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The Researcher's Guide to VA Data

VA Information Resource Center

 

Publications

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Overview

VIReC publications include peer reviewed articles, papers, and journal supplements published by VIReC staff.

VIReC collaborates with peer reviewed journals to publish journal supplements that are informative and useful to researchers and others whose interests include VA data and information systems.

Current Articles & Papers


Fischer, M, Stroupe, K, Kaufman, J, O'Hare, A, Browning, M, Sohn, MW, Huo, Z, Hynes, DM. Predialysis Nephrology Care and Dialysis-Related Health Outcomes Among Older Adults Initiating Dialysis BMC Nephrology, In press. Med Care. 2013; 51:S4–S5.

Abstract

Background: Predialysis nephrology care is associated with lower mortality and rates of hospitalization following chronic dialysis initiation. Whether more frequent predialysis nephrology care is associated with other favorable outcomes for older adults is not known.

Methods: Retrospective cohort study of patients =66 years who initiated chronic dialysis in 2000–2001 and were eligible for VA and/or Medicare-covered services. Nephrology visits in VA and/or Medicare during the 12-month predialysis period were identified and classified by low intensity (<3 visits), moderate intensity (3–6 visits), and high intensity (>6 visits). Outcome measures included very low estimated glomerular filtration rate, severe anemia, use of peritoneal dialysis, and receipt of permanent vascular access at dialysis initiation and death and kidney transplantation within two years of initiation. Generalized linear models with propensity score weighting were used to examine the association between nephrology care and outcomes.

Results: Among 58,014 patients, 46 % had none, 22 % had low, 13 % had moderate, and 19 % had high intensity predialysis nephrology care. Patients with a greater intensity of predialysis nephrology care had more favorable outcomes (all p <0.001). In adjusted models, patients with high intensity predialysis nephrology care were less likely to have severe anemia (RR = 0.70, 99 % CI: 0.65–0.74) and more likely to have permanent vascular access (RR = 3.60, 99 % CI: 3.42–3.79) at dialysis initiation, and less likely to die within two years of dialysis initiation (RR = 0.80, 99 % CI: 0.77–0.82).

Conclusion: In a large cohort of older adults treated with chronic dialysis, greater intensity of predialysis nephrology care was associated with more favorable outcomes.


Cukor, D, Cohen, L, Cope, E, Ghahramani, N, Hedayati, S, Hynes, et al. Patient and stakeholder engagement in kidney diseases related research. Clinical Journal of the American Society of Nephrology. 2016; May 19.

Abstract

Including target populations in the design and implementation of research trials has been one response to the growing health disparities endemic to our health care system, as well as an aid to study generalizability. One type of community-based participatory research is "Patient Centered-Research", in which patient perspectives on the germane research questions and methodologies are incorporated into the study. The Patient-Centered Outcomes Research Institute (PCORI) has mandated that meaningful patient and stakeholder engagement be incorporated into all applications. As of March 2015, PCORI funded seven clinically-focused studies of patients with kidney disease. The goal of this paper is to synthesize the experiences of these studies to gain an understanding of how meaningful patient and stakeholder engagement can occur in clinical research of kidney diseases, and what the key barriers are to its implementation. Our collective experience suggests that successful implementation of a patient- and stakeholder-engaged research paradigm involves: (1) defining the roles and process for the incorporation of input; (2) identifying the particular patients and other stakeholders; (3) engaging patients and other stakeholders so they appreciate the value of their own participation and have personal investment in the research process; and (4) overcoming barriers and challenges that arise and threaten the productivity of the collaboration. It is our hope that the experiences of these studies will further interest and capacity for incorporating patient and stakeholder perspectives in research of kidney diseases.


Wu AW, White SM, Blackford AL, Wolff AC, Carducci MA, Herman JM, Snyder CF, and the PatientViewpoint Scientific Advisory Board. Improving an electronic system for measuring PROs in routine oncology practice. J Cancer Surviv. 2015; Dec 7.

Abstract

Purpose: Our aim was to study how patients and their clinicians evaluated the usability of PatientViewpoint, a webtool designed to allow patient-reported outcome (PRO) measures to be used in clinical practice.

Methods: As part of a two-round quality improvement study, breast and prostate cancer patients and their medical and radiation oncology clinicians completed semi-structured interviews about their use of PatientViewpoint. The patient interview addressed different phases of the PRO completion workflow: reminders, completing the survey, and viewing the results. The clinician interviews asked about use of PatientViewpoint, integration with the clinical workflow, barriers to use, and helpful and desired features. Responses were recorded, categorized, and reviewed. After both rounds of interviews, modifications were made to PatientViewpoint.

Results: Across the two rounds, 42 unique patients (n=19 in round 1, n=23 in round 2) and 12 clinicians (all in both rounds) completed interviews. For patients, median age was 65, 81% were white, 69% were college graduates, 80% had performance status of 0, 69% had loco-regional disease, and 81% were regular computer users. In the quality improvement interviews, patients identified numerous strengths of the system, including its ability to flag issues for discussion with their provider. Comments included confusion about how scores were presented and that the value of the system was diminished if the doctor did not look at the results. Requests included tailoring questions to be applicable to the individual and providing more explanation about the score meaning, including having higher scores consistently indicating either better or worse status. Clinicians also provided primarily positive feedback about the system, finding it helpful in some cases, and confirmatory in others. Their primary concern was with impact on their workflow.

Conclusions: Systematically collected feedback from patients and clinicians was useful to identify ways to improve a system to incorporate PRO measures into oncology practice. The findings and evaluation methods should be useful to others in efforts to integrate PRO assessments into ambulatory care.

Implications for Cancer Survivors: Systems to routinely collect patient-reported information can be incorporated into oncology practices and provide useful information that promote patient and clinician partnership to improve the quality of care.


Solomonides A, Goel, S, Hynes DM, Silverstein, S, Hota, B, Trick, W, Angulo, F, Price, R, Sadhu, E, Zelisko, S, Fischer, J, Furner, B, Hamilton, A, Phua, J, Brown, W, Hohmann, S, Meltzer, D, Tarlov, E, Weaver, F, Zhang, H, Kho, A. Patient-Centered Outcomes Research in Practice: The CAPriCORN Infrastructure. Stud Health Technol Inform. 2015;216:584-8.

Abstract

The Chicago Area Patient-Centered Outcomes Research Network (CAPriCORN) represents an unprecedented collaboration across diverse healthcare institutions including private, county, and state hospitals and health systems, a consortium of Federally Qualified Health Centers, and two Department of Veterans Affairs hospitals. CAPriCORN builds on the strengths of our institutions to develop a cross-cutting infrastructure for sustainable and patient-centered comparative effectiveness research in Chicago. Unique aspects include collaboration with the University HealthSystem Consortium to aggregate data across sites, a centralized communication center to integrate patient recruitment with the data infrastructure, and a centralized institutional review board to ensure a strong and efficient human subject protection program. With coordination by the Chicago Community Trust and the Illinois Medical District Commission, CAPriCORN will model how healthcare institutions can overcome barriers of data integration, marketplace competition, and care fragmentation to develop, test, and implement strategies to improve care for diverse populations and reduce health disparities.


Hynes DM, Buscemi J, Quintiliani LM, on behalf of the Society of Behavioral Medicine Health Policy Committee. Society of Behavioral Medicine (SBM) Position Statement: SBM supports increased efforts to integrate Community Health Workers into the Patient-Centered Medical Home.Transl Behav Med. 2015;5(4):483-5.

Abstract

Integrating community health workers (CHWs) into health care systems has been associated with enhanced patient experience, improved population health, and reduced costs and unnecessary utilization of resources. Under the Affordable Care Act (ACA), care provided by CHWs is eligible for reimbursement. However, optimal integration of CHWs into health care requires purposeful implementation. This health policy brief is focused on the benefits of integrating CHWs specifically into the patient-centered medical home (PCMH). CHWs in the PCMH can serve as primary providers of culturally relevant information and advocacy, assist providers in understanding the influence of patients’ environment on disease management, and enhance motivation for self-care management among patients with chronic diseases. Despite the important role of CHWs, there are some barriers to integration into existing systems of care. The Society of Behavioral Medicine (SBM) recommends overcoming these barriers by establishing standards that ensure a skilled CHW workforce, clearly defining roles for CHWs, and expanding the scope of reimbursable prevention and primary care services to include those provided by CHWs.


Boyd AD, Moores K, Shah V, Sadhu E, Shroff A, Groo V, Dickens C, Field J, Baumann M, Welland B, Gutowski G, Flores Jr JD, Zhao Z, Bahroos N, Hynes DM, Wilkie DJ. My Interventional Drug-Eluting Stent Educational App (MyIDEA): Patient-Centered Design Methodology. JMIR mHealth uHealth. 2015;3(3):e74.

Abstract

Background: Patient adherence to medication regimens is critical in most chronic disease treatment plans. This study uses a patient-centered tablet app, “My Interventional Drug-Eluting Stent Educational App (MyIDEA).” This is an educational program designed to improve patient medication adherence.

Objective: Our goal is to describe the design, methodology, limitations, and results of the MyIDEA tablet app. We created a mobile technology-based patient education app to improve dual antiplatelet therapy adherence in patients who underwent a percutaneous coronary intervention and received a drug-eluting stent.

Methods: Patient advisers were involved in the development process of MyIDEA from the initial wireframe to the final launch of the product. The program was restructured and redesigned based on the patient advisers’ suggestions as well as those from multidisciplinary team members. To accommodate those with low health literacy, we modified the language and employed attractive color schemes to improve ease of use. We assumed that the target patient population may have little to no experience with electronic tablets, and therefore, we designed the interface to be as intuitive as possible.

Results: The MyIDEA app has been successfully deployed to a low-health-literate elderly patient population in the hospital setting. A total of 6 patients have interacted with MyIDEA for an average of 17.6 minutes/session.

Conclusions: Including patient advisers in the early phases of a mobile patient education development process is critical. A number of changes in text order, language, and color schemes occurred to improve ease of use. The MyIDEA program has been successfully deployed to a low-health-literate elderly patient population. Leveraging patient advisers throughout the development process helps to ensure implementation success.


Porter AC, Fitzgibbon ML, Fischer MJ, Gallardo R, Berbaum A, Lash JP, Castillo S, Schiffer L, Sharp L, Tulley J , Arruda JA, Hynes DM. Rationale and Design of a Patient-Centered Medical Home Intervention for Patients with End-stage Renal Disease on Hemodialysis. Contemp Clin Trials;. 2015;42:1-8.

Abstract

In the U.S., more than 400,000 individuals with end-stage renal disease (ESRD) require hemodialysis (HD) for renal replacement therapy. ESRD patients experience a high burden of morbidity, mortality, resource utilization, and poor quality of life (QOL). Under current care models, ESRD patients receive fragmented care from multiple providers at multiple locations. The Patient-Centered Medical Home (PCMH) is a team approach, providing coordinated care across the healthcare continuum. While this model has shown some early benefits for complex chronic diseases such as diabetes, it has not been applied to HD patients. This study is a non-randomized quasi-experimental intervention trial implementing a Patient-Centered Medical Home for Kidney Disease (PCMH-KD). The PCMH-KD extends the existing dialysis care team (comprised of a nephrologist, dialysis nurse, dialysis technician, social worker, and dietitian) by adding a general internist, pharmacist, nurse coordinator, and a community health worker, all of whom will see the patients together, and separately, as needed. The primary goal is to implement a comprehensive, multidisciplinary care team to improve care coordination, quality of life, and healthcare use for HD patients. Approximately 240 patients will be recruited from two sites; a non-profit university-affiliated dialysis center and an independent for-profit dialysis center. Outcomes include (i) patient-reported outcomes, including QOL and satisfaction; (ii) clinical outcomes, including blood pressure and diet; (iii) healthcare use, including emergency room visits and hospitalizations; and (iv) staff perceptions. Given the significant burden that patients with ESRD on HD experience, enhanced care coordination provides an opportunity to reduce this burden and improve QOL.


Stroupe KD, Tarlov E, Weichle T, Zhang Q, Michaelis LC, Ozer H, Durazo-Arvizu R, Hynes DM. Costs of care for lung and colon cancer patients receiving chemotherapy following FDA policy changes. Journal of Supportive Care in Cancer. 2014;22(12):3153-63.

Abstract

Purpose: Use of erythropoiesis-stimulating agents (ESAs) in US cancer care declined amidst post-marketing evidence of adverse effects and the Food and Drug Administration's (FDA) addition of a "black-box" warning to product labeling in March 2007. Because reduced ESA use may have led to more transfusions or increased anemia-related health care needs, we measured the policy's impact on health care costs of lung and colon cancer patients receiving chemotherapy.

Methods: In a retrospective cohort study of 13,630 lung and 3,198 colon cancer patients in the Department of Veterans Affairs (VA) between 2002 and 2008, we calculated anemia treatment (ESA and transfusion), cancer- and non-cancer-related, and total health care costs for the chemotherapy episode of care. We used multivariable regression to examine health care costs and utilization between patients whose chemotherapy was administered before (PRE) or after (POST) March 1, 2007.

Results: ESA costs declined and transfusion costs were similar, resulting in lower overall POST-period anemia treatment costs (lung, $526 lower, P <0.01; colon, $504 lower, P <0.01). Other cancer-related health care costs increased, resulting in markedly higher POST-period total health care costs (lung, $4,706 higher, P <0.01; colon, $11,414 higher, P <0.01).

Conclusions: Although chemotherapy episode anemia treatment costs declined after the black-box warning, the savings were offset by increases in other cancer-related costs. Those increases were mainly in outpatient services and pharmacy, suggesting that likely drivers include adoption of new high-cost diagnostic approaches and therapeutic modalities. Additional research is needed to determine the effects of anemia management changes on patient outcomes and to more fully understand cost-benefit relationships in cancer treatment.


Kho AN, Hynes DM, Goel, S, et al. CAPriCORN: Chicago Area Patient-Centered Outcomes Research Network. J Am Med Inform Assoc. 2014;21(4):607-11.

Abstract

The Chicago Area Patient-Centered Outcomes Research Network (CAPriCORN) represents an unprecedented collaboration across diverse healthcare institutions including private, county, and state hospitals and health systems, a consortium of Federally Qualified Health Centers, and two Department of Veterans Affairs hospitals. CAPriCORN builds on the strengths of our institutions to develop a cross-cutting infrastructure for sustainable and patient-centered comparative effectiveness research in Chicago. Unique aspects include collaboration with the University HealthSystem Consortium to aggregate data across sites, a centralized communication center to integrate patient recruitment with the data infrastructure, and a centralized institutional review board to ensure a strong and efficient human subject protection program. With coordination by the Chicago Community Trust and the Illinois Medical District Commission, CAPriCORN will model how healthcare institutions can overcome barriers of data integration, marketplace competition, and care fragmentation to develop, test, and implement strategies to improve care for diverse populations and reduce health disparities.


Snyder CF, Blackford AL, Wolff AC, Carducci MA, Herman JM, Wu AW, PatientViewpoint Scientific Advisory Board. Feasibility and Value of PatientViewpoint: A Web System for Patient-Reported Outcomes Assessment in Clinical Practice. Psycho-Oncology. 2013 Apr;22(4):895-901.

Abstract

Objective: The PatientViewpoint website collects patient-reported outcomes (PROs) and links them with the electronic health record to aid patient management. This pilot-test evaluated PatientViewpoint’s use, usefulness, and acceptability to patients and clinicians.

Methods: This was a single-arm prospective study that enrolled breast and prostate cancer patients undergoing treatment and the clinicians who managed them. Patients completed PROs every two weeks, and clinicians could access the results for patient visits. Scores that were poor relative to norms or substantially worse than the previous assessment were highlighted. After three on-study visits, we assessed patient and clinician perspectives on PatientViewpoint using close-ended and open-ended questions.

Results: 11/12 eligible clinicians (92%) and 52/76 eligible patients (68%) enrolled. Patients completed a median of 71% of assigned questionnaires; clinicians reported using the information for 79% of patients, most commonly as a source of additional information (51%). At the median, score reports identified 3 potential issues, of which 1 was discussed during the visit. Patients reported the system was easy to use (92%), useful (70%), aided recall of symptoms/side effects (72%), helped them feel more in control of their care (60%), improved discussions with their provider (49%), and improved care quality (39%). Patients and clinicians desired more information on score interpretation and minor adjustments to site navigation.

Conclusions: These results support the feasibility and value of PatientViewpoint. An ongoing study is using a continuous quality improvement approach to further refine PatientViewpoint. Future studies will evaluate its impact on patient care and outcomes.


Hynes DM. Health information technology in VA quality improvement research overview. Med Care. 2013;51(3 SUPPL. 1):S4-5.


Hynes DM, Whittier E, Owens A. Health Information Technology and Implementation Science: Partners in Progress in the VHA. Med Care. 2013;51(3 SUPPL. 1):S6-12.

Abstract

Background: The Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) has demonstrated how implementation science can enhance the quality of health care. During this time an increasing number of implementation research projects have developed or utilized health information technology (HIT) innovations to leverage the VA's electronic health record and information systems.

Objective: To describe the HIT approaches used and to characterize the facilitators and barriers to progress within implementation research projects in the VA QUERI program.

Participants: Nine case studies were selected from among 88 projects and represented 8 of 14 HIT categories identified. Each case study included key informants whose roles on the project were principal investigator, implementation science and informatics development.

Approach: We conducted documentation analysis and semistructured in-person interviews with key informants for each of the 9 case studies. We used qualitative analysis software to identify and thematically code information and interview responses.

Results: Thematic analyses revealed 3 domains or pathways critical to progression through the QUERI steps. These pathways addressed: (1) compliance and collaboration with information technology policies and procedures; (2) operating within organizational policies and building collaborations with end users, clinicians, and administrators; and (3) obtaining and maintaining research resources and approvals.

Conclusion: Sustained efforts in HIT innovation and in implementation science in the Veterans Health Administration demonstrates the interdependencies of these initiatives and the critical pathways that can contribute to progress. Other health care quality improvement efforts that rely on HIT can learn from the Veterans Health Administration experience.


Humensky JL, Jordan N, Stroupe KT, Hynes D. Employment status of veterans receiving substance abuse treatment from the U.S. Department of Veterans Affairs. Psychiatr Serv. 2013. Feb 1;64(2):177-80.

Abstract

Objective: This study examined employment outcomes of veterans with substance use disorders and comorbid general medical and psychiatric disorders following substance abuse treatment.

Methods: The authors obtained employment and other information reported by 5,729 veterans at intake and at follow-up three to nine months after receiving substance abuse treatment from the U.S. Department of Veterans Affairs during 2001-2010. Random-effects logistic regression models examined the probability of having employment earnings and days of paid work during the past 30 days among veterans with comorbid conditions.

Results: The percentage of veterans with any days of paid work rose from 28% at intake to 35% at follow-up. Veterans with comorbid anxiety and general medical conditions had lower odds of having earnings from employment or days of paid work at follow-up.

Conclusion: Veterans with substance use disorders, particularly those with comorbid general medical and anxiety disorders, may be at risk of employment problems.


Wang V, Maciejewski ML, Patel UD, Stechuchak KM, Hynes DM, Weinberger M. Comparison of outcomes for Veterans receiving dialysis care from VA and non-VA providers. BMC Health Serv Res. 2013;13:26.

Abstract

Background: Demand for dialysis treatment exceeds its supply within the Veterans Health Administration (VA), requiring VA to outsource dialysis care by purchasing private sector dialysis for veterans on a fee-for-service basis. It is unclear whether outcomes are similar for veterans receiving dialysis from VA versus non-VA providers. We assessed the extent of chronic dialysis treatment utilization and differences in all-cause hospitalizations and mortality between veterans receiving dialysis from VA versus VA-outsourced providers.

Methods: We constructed a retrospective cohort of veterans in 2 VA regions who received chronic dialysis treatment financed by VA between January 2007 and December 2008. From VA administrative data, we identified veterans who received outpatient dialysis in (1) VA, (2) VA-outsourced settings, or (3) both (“dual”) settings. In adjusted analyses, we used two-part and logistic regression to examine associations between dialysis setting and all-cause hospitalization and mortality one-year from veterans’ baseline dialysis date.

Results: Of 1,388 veterans, 27% received dialysis exclusively in VA, 47% in VA-outsourced settings, and 25% in dual settings. Overall, half (48%) were hospitalized and 12% died. In adjusted analysis, veterans in VA-outsourced settings incurred fewer hospitalizations and shorter hospital stays than users of VA due to favorable selection. Dual-system dialysis patients had lower one-year mortality than veterans receiving VA dialysis.

Conclusion: VA expenditures for “buying” outsourced dialysis are high and increasing relative to “making” dialysis treatment within its own system. Outcomes comparisons inform future make-or-buy decisions and suggest the need for VA to consider veterans’ access to care, long-term VA savings, and optimal patient outcomes in its placement decisions for dialysis services.

Keywords: Veterans Dialysis Hospitalization Mortality


Dong X, Bahroos N, Sadhu E, Jackson T, Chukman M, Johnson R, Boyd A, Hynes D. Leverage Hadoop Framework for Large Scale Clinical Informatics Applications. AMIA Summits Transl Sci Proc. 2013;2013:53.

Abstract

In this manuscript, we present our experiences using the Apache Hadoop framework for high data volume and computationally intensive applications, and discuss some best practice guidelines in a clinical informatics setting. There are three main aspects in our approach: (a) process and integrate diverse, heterogeneous data sources using standard Hadoop programming tools and customized MapReduce programs; (b) after fine-grained aggregate results are obtained, perform data analysis using the Mahout data mining library; (c) leverage the column oriented features in HBase for patient centric modeling and complex temporal reasoning. This framework provides a scalable solution to meet the rapidly increasing, imperative "Big Data" needs of clinical and translational research. The intrinsic advantage of fault tolerance, high availability and scalability of Hadoop platform makes these applications readily deployable at the enterprise level cluster environment.


Humensky JL, Jordan N, Stroupe KT, Hynes DM. How Are Iraq/Afghanistan-Era Veterans Faring in the Labor Market? Armed Forces Soc. 2013;39(1):158-183.

Abstract

This study examines labor market status of Veterans of the Iraq/Afghanistan-era and previous eras, and variations by age and by health status, using the Current Population Survey (CPS) March supplement from 2006 to 2011. Although this observational study does not demonstrate a causal effect of military service on labor market outcomes, the authors find that Iraq/Afghanistan-era service among the youngest Veterans (ages 18–24) was associated with higher earnings and greater odds of being enrolled in school, but also higher odds of unemployment. Military service in previous eras by older Veterans, particularly those in fair or poor health, was associated with higher odds of unemployment and lower earnings than their nonveteran counterparts. Future research should examine the reasons for the higher unemployment rates of the youngest Veterans and should examine whether receipt of services such as health care services, disability benefits, and military reintegration programs are associated with improved labor market outcomes.


Weichle T, Hynes DM, Durazo-Arvizo R, Zhang Q. Impact of alternative approaches to assess outlying and influential observations on health care costs. Springer Plus. 2013. Nov 18;2:614.

Abstract

The distributions of medical costs are often skewed to the right because small numbers of patients use large amounts of health care resources. Using data from a study of colon cancer costs, we show, by example, the impact and magnitude of outliers and influential observations on health care costs and compared the effects of statistical costing methods for addressing the disproportionate influence of outliers and influential observations. We used data from a retrospective cohort study of 3,842 elderly veterans with colon cancer who were enrolled in and used health care from, both the Department of Veterans Affairs and Medicare in 1999-2004. After calculating the average colon cancer episode cost and distribution for the full cohort, we used box-plot methods, Winsorization, DFBETAs, and Cook's distance to identify and assess or adjust the outlying and/or influential observations. The number of observations identified as outlying and/or influential ranged from 13 when the predicted DFBETA measurement was greater than 0.15 and the observation was a qualified box-plot outlier to 384 cases using the Winsorization method at the 5th and 95th percentiles. Average costs of colon cancer episodes using these methods were similar. The method of choice from the results of this particular analysis can be conditionally based on whether the purpose is to control only for influential observations or to simultaneously control for outliers and influential observations. Understanding how estimates could change with each approach is important in assessing the impact of a particular method on the results.


Older Publications

Publications from 2008 - 2012


Humensky, J; Carretta, H; de Groot, K; Brown, MM; Tarlov, E; Hynes, DM. Service Utilization of Veterans Dually Eligible for VA and Medicare Fee-For-Service: 1999?2004. Medicare Care & Medicaid Research Review, 2012; 2(3): E1?E22.

Abstract

Objective: To examine care system choices for Veterans dually-eligible for VA and Medicare FFS following changes in VA eligibility policy, which expanded availability of VA health care services.

Data Sources: VA and Medicare FFS enrollment and outpatient utilization databases in 1999 and 2004. Study Design: Multinomial logistic regression was used to examine odds of VA-only and Medicare-only utilization, relative to dual utilization, in 1999 and 2004. Observational cohort comprising a 5% random sample of dually-eligible Veterans: 73,721 in 1999 and 125,042 in 2004.

Principal Findings: From 1999 to 2004, persons with the highest HCC risk scores had decreasing odds of exclusive VA reliance (OR=0.26 in 1999 and 0.17 in 2004, p<0.05), but had increasing odds of exclusive Medicare reliance (OR=0.43 in 1999 and 0.56 in 2004, p<0.05).Persons in high VA priority groups had decreasing odds of exclusive VA reliance, as well as decreasing odds of exclusive Medicare reliance, indicating increasing odds of dual use. Newly eligible Veterans with the highest HCC risk scores had higher odds of dual system use, while newly eligible Black Veterans had lower odds of dual system use.

Conclusions: Veterans newly eligible for VA healthcare services, particularly those with the highest risk scores, had higher odds of dual system use compared to earlier eligibles. Providers should ensure coordination of care for Veterans who may be receiving care from multiple sources. Provisions of the Patient Protection and Affordable Care Act may help to ensure care coordination for persons receiving care from multiple systems.


Tarlov E, Stroupe KT. Advancing Veterans' Healthcare Using Electronic Data: Lessons Learned From Researchers in the Field. J Rehabil Res Dev. November 2010; 47(8):vii-vxi.


Stroupe KT, Tarlov E, Zhang Q, Haywood T, Owens A, Hynes DM. Use of Medicare and DOD Data for Improving VA Race Data Quality. J Rehabil Res Dev. November 2010; 47(8): 781-795.

Abstract

We evaluated the improvement in Department of Veterans Affairs (VA) race data completeness that could be achieved by linking VA data with data from Medicare and the Department of Defense (DOD) and examined agreement in values across the data sources. After linking VA with Medicare and DOD records for a 10% sample of VA patients, we calculated the percentage for which race could be identified in those sources. To evaluate race agreement, we calculated sensitivities, specificities, positive predictive values (PPVs), negative predictive values, and kappa statistics. Adding Medicare (and DOD) data improved race data completeness from 48% to 76%. Among older patients (≥65 years), adding Medicare data improved data completeness to nearly 100%. Among younger patients (<65 years), combining Medicare and DOD data improved completeness to 75%, 18 percentage points beyond that achieved with Medicare data alone. PPVs for white and African-American categories were 98.6 and 94.7, respectively, in Medicare and 97.0 and 96.5, respectively, in DOD data using VA self-reported race as the gold standard. PPVs for the non-African-American minority groups were lower, ranging from 30.5 to 48.2. Kappa statistics reflected these patterns. Supplementing VA with Medicare and DOD data improves VA race data completeness substantially. More study is needed to understand poor rates of agreement between VA and external sources in identifying non-African-American minority individuals.


Noel PH, Copeland LA, Perrin RA, Lancaster AE, Pugh MJ, Wang CP, et al. VHA Corporate Data Warehouse Height and Weight Data: Opportunities and Challenges for Health Services Research. J Rehabil Res Dev. November 2010; 47(8):739-750.

Abstract

Within the Veterans Health Administration (VHA), anthropometric measurements entered into the electronic medical record are stored in local information systems, the national Corporate Data Warehouse (CDW), and in some regional data warehouses. This article describes efforts to examine the quality of weight and height data within the CDW and to compare CDW data with data from warehouses maintained by several of VHA's regional groupings of healthcare facilities (Veterans Integrated Service Networks [VISNs]). We found significantly fewer recorded heights than weights in both the CDW and VISN data sources. In spite of occasional anomalies, the concordance in the number and value of records in the CDW and the VISN warehouses was generally 97% to 99% or greater. Implausible variation in same-day and same-year heights and weights was noted, suggesting measurement or data-entry errors. Our work suggests that the CDW, over time and through validation, has become a generally reliable source of anthropometric data. Researchers should assess the reliability of data contained within any source and apply strategies to minimize the impact of data errors appropriate to their study population.


Hynes DM, Weddle T, Smith N, Whittier E, Atkins D, Francis J. Use of Health Information Technology to Advance Evidence-Based Care: Lessons From the VA QUERI Program. J Gen Intern Med. January 2010; 25 (suppl) 1:44-49.

Abstract

Background: As the Department of Veterans Affairs (VA) Health Services Research and Development Service's Quality Enhancement Research Initiative (QUERI) has progressed, health information technology (HIT) has occupied a crucial role in implementation research projects.

Objectives: We evaluated the role of HIT in VA QUERI implementation research, including HIT use and development, the contributions implementation research has made to HIT development, and HIT-related barriers and facilitators to implementation research.

Participants: Key informants from nine disease-specific QUERI Centers.

Approach: Documentation analysis of 86 implementation project abstracts followed up by semi-structured interviews with key informants from each of the nine QUERI centers. We used qualitative and descriptive analyses. Results: We found: (1) HIT provided data and information to facilitate implementation research, (2) implementation research helped to further HIT development in a variety of uses including the development of clinical decision support systems (23 of 86 implementation research projects), and (3) common HIT barriers to implementation research existed but could be overcome by collaborations with clinical and administrative leadership.

Conclusions: Our review of the implementation research progress in the VA revealed interdependency on an HIT infrastructure and research-based development. Collaboration with multiple stakeholders is a key factor in successful use and development of HIT in implementation research efforts and in advancing evidence-based practice.


Publications from 2003 - 2007


Hynes DM, Koelling K, Stroupe KT, Arnold N, Mallin, K, Sohn, MW, et al. Veterans' Access to and Use of Medicare and Veterans Affairs Health Care. Med Care. March 2007; 45(3):214-223.

Abstract

Objectives: We examined the impact of access to care characteristics on health care use patterns among those veterans dually eligible for Medicare and Veterans Affairs (VA) services.

Methods: We used a retrospective, cross-sectional design to identify veterans who were eligible to use VA and Medicare health care in calendar year 1999. We analyzed national VA utilization and Medicare claims data. We used descriptive and multivariable generalized ordered logit analyses to examine how patient, geographic, and environmental factors affect the percent reliance on VA and Medicare inpatient and outpatient services.

Results: Of the 1.47 million veterans in our study population with outpatient use, 18% were VA-only users, 36% were Medicare-only users, and 46% were both VA and Medicare users. Among veterans with inpatient use, 24% were VA only, 69% were Medicare only, and 6% were both VA and Medicare users. Multivariable analysis revealed that veterans who were black or had a higher VA priority were most likely to rely on the VA. Patient with higher risk scores were most likely to rely on a combination of VA and Medicare health care. Patients who lived farther from VA hospitals were less likely to rely on VA health care, particularly for inpatient care. Patients living in urban areas with more health care resources were less likely to rely on VA health care.

Conclusions: VA health care provides an important safety net for vulnerable populations. Targeted approaches that carefully consider the simultaneous impacts of VA and Medicare policy changes on minority and high-risk populations are essential to ensure veterans have access to needed health care.


Hynes DM, Koelling K, Stroupe KT, Arnold N, Mallin, K, Sohn, MW, et al. Veterans' Access to and Use of Medicare and Veterans Affairs Health Care. Med Care. March 2007; 45(3):214-223.

Abstract

Objectives: We examined the impact of access to care characteristics on health care use patterns among those veterans dually eligible for Medicare and Veterans Affairs (VA) services.

Methods: We used a retrospective, cross-sectional design to identify veterans who were eligible to use VA and Medicare health care in calendar year 1999. We analyzed national VA utilization and Medicare claims data. We used descriptive and multivariable generalized ordered logit analyses to examine how patient, geographic, and environmental factors affect the percent reliance on VA and Medicare inpatient and outpatient services.

Results: Of the 1.47 million veterans in our study population with outpatient use, 18% were VA-only users, 36% were Medicare-only users, and 46% were both VA and Medicare users. Among veterans with inpatient use, 24% were VA only, 69% were Medicare only, and 6% were both VA and Medicare users. Multivariable analysis revealed that veterans who were black or had a higher VA priority were most likely to rely on the VA. Patient with higher risk scores were most likely to rely on a combination of VA and Medicare health care. Patients who lived farther from VA hospitals were less likely to rely on VA health care, particularly for inpatient care. Patients living in urban areas with more health care resources were less likely to rely on VA health care.

Conclusions: VA health care provides an important safety net for vulnerable populations. Targeted approaches that carefully consider the simultaneous impacts of VA and Medicare policy changes on minority and high-risk populations are essential to ensure veterans have access to needed health care.

Sohn MW, Zhang H, Arnold N, Stroupe KT, Taylor BC, Wilt TJ, et al. Transition to the New Race/Ethnicity Data Collection Standards in the Department of Veterans Affairs. Popul Health Metr. Jul 6 2006; 4:7.

Abstract

Background: Patient race in the Department of Veterans Affairs (VA) information system was previously recorded based on an administrative or clinical employee's observation. Since 2003, the VA started to collect self-reported race in compliance with a new federal guideline. We investigated the implications of this transition for using race/ethnicity data in multi-year trends in the VA and in other healthcare data systems that make the transition.

Methods: All unique users of VA healthcare services with self-reported race/ethnicity data in 2004 were compared with their prior observer-recorded race/ethnicity data from 1997-2002 (N = 988,277).

Results: In 2004, only about 39% of all VA healthcare users reported race/ethnicity values other than "unknown" or "declined." Females reported race/ethnicity at a lower rate than males (27% vs. 40%; p < 0.001). Over 95% of observer-recorded data agreed with self-reported data. Compared with the patient self-reported data, the observer-recorded White and African American races were accurate for 98% (kappa = 0.89) and 94% (kappa = 0.93) individuals, respectively. Accuracy of observer-recorded races was much worse for other minority groups with kappa coefficients ranging between 0.38 for American Indian or Alaskan Natives and 0.79 for Hispanic Whites. When observer-recorded race/ethnicity values were reclassified into non-African American groups, they agreed with the self-reported data for 98% of all individuals (kappa = 0.93).

Conclusions: For overall VA healthcare users, the agreement between observer-recorded and self-reported race/ethnicity was excellent and observer-recorded and self-reported data can be used together for multi-year trends without creating serious bias. However, this study also showed that observation was not a reliable method of race/ethnicity data collection for non-African American minorities and racial disparity might be underestimated if observer-recorded data are used due to systematic patterns of inaccurate race/ethnicity assignments.


Sohn MW, Arnold N, Maynard C, Hynes DM. Accuracy and Completeness of Mortality Data in the Department of Veterans Affairs. Popul Health Metr. Apr 10 2006; 4:2.

Abstract

Background: One of the national mortality databases in the U.S. is the Beneficiary Identification and Record Locator Subsystem (BIRLS) Death File that contains death dates of those who have received any benefits from the Department of Veterans Affairs (VA). The completeness of this database was shown to vary widely from cohort to cohort in previous studies. Three other sources of death dates are available in the VA that can complement the BIRLS Death File. The objective of this study is to evaluate the completeness and accuracy of death dates in the four sources available in the VA and to examine whether these four sources can be combined into a database with improved completeness and accuracy.

Methods: A random sample of 3,000 was drawn from 8.3 million veterans who received benefits from the VA between 1997 and 1999 and were alive on January 1, 1999 according to at least one source. Death dates found in BIRLS Death File, Medical SAS Inpatient Datasets, Medicare Vital Status, and Social Security Administration (SSA) Death Master File were compared with dates obtained from the National Death Index. A combined dataset from these sources was also compared with National Death Index dates.

Results: Compared with the National Death Index, sensitivity (or the percentage of death dates correctly recorded in a source) was 77.4% for BIRLS Death File, 12.0% for Medical SAS Inpatient Datasets, 83.2% for Medicare Vital Status, and 92.1% for SSA Death Master File. Over 95% of death dates in these sources agreed exactly with dates from the National Death Index. Death dates in the combined dataset demonstrated 98.3% sensitivity and 97.6% exact agreement with dates from the National Death Index.

Conclusion: The BIRLS Death File is not an adequate source of mortality data for the VA population due to incompleteness. When the four sources of mortality data are carefully combined, the resulting dataset can provide more timely data for death ascertainment than the National Death Index and has comparable accuracy and completeness.


Kraft MR, Hynes DM. Decision Support Within the Veterans' Health Administration. Stud Health Technol Inform. July 2006; 122:100-104.

Abstract

The Decision Support System (DSS) of the Veterans Health Administration (VHA) uses available data sources to produce information that supports strategic management and planning. At the same time, the clinical information in the system is useful for measurement of performance and quality of care initiatives. Clinical decision makers can correlate processes of care with outcomes to refine best practices and determine if treatment/monitoring standards are met. The DSS information has also proven to be very useful for health services researchers.

Note: The Decision Support System (DSS) is now known as the Managerial Cost Accounting (MCA) System.


Kraft MR, Androwich, I. Clinical Decision Support Systems. in Saba, VK; McCormick, KA, editors. Essentials of Nursing Informatics 4th Ed. 2006; New York: McGraw-Hill, Medical Pub. Division.


Sohn MW, Zhang H, Arnold N, Stroupe KT, Taylor BC, Wilt TJ, et al. Transition to the New Race/Ethnicity Data Collection Standards in the Department of Veterans Affairs. Popul Health Metr. Jul 6 2006; 4:7.

Abstract

Background: Patient race in the Department of Veterans Affairs (VA) information system was previously recorded based on an administrative or clinical employee's observation. Since 2003, the VA started to collect self-reported race in compliance with a new federal guideline. We investigated the implications of this transition for using race/ethnicity data in multi-year trends in the VA and in other healthcare data systems that make the transition.

Methods: All unique users of VA healthcare services with self-reported race/ethnicity data in 2004 were compared with their prior observer-recorded race/ethnicity data from 1997-2002 (N = 988,277).

Results: In 2004, only about 39% of all VA healthcare users reported race/ethnicity values other than "unknown" or "declined." Females reported race/ethnicity at a lower rate than males (27% vs. 40%; p < 0.001). Over 95% of observer-recorded data agreed with self-reported data. Compared with the patient self-reported data, the observer-recorded White and African American races were accurate for 98% (kappa = 0.89) and 94% (kappa = 0.93) individuals, respectively. Accuracy of observer-recorded races was much worse for other minority groups with kappa coefficients ranging between 0.38 for American Indian or Alaskan Natives and 0.79 for Hispanic Whites. When observer-recorded race/ethnicity values were reclassified into non-African American groups, they agreed with the self-reported data for 98% of all individuals (kappa = 0.93).

Conclusions: For overall VA healthcare users, the agreement between observer-recorded and self-reported race/ethnicity was excellent and observer-recorded and self-reported data can be used together for multi-year trends without creating serious bias. However, this study also showed that observation was not a reliable method of race/ethnicity data collection for non-African American minorities and racial disparity might be underestimated if observer-recorded data are used due to systematic patterns of inaccurate race/ethnicity assignments.


Sohn MW, Arnold N, Maynard C, Hynes DM. Accuracy and Completeness of Mortality Data in the Department of Veterans Affairs. Popul Health Metr. Apr 10 2006; 4:2.

Abstract

Background: One of the national mortality databases in the U.S. is the Beneficiary Identification and Record Locator Subsystem (BIRLS) Death File that contains death dates of those who have received any benefits from the Department of Veterans Affairs (VA). The completeness of this database was shown to vary widely from cohort to cohort in previous studies. Three other sources of death dates are available in the VA that can complement the BIRLS Death File. The objective of this study is to evaluate the completeness and accuracy of death dates in the four sources available in the VA and to examine whether these four sources can be combined into a database with improved completeness and accuracy.

Methods: A random sample of 3,000 was drawn from 8.3 million veterans who received benefits from the VA between 1997 and 1999 and were alive on January 1, 1999 according to at least one source. Death dates found in BIRLS Death File, Medical SAS Inpatient Datasets, Medicare Vital Status, and Social Security Administration (SSA) Death Master File were compared with dates obtained from the National Death Index. A combined dataset from these sources was also compared with National Death Index dates.

Results: Compared with the National Death Index, sensitivity (or the percentage of death dates correctly recorded in a source) was 77.4% for BIRLS Death File, 12.0% for Medical SAS Inpatient Datasets, 83.2% for Medicare Vital Status, and 92.1% for SSA Death Master File. Over 95% of death dates in these sources agreed exactly with dates from the National Death Index. Death dates in the combined dataset demonstrated 98.3% sensitivity and 97.6% exact agreement with dates from the National Death Index.

Conclusion: The BIRLS Death File is not an adequate source of mortality data for the VA population due to incompleteness. When the four sources of mortality data are carefully combined, the resulting dataset can provide more timely data for death ascertainment than the National Death Index and has comparable accuracy and completeness.


Kraft MR, Hynes DM. Decision Support Within the Veterans' Health Administration. Stud Health Technol Inform. July 2006; 122:100-104.

Abstract

The Decision Support System (DSS) of the Veterans Health Administration (VHA) uses available data sources to produce information that supports strategic management and planning. At the same time, the clinical information in the system is useful for measurement of performance and quality of care initiatives. Clinical decision makers can correlate processes of care with outcomes to refine best practices and determine if treatment/monitoring standards are met. The DSS information has also proven to be very useful for health services researchers.

Note: The Decision Support System (DSS) is now known as the Managerial Cost Accounting (MCA) System.


Kraft MR, Androwich, I. Clinical Decision Support Systems. in Saba, VK; McCormick, KA, editors. Essentials of Nursing Informatics 4th Ed. 2006; New York: McGraw-Hill, Medical Pub. Division.


Hynes DM, Perrin RA, Rappaport S, Stevens JM, Demakis JG. Informatics Resources to Support Health Care Quality Improvement in the Veterans Health Administration. J Am Med Inform Assoc. September 2004; 11(5):344-350.

Abstract

Information systems are increasingly important for measuring and improving health care quality. A number of integrated health care delivery systems use advanced information systems and integrated decision support to carry out quality assurance activities, but none as large as the Veterans Health Administration (VHA). The VHA's Quality Enhancement Research Initiative (QUERI) is a large-scale, multidisciplinary quality improvement initiative designed to ensure excellence in all areas where VHA provides health care services, including inpatient, outpatient, and long-term care settings. In this paper, we describe the role of information systems in the VHA QUERI process, highlight the major information systems critical to this quality improvement process, and discuss issues associated with the use of these systems.


Perrin R, Stevens JM. Facilitating the Translation of Research Into Practice. QUERI Quarterly. March 2004;(6).


Cowper DC, Yu W, Kuebeler M, Kubal JD, Manheim LM, Ripley BA. Using GIS in Government: an Overview of the VHA's Healthcare Atlas, FY-2000. J Med Syst. Jun 2004; 28(3):257-269.

Abstract

The amount of VA data available for analysis can be overwhelming to individuals who need to translate these data into usable information. The Atlas, using current GIS technology, was funded to provide data in a comprehensive guide. Patients were identified using a disease classification scheme based on Kaiser Permanente methodology and the Clinical Classifications Software (AHRQ). Utilization data were extracted from the Medical SAS Datasets. Cost data were obtained from the HERC. GIS tools were used to create the Atlas. The Atlas overviews the location of VA hospitals; profiles veteran, VA enrollee and patient populations; examines overall utilization; depicts patterns in healthcare use by specific disease cohorts; and examines geographic variations in costs. This product will enhance knowledge of VA's enrolled patient population and their healthcare needs, and provide background information that will improve the formulation of specific research questions to address those needs.


Hynes DM, Perrin RA, Rappaport S, Stevens JM, Demakis JG. Informatics Resources to Support Health Care Quality Improvement in the Veterans Health Administration. J Am Med Inform Assoc. September 2004; 11(5):344-350.

Abstract

Information systems are increasingly important for measuring and improving health care quality. A number of integrated health care delivery systems use advanced information systems and integrated decision support to carry out quality assurance activities, but none as large as the Veterans Health Administration (VHA). The VHA's Quality Enhancement Research Initiative (QUERI) is a large-scale, multidisciplinary quality improvement initiative designed to ensure excellence in all areas where VHA provides health care services, including inpatient, outpatient, and long-term care settings. In this paper, we describe the role of information systems in the VHA QUERI process, highlight the major information systems critical to this quality improvement process, and discuss issues associated with the use of these systems.


Perrin R, Stevens JM. Facilitating the Translation of Research Into Practice. QUERI Quarterly. March 2004;(6).


Cowper DC, Yu W, Kuebeler M, Kubal JD, Manheim LM, Ripley BA. Using GIS in Government: an Overview of the VHA's Healthcare Atlas, FY-2000. J Med Syst. Jun 2004; 28(3):257-269.

Abstract

The amount of VA data available for analysis can be overwhelming to individuals who need to translate these data into usable information. The Atlas, using current GIS technology, was funded to provide data in a comprehensive guide. Patients were identified using a disease classification scheme based on Kaiser Permanente methodology and the Clinical Classifications Software (AHRQ). Utilization data were extracted from the Medical SAS Datasets. Cost data were obtained from the HERC. GIS tools were used to create the Atlas. The Atlas overviews the location of VA hospitals; profiles veteran, VA enrollee and patient populations; examines overall utilization; depicts patterns in healthcare use by specific disease cohorts; and examines geographic variations in costs. This product will enhance knowledge of VA's enrolled patient population and their healthcare needs, and provide background information that will improve the formulation of specific research questions to address those needs.


Demakis JG. The Cost of VA Care: Lessons of the Evaluating VA Costs Study. Preface. Med Care. Jun 2003; 41(6 suppl):II-1.


Smith MW, Joseph GJ. Pharmacy Data in the VA Health Care System. Med Care Res Rev. Sep 2003; 60(3 suppl):92S-123S.

Abstract

Recent advances in Department of Veterans Affairs (VA) health care data systems have greatly increased access to operational pharmacy information. This article presents a brief guide to VA pharmacy data sources: the Veterans Health Information Systems and Technology Architecture files, the Pharmacy Benefits Management database, Decision Support System (DSS) National Data Extracts for inpatient and outpatient care, the planned DSS National Pharmacy Extract, DSS databases at local VA facilities, and the Non-VA Fee Basis files. Depending on the source, available data elements include patient demographics, clinical care information, characteristics of the medication and of the prescribing physician, and cost. Access policies are detailed for VA and non-VA researchers. Linking these sources to VA databases containing data on inpatient and outpatient services offers a comprehensive view of health care within several VA populations of general interest, including people over age 65 and those with physical and psychiatric disabilities.

Note: The Decision Support System (DSS) is now known as the Managerial Cost Accounting (MCA) System.


Demakis JG. The Cost of VA Care: Lessons of the Evaluating VA Costs Study. Preface. Med Care. Jun 2003; 41(6 suppl):II-1.


Smith MW, Joseph GJ. Pharmacy Data in the VA Health Care System. Med Care Res Rev. Sep 2003; 60(3 suppl):92S-123S.

Abstract

Recent advances in Department of Veterans Affairs (VA) health care data systems have greatly increased access to operational pharmacy information. This article presents a brief guide to VA pharmacy data sources: the Veterans Health Information Systems and Technology Architecture files, the Pharmacy Benefits Management database, Decision Support System (DSS) National Data Extracts for inpatient and outpatient care, the planned DSS National Pharmacy Extract, DSS databases at local VA facilities, and the Non-VA Fee Basis files. Depending on the source, available data elements include patient demographics, clinical care information, characteristics of the medication and of the prescribing physician, and cost. Access policies are detailed for VA and non-VA researchers. Linking these sources to VA databases containing data on inpatient and outpatient services offers a comprehensive view of health care within several VA populations of general interest, including people over age 65 and those with physical and psychiatric disabilities.

Note: The Decision Support System (DSS) is now known as the Managerial Cost Accounting (MCA) System.


Publications 2002 and Prior


Murphy PA. VIReC Begins Fifth Year With New Initiatives. VA Research Currents. Dec 2002.


Cowper DC, Kubal JD, Maynard C, Hynes DM. A Primer and Comparative Review of Major US Mortality Databases. Ann Epidemiol. October 2002; 12(7):462-468.

Abstract

Purpose: Mortality data are important tools for research requiring vital status information. We reviewed the major mortality databases and mortality ascertainment services available in the United States, including the National Death Index (NDI), the Social Security Administration (SSA) files, and the Department of Veterans Affairs databases.

Methods: The content, reliability, and accuracy of mortality sources are described and compared. We also describe how investigators can gain access to these resources and provide further contact information.

Results: We reviewed the accuracy of major mortality sources. The sensitivity (i.e., the proportion of the true number of deaths) of the NDI ranged from 87.0% to 97.9%, whereas the sensitivity for the VA Beneficiary Identification and Records Locator System (BIRLS) ranged between 80.0% and 94.5%. The sensitivity of SSA files ranged between 83.0% and 83.6%. Sensitivity for the VA Patient Treatment File (PTF) was 33%.

Conclusions: While several national mortality ascertainment services are available for vital status (i.e., death) analyses, the NDI information demonstrated the highest sensitivity and, currently, it is the only source at the national level with a cause of death field useful for research purposes. Researchers must consider methods used to ascertain vital status as well as the quality of the information in mortality databases.


Murphy PA, Cowper DC, Seppala G, Stroupe KT, Hynes DM. Veterans Health Administration Inpatient and Outpatient Care Data: an Overview. Eff Clin Pract. May 2002; 5(3 Suppl):E4.


Hynes DM, Cowper DC, Kerr M, Kubal JD, Murphy PA. Database and Informatics Support for QUERI: Current Systems and Future Needs. Quality Enhancement Research Initiative. Med Care. June 2000; 38(6 Suppl 1):I-114-I-128.

Abstract

Objectives: Our primary objective is to provide an overview of database and informatics support for the Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI).

Methods: We discuss the role of information technology resources in the QUERI process. We also review current VA information systems and specific databases in terms of strengths and weaknesses for addressing the QUERI goals. A synthesis of the issues and strategies for addressing specific data needs are presented by use of examples from 2 of the QUERI disease modules: Diabetes Mellitus and Human Immunodeficiency Virus. Finally, we discuss issues that need to be considered during development of new information systems to address the needs of clinical quality-improvement efforts.

Conclusions: Quality enhancement in VA health care requires coordination and careful planning among clinical, administrative, research, policy, and information technology leaders to ensure that key clinical process and outcome measures are reliably collected in the VA information systems. As the QUERI progresses, data needs will probably shift from addressing data gaps to developing approaches for feedback and evaluation. Continued and enhanced cooperation among all VHA business processes is vital to the success of the QUERI.


Hynes DM. Research As a Key to Promoting and Sustaining Innovative Practice. Nurs Clin North A. June 2000; 35(2):453-459.

Abstract

During the past decade, we have witnessed increasing emphasis on the integration of research and clinical care with the evolution of evidence-based practice and best practices. The principles underlying evidence-based medicine and best practices are fundamental to understanding the interdependence of research and innovation. These principles helped guide the US Department of Veterans Affairs (VA) Nursing Innovations Task Force to review and critique programs at VA health care facilities across the United States. This article reviews how the task force applied concepts and principles of evidence-based practice to identify innovative practices at VA health care facilities. Also described are task force recommendations to foster innovative practice through increased nursing research capacity, and strategies are suggested for applying these principles in other health care settings.


Kubal JD, Webber S, Cowper DC, Hynes DM. VIReC: Promoting Information Sharing in the Health Services Research Community. Federal Practitioner. October 2000; 17(10):13-14.


Kubal JD. VA Information Resource Center: Your Guide to VA Data. Veterans Health Systems Journal. April 2000; 5(4):21-23.


Kubal JD. Database Information Available From New VA Center. Medical Geography Newsletter. January 2000; 17(1):7.


Cowper DC, Hynes DM. Solid Data, Solid Research: A Response From the VA Information Resource Center. Forum (Genova). November 1999.

Abstract

In keeping with the Veterans Health Administration (VHA) goal of becoming the Nation's state-of-the-art health care system, improving current information systems for better assessment of patient outcomes, reimbursement rates, quality of care, and customer service is essential. This challenge requires that information systems serve multiple purposes and be easily accessible to potential users: policy makers, researchers, managers, and clinicians. Part of this endeavor includes the compilation of available information and the creation of a dynamic system to disseminate this information to individuals who can use it to implement necessary changes.


Cowper DC, Hynes DM, Kubal JD, Murphy PA. Using Administrative Databases for Outcomes Research: Select Examples From VA Health Services Research and Development. J Med Syst. June 1999; 23(3):249-259.

Abstract

The U.S. Department of Veterans Affairs (VA) operates and maintains one of the largest health care systems under a single management structure in the world. The coordination of administrative and clinical information on veterans served by the VA health care system is a daunting and critical function of the Department. This article provides an overview of VA Health Services Research and Development Service initiatives to assist researchers in using extant VA databases to study patient-centered health care outcomes. As examples, studies using the VA's Patient Treatment File (PTF) and the Beneficiary Identification and Records Locator System (BIRLS) Death File are described.


Guihan M, Weaver FM, Cowper DC, Nydam T, Miskevics S. Using Department of Veterans Affairs Databases to Examine Long Term Care Utilization for Men and Women Veterans. J Med Syst. 1999; 23:201-218.

Abstract

We examined long-term care (LTC) utilization by male and female veterans using administrative databases maintained by VA. Research questions included: (1) Which LTC services are utilized? (2) Do utilization patterns of older veterans differ from those of elderly persons in the general U.S. population? (3) Do LTC needs of veterans vary by gender? We were unable to track LTC utilization of individuals across administrative databases. Some databases could only provide information at the national level, or alternatively, were available only at local facilities, or only at the patient or program-level data--making it impossible to get a clear picture of all the services received by an individual. Those planning to use administrative databases to conduct research must: (1) take more time than expected; (2) be flexible/willing to compromise, (3) "ferret out" information, and (4) recognize that because of dynamism inherent in information systems, results may change over time.


Kubal JD, Guihan M, Hynes DM, Cowper DC. The Long-Term Care Database Guide: A Resource on VA Community Based Programs. Illinois Morbity and Mortality Review. 1998; 3(4):10-15.


Journal Supplements


Health Information Technology in VHA Quality Improvement Research

Medical Care
Volume 51, March 2013

VIReC collaborated with Medical Care to publish a supplement focusing on the use and impact of health information technology (HIT) in quality improvement (QI) research conducted within the VHA. Topics addressed in the foreword and introduction include the state of VHA informatics research and the evolution of HIT within the VHA’s Quality Enhancement Research Initiative (QUERI) program. The 8 peer-reviewed articles and reports highlight various HIT approaches, including innovative and interactive uses of VHA’s electronic health record, databases, and information systems.

A list of the articles in the issue is provided below. The articles are available on the Medical Care website.

Foreword & Introduction


The Future of Health Information Technology: Implications for Research

Authors: Atkins, David; Cullen, Theresa


Health Information Technology in VHA Quality Improvement Research Overview

Authors: Hynes, Denise M.


Health Information Technology and Implementation Science: Partners in Progress in the VHA

Authors: Hynes, Denise M.; Whittier, Erika R.; Owens, Arika


Original Articles


Using Patient-facing Kiosks to Support Quality Improvement at Mental Health Clinics

Authors: Cohen, Amy N.; Chinman, Matthew J.; Hamilton, Alison B.; Whelan, Fiona; Young, Alexander S.


Patient-Provider Secure Messaging in VA: Variations in Adoption and Association With Urgent Care Utilization

Authors: Shimada, Stephanie L.; Hogan, Timothy P.; Rao, Sowmya R.; Allison, Jeroan J.; Quill, Ann L.; Feng, Hua; Phillips, Barrett D.; Nazi, Kim M.; Haidary, Susan T.; Houston, Thomas K.


VHA Mental Health Information System: Applying Health Information Technology to Monitor and Facilitate Implementation of VHA Uniform Mental Health Services Handbook Requirements

Authors: Trafton, Jodie A.; Greenberg, Greg; Harris, Alex H. S.; Tavakoli, Sara; Kearney, Lisa; McCarthy, John; Blow, Fredric; Hoff, Rani; Schohn, Mary


Redesign of an Electronic Clinical Reminder to Prevent Falls in Older Adults

Authors: Spears, Gwendolyn V.; Roth, Carol P.; Miake-Lye, Isomi M.; Saliba, Debra; Shekelle, Paul G.; Ganz, David A.


Chronic Disease Management for Recently Homeless Veterans: A Clinical Practice Improvement Program to Apply Home Telehealth Technology to a Vulnerable Population

Authors: Gabrielian, Sonya; Yuan, Anita; Andersen, Ronald M.; McGuire, James; Rubenstein, Lisa; Sapir, Negar; Gelberg, Lillian


Brief Reports


Evaluating Patient Access to Electronic Health Records: Results From a Survey of Veterans

Authors: Nazi, Kim M.; Hogan, Timothy P.; McInnes, D. Keith; Woods, Susan S.; Graham, Gail


Feasibility of Proactive Medical Device Surveillance: The VA Clinical Assessment Reporting and Tracking (CART) Program

Authors: Tsai, Thomas T.; Box, Tamara L.; Gethoffer, Hans; Noonan, Gregory; Varosy, Paul D.; Maddox, Thomas M.; Fihn, Stephan D.; Gross, Thomas P.; Jesse, Robert L.; Rumsfeld, John S.


Development and Evaluation of an Internet and Personal Health Record Training Program for Low-income Patients With HIV or Hepatitis C

Authors: McInnes, D. Keith; Solomon, Jeffrey L.; Shimada, Stephanie L.; Petrakis, Beth A.; Bokhour, Barbara G.; Asch, Steven M.; Nazi, Kim M.; Houston, Thomas K.; Gifford, Allen L.


Quality and Utility of Secondary Data for VA Research

Journal of Rehabilitation Research & Development
Volume 47, Issue 8, November 2010

VIReC collaborated with the Journal of Rehabilitation Research & Development (JRRD) to publish a special issue focused on data commonly used in research on Veterans. The 13 peer-reviewed studies and 2 editorials in this issue are representative of the vast stores of information about VA data that researchers generate nationwide in the normal course of their data analysis activities.

A list of the articles contained in the issue is provided below. The full text of the articles is available on the JRRD website.

Guest Editorials


Advancing Veterans' healthcare using electronic data: Lessons learned from researchers in the field

Authors: Tarlov, Elizabeth; Stroupe, Kevin


Transformation of VHA health data into clinically useful information to provide quality Veteran care

Authors: Eisen, Seth; Francis, Joseph


Articles


Using VA data for research in persons with spinal cord injuries and disorders (SCI/D): Lessons from SCI QUERI

Authors: Smith, Bridget; Evans, Charlesnika; Ullrich, Philip; Burns, Stephen; Guihan, Marylou


Accuracy of external cause-of-injury coding in VA polytrauma patient discharge records

Authors: Carlson, Kathleen; Nugent, Sean; Grill, Joseph; Sayer, Nina


Are VHA administrative location codes valid indicators of specialty substance use Disorder Treatment?

Authors: Harris, Alex; Reeder, Rachelle; Ellerbe, Laura; Bowe, Thomas


Mental illness-related disparities in length of stay: Algorithm choice influences results

Authors: Frayne, Susan; Berg, Eric; Holmes, Tyson; Laungani, Kaajal; Berlowitz, Dan


Can administrative data identify active diagnoses for the Minimum Data Set?

Authors: Berlowitz, Dan; Hickey, Elaine; Saliba, Debra


Matching prosthetics order records in the VA National Prosthetics Patient Database (NPPD) to health care utilization databases

Authors: Smith, Mark; Su, Pon; Phibbs, Ciaran


VHA corporate data warehouse height & weight data: Opportunities and challenges for health services research

Authors: Noel, Polly; Copeland, Laurel; Perrin, Ruth; Lancaster, Betsy; Pugh, Mary Jo


Validation of erythropoietin utilization data on Medicare's end-stage renal disease medical evidence report

Authors: Fischer, Michael; Stroupe, Kevin; Hynes, Denise; Blemur, Pierre; Sohn, Min-Woong; Browning, Margaret; PhD; Huo, Zhiping MS; O'Hare, Ann M. MD; Kaufman, James S.


Creating a sampling frame for population-based Veteran research: Representativeness and overlap of VA and Department of Defense databases

Authors: Washington, Donna; Sun, Su; Canning, Mark


What can Medicaid data add to research on VA patients?

Authors: Hendricks, Ann; Gardner, John; Gilden, Daniel; Prentice, Julia; Wolfsfeld, Lynn


Utility of Medicare and DoD data for improving VA race data quality

Authors: Stroupe, Kevin; Tarlov, Elizabeth; Zhang, Qiuying; Haywood, Thomas; Owens, Arika; Hynes, Denise


Using the Medicare current beneficiary survey to conduct research on Medicare-eligible Veterans

Authors: Jonk, Yvonne; O'Connor, Heidi; Schult, Tamara; Cutting, Andrea; Feldman, Roger


A brief report: A comparison of methods to identify Iraq and Afghanistan war Veterans using VA administrative data

Authors: Bangerter, AnnMarie; Gravely, Amy; Cutting, Andrea; Clothier, Barb; Sayer, Nina