VA Health Services 

Research & 

Development

Service

Impacts 2002

Working to 

Improve Health Care 

for Veterans
VA Health Services 

Research & Development Service

Impacts 2002
The Health Services Research & Development Service

(HSR&D) is a program within the Veterans Health

Administration’s Office of Research and Development. 

HSR&D provides expertise in health services research,

a field that examines the effects of organization, financing, 

and management on a wide range of problems in health care

delivery – quality of care, access, cost, and patient outcomes.

Its programs span the continuum of health care research 

and delivery, from basic research to the dissemination of

research results, and ultimately to the application of these

findings to clinical, managerial and policy decisions.
IMPACTS 2002 Table of Contents

Message from the Director . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Aging & Age Related Changes

Pain management helps patients with dementia . . . . . . . . . . . . . . . . 2

Determining the impact of dementia on veterans’ families . . . . . . . . 3

Measuring the quality of dying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Specialized primary care services for at-risk elders . . . . . . . . . . . . . . 5

Increasing daytime activity improves nighttime sleep

in the elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Chronic Diseases

Telecommunications system for patients with COPD . . . . . . . . . . . . 7

Study shows that combination HIV treatments lower cost . . . . . . . . 8

Off-pump coronary artery bypass improves surgical outcomes . . . . . 9

Telemedicine and improving diabetes care . . . . . . . . . . . . . . . . . . . . 10

Exercise training improves ability to function in patients

with heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Health Services & Systems

The reliability of rating medical errors . . . . . . . . . . . . . . . . . . . . . . 12

Study shows ICU mortality similar in VA and private sector . . . . . . . 13

Understanding differences in patient characteristics . . . . . . . . . . . . 14

Assessing the effect of managed care on hospitals . . . . . . . . . . . . . . 15 

Teledermatology produces faster results . . . . . . . . . . . . . . . . . . . . . 16

Mental Illness

Study examines antipsychotic prescribing practices . . . . . . . . . . . . 17

Treating depression in patients with PTSD . . . . . . . . . . . . . . . . . . . 18

Sensory Disorders and Loss

Adherence to guidelines improves recovery from stroke . . . . . . . . . 19

Special Populations

Study shows black patients admitted to VA hospitals have lower 

mortality rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Is patient ethnicity related to ambulatory care use? . . . . . . . . . . . . 21

How ethnicity may affect patient choices in the care 

of osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Substance Abuse, Addictive Disorders

Working to improve the quality of substance abuse care. . . . . . . . . . 23
1

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Message from the Director

Providing the highest quality health care to millions of veterans each

year is an enormous and complex undertaking. It is further complicated

by the breathtakingly rapid change in the larger health care environment

over the past decade. More and more the expertise of health services

researchers is in high demand to tackle the many new and challenging

health care questions that managers and clinicians face.

The Health Services Research and Development Service (HSR&D) 

strives to identify high quality, cost effective ways to organize and deliver

health care to veterans. We seek strategies that work to improve patient

outcomes as well as system level outcomes. HSR&D’s research agenda

supports VA’s quest for innovative solutions to today’s health care

challenges. Through an extensive portfolio of merit-reviewed research

studies, HSR&D works to improve the quality of health care for veterans

by examining the effects of the organization, financing and management

of health care services on the quality, cost, access to, and outcomes of 

those services.

This document, HSR&D Impacts 2002, summarizes a number of 

studies that demonstrate HSR&D’s commitment to making a difference in veterans health care. The highlighted studies are organized 

into categories of importance to the veteran population, such as aging,

chronic diseases, health systems (eg, health care delivery, organization,

quality and outcomes), mental illness, sensory disorder and loss,

substance abuse, and special populations (eg, women, ethnic and 

cultural groups).

We are pleased to share with you some of HSR&D’s important impacts

over the past year. With the dedication of the entire HSR&D research

community, we will continue to seek innovative strategies that improve 

the health care of every veteran.

John G. Demakis, M.D.

Director, HSR&D
2

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Aging & Age Related Changes

Pain management helps patients with dementia

Dementia illness often co-exists with painful medical conditions

associated with aging such as osteoarthritis, skin ulcers, cancer, 

and angina. These painful conditions can go unnoticed in patients 

with dementia because of communication problems, but signs of 

this pain may include agitation and behaviors associated with discomfort.

HSR&D researchers reveal a significant relationship between discomfort

and agitation among nursing home residents with dementia, which

suggests that agitated behaviors may be associated with increased pain. 

In a clinical trial of acetaminophen, a change in discomfort was found to

be significantly related to a change in agitation. Since one treatment does

not benefit all persons, patients with dementia need individualized pain

assessment and treatment. Better quality of life for long-term care

residents may result from regularly scheduled pain management. 

This is particularly relevant to the VA health care system due to the

increasing number of aging veterans. 

Buffum MD, Miakowski C, Sand L, Brod M. A pilot study of the

relationship between discomfort and agitation in patients with dementia.

Geriatric Nursing 2001; 22:80-85.

NRI 95-192
3

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Aging & Age Related Changes

Determining the impact of dementia on veterans’ families

Within VA, the number of veterans with severe dementia has greatly

increased over the last few decades and is now approximately 600,000.

Equal or higher numbers of veterans are estimated to have mild to

moderate dementia. The goal of this HSR&D research is to determine

the impact of dementia on veterans’ families in terms of informal

caregiving, costs, and quality of life. Further, the direct non-medical

costs (ie, caregiving), indirect morbidity costs (ie, lost productivity), 

and quality of life related to caregiving were examined on a national 

level in relation to the amount and types of services that are being

utilized, including institutionalization. Results of the study show that

the largest units of caregiving cost come from the amount of time

allocated to caregiving and the caregiver’s lost earnings. Moreover, all

aspects of costs increase with disease severity and problem behavior.

Most of this cost increase derives from the increased caregiving time

required for the provision of physical care. An estimated $4 billion per

year could be saved in the US if institutionalization from dementing

illnesses, such as Alzheimer’s disease, is delayed by one month.

Therefore, VA would benefit greatly from an increase in the precision by

which community care is monitored and supported. More importantly,

veterans with dementia who receive appropriately targeted interventions

may be able to remain at home longer in environments that promote

maximum independence for both caregivers and patients.

Moore MJ, Zhu CW, Clipp EC. Informal costs of dementia care: Estimates

from the National Longitudinal Caregiver Study. Journal of 

Gerontology 2001; 56B:S219-S228.

Zhu C, Clipp EC, Moore MJ. Informal Costs of Dementia. In Research

and Practice in Alzheimer’s Disease and Other Dementias (special issue

on caregiving). B. Vellas, Editor-in-Chief. European Alzheimer’s Disease

Consortium (EADC). In Press.

NRI 95-218
4

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Aging & Age Related Changes

Measuring the quality of dying

Improving care for the dying has become a national priority in a 

medical culture that often defines death not as a natural part of life, but

as a negative medical outcome. Despite efforts to improve the experience

for dying patients, no well-established standardized outcome measures

exist to assess the quality of care at the end of life, especially those that

take into consideration patient and family perspectives. Toward this 

goal, this study examined patients’, families’, and health care providers’

preferences regarding preparation for the end of life. Study findings

show that all of these groups agree on several priorities: naming 

someone to make decisions, knowing what to expect regarding the 

dying person’s physical condition, having financial affairs in order, 

having treatment preferences in writing, and knowing that the physician

is comfortable talking about death and dying. Patients were more likely

than physicians to want to plan funerals and know the timing of death,

and were less likely than all other groups to want to discuss personal

fears. Although participants in this study agreed with the importance 

of preparation, previous studies show that actual discussions about

preparing for the end of life are less frequent. Further research and

training may ensure that the desire for greater preparation is translated

into improved action in medical practice.

Stenhauser KE, Christakis NA, Clipp EC, McNeilly M, Grambow S, Parker

J, Tulsky JA. Preparing for the end of life: Preferences of patients,

families, physicians, and other care providers. Journal of Pain and

Symptom Management 2001; 22(3):727-737.

IIR 98-162
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Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Aging & Age Related Changes

Specialized primary care services for at-risk elders

Currently, three of every five American men age 65 or older are 

veterans, accounting for more than half of VA’s patient population. 

While many innovative programs for geriatric care exist within VHA,

there is the need for a systematic process to identify at-risk elderly

veterans within the larger VA population who would benefit from these

specialized services. An HSR&D study seeks to improve care for at-risk

older veterans through a comprehensive system of casefinding,

assessment, referral, and follow-up case management within the primary

care setting. Community-living veterans, aged 65 years and older who

were not already using geriatric services, were mailed a survey to identify

those with risk factors for functional decline, hospitalization, or nursing

home placement. Subjects in the intervention group who were identified

as at-risk then received a structured telephone assessment to further

identify specific geriatric conditions. If indicated, intervention subjects

received referrals to appropriate VA services and follow-up telephone 

case management for three years. Subjects in the control group 

received usual care. During the first year of follow-up, documentation

in the medical record of screening or questioning for the target

conditions was found much more often for intervention subjects than 

for control subjects. Overall, 67 percent of intervention subjects received

a referral for specialized geriatric assessment and/or care. These results

are very significant to VA as plans are made for the care of the increasing

older population within the primary care setting.

Alessi CA, Josephson KR, Pietruszka FM, Harker JO, Rubenstein LZ.

Recognition of geriatric conditions in an outpatient geriatric assessment

trial. Gerontologist 2000; 40(SI):77.

IIR 95-050
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Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Aging & Age Related Changes

Increasing daytime activity improves nighttime 

sleep in the elderly

Sleep disturbance is a highly prevalent, disabling symptom in 

elderly persons who are cognitively-impaired. Their nighttime sleep 

is light and inefficient with frequent arousals and awakenings, and 

short daytime naps interfere with daytime activity and functioning.

In addition, daytime disruptive behaviors are related significantly to 

sleep disturbance. Medical treatment for behavior and sleep 

disturbances with benzodiazepines or antipsychotic medications is 

only minimally effective and can present serious side effects, such as

impaired memory, coordination, and balance, or severe rebound

insomnia. This HSR&D study sought to determine whether or not

increased daytime activity would be an effective nonpharmacological

intervention, especially for elders living in institutions where they may 

be physically, cognitively, and emotionally understimulated. This pilot

study showed that activities timed to occur during usual naptime, while

tailored to their interests and abilities, improved nighttime sleep.

Thus, residents who received the Individualized Activity Intervention

were awake less at night and fell asleep faster. Investigators are now 

evaluating this intervention in terms of cost and its effect on the

residents’ psychological well-being and disruptive behavior.

Richards KC, Sullivan SC, Phillips RL, Beck CK, Overton-McCoy AL. The

effect of individualized activities on the sleep of nursing home residents

who are cognitively impaired: A pilot study. Journal of Geronotological

Nursing 2001; 27(9):30-37.

NRM 95-184
7

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Chronic Diseases

Telecommunications system for patients with COPD

Current advances in technology provide an opportunity for innovative

approaches to the management of some medical conditions. As health

care costs increase, computerized, telephone-linked communication

systems offer a less costly, widely available alternative for maintaining

contact between patients and providers. This may be particularly

appropriate for patients with debilitating and/or serious illness, such 

as chronic obstructive pulmonary disease (COPD) – one of the most

common chronic illnesses among veterans. HSR&D researchers have

designed a telephone-linked care (TLC) system for patients with COPD.

The TLC-COPD system will monitor, educate, and counsel patients

through regular automated conversations in the patients’ homes. 

A routine call would include: a verification of the patient’s identity 

using a password; an assessment of the patient’s clinical status, focusing

on symptoms; questions regarding their medication regimen; and a

counseling component that would include reminders about physician

appointments, encouragement to exercise, and recommendations

regarding influenza and pneumococcal vaccinations. It is expected that

this ongoing telemedicine project will improve functional status and

quality of life, as well as decrease health care utilization and costs. The

TLC-COPD system will also increase access to health care for the many

veterans with this condition who live in rural areas.

Young M, Sparrow D, Gottlieb D, Selim A, Friedman R. A telephonelinked computer system for COPD care. Chest 2001; 119(5):1565-1575.

IIR 97-022
8

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Chronic Diseases

Study shows that combination HIV treatments lower cost 

Investigators from HSR&D’s HIV Quality Enhancement Research

Initiative (QUERI) group conducted a study which indicates that the 

total cost of care for adults with HIV infection has declined since the

introduction of highly active antiretroviral therapy. The study, which

followed 2864 patients receiving care for HIV infection for 36 months,

found that the use of highly active antiretroviral therapy was

independently associated with a reduction in health care expenditures.

This is important because the introduction of highly active combination

antiretroviral therapy for HIV infection has caused concern about

increased costs of care. Findings from this study also showed that

pharmaceutical costs were lowest and hospital costs highest among

blacks, women, and patients without private insurance. This study

suggests that even though HIV drugs are costly, they represent a good

value in that they save more than they cost, especially in quality of life 

for veterans afflicted with this disease.

Bozzette SA, Joyce G, McCaffrey DF, Leibowitz AA, Morton SC, Berry SH,

Rastegar A, Timberlake D, Shapiro MF, Goldman DP. Expenditures for the

care of HIV-infected patients in the era of highly active antiretroviral

therapy. New England Journal of Medicine 2001; 344(11): 817-823.

RCD 94-312
9

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Chronic Diseases

Off-pump coronary artery bypass improves 

surgical outcomes

Heart disease is the leading cause of death in the United States and

results in an ever-increasing number of cardiac surgeries each year. 

To help the decision-making process regarding these costly surgical

procedures, HSR&D investigators compared the risks and benefits to 

VA patients who received a coronary artery bypass grafting (CABG-only)

procedure using cardiopulmonary bypass (called "on-pump" surgery)

compared to the relatively recent technique of operating on a beating

heart (referred to as "off-pump"). Data were examined from VAMCs that

reflect a higher volume of off-pump procedures and were then compared

with other VA cardiac surgery programs to evaluate the impact upon riskadjusted 30-day mortality and morbidity, based upon nine different

perioperative complications. Findings from the study show that patients

treated off-pump versus on-pump had lower complication rates and lower

mortality rates. Thus an off-pump approach to coronary artery bypass

grafting procedures appears to be associated with lower risk-adjusted

morbidity and mortality in VA. This research has led investigators to

work on a new VA study to determine the efficacy of the off-pump

procedure on a broader range of patient outcomes.

Plomondon ME, Cleveland JC, Ludwig ST, Grunwald GK, Kiefe CI, Grover

FL, Shroyer AL. Off-pump coronary artery bypass is associated with

improved risk-adjusted outcomes. Annals of Thoracic Surgery 2001;

72(1):114-119.

IHY 99-214
10

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Chronic Diseases

Telemedicine and improving diabetes care

This ongoing study uses an automated telephone disease management

(ATDM) system to administer patient assessments and provide self-care

education, in between their clinic visits, for veterans with diabetes. 

The study is a follow-up to the researchers’ prior work, in which they

evaluated an ATDM system that included automated health assessment

and self-care education calls that were followed up by a nurse educator 

on an as needed basis. After a 12-month intervention, patients reported

more frequent glucose self-monitoring and foot inspections, and were

more likely to be seen in podiatry and diabetes specialty clinics than

patients without the ATDM intervention. The model of automated

telephone assessments developed and evaluated in this study could be 

a cost-effective means for improving clinical decision-making and

diabetes treatment outcomes. 

Piette JD, Weinberger M, Kraemer FB, McPhee SJ. Impact of automated

calls with nurse follow-up on diabetes treatment outcomes in a

Department of Veterans Affairs health care system. Diabetes Care 

2001; 24(2):202-208.

Piette J. Interactive resources for patient education and support. Diabetes

Spectrum 2000; 13: 110-112.

DII 99-187
11

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Chronic Diseases

Exercise training improves ability to function in patients

with heart failure

Heart failure is a major public health burden in the United States, 

and despite advances in diagnosis and treatment it remains one of the

leading causes of illness and death. Currently, much of the therapy for

heart failure is aimed at prolonging life; this nursing research study

focuses on improving the quality of that life. Nurse investigators

designed a home walking exercise (HWE) program and then compared

those who participated in HWE to those who did not. Findings showed 

a significant difference in the two groups. Those patients who exercised

were able to increase the amount of time they could exercise and were

better able to perform activities associated with daily living, with less or

no symptoms of fatigue and shortness of breath. 

Corvera-Tindel TE. A home exercise program increases walking duration

and decreases symptoms in heart failure patients. Poster presentation at

the VA Rehabilitation Research and Development Conference. Arlington,

February, 2002.

Corvera-Tindel TE. Nurse-managed home walking program improves

exercise duration and reduces symptoms in heart failure. Poster

presentation at the Health Services Research & Development 20th Annual

Meeting. Washington, DC, February, 2002.

Corvera-Tindel TE. A home exercise program increases walking duration

and decreases symptoms in heart failure patients. Oral Presentation at

the American Heart Association 2001 Scientific Sessions. Anaheim,

November, 2001.

NRI 96-031
12

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Health Services & Systems

The reliability of rating medical errors

Previously reported statistics have suggested that as many as 98,000

people die each year in US hospitals due to medical errors. This study

was designed to determine whether the methods used to arrive at these

statistics are reliable by examining how deaths are determined to be

“preventable by better care,” and by looking at the reliability of rating

medical errors. Investigators also estimated the probability of patients

living if care had been optimal. Results of the study showed that 22.7

percent of patient deaths were rated as possibly preventable by optimal

care, with 6 percent being rated as probably or definitely preventable.

However, after considering patients’ 3 month prognoses and adjusting 

for the variability of reviewers’ ratings, clinicians estimated that roughly

1 additional patient per 10,000 admissions would have lived three 

months or more in good health if care had been optimal. Thus, while

medical errors are a major concern regardless of a patient’s life

expectancy, this study suggests that previous interpretations of medical

error statistics are probably misleading. This study also points out the

limitations in identifying medical errors and assessing their impact on

patient outcomes.

Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors:

Preventability is in the eye of the reviewer. Journal of the American

Medical Association 2001; 286:415-420. 

Dr. Timothy Hofer (Co-PI with Dr. Rodney Hayward) is supported by a

Career Development Award from HSR&D.

IIR 94-131
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Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Health Services & Systems

Study shows ICU mortality similar in VA and 

private sector

Nationally, ICUs comprise nearly 10 percent of all inpatient beds and

account for more than 20 percent of all inpatient hospital costs.

An HSR&D study was the first to directly compare intensive care unit

(ICU) mortality and patients’ length of stay in a VA medical center with

private sector hospitals. It also examined the impact of hospital length 

of stay on mortality comparisons. Data collected on ICU admissions

covering a two-year period show that after adjusting for the patients’

severity of illness, ICU mortality was lower in VA compared to private

sector patients. ICU length of stay was similar, however, hospital length

of stay was significantly longer in VA patients.

Kaboli PJ, Barnett MJ, Fuehrer SM, Rosenthal GE. Length of stay as a

source of bias in comparing performance in VA and private sector

facilities: Lessons learned from a regional evaluation of intensive care

outcomes. Medical Care 2001; 39(9):1014-1024.

IIR 94-093
14

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Health Services & Systems

Understanding differences in patient characteristics

VHA is committed to administering the SF-36V, a patient assessment 

tool, on an annual basis to more than 40,000 veteran patients. The SF36V data are evaluated to provide a summary score of patients’ physical

and mental health status. Changes in these functional status scores are

viewed as changes in patient outcomes that may reflect quality of care.

However, differences in patient characteristics among veteran health 

care facilities need to be considered before VA managers can draw

meaningful inferences about facility performance based on these 

changes. Using three diagnosis-based measures of patient status,

investigators in this study compared the measures to determine which

one has the greatest predictive power. After making that determination,

investigators built a risk-adjustment model that included additional

sociodemographic and baseline functional status information. This

model allowed comparisons at the network level between observed and

adjusted functional status changes. The vast majority (96%) of veteran

patients had at least one of the common chronic conditions, and of those,

85% had two or more (comorbidity). This study advances our

understanding of the predictors of decline or improvement in patients’

functional status.

Jones D, Kazis L, Lee A, Rogers W, Skinner K, Cassar L, Wilson N,

Hendricks A. Health status assessments using the Veterans SF-12 

and SF-36: Methods for evaluating outcomes in the Veterans Health

Administration. Journal of Ambulatory Care Management 2001; 

24(3):68-86.

Ren XS, Kazis L, Lee A, Rogers W, Pendergrass S. Health status and

satisfaction with health care: A longitudinal study among patients served

by the Veterans Health Administration. American Journal of Medical

Quality 2001; 16(5):166-173.

IIR 95-019
15

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Health Services & Systems

Assessing the effect of managed care on hospitals

Some structural and functional changes within VHA parallel the

widespread movement toward managed care that occurred throughout

the US health care system. The future of VHA as a viable alternative

within this competitive environment requires knowledge concerning 

the relationship between care management and cost within the new

organizational structure. Goals of this study include determining how

much cost reduction is actually being achieved through the aggressive

practice of reducing the length of hospitalizations, as well as evaluating

the cost consequences of changes in treatment settings. Thus far,

findings from this study show that facilities more heavily penetrated 

by the primary care model are slightly more effective at controlling the

costs of their sicker patients. This kind of information will aid decision

makers in anticipating changes in inpatient and outpatient workload so

that they can more effectively manage their budget.

Burgess JF, Christiansen CL, Michalak SE, Morris CN. Medical profiling:

Improving standards and risk adjustments using hierarchical models.

Journal of Health Economics 2001; 19:291-309.

Carey K. A multilevel modelling approach to analysis of patient costs

under managed care. Health Economics 2001; 9:435-446.

MPC 97-008
16

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Health Services & Systems

Teledermatology produces faster results

Previous studies have shown that teledermatology can result in 

reliable and accurate diagnostic outcomes when compared to

dermatology consultations that occur in clinics. This ongoing study

focuses on the health services research implications of a teledermatology

consult system, such as the time it takes to diagnose and initiate

treatment, the proportion of patients that may avoid the need to go to

a clinic, as well as the economic implications. Patients in this study

receive either usual care or a teledermatology consultation. Patients

receiving usual care were scheduled for a clinic visit after their

dermatologist reviewed a text-based electronic consult. Patients in

the teledermatology arm were either scheduled for a clinic visit, or the

consulting dermatologist provided information and recommendations 

for the referring clinician to implement, thus avoiding the need for a

clinic visit. Findings thus far show that the median time to diagnosis 

and treatment initiation for those patients who received usual care was

127 days compared to 41 days for those participating in teledermatology.

The finding that patients are diagnosed and treated sooner via

teledermatology may have important implications for quality of care 

and resource utilization. In health care settings with limited resources,

including specialty care, teledermatology may be a way to provide

dermatology services, while improving the health care delivery process

and patient outcomes. 

Whited JD. Teledermatology: Current status and future directions.

American Journal of Clinical Dermatology 2001; 2:59-64. 

IIR 98-159
17

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Mental Illness

Study examines antipsychotic prescribing practices

Schizophrenia is the second most frequent VA discharge diagnosis. 

There are effective pharmacologic therapies for schizophrenia. However,

while novel (or newer) agents (i.e., risperidone, olanzapine, quetiapine)

are more efficacious and have a more favorable side effect profile than

conventional antipsychotics, VA facilities have significant variation in

prescribing rates for novel antipsychotics. A study conducted through 

the Mental Health Quality Enhancement Research Initiative (QUERI)

Coordinating Center examined prescribing practices in VA medical

centers to determine whether patient sociodemographic factors were

associated with receiving novel antipsychotic medications compared to

those receiving conventional antipsychotics. Investigators found that

Caucasians were more likely than non-Caucasians to receive novel

antipsychotics (54% vs. 40%). This study also found a higher rate of

novel antipsychotic prescribing than reported in other recent studies 

of patients hospitalized for schizophrenia, but novel antipsychotic use

still varied significantly among facilities. Local organizational climates

may have a profound effect on prescribing practices. Thus, medication

management practices for schizophrenia often are not guidelineconcordant and may place patients at risk for adverse outcomes. 

Owen RR, Feng W, Thrush CR, Hudson TJ, Austen MA. Variations in

prescribing practices for novel antipsychotic medications among Veterans

Affairs hospitals. Psychiatric Services 2001; 52(11):1523-1525.

IIR 98-108
18

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Mental Illness

Treating depression in patients with PTSD

Post-traumatic stress disorder (PTSD) is a serious mental health 

problem within VA for both male and female veterans. The 40 percent 

of veterans with PTSD and concurrent clinically significant depression

are particularly difficult to treat. Well-validated treatments of PTSD 

and its complications are rare. Male veterans suffering from both

depression and combat-related PTSD, and female veterans with

depression and trauma related to sexual assault are participating in 

this ongoing HSR&D study – the first to evaluate the impact of two

psychosocial interventions on clinical outcomes and the use of hospital

resources by veterans with these co-existing disorders. Veterans in the

study were randomly assigned to one of two therapy programs – both

involving short-term group therapy designed to teach them about their

disorders and to provide new strategies and skills for overcoming the

disorders. Preliminary findings show that nearly 80 percent of the male

veterans in the study completed the therapy regimen, and that they felt

the course of therapy was beneficial and clear. Female veterans recently

completed therapy and their assessments will be available soon.

It is anticipated that effective treatment of depression and PTSD will

improve veterans’ psychiatric symptoms, as well as other aspects of 

their lives, thus requiring fewer psychiatric and medical services after

treatment. If the program proves to be effective, it may become a 

model for such programs within VA nationally. 

Dunn NJ, Yanasak E, Schillaci J, Simotas S, Rehm LP, Souchek J, Menke

T, Ashton C, Hamilton JD. Personality disorders in veterans with PTSD

and depression. Poster presented at the International Society for

Traumatic Stress Studies. New Orleans, December, 2001. 

IIR 95-074
19

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Sensory Disorders

Adherence to guidelines improves recovery from stroke

Stroke is the leading cause of disability in the United States. In the 

VA health care system, approximately 10,000 to 13,000 veterans receive

inpatient care for stroke annually, and about 70 percent of all stroke

survivors receive some type of rehabilitation care. This HSR&D study

sought to determine if compliance with post-stroke rehabilitation

guidelines is associated with better functional outcomes. Study 

findings show that those patients who were given post-acute

rehabilitation according to guidelines had improved FIM motor, IADL

(IADL = Instrumental Activities of Daily Living Scale that includes

shopping, food preparation, transportation, etc.), and SIS physical

domain scores. Thus, greater levels of adherence to post-acute stroke

rehabilitation guidelines are associated with improved patient outcomes.

This study also showed differences in the level of guideline compliance

based on the rehabilitation setting. For example, compliance within 

the nursing home setting was substantially worse than for inpatient

rehabilitation settings.

Duncan PW, Horner RD, Reker DM, Samsa GP, Hoenig H, 

Hamilton B, LaClair BJ, Dudley TK. Adherence to post-acute

rehabilitation guidelines is associated with functional recovery 

in stroke. Stroke 2002; 33:167-78.

ACC 97-114
20

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Special Populations

Study shows black patients admitted to VA hospitals have

lower mortality rates

This study indicates that black patients admitted to VA hospitals with

common medical diagnoses have lower mortality rates than white

patients. Investigators examined racial differences in mortality among

more than 35,000 patients admitted to 147 VA hospitals. Thirty-day

mortality rates for patients admitted with 1 of 6 common medical

diagnoses (angina, chronic obstructive pulmonary disease, congestive

heart failure, chronic renal failure, diabetes, and pneumonia) were

compared. Study findings show that 30-day mortality was lower 

among blacks than whites for each of the six medical diagnoses, and 

that black patients also had lower in-hospital and 6-month mortality

rates. This survival advantage is not readily explained, however, it 

may reflect the benefits of equal access to health care and the quality 

of inpatient treatment at VA medical centers.

Jha AK, Shlipak MG, Hosmer W, Frances CD, Browner WS. Racial

differences in mortality among men hospitalized in the Veterans Affairs

Health Care System. Journal of the American Medical Association 

2001; 285:297-303.

(Dr. Shlipak is an HSR&D Career Development Awardee. Researchers

credit Carol Ashton, MD, MPH and staff at the HSR&D Center for 

Quality of Care and Utilization Studies for their aid in providing data 

for the study.)
21

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Special Populations

Is patient ethnicity related to ambulatory care use?

In the mid-90s, the VA health care system shifted many of its resources

toward ambulatory care. This is the first study to address ambulatory

care access and use for minority veterans. The primary goal of this 

study was to understand racial/ethnic differences in utilization of VA

ambulatory care, and the reasons why these variations exist. Findings

from this study reveal that there are significant associations between race

and the type of outpatient care used (eg., VA only, non-VA only, or both).

For example, black and Hispanic veterans are more likely to use VA only

ambulatory care as compared with non-Hispanic white veterans and

Asian/Pacific Islander veterans. Black and Hispanic veterans are also

more likely to be dual VA/non-VA users, and are least likely to use nonVA ambulatory care only. Preferences for, use of, and satisfaction with 

VA ambulatory care are significantly influenced by race/ethnicity and

veteran identity factors, including membership in veterans’ organizations

and veteran influence on daily life. Black veterans reported worse health

status as compared to non-Hispanic white veterans, regardless of

socioeconomic status, disease, mental health, or war period served.

These findings will be used to develop specific strategies and

interventions to improve access and utilization of ambulatory care

services for minority veterans.

Harada ND, Damron-Rodriguez J, Villa VM, Washington DL, Dhanani S,

Shon H, Chattopadhyay M, Fishbein H, Lee M, Makinodan T, Andersen R.

Veteran identity and race/ethnicity: Influences on VA outpatient care

utilization. Medical Care 2002; 40 (Supplement 1): I-117-I-128.

Harada ND, Villa VM, Damron-Rodriguez J, Washington DL, Makinodan

T, Dhanani S, Shon H, Liu H, Andersen R. The influence of military

service on outpatient care use among racial/ethnic groups in Department

of Veterans Affairs Medical Centers. Military Medicine; In Press.

Dhanani S, Damron-Rodriguez J, Leung M, Villa V, Washington DL,

Makinodan T, Harada ND. Community-based strategies for focus group

recruitment of minority veterans. Military Medicine; In Press.

Washington DL, Harada ND, Villa VM, Damron-Rodriguez J, Shon H,

Dhanani S, Makinodan T. Racial variations in VA ambulatory care use

and unmet health care needs. Military Medicine; In Press. 

Harada ND, Villa VM, Andersen R. Satisfaction with VA and non-VA

outpatient care among veterans. American Journal of Medical Quality

2002; 17(4); In Press.

ECV 97-028
22

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Special Populations

How ethnicity may affect patient choices in the 

care of osteoarthritis

Previous studies report that African-American patients are much less

likely than white patients to receive total joint replacement for

osteoarthritis of the hip or knee – the leading cause of disability among

veterans. This HSR&D study assessed ethnic variation in regard to

surgical choices and found that African-American veterans with chronic

knee/hip pain were less likely than white veterans to consider joint

replacement as a treatment option. African-Americans were more likely

to expect worse outcomes following joint replacement, such as pain and

functional disability following surgery and a longer hospital stay. 

African-Americans were also more likely to consider alternative therapies,

such as prayer, as effective treatments for arthritis. Patients that viewed

prayer as helpful to their condition were less likely to consider joint

replacement. This study has provided important insight into the cultural

factors that may account for variations in patient decision-making

regarding joint replacement for veterans with osteoarthritis. 

Ibrahim SA, Burant CJ, Siminoff LS, Kwoh CK. Understanding ethnic

differences in the utilization of joint replacement for osteoarthritis: The

role of patient-level factors. Medical Care 2002; 40 (1 suppl):I44-I51.

Ibrahim SA, Burant CJ, Siminoff LA, Kwoh CK. Variation in perceptions

of treatment and self-care practices in the elderly with osteoarthritis: A

comparison between African-Americans and white patients. Arthritis

Care & Research 2001; 45(4):398-403.

Ibrahim SA, Burant CJ, Siminoff LS, Kwoh CK. Ethnic differences in

patients’ perceptions on quality of life: A study of elderly patients with

osteoarthritis. Journal of Clinical Epidemiology 2002; In Press.

Ibrahim SA, Burant CJ, Siminoff LS, Kwoh CK. Differences in

expectations on outcomes mediate African American/white differences in

‘willingness’ to consider joint replacement. Arthritis and Rheumatism

2002; In Press.

ECV 97-014
23

Health Services Research & Development Service: Working to Improve Health Care for Veterans

IMPACTS 2002 Substance Abuse, Addictive Disorders

Working to improve the quality of substance abuse care

The economic cost of drug and alcohol abuse in the US is estimated to be

more than $150 billion per year, with an additional $50 billion stemming

from tobacco use. Substance use disorders are also prevalent and

extremely costly among the veteran population. In FY 2000, 21 percent

of all VA inpatients and 32 percent of all VA extended care patients had

substance abuse or dependence diagnoses. That same year, almost

324,000 VA outpatients had substance abuse diagnoses. Because of the

high prevalence and cost of substance abuse among veteran patients,

HSR&D’s Quality Enhancement Research Initiative (QUERI) Substance

Abuse group is focusing on these disorders. The QUERI Substance Abuse

group has produced recent findings that include: the cost effectiveness of

methadone and buprenorphine for the treatment of opioid dependence;

the effectiveness of continuing outpatient care and self-help group

involvement; and factors related to deterioration among patients in

treatment for substance abuse. 

Barnett PG, Zaric GS, Brandeau ML. The cost-effectiveness of

buprenorphine maintenance therapy for opiate addiction in the United

States. Addiction 2001; 96:1267-1278.

Willenbring ML. New guideline for the management of substance-abuse

disorders nearing completion. Psychiatric Times 2001;18:16-17.

Fiellin DA, Rosenheck RA, Kosten TR. Office-based treatment for opioid

dependence: reaching new patient populations. American Journal of

Psychiatry 2001; 158:1200-1204.

Moos RH, Moos BS, Finney JW. Predictors of deterioration among

patients with substance use disorders. Journal of Clinical Psychology

2001; 57:1403-1419.

Finney JW, Willenbring ML, Moos RH. Improving the quality of VA care

for patients with substance use disorders: The Quality Enhancement

Research Initiative (QUERI) Substance Abuse Module. Medical Care 2000;

38:105-113.

Moos RH, Finney JW, Federman EB, Suchinsky R. Specialty mental

health care improves patients’ outcomes: Findings from a nationwide

program to monitor the quality of care for patients with substance use

disorders. Journal of Studies on Alcohol 2000; 61:704-713.

SDR 98-000 
25

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

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410-642-1092.
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