Trends and Regional Variation in Opioid Overdose Mortality Among Veterans Health Administration Patients, Fiscal Year 2001 to 2009

2013 ◽  
pp. 1 ◽  
Author(s):  
Amy S. B. Bohnert ◽  
Mark A. Ilgen ◽  
Jodie A. Trafton ◽  
Robert D. Kerns ◽  
Anna Eisenberg ◽  
...  
Keyword(s):  
Regional Variation ◽  
Veterans Health Administration ◽  
Fiscal Year ◽  
Opioid Overdose ◽  
Veterans Health ◽  
Health Administration ◽  
Overdose Mortality

scholarly journals Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation

BMJ ◽  
2020 ◽  
pp. m283 ◽  
Author(s):  
Elizabeth M Oliva ◽  
Thomas Bowe ◽  
Ajay Manhapra ◽  
Stefan Kertesz ◽  
Jennifer M Hah ◽  
...  
Keyword(s):  
Opioid Analgesic ◽  
Veterans Health Administration ◽  
Fiscal Year ◽  
Veterans Health ◽  
Health Administration ◽  
Opioid Treatment ◽  
Risk Of Death ◽  
Length Of Treatment ◽  
Increased Risk ◽  
Stopping Treatment

Abstract Objective To examine the associations between stopping treatment with opioids, length of treatment, and death from overdose or suicide in the Veterans Health Administration. Design Observational evaluation. Setting Veterans Health Administration. Participants 1 394 102 patients in the Veterans Health Administration with an outpatient prescription for an opioid analgesic from fiscal year 2013 to the end of fiscal year 2014 (1 October 2012 to 30 September 2014). Main outcome measures A multivariable Cox non-proportional hazards regression model examined death from overdose or suicide, with the interaction of time varying opioid cessation by length of treatment (≤30, 31-90, 91-400, and >400 days) as the main covariates. Stopping treatment with opioids was measured as the time when a patient was estimated to have no prescription for opioids, up to the end of the next fiscal year (2014) or the patient’s death. Results 2887 deaths from overdose or suicide were found. The incidence of stopping opioid treatment was 57.4% (n = 799 668) overall, and based on length of opioid treatment was 32.0% (≤30 days), 8.7% (31-90 days), 22.7% (91-400 days), and 36.6% (>400 days). The interaction between stopping treatment with opioids and length of treatment was significant (P<0.001); stopping treatment was associated with an increased risk of death from overdose or suicide regardless of the length of treatment, with the risk increasing the longer patients were treated. Hazard ratios for patients who stopped opioid treatment (with reference values for all other covariates) were 1.67 (≤30 days), 2.80 (31-90 days), 3.95 (91-400 days), and 6.77 (>400 days). Descriptive life table data suggested that death rates for overdose or suicide increased immediately after starting or stopping treatment with opioids, with the incidence decreasing over about three to 12 months. Conclusions Patients were at greater risk of death from overdose or suicide after stopping opioid treatment, with an increase in the risk the longer patients had been treated before stopping. Descriptive data suggested that starting treatment with opioids was also a risk period. Strategies to mitigate the risk in these periods are not currently a focus of guidelines for long term use of opioids. The associations observed cannot be assumed to be causal; the context in which opioid prescriptions were started and stopped might contribute to risk and was not investigated. Safer prescribing of opioids should take a broader view on patient safety and mitigate the risk from the patient’s perspective. Factors to address are those that place patients at risk for overdose or suicide after beginning and stopping opioid treatment, especially in the first three months.

Opioid use disorder and homelessness in the Veterans Health Administration: The challenge of multimorbidity

2018 ◽  
Vol 14 (3) ◽  
pp. 171-182 ◽  
Author(s):  
Theddeus Iheanacho, MD ◽  
Elina Stefanovics, PhD ◽  
Robert Rosenheck, MD
Keyword(s):  
Risk Factor ◽  
Service Use ◽  
Veterans Health Administration ◽  
Opioid Use Disorder ◽  
Fiscal Year ◽  
Veterans Health ◽  
Health Administration ◽  
Opioid Use ◽  
Agonist Therapy ◽  
Homeless Veterans

Objective: The aim of this study is to estimate the prevalence and sociodemographic and clinical correlates of opioid use disorder (OUD), a major cause of morbidity and mortality in the United States, among homeless veterans nationally in the Veterans Health Administration (VHA).Design: Administrative data on 256,404 veterans who were homeless and/or had OUD in fiscal year 2012 were analyzed to evaluate OUD as a risk factor for homelessness along with associated characteristics, comorbidities, and patterns of service use. Bivariate analyses and logistic regression were used to compare homeless veterans with OUD to veterans with OUD but no homelessness and homeless veterans with no OUD.Results: Altogether 17.9 percent of homeless VHA users were diagnosed with OUD and 34.6 percent of veterans with OUD were homeless. The risk ratio (RR) for homelessness among veterans with OUD was 28.7. Homeless veterans with OUD, compared to nonhomeless veterans with OUD showed extensive multimorbidity with greater risk for HIV (RR = 1.57), schizophrenia (RR = 1.62), alcohol use disorder (RR = 1.67), and others. Homeless veterans with OUD also showed more multimorbidity and used more services than homeless veterans without OUD. Homeless and nonhomeless OUD veterans used opiate agonist therapy at similar, but very low rates (13 and 15 percent).Conclusions: OUD is a major risk factor for homelessness. Homeless veterans with OUD have high levels of multimorbidity and greater service use than veterans with either condition alone. Tailored, facilitated access to opioid agonist therapy may improve outcomes for these vulnerable veterans.

scholarly journals Regional and Rural–Urban Variation in Opioid Prescribing in the Veterans Health Administration

2019 ◽  
Vol 184 (11-12) ◽  
pp. 894-900 ◽  
Author(s):  
Brian C Lund ◽  
Michael E Ohl ◽  
Katherine Hadlandsmyth ◽  
Hilary J Mosher
Keyword(s):  
Rural Areas ◽  
Regional Variation ◽  
Veterans Health Administration ◽  
Veterans Health ◽  
Health Administration ◽  
Opioid Use ◽  
Opioid Prescribing ◽  
Rural And Urban ◽  
Per Capita

Abstract Introduction Opioid prescribing is heterogenous across the US, where 3- to 5-fold variation has been observed across states or other geographical units. Residents of rural areas appear to be at greater risk for opioid misuse, mortality, and high-risk prescribing. The Veterans Health Administration (VHA) provides a unique setting for examining regional and rural–urban differences in opioid prescribing, as a complement and contrast to extant literature. The objective of this study was to characterize regional variation in opioid prescribing across Veterans Health Administration (VHA) and examine differences between rural and urban veterans. Materials and Methods Following IRB approval, this retrospective observational study used national administrative VHA data from 2016 to assess regional variation and rural–urban differences in schedule II opioid prescribing. The primary measure of opioid prescribing volume was morphine milligram equivalents (MME) dispensed per capita. Secondary measures included incidence, prevalence of any use, and prevalence of long-term use. Results Among 4,928,195 patients, national VHA per capita opioid utilization in 2016 was 1,038 MME. Utilization was lowest in the Northeast (894 MME), highest in the West (1,368 MME), and higher among rural (1,306 MME) than urban (988 MME) residents (p &lt; 0.001). Most of the difference between rural and urban veterans (318 MME) was attributable to differences in long-term opioid use (312 MME), with similar rates of short-term use. Conclusion There is substantial regional and rural–urban variation in opioid prescribing in VHA. Rural veterans receive over 30% more opioids than their urban counterparts. Further research is needed to identify and address underlying causes of these differences, which could include access barriers for non-pharmacologic treatments for chronic pain.

scholarly journals Review of purchases of unapproved medications by the Veterans Health Administration

2019 ◽  
Vol 76 (23) ◽  
pp. 1934-1943 ◽  
Author(s):  
Ron L Carico ◽  
Thomas R Emmendorfer ◽  
Sherrie L Aspinall ◽  
Margaret T Mizah ◽  
Chester B Good
Keyword(s):  
Pharmaceutical Expenditure ◽  
Sodium Hyaluronate ◽  
Active Pharmaceutical Ingredient ◽  
Veterans Health Administration ◽  
The United States ◽  
Fiscal Year ◽  
Veterans Health ◽  
Health Administration ◽  
Safety And Efficacy ◽  
Usage Patterns

Abstract Purpose Many medications that were marketed prior to 1962 but lack Food and Drug Administration (FDA) approval are prescribed in the United States. Usage patterns of these “unapproved medications” are poorly elucidated, which is concerning due to potential lack of data on safety and efficacy. The purpose of this project was to characterize purchases of unapproved medications within the Veterans Health Administration (VHA) by type, frequency, and cost. Methods VHA purchasing databases were used to create a list of all products with National Drug Codes (NDCs) purchased nationwide in fiscal year 2016 (FY16). This list was compared to FDA databases to identify unapproved prescription medications. For each identified combination of active pharmaceutical ingredient (API) and route of administration (“API/route combination”), numbers of packages purchased and associated costs were added. Results VHA pharmacy purchasing records contained 3,299 unapproved products with NDCs in FY16. After excluding equipment, nutrition products, compounding ingredients, nonmedication products, and duplicate NDCs, there were 600 unique NDCs associated with 130 distinct API/route combinations. The most commonly acquired product was prescription sodium fluoride dental paste (350,775 packages). The greatest pharmaceutical expenditure was for sodium hyaluronate injection ($24.5 million). Unapproved products accounted for less than 1% of overall VHA pharmacy purchasing in FY16. Conclusion VHA purchased many unapproved prescription products in FY16 but is taking action to address use of such products in consideration of safety and efficacy data and available alternatives.

scholarly journals Surveillance for Opioid Overdose in the Veterans Health Administration, 2004-2014

2015 ◽  
Vol 7 (1) ◽  
Author(s):  
Carla Winston ◽  
Mark Holodniy
Keyword(s):  
Syndromic Surveillance ◽  
Veterans Health Administration ◽  
Surveillance Data ◽  
Opioid Overdose ◽  
Opioid Epidemic ◽  
Veterans Health ◽  
Health Administration ◽  
Trends Over Time ◽  
Us Census ◽  
Over Time

We analyzed VHA syndromic surveillance data to assess the opioid epidemic among Veterans in terms of trends over time by age and US Census region from 2004 through 2014.

Abstract 321: Association of Specialist Physician Productivity With Trainee and Staffing Levels in the Veterans Health Administration

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Neil M Kalwani ◽  
Paul A Heidenreich
Keyword(s):  
Veterans Health Administration ◽  
Support Staff ◽  
Fiscal Year ◽  
Full Time ◽  
Veterans Health ◽  
Health Administration ◽  
Staffing Levels ◽  
Physician Productivity ◽  
Specialist Physician ◽  
Clinical Support

Background: The effect of trainee, associate provider, and support staff levels on physician productivity by specialty is unknown. In 2013, the Veterans Health Administration (VHA) introduced a program to measure specialist physician productivity at the practice level, defined as the total work Relative Value Units (RVUs) generated by the physicians in a practice divided by the number of clinical full-time equivalents (FTEs) attributed to that practice. Data from this program can be utilized to understand the effect of specialty practice features on physician productivity. Methods: We extracted physician productivity levels and the numbers of trainees, associate providers, administrative support staff, and clinical support staff from fiscal year 2019 workforce reports produced by the VHA Office of Productivity, Efficiency, and Staffing for practices in four representative specialties: cardiology, gastroenterology, neurology, and surgery. We used linear regression to identify associations between physician productivity and trainee and staffing levels, adjusting for the complexity group of included practices as some practices do not perform procedures. Results: A total of 122 cardiology, 112 gastroenterology, 118 neurology, and 123 surgery practices with at least 0.5 clinical FTE were included. Physician (practice) productivity ranged from 2153 to 12,497 (mean 6899) RVUs/FTE for cardiology, 1189 to 13,435 (mean 7080) RVUs/FTE for gastroenterology, 1753 to 11,322 (mean 4154) RVUs/FTE for neurology, and 1761 to 8792 (mean 4251) RVUs/FTE for surgery. Physician productivity was positively associated with the number of trainees per clinical FTE for cardiology [coefficient 818 (95% CI 260, 1376) additional RVUs/FTE] and surgery [coefficient 253 (95% CI 56, 451) additional RVUs/FTE] but not for other specialties. Only neurologist productivity was positively associated with the number of associate providers per clinical FTE [coefficient 1095 (95% CI 128, 2061) additional RVUs/FTE]. There were no significant associations between physician productivity and the numbers of administrative and clinical support staff per clinical FTE. Conclusion: There is significant variation in VHA physician productivity across practices within each specialty. Physician productivity is positively associated with the number of trainees in a practice for some specialties, including cardiology, suggesting that trainees in those specialties may enhance physician productivity. The relationship between physician productivity and trainee and associate provider ratios varies by specialty. These specialty-specific associations can inform efforts to improve VHA physician productivity.

scholarly journals The impact of benchmarking operating room efficiency within the Veterans Health Administration

2018 ◽  
Vol 5 (1) ◽  
pp. 8
Author(s):  
Marilyn Lynn ◽  
Douglas Bronson ◽  
William Gunnar
Keyword(s):  
Operating Room ◽  
Surgical Care ◽  
Veterans Health Administration ◽  
Fiscal Year ◽  
Veterans Health ◽  
Department Of Veterans Affairs ◽  
Health Administration ◽  
Or Efficiency ◽  
Internal Benchmarking ◽  
The Impact

Purpose: The Department of Veterans Affairs (VA) provides surgical care and services through a network of Veterans Health Administration (VHA) Surgical Programs. This study examined the impact of benchmarking on improvements in VHA surgery program operating room efficiency.Methods: The VA National Surgery Office (NSO) developed the operating room (OR) Efficiency Matrix with four common metrics that characterize OR processes. The OR Efficiency Matrix assigned a performance level to each VHA Surgery Program identified in the NSO Quarterly Report. The NSO Quarterly Report provided ongoing and regular feedback allowing VHA Surgery Programs to develop action plans and improve performance.Results: Beginning with the Fiscal Year (FY) 2013 Quarter (Q) 2 NSO Quarterly Report, the NSO has been reporting to VHA Surgery Programs on the OR Efficiency Matrix through several tables and figures in the NSO Quarterly Report. Overall, raw metric rates have improved nationally, with most improvements coming in the metrics of OR first time starts and surgical case cancellation.Conclusions: The NSO developed and implemented the OR Efficiency Matrix, representing four well recognized metrics, to assess, track, and report OR efficiency at 137 VHA Surgery Programs. This internal benchmarking process and data reporting was associated with sustainable improvements in OR efficiency over time.

scholarly journals Rheumatology Clinicians’ Perceptions of Telerheumatology Within the Veterans Health Administration: A National Survey Study

2020 ◽  
Vol 185 (11-12) ◽  
pp. e2082-e2087 ◽  
Author(s):  
Rachel A Matsumoto ◽  
Bryant R England ◽  
Ginnifer Mastarone ◽  
J Steuart Richards ◽  
Elizabeth Chang ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Veterans Health Administration ◽  
Past Experience ◽  
Easy Access ◽  
Fiscal Year ◽  
Host Institution ◽  
Veterans Health ◽  
Health Administration ◽  
The Impact

Abstract Introduction The Department of Veterans Affairs Veterans Health Administration (VA) Strategic Plan (Fiscal Year 2018–2024) identified four priorities for care including easy access, timely and integrated care, accountability, and modernization, all of which can be directly or indirectly impacted by telemedicine technologies. These strategic goals, coupled with an anticipated rheumatology workforce shortage, has created a need for additional care delivery methods such as clinical video telehealth application to rheumatology (ie, telerheumatology). Rheumatology clinician perceptions of clinical usefulness telerheumatology have received limited attention in the past. The present study aimed to evaluate rheumatologists’ perceptions of and experiences with telemedicine, generally, and telerheumatology, specifically, within the VA. Materials and Methods A 38-item survey based on an existing telehealth providers’ satisfaction survey was developed by two VA rheumatologists with experience in telemedicine as well as a social scientist experienced in survey development and user experience through an iterative process. Questions probed VA rheumatology clinician satisfaction with training and information technology (IT) supports, as well as barriers to using telemedicine. Additionally, clinician perceptions of the impact and usefulness of and appropriate clinical contexts for telerheumatology were evaluated. The survey was disseminated online via VA REDCap to members of the VA Rheumatology Consortium (VARC) through a LISTSERV. The study protocol was approved by the host institution IRB through expedited review. Survey responses were analyzed using descriptive statistics. Results Forty-five anonymous responses (20% response rate) were collected. Of those who responded, 47% were female, 98% were between 35 and 64 years old, 71% reported working at an academic center, and the majority was physician-level practitioners (98%). Respondents generally considered themselves to be tech savvy (58%). Thirty-six percent of the sample reported past experience with telemedicine, and, of those, 29% reported experience with telerheumatology specifically. Clinicians identified the greatest barrier to effective telerheumatology as the inability to perform a physical exam (71%) but agreed that telerheumatology is vital to increasing access to care (59%) and quality of care (40%) in the VA. Overall, regardless of experience with telemedicine, respondents reported that telerheumatology was more helpful for management of rheumatologic conditions rather than initial diagnosis. Conclusions While the majority of rheumatology clinicians did not report past experience with telerheumatology, they agreed that it has potential to further the VA mission of improved access and quality of care. Rheumatology clinicians felt the suitability of telerheumatology is dependent on the phase of care. As remote care technologies continue to be rapidly adopted into clinic, clinician perceptions of and experiences with telemedicine will need to be addressed in order to maintain high-quality and clinician- and patient-centric care within VA rheumatology.

Prevalence and correlates of coprescribing anxiolytic medications with extensive prescription opioid use in Veterans Health Administration patients with metastatic cancer

2016 ◽  
Vol 12 (4) ◽  
pp. 259 ◽  
Author(s):  
Declan T. Barry, PhD ◽  
Mehmet Sofuoglu, MD ◽  
Robert D. Kerns, PhD ◽  
Ilse R. Wiechers, MD ◽  
Robert A. Rosenheck, MD
Keyword(s):  
Multivariate Analyses ◽  
Metastatic Cancer ◽  
Veterans Health Administration ◽  
Fiscal Year ◽  
Prescription Opioid ◽  
Veterans Health ◽  
Health Administration ◽  
Opioid Use ◽  
Medical Indication ◽  
Prescription Opioid Use

Objective: To examine the prevalence and correlates of concomitant anxiolytic prescription fills in Veterans Health Administration (VHA) patients with metastatic cancer who have extensive prescription opioid use.Design, Setting, and Participants: National VHA data for fiscal year 2012 were used to identify veterans diagnosed with metastatic cancer (ICD-9 codes 196-199) who also had extensive prescription opioid use (at least 10 opioid prescriptions during the year, comprising the highest 29 percent of opioid users). Bivariate and multivariate analyses were used to examine correlates of receiving anxiolytic medication among veterans with metastatic cancer and extensive prescription opioid use.Results: Of the 5,950 veterans with metastatic cancer and extensive prescription opioid use, 51 percent also received anxiolytic medication, of whom 64 percent had a medical indication and 85 percent had a psychiatric or medical indication for psychotropics. Of those with extensive prescription opioid use who filled an anxiolytic, 64 percent also received antidepressants and 38 percent received three or more classes of psychotropic medication (ie, polypharmacy). In multivariate analyses, factors associated with receipt of an anxiolytic included any anxiety disorder, insomnia, the prescription of antidepressants or antipsychotics, bipolar disorder, younger age, more emergency department visits, and greater number of opioid prescriptions.Conclusions: VHA patients with metastatic cancer and extensive prescription opioid use who are prescribed anxiolytics are likely to have a Food and Drug Administration-approved indication for psychotropics, and anxiolytics in particular, but represent a clinically vulnerable group which merits careful monitoring.

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