What Should Health Care Systems Consider When Implementing Complementary and Integrative Health: Lessons from Veterans Health Administration

Background: Direct oral anticoagulants (DOACs) have strict dosing guidelines, but recent studies indicate that inappropriate dosing is common, particularly in chronic kidney disease (CKD), for which it has been reported to be as high as 43%. Since 2011, the Veterans Health Administration (VA) has implemented anticoagulation management programs for DOACs, generally led by pharmacists, which has previously been shown to improve medication adherence. Objective: We investigated the prevalence of overdosing and underdosing of DOACs in the VA. Methods: Using data from the TREAT-AF cohort study (The Retrospective Evaluation and Assessment of Therapies in AF), we identified VA patients with newly diagnosed atrial fibrillation (AF) and receipt of a DOAC between 2003 and 2015. We classified dosing as correct, overdosed, or underdosed based on the Food and Drug Administration–approved dosing criteria. Results: Of 230 762 patients, 5060 received dabigatran (77.3%) or rivaroxaban (22.7%) within 90 days of AF diagnosis (age 69 [10[ years; CHA2DS2-VASc 1.6 [1.4]), of which 1312 (25.9%) had CKD based on estimated glomerular filtration rate <60. Overall, 93.6% of patients, 83.2% with CKD, received appropriate DOAC dosing. Incorrect dosing increased with worsening renal function. Conclusion: Compared to recent studies of commercial payers and health-care systems, incorrect dosing of DOACs is less common across the VA. Pharmacist-led DOAC management or similar anticoagulation management interventions may reduce the risk of incorrect dosing across health-care systems.

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Assessing the Relative Effectiveness of Combining Self-Care with Practitioner-Delivered Complementary and Integrative Health Therapies to Improve Pain in a Pragmatic Trial

Pain Medicine ◽

10.1093/pm/pnaa349 ◽

2020 ◽

Vol 21 (Supplement_2) ◽

pp. S100-S109

Author(s):

Steven B Zeliadt ◽

Scott Coggeshall ◽

Hannah Gelman ◽

Marlena H Shin ◽

A Rani Elwy ◽

...

Keyword(s):

Health Care ◽

Health Care Systems ◽

Pragmatic Trial ◽

Self Care ◽

Pain Patient ◽

Business Practices ◽

Health Administration ◽

Integrative Health ◽

Patient Reported ◽

Care Systems

Abstract Background Many health care systems are beginning to encourage patients to use complementary and integrative health (CIH) therapies for pain management. Many clinicians have anecdotally reported that patients combining self-care CIH therapies with practitioner-delivered therapies report larger health improvements than do patients using practitioner-delivered or self-care CIH therapies alone. However, we are unaware of any trials in this area. Design The APPROACH Study (Assessing Pain, Patient-Reported Outcomes and Complementary and Integrative Health) assesses the value of veterans participating in practitioner-delivered CIH therapies alone or self-care CIH therapies alone compared with the combination of self-care and practitioner-delivered care. The study is being conducted in 18 Veterans Health Administration sites that received funding as part of the Comprehensive Addiction and Recovery Act to expand availability of CIH therapies. Practitioner-delivered therapies under study include chiropractic care, acupuncture, and therapeutic massage, and self-care therapies include tai chi/qi gong, yoga, and meditation. The primary outcome will be improvement on the Brief Pain Inventory 6 months after initiation of CIH as compared with baseline scores. Patients will enter treatment groups on the basis of the care they receive because randomizing patients to specific CIH therapies would require withholding therapies routinely offered at VA. We will address selection bias and confounding by using sites’ variations in business practices and other encouragements to receive different types of CIH therapies as a surrogate for direct randomization by using instrumental variable econometrics methods. Summary Real-world evidence about the value of combining self-care and practitioner-delivered CIH therapies from this pragmatic trial will help guide the VA and other health care systems in offering specific nonpharmacological approaches to manage patients’ chronic pain.

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Development of Predictive Informatics Tool Using Electronic Health Records to Inform Personalized Evidence-Based Pressure Injury Management for Veterans with Spinal Cord Injury

Military Medicine ◽

10.1093/milmed/usaa469 ◽

2021 ◽

Vol 186 (Supplement_1) ◽

pp. 651-658

Author(s):

Kath M Bogie ◽

Steven K Roggenkamp ◽

Ningzhou Zeng ◽

Jacinta M Seton ◽

Katelyn R Schwartz ◽

...

Keyword(s):

Risk Factors ◽

Health Care ◽

Spinal Cord ◽

Spinal Cord Injury ◽

User Interface ◽

Veterans Health Administration ◽

Study Cohort ◽

Veterans Health ◽

Health Administration ◽

Cord Injury

ABSTRACT Background Pressure injuries (PrI) are serious complications for many with spinal cord injury (SCI), significantly burdening health care systems, in particular the Veterans Health Administration. Clinical practice guidelines (CPG) provide recommendations. However, many risk factors span multiple domains. Effective prioritization of CPG recommendations has been identified as a need. Bioinformatics facilitates clinical decision support for complex challenges. The Veteran’s Administration Informatics and Computing Infrastructure provides access to electronic health record (EHR) data for all Veterans Health Administration health care encounters. The overall study objective was to expand our prototype structural model of environmental, social, and clinical factors and develop the foundation for resource which will provide weighted systemic insight into PrI risk in veterans with SCI. Methods The SCI PrI Resource (SCI-PIR) includes three integrated modules: (1) the SCIPUDSphere multidomain database of veterans’ EHR data extracted from October 2010 to September 2015 for ICD-9-CM coding consistency together with tissue health profiles, (2) the Spinal Cord Injury Pressure Ulcer and Deep Tissue Injury Ontology (SCIPUDO) developed from the cohort’s free text clinical note (Text Integration Utility) notes, and (3) the clinical user interface for direct SCI-PIR query. Results The SCI-PIR contains relevant EHR data for a study cohort of 36,626 veterans with SCI, representing 10% to 14% of the U.S. population with SCI. Extracted datasets include SCI diagnostics, demographics, comorbidities, rurality, medications, and laboratory tests. Many terminology variations for non-coded input data were found. SCIPUDO facilitates robust information extraction from over six million Text Integration Utility notes annually for the study cohort. Visual widgets in the clinical user interface can be directly populated with SCIPUDO terms, allowing patient-specific query construction. Conclusion The SCI-PIR contains valuable clinical data based on CPG-identified risk factors, providing a basis for personalized PrI risk management following SCI. Understanding the relative impact of risk factors supports PrI management for veterans with SCI. Personalized interactive programs can enhance best practices by decreasing both initial PrI formation and readmission rates due to PrI recurrence for veterans with SCI.

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Predictors of Veterans Health Administration utilization and pain persistence among soldiers treated for postdeployment chronic pain in the Military Health System

BMC Health Services Research ◽

10.1186/s12913-021-06536-8 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Rachel Sayko Adams ◽

Esther L. Meerwijk ◽

Mary Jo Larson ◽

Alex H. S. Harris

Keyword(s):

Mental Health ◽

Health Care ◽

Chronic Pain ◽

Veterans Health Administration ◽

First Year ◽

Veterans Health ◽

Health Administration ◽

Military Health System ◽

Military Health ◽

The Military

Abstract Background Chronic pain presents a significant burden for both federal health care systems designed to serve combat Veterans in the United States (i.e., the Military Health System [MHS] and Veterans Health Administration [VHA]), yet there have been few studies of Veterans with chronic pain that have integrated data from both systems of care. This study examined 1) health care utilization in VHA as an enrollee (i.e., linkage to VHA) after military separation among soldiers with postdeployment chronic pain identified in the MHS, and predictors of linkage, and 2) persistence of chronic pain among those utilizing the VHA. Methods Observational, longitudinal study of soldiers returning from a deployment in support of the Afghanistan/Iraq conflicts in fiscal years 2008–2014. The analytic sample included 138,206 active duty soldiers for whom linkage to VHA was determined through FY2019. A Cox proportional hazards model was estimated to examine the effects of demographic characteristics, military history, and MHS clinical characteristics on time to linkage to VHA after separation from the military. Among the subpopulation of soldiers who linked to VHA, we described whether they met criteria for chronic pain in the VHA and pain management treatments received during the first year in VHA. Results The majority (79%) of soldiers within the chronic pain cohort linked to VHA after military separation. Significant predictors of VHA linkage included: VHA utilization as a non-enrollee prior to military separation, separating for disability, mental health comorbidities, and being non-Hispanic Black or Hispanic. Soldiers that separated because of misconduct were less likely to link than other soldiers. Soldiers who received nonpharmacological treatments, opioids/tramadol, or mental health treatment in the MHS linked earlier to VHA than soldiers who did not receive these treatments. Among those who enrolled in VHA, during the first year after linking to the VHA, 49.7% of soldiers met criteria for persistent chronic pain in VHA. Conclusions The vast majority of soldiers identified with chronic pain in the MHS utilized care within VHA after military separation. Careful coordination of pain management approaches across the MHS and VHA is required to optimize care for soldiers with chronic pain.

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Transformation of the US Veterans Health Administration

Health Economics Policy and Law ◽

10.1017/s1744133105001222 ◽

2006 ◽

Vol 1 (2) ◽

pp. 99-105 ◽

Cited By ~ 12

Author(s):

Jonathan B. Perlin

Keyword(s):

United States ◽

Health Care ◽

Veterans Health Administration ◽

The United States ◽

Veterans Affairs ◽

United States Department ◽

Veterans Health ◽

Department Of Veterans Affairs ◽

Health Administration ◽

The Us

Ten years ago, it would have been hard to imagine the publication of an issue of a scholarly journal dedicated to applying lessons from the transformation of the United States Department of Veterans Affairs Health System to the renewal of other countries' national health systems. Yet, with the recent publication of a dedicated edition of the Canadian journal Healthcare Papers (2005), this actually happened. Veterans Affairs health care also has been similarly lauded this past year in the lay press, being described as ‘the best care anywhere’ in the Washington Monthly, and described as ‘top-notch healthcare’ in US News and World Report's annual health care issue enumerating the ‘Top 100 Hospitals’ in the United States (Longman, 2005; Gearon, 2005).

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