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.

Association between acute psychiatric bed availability in the Veterans Health Administration and veteran suicide risk: a retrospective cohort study

2021 ◽  
pp. bmjqs-2020-012975
Author(s):  
Peter J Kaboli ◽  
Matthew R Augustine ◽  
Bjarni Haraldsson ◽  
Nicholas M Mohr ◽  
M Bryant Howren ◽  
...  
Keyword(s):  
Mental Health ◽  
Cohort Study ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Suicide Risk ◽  
Veterans Health Administration ◽  
Veterans Health ◽  
Health Administration ◽  
Bed Occupancy ◽  
Increased Risk

BackgroundVeteran suicides have increased despite mental health investments by the Veterans Health Administration (VHA).ObjectiveTo examine relationships between suicide and acute inpatient psychiatric bed occupancy and other community, hospital and patient factors.MethodsRetrospective cohort study using administrative and publicly available data for contextual community factors. The study sample included all veterans enrolled in VHA primary care in 2011–2016 associated with 111 VHA hospitals with acute inpatient psychiatric units. Acute psychiatric bed occupancy, as a measure of access to care, was the main exposure of interest and was categorised by quarter as per cent occupied using thresholds of ≤85%, 85.1%–90%, 90.1%–95% and >95%. Hospital-level analyses were conducted using generalised linear mixed models with random intercepts for hospital, modelling number of suicides by quarter with a negative binomial distribution.ResultsFrom 2011 to 2016, the national incidence of suicide among enrolled veterans increased from 39.7 to 41.6 per 100 000 person-years. VHA psychiatric bed occupancy decreased from a mean of 68.2% (IQR 56.5%–82.2%) to 65.4% (IQR 53.9%–79.9%). VHA hospitals with the highest occupancy (>95%) in a quarter compared with ≤85% had an adjusted incident rate ratio (IRR) for suicide of 1.10 (95% CI 1.01 to 1.19); no increased risk was observed for 85.1%–90% (IRR 0.96; 95% CI 0.89 to 1.03) or 90.1%–95% (IRR 0.96; 95% CI 0.89 to 1.04) compared with ≤85% occupancy. Of hospital and community variables, suicide risk was not associated with number of VHA or non-VHA psychiatric beds or amount spent on community mental health. Suicide risk increased by age categories, seasons, geographic regions and over time.ConclusionsHigh VHA hospital occupancy (>95%) was associated with a 10% increased suicide risk for veterans whereas absolute number of beds was not, suggesting occupancy is an important access measure. Future work should clarify optimal bed occupancy to meet acute psychiatric needs and ensure adequate bed distribution.

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 Mild TBI and risk of Parkinson disease

Neurology ◽  
2018 ◽  
Vol 90 (20) ◽  
pp. e1771-e1779 ◽  
Author(s):  
Raquel C. Gardner ◽  
Amy L. Byers ◽  
Deborah E. Barnes ◽  
Yixia Li ◽  
John Boscardin ◽  
...  
Keyword(s):  
Brain Injury ◽  
Parkinson Disease ◽  
Veterans Health Administration ◽  
Veterans Health ◽  
Health Administration ◽  
Mild Tbi ◽  
Psychiatric Comorbidities ◽  
Increased Risk ◽  
Severe Tbi

ObjectiveOur aim was to assess risk of Parkinson disease (PD) following traumatic brain injury (TBI), including specifically mild TBI (mTBI), among care recipients in the Veterans Health Administration.MethodsIn this retrospective cohort study, we identified all patients with a TBI diagnosis in Veterans Health Administration databases from October 2002 to September 2014 and age-matched 1:1 to a random sample of patients without TBI. All patients were aged 18 years and older without PD or dementia at baseline. TBI exposure and severity were determined via detailed clinical assessments or ICD-9 codes using Department of Defense and Defense and Veterans Brain Injury Center criteria. Baseline comorbidities and incident PD more than 1 year post-TBI were identified using ICD-9 codes. Risk of PD after TBI was assessed using Cox proportional hazard models adjusted for demographics and medical/psychiatric comorbidities.ResultsAmong 325,870 patients (half with TBI; average age 47.9 ± 17.4 years; average follow-up 4.6 years), 1,462 were diagnosed with PD during follow-up. Compared to no TBI, those with TBI had higher incidence of PD (no TBI 0.31%, all-severity TBI 0.58%, mTBI 0.47%, moderate-severe TBI 0.75%). In adjusted models, all-severity TBI, mTBI, and moderate-severe TBI were associated with increased risk of PD (hazard ratio [95% confidence interval]: all-severity TBI 1.71 [1.53–1.92]; mTBI 1.56 [1.35–1.80]; moderate-severe TBI 1.83 [1.61–2.07]).ConclusionsAmong military veterans, mTBI is associated with 56% increased risk of PD, even after adjusting for demographics and medical/psychiatric comorbidities. This study highlights the importance of TBI prevention, long-term follow-up of TBI-exposed veterans, and the need to determine mechanisms and modifiable risk factors for post-TBI PD.

scholarly journals Indicators of Elder Mistreatment: Correlates among Veterans Receiving Care in the Veterans Health Administration

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 884-884
Author(s):  
Jenefer Jedele ◽  
Cameron Griffin ◽  
Julie Weitlauf
Keyword(s):  
Mental Health ◽  
Military Service ◽  
Female Gender ◽  
Veterans Health Administration ◽  
Community Dwelling ◽  
Veterans Health ◽  
Health Administration ◽  
Elder Mistreatment ◽  
Financial Exploitation ◽  
Increased Risk

Abstract Among community-dwelling adults ages 65 and older, approximately 11% have experienced elder mistreatment (EM), including physical, emotional or sexual abuse, neglect, or financial exploitation. EM research typically focuses on this age group; however, Veterans receiving Veterans Health Administration (VHA) care have increased earlier morbidity, which may accelerate the impacts of EM. Using a cohort of all VHA Veterans 50 years and older with VHA use in 2018-2020, we examined correlates of EM. ICD-10 codes from clinical encounters identified Veterans with indications of EM (n=4,427). A 10% sample of Veterans without indications of EM was selected for comparison (n=530,535). Logistic regression compared EM+ Veterans to the comparison sample and assessed overall demographic and clinical differences as well as differences by age, i.e. 50-64 versus 65 and older. Overall, female gender (OR=5.3, 95% CI=4.3-6.5), non-white race/ethnicity (OR=1.7, CI=1.5-1.9), dementia (OR=3.0, CI=2.6-3.5), PTSD (OR=2.0, CI=1.6-2.5), anxiety (OR=1.3, CI=1.0-1.5), military service connected disability status (OR=1.3, CI=1.1-1.5), and higher Elixhauser medical morbidity scores (OR=1.1, CI=1.1-1.1) were associated with EM. Prior year ER visits (OR=28.0, CI=23.6-33.4), inpatient stays (OR=14.0, CI=11.5-17.0), and mental health visits (OR=26.1, CI=22.2-30.6) also predicted EM+ status. Forty-six percent of VHA Veterans with indicators of EM were aged 50-64. For these Veterans, female gender, PTSD, service connection, and mental health visits were associated with increased risk of EM compared to Veterans 65+. Findings highlight clinical correlates of EMs among Veterans in VHA care. Increased awareness of EM risk factors is warranted and may inform VHA efforts for EM prevention, detection and intervention.

Treatment of Diffuse Large B-Cell Lymphoma (DLBCL) Patients (pts) Age 80 and Older: Analysis of the Veterans Health Administration (VHA) National Database

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 968-968
Author(s):  
Kenneth R. Carson ◽  
Ryan Lynch ◽  
Peter Riedell ◽  
Ryan P. Roop ◽  
Arun Ganti ◽  
...  
Keyword(s):  
Elderly Population ◽  
Performance Status ◽  
B Cell Lymphoma ◽  
National Database ◽  
Veterans Health ◽  
Health Administration ◽  
Very Elderly ◽  
Risk Of Death ◽  
Increased Risk ◽  
The Relationship

Abstract Abstract 968 Introduction: The incidence of DLBCL increases with age and the population ≥80 is the fastest growing segment of the elderly population. Optimal treatment of these very elderly DLBCL pts remains unclear. While chemo-immunotherapy can be curative, benefits of treatment must be balanced against toxicities in older, frail pts. Previous studies have suggested that doxorubicin treatment is associated with better survival in the very elderly population, though only on univariate analyses. To better understand the relationship between treatment and survival in pts ≥80, we performed a retrospective analysis of veterans to examine the relationship between treatment and overall survival (OS). Methods: We identified 523 DLBCL pts ≥80 diagnosed between 1998 and 2008 in the VHA Central Cancer Registry. We excluded pts with primary cutaneous or central nervous system DLBCL and pts treated with unknown agents outside the VHA. Data on stage, LDH, co-morbidities, date of death, treatment and supportive care medications were obtained for each pt. Treatment related mortality (TRM) was defined as death in the 30 days following any cycle of therapy. OS was defined as time from diagnosis to death. ECOG Performance Status (PS) at diagnosis was either obtained from pt charts or assessed from physician, nursing, and physical therapy notes available for each patient. Results: Of the 476 pts that met inclusion criteria, 193 received at least one dose of doxorubicin therapy (DT), 92 were treated without doxorubicin (non-DT) and 191 received no system therapy (NST). Median OS times were 30.2 months, 12.3 months, and 1.9 months in the DT, non-DT, and NST groups, respectively (Log-rank p<0.001). Baseline characteristics of 285 treated patients presented in Table 1. Among the 273 pts in whom treatment dates were available, 48 (18%) experienced TRM. Of these 48 deaths, 32 (67%) were associated with the first treatment cycle. On multivariate analysis, rituximab significantly reduced the risk of death (HR .62, CI .44 - .87), while GCSF use demonstrated a trend towards decreased death (HR .76, CI .57 – 1.03). Comorbidities (HR 1.1, CI 1.02 – 1.19) and PS were associated with increased risk of death. PS of 2–4 was associated with a marked increased risk of death within the first 45 days after diagnosis (HR 19.7, CI 2.6– 146) and a lesser risk after 45 days (HR 1.9, CI 1.4 –2.6). After controlling for other variables, doxorubicin use was no longer significantly associated with OS (HR .87, CI .64 – 1.17), suggesting the OS difference noted between the DT and non-DT groups was primarily due to differences in baseline patient characteristics. Conclusions: While we acknowledge the limitations of analyses of observational data, the observed 18% rate of TRM (compared to historical TRM rates of 4–6% seen in trials of R-CHOP) suggests that standard treatment paradigms are too toxic for many patients in this age group. The lack of association between doxorubicin and OS calls into question the importance of this drug in this patient population. In the absence of better risk stratification, treatment with less toxic regimens- either through attenuated doses or different drugs- may be appropriate in this population. Disclosures: Carson: Genentech: Consultancy, Honoraria, Speakers Bureau. Nabhan:Genentech: Research Funding, Speakers Bureau.

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 Association between admission haematocrit and mortality among men with acute ischaemic stroke

2018 ◽  
Vol 3 (3) ◽  
pp. 160-168 ◽  
Author(s):  
Jason J Sico ◽  
Laura J Myers ◽  
Brenda J Fenton ◽  
John Concato ◽  
Linda S Williams ◽  
...  
Keyword(s):  
Heart Disease ◽  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Severe Anaemia ◽  
Impact Factors ◽  
Fiscal Year ◽  
Health Administration ◽  
Risk Of Death ◽  
Increased Risk ◽  
The Relationship

ObjectiveAnaemia is associated with higher mortality among patients with non-stroke cardiovascular conditions; less is known regarding the relationship between anaemia and mortality among patients with acute ischaemic stroke.MethodsMedical records were abstracted for n=3965 veterans from 131 Veterans Health Administration facilities who were admitted with ischaemic stroke in fiscal year 2007. Haematocrit values within 24 hours of admission were classified as ≤27%, 28%–32%, 33%–37%, 38%–42%, 43%–47% or ≥48%. Multivariate logistic regression was used to examine the relationship between anaemia and in-hospital, 30-day, 6-month and 1-year mortality, adjusting for age, medical comorbidities, modified Acute Physiology and Chronic Health Evaluation-III and stroke severity. Impact factors were calculated to standardise comparisons between haematocrit tier and other covariates.ResultsAmong n=3750 patients included in the analysis, the haematocrit values were ≤27% in 2.1% (n=78), 28%–32% in 6.2% (n=234), 33%–37% in 17.9% (n=670), 38%–42% in 36.4% (n=1366), 43%–47% in 28.2% (n=1059) and ≥48% in 9.1% (n=343). Patients with haematocrit ≤27%, compared with patients in the 38%–42% range, were more likely to have died across all follow-up intervals, with statistically significant adjusted ORs (aORs) ranging from 2.5 to 3.5. Patients with polycythaemia (ie, haematocrit ≥48%) were at increased risk of in-hospital mortality (aOR=2.9; 95% CI 1.4 to 6.0), compared with patients with mid-range admission haematocrits. Pronounced differences between patients receiving and not receiving blood transfusion limited our ability to perform a propensity analysis. Impact factors in the 1-year mortality model were 0.46 (severe anaemia), 0.06 (cancer) and 0.018 (heart disease).ConclusionsAnaemia is independently associated with an increased risk of death throughout the first year post stroke; high haematocrit is associated with early poststroke mortality. Severe anaemia is associated with 1-year mortality to a greater degree than cancer or heart disease. These data cannot address the question of whether interventions targeting anaemia might improve patient outcomes.

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.

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