eligible VA clinician and

non-clinician investigators to address VA healthcare priorities that ultimately help to improve

healthcare for Veterans and the nation.

HSR&D pursues its goals through its key centers, including 14 Centers of Excellence that

cover an array of healthcare issues such as: care of complex chronic diseases, healthcare

disparities, mental illness, elder care, medical informatics, organization of care, primary

care, long-term care, and others. HSR&D research also addresses critical issues for Veterans

returning home from Iraq and Afghanistan with conditions that may require care over their

lifetimes. In addition, HSR&D oversees and facilitates VA’s Quality Enhancement Research

Initiative (QUERI), designed to improve care by facilitating the adoption of new evidencebased treatments, tests, and models of care into routine clinical practice. QUERI is a central

component of VA’s commitment to improving the quality of Veterans’ health care.

HSR&D also supports education and career development for VA clinician and non-clinician

scientists through the VA Office of Research and Development’s Career Development

Program, which includes post-doctoral awards that provide full salary support, allowing

awardees to pursue an intensive period of mentored health services research and training.

I M P A C T S
A summary of select

research findings and impacts from

VA’s Health Services Research &

Development Service

Produced by

HSR&D’s Center for Information Dissemination and Education Resources

VA Boston Healthcare System (152-C)

150 South Huntington Avenue, Building 9

Boston, MA 02130

Email: cider.boston@va.gov

www.hsrd.research.va.gov

IMPACTS

VA Health Services

Research & Development Service:

VA Health Services Research: Improving the Quality of Healthcare for Veterans

i

VA Health Services Research: Improving the Quality of Healthcare for Veterans
The Department of Veterans Affairs’ Office of Research and Development (ORD) is a Veterancentric research enterprise focused on developing and funding research that improves the lives and

healthcare of Veterans and the nation. As one of the four VA research services under the umbrella

of the ORD, the Health Services Research and Development Service (HSR&D) focuses on

identifying, evaluating, and implementing innovative strategies that lead to accessible, high quality,

cost-effective healthcare. For example, HSR&D investigators developed and implemented

interventions that have increased screening rates for HIV, colorectal cancer, and alcohol abuse

among Veterans, as well as interventions that have increased pneumonia and flu vaccines among

Veterans with spinal cord injury. Interventions such as these help Veterans receive quality, accessible

and timely care which leads to better patient outcomes.

HSR&D researchers work on numerous issues that impact the health and healthcare of Veterans,

including complex chronic diseases, healthcare disparities, mental illness, elder care, and medical

informatics. HSR&D research also addresses critical issues for Veterans returning from Iraq and

Afghanistan with conditions that may require long-term care, such as traumatic brain injury.

In addition, HSR&D oversees and facilitates VA’s Quality Enhancement Research Initiative

(QUERI), designed to improve healthcare by facilitating the adoption of new evidence-based

treatments, tests, and models of care into routine clinical practice. For example, QUERI

investigators developed and implemented a collaborative care model for the treatment of

depression. Strong collaborations are necessary for the successful implementation of innovations

into practice. Therefore, HSR&D maintains active collaborations and partnerships with managers

and policymakers in VA Central Office, including the Office of Quality and Performance and Patient

Care Services, VA’s healthcare Networks, and field-based healthcare facilities across the country.

HSR&D is a key part of VA’s quest for innovative solutions to the unique healthcare challenges

facing our new generation of Veterans, as well as our aging Veteran population. HSR&D continues

to make important contributions to VA’s mission to serve Veterans by increasing their access to high

quality healthcare, and by helping our Veterans become an integral part of the healthcare process.

The impacts included in this booklet highlight these efforts.

Joel Kupersmith, MD

Chief Research and Development Officer

ii

I M P A C T S

Preface
iii

Message From The Director

Over the past five years, VA’s Health Services Research and Development Service (HSR&D)

has made significant strides toward improving the quality of healthcare for Veterans. With so

many changes in healthcare on the horizon, we thought it would be a good time to highlight a

selection of studies that have either already impacted VA healthcare or that have the potential

to do so in the near future.

As one of the four VA Office of Research and Development services, HSR&D is an integral

part of VA’s quest for innovative solutions to today’s healthcare challenges. HSR&D works

to improve the quality of healthcare for Veterans by examining the effects of the organization,

financing, and management of healthcare services. HSR&D programs span the continuum

of healthcare research and delivery – from clinical research to the dissemination of research

results, and ultimately to the application of these findings into clinical, managerial, and

policy decisions.

HSR&D investigators target conditions of great importance to the health of Veterans returning

from conflicts in Iraq and Afghanistan, including post-traumatic stress disorder (PTSD),

polytrauma, and blast-related injuries such as traumatic brain injury. HSR&D also funds a

broad range of research on diseases and conditions that are prevalent among Veterans, such as

diabetes, heart disease, stroke, substance use disorders, and mental health disorders.

Funding emphasis is placed on research that is Veteran-centric and evaluates the effectiveness

of clinical procedures and processes of care in the “real world.” In other words, we look at how

interventions perform in the complex and variable context of real-world healthcare use and

practice. Impacts included in this booklet represent just some of the exceptional research

conducted by HSR&D’s talented investigators that will contribute to improved health care

for Veterans and the nation. Impacts are organized by broad categories of research:

• Access to Care,

• Care of Complex Chronic Conditions,

• Comparative Effectiveness Research,

• Equity and Health Disparities,

• Long-Term Care and Caregiving,

• Mental Health,

• Post-Deployment Health,

• Quality Improvement, and

• Women’s Health

It is our privilege to continue to conduct innovative research that will advance the best quality

and most cost-effective healthcare for our Veterans.

Seth Eisen, MD, MSc

Director, Health Services Research and Development Service

VA Health Services Research: Improving the Quality of Healthcare for Veterans
Table of Contents

Research Areas

Access to Care 1

Telehealth Communication Improves

Quality of Life for Veterans with Cancer 1

Multidisciplinary Telemedicine Consultations

Benefit Veterans with Chronic Wounds 2

Better Outcomes among Veterans Using

Home Care Telehealth Intervention 2

Veterans Using VA Healthcare More Likely

to Receive Recommended Preventive and

Ambulatory Care 3

VA Community-Based Outpatient Clinics

Improve Access to Primary Care 4

VA Healthcare Provides Safety Net for

Vulnerable Veterans 4

Care of Complex Chronic Conditions 5

Increasing Influenza Vaccination Rates in

Veterans with Spinal Cord Injuries 5

Effective Strategies to Control Blood Pressure 6

Making an Impact on Glycemic and Blood

Pressure Performance Measures 6

Web-Based Care Improves Poorly

Controlled Diabetes 7

Care Coordination/Home-Telehealth

Program Reduces Hospitalizations for Diabetes 7

Tracking System for Veterans Undergoing Invasive

Cardiac and Vascular Procedures 8

Improving HIV Screening with Rapid Testing 8

Improving Screening Guidelines for

Osteoporosis in Male Veterans 9

Comparative Effectiveness Research 10

Improving Treatment Adherence for PTSD 10

Improving Hypertension Control 11

Providing Smoking Cessation Treatment

in an Inpatient Setting 11

Improving Treatment for Chronic Pain

in the Primary Care Setting 11

Equity and Health Disparities 12

African-American Veterans have Lower

Hospital Mortality Rates for Six Conditions 12

Assessing Disparities in VA Treatment

and Outcomes for Heart Failure 13

No Disparities in Care between African-American

and White Veterans with HIV 13

Understanding VA Healthcare Use by American

Indian and Alaska Native Women Veterans 14

African-American Veterans More Likely to

Receive Mechanical Ventilation for COPD 14

Long-Term Care and Caregiving 15

Guidebook for Caregivers of Veterans

with Stroke 15

Geriatric Evaluation and Management Units

Decrease Nursing Home Placement but

Do Not Increase Cost 16

Promoting Hospice Care Improves

End-of-Life Care 16

I M P A C T S

iv

I M P A C T S
Mental Health 17

Primer on Collaborative Care for Depression

as an Educational Tool for Managers 17

Monitoring the Use of Pharmacotherapies

for Addiction 18

Telemedicine Technology Improves

Depression Collaborative Care 18

Improving Schizophrenia Care 19

Smoking and Diabetes:

Creating New Knowledge of Tobacco Risk 19

Community Care Yields Better Outcomes

for Veterans with Substance Use and

Psychiatric Disorders 19

Telephone Care Coordination Increases

Treatment for Smoking Cessation 20

National Dissemination of a Clinical Reminder

for Brief Alcohol Counseling Increases

Counseling Rates 20

Alcohol Screening Scores Help Identify

Patients at Risk of Medication Non-Adherence 21

Using the VA Depression Registry to Identify

Predictors of Suicide among Veterans 21

PTSD Strongly Associated with

Increased Risk for Dementia 22

Engaging Veterans and Families in

Psychoeducation to Improve Treatment for

Mental Illness 22

Post-Deployment Health 23

Assessing Impairments and Outcomes for

Veterans with Blast-Related Injuries 23

Polytrauma Rehabilitation Centers’ Family

Care Map 24

Examining Unique Needs of Soldiers with

SCI Results in Increased Funding for Equipment 24

Identifying OEF/OIF Veterans with Mental

Illness Can Lead to More Targeted Care 25

Examining Virtual Reality Therapy for

Veterans with PTSD 25

Mental Health Diagnoses among OEF/OIF

Veterans Increased Rapidly Following

Invasion of Iraq 26

Traumatic Brain Injury and PTSD:

A Synthesis of the Evidence 26

Quality Improvement 27

HSR&D Improves Performance Monitoring 27

Improving Bar Code Medication Administration 28

Primary Care Characteristics that Result

in Improved Colorectal Cancer Screening Rates 28

Preoperative Antibiotics:

Influencing the Standard of Care 29

Advancing Implementation Science to Improve

Quality of Care 29

Women’s Health 30

Evaluating VA Healthcare for Women Veterans 30

Planning VA Healthcare to Meet the Needs

of Women Veterans 31

Breast Cancer Screening Mammography

More Common among Wealthy Women 31

Women Veterans’ Perceptions about –

and Experiences with VA Healthcare 32

References 33

v

VA Health Services Research: Improving the Quality of Healthcare for Veterans
I M P A C T S

vi
Access to Care

The Veterans Health Administration

(VHA) is the largest integrated healthcare

organization in the country and is charged

with providing medical, surgical, and

rehabilitative care for our nation’s

Veterans. This includes Veterans living in

relatively close proximity to VA healthcare

facilities, as well as those who live in rural

settings that may not be close to VA

providers. Access to care also may be

restricted for older, disabled, and/or

chronically ill Veterans, who may

experience difficulty traveling even

relatively short distances, or Veterans

living in long-term care facilities.

Making sure that all Veterans eligible for

VA healthcare services have accessible

care is a high priority and a continuing

challenge.

Over the years, VHA has implemented

several initiatives to improve access to

care, including the fast growing

community-based outpatient clinics

(CBOCs) that were designed to improve

access for Veterans living long distances

from VA facilities and/or in rural settings.

VHA also has made advances in information technology to improve access to care,

such as telehealth – the delivery of healthrelated electronic information and

services via telecommunication technologies that may include the telephone, the

Internet, and videoconferencing.

Telehealth Communication

Improves Quality of Life for

Veterans with Cancer

Uncontrolled symptoms experienced by

cancer patients at home during chemotherapy

treatment are associated with poor health

outcomes, including worse health-related

quality of life (HRQL). Moreover, ineffective

communication between patients and their

providers impedes treatment of some

symptoms and has been associated with poor

HRQL. This study was designed to test the

feasibility of a Cancer Care Dialogues Model

that incorporated daily telehealth interactions

between Veterans at home and their care

coordinators, who served as adjuncts to their

oncologists. Study results show:

• Veterans experienced a significant increase in

HRQL over the six-month treatment period,

and Veterans who reported reduced nervousness/worry experienced better HRQL.

Chumbler N, Mkanta W, Richardson L, et al. Remote patient-provider

communication and quality of life: Empirical test of a dialogic model

of cancer care. Journal of Telemedicine and Telecare January

2007;13(1):20-25.

1

VA Health Services Research: Improving the Quality of Healthcare for Veterans
Multidisciplinary Telemedicine

Consultations Benefit Veterans

with Chronic Wounds

Wound care teams have had significant success

in both reducing the costs and improving the

outcomes of chronic wound care. This study

sought to evaluate the feasibility of a web-based

telemedicine program for remote wound care

team consultations. Wound care nurses

evaluating Veterans with chronic wounds at

VA outpatient clinics used the VA Computerized Patient Record System (CPRS) and the

Internet to obtain consultations and to transmit clinical data and images to a multidisciplinary wound care team located at the regional

tertiary care center. Study results show:

• The mean response time for consultations

was just 2.61 days.

• Overall, 98.2% of Veterans were either

satisfied or very satisfied with their care,

and 95.5% of Veterans found the

telemedicine consultations more convenient

than traveling to the tertiary care center.

Wilkins E, Lowery J, Goldfarb S. Feasibility of virtual wound care.

Advances in Skin and Wound Care May 2007;20(5):275-78.

Better Outcomes among

Veterans Using Home Care

Telehealth Intervention

VA is among the largest providers of home

care services, with 88 home care programs

nationwide and annual costs of about

$72 million. Telehealth has the potential to

positively impact home care patients, but little

is known about telehealth outcomes and

whether these technologies reduce the use

of hospital services. This study examined

outcomes associated with the provision of

telehealth care (e.g., interactive voice and video

technology) for Veterans receiving home care

services through one VAmedical center

compared with Veterans receiving traditional

home care services. Findings show:

• Veterans provided with telehealth care had

significant improvement in the mental health

component of their health–related quality

of life, compared to Veterans receiving

traditional home care services.

• There was a trend toward fewer outpatient

visits for Veterans in the intervention

group compared with the control group

(mean visits = 29.06 vs. 38.89).

Hopp F, Woodbridge P, Subramanian U, et al. Outcomes associated with

a home care telehealth intervention. Telemedicine Journal and E-Health

June 2006;12(3):297-307.

2

I M P A C T S
Veterans Using VA Healthcare More Likely to Receive

Recommended Preventive and Ambulatory Care

Using data from the 2000 and 2004 surveys of

the Behavioral Risk Factor Surveillance System

– nationally representative health surveys

conducted by the Centers for Disease Control

and Prevention (CDC) – HSR&D

investigators compared self-reported use of

17 recommended ambulatory care services

for cancer prevention, cardiovascular risk

reduction, diabetes mellitus management, and

infectious disease prevention among insured

adults receiving and not receiving care at

VA medical centers (VAMC).

• In both 2000 and 2004, Veterans receiving

VA care reported significantly greater use of

most recommended services when compared

with adults not receiving VAMC care.

• Differences in the use of recommended

services did not change during the four-year

period, indicating that insured adults

received a higher standard of care at VA

medical centers compared to the private

sector.

Ross J, Keyhani S, Keenan P, et al. Use of recommended ambulatory

services: Is the Veterans Affairs quality gap narrowing? Archives of

Internal Medicine May 12, 2008;168(9):950-8.

Another study used VA and Medicare data

to examine self-reported use of influenza

vaccination, pneumococcal vaccination,

serum cholesterol screening, and serum

prostate-specific antigen measurement

(PSA for prostate cancer screening) among

male Veterans 65 years and older. Receiving

all or some healthcare through VA was

associated with increased use of preventive care.

These results are particularly notable in as

much as the population cared for by VA is

more likely to have lower socio-demographic

characteristics and be in fair or poor

health – groups that often receive lowerquality care in the private sector.

Keyhani S, Ross J, Hebert P, et al. Use of preventive care by Veterans

receiving care through the Veterans Health Administration, Medicare

FFS and Medicare HMO plans. American Journal of Public Health

December 2007;97(12):2179-85.

3

VA Health Services Research: Improving the Quality of Healthcare for Veterans
VA Community-Based

Outpatient Clinics Improve

Access to Primary Care

Over the past decade, VA has added to the

number of Community-Based Outpatient

Clinics (CBOCs) to increase access to primary

care for Veterans. This study compares VA

inpatient and outpatient utilization and

expenditures of Veterans seeking primary care

in 108 CBOCs and 72 affiliated VA medical

centers in FY00 and FY01. Results show:

• CBOCs provided Veterans with improved

access to primary care and other services, but

costs were contained because they had fewer

healthcare visits and hospital stays than

Veterans receiving care at VA medical centers (VAMC).

• Overall costs for CBOC patients were $1,588

less (per year) than for VAMC patients, and

these results held even after adjusting for

demographics, patient risk, and distance

from care.

Maciejewski M, Perkins M, Li YF, et al. Utilization and expenditures of

Veterans obtaining primary care in community clinics and VA medical

centers: An observational cohort study. BioMed Central Health Services

Research April 18, 2007;7(1):56.

VA Healthcare Provides Safety

Net for Vulnerable Veterans

For elderly Veterans eligible for both VA

healthcare and Medicare, dual use has been

estimated to be as high as 54% among surgical

patients and nearly 30% among outpatients.

This study examined the impact of access to

care characteristics on healthcare use among

1.48 million Veterans (age 66 and older) who

were dually eligible for Medicare and VA

healthcare services in calendar year 1999.

Findings show:

• Among the 1.47 million Veterans who used

VA or Medicare outpatient services, 18%

used only VA care, nearly 36% used only

Medicare, and 46% used a combination of

VA and Medicare services.

• Among 416,455 Veterans who used inpatient

care, 24% used VA only, 69% used Medicare

only, and 6% used both VA and Medicare

inpatient services. Reliance on VA healthcare

was greatest among “high-priority” and

African-American Veterans. [High-priority

Veterans were those with a service-connected

condition or whose income was less than a

threshold annually established by VA.]

• Veterans in the highest health risk groups are

most likely to rely on both VA and Medicare,

with the lowest-risk patients most likely to

use VA services exclusively.

Hynes D, Koelling K, Stroupe K, et al. Veterans’ access to and use

of Medicare and Veterans Affairs health care. Medical Care

March 2007;45(3):214-23.

4

I M P A C T S
Care of Complex

Chronic Conditions

Chronic diseases and conditions are

prolonged conditions that often do

not improve and are rarely curable.

Examples of chronic diseases and

conditions include diabetes, congestive

heart failure, hypertension, depression,

HIV, and spinal cord injury; moreover,

many people may have more than one

chronic condition. These types of

conditions can have a profound effect

on a person’s quality of life, from limiting

physical function to causing serious

disabilities. This can result in dramatic

changes in lifestyle that affect not only

the person with the chronic condition,

but their family as well. Thus, those

with chronic disease may require a

variety of healthcare services to help with

their physical, emotional, and mental

well-being.

Increasing Influenza Vaccination

Rates in Veterans with Spinal

Cord Injuries

Individuals with spinalcord injury and

disease(SCI&D) who contract influenza or

pneumoniaare 37 times morelikely to diethan

thosein the general population. Vaccination

iseffectivein reducing thelikelihood of

contracting theseillnesses, thus investigators

in this study developed a quality improvement

project to increaseinfluenza vaccination rates

among Veterans with SCI&D. Four multi-level

(patient, provider,and system level),evidencebased interventions wereimplemented in 23

VA Spinal Cord Injury Centers. Interventions

included: 1) patient reminder lettersand

education, 2) provider remindersand posters,

3)computerized clinical reminders,and

4) nursestanding orders. Findings show:

• Self-reported vaccination rates increased

significantly from 62.5% in year one of the

study to 67.4% in year two.

• Vaccination rates improved for all age

groups, increasing from 50% to 54% for

Veterans younger than age 50, 61% to 67%

for Veterans ages 50 to 64, and from 76% to

80% for those 65 years and older.

Weaver FM, Smith B, LaVela S, et al. Interventions to increase influenza

vaccination rates in Veterans with spinal cord injuries and disorders.

Journal of Spinal Cord Medicine 2007;30(1):10-9.

5

VA Health Services Research: Improving the Quality of Healthcare for Veterans
Effective Strategies to

Control Blood Pressure

More than 50 million Americans have

hypertension, and 65% have poorly controlled

hypertension. This study, which included

1,341 Veterans with hypertension who were

treated by VA providers at two hospitals and

eight community-based outpatient clinics in

the VA Tennessee Valley Healthcare System,

evaluated provider and patient interventions

to improve blood pressure (BP) control.

Investigators randomly assigned providers and

patients to one of three interventions designed

to lower BP: 1) provider education, 2) provider

education and alert, or 3) patient education.

Findings show:

• Veterans in all groups had significant

reductions in BP. However, Veterans in

the patient education group had greater

improvement than those in the provider

education group – or the provider

education and alert group.

• The additional improvement in the patient

education group hasthe potential to reduce

heart failure by 50%, cerebrovascular

morbidity and mortality by 42%, and

coronary heart disease by 14%.

Roumie C, Elasy T, Greevy R, et al. Improving blood pressure control

through provider education, provider alerts, and patient education:

A cluster randomized trial. Annals of Internal Medicine

August 2006;145(3):165-75.

Making an Impact on

Glycemic and Blood Pressure

Performance Measures

Hemoglobin A1c control is an important

intermediate outcome for measuring the

quality of care provided to about 24 million

Americans with diabetes. HSR&D

investigators played a leadership role in

establishing the <7% A1c measure as a

supporting indicator rather than a missioncritical measure for FY08. This decision was

consistent with the evidence-based approach

of the VHA-DoD (Department of Defense)

Diabetes Guidelines. In addition,

• A body of VA/HSR&D research on this

topic that indicated a “one size fits all”

performance measurement approach to A1c

control (i.e., all patients recommended to

have <7% A1c), as advocated by the American

Diabetes Association and the National

Committee for Quality Assurance, could have

unintended consequences was disseminated

to the Under Secretary for Health and the

Performance Measurement Workgroup by

the Chief Consultant, Patient Care Services

(November 2007).

Subsequent efforts by HSR&D investigators

underscored the importance that policy

decisions on quality measures should be driven

by evidence and research that documents

population health benefit and fairness of

comparison, rather than by advocacy groups

and industry.

Aron D, Pogach L. Commentary: Transparency standards for diabetes

performance measures. JAMA January 14, 2009;301(2):210-212.

6

I M P A C T S
Web-Based Care Improves

Poorly Controlled Diabetes

More patients are accessing medical

information on the Internet, but few studies

have examined the effects of web-based

interventions that incorporate an interactive

component requiring feedback from patients.

This study tested diabetes care management

using a web-based system for Veterans with

poorly controlled diabetes mellitus.

Findings show:

• Veterans participating in the web-based

management program had significant

improvements in HbA1c over one year

compared to usual care, and persistent

website users had even greater improvements

compared to intermittent website users.

Improvements also were seen in lipid

profiles, as well as significantly greater

declines in systolic blood pressure for

Veterans with hypertension.

• Major advantages of a web-based care

management program include the ability to

post information on secure websites that are

accessible 24 hours a day for Veterans from

their homes.

McMahon G, Gomes H, Hickson S, et al. Web-based care management

in patients with poorly controlled diabetes mellitus. Diabetes Care

July 2005;28(7):1624-1629.

Care Coordination/HomeTelehealth Program Reduces

Hospitalizations for Diabetes

Home-telehealth technologies allow Veterans

and their care coordinators to maintain direct

communication. One of the main goals of the

VA Care Coordination/Home-Telehealth

(CCHT) approach is to improve care for

Veterans, thereby reducing healthcare use and

hospitalizations. This two-year study

compared healthcare use among 400 Veterans

who were enrolled in a VA CCHT program

with 400 Veterans who were not enrolled.

All Veterans had type 2 diabetes and were

considered to be at high risk for multiple

inpatient and outpatient visits. Results show:

• Two years after enrollment, the likelihood

of all-cause hospital admissions decreased

significantly in the CCHT treatment group

(38.8% to 29.9%), while the comparison

group experienced an increase (31.2% to

33.1%).

• The CCHT treatment group also had a

significant reduction in diabetes-related

hospital admissions over the 24-month

period – 35.3% to 26.9%, while the

comparison group had very little change.

Barnett T, Chumbler N, Vogel B, et al. The effectiveness of a care

coordination/home-telehealth program for Veterans with diabetes:

A two-year follow-up. American Journal of Managed Care

August 2006;12(8):467-474.

7

VA Health Services Research: Improving the Quality of Healthcare for Veterans
Tracking System for Veterans

Undergoing Invasive Cardiac

and Vascular Procedures

Ischemic heart disease (IHD) remains the

single leading cause of morbidity and mortality

in the United States, and among Veterans

who use the VA healthcare system. Cardiac

catheterization and interventional procedures

are primary therapy for IHD, and increased

access to this therapy may lead to improved

outcomes for Veterans. The Ischemic Heart

Disease Quality Enhancement Research

Initiative (IHD-QUERI), working with VA’s

Patient Care Services, the Office of Quality and

Performance, and the Office of Information,

developed a national VA reporting system

for procedures performed in VA cardiac

catheterization clinics. The Cardiovascular

Assessment, Reporting and Tracking System

for Cardiac Catheterization Laboratories

(CART-CL) tracks coronary procedures such

as percutaneous coronary interventions, the

primary therapy for IHD.

• CART-CL is installed or in the process of

installation at all 75 VA cath labs, and will

help to improve clinical care and patient

safety.

• Data from CART-CL are reported monthly

to the Chief Consultant for Cardiology and

to all catheterization laboratories, and have

been used to monitor the use and safety of

these procedures.

Box T, et al. Strategies from a nationwide health information technology

implementation: The VA CART story. Journal of General Internal

Medicine (in press).

Improving HIV Screening

with Rapid Testing

Testing for HIV is cost-effective, yet testing

rates remain low. Standard screening test

results are unavailable on the same day and

many patients do not return for their results,

but rapid HIV testing results can be available

in 20 minutes. This HIV/Hepatitis Quality

Enhancement Research Initiative (QUERI)

study shows that administering the rapid HIV

test with streamlined counseling to Veterans

greatly increased both HIV testing and receipt

of results. For Veterans, this results in faster

treatment, better outcomes, and less risky

behaviors.

• Rapid HIV testing has been implemented in

one VeteransIntegrated Service Network,

and if cost-effectiveness and increased testing

turn out as expected, rapid testing will be implemented in VA facilities across the country.

Anaya H, Hoang T, Golden J, et al. Improving HIV screening and receipt

of results by nurse-initiated streamlined counseling and rapid testing.

Journal of General Internal Medicine June 2008;23(6):800-807.

8

I M P A C T S
Improving Screening

Guidelines for Osteoporosis

in Male Veterans

Although 25% of men older than age 60 will

sustain osteoporotic fractures during their

lifetime, data suggest that male osteoporosis is

under-diagnosed and under-treated. In order

to help inform decisions about whether VA

should develop screening guidelines for male

osteoporosis, investigators conducted a

literature review of studies from 1990-2006.

Findings show:

• Strong predictors of an increased risk of

osteoporosis in men include age, low body

weight, physical inactivity, and weight loss.

• Certain health conditions also are strong or

moderate predictors of an increased risk of

osteoporosis in men (e.g., androgen

deprivation).

• Spinal cord injury also is associated with an

increased risk of osteoporosis and possibly

osteoporotic fractures.

Shekelle P, Munjas B, Liu H, et al, Screening Men for Osteoporosis,

Final Report, May 2007, Department of Veterans Affairs, Health Services

Research & Development Service, Evidence-Based Synthesis Program.

9

VA Health Services Research: Improving the Quality of Healthcare for Veterans
Comparative

Effectiveness Research

Most clinical and health policy decisions

involve choices among alternatives –

which treatment to prescribe, which drugs

to include on a formulary, what procedures to reimburse, what technologies to

invest in. Research that evaluates the

clinical effectiveness, risks, and benefits of

two or more medical treatments or services

is referred to as Comparative Effectiveness

Research (CER). CER is an essential

component of providing patient-centered

care because it will increase the

information available to both Veterans

and their clinicians to help them make

well-informed decisions. CER also is

critical for healthcare managers because it

identifies which interventions should be

promoted because they provide greater

overall benefits than the alternatives.

Finally, CER offers the best hope for

increasing value in the healthcare system

by identifying where directing care to

certain alternatives can provide better

outcomes at comparable costs – or

comparable outcomes at lower costs.

HSR&D is currently conducting CER in

many areas of importance to Veterans.

Improving Treatment

Adherence for PTSD

In direct costs alone, VA’s provision of

compensation and treatment for Veterans with

post-traumatic stress disorder (PTSD) exceeds

$1.2 billion annually. Although many factors

can contribute to a chronic course of PTSD,

one critical factor is inconsistent treatment

participation. About 75% of Veterans

receiving VA outpatient treatment for PTSD

participate only episodically, often with long

periods between episodes of care. This ongoing

study compares Veterans who stay in treatment

for PTSD with those who drop out to

determine whether characteristics such as race,

gender, treatment preferences, social support,

and PTSD symptoms make a difference in who

remains in treatment.

Results of this study will help VA healthcare

providers better understand how to encourage

PTSD treatment participation and what may

prevent Veterans from maintaining treatment.

HSR&D study IAC 06-266; Principal Investigator: Michele Spoont, PhD.

10

I M P A C T S
Improving Hypertension Control

High blood pressure(BP)affects morethan one

million Veterans. Despitetherelativeeaseand

low cost of treating high BP,and despite being

prescribed treatment, many Veterans remain

non-adherentand have uncontrolled hypertension.

This ongoing study iscomparing whether

Veterans with high BP who receivecounseling

on exercise, diet,and medication that is tailored

specifically for them havelower BP and taketheir

medication moreregularly than Veterans who

receive generaleducation or standard care.

This intervention could proveto bean efficient

and cost-effective way to enhancetreatment

adherencefor Veterans with hypertension.

HSR&D study IIR 04-170; Principal Investigator: Sundar Natarajan, MD.

Providing Smoking Cessation

Treatment in an Inpatient Setting

Smoking cessation programsarecurrently

provided by VA outpatient groups,and, in some

cases, Veterans’ physicians prescribe medications

to help them quit smoking. However, inconsistent

or minimalcessation servicesare provided to

inpatients in the VA healthcaresystem. This

ongoing study compares hospitalized Veterans

who receivea“quit-smoking” program that includes

nursecounseling and educational materials, followup phonecalls,and medication with Veterans who

receivestandard careto determine whetherthe program helps more Veterans quit smoking by bringing

the program to them whilethey arein the hospital.

Theend-product will bea portabletoolkit fora

nurse-administered smoking cessation intervention.

Ifeffective, this intervention has the potential to

reduce both cardiovascular diseaseand cancerrates

among Veterans.

HSR&D study SDP 06-003; Principal Investigator: Sonia Duffy, PhD.

Improving Treatment for Chronic

Pain in the Primary Care Setting

Chronic pain is very common and is associated

with substantial physical and psychosocial

impairment and increased healthcare use.

Depression is frequently comorbid with pain

and limits treatment response. This study

compared a primary care-based collaborative

care program for Veterans with chronic pain

that included education for clinicians and

Veterans, symptom monitoring, and referrals

to specialty care when needed versus standard

pain treatment. Study findings show:

• Collaborative care for chronic pain was

significantly more effective than treatment

as usual across a variety of measures, such as

pain disability and intensity, as well as

depression severity.

• Among Veterans with chronic pain and

depression, there was greater improvement

in the severity of depression for those in the

intervention group compared to Veterans in

standard pain treatment.

Dobscha S, Corson K, Perrin N, et al. Collaborative care for chronic

pain in primary care: A cluster-randomized trial. JAMA March 25,

2009;301(12):1242-1252.

11

VA Health Services Research: Improving the Quality of Healthcare for Veterans
Equity and Health

Disparitites

According to the National Healthcare

Disparities Report, “...racial, ethnic, and

socioeconomic disparities are national

problems that affect health care at all

points in the process, at all sites of care,

and for all medical conditions....” 1

VA is committed to identifying and

understanding the reasons for disparities

and to developing interventions to

eliminate them for all Veterans receiving

care in the VA healthcare system.

Research on healthcare disparities has

been and remains a priority. HSR&D

research is an important part of this

effort. For example, HSR&D supports

the Center for Health Equity Research

and Promotion (CHERP), located in

Pittsburgh and Philadelphia, which is

devoted to research on disparities

related to race/ethnicity, socioeconomic

status, and comorbid illness.

African-American Veterans have

Lower Hospital Mortality Rates

for Six Conditions

This study sought to determine if racial

disparities in 30-day mortality exist for six

specific conditions among Veterans who were

in VA hospitals during FY96-FY02 (284,974

Veterans treated at 120 VA sites). Investigators

focused on three conditions for which hospital

admission is non-discretionary – acute

myocardial infarction, hip fracture, and stroke,

and three conditions for which hospital

admission is discretionary – congestive heart

failure, gastrointestinal bleeding, and

pneumonia. Findings show:

• For each of the six conditions, unadjusted

30-day mortality rates were significantly

lower for African-American Veterans

compared to white Veterans.

• Among Veterans older than age 65,

African-Americans consistently had

significantly lower odds of risk-adjusted

mortality than whites. However, among

Veterans younger than age 65, AfricanAmericans had significantly reduced

risk-adjusted mortality only for chronic

heart failure.

Volpp K, Stone R, Lave J, et al. Is thirty-day hospital mortality really

lower for black Veterans compared with white Veterans? Health Services

Research August 2007;42(4):1613-1631.

12

I M P A C T S
Assessing Disparities in VA

Treatment and Outcomes

for Heart Failure

Despite the fact that African-Americans have

a higher prevalence of heart failure (HF) than

whites, the literature shows that AfricanAmerican patients receive suboptimal medical

care compared with whites. This study

evaluated racial differences in both the

quality of care and outcomes among 18,611

Veterans (12.4% African-American and 87.6%

white) treated as outpatients at VA medical

centers between 10/00 and 9/02. Investigators

assessed racial variations in quality of care based

on recommended HF guidelines, including

documentation of left ventricular ejection

fraction (LVEF) measurement and the

prescription of angiotensin-converting enzyme

inhibitors (ACEI) and beta-blockers in patients

with an LVEF of <40%. Findings show:

• Quality of care, including evaluation of

LVEF and prescription of ACEI and betablockers, was similar or better for AfricanAmericans compared to whites.

• Mortality did not differ significantly by race.

Deswal A, Petersen NJ, Urbauer DL, et al. Racial variations in quality of

care and outcomes in an ambulatory heart failure cohort. American

Heart Journal August 2006;152(2):348-54.

No Disparities in Care between

African-American and White

Veterans with HIV

HIV infection and HIV-related mortality

disproportionately affect African-Americans

compared to whites in the United States.

Moreover, even though we now have more

effective HIV treatment (e.g., highly active

antiretroviral therapy), national CDC data

show that mortality for African-American

patients after an AIDS diagnosis is higher than

for white patients who develop AIDS. This

study examined the survival of Veterans with

HIV who were cared for in a setting with few

barriers to HIV care – the VA healthcare system

(VA is the largest single provider of HIV care in

the country) – in order to determine if there

were any race-based disparities in survival.

Findings show:

• Overall, both hospital and long-term survival

rates were similar among African-American

and white Veterans with HIV. However,

compared to whites, African-American

Veterans had more severe HIV disease and

more non-HIV related comorbidities.

• African-Americans also were more likely to

be diagnosed with hepatitis C, and were more

often hospitalized with a psychiatric or

substance use disorder as their primary

diagnosis.

Giordano T, Morgan R, Kramer J, et al. Is there a race-based disparity

in the survival of Veterans with HIV? Journal of General Internal

Medicine June 2006;21(6):613-617.

13

VA Health Services Research: Improving the Quality of Healthcare for Veterans
Understanding VA Healthcare Use

by American Indian and Alaska

Native Women Veterans

American Indian and Alaska Native (AIAN)

women Veterans who are members of federally

recognized Tribes also may be eligible for

healthcare from the Indian Health Service

(IHS). This study reports on the healthcare

utilization patterns of AIAN women Veterans.

Investigators analyzed IHS and VA data for

5,856 AIAN women receiving outpatient care

in either or both healthcare systems during

FY02 and FY03. Findings show:

• VA-only users received specialty care or

mental healthcare twice as frequently as

IHS-only users. In addition, VA-only users

received care in rehabilitation clinics or

diagnostic clinics at least four times more

frequently than IHS-only users.

• Veteran dual-users received two-thirds of

their healthcare at VA facilities, while

non-Veteran dual-users received most of

their healthcare atIHS facilities.

• Results also show that PTSD was a leading

reason for a healthcare visit only at VA

facilities, and 25% of all Veterans who sought

VA care had a spinal cord injury.

In 2003, VA and the IHS executed a

Memorandum of Understanding to improve

access and health outcomes for AIAN Veterans

by encouraging cooperation and resource

sharing. These results will help improve this

process.

Kramer B, Jouldjian S, Washington D, et al. Healthcare for American

Indian and Alaska Native women: The roles of the Veterans Health

Administration and the Indian Health Service. Women’s Health Issues

March-April 2009;19(2):135-43.

African-American Veterans More

Likely to Receive Mechanical

Ventilation for COPD

African-American patients are more likely than

white patients to prefer and receive life-sustaining interventions in advanced stages of disease.

However, little is known about potential

differences in the use of mechanical ventilation

and the newer, non-invasive ventilation

(NIV) in the treatment of chronic obstructive

pulmonary disease (COPD). Using VA data,

investigators sought to determine if rates of

mechanical ventilation and NIV use differ

among African-American (n=5,479) and

white Veterans (n=31,537) admitted to 153

VA hospitals for COPD exacerbation.

Findings show:

• African-American Veterans with COPD

exacerbation in VA hospitals are more

likely than white Veterans to receive

mechanical ventilation, and this difference

is not explained by available clinical or

demographic variables.

• By contrast, African-American and white

Veterans are equally likely to receive NIV

when being treated for COPD exacerbation.

Authors suggest that unmeasured factors, such

as patient preferences or disease severity may be

affecting the use of mechanical ventilation, and

thus warrant further investigation.

Cannon K, Vaughan Sarrazin M, Rosenthal G, et al. Use of mechanical

and non-invasive ventilation in black and white COPD patients within the

VA healthcare system. Medical Care January 2009;47(1):129-33.

14

I M P A C T S
Long-Term Care

and Caregiving

Long-term care (LTC) encompasses an

array of services for people who need

chronic care for reasons that range from

stroke to chronic illness to frailty.

Individuals with unremitting and

debilitating conditions require constant

care that can be provided in an

institutional, home, or community-based

setting. Services provided for those who

need LTC may include nursing home

care, adult day care, hospice, or home

health care. The degree of disability and

dependence on daily living assistance

increases progressively with age. The

portion of the U.S. population who need

long-term care is growing because our

population is aging. The number of

Veterans older than 85 will more than

double in the next decade, and these are

the people who will most need VA’s

long-term care services.

2

Veterans who require long-term care

may prefer not to reside in an institutional

setting, thus VA seeks to provide the best

cost-effective long-term care in the least

restrictive environment. VA has

developed a national strategy to enhance

the quality of long-term health care and

to improve access to LTC for all eligible

Veterans. This includes an array of home

and community-based extended care

services, such as: nursing home care,

home-based primary care, adult day health

care, and community residential care.

Guidebook for Caregivers of

Veterans with Stroke

A “Guidebook for Caregivers of Veterans with

Stroke” was developed by an HSR&D nurse

investigator in responseto the VHA Clinical

Practice Guidelines for the Management of

Stroke Rehabilitation recommendation to

increase guidelinecompliancein family

education. (Thecontent of the guidebook

was partially based on findings from another

HSR&D study). Providing caregivers with

information about strokesurvivors’ needs

following dischargecan promote positive

health outcomesand prevent strokerecurrence.

To provideculturally sensitiveinformation,

one version of the Guidebook was developed

in Spanish forcaregivers of Veterans in Puerto

Rico and one version in English forcaregivers

of Veterans on the Mainland. The Guidebooks

are being disseminated across VHA.

HSR&D study NRI 05-246; Principal Investigator: Maude Rittman, PhD.

15

VA Health Services Research: Improving the Quality of Healthcare for Veterans
Geriatric Evaluation and

Management Units Decrease

Nursing Home Placement but

Do Not Increase Cost

A Geriatric Evaluation and Management

(GEM) study analysis assessed the cost and

clinical impact of inpatient units and outpatient

clinics for geriatric evaluation and management.

Findings show:

• Veterans treated in inpatient geriatric units

were significantly less likely to have any

long-term care admissions following their

initial discharge from the hospital. As a

result, the average number of nursing home

days and nursing home costs were lower for

Veterans treated in the inpatient units.

• Inpatient and outpatient geriatric evaluation

and management units did not increase costs

of care.

Phibbs C, Holty J, Goldstein M, et al. The effect of geriatrics evaluation

and management on nursing home use and health care costs: Results

from a randomized trial. Medical Care January 2006;44(1):91-95.

Promoting Hospice Care

Improves End-of-Life Care

Hospice care is provided for terminally ill

patients and may include in-home care, grief

counseling, and pain management. This study

examined an intervention promoting

information about hospice care to see if it

would increase enrollment and improve the

quality of end-of-life care for nursing home

residents. Nursing home residents at three

different nursing homes, including one VA

nursing home, received a hospice informational

visit. Results show:

• Among Veterans who participated in the

informational visit, hospice referral rates

were significantly higher, they received more

days of hospice care, and their families’

ratings of their care in the last week of life

were significantly higher.

Casarett D, Karlawish J, Morales K, et al. Improving the use of hospice

services in nursing homes: A randomized controlled trial. JAMA July 13,

2005;294(2):211-217.

16

I M P A C T S
Mental Health

The Veterans Health Administration

operates the largest mental health care

system in the country, providing services

to more than 500,000 Veterans. A health

survey of 1.5 million Veterans enrolled in

VA healthcare found that 36% had at least

one mental disorder, with depression

being the most common diagnosis,

followed by anxiety disorders, including

post-traumatic stress disorder (PTSD),

and schizophrenia.

3

Many mental disorders, including

depression, anxiety disorders, and

schizophrenia, can be treated by a

combination of medication to relieve

symptoms, and psychotherapy to help

cope with effects of the illness. In

addition, many people with anxiety

disorders also will benefit from joining

a self-help or support group. Treatment

choice will depend upon several things

such as a diagnostic evaluation, reaction

to medications, and patients’ personal

preferences.

Primer on Collaborative Care for

Depression as an Educational

Tool for Managers

The Mental Health Quality Enhancement

Research Initiative (MH-QUERI) developed

Translating Initiatives for Depression into

Effective Solutions (TIDES) — an evidencebased collaborative approach to depression

management that has proven successful in the

VA healthcare system. “Collaborative Care for

Depression in the Primary Care Setting:

A Primer on VA’s Translating Initiatives for

Depression into Effective Solutions TIDES)

Project” is now available online at

www.hsrd.research.va.gov/publications/

primer/. This Primer discusses several

collaborative care models for the treatment of

depression, focusing on VA’s TIDES project.

This Primer can help managers make informed

decisions about what care model is best for their

facilities. It also can be used as a training tool

for staff in facilities that plan to implement this

model of depression care.

17

VA Health Services Research: Improving the Quality of Healthcare for Veterans
Monitoring the Use of

Pharmacotherapies for Addiction

Investigators with the Substance Use Disorder

Quality Enhancement Research Initiative

(SUD-QUERI) worked with VA Pharmacy

Benefits Management and the Program

Evaluation and Resource Center to monitor use

of pharmacotherapies for addiction, including

buprenorphine, naltrexone, acamprosate, and

disulfiram, across the VA healthcare system.

During FY08, this project put particular

emphasis on supporting and encouraging

buprenorphine uptake via two initiatives:

a formative evaluation at the 14 sites that

obtained funds to recruit new staff to provide

buprenorphine, and the establishment of a

buprenorphine help-line to answer provider

and administrator questions about how to set

up a program, obtain training certification or a

clinical mentor, and address barriers to care.

As a result of these efforts:

• The use of buprenorphine increased from

234 providers at 82 VA facilities prescribing

to 1,406 Veterans, to 333 providers at 114

VA facilities providing prescriptions to 2,091

Veterans.

Gordon A, Liberto J, Granda S, et al. Outcomes of DATA 2000 certification

trainings for the provision of buprenorphine treatment in the Veterans

Health Administration. The American Journal on Addictions NovemberDecember 2008;17(6):459-462.

Telemedicine Technology

Improves Depression

Collaborative Care

The Telemedicine Enhanced Antidepressant

Management (TEAM) study evaluated a

collaborative care model that was adapted for

smaller clinics without onsite psychiatrists.

It included the use of telemedicine technology

(e.g. telephone, interactive video) to facilitate

communication between primary care and

an off-site depression care team. The TEAM

study targeted 395 Veterans with depression

who received care in seven smaller VA

outpatient clinics. Findings show:

• Telemedicine technologies can be used

successfully to adapt the collaborative care

model for implementation in smaller primary

care clinics that lack onsite psychiatrists.

• Veterans who received the telemedicine

intervention were more likely to adhere to

depression treatment compared to Veterans

in usual care. They also were more likely to

respond to treatment by 6 months and to

remit by 12 months.

• Veterans who received the telemedicine

intervention reported larger gains in mental

health status and health-related quality of

life, and reported higher satisfaction with

care.

Fortney J, Pyne J, Edlund M, et al. A randomized trial of telemedicinebased collaborative care for depression. Journal of General Internal

Medicine August 2007;22(8):1086-93.

18

I M P A C T S
Improving Schizophrenia Care

Annually, VA treats more than 100,000 people

with schizophrenia, which accounts for nearly

12% of all VA healthcare costs. Outcomes for

schizophrenia are good when appropriate

medication and psychosocial treatments are

received; however, rates of appropriate care

nationally are moderate to low. This study

developed and evaluated a chronic illness care

model for schizophrenia that resulted in

significant improvements in medication

treatment quality for psychosis, as well as

improved management of side effects and

weight gain among Veterans.

Brown A, Cohen A, Chinman M, et al. EQUIP: Implementing chronic

care principles and applying formative evaluation methods to improve

care for schizophrenia: QUERI Series. Implementation Science

February 2008;15:3:9.

Smoking and Diabetes: Creating

New Knowledge of Tobacco Risk

An HSR&D investigator published alandmark

manuscript in the British Medical Journal that

was thefirst to link active or passivetobacco

smokeexposure with increased risk of incident

diabetes. In December 2007, datafrom this landmark study wereincorporated into a definitive

meta-analysis of studiesassessing theassociation

between activesmoking and incidence of type 2

diabetes. Thisanalysis, which included a

literaturesearch of two sources – MEDLINE

(1966-2007)and EMBASE (1980-2007),

was published in JAMA and confirmed the

association of smoking and type 2 diabetes.

Investigators suggest futureresearch should

attempt to establish whether thisassociation is

causaland to clarify how they arerelated.

Willi C, Bodenmann P, Ghali W, et al. Active smoking and the risk of

type 2 diabetes: A systematic review and meta-analysis. JAMA

December 2007;298(22):2654-64.

Community Care Yields Better

Outcomes for Veterans with

Substance Use and Psychiatric

Disorders

Individuals with both addiction and psychiatric

disorders (dual-diagnosis patients) use more

health services compared to those with either

disorder. In an effort to reduce the burden on

healthcare systems for dually-diagnosed

patients, there has been a shift in acute

treatment from hospital-based inpatient to

community residential care. This study

evaluated the effectiveness and cost-effectiveness of community-based and hospital-based

acute residential treatment for Veterans with

both addiction and psychiatric disorders.

Findings show:

• Veterans had better substance use outcomes

when they were initially assigned to community rather than to hospital acute care.

• Veterans assigned to hospital care had more

mental health follow-up outpatient visits and

more costly mental health follow-up

inpatient stays.

Investigators conclude that hospital care was

more expensive without yielding better

outcomes, suggesting cost-savings can be

achieved without loss of benefit to most

dually-diagnosed Veterans by shifting the locus

of treatment from hospital to community care.

Timko C, Shuo C, Sempel J, Barnett P. Dual diagnosis patients in

community or hospital care: One-year outcomes and health care

utilization and costs. Journal of Mental Health April 2006;15(2):163-77.

19

VA Health Services Research: Improving the Quality of Healthcare for Veterans
Telephone Care Coordination

Increases Treatment for

Smoking Cessation

VA has done an excellent job of identifying

Veterans who smoke and advising them to quit,

with rates for asking and advising exceeding

90% nationwide. However, the prevalence of

smoking has remained high, in part because

treatment rates have remained low. This

HSR&D study tested the effectiveness of

the Telephone Care Coordination Program

(TCCP) in raising referral and treatment

rates for smoking cessation. The TCCP

incorporated a simple computerized referral

designed to help increase patient referrals to

telephone counseling. The TCCP generated

a large number of referrals to telephone

counseling for smoking cessation (nearly

3,000), and providers at TCCP sites reported

referring many more Veterans to telephone

counseling than providers at the control sites

(15.6 vs. 0.7).

Increased telephone counseling should result

in increased numbers of Veterans who quit

smoking, resulting in lower rates of smokingrelated illness. Telephone counseling is

particularly helpful for Veterans who live in

rural settings and have difficulty accessing care.

Sherman S, Takahashi N, Kalra P, et al. Care coordination to increase

referrals to smoking cessation telephone counseling: A demonstration

project. American Journal of Managed Care March 2008;14(3):141-148.

I M P A C T S

20

National Dissemination of a

Clinical Reminder for Brief

Alcohol Counseling Increases

Counseling Rates

Brief alcohol counseling has been shown to be

effective in reducing hazardous drinking.

With a goal to improve rates of brief alcohol

counseling in VA, the Substance Use Disorders

Quality Enhancement Research Initiative

(SUD-QUERI) developed a clinical reminder

for brief alcohol counseling for implementation

in VA’s computerized patient record system

(CPRS). The clinical reminder was pilot-tested

at an 8-site facility, underwent evaluation,

and was revised based on user feedback.

The reminder was then recommended for use

to meet new 2008 performance measures for

follow-up patients screening positive for

alcohol misuse and was disseminated nationally

in the fall of 2007.

Evaluation of VA data shows there was a

substantial increase in rates of brief alcohol

counseling for eligible patients during the 2nd

and 3rd quarters of FY2008 (19% and 37%,

respectively).

Bradley K, Williams E, Greiner G, et al. Use of electronic reminders

and a performance measure to increase brief alcohol counseling by

primary care providers in VA. Annual Meeting of the Research

Society of Alcoholism, Washington, DC: July 15, 2008.

I M P A C T S
VA Health Services Research: Improving the Quality of Healthcare for Veterans

21

Using the VA Depression

Registry to Identify Predictors

of Suicide among Veterans

The largest and most up-to-date study of

suicides among depressed Veterans provides

important new data that may help guide

screening and treatment for all Veterans.

The study finds that the predictors of suicide

among Veterans in depression treatment differ

from those seen in the general population, with

younger, white, non-Hispanic men having the

highest risk among Veterans. Veterans with

substance abuse issues, and those who had been

hospitalized for psychiatric reasons in the year

before their depression diagnosis also had a

higher suicide risk. Surprisingly, older Veterans

who had been diagnosed with post-traumatic

stress disorder (PTSD) in addition to

depression had a lower overall rate of suicide

than those without a PTSD diagnosis, perhaps

because they were more likely to receive care

through VA PTSD programs.

HSR&D study IIR 04-211; Principal Investigator: Marcia Valenstein, MD.

Alcohol Screening Scores Help

Identify Patients at Risk of

Medication Non-Adherence

Alcohol misuse is common, and may be a

significant risk factor for non-adherence to

medications. This study examined the

association between scores on a brief alcohol

screening questionnaire – the Alcohol Use

Disorder Identification Test-Consumption

(AUDIT-C) – and medication non-adherence

for patients in general internal medicine clinics

at seven VA medical centers nationwide.

Medication adherence was calculated for

90-day and 1-year periods; Veterans were

considered adherent if they had medication

available for at least 80% of the observation

period. Findings show:

• Approximately 20% of participants overall

had AUDIT-C scores of 4 or more, signifying

positive screenings for alcohol misuse.

• For both the 90-day and 1-year observation

periods, increasing AUDIT-C scores were

associated with decreasing medication

adherence.

This is the first study to show that a validated,

clinically practical alcohol screening

questionnaire can identify patients with

alcohol misuse who are at risk for poor

medication adherence, independent of other

patient characteristics.

Bryson C, Au D, Sun H, et al. Alcohol screening scores and

medication non-adherence. Annals of Internal Medicine

December 2008;149(11):795-804.

VA Health Services Research: Improving the Quality of Healthcare for Veterans
PTSD Strongly Associated with

Increased Risk for Dementia

Some studies have shown that chronic

post-traumatic stress disorder (PTSD) is

related to an “accelerated aging” process.

This HSR&D study sought to determine if

PTSD is associated with an increased risk of

developing dementia among older Veterans.

Using VA data, investigators conducted a

study of 181,093 Veterans aged >55 without

dementia from 1997 to 2000. Of these

Veterans, 53,155 were diagnosed with PTSD.

During the follow-up period from 2001-2007,

investigators gathered data on newly diagnosed

dementia. Findings show:

• Veterans with a diagnosis of PTSD were

twice as likely to develop dementia, even after

accounting for other medical and psychiatric

conditions.

• Veterans with PTSD had a dementia rate of

10.6% over the seven years of follow-up,

whereas those without PTSD had a rate of

6.6%.

While this is early emerging evidence, investigators believe it is critical to follow Veterans with

PTSD, and to screen them early for dementia.

Yaffe K, et al. Alzheimer's Association International Conference on

Alzheimer's Disease, Vienna, Austria, July 13, 2009.

Engaging Veterans and Families

in Psychoeducation to Improve

Treatment for Mental Illness

Family psychoeducation is widely considered

an evidence-based practice in the treatment of

psychotic disorders that results in reduced risk

of relapse, remission of residual psychotic

symptoms, and enhanced social and family

functioning. Recently, VA funded 19 initiatives to implement family psychoeducation.

One of these initiatives – Reaching out to

Educate and Assist Caring, Healthy Families

(REACH) is a family psychoeducation

program for Veterans with serious mental illness or post-traumatic stress disorder (PTSD).

Findings show:

• REACH has had notable success in engaging

Veterans and their families. Of the 1,539

Veterans told about the program over one

year, 41% had a family member who was

willing to meet with a provider to learn more.

• REACH providers then met with 505

Veterans to explore family participation.

Of those, 28% of Veterans with PTSD, 34%

of Veterans with affective disorders, and 25%

of Veterans with schizophrenia went on to

participate in the REACH Program.

These rates suggest that the REACH

engagement strategy may be a promising tool

in recruiting Veterans and their families into

family psychoeducation.

Sherman M, Fischer E, Bowling U, et al. Effectiveness of new

engagement strategies in a VA-based family psychoeducation program.

Psychiatric Services February 2009;60(2):254-57.

22

I M P A C T S
Post-Deployment

Health

Veterans returning from Iraq and

Afghanistan come home with a broad

range of injuries and illnesses that present

new challenges for Veterans and the

VA healthcare system. For example,

thousands of Veterans are returning with

blast-related injuries from mortar shells,

rocket-propelled grenades, and

improvised explosive devices (IEDs).

Many have complex medical problems

that include: traumatic brain injury

(TBI), traumatic or partial limb

amputation, nerve damage, vision and

hearing loss, pain, as well as mental

health and adjustment issues.

VA has a collaborative relationship

with the military, working together to

provide a seamless continuum of care for

returning OEF/OIF soldiers. VA’s Office

of Research and Development encourages

innovative research on an array of topics

important to the healthcare of these

Veterans, and researchers are dedicated

to improving the quality of their care by

discovering solutions to this new

generation of Veterans’ unique injuries

and problems. HSR&D is an important

part of this effort.

Assessing Impairments and

Outcomes for Veterans with

Blast-Related Injuries

VA designated four Polytrauma Rehabilitation

Centers (PRCs) to provide specialized

rehabilitation treatment and to expand clinical

expertise in polytrauma throughout VA. This

study sought to describe characteristics and

rehabilitation outcomes among 188 OEF/OIF

Veterans who received inpatient rehabilitation

for blast and other injuries at a PRC from

10/01 through 1/06. Findings show:

• Penetrating brain, eye,skin and soft tissue,

and oral maxillofacial injuries, as well as

auditory impairments and post-traumatic

stress disordersymptoms are more common

among Veterans exposed to blastsrelative to

othersources of injury in a war zone.

• Veterans with blast-related injuries had more

impairments related to Veterans with other

injuries. Type of injury did not predict

functional outcomes among these Veterans;

however, earlier acute rehabilitation

intervention, higher education, and,

surprisingly, the presence of psychiatric

symptoms were positively associated with

gains in cognitive function scores.

These findings will help healthcare providers

to develop more effective treatments to

improve functional outcomes for Veterans

with blast-related injuries.

Sayer N, Chiros C, Sigford B, et al. Characteristics and rehabilitation

outcomes among patients with blast and other injuries sustained during

the global war on terror. Archives of Physical Medicine and Rehabilitation January 2008;89(1):163-170.

23

VA Health Services Research: Improving the Quality of Healthcare for Veterans
I M P A C T S

24

Examining Unique Needs of

Soldiers with SCI Results in

Increased Funding for Equipment

This VA/HSR&D Spinal Cord Injury

Quality Enhancement Research Initiative

(SCI-QUERI) study examined the

characteristics and needs of soldiers returning

from the Iraq and Afghanistan conflicts

with spinal cord injuries (SCI). These soldiers

are transferred from military facilities to VA

SCI Centers with multiple other problems in

addition to spinal cord injury, including mild

traumatic brain injury, PTSD, fractures,

pressure ulcers, and other conditions that often

delay the start of rehabilitation. These patients

are younger than the typical SCI veteran and

have a greater desire to obtain and use

technology, and to return to active lives in the

community. This information was presented

to the VA Under Secretary for Health as part

of a presentation by the VA SCI and Disease

(SCI&D) Service Chief and SCI-QUERI

Co-Clinical Coordinator, Dr. Margaret

Hammond.

As a result, SCI&D Services has received

funding to purchase exercise and sports

equipment, as well as telehealth equipment to

support the needs of our new Veterans.

Weaver F, Burns S, Evans C, et al. Provider perspectives on soldiers with

new spinal cord injuries returning from Iraq and Afghanistan. Archives of

Physical Medicine and Rehabilitation March 2009;90(3):517-521.

Polytrauma Rehabilitation

Centers’ Family Care Map

To address the high-priority need to

standardize and improve services for family

members of polytrauma inpatients, the

Polytrauma/Blast-Related Injuries Quality

Enhancement Research Initiative (PT/BRIQUERI) led the development of a web-based

tool for staff and family caregivers that

describes the inpatient rehabilitation process

and how family members can help their loved

ones during their inpatient stay.

The web-based ‘Family Care Map’ has been

incorporated into the nurse training programs

and interdisciplinary plans on the polytrauma

inpatient units. It also has been recognized as

a valuable resource by the Polytrauma Action

Committee and the Center for Ethics within

VA, as well as the Government Accountability

Office (GAO).

HSR&D study PLY 05-184; Principal Investigator: Carmen Hall, PhD, RN.

I M P A C T S
VA Health Services Research: Improving the Quality of Healthcare for Veterans

25

Examining Virtual Reality

Therapy for Veterans with PTSD

Early treatment is critical to improving

outcomes for both active duty military and

Veterans with PTSD, and research suggests

that virtual reality exposure (VRE) therapy is

an effective new therapy for treating Veterans

with PTSD. An HSR&D investigator, working

on a study funded by the Department of

Defense (DoD), is comparing the effects of

virtual reality graded exposure therapy

(VRGET) with cognitive behavioral group

therapy on active-duty personnel.

Preliminary findings show:

• Virtual reality graded exposure therapy

led to measurable reductions in reported

difficulties with PTSD and was well-tolerated.

Wood D, Murphy J, Center K, et al. Combat-related post-traumatic

stress disorder: A case report using virtual reality exposure therapy

with physiological monitoring. Cyber Psychology & Behavior

April 2007;10(2):309-315.

Identifying OEF/OIF Veterans

with Mental Illness Can Lead

to More Targeted Care

This study describes the proportion of

Operation Enduring Freedom (OEF) and

Operation Iraqi Freedom (OIF) Veterans seen

in VA facilities who received single or multiple

mental health and/or psychosocial diagnoses,

and also examined the subgroups of Veterans

at high risk for mental health problems.

Findings show:

• Nearly one-third of the 103,788 OEF/OIF

Veterans were classified as having either

mental health diagnoses and/or psychological problems, with more than half diagnosed

with PTSD.

• Investigators suggest that targeted early

detection and intervention beginning in

primary care settings can help prevent

chronic mental illness and disability.

Seal K, Bertenthal D, Miner C, et al. Bringing the war back home: Mental

health disorders among 103,788 U.S. Veterans returning from Iraq and

Afghanistan seen at VA facilities. Archives of Internal Medicine

March 12, 2007;167(5):476-82.

VA Health Services Research: Improving the Quality of Healthcare for Veterans
Mental Health Diagnoses among

OEF/OIF Veterans Increased

Rapidly Following Invasion of Iraq

This study investigated trends and risk factors for

mental health diagnoses among Veterans from

Operation Enduring Freedom (OEF) in

Afghanistan and Operation Iraqi Freedom (OIF)

in Iraq. Using VA data, investigators identified

289,328 OEF/OIF Veterans who were first-time

users of VA healthcare between 4/02 and 3/08.

Investigators examined new mental health

diagnoses, as well as two-year prevalence rates,

focusing on four mental health disorders

associated with military service: PTSD,

depression, alcohol use disorders, and drug

use disorders. Finding show:

• The prevalence of new mental health

diagnoses among OEF/OIF Veterans using

VA healthcare increased rapidly following the

Iraq invasion.

• Among the 289,328 Veterans in this study, new

mental health diagnoses increased 6-fold from

6.4% in April of 2002 to 36.9% by March

2008: 21.8% of Veterans were diagnosed with

post-traumatic stress disorder (PTSD), and

17.4% with depression.

• Two-year prevalence rates of PTSD increased

4-7 times after the invasion ofIraq.

• The youngest active duty OEF/OIF Veterans

(< 25 years) were at nearly twice the risk for

PTSD, more than twice the risk for alcohol use

disorders, and at a nearly 5-fold risk for drug

use disorders than older active duty Veterans (>

40 years).

Authors suggest that early targeted interventions

may prevent chronic mental illness.

Seal K, Metzler T, Gima K, et al. Trends and risk factors for mental health

diagnoses among Iraq and Afghanistan Veterans using Department of Veterans Affairs health care, 2002-2008. American Journal of Public Health

September 2009; 99(9): 1651-1658.

Traumatic Brain Injury and PTSD:

A Synthesis of the Evidence

HSR&D's Evidence-Based Synthesis Program(ESP)

recently produced an important report on

traumatic brain injury (TBI) and post traumatic

stress disorder (PTSD). Investigators at the

Minneapolis VAMC and HSR&D’s Center for

Chronic Disease Outcomes Research conducted

a literature review to answer key questions

regarding TBI and PTSD. Findings show:

• The reported prevalence of comorbid

TBI and PTSD varies widely; for example,

from 0% among medical patients recruited

from a single neurology department to 70%

in a clinical sample of patients with obsessivecompulsive disorder.

• There is no information on the relative

diagnostic accuracy of commonly used tests to

assess history and symptoms of mild TBI or

PTSD when the conditions are co-occuring.

• There is no information on the effectiveness

and harms of therapies in adults with these

comorbid conditions.

Thetopicis importantand timely because both

VA and DoD areserving asignificant number of

Operation Enduring Freedom and Operation

Iraqi Freedom Veterans with TBI, PTSD, or both.

Therefore, long-term prospective observational

studiesare needed that use validated measures of

both history and symptoms of TBIand PTSD,

in order to determine prevalence, severity,and

long-term outcomes.

To read the full report, go to

www.hsrd.research.va.gov/publications/esp/ .

Carlson K, Kehle S, Meis L, et al. The Assessment and Treatment of Individuals with History of Traumatic Brain Injury and Post-Traumatic Stress Disorder: A Systematic Review of the Evidence. Final Report, August 2009.

Department of Veterans Affairs, Health Services Research & Development

Service, Evidence-Based Synthesis Program.

26

I M P A C T S
Quality Improvement

Providing quality healthcare to Veterans

is paramount in the VA healthcare system

– the largest integrated healthcare system

in the country.

Overthe past decade, VA has undergone

a dramatic transformation and has emerged

as a nationally and internationally known

leaderin quality improvement efforts.

VA supports a powerful electronic

medical record, sophisticated systems of

performance measurement and patient

safety—all of which contribute to quality

of care. VA also supports a vibrant health

services research program that works

to discover new knowledge to improve

quality and patient outcomes.

A cornerstone of this work is the

Quality Enhancement Research Initiative

(QUERI), which works to accelerate the

implementation of new research findings

into routine clinical practice, thereby

improving the quality of Veteran care

and outcomes.

HSR&D Improves

Performance Monitoring

This study explored the impact of an electronic

medical record, routine performance

monitoring, and other quality-related system

changes. In order to analyze performance in

the years after the institution of these system

changes, investigators compared the quality

of outpatient and inpatient care across 26

conditions among two populations:

1) a national sample of 992 patients drawn

from 12 communities, and 2) 596 VHA

patients from 26 facilities in 12 health care

systems located in the Southwest and Midwest.

Findings show:

• VHA performed consistently better across

the entire spectrum of quality indicators

for care, including screening, diagnosis,

treatment, and follow-up.

• VHA patients were more likely than patients

in the national sample to receive care

specified by the indicators (67% vs. 51%).

Performance in VHA outpaced that of the

nation for both chronic care (72% vs. 59%)

and preventive care (64% vs. 44%), but not

acute care (53% vs. 55%).

• VHA patients received significantly better

care for depression (80% vs. 62%), diabetes

(70% vs. 57%), hyperlipidemia (64% vs.

53%), and hypertension (78% vs. 65%).

Asch S, McGlynn E, Hogan M, et al. Comparison of quality of care for

patients in the Veterans Health Administration and patients in a national

sample. Annals of Internal Medicine December 2004;141(12):938-945.

27

VA Health Services Research: Improving the Quality of Healthcare for Veterans
Improving Bar Code

Medication Administration

Medication errors are the most common cause

of adverse events in hospitals. To reduce these

types of errors, VHA pioneered the

development of a bar code medication

administration (BCMA) system. Nurses access

BCMA software by using a laptop computer

attached to a wheeled medication cart and

linked by a wireless network to electronic

databases. If the scanned medication bar code

data does not match the patient’s bar-coded

wristband, the BCMA software alerts the

nurse. BCMA is currently used in all VHA

facilities, but it is a relatively new technology.

Investigators in this study collected data on

potential problems in using BCMA within

VHA, and proposed 15 practices to maximize

the effective use of BCMA, including:

• Put into place a standing interdisciplinary

committee that would conduct continuous

improvement on the use of BCMA;

• Train all nurses on BCMA software, and

cross-train pharmacists and select physicians;

Alert nurses to new STAT orders; Scan

patients’ wristbands and medications prior to

administration to verify patient identity; and

• Replace missing, inaccurate, or worn wristbands, especially for those in long-term care.

Patterson E, Rogers M, Render M. Fifteen best practice recommendations for bar-code medication administration in the Veterans Health

Administration. Joint Commission Journal on Quality and Safety

July 2004;30(7):355-65.

Primary Care Characteristics that

Result in Improved Colorectal

Cancer Screening Rates

VA has increased colorectal cancer (CRC)

screening rates to 68% through several

methods, including a focus on primary care

screening efforts. This study explored VA

primary care practice-level characteristics

associated with CRC screening, while

controlling for patient-level factors.

Investigators analyzed survey data for 155 VA

primary care clinics, as well as administrative

and chart review data for 38,818 Veterans.

Findings show:

• Overall, VA facilities in this study achieved

a 62.2% CRC screening rate – ranging from

29.1% to 89.3%.

• Veterans who received their care at primary

care practices with higher levels of autonomy

(i.e., authority over operations) and greater

clinical support resources were more likely to

receive CRC screening.

Yano E, Soban L, Parkerton P, Etzioni D. Primary care practice

organization influences colorectal cancer screening performance.

Health Services Research June 2007;42(3 Pt 1):1130-49.

28

I M P A C T S
Preoperative Antibiotics:

Influencing the Standard of Care

HSR&D investigators collaborated with VA’s

Office of Quality and Performance (OQP) on

the rapid-response project ‘Timely Prophylactic

Antibiotic Administration for Major Surgical

Procedures.’ The results of their work have

transformed the manner in which prophylactic

antibiotics are given. The standard both in VA

and the private sector is now for antibiotics

to be given in the operating room by the

anesthesia provider, resulting in a substantial

improvement in timely administration of

prophylactic antibiotics.

Hawn M, Itani K, Gray S, et al. Association of Timely Administration of

Prophylactic Antibiotics for Major Surgical Procedures and Surgical Site

Infection. HSR&D 2009 National Meeting, Baltimore, MD.

Advancing Implementation

Science to Improve Quality of Care

This Implementation Science Editorial offers a

perspective from implementation researchers

outside the U.S. about VA/HSR&D’s Quality

Enhancement Research Initiative (QUERI)

and its impact on and contributions to

implementation science. This involved factors

such as:

• QUERIserving as the change agent;

• Designing guiding frameworks (i.e., six-step

QUERI process);

• Producing mechanisms to increase

opportunities for service providers and

researchers to develop meaningful and

sustained interactions and collaborations;

• Focusing on changing attitudes and cultures;

and

• Developing methods and tools.

The authors suggest that other health systems

and health research funders carefully consider

what aspects of QUERI they could and should

emulate or adapt, since much can be learned

from this comprehensive approach to bringing

about health system change to nurture and

support evidence-based quality improvement

and implementation research.

Graham I and Tetroe J. Learning from the U.S. Department of Veterans

Affairs Quality Enhancement Research Initiative. Implementation Science

March 6, 2009;4:13.

This article was part of a special QUERI Series featured in the online

journal, Implementation Science. VA’s Quality Enhancement Research

Initiative (QUERI) is managed through HSR&D.

29

VA Health Services Research: Improving the Quality of Healthcare for Veterans
Women’s Health

The number of women Veterans is

growing rapidly. Due to the increasing

number of women on active duty

(currently 14% of active duty deployed

forces) and those entering military

service, the percentage of female Veterans

is expected to increase from 7.7% in 2008

to 14.3% in 2033. In addition, of the

more than 102,126 Operation Enduring

Freedom/Operation and Operation Iraqi

Freedom women Veterans, 44.2% are

enrolled in VA healthcare.

4

In response to the changing

demographic in the Veteran population

and the specialized healthcare needs of

women, VA has established women’s

health as a research priority. Areas of

particular research interest include

redesigning primary care service

delivery for women, and understanding

post-deployment health issues unique to

women. In addition to expanding the

research portfolio, the Center for Women

Veterans was established to ensure that

women Veterans have access to VA

benefits and services, and that VA health

care and benefits programs are responsive

to the gender-specific needs of women.

For more information about healthcare

for women Veterans, go to

www.va.gov/WOMENVET/.

Evaluating VA Healthcare for

Women Veterans

VA research is evaluating the impact of VHA

practice structures and primary care delivery

models on the quality of care for women

Veterans, which will inform VApolicymakers

about the best ways to organize care and

optimize the outcomes and satisfaction of

women Veterans. The initial phase of this

research focused on service availability, staffing,

and resources of VA women’s healthcare, and

is now examining possible quality of care

differences. The second phase of this research

will evaluate environmental, organizational,

and resource determinants of changes in the

delivery of VA women’s healthcare over the last

five years – a time of growth in the number of

women using VA.

Ongoing and planned research also will shed

light on the health consequences of sexual

assault, military sexual trauma, and other

military traumas affecting women Veterans.

This research will help VAto better tailor

necessary healthcare services for women

Veterans.

Bean-Mayberry B, Yano E, Bayliss N, et al. Federally funded

comprehensive women’s health centers: leading innovation in

women’s healthcare delivery. Journal of Women’s Health

November 2007;16(9):1281-90.

Bean-Mayberry B, Yano E, Caffrey C, et al. Organizational characteristics

associated with the availability of women’s health clinics for primary

care in the Veterans Health Administration. Military Medicine August

2007;172(8):824-8.

30

I M P A C T S
Planning VA Healthcare to Meet

the Needs of Women Veterans

Historically, men have been the predominant

users of VHA care. In response to more women

entering the system, HSR&D investigators

provided a needed assessment of female

Veterans’ health care use and costs. They

examined how utilization and costs of VHA

care differ in women Veterans compared to

male Veterans and found that women had:

• 11.8% more outpatient encounters,

• 25.9% fewer inpatient days, and

• 11.4% lower total cost than men.

Afteradjusting forageand medical

comorbidity, these differences wereless

pronounced. VHA’sefforts to build capacity

for women Veterans mustaccount for their

relatively high use of outpatient services, which is

especially prominent in women who have both

medicaland mental health conditions. Meeting

their needs may require delivery systems

integrating medicaland mental health care.

Frayne S, Yu W, Yano E, et al. Gender and use of care: planning for

tomorrow’s Veterans Health Administration. Journal of Women’s Health

October 2007;16(8):1188-99.

Breast Cancer Screening

Mammography More Common

among Wealthy Women

This study examined the relationship between

wealth and screening mammography use in

4,222 women aged 65 years and older.

All women in this study had Medicare and

participated in the Health and Retirement

Survey – a nationally representative,

population-based, longitudinal study of older

adults. Results show:

• Screening mammography was more common

among wealthy women than poor women,

no matter their prognoses.

Authors suggest that attention should be

focused on two groups: Poor women with

good prognoses who are at risk of low screening

rates, and wealthy women with limited

prognoses who have high rates of screening

when they are unlikely to benefit.

Williams B, Lindquist K, Sudore R, et al. Screening mammography in

older women: Effect of wealth and prognosis. Archives of Internal

Medicine March 2008;168(5):514-520.

31

VA Health Services Research: Improving the Quality of Healthcare for Veterans
Women Veterans’ Perceptions

about – and Experiences with

VA Healthcare

The growth in the number of women in the

military is reshaping the Veteran population,

and thus, VHA priorities. Currently there are

1.7 million women Veterans, and 1 in 7 VA

outpatients under the age of 50 are women.

Compared with male Veterans, women have

unique needs with respect to gender-specific

care, the VA environment, and privacy.

This study sought to describe women

Veterans’ perspectives, experiences with, and

decision-making about VA health care use.

Findings show:

• Despite system-wide advances in VAhealth

care for women, gender-related barriers

remain, such as lack of information about

eligibility and available services.

Washington D, Kleimann S, Michelini A, et al. Women Veterans’

perceptions and decision-making about VA health care.

Military Medicine August 2007;172(8):812-17.

I M P A C T S

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I M P A C T S
VA Health Services Research: Improving the Quality of Healthcare for Veterans

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VA Health Services Research: Improving the Quality of Healthcare for Veterans
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I M P A C T S
VA Health Services Research: Improving the Quality of Healthcare for Veterans

35

References

1) National Healthcare Disparities Report. 2006.

Agency for Healthcare Research and Quality.

www.ahrq.gov/QUAL/nhdr03/nhdrsum03.htm.

2) U.S. Government Accountability Office(GAO).

Service gapsand facility restrictions limit

Veterans’access to non-institutionalcare. 03-487.

2003; Washington, D.C.

3) Mental Disorders in the Veterans Health

Administration: The 1999 Health Survey of

Veterans. www.hsrd.research.va.gov/meetings/2001/HSRD2001AMab99.htm.

4) Hayes P. Thechanging face of VA: Opportunities

in women’s health research. Presented at the

QUERI National Meeting, December 2008,

Phoenix,AZ.
Department of Veterans Affairs

Office of Research & Development

Health Services Research and Development Service (124)

810 Vermont Ave., NW

Washington DC 20420

www.hsrd.research.va.gov

For further information or additional copies:

Email: cider.boston@va.gov

2009