Todd Wagner is a Professor in the Department of Surgery at Stanford University. He studies health information, efficiency and value, and health care access. He is particularly interested in developing learning health care systems that provide high value care. In addition to his role at Stanford, he Directs the Health Economics Resource Center at the Palo Alto VA, where he is a VA Research Career Scientist and he co-directs the VA/NCI Big Data Fellowship.

Academic Appointments

Clinical Trials

  • Bronchitis and Emphysema Advice and Training to Reduce Hospitalization Not Recruiting

    EXECUTIVE SUMMARY: Purpose: To evaluate the efficacy and cost-effectiveness of a novel intervention incorporating self-management education, an action plan, and case-management to decrease the risk of hospitalizations due to chronic obstructive pulmonary disease (COPD) among veterans with severe COPD. Hypotheses: Primary Hypothesis: Veterans with COPD who receive a self-management program incorporating education sessions, development of an action plan, and case-management will have a decreased risk of COPD hospitalization compared to standardized COPD care. Primary Objective: In an intent-to-treat analysis, determine the efficacy of a comprehensive self-management program for reducing the risk of COPD hospitalization in veterans with severe COPD in comparison to patients receiving standardized COPD care. Secondary Hypotheses: Compared with standardized COPD care, veterans with COPD who receive a comprehensive self-management intervention will have: A) decreased health-related costs resulting from decreased hospitalizations and outpatient utilization, B) decreased hospitalization rates and average length of stay due to both COPD and all-cause admissions, and C) improvement in a set of outcomes including mortality, health-related quality of life, medication adherence, patient satisfaction, disease knowledge, skill acquisition and self-efficacy. Secondary Objectives: To evaluate the healthcare costs, hospitalization days, mortality, adherence, and health outcomes of a comprehensive self-management program compared to standardized COPD care among patients with severe COPD measured by: A)Healthcare-related costs B)Health services use due to COPD and to all causes C)Clinical outcome measures 1. Mortality 2. Health-related quality of life measured by generic and COPD-specific measures 3. Patient satisfaction 4. Medication adherence 5. Disease knowledge, skill acquisition and self-efficacy In the proposed study, 960 veterans with severe COPD hospitalized in the previous year will be randomly assigned to either a comprehensive case management program or standardized COPD care. The comprehensive group will receive an initial, intense education program with development of an action plan, and regular telephone contacts by a case manager in addition to standardized COPD care. Patients allocated to the control arm will receive standardized care that incorporates guideline-based recommendations including influenza vaccination, a short-acting bronchodilator, and either a long-acting bronchodilator or inhaled corticosteroid inhaler. The study will be conducted in 2 phases, a 12-month feasibility study conducted at 6 VA sites followed by the full study in which an additional 8 sites will enroll patients over the next 24 months. As a result, 180 patients will be initially enrolled in the feasibility study over the first year and the remaining 780 patients will be enrolled in the second and third years of the study when the full study is implemented. Subjects will be followed until the completion of the study, for at least one, and up to four years. The primary outcome is time to first COPD hospitalization.

    Stanford is currently not accepting patients for this trial.

    View full details

  • Drug-Eluting Stents vs. Bare Metal Stents In Saphenous Vein Graft Angioplasty Not Recruiting

    Patients who have undergone coronary bypass surgery have had a vein removed from the leg and implanted in the chest to "bypass" blockages in the coronary arteries. These veins are called saphenous vein grafts or SVGs. SVGs often develop blockages that can cause chest pain and heart attacks. SVG blockages can be opened by using small balloons and stents (metal coils that keep the artery open). Two types of stents are currently used: bare metal stents (BMS) and drug-eluting stents (DES). Both BMS and DES are made of metal. DES are also coated with a drug that releases into the wall of the blood vessel to prevent scar tissue from forming and re-narrowing the vessel. Both stents have advantages and disadvantages: DES require taking special blood thinners (called thienopyridines, such as clopidogrel or prasugrel) longer than bare metal stent and could have more bleeding but are also less likely to renarrow. Both BMS and DES are routinely being used in SVGs, but it is not known which one is better. Neither bare metal (except for an outdated model) nor drug-eluting stents are FDA approved for use in SVGs. The purpose of CSP#571 is to compare the outcomes after DES vs. BMS use in SVGs. In CSP#571 patients who need stenting of SVG blockages will be randomized to receive DES or BMS in a 1:1 ratio. Per standard practice, patients will receive 12 months of an open label thienopyridine if they have acute coronary syndrome (ACS), or if they have another clinical reason for needing the medication. Patients without ACS who receive DES also need to take 12 months of a thienopyridine whether or not they are in the study, but non-ACS patients who receive a BMS do not. In order to make sure patients do not know which stent they received, non-ACS patients who received BMS will receive 1 month of open label thienopyridine followed by 11 months of blinded placebo, while those who received DES will receive 1 month of open label thienopyridine followed by 11 months of blinded clopidogrel, which is a thienopyridine. All study patients will be followed in the clinic for at least 1 year after their stenting procedure to see if there is a difference in the rate of cardiac death, heart attack, or any procedure that is required in order to increase the flow of blood to and from the heart between the BMS and DES groups.

    Stanford is currently not accepting patients for this trial. For more information, please contact Todd Wagner, (650) 493 - 5000.

    View full details

  • Outcomes Following Myocardial Revascularization: On and Off Cardiopulmonary Bypass Not Recruiting

    Ischemic heart disease is one of the most frequent diagnoses in the VA system. Moreover, 5,819 coronary artery bypass graft (CABG-only) procedures were performed in the VA in Fiscal Year (FY) 1999. Throughout VA and non-VA cardiac surgery programs nationwide, myocardial revascularization is now being performed using two surgical techniques. One technique is performed with cardiopulmonary bypass (CPB) usually with cardioplegic arrest ("on-pump") and the other without CPB on a beating heart ("off-pump"). The overall purpose of this proposed randomized, controlled, clinical trial is to rigorously evaluate the impact of using an on-pump versus off-pump surgical technique for coronary artery bypass graft (CABG-only) procedures (performed with a traditional median sternotomy incision) upon patient clinical outcomes and resource utilization.

    Stanford is currently not accepting patients for this trial.

    View full details

  • Radial Artery Versus Saphenous Vein Grafts in Coronary Artery Bypass Surgery Not Recruiting

    VA patients with coronary artery disease and who have agreed to undergo coronary artery bypass graft surgery would be randomized to receive either radial artery or saphenous vein to the study vessel. The primary outcome variable is graft patency at one year.

    Stanford is currently not accepting patients for this trial.

    View full details

  • Robotic Assisted Upper-Limb Neurorehabilitation in Stroke Patients Not Recruiting

    This study will compare robotic training with usual care and intensive comparison therapy to attempt to improve upper extremity function.

    Stanford is currently not accepting patients for this trial.

    View full details

  • ROOBY Trial Follow-up Extension Not Recruiting

    The Department of Veterans Affairs "Randomized On/Off Bypass" (ROOBY) Trial (CSP #517) was funded in 2001. ROOBY was designed to compare the short-term (30-day) and intermediate-term (1-year) outcomes for patients undergoing off-pump versus on-pump coronary artery bypass graft (CABG) procedures. The ROOBY trial reported a significantly higher 1-year adverse composite outcome rate (i.e., all-cause death, non-fatal myocardial infarction (MI) and/or repeat revascularization) for off-pump versus on-pump patients. ROOBY documented that a higher percentage of off-pump patients received fewer grafts than originally planned (i.e., off-pump patients were less completely revascularized) as compared to on-pump patients. Across all anatomic regions of the heart, the 1-year graft patency rates were significantly lower for off-pump CABG patients. Based on these ROOBY trial initial findings, critically important clinical questions related to the long-term efficacy, stability and durability of the off-pump versus on-pump techniques have been raised. Extending the original ROOBY trial, this CSP #517 follow-up study (CSP 517-FS) will evaluate the longer-term impact of off-pump versus on-pump surgical approaches upon the future occurrence of major adverse cardiovascular events (MACE).

    Stanford is currently not accepting patients for this trial.

    View full details

  • Spinal Cord Injury Vocational Integration Program (SCI-VIP) Not Recruiting

    This study involves research about how to help Veterans with spinal cord injury (SCI) gain employment. During the first couple of years following SCI, many people are concentrating on their rehabilitation and are unable to afford the time for return to work. However, studies have shown people often regain the necessary strength and function about two years after SCI to resume activities of daily living very similar to what they experienced prior to the SCI. Even though many social and legal efforts have been made in the last decade to improve chances for people with disabilities to return to work, Veterans with SCI are sometimes hindered in finding employment because of age, past work history, and many other factors. Other Veterans with SCI are very successful at finding employment either working for themselves or working for a company. The investigators know very little about what issues Veterans with SCI face when they attempt to find employment after SCI. The study will analyze both quantitative and qualitative measures to maximize its findings.

    Stanford is currently not accepting patients for this trial.

    View full details

Stanford Advisees

All Publications

  • Implementation, intervention, and downstream costs for implementation of a multidisciplinary complex pain clinic in the Veterans Health Administration. Health services research Daniels, S. I., Cave, S., Wagner, T. H., Perez, T. A., Edmond, S. N., Becker, W. C., Midboe, A. M. 2024


    OBJECTIVE: To determine the budget impact of implementing multidisciplinary complex pain clinics (MCPCs) for Veterans Health Administration (VA) patients living with complex chronic pain and substance use disorder comorbidities who are on risky opioid regimens.DATA SOURCES AND STUDY SETTING: We measured implementation costs for three MCPCs over 2years using micro-costing methods. Intervention and downstream costs were obtained from the VA Managerial Cost Accounting System from 2years prior to 2years after opening of MCPCs.STUDY DESIGN: Staff at the three VA sites implementing MCPCs were supported by Implementation Facilitation. The intervention cohort was patients at MCPC sites who received treatment based on their history of chronic pain and risky opioid use. Intervention costs and downstream costs were estimated with a quasi-experimental study design using a propensity score-weighted difference-in-difference approach. The healthcare utilization costs of treated patients were compared with a control group having clinically similar characteristics and undergoing the standard route of care at neighboring VA medical centers. Cancer and hospice patients were excluded.DATA COLLECTION/EXTRACTION METHODS: Activity-based costing data acquired from MCPC sites were used to estimate implementation costs. Intervention and downstream costs were extracted from VA administrative data.PRINCIPAL FINDINGS: Average Implementation Facilitation costs ranged from $380 to $640 per month for each site. Upon opening of three MCPCs, average intervention costs per patient were significantly higher than the control group at two intervention sites. Downstream costs were significantly higher at only one of three intervention sites. Site-level differences were due to variation in inpatient costs, with some confounding likely due to the COVID-19 pandemic. This evidence suggests that necessary start-up investments are required to initiate MCPCs, with allocations of funds needed for implementation, intervention, and downstream costs.CONCLUSIONS: Incorporating implementation, intervention, and downstream costs in this evaluation provides a thorough budget impact analysis, which decision-makers may use when considering whether to expand effective programming.

    View details for DOI 10.1111/1475-6773.14345

    View details for PubMedID 38956400

  • Assessing and Improving Productivity in Primary Care: Proof of Concept Results for a Novel Value-Based Metric. Journal of general internal medicine Tran, L. D., Wagner, T. H., Shekelle, P., Nelson, K. M., Fihn, S. D., Newberry, S., Ghai, I., Curtis, I., Rubenstein, L. V. 2024

    View details for DOI 10.1007/s11606-024-08710-0

    View details for PubMedID 38926317

    View details for PubMedCentralID 7295229

  • Disparities in Access, Quality, and Clinical Outcome for Latino Californians with Colon Cancer. Annals of surgery Dawes, A. J., Rajasekar, G., Arnow, K. D., Trickey, A. W., Harris, A. H., Morris, A. M., Wagner, T. H. 2024


    OBJECTIVE: To compare access, quality, and clinical outcomes between Latino and non-Latino White Californians with colon cancer.SUMMARY BACKGROUND DATA: Racial and ethnic disparities in cancer care remain understudied, particularly among patients who identify as Latino. Exploring potential mechanisms, including differential utilization of high-volume hospitals, is an essential first step to designing evidence-based policy solutions.METHODS: We identified all adults diagnosed with colon cancer between January 1, 2010 and December 31, 2020 from a statewide cancer registry linked to hospital administrative records. We compared survival, access (stage at diagnosis, receipt of surgical care, treatment at a high-volume hospital), and quality of care (receipt of adjuvant chemotherapy, adequacy of lymph node resection) between patients who identified as Latino and as non-Latino White.RESULTS: 75,543 patients met inclusion criteria, including 16,071 patients who identified as Latino (21.3%). Latino patients were significantly less likely to undergo definitive surgical resection (marginal difference [MD] -0.72 percentage points, 95% CI -1.19,-0.26), have an operation in a timely fashion (MD -3.24 percentage points, 95% CI -4.16,-2.32), or have an adequate lymphadenectomy (MD -2.85 percentage points, 95% CI -3.59,-2.12) even after adjustment for clinical and sociodemographic factors. Latino patients treated at high-volume hospitals were significantly less likely to die and more likely to meet access and quality metrics.CONCLUSIONS: Latino colon cancer patients experienced delays, segregation, and lower receipt of recommended care. Hospital-level colectomy volume appears to be strongly associated with access, quality, and survival--especially for patients who identify as Latino--suggesting that directing at-risk cancer patients to high-volume hospitals may improve health equity.

    View details for DOI 10.1097/SLA.0000000000006251

    View details for PubMedID 38407273

  • Mapping the Discharge Process After Surgery. JAMA surgery Graham, L. A., Illarmo, S., Gray, C. P., Harris, A. H., Wagner, T. H., Hawn, M. T., Iannuzzi, J. C., Wren, S. M. 2024


    Care transition models are structured approaches used to ensure the smooth transfer of patients between health care settings or levels of care, but none currently are tailored to the surgical patient. Tailoring care transition models to the unique needs of surgical patients may lead to significant improvements in surgical outcomes and reduced care fragmentation. The first step to developing surgical care transition models is to understand the surgical discharge process.To map the surgical discharge process in a sample of US hospitals and identify key components and potential challenges specific to a patient's discharge after surgery.This qualitative study followed a cognitive task analysis framework conducted between January 1, 2022, and April 1, 2023, in Veterans Health Administration (VHA) hospitals. Observations (n = 16) of discharge from inpatient care after a surgical procedure were conducted in 2 separate VHA surgical units. Interviews (n = 13) were conducted among VHA health care professionals nationwide.Postoperative hospital discharge.Data were coded according to the principles of thematic analysis, and a swim lane process map was developed to represent the study findings.At the hospitals in this study, the discharge process observed for a surgical patient involved multidisciplinary coordination across the surgery team, nursing team, case managers, dieticians, social services, occupational and physical therapy, and pharmacy. Important components for a surgical discharge that were not incorporated in the current care transition models included wound care education and supplies; pain control; approvals for nonhome postdischarge locations; and follow-up plans for wounds, ostomies, tubes, and drains at discharge. Potential challenges to the surgical discharge process included social situations (eg, home environment and caregiver availability), team communication issues, and postdischarge care coordination.These findings suggest that current and ongoing studies of discharge care transitions for a patient after surgery should consider pain control; wounds, ostomies, tubes, and drains; and the impact of challenging social situations and interdisciplinary team coordination on discharge success.

    View details for DOI 10.1001/jamasurg.2023.7539

    View details for PubMedID 38381415

  • The impact of informal caregiving on U.S. Veterans Health Administration utilization and expenditures. Social science & medicine (1982) Jacobs, J. C., Lo, J., Van Houtven, C. H., Wagner, T. H. 2024; 344: 116625


    Few studies have examined the effect of informal care receipt on health care utilization and expenditures while accounting for the potentially endogenous relationship between informal and formal care, and none have examined these relationships for U.S. Veterans. With rapidly increasing investments in caregiver supports over the past decade, including stipends for caregivers, the U.S. Department of Veterans Affairs (VA) needs to better understand the costs and benefits of informal care provision. Using a unique data linkage between the 1998-2010 Health and Retirement Study and VA administrative data (n = 2083 Veterans with 9511 person-wave observations), we applied instrumental variable techniques to understand the effect of care from an adult child on Veterans' two-year VA utilization and expenditures. We found that informal care decreased overall utilization by 53 percentage points (p < 0.001) and expenditures by $19,977 (p < 0.01). These reductions can be explained by informal care decreasing the probability of inpatient utilization by 17 percentage points (p < 0.001), outpatient utilization by 57 percentage points (p < 0.001), and institutional long-term care by 3 percentage points (p < 0.05). There were no changes in the probability of non-institutional long-term care use, though these expenditures decreased by $882 (p < 0.05). Expenditure decreases were greatest amongst medically complex patients. Our results indicate relative alignment between VA's stipend payments, which are based on replacement cost methods, and the monetary benefits derived through VA cost avoidances due to informal care. For health systems considering similar caregiver stipend payments, our findings suggest that the cost of these programs may be offset by informal care substituting for formal care, particularly for higher need patients.

    View details for DOI 10.1016/j.socscimed.2024.116625

    View details for PubMedID 38324974

  • The Practical Realities of Local-Level Economic Evaluations: Toward Informed Decision Making in Health Care. MDM policy & practice Wagner, T. H., Carrandi, A. 2024; 9 (1): 23814683241247151

    View details for DOI 10.1177/23814683241247151

    View details for PubMedID 38638864

  • Sociodemographic Differences in the Impacts of Video-Enabled Tablets on Psychotherapy Usage Among Veterans. Psychiatric services (Washington, D.C.) Gujral, K., Van Campen, J., Jacobs, J., Lo, J., Kimerling, R., Blonigen, D. M., Wagner, T. H., Zulman, D. M. 2023: appips20230134


    To examine potential health disparities due to a broad reliance on telehealth during the COVID-19 pandemic, the authors studied the impact of video-enabled tablets provided by the U.S. Department of Veterans Affairs (VA) on psychotherapy usage among rural versus urban, Black versus White, and female versus male veterans.Psychotherapy usage trends before and after onset of the COVID-19 pandemic were examined among veterans with at least one mental health visit in 2019 (63,764 tablet recipients and 1,414,636 nonrecipients). Adjusted difference-in-differences and event study analyses were conducted to compare psychotherapy usage among tablet recipients and nonrecipients (March 15, 2020-December 31, 2021) 10 months before and after tablet issuance. Analyses were stratified by rurality, sex, and race.Adjusted analyses demonstrated that tablet receipt was associated with increases in psychotherapy visit frequency in every patient group studied (rural, 27.4%; urban, 24.6%; women, 30.5%; men, 24.4%; Black, 20.8%; White, 28.1%), compared with visits before tablet receipt. Compared with men, women had statistically significant tablet-associated psychotherapy visit increases (video visits, 1.2 per year; all modalities, 1.0 per year).VA-issued tablets led to increased psychotherapy usage for all groups examined, with similar increases found for rural versus urban and Black versus White veterans and higher increases for women versus men. Eliminating barriers to Internet access or device ownership may improve mental health care access among underserved or historically disadvantaged populations. VA's tablet program offers insights to inform policy makers' and health systems' efforts to bridge the digital divide.

    View details for DOI 10.1176/

    View details for PubMedID 38088041

  • State-Level Variability in Hospital Presumptive Eligibility Programs. JAMA network open Gibson, A. B., Hendricks, W. D., Arnow, K., Tran, L. D., Wagner, T. H., Knowlton, L. M. 2023; 6 (11): e2345244

    View details for DOI 10.1001/jamanetworkopen.2023.45244

    View details for PubMedID 38015508

  • Do Hospital-Based Emergency Medicaid Programs Benefit Trauma Centers? A Mixed-Methods Analysis. The journal of trauma and acute care surgery Knowlton, L. M., Logan, D. S., Arnow, K., Hendricks, W. D., Gibson, A. B., Tran, L. D., Wagner, T. H., Morris, A. M. 2023


    INTRODUCTION: Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization which can offset patient costs of care, increase access to post-discharge resources, and provide a path to sustain coverage through Medicaid. Less is known about the implications of HPE programs on trauma centers (TCs). We aimed to describe the association with HPE and hospital Medicaid reimbursement, as well as characterize incentives for HPE participation among hospitals and TCs. We hypothesized there would be financial, operational, and mission-based incentives.METHODS: We performed a convergent mixed methods study of HPE hospitals in California (including all verified TCs). We analyzed Annual Financial Disclosure Reports from California's Department of Health Care Access and Information (HCAI) (2005-2021). Our primary outcome was Medicaid net revenue. We also conducted thematic analysis of semi-structured interviews with hospital stakeholders to understand incentives for HPE participation (n = 8).RESULTS: Among 367 California hospitals analyzed, 285 (77.7%) participate in HPE 77 (21%) of which are TCs. As of early 2015, 100% of trauma centers had elected to enroll in HPE. There is a significant positive association between HPE participation and net Medicaid revenue. The highest Medicaid revenues are in HPE level I and level II trauma centers. Controlling for changes associated with the Affordable Care Act, HPE enrollment is associated with increased net patient Medicaid revenue (b = 6.74, p < 0.001) and decreased uncompensated care costs (b = -2.22, p < 0.05). Stakeholder interviewees' explanatory incentives for HPE participation included: reduction of hospital bad debt, improved patient satisfaction and community benefit in access to care.CONCLUSION: HPE programs are a promising pathway not only for long-term insurance coverage for trauma patients, but also play a role in TC viability. Future interventions will target streamlining the HPE Medicaid enrollment process to reduce resource burden on participating hospitals and ensure ongoing patient engagement in the program.LEVEL OF EVIDENCE: Economic/decision study, Level II.

    View details for DOI 10.1097/TA.0000000000004162

    View details for PubMedID 37828656

  • Negotiated Rates for Surgical Cancer Care in the Era of Price Transparency-Prices Reflect Market Competition. Annals of surgery Rochlin, D. H., Rizk, N. M., Matros, E., Wagner, T. H., Sheckter, C. C. 2023


    To measure commercial price variation for cancer surgery within and across hospitals.Surgical care for solid organ tumors is costly and negotiated commercial rates have been hidden from public view. The Hospital Price Transparency Rule, enacted in 2021, requires all hospitals list their negotiated rates on their website, thus opening the door for an examination of pricing for cancer surgery.This was a cross-sectional study using 2021 negotiated price data disclosed US hospitals for the ten most common cancers treated with surgery. Price variation was measured using within- and across-hospital ratios. Commercial rates relative to cancer center designation and the Herfindahl-Hirschman Index at the facility level were evaluated with mixed effects linear regression with random intercepts per procedural code.495,200 unique commercial rates from 2,232 hospitals resulted for the ten most common solid-organ tumor cancers. Gynecologic cancer operations had the highest median rates at $6,035.8/operation compared to bladder cancer surgery at $3,431.0/operation. Compared to competitive markets, moderately and highly concentrated markets were associated with significantly higher rates (HHI 1501-2500, coefficient $513.6, 95% CI, $295.5 - $731.7; HHI >2500, coefficient $1,115.5, 95% CI, $913.7-$1,317.2). National Cancer Institute designation was associated with higher rates, coefficient $3,451.9 (95% CI, -$2,853.2-$4,050.7).Commercial payer-negotiated prices for the surgical management of 10 common, solid-tumor malignancies varied widely both within and across hospitals. Higher rates were observed in less competitive markets. Future efforts should facilitate price competition and limit health market concentration.

    View details for DOI 10.1097/SLA.0000000000006091

    View details for PubMedID 37678179

  • Association of High-Deductible Health Plans and Time to Surgery for Breast and Colon Cancer. Journal of the American College of Surgeons Sheckter, C. C., Rochlin, D. H., Rubenstein, R., Shamsunder, M. G., Morris, A. M., Wagner, T. H., Matros, E. 2023; 237 (3): 473-482


    High-deductible health plans (HDHPs) have been shown to delay timing of breast and colon cancer screening, although the relationship to the timing of cancer surgery is unknown. The objective of this study was to characterize timing of surgery for breast and colon cancer patients undergoing cancer operations following routine screening.Data from the IBM MarketScan Commercial Claims Database from 2007 to 2016 were queried to identify patients who underwent screening mammogram and/or colonoscopy. The calendar quarters of screening and surgery were analyzed with ordinal logistic regression. The time from screening to surgery (time to surgery, TTS) was evaluated using a Cox proportional hazard function.Among 32,562,751 patients who had screening mammograms, 0.7% underwent breast cancer surgery within the following year. Among 9,325,238 patients who had screening colonoscopies, 0.9% were followed by colon cancer surgery within a year. The odds of screening (OR 1.146 for mammogram, 1.272 for colonoscopy; p < 0.001) and surgery (OR 1.120 for breast surgery, 1.219 for colon surgery; p < 0.001) increased each quarter for HDHPs compared to low-deductible health plans. Enrollment in an HDHP was not associated with a difference in TTS. Screening in Q3 or Q4 was associated with shorter TTS compared to screening in Q1 (hazard ratio 1.061 and 1.046, respectively; p < 0.001).HDHPs were associated with delays in screening and surgery. However, HDHPs were not associated with delays in TTS. Interventions to improve cancer care outcomes in the HDHP population should concentrate on reducing barriers to timely screening.

    View details for DOI 10.1097/XCS.0000000000000737

    View details for PubMedID 38085770

  • Association of High-Deductible Health Plans and Time to Surgery for Breast and Colon Cancer JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Sheckter, C. C., Rochlin, D. H., Rubenstein, R., Shamsunder, M. G., Morris, A. M., Wagner, T. H., Matros, E. 2023; 237 (3): 473-482
  • Healthcare costs and use before and after opioid overdose in Veterans Health Administration patients with opioid use disorder. Addiction (Abingdon, England) Joyce, V. R., Oliva, E. M., Garcia, C. C., Trafton, J., Asch, S. M., Wagner, T. H., Humphreys, K., Owens, D. K., Bounthavong, M. 2023


    To compare healthcare costs and use between United States (US) Veterans Health Administration (VHA) patients with opioid use disorder (OUD) who experienced an opioid overdose (OD cohort) and patients with OUD who did not experience an opioid overdose (non-OD cohort).This is a retrospective cohort study of administrative and clinical data.The largest integrated national health-care system is the US Veterans Health Administration's healthcare systems.We included VHA patients diagnosed with OUD from October 1, 2017 through September 30, 2018. We identified the index date of overdose for patients who had an overdose. Our control group, which included patients with OUD who did not have an overdose, was randomly assigned an index date. A total of 66 513 patients with OUD were included for analysis (OD cohort: n = 1413; non-OD cohort: n = 65 100).Monthly adjusted healthcare-related costs and use in the year before and after the index date. We used generalized estimating equation models to compare patients with an opioid overdose and controls in a difference-in-differences framework.Compared with the non-OD cohort, an opioid overdose was associated with an increase of $16 890 [95% confidence interval (CI) = $15 611-18 169; P < 0.001] in healthcare costs for an estimated $23.9 million in direct costs to VHA (95% CI = $22.1 million, $25.7 million) within the 30 days following overdose after adjusting for baseline characteristics. Inpatient costs ($13 515; 95% CI = $12 378-14 652; P < 0.001) reflected most of this increase. Inpatient days (+6.15 days; 95% CI, = 5.33-6.97; P < 0.001), inpatient admissions (+1.01 admissions; 95% CI = 0.93-1.10; P < 0.001) and outpatient visits (+1.59 visits; 95% CI = 1.34-1.84; P < 0.001) also increased in the month after opioid overdose. Within the overdose cohort, healthcare costs and use remained higher in the year after overdose compared with pre-overdose trends.The US Veterans Health Administration patients with opioid use disorder (OUD) who have experienced an opioid overdose have increased healthcare costs and use that remain significantly higher in the month and continuing through the year after overdose than OUD patients who have not experienced an overdose.

    View details for DOI 10.1111/add.16289

    View details for PubMedID 37465971

  • Association Between Self-Reported Health and Reliance on Veterans Affairs for Health Care Among Veterans Affairs Enrollees. JAMA network open Rose, L., Schmidt, A., Gehlert, E., Graham, L. A., Aouad, M., Wagner, T. H. 2023; 6 (7): e2323884


    This cross-sectional study using survey data investigates the association between level of reliance on the Department of Veterans Affairs for health care and self-reported health by type of insurance coverage among VA enrollees.

    View details for DOI 10.1001/jamanetworkopen.2023.23884

    View details for PubMedID 37459100

  • Strategies to Assess the Effect of Continuous Positive Airway Pressure on Long-Term Clinically Important Outcomes among Patients with Symptomatic Obstructive Sleep Apnea An Official American Thoracic Society Workshop Report ANNALS OF THE AMERICAN THORACIC SOCIETY Donovan, L. M., Hoyos, C. M., Kimoff, R., Morrell, M. J., Bosch, N. A., Chooljian, D. M., McEvoy, R., Sawyer, A. M., Wagner, T. H., Al-Lamee, R. R., Bishop, D., Carno, M. A., Epstein, M., Hanson, M., Ip, M. M., Letourneau, M., Pamidi, S., Patel, S. R., Pepin, J., Punjabi, N. M., Redline, S., Thornton, J., Patil, S. P., American Thoracic Soc 2023; 20 (7): 931-943


    Continuous positive airway pressure (CPAP) is the first-line treatment for obstructive sleep apnea (OSA). Although CPAP improves symptoms (e.g., daytime sleepiness), there is a lack of high-quality evidence that CPAP prevents many long-term outcomes, including cognitive impairment, myocardial infarction, and stroke. Observational studies suggest that patients with symptoms may be particularly likely to experience these preventive benefits with CPAP, but ethical and practical concerns limited the participation of such patients in prior long-term randomized trials. As a result, there is uncertainty about the full benefits of CPAP, and resolving this uncertainty is a key priority for the field. This workshop assembled clinicians, researchers, ethicists, and patients to identify strategies to understand the causal effects of CPAP on long-term clinically important outcomes among patients with symptomatic OSA. Quasi-experimental designs can provide valuable information and are less time and resource intensive than trials. Under specific conditions and assumptions, quasi-experimental studies may be able to provide causal estimates of CPAP's effectiveness from generalizable observational cohorts. However, randomized trials represent the most reliable approach to understanding the causal effects of CPAP among patients with symptoms. Randomized trials of CPAP can ethically include patients with symptomatic OSA, as long as there is outcome-specific equipoise, adequate informed consent, and a plan to maximize safety while minimizing harm (e.g., monitoring for pathologic sleepiness). Furthermore, multiple strategies exist to ensure the generalizability and practicality of future randomized trials of CPAP. These strategies include reducing the burden of trial procedures, improving patient-centeredness, and engaging historically excluded and underserved populations.

    View details for DOI 10.1513/AnnalsATS.202303-258ST

    View details for Web of Science ID 001028827800001

    View details for PubMedID 37387624

  • PRODUCTIVITY IN PRIMARY CARE: A VALUE-BASED ECONOMETRIC MEASUREMENT APPROACH Tran, L. D., Wagner, T. H., Shekelle, P., Fihn, S. D., Nelson, K., Rubenstein, L. V. SPRINGER. 2023: S347
  • Predicting treatment response for the safe non-operative management of patients with rectal cancer using an MRI-based deep-learning model Selby, H. M., Liu, C., Sheth, V., Napel, S., Wagner, T., Morris, A. M. LIPPINCOTT WILLIAMS & WILKINS. 2023
  • VA's implementation of universal screening and evaluation for the suicide risk identification program in November 2020 -Implications for Veterans with prior mental health needs. PloS one Gujral, K., Bahraini, N., Brenner, L. A., Van Campen, J., Zulman, D. M., Illarmo, S., Wagner, T. H. 2023; 18 (4): e0283633


    IMPORTANCE: United States Veterans are at higher risk for suicide than non-Veterans. Veterans in rural areas are at higher risk than their urban counterparts. The coronavirus pandemic intensified risk factors for suicide, especially in rural areas.OBJECTIVE: To examine associations between Veterans Health Administration's (VA's) universal suicide risk screening, implemented November 2020, and likelihood of Veterans being screened, and receiving follow-up evaluations, as well as post-screening suicidal behavior among patients who used VA mental health services in 2019.METHODS: VA's Suicide Risk Identification Strategy (Risk ID), implemented October 2018, is a national, standardized process for suicide risk screening and evaluation. In November 2020, VA expanded Risk ID, requiring annual universal suicide screening. As such, we are evaluating outcomes of interest before and after the start of the policy among Veterans who had ≥1 VA mental health care visit in 2019 (n = 1,654,180; rural n = 485,592, urban n = 1,168,588). Regression-adjusted outcomes were compared 6 months pre-universal screening and 6, 12 and 13 months post-universal screening implementation.MEASURES: Item-9 on the Patient Health Questionnaire (I-9, VA's historic suicide screener), Columbia- Suicide Severity Risk Scale (C-SSRS) Screener, VA's Comprehensive Suicide Risk Evaluation (CSRE), and Suicide Behavior and Overdose Report (SBOR).RESULTS: 12 months post-universal screening implementation, 1.3 million Veterans (80% of the study cohort) were screened or evaluated for suicide risk, with 91% the sub-cohort who had at least one mental health visit in the 12 months post-universal screening implementation period were screened or evaluated. At least 20% of the study cohort was screened outside of mental health care settings. Among Veterans with positive screens, 80% received follow-up CSREs. Covariate-adjusted models indicated that an additional 89,160 Veterans were screened per month via the C-SSRS and an additional 30,106 Veterans/month screened via either C-SSRS or I-9 post-universal screening implementation. Compared to their urban counterparts, 7,720 additional rural Veterans/month were screened via the C-SSRS and 9,226 additional rural Veterans/month were screened via either the C-SSRS or I-9.CONCLUSION: VA's universal screening requirement via VA's Risk ID program increased screening for suicide risk among Veterans with mental health care needs. A universal approach to screening may be particularly advantageous for rural Veterans, who are typically at higher risk for suicide but have fewer interactions with the health care system, particularly within specialty care settings, due to higher barriers to accessing care. Insights from this program offer valuable insights for health systems nationwide.

    View details for DOI 10.1371/journal.pone.0283633

    View details for PubMedID 37040367

  • Commercial Price Variation for Breast Reconstruction in the Era of Price Transparency. JAMA surgery Rochlin, D. H., Rizk, N. M., Matros, E., Wagner, T. H., Sheckter, C. C. 2022


    Importance: Breast reconstruction is costly, and negotiated commercial rates have been hidden from public view. The Hospital Price Transparency Rule was enacted in 2021 to facilitate market competition and lower health care costs. Breast reconstruction pricing should be analyzed to evaluate for market effectiveness and opportunities to lower the cost of health care.Objective: To evaluate the extent of commercial price variation for breast reconstruction. The secondary objective was to characterize the price of breast reconstruction in relation to market concentration and payer mix.Design, Setting, and Participants: This was a cross-sectional study conducted from January to April 2022 using 2021 pricing data made available after the Hospital Price Transparency Rule. National data were obtained from Turquoise Health, a data service platform that aggregates price disclosures from hospital websites. Participants were included from all hospitals with disclosed pricing data for breast reconstructive procedures, identified by Current Procedural Terminology (CPT) code.Main Outcomes and Measures: Price variation was measured via within- and across-hospital ratios. A mixed-effects linear model evaluated commercial rates relative to governmental rates and the Herfindahl-Hirschman Index (health care market concentration) at the facility level. Linear regression was used to evaluate commercial rates as a function of facility characteristics.Results: A total of 69 834 unique commercial rates were extracted from 978 facilities across 335 metropolitan areas. Commercial rates increased as health care markets became less competitive (coefficient, $4037.52; 95% CI, $700.12 to $7374.92; P = .02; for Herfindahl-Hirschman Index [HHI] 1501-2500, coefficient $3290.21; 95% CI, $878.08 to $5702.34; P = .01; both compared with HHI ≤1500). Commercial rates demonstrated economically insignificant associations with Medicare and Medicaid rates (Medicare coefficient, -$0.05; 95% CI, -$0.14 to $0.03; P = .23; Medicaid coefficient, $0.14; 95% CI, $0.07 to $0.22; P < .001). Safety-net and nonprofit hospitals reported lower commercial rates (coefficient, -$3269.58; 95% CI, -$3815.42 to -$2723.74; P < .001 and coefficient, -$1892.79; -$2519.61 to -$1265.97; P<.001, respectively). Extra-large hospitals (400+ beds) reported higher commercial rates compared with their smaller counterparts (coefficient, $1036.07; 95% CI, $198.29 to $1873.85, P=.02).Conclusions and Relevance: Study results suggest that commercial rates for breast reconstruction demonstrated large nationwide variation. Higher commercial rates were associated with less competitive markets and facilities that were large, for-profit, and nonsafety net. Privately insured patients with breast cancer may experience higher premiums and deductibles as US hospital market consolidation and for-profit hospitals continue to grow. Transparency policies should be continued along with actions that facilitate greater health care market competition. There was no evidence that facilities increase commercial rates in response to lower governmental rates.

    View details for DOI 10.1001/jamasurg.2022.6402

    View details for PubMedID 36515928

  • Applying Cognitive Task Analysis to Health Services Research. Health services research Graham, L. A., Gray, C., Wagner, T. H., Illarmo, S., Hawn, M. T., Wren, S. M., Iannuzzi, J., Harris, A. H. 2022


    OBJECTIVE: Designing practical decision support tools and other healthcare technology in health services research relies on a clear understanding of the cognitive processes that underlie the use of these tools. Unfortunately, methods to explore cognitive processes are rarely used in health services research. Thus, the objective of this manuscript is to introduce cognitive task analysis (CTA), a family of methods to study cognitive processes involved in completing a task, to a health services research audience. This methods article describes CTA procedures, proposes a framework for their use in health services research studies, and provides an example of its application in a pilot study.DATA SOURCES AND STUDY SETTING: Observations and interviews of healthcare providers involved in discharge planning at 6 hospitals in the Veterans Health Administration.STUDY DESIGN: Qualitative study of discharge planning using CTA.DATA COLLECTION / EXTRACTION METHODS: Data were collected from structured observations and semi-structured interviews using the Critical Decision Method and analyzed using thematic analysis.PRINCIPAL FINDINGS: We developed an adaptation of CTA that could be used in a clinical environment to describe clinical decision-making and other cognitive processes. The adapted CTA framework guides the user through four steps: 1) Planning, 2) Environmental Analysis, 3) Knowledge Elicitation, and 4) Analyses and Results. This adapted CTA framework provides an iterative and systematic approach to identifying and describing the knowledge, expertise, thought processes, procedures, actors, goals, and mental strategies that underlie completing a clinical task.CONCLUSIONS: A better understanding of the cognitive processes that underly clinical tasks is key to developing healthcare technology and decision-support tools that will have a meaningful impact on processes of care and patient outcomes. Our adapted framework offers a more rigorous and detailed method for identifying task-related cognitive processes in implementation studies and quality improvement. Our adaptation of this underutilized qualitative research method may be helpful to other researchers and inform future research in health services research. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/1475-6773.14106

    View details for PubMedID 36421922

  • Atherectomy Overuse: Do Policy Solutions Exist? Journal of the American Heart Association George, E. L., Wagner, T. H., Arya, S. 2022; 11 (22): e027422

    View details for DOI 10.1161/JAHA.122.027422

    View details for PubMedID 36373835

  • Variation in Initial and Continued use of Primary, Mental Health, and Specialty Video Care among Veterans. Health services research Ferguson, J. M., Wray, C. M., Jacobs, J., Greene, L., Wagner, T. H., Odden, M. C., Freese, J., Van Campen, J., Asch, S. M., Heyworth, L., Zulman, D. M. 2022


    OBJECTIVE: To identify which Veteran populations are routinely accessing video-based care.DATA SOURCES AND STUDY SETTING: National, secondary administrative data from electronic health records at the Veterans Health Administration (VHA), 2019-2021 STUDY DESIGN: This retrospective cohort analysis identified patient characteristics associated with the odds of using any video care; and then, among those with a previous video visit, the annual rate of video care utilization. Video care use was reported overall and stratified into care type (e.g., primary, mental health, and specialty video care) between March 10, 2020 and February 28, 2021.DATA COLLECTION: Veterans active in VA health care (>1 outpatient visit between March 11, 2019 and March 10, 2020) were included in this study.PRINCIPAL FINDINGS: Among 5,389,129 Veterans in this evaluation, approximately 27.4% of Veterans had at least one video visit. We found differences in video care utilization by type of video care: 14.7% of Veterans had at least one primary care video visit, 10.6% a mental health video visit, and 5.9% a specialty care video visit. Veterans with a history of housing instability had a higher overall rate of video care driven by their higher usage of video for mental health care compared with Veterans in stable housing. American Indian/Alaska Native Veterans had reduced odds of video visits, yet similar rates of video care when compared to White Veterans. Low-income Veterans had lower odds of using primary video care yet slightly elevated rates of primary video care among those with at least one video visit when compared to Veterans enrolled at VA without special considerations.CONCLUSIONS: Variation in video care utilization patterns by type of care identified Veteran populations that might require greater resources and support to initiate and sustain video care use. Our data support service specific outreach to homeless and American Indian/Alaska Native Veterans.

    View details for DOI 10.1111/1475-6773.14098

    View details for PubMedID 36345235

  • Long-Term Mortality Follow-Up of Radial Artery Versus Saphenous Vein in Coronary Artery Bypass Grafting: A Multicenter, Randomized Trial. Circulation Goldman, S., McCarren, M., Sethi, G. K., Holman, W., Bakaeen, F. G., Wagner, T. H., Wang, Y., Shih, M. C., Edson, R. 2022; 146 (17): 1323-1325

    View details for DOI 10.1161/CIRCULATIONAHA.122.062343

    View details for PubMedID 36279414

  • Expansion of the Veterans Health Administration Network and Surgical Outcomes. JAMA surgery Graham, L. A., Schoemaker, L., Rose, L., Morris, A., Aouad, M., Wagner, T. H. 2022


    Importance: The US Department of Veterans Affairs (VA) Veterans Choice Program (VCP) expanded health care access to community settings outside the VA for eligible patients. Little is known about the effect of VCP on access to surgery and postoperative outcomes. Since its initiation, care coordination issues, which are often associated with adverse postoperative outcomes, have been reported. Research findings on the association of VCP and postoperative outcomes are limited to only a few select procedures and have been mixed, potentially due to bias from unmeasured confounding.Objective: To investigate the association of the VCP with access to surgery and postoperative outcomes using a nonrandomized controlled regression discontinuity design (RDD) to reduce the impact of unmeasured confounders.Design, Setting, and Participants: This was a nonrandomized RDD study of the Veterans Health Administration (VHA). Participants included veterans enrolled in the VHA who required surgery between October 1, 2014, and June 1, 2019.Interventions: The VCP, which expanded access to VA-paid community care for eligible veterans living 40 miles or more from their closest VA hospital.Main Outcomes and Measures: Postoperative emergency department visits, inpatient readmissions, and mortality at 30 and 90 days.Results: A total of 615 473 unique surgical procedures among 498 427 patients (mean [SD] age, 63.0 [12.9] years; 450 366 male [90.4%]) were identified. Overall, 94 783 procedures (15.4%) were paid by the VHA, and the proportion of VHA-paid procedures varied by procedure type. Patients who underwent VA-paid procedures were more likely to be women (9209 [12.7%] vs men, 38 771 [9.1%]), White race (VA paid, 54 544 [74.4%] vs VA provided, 310 077 [73.0%]), and younger than 65 years (VA paid, 36 054 [49.1%] vs 229 411 [46.0%] VA provided), with a significantly lower comorbidity burden (mean [SD], 1.8 [2.2] vs 2.6 [2.7]). The nonrandomized RDD revealed that VCP was associated with a slight increase of 0.03 in the proportion of VA-paid surgical procedures among eligible veterans (95% CI, 0.01-0.05; P=.01). However, there was no difference in postoperative mortality, readmissions, or emergency department visits.Conclusions and Relevance: Expanded access to health care in the VHA was associated with a shift in the performance of surgical procedures in the private sector but had no measurable association with surgical outcomes. These findings may assuage concerns of worsened patient outcomes resulting from care coordination issues when care is expanded outside of a single health care system, although it remains unclear whether these additional procedures were appropriate or improved patient outcomes.

    View details for DOI 10.1001/jamasurg.2022.4978

    View details for PubMedID 36223115

  • The economics of adaptations to evidence-based practices. Implementation science communications Salloum, R. G., Wagner, T. H., Midboe, A. M., Daniels, S. I., Quanbeck, A., Chambers, D. A. 2022; 3 (1): 100


    BACKGROUND: Evidence-based practices (EBPs) are frequently adapted in response to the dynamic contexts in which they are implemented. Adaptation is defined as the degree to which an EBP is altered to fit the setting or to improve fit to local context and can be planned or unplanned. Although adaptations are common and necessary to maximizing the marginal impact of EBPs, little attention has been given to the economic consequences and how adaptations affect marginal costs.DISCUSSION: In assessing the economic consequences of adaptation, one should consider its impact on core components, the planned adaptive periphery, and the unplanned adaptive periphery. Guided by implementation science frameworks, we examine how various economic evaluation approaches accommodate the influence of adaptations and discuss the pros and cons of these approaches. Using the Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME), mixed methods can elucidate the economic reasons driving the adaptations. Micro-costing approaches are applied in research that integrates the adaptation of EBPs at the planning stage using innovative, adaptive study designs. In contrast, evaluation of unplanned adaptation is subject to confounding and requires sensitivity analysis to address unobservable measures and other uncertainties. A case study is presented using the RE-AIM framework to illustrate the costing of adaptations. In addition to empirical approaches to evaluating adaptation, simulation modeling approaches can be used to overcome limited follow-up in implementation studies.CONCLUSIONS: As implementation science evolves to improve our understanding of the mechanisms and implications of adaptations, it is increasingly important to understand the economic implications of such adaptations, in addition to their impact on clinical effectiveness. Therefore, explicit consideration is warranted of how costs can be evaluated as outcomes of adaptations to the delivery of EBPs.

    View details for DOI 10.1186/s43058-022-00345-8

    View details for PubMedID 36153575

  • EMERGENCY MEDICAID PROGRAMS MAY BE AN EFFECTIVE MEANS OF PROVIDING SUSTAINED INSURANCE AMONG TRAUMA PATIENTS: A STATEWIDE LONGITUDINAL ANALYSIS. The journal of trauma and acute care surgery Knowlton, L. M., Tran, L. D., Arnow, K., Trickey, A. W., Morris, A. M., Spain, D. A., Wagner, T. H. 2022


    INTRODUCTION: Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization that offsets costs of care, increases access to post-discharge resources, and provides patients with a path to sustain coverage through Medicaid. As HPE only lasts up to 60 days, we aimed to determine Medicaid insurance status six months after injury among HPE-approved trauma patients and identify factors associated with successful sustainment.METHODS: Using a customized longitudinal claims dataset for HPE-approved patients from the California Department of Health Care Services (DHCS), we analyzed adults with a primary trauma diagnosis (ICD-10) who were HPE approved in 2016 and 2017. Our primary outcome was Medicaid sustainment at six months. Univariate and multivariate analyses were performed.RESULTS: A total of 9,749 trauma patients with HPE were analyzed; 6,795 (69.7%) sustained Medicaid at six months. Compared to patients who did not sustain, those who sustained had higher injury severity score (ISS > 15: 73.5% vs. 68.7%, p < 0.001), more frequent surgical intervention (74.8% vs. 64.5%, p < 0.001) and were more likely to be discharged to post-acute services (23.9% vs. 10.4%, p < 0.001). Medicaid sustainment was high among patients who identified as White (86.7%), Hispanic (86.7%), Black (84.3%) and Asian (83.7%). Medicaid sustainment was low among the 2,505 patients (25.7%) who declined to report race, ethnicity, or preferred language (14.8% sustainment). In adjusted analyses, major injuries (ISS > 16) (vs. ISS < =15: aOR 1.51, p = 0.02) and surgery (aOR 1.85, p < 0.001) were associated with increased likelihood of Medicaid sustainment. Declining to disclose race, ethnicity, or language (aOR 0.05, p < 0.001) decreased the likelihood of Medicaid sustainment.CONCLUSION: HPE programs are a promising pathway for securing long-term insurance coverage for trauma patients, particularly among the severely injured who likely require ongoing access to healthcare services. Patient and provider interviews would help to elucidate barriers for patients who do not sustain.LEVEL OF EVIDENCE: Epidemiologic, Level III.

    View details for DOI 10.1097/TA.0000000000003796

    View details for PubMedID 36138539

  • Association of Quality of Care With Where Veterans Choose to Get Knee Replacement Surgery. JAMA network open Giori, N. J., Beilstein-Wedel, E. E., Shwartz, M., Harris, A. H., Vanneman, M. E., Wagner, T. H., Rosen, A. K. 2022; 5 (9): e2233259


    Recent legislation expanded veterans' access to Veterans Health Administration (VA)-purchased care. Quality should be considered when choosing where to get total knee arthroplasty (TKA), but currently available quality metrics provide little guidance.To determine whether an association exists between the proportion of TKAs performed (vs purchased) at each VA facility and the quality of care provided (as measured by short-term complication rates).This 3-year cohort study used VA and community care data (fiscal year 2017 to fiscal year 2019) from the VA's Corporate Data Warehouse. Complications were defined following the Centers for Medicare and Medicaid Services' methodology. The setting included 140 VA health care facilities performing or purchasing TKAs. Participants included veterans who had 43 371 primary TKA procedures that were either VA-performed or VA-purchased during the study period.Of the 43 371 primary TKA procedures, 18 964 (43.7%) were VA-purchased.The primary outcome was risk-standardized short-term complication rates of VA-performed or VA-purchased TKAs. The association between the proportion of TKAs performed at each VA facility and quality of VA-performed and VA-purchased care was examined using a regression model. Subgroups were also identified for facilities that had complication rates above or below the overall mean complication rate and for facilities that performed more or less than half of the facility's TKAs.Among the study sample's 41 775 veterans who underwent 43 371 TKAs, 38 725 (89.3%) were male, 6406 (14.8%) were Black, 33 211 (76.6%) were White, and 1367 (3.2%) had other race or ethnicity (including American Indian or Alaska Native, Asian, and Native Hawaiian or other Pacific Islander); mean (SD) age was 66.9 (8.5) years. VA-performed and VA-purchased TKAs had a mean (SD) raw overall short-term complication rate of 2.97% (0.08%). There was no association between the proportion of TKAs performed in VA facilities and risk-standardized complication rates for VA-performed TKAs, and no association for VA-purchased TKAs.In this cohort study, surgical quality did not have an association with where veterans had TKA, possibly because meaningful comparative data are lacking. Reporting local and community risk-standardized complication rates may inform veterans' decisions and improve care. Combining these data with the proportion of TKAs performed at each site could facilitate administrative decisions on where resources should be allocated to improve care.

    View details for DOI 10.1001/jamanetworkopen.2022.33259

    View details for PubMedID 36178687

  • Differences Between VHA-Delivered and VHA-Purchased Behavioral Health Care in Service and Patient Characteristics. Psychiatric services (Washington, D.C.) Vanneman, M. E., Rosen, A. K., Wagner, T. H., Shwartz, M., Gordon, S. H., Greenberg, G., Zheng, T., Cook, J., Beilstein-Wedel, E., Greene, T., Kelley, A. T. 2022: appips202100730


    OBJECTIVE: Federal legislation has expanded Veterans Health Administration (VHA) enrollees' access to VHA-purchased "community care." This study examined differences in the amount and type of behavioral health care delivered in VHA and purchased in the community, along with patient characteristics and area supply and demand factors.METHODS: This retrospective cross-sectional study examined data for 204,094 VHA enrollees with 448,648 inpatient behavioral health stays and 3,467,010 enrollees with 55,043,607 outpatient behavioral health visits from fiscal years 2016 to 2019. Standardized mean differences (SMDs) were calculated for patient and provider characteristics at the outpatient-visit level for VHA and community care. Linear probability models assessed the association between severity of behavioral health condition and site of care.RESULTS: Twenty percent of inpatient stays were purchased through community care, with severe behavioral health conditions more likely to be treated in VHA inpatient care. In the outpatient setting, community care accounted for 3% of behavioral health care visits, with increasing use over time. For outpatient care, veterans receiving community care were more likely than those receiving VHA care to see clinicians with fewer years of training (SMD=1.06).CONCLUSIONS: With a large portion of inpatient behavioral health care occurring in the community and increased use of outpatient behavioral health care with less highly trained community providers, coordination between VHA and the community is essential to provide appropriate inpatient follow-up care and address outpatient needs. This is especially critical given VHA's expertise in providing behavioral health care to veterans and its legislative responsibility to ensure integrated care.

    View details for DOI 10.1176/

    View details for PubMedID 36039555

  • Costs of Endoscopic vs Open Vein Harvesting for Coronary Artery Bypass Grafting: A Secondary Analysis of the REGROUP Trial. JAMA network open Wagner, T. H., Hattler, B., Stock, E. M., Biswas, K., Bhatt, D. L., Bakaeen, F. G., Gujral, K., Zenati, M. A. 2022; 5 (6): e2217686


    Importance: Value-based purchasing creates pressure to examine whether newer technologies and care processes, including new surgical techniques, yield any economic advantage.Objective: To compare health care costs and utilization between participants randomized to receive endoscopic vein harvesting (EVH) or open vein harvesting (OVH) during a coronary artery bypass grafting (CABG) procedure.Design, Setting, and Participants: This secondary economic analysis was conducted alongside the 16-site Randomized Endo-Vein Graft Prospective (REGROUP) clinical trial funded by the Department of Veterans Affairs (VA) Cooperative Studies Program. Adults scheduled for urgent or elective bypass involving a vein graft were eligible. The first participant was enrolled in September 2013, with most sites completing enrollment by March 2014. The last participant was enrolled in April 2017. A total of 1150 participants were randomized, with 574 participants receiving OVH and 576 receiving EVH. For this secondary analysis, cost and utilization data were extracted through September 30, 2020. Participants were linked to administrative data in the VA Corporate Data Warehouse and activity-based cost data starting with the index procedure.Interventions: EVH vs OVH, with comparisons based on intention to treat.Main Outcomes and Measures: Discharge costs for the index procedure as well as follow-up costs (including intended and unintended events; mean [SD] follow-up time, 33.0 [19.9] months) were analyzed, with results from different statistical models compared to test for robustness (ie, lack of variation across models). All costs represented care provided or paid by the VA, standardized to 2020 US dollars.Results: Among 1150 participants, the mean (SD) age was 66.4 (6.9) years; most participants (1144 [99.5%] were male. With regard to race and ethnicity, 6 participants (0.5%) self-reported as American Indian or Alaska Native, 10 (0.9%) as Asian or Pacific Islander, 91 (7.9%) as Black, 62 (5.4%) as Hispanic, 974 (84.7%) as non-Hispanic White, and 6 (0.5%) as other race and/or ethnicity; data were missing for 1 participant (0.1%). The unadjusted mean (SD) costs for the index CABG procedure were $76 607 ($43 883) among patients who received EVH and $75 368 ($45 900) among those who received OVH, including facility costs, insurance costs, and physician-related costs (commonly referred to as provider costs in Centers for Medicare and Medicaid and insurance data). No significant differences were found in follow-up costs; per 90-day follow-up period, EVH was associated with a mean (SE) added cost of $302 ($225) per patient. The results were highly robust to the statistical model.Conclusions and Relevance: In this study, EVH was not associated with a reduction in costs for the index CABG procedure or follow-up care. Therefore, the choice to provide EVH may be based on surgeon and patient preferences.Trial Registration: Identifier: NCT01850082.

    View details for DOI 10.1001/jamanetworkopen.2022.17686

    View details for PubMedID 35727582

  • One-Year Costs Associated With the Veterans Affairs National TeleStroke Program. Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research Wagner, T. H., Schoemaker, L., Gehlert, E., Nelson, R. E., Murphy, K., Martini, S., Graham, G. D., Govindarajan, P., Williams, L. S. 2022


    OBJECTIVES: Access to timely care is important for patients with stroke, where rapid diagnosis and treatment affect functional status, disability, and mortality. Telestroke programs connect stroke specialists with emergency department staff at facilities without on-site stroke expertise. The objective of this study was to examine healthcare costs for patients with stroke who sought care before and after implementation of the US Department of Veterans Affairs National TeleStroke Program (NTSP).METHODS: We identified 471 patients who had a stroke and sought care at a telestroke site and compared them to 529 patients with stroke who received stroke care at the same sites before telestroke implementation. We examined patient costs for 12 months before and after stroke, using a linear model with a patient-level fixed effect.RESULTS: NTSP was associated with significantly higher rates of patients receiving guideline concordant care. Compared with control patients, those treated by NTSP were 14.3 percentage points more likely to receive tissue plasminogen activator and 4.3 percentage points more likely to receive a thrombectomy (all P < .0001). NTSP was associated with $4821 increased costs for patients with stroke in the first 30 days after the program (2019 dollars). There were no observed savings over 12 months, and the added costs of care were attributable to higher rates of guideline concordant care.CONCLUSIONS: Telestroke programs are unlikely to yield short-term savings because optimal stroke care is expensive. Healthcare organizations should expect increases in healthcare costs for patients treated for stroke in the first year after implementing a telestroke program.

    View details for DOI 10.1016/j.jval.2022.02.010

    View details for PubMedID 35346590

  • Outpatient care fragmentation in Veterans Affairs patients at high-risk for hospitalization. Health services research Zulman, D. M., Greene, L., Slightam, C., Singer, S. J., Maciejewski, M. L., Goldstein, M. K., Vanneman, M. E., Yoon, J., Trivedi, R. B., Wagner, T., Asch, S. M., Boothroyd, D. 2022


    OBJECTIVE: To examine outpatient care fragmentation and its association with future hospitalization among patients at high risk for hospitalization.DATA SOURCES: Veterans Affairs (VA) and Medicare data.STUDY DESIGN: We conducted a longitudinal study, using logistic regression to examine how outpatient care fragmentation in FY14 (as measured by number of unique providers, Breslau's Usual Provider of Care (UPC), Bice-Boxerman's Continuity of Care Index (COCI), and Modified Modified Continuity Index (MMCI)) was associated with all-cause hospitalizations and hospitalizations related to ambulatory care sensitive conditions (ACSC) in FY15. We also examined how fragmentation varied by patient's age, gender, race, ethnicity, marital status, rural status, history of homelessness, number of chronic conditions, Medicare utilization, and mental healthcare utilization.DATA EXTRACTION METHODS: We extracted data for 130,704 VA patients ≥65years old with a hospitalization risk ≥90th percentile and≥four outpatient visits in the baseline year.PRINCIPAL FINDINGS: Mean (standard deviation) of FY14 outpatient visits was 13.2 (8.6). Fragmented care (more providers, less care with a usual provider, more dispersed care based on COCI) was more common among patients with more chronic conditions and those receiving mental health care. In adjusted models, most fragmentation measures were not associated with all-cause hospitalization, and patients with low levels of fragmentation (more concentrated care based on UPC, COCI, and MMCI) had a higher likelihood of an ACSC-related hospitalization (AOR, 95% CI=1.21 (1.09-1.35), 1.27 (1.14-1.42), and 1.28 (1.18-1.40), respectively).CONCLUSIONS: Contrary to expectations, outpatient care fragmentation was not associated with elevated all-cause hospitalization rates among VA patients in the top 10th percentile for risk of admission; in fact, fragmented care was linked to lower rates of hospitalization for ACSCs. In integrated settings such as the VA, multiple providers and dispersed care might offer access to timely or specialized care that offsets risks of fragmentation, particularly for conditions that are sensitive to ambulatory care.

    View details for DOI 10.1111/1475-6773.13956

    View details for PubMedID 35178702

  • Anticipating VA/non-VA care coordination demand for Veterans at high risk for hospitalization. Medicine Vanneman, M. E., Yoon, J., Singer, S. J., Wagner, T. H., Goldstein, M. K., Hu, J., Boothroyd, D., Greene, L., Zulman, D. M. 2022; 101 (7): e28864


    ABSTRACT: U.S. Veterans Affairs (VA) patients' multi-system use can create challenges for VA clinicians who are responsible for coordinating Veterans' use of non-VA care, including VA-purchased care ("Community Care") and Medicare.To examine the relationship between drive distance and time-key eligibility criteria for Community Care-and VA reliance (proportion of care received in VA versus Medicare and Community Care) among Veterans at high risk for hospitalization. We used prepolicy data to anticipate the impact of the 2014 Choice Act and 2018 Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act), which expanded access to Community Care.Cross-sectional analysis using fractional logistic regressions to examine the relationship between a Veteran's reliance on VA for outpatient primary, mental health, and other specialty care and their drive distance/time to a VA facility.Thirteen thousand seven hundred three Veterans over the age of 65 years enrolled in VA and fee-for-service Medicare in federal fiscal year 2014 who were in the top 10th percentile for hospitalization risk.Key explanatory variables were patients' drive distance to VA > 40 miles (Choice Act criteria) and drive time to VA ≥ 30 minutes for primary and mental health care and ≥60 minutes for specialty care (MISSION Act criteria).Veterans at high risk for hospitalization with drive distance eligibility had increased odds of an outpatient specialty care visit taking place in VA when compared to Veterans who did not meet Choice Act eligibility criteria (odds ratio = 1.10, 95% confidence interval 1.05-1.15). However, drive time eligibility (MISSION Act criteria) was associated with significantly lower odds of an outpatient specialty care visit taking place in VA (odds ratio = 0.69, 95% confidence interval 0.67, 0.71). Neither drive distance nor drive time were associated with reliance for outpatient primary care or mental health care.VA patients who are at high risk for hospitalization may continue to rely on VA for outpatient primary care and mental health care despite access to outside services, but may increase use of outpatient specialty care in the community in the MISSION era, increasing demand for multi-system care coordination.

    View details for DOI 10.1097/MD.0000000000028864

    View details for PubMedID 35363189

  • Prehospital Bypass Policies Increase The Proportion Of Stroke Patients Transported To Primary Stroke Centers - A Quasi-experimental Study In A National Sample Of Medicare Beneficiaries Govindarajan, P., Meng, T., Trickey, A., Matheson, L., Gilchrist, S., Rosenthal, S., Sox-Harris, A., Wagner, T. LIPPINCOTT WILLIAMS & WILKINS. 2022
  • Comparing Postoperative Readmission Rates Between Veterans Receiving Total Knee Arthroplasty in the Veterans Health Administration Versus Community Care. Medical care Rosen, A. K., Beilstein-Wedel, E. E., Harris, A. H., Shwartz, M., Vanneman, M. E., Wagner, T. H., Giori, N. J. 1800; 60 (2): 178-186


    BACKGROUND: There are growing concerns that Veterans' increased use of Veterans Health Administration (VA)-purchased care in the community may lead to lower quality of care.OBJECTIVE: We compared rates of hospital readmissions following elective total knee arthroplasties (TKAs) that were either performed in VA or purchased by VA through community care (CC) at both the national and facility levels.METHODS: Three-year cohort study using VA and CC administrative data from the VA's Corporate Data Warehouse (October 1, 2016-September 30, 2019). We obtained Medicare data to capture readmissions that were paid by Medicare. We used the Centers for Medicare and Medicaid Services (CMS) methods to identify unplanned, 30-day, all-cause readmissions. A secondary outcome, TKA-related readmissions, identified readmissions resulting from complications of the index surgery. We ran mixed-effects logistic regression models to compare the risk-adjusted odds of all-cause and TKA-related readmissions between TKAs performed in VA versus CC, adjusting for patients' sociodemographic and clinical characteristics.PRINCIPAL FINDINGS: Nationally, the odds of experiencing an all-cause or TKA-related readmission were significantly lower for TKAs performed in VA versus CC (eg, the odds of experiencing an all-cause readmission in VA were 35% of those in CC. At the facility level, most VA facilities performed similarly to their corresponding CC providers, although there were 3 VA facilities that performed worse than their corresponding CC providers.CONCLUSIONS: Given VA's history in providing high-quality surgical care to Veterans, it is important to closely monitor and track whether the shift to CC for surgical care will impact quality in both settings over time.

    View details for DOI 10.1097/MLR.0000000000001678

    View details for PubMedID 35030566

  • Cost data in implementation science: categories and approaches to costing. Implementation science : IS Gold, H. T., McDermott, C., Hoomans, T., Wagner, T. H. 1800; 17 (1): 11


    A lack of cost information has been cited as a barrier to implementation and a limitation of implementation research. This paper explains how implementation researchers might optimize their measurement and inclusion of costs, building on traditional economic evaluations comparing costs and effectiveness of health interventions. The objective of all economic evaluation is to inform decision-making for resource allocation and to measure costs that reflect opportunity costs-the value of resource inputs in their next best alternative use, which generally vary by decision-maker perspective(s) and time horizon(s). Analyses that examine different perspectives or time horizons must consider cost estimation accuracy, because over longer time horizons, all costs are variable; however, with shorter time horizons and narrower perspectives, one must differentiate the fixed and variable costs, with fixed costs generally excluded from the evaluation. This paper defines relevant costs, identifies sources of cost data, and discusses cost relevance to potential decision-makers contemplating or implementing evidence-based interventions. Costs may come from the healthcare sector, informal healthcare sector, patient, participant or caregiver, and other sectors such as housing, criminal justice, social services, and education. Finally, we define and consider the relevance of costs by phase of implementation and time horizon, including pre-implementation and planning, implementation, intervention, downstream, and adaptation, and through replication, sustainment, de-implementation, or spread.

    View details for DOI 10.1186/s13012-021-01172-6

    View details for PubMedID 35090508

  • Ten-Year Outcomes of Off-Pump vs On-Pump Coronary Artery Bypass Grafting in the Department of Veterans Affairs: A Randomized Clinical Trial. JAMA surgery Quin, J. A., Wagner, T. H., Hattler, B., Carr, B. M., Collins, J., Almassi, G. H., Grover, F. L., Shroyer, A. L. 2022


    The long-term benefits of off-pump ("beating heart") vs on-pump coronary artery bypass grafting (CABG) remain controversial.To evaluate the 10-year outcomes and costs of off-pump vs on-pump CABG in the Department of Veterans Affairs (VA) Randomized On/Off Bypass (ROOBY) trial.From February 27, 2002, to May 7, 2007, 2203 veterans in the ROOBY trial were randomly assigned to off-pump or on-pump CABG procedures at 18 participating VA medical centers. Per protocol, the veterans were observed for 10 years; the 10-year, post-CABG clinical outcomes and costs were assessed via centralized abstraction of electronic medical records combined with merges to VA and non-VA databases. With the use of an intention-to-treat approach, analyses were performed from May 7, 2017, to December 9, 2021.On-pump and off-pump CABG procedures.The 10-year coprimary end points included all-cause death and a composite end point identifying patients who had died or had undergone subsequent revascularization (ie, percutaneous coronary intervention [PCI] or repeated CABG); these 2 end points were measured dichotomously and as time-to-event variables (ie, time to death and time to composite end points). Secondary 10-year end points included PCIs, repeated CABG procedures, changes in cardiac symptoms, and 2018-adjusted VA estimated costs. Changes from baseline to 10 years in post-CABG, clinically relevant cardiac symptoms were evaluated for New York Heart Association functional class, Canadian Cardiovascular Society angina class, and atrial fibrillation. Outcome differences were adjudicated by an end points committee. Given that pre-CABG risks were balanced, the protocol-driven primary and secondary hypotheses directly compared 10-year treatment-related effects.A total of 1104 patients (1097 men [99.4%]; mean [SD] age, 63.0 [8.5] years) were enrolled in the off-pump group, and 1099 patients (1092 men [99.5%]; mean [SD] age, 62.5 [8.5] years) were enrolled in the on-pump group. The 10-year death rates were 34.2% (n = 378) for the off-pump group and 31.1% (n = 342) for the on-pump group (relative risk, 1.05; 95% CI, 0.99-1.11; P = .12). The median time to composite end point for the off-pump group (4.6 years; IQR, 1.4-7.5 years) was approximately 4.3 months shorter than that for the on-pump group (5.0 years; IQR, 1.8-7.9 years; P = .03). No significant 10-year treatment-related differences were documented for any other primary or secondary end points. After the removal of conversions, sensitivity analyses reconfirmed these findings.No off-pump CABG advantages were found for 10-year death or revascularization end points; the time to composite end point was lower in the off-pump group than in the on-pump group. For veterans, in the absence of on-pump contraindications, a case cannot be made for supplanting the traditional on-pump CABG technique with an off-pump Identifier: NCT01924442.

    View details for DOI 10.1001/jamasurg.2021.7578

    View details for PubMedID 35171210

  • Lessons Learned From the Historical Trends on Thrombolysis Use for Acute Ischemic Stroke Among Medicare Beneficiaries in the United States. Frontiers in neurology Meng, T., Trickey, A. W., Harris, A. H., Matheson, L., Rosenthal, S., Traboulsi, A. A., Saver, J. L., Wagner, T., Govindarajan, P. 2022; 13: 827965


    Background: The most recent time trends on intravenous thrombolysis (IVT) utilization for acute ischemic stroke was reported in 2011 using the Get with the Guidelines. Our objectives are to assess and validate the change in IVT utilization through 2014 in a national sample of Medicare beneficiaries and to examine the effect of patient, stroke center designation, and geography on IVT utilization.Methods: We built a comprehensive national stroke registry by combining patient-level, stroke center status, and geographical characteristics, using multiple data sources. Using multiple national administrative databases from 2007 to 2014, we generated a mixed-effect logistic regression model to characterize the independent associations of patient, hospital, and geographical characteristics with IVT in 2014.Results: Use of IVT increased consistently from 2.8% in 2007 to 7.7% in 2014, P < 0.001. Between group differences persisted, with lower odds of use in patients who were ≥86 years (aOR 0.74, 95% CI 0.65-0.83), Black (aOR 0.73, 95% CI 0.61-0.87), or treated at a rural hospital (aOR 0.88, 95% CI 0.77-1.00). Higher odds of use were observed in patients who arrived by ambulance (aOR 2.67, 95% CI 2.38-3.00), were treated at a hospital certified as a stroke center (aOR 1.96, 95% CI 1.68-2.29), or were treated at hospitals located in the most socioeconomically advantaged areas (aOR 1.27, 95% CI 1.05-1.54).Conclusions: Between 2007 and 2014, the frequency of IVT for patients with acute ischemic stroke increased substantially, though differences persisted in the form of less frequent treatment associated with certain characteristics. These findings can inform ongoing efforts to optimize the delivery of IVT to all AIS patients nationwide.

    View details for DOI 10.3389/fneur.2022.827965

    View details for PubMedID 35309566

  • Evaluation of the Completeness of ALS Case Ascertainment in the US National ALS Registry: Application of the Capture-Recapture Method. Neuroepidemiology Nelson, L. M., Topol, B., Kaye, W., Raymond, J., Horton, D. K., Mehta, P., Wagner, T. 2022; 56 (2): 104-114


    INTRODUCTION: The Centers for Disease Control and Prevention (CDC) National Amyotrophic Lateral Sclerosis (ALS) Registry is the first national registry for a chronic neurologic disease in the USA and uses a combination of case-finding methods including administrative healthcare data and patient self-registration.METHODS: We applied capture-recapture methodology to estimate the completeness of the Registry for ascertaining patients with ALS for the first full year and the fourth year of the Registry (2011, 2014). The Registry uses the combination of two national administrative claims databases (Medicare and Veterans Affairs) with a self-register option at the registry portal. We conducted descriptive analyses of the demographic and clinical characteristics of the ALS cases identified by each of the sources and estimated the completeness of case ascertainment for each of the three ALS Registry sources individually, pairwise, and in all combinations.RESULTS: Case-finding completeness was 54% in 2011 and improved to 56% in 2014. A smaller proportion of ALS patients under age 65 were ascertained than those 65 or older, and ascertainment was also lower for nonwhite than white patients. The uncorrected ALS prevalence was 4.3/100,000 in 2011 (in 2014, 5.0/100,000), but after correction for underascertainment, annual prevalence in 2011 was 7.9/100,000 (95% CI: 7.6-8.2) (in 2014 was 8.9/100,000 [95% CI: 8.7-9.2]).DISCUSSION/CONCLUSION: Our findings indicate that administrative healthcare databases are a very efficient method for identifying the majority of ALS prevalent cases in the National ALS Registry and that the inclusion of a web registry portal for patients to self-register is important to ensure a more representative population for estimating ALS prevalence. Nonetheless, more than 40% of ALS cases were not ascertained by the Registry, with individuals younger than age 65 and people of color underrepresented. Recommendations are provided for additional methods that can be considered to improve the completeness of case ascertainment.

    View details for DOI 10.1159/000521591

    View details for PubMedID 34929703

  • Improving Prediction of Long-Term Care Utilization Through Patient-Reported Measures: Cross-Sectional Analysis of High-Need U.S. Veterans Affairs Patients. Medical care research and review : MCRR Jacobs, J. C., Maciejeweski, M. L., Wagner, T. H., Van Houtven, C. H., Lo, J., Greene, L., Zulman, D. M. 1800: 10775587211062403


    This article examines the relative merit of augmenting an electronic health record (EHR)-derived predictive model of institutional long-term care (LTC) use with patient-reported measures not commonly found in EHRs. We used survey and administrative data from 3,478 high-risk Veterans aged ≥65 in the U.S. Department of Veterans Affairs, comparing a model based on a Veterans Health Administration (VA) geriatrics dashboard, a model with additional EHR-derived variables, and a model that added survey-based measures (i.e., activities of daily living [ADL] limitations, social support, and finances). Model performance was assessed via Akaike information criteria, C-statistics, sensitivity, and specificity. Age, a dementia diagnosis, Nosos risk score, social support, and ADL limitations were consistent predictors of institutional LTC use. Survey-based variables significantly improved model performance. Although demographic and clinical characteristics found in many EHRs are predictive of institutional LTC, patient-reported function and partnership status improve identification of patients who may benefit from home- and community-based services.

    View details for DOI 10.1177/10775587211062403

    View details for PubMedID 34906010

  • The Evolving Economics of Implementation. BMJ quality & safety Knocke, K., Wagner, T. W. 2021

    View details for DOI 10.1136/bmjqs-2021-014411

    View details for PubMedID 34873022

  • Timing and Cost of Wound Complications After Colorectal Resection. Diseases of the colon and rectum Graham, L. A., Wagner, T. H., Sambare, T. D., Hawn, M. T. 2021; 64 (12): 1551-1558


    BACKGROUND: More than 50% of postoperative wound complications occur after discharge. They are the most common postoperative complication and the most common reason for readmission after a surgical procedure. Little is known about the long-term costs of postdischarge wound complications after surgery.OBJECTIVE: We sought to understand the differences in costs and characteristics of wound complications identified after hospital discharge for patients undergoing colorectal surgery in comparison with in-hospital complications.DESIGN: This is an observational cohort study using Veterans Health Administration Surgical Quality Improvement Program data.SETTING: This study was conducted at a Veterans Affairs medical center.SETTING: Patients undergoing colorectal resection between October 1, 2007 and September 30, 2014.MAIN OUTCOME MEASURES: The primary outcomes measured were adjusted costs of care at discharge, 30 days, and 90 days after surgery.RESULTS: Of 20,146 procedures, 11.9% had a wound complication within 30 days of surgery (49.2% index-hospital, 50.8% postdischarge). In comparison with patients with index-hospital complications, patients with postdischarge complications had fewer superficial infections (65.0% vs 72.2%, p < 0.01), more organ/space surgical site infections (14.3% vs 10.1%, p < 0.01), and higher rates of diabetes (29.1% vs 25.0%, p = 0.02), and they were to have had a laparoscopic approach for their surgery (24.7% vs 18.2%, p < 0.01). The average cost including surgery at 30 days was $37,315 (SD = $29,319). Compared with index-hospital wound complications, postdischarge wound complications were $9500 (22%, p < 0.001) less expensive at 30 days and $9736 (15%, p < 0.001) less expensive at 90 days. Patients with an index-hospital wound complication were 40% less likely to require readmission at 30 days, but their readmissions were $12,518 more expensive than readmissions among patients with a newly identified postdischarge wound complication (p < 0.001).LIMITATIONS: This study was limited to patient characteristics and costs accrued only within the Veterans Affairs system.CONCLUSIONS: Patients with postdischarge wound complications have lower 30- and 90-day postoperative costs than those with wound complications identified during their index hospitalization and almost half were managed as an outpatient.TIEMPO Y COSTO DE LAS COMPLICACIONES LA HERIDA DESPUS DE LA RESECCIN COLORRECTAL: ANTECEDENTES:Mas del 50% de complicaciones postoperatorias de la herida ocurren despues del alta. Es la complicacion postoperatoria mas comun y el motivo mas frecuente de reingreso despues del procedimiento quirurgico. Poco se sabe sobre los costos a largo plazo de las complicaciones de la herida despues del alta quirurgica.OBJETIVO:Intentar en comprender las diferencias en los costos y las caracteristicas de las complicaciones de la herida, identificadas despues del alta hospitalaria, en pacientes sometidos a cirugia colorrectal, en comparacion con las complicaciones intrahospitalarias.DISENO:Estudio de cohorte observacional utilizando datos del Programa de Mejora de la Calidad Quirurgica de la Administracion de Salud de Veteranos.ENTORNO CLINICO:Administracion de Veteranos.PACIENTES:Pacientes sometidos a reseccion colorrectal entre el 1/10/2007 y el 30/9/2014.PRINCIPALES MEDIDAS DE VALORACION:Costos de atencion ajustados al alta, 30 dias y 90 dias despues de la cirugia.RESULTADOS:De 20146 procedimientos, el 11,9% tuvo una complicacion de la herida dentro de los 30 dias de la cirugia. (49,2% indice hospitalario, 50,8% despues del alta). En comparacion con los pacientes, del indice de complicaciones hospitalarias, los pacientes con complicaciones posteriores al alta, tuvieron menos infecciones superficiales (65,0% frente a 72,2%, p <0,01), mas infecciones de organos/espacios quirurgicos (14,3% frente a 10,1%, p <0,01), tasas mas altas de diabetes (29,1% versus 25,0%, p = 0,02), y deberian de haber tenido un abordaje laparoscopico para su cirugia (24,7% versus 18,2%, p <0,01). El costo promedio, incluida la cirugia a los 30 dias, fue de $ 37,315 (desviacion estandar = $ 29,319). En comparacion con el indice de complicaciones de las herida hospitalaria, las complicaciones de la herida despues del alta fueron $ 9,500 (22%, p <0,001) menor costo a los 30 dias y $ 9,736 (15%, p<0,001) y menor costo a los 90 dias. Los pacientes con indice de complicacion de la herida hospitalaria, tenian un 40% menos de probabilidades de requerir reingreso a los 30 dias, pero sus reingresos eran $ 12,518 mas costosos que los reingresos entre los pacientes presentando complicacion de la herida recien identificada despues del alta (p <0,001).LIMITACIONES:Limitado a las caracteristicas del paciente y los costos acumulados solo dentro del sistema VA.CONCLUSIONES:Pacientes con complicaciones de la herida post alta, tienen menores costos postoperatorios a los 30 y 90 dias, que aquellos con complicaciones de la herida identificadas durante su indice de hospitalizacion y aproximadamente la mitad fueron tratados de forma ambulatoria.

    View details for DOI 10.1097/DCR.0000000000002065

    View details for PubMedID 34747918

  • In-Stent Restenosis in Saphenous Vein Grafts (from the DIVA Trial). The American journal of cardiology Xenogiannis, I., Rangan, B. V., Uyeda, L., Banerjee, S., Edson, R., Bhatt, D. L., Goldman, S., Holmes, D. R., Rao, S. V., Shunk, K., Mavromatis, K., Ramanathan, K., Bavry, A. A., McFalls, E. O., Garcia, S., Thai, H., Uretsky, B. F., Latif, F., Armstrong, E., Ortiz, J., Jneid, H., Liu, J., Aggrawal, K., Conner, T. A., Wagner, T., Karacsonyi, J., Ventura, B., Alsleben, A., Lu, Y., Shih, M., Brilakis, E. S. 2021


    Saphenous vein grafts (SVGs) have high rates of in-stent restenosis (ISR). We compared the baseline clinical and angiographic characteristics of patients and lesions that did develop ISR with those who did not develop ISR during a median follow-up of 2.7 years in the DIVA study (NCT01121224). We also examined the ISR types using the Mehran classification. ISR developed in 119 out of the 575 DIVA patients (21%), with similar incidence among patients with drug-eluting stents and bare-metal stents (BMS) (21% vs 21%, p=0.957). Patients in the ISR group were younger (67 ± 7 vs 69 ± 8 years, p=0.04) and less likely to have heart failure (27% vs 38%, p=0.03) and SVG lesions with Thrombolysis In Myocardial Infarction 3 flow before the intervention (77% vs 83%, p <0.01), but had a higher number of target SVG lesions (1.33 ± 0.64 vs 1.16 ± 0.42, p <0.01), more stents implanted in the target SVG lesions (1.52 ± 0.80 vs 1.31 ± 0.66, p <0.01), and longer total stent length (31.37 ± 22.11 vs 25.64 ± 17.42 mm, p=0.01). The incidence of diffuse ISR was similar in patients who received drug-eluting-stents and BMS (57% vs 54%, p=0.94), but BMS patients were more likely to develop occlusive restenosis (17% vs 33%, p=0.05).

    View details for DOI 10.1016/j.amjcard.2021.09.024

    View details for PubMedID 34736721

  • Association of Expanded Health Care Networks With Utilization Among Veterans Affairs Enrollees. JAMA network open Rose, L., Aouad, M., Graham, L., Schoemaker, L., Wagner, T. 2021; 4 (10): e2131141


    Importance: Health insurers alter the size of their networks, offering lower premiums in exchange for a more limited set of care choices. However, little is known about the association of network size with health care utilization and outcomes, particularly outside of the context of private insurance plans.Objective: To evaluate changes in health care utilization after an expansion in the Veterans Affairs Health Care System (VA) health care network.Design, Setting, and Participants: This cross-sectional study included individuals enrolled in the VA from 2015 to 2018. Considering that the health care network expansion only affected a portion of enrollees, only those who lived between 20 and 60 miles from a VA facility were included. Data analysis was conducted from September 2020 to February 2021.Exposures: Individuals who lived 40 or more miles away from a VA facility were automatically eligible for an expanded health care network through non-VA practitioners (VA community care); those living less than 40 miles away from a VA facility were not automatically eligible.Main Outcomes and Measures: A regression discontinuity analysis of individuals who became eligible for an expanded network based on geographic residence was performed. Inpatient and outpatient utilization rates per VA enrollee during the study period, with utilization differentiated by whether services were provided by a VA or non-VA practitioner, were calculated.Results: The study included more than 2.7 million unique individuals whose characteristics largely reflected the demographic characteristics of the VA system (mean [SD] age, 62 [17] years; 2 589 252 [90%] men; 282 168 [10%] Black; 2 203 352 [77%] White). Patient characteristics (age, race, and comorbidities) did not vary significantly by eligibility status. Outpatient utilization was 3.2% higher (95% CI, 1.0% to 5.3%) among those with access to an expanded network. Increased utilization was most pronounced among those with a higher VA disability rating (3.1%; 95% CI, 0.5% to 5.7%) and among younger individuals without service-connected disabilities (7.0%, 95% CI, 1.7% to 12.3%). There was no evidence of changes to inpatient utilization (1.2%; 95% CI. -2.5% to 4.9%; P=.37) for those with access to the expanded network.Conclusions and Relevance: In this study, expanded network access was associated with increased total health care utilization among affected enrollees in the VA. Understanding how network size affects utilization is immediately informative for the VA, but it can also help to guide policies for insurance markets.

    View details for DOI 10.1001/jamanetworkopen.2021.31141

    View details for PubMedID 34698845

  • Long-term care service mix in the Veterans Health Administration after home care expansion. Health services research Jacobs, J. C., Wagner, T. H., Trivedi, R., Lorenz, K., Van Houtven, C. H. 2021


    OBJECTIVE: To determine whether the Veterans Health Administration's (VHA) efforts to expand access to home- and community-based services (HCBS) after the 2001 Millennium Act significantly changed Veterans' utilization of institutional, paid home, and unpaid home care relative to a non-VHA user Medicare population that was not exposed to HCBS expansion efforts.DATA SOURCES: We used linkages between the Health and Retirement Study and VHA administrative data from 1998 until 2012.STUDY DESIGN: We conducted a retrospective-matched cohort study using coarsened exact matching to ensure balance on observable characteristics for VHA users (n=943) and nonusers (n=6106). We used a difference-in-differences approach with a person fixed-effects estimator.DATA COLLECTION/EXTRACTION METHODS: Individuals were eligible for inclusion in the analysis if they were age 65 or older and indicated that they were covered by Medicare insurance in 1998. Individuals were excluded if they were covered by Medicaid insurance at baseline. Individuals were considered exposed to VHA HCBS expansion efforts if they were enrolled in the VHA and used VHA services.PRINCIPAL FINDINGS: Theory predicts that an increase in the public allocation of HCBS will decrease the utilization of its substitutes (e.g., institutional care and unpaid caregiving). We found that after the Millennium Act was passed, there were no observed differences between VHA users and nonusers in the probability of using institutional long-term care (0.7% points, 95% CI: -0.009, 0.022) or in receiving paid help with activities of daily living (0.06% points, 95% CI: -0.011, 0.0125). VHA users received more hours of unpaid care post-Millennium Act (1.48, 95% CI: -0.232, 3.187), though this effect was not significant once we introduced controls for mental health.CONCLUSIONS: Our findings indicate that mandating access to HCBS services does not necessarily imply that access to these services will follow suit.

    View details for DOI 10.1111/1475-6773.13687

    View details for PubMedID 34085283

  • Comparing Driving Miles for Department of Veterans Affairs-delivered Versus Department of Veterans Affairs-purchased Cataract Surgery. Medical care Pettey, W. B., Wagner, T. H., Rosen, A. K., Beilstein-Wedel, E., Shwartz, M., Vanneman, M. E. 2021; 59 (Suppl 3): S307–S313


    BACKGROUND: The Veterans Choice Act of 2014 increased the number of Veterans eligible for Department of Veterans Affairs (VA)-purchased care delivered in non-VA community care (CC) facilities. Driving >40 miles from home to a VA facility is a key eligibility criterion for CC. It remains unclear whether this policy change improved geographical access by reducing drive distance for Veterans.OBJECTIVES: Describe the driving distance for Veterans receiving cataract surgery in VA and CC facilities, and if they visited the closest-to-home facility or if they drove to farther facilities.SUBJECTS: Veterans who had cataract surgery in federal fiscal year 2015.MEASURES: We calculated driving miles to the Closest VA and CC facilities that performed cataract surgeries, and to the location where Veterans received care.RESULTS: A total of 61,746 Veterans received 83,875 cataract surgeries. More than 50% of CC surgeries occurred farther than the Closest CC facility providing cataract surgery (median Closest CC facility 8.7 miles vs. Actual CC facility, 19.7 miles). Most (57%) Veterans receiving cataract surgery at a VA facility used the Closest VA facility (median Closest VA facility 28.1 miles vs. Actual VA facility at 31.2 miles). In all, 26.1% of CC procedures occurred in facilities farther away than the Closest VA facility.CONCLUSIONS: Although many Veterans drove farther than needed to get cataract surgery in CC, this was not true for obtaining care in the VA. Our findings suggest that there may be additional reasons, besides driving distance, that affect whether Veterans choose CC and, if they do, where they seek CC.

    View details for DOI 10.1097/MLR.0000000000001491

    View details for PubMedID 33976081

  • County-level Predictors of Growth in Community-based Primary Care Use Among Veterans. Medical care Gordon, S. H., Beilstein-Wedel, E., Rosen, A. K., Zheng, T., Kelley, A. T., Cook, J., Zahakos, S. S., Wagner, T. H., Vanneman, M. E. 2021; 59 (Suppl 3): S301–S306


    BACKGROUND: The 2014 Choice Act expanded the Veterans Health Administration's (VA) capacity to purchase services for VA enrollees from community providers, yet little is known regarding the growth of Veterans' primary care use in community settings.OBJECTIVES: The aim was to measure county-level growth in VA community-based primary care (CBPC) penetration following the Choice Act and to assess whether CBPC penetration increased in rural counties with limited access to VA facilities.DATA AND SAMPLE: A total of 3132 counties from VA administrative data from 2015 to 2018, Area Health Resources Files, and County Health Rankings.ANALYSIS: We defined the county-level CBPC penetration rate as the proportion of VA-purchased primary care out of all VA-purchased primary care (ie, within and outside VA). We estimated county-level multivariate linear regression models to assess whether rurality and supply of primary care providers and health care facilities were significantly associated with CBPC growth.RESULTS: Nationally, CBPC penetration rates increased from 2.7% in 2015 to 7.3% in 2018. The rurality of the county was associated with a 2-3 percentage point (pp) increase in CBPC penetration growth (P<0.001). The presence of a VA facility was associated with a 1.7 pp decrease in CBPC penetration growth (P<0.001), while lower primary care provider supply was associated with a 0.6 pp increase in CBPC growth (P<0.001).CONCLUSION: CBPC as a proportion of all VA-purchased primary care was small but increased nearly 3-fold between 2015 and 2018. Greater increases in CBPC penetration were concentrated in rural counties and counties without a VA facility, suggesting that community care may enhance primary care access in rural areas with less VA presence.

    View details for DOI 10.1097/MLR.0000000000001555

    View details for PubMedID 33976080

  • ACQUISITION OF MEDICAID AT THE TIME OF INJURY: AN OPPORTUNITY FOR SUSTAINABLE INSURANCE COVERAGE. The journal of trauma and acute care surgery Jaramillo, J. D., Arnow, K., Trickey, A. W., Dickerson, K., Wagner, T. H., Harris, A. H., Tran, L. D., Bereknyei, S., Morris, A. M., Spain, D. A., Knowlton, L. M. 2021


    INTRODUCTION: Uninsured trauma patients are at higher risk of mortality, limited access to postdischarge resources and catastrophic health expenditure. Hospital Presumptive Eligibility (HPE), enacted with the 2014 Affordable Care Act, enables uninsured patients to be screened and acquired emergency Medicaid at the time of hospitalization. We sought to identify factors associated with successful acquisition of HPE insurance at the time of injury, hypothesizing that patients with higher injury severity (ISS>15) would be more likely to be approved for HPE.METHODS: We identified Medicaid and uninsured patients aged 18-64 years old with a primary trauma diagnosis (ICD-10) in a large level I trauma center between 2015-2019. We combined trauma registry data with review of electronic medical records, to determine our primary outcome, HPE acquisition. Descriptive and multivariate analyses were performed.RESULTS: Among 2,320 trauma patients, 1,374 (59%) were already enrolled in Medicaid at the time of hospitalization. Among those uninsured at arrival, 386 (40.8%) acquired HPE before discharge, and 560 (59.2%) remained uninsured. HPE patients had higher injury severity score (ISS > 15: 14.8% vs. 5.7%, p < .001), longer median length of stay (LOS) (2 [IQR: 0,5] vs. 0 [0,1] days, p < .001), were more frequently admitted as inpatients (64.5% vs. 33.6%, p < .001) and discharged to post-acute services (11.9% vs. 0.9%, p < .001). Patient, hospital and policy factors contributed to HPE non-approval. In adjusted analyses, Hispanic ethnicity (vs. non-Hispanic whites: aOR 1.58, p = .02) and increasing ISS (p ≤ .001) were associated with increased likelihood of HPE approval.CONCLUSION: The time of hospitalization due to injury is an underutilized opportunity for intervention, whereby uninsured patients can acquire sustainable insurance coverage. Opportunities to increase HPE acquisition merit further study nationally across trauma centers. As administrative and trauma registries do not capture information to compare HPE and traditional Medicaid patients, prospective insurance data collection would help to identify targets for intervention.LEVEL OF EVIDENCE: Epidemiologic, level III.

    View details for DOI 10.1097/TA.0000000000003195

    View details for PubMedID 33783416

  • Intermediate-Term Outcomes of Endoscopic or Open Vein Harvesting for Coronary Artery Bypass Grafting: The REGROUP Randomized Clinical Trial. JAMA network open Zenati, M. A., Bhatt, D. L., Stock, E. M., Hattler, B., Wagner, T. H., Bakaeen, F. G., Biswas, K. 2021; 4 (3): e211439

    View details for DOI 10.1001/jamanetworkopen.2021.1439

    View details for PubMedID 33720367

  • The Association Between Alpha-1 Adrenergic Receptor Antagonists and In-Hospital Mortality From COVID-19. Frontiers in medicine Rose, L., Graham, L., Koenecke, A., Powell, M., Xiong, R., Shen, Z., Mench, B., Kinzler, K. W., Bettegowda, C., Vogelstein, B., Athey, S., Vogelstein, J. T., Konig, M. F., Wagner, T. H. 2021; 8: 637647


    Effective therapies for coronavirus disease 2019 (COVID-19) are urgently needed, and pre-clinical data suggest alpha-1 adrenergic receptor antagonists (alpha1-AR antagonists) may be effective in reducing mortality related to hyperinflammation independent of etiology. Using a retrospective cohort design with patients in the Department of Veterans Affairs healthcare system, we use doubly robust regression and matching to estimate the association between baseline use of alpha1-AR antagonists and likelihood of death due to COVID-19 during hospitalization. Having an active prescription for any alpha1-AR antagonist (tamsulosin, silodosin, prazosin, terazosin, doxazosin, or alfuzosin) at the time of admission had a significant negative association with in-hospital mortality (relative risk reduction 18%; odds ratio 0.73; 95% CI 0.63-0.85; p ≤ 0.001) and death within 28 days of admission (relative risk reduction 17%; odds ratio 0.74; 95% CI 0.65-0.84; p ≤ 0.001). In a subset of patients on doxazosin specifically, an inhibitor of all three alpha-1 adrenergic receptors, we observed a relative risk reduction for death of 74% (odds ratio 0.23; 95% CI 0.03-0.94; p = 0.028) compared to matched controls not on any alpha1-AR antagonist at the time of admission. These findings suggest that use of alpha1-AR antagonists may reduce mortality in COVID-19, supporting the need for randomized, placebo-controlled clinical trials in patients with early symptomatic infection.

    View details for DOI 10.3389/fmed.2021.637647

    View details for PubMedID 33869251

  • From implementation to sustainment: A large-scale adverse event disclosure support program generated through embedded research in the Veterans Health Administration. Healthcare (Amsterdam, Netherlands) Elwy, A. R., Maguire, E. M., McCullough, M., George, J., Bokhour, B. G., Durfee, J. M., Martinello, R. A., Wagner, T. H., Asch, S. M., Gifford, A. L., Gallagher, T. H., Walker, Y., Sharpe, V. A., Geppert, C., Holodniy, M., West, G. 2021; 8 Suppl 1: 100496


    In 2008, the Veterans Health Administration published a groundbreaking policy on disclosing large-scale adverse events to patients in order to promote transparent communication in cases where harm may not be obvious or even certain. Without embedded research, the evidence on whether or not implementation of this policy was generating more harm than good among Veteran patients was unknown. Through an embedded research-operations partnership, we conducted four research projects that led to the development of an evidence-based large-scale disclosure toolkit and disclosure support program, and its implementation across VA healthcare. Guided by the Consolidated Framework for Implementation Research, we identified specific activities corresponding to planning, engaging, executing, reflecting and evaluating phases in the process of implementation. These activities included planning with operational leaders to establish a shared research agenda; engaging with stakeholders to discuss early results, establishing buy-in of our efforts and receiving feedback; joining existing operational teams to execute the toolkit implementation; partnering with clinical operations to evaluate the toolkit during real-time disclosures; and redesigning the toolkit to meet stakeholders' needs. Critical lessons learned for implementation success included a need for stakeholder collaboration and engagement, an organizational culture involving a strong belief in evidence, a willingness to embed researchers in clinical operation activities, allowing for testing and evaluation of innovative practices, and researchers open to constructive feedback. At the conclusion of the research, VA operations worked with the researchers to continue to support efforts to spread, scale-up and sustain toolkit use across the VA healthcare system, with the final goal to establish long-term sustainability.

    View details for DOI 10.1016/j.hjdsi.2020.100496

    View details for PubMedID 34175102

  • End-of-Life Cost Trajectories in Cancer Patients Treated by Medicare versus the Veterans Health Administration. Journal of the American Geriatrics Society Gidwani, R., Asch, S. M., Needleman, J., Faricy-Anderson, K., Boothroyd, D. B., Illarmo, S., Lorenz, K. A., Patel, M. I., Hsin, G., Ramchandran, K., Wagner, T. H. 2020


    BACKGROUND/OBJECTIVES: To evaluate differences in end-of-life cost trajectories for cancer patients treated through Medicare versus by the Veterans Health Administration (VA).DESIGN: A retrospective analysis of VA and Medicare administrative data from FY 2010 to 2014. We employed three-level generalized estimating equation to evaluate monthly cost trajectories experienced by patients in their last year of live, with patients nested within hospital referral region.SETTING: Care received at VA facilities or by Medicare-reimbursed providers nationwide.PARTICIPANTS: A total of 36,401 patients dying from cancer and dually enrolled in VA and Medicare.MEASUREMENTS: We evaluated trajectories for total, inpatient, outpatient, and drug costs, using the last 12months of life. Cost trajectories were prioritized as costs are not directly comparable across Medicare and VA. Patients were assigned to be VA-reliant, Medicare-reliant or Mixed-reliant based on their healthcare utilization in the last year of life.RESULTS: All three groups experienced significantly different cost trajectories for total costs in the last year of life. Inpatient cost trajectories were significantly different between Medicare-reliant and VA-reliant patients, but did not differ between VA-reliant and Mixed-reliant patients. Outpatient and drug cost trajectories exhibited the inverse pattern: they were significantly different between VA-reliant and Mixed-reliant patients, but not between VA-reliant and Medicare-reliant patients. However, visual examination of cost trajectories revealed similar cost patterns in the last year of life among all three groups; there was a sharp rise in costs as patients approach death, largely due to inpatient care.CONCLUSION: Despite substantially different financial incentives and organization, VA- and Medicare-treated patients exhibit similar patterns of increasing end-of-life costs, largely driven by inpatient costs. Both systems require improvement to ensure quality of end-of-life care is aligned with recommended practice.

    View details for DOI 10.1111/jgs.16941

    View details for PubMedID 33368171

  • Laboratory-wide association study of survival with prostate cancer. Cancer Sohlberg, E. M., Thomas, I., Yang, J., Kapphahn, K., Velaer, K. N., Goldstein, M. K., Wagner, T. H., Chertow, G. M., Brooks, J. D., Patel, C. J., Desai, M., Leppert, J. T. 2020


    BACKGROUND: Estimates of overall patient health are essential to inform treatment decisions for patients diagnosed with cancer. The authors applied XWAS methods, herein referred to as "laboratory-wide association study (LWAS)", to evaluate associations between routinely collected laboratory tests and survival in veterans with prostate cancer.METHODS: The authors identified 133,878 patients who were diagnosed with prostate cancer between 2000 and 2013 in the Veterans Health Administration using any laboratory tests collected within 6 months of diagnosis (3,345,083 results). Using the LWAS framework, the false-discovery rate was used to test the association between multiple laboratory tests and survival, and these results were validated using training, testing, and validation cohorts.RESULTS: A total of 31 laboratory tests associated with survival met stringent LWAS criteria. LWAS confirmed markers of prostate cancer biology (prostate-specific antigen: hazard ratio [HR], 1.07 [95% confidence interval (95% CI), 1.06-1.08]; and alkaline phosphatase: HR, 1.22 [95% CI, 1.20-1.24]) as well laboratory tests of general health (eg, serum albumin: HR, 0.78 [95% CI, 0.76-0.80]; and creatinine: HR, 1.05 [95% CI, 1.03-1.07]) and inflammation (leukocyte count: HR, 1.23 [95% CI, 1.98-1.26]; and erythrocyte sedimentation rate: HR, 1.33 [95% CI, 1.09-1.61]). In addition, the authors derived and validated separate models for patients with localized and advanced disease, identifying 28 laboratory markers and 15 laboratory markers, respectively, in each cohort.CONCLUSIONS: The authors identified routinely collected laboratory data associated with survival for patients with prostate cancer using LWAS methodologies, including markers of prostate cancer biology, overall health, and inflammation. Broadening consideration of determinants of survival beyond those related to cancer itself could help to inform the design of clinical trials and aid in shared decision making.LAY SUMMARY: This article examined routine laboratory tests associated with survival among veterans with prostate cancer. Using laboratory-wide association studies, the authors identified 31 laboratory tests associated with survival that can be used to inform the design of clinical trials and aid patients in shared decision making.

    View details for DOI 10.1002/cncr.33341

    View details for PubMedID 33237577

  • Rethinking How We Measure Costs in Implementation Research. Journal of general internal medicine Wagner, T. H. 2020


    BACKGROUND: Hospitals and other health care delivery organizations are sometimes resistant to implementing evidence-based programs, citing unknown budgetary implications.OBJECTIVE: In this paper, I discuss challenges when estimating health care costs in implementation research.DESIGN: A case study with intensive care units highlights how including fixed costs can cloud a short-term analysis.PARTICIPANTS: None.INTERVENTIONS: None.MAIN MEASURES: Health care costs, charges and payments.KEY RESULTS: Cost data should accurately reflect the opportunity costs for the organization(s) providing care. Opportunity costs are defined as the benefits foregone because the resources were not used in the next best alternative. Because there is no database of opportunity costs, cost studies rely on accounting data, charges, or payments as proxies. Unfortunately, these proxies may not reflect the organization's opportunity costs, especially if the goal is to understand the budgetary impact in the next few years.CONCLUSIONS: Implementation researchers should exclude costs that are fixed in the time period of observation because these assets (e.g., space) cannot be used in the next best alternative. In addition, it is common to use costs from accounting databases where we implicitly assume health care providers are uniformly efficient. If providers are not operating efficiently, especially if there is variation in their efficiency, then this can create further problems. Implementation scientists should be judicious in their use of cost estimates from accounting data, otherwise research results can misguide decision makers.

    View details for DOI 10.1007/s11606-020-06104-6

    View details for PubMedID 33107005

  • Estimating Costs of an Implementation Intervention. Medical decision making : an international journal of the Society for Medical Decision Making Wagner, T. H., Yoon, J., Jacobs, J. C., So, A., Kilbourne, A. M., Yu, W., Goodrich, D. E. 2020: 272989X20960455


    Health care systems frequently have to decide whether to implement interventions designed to reduce gaps in the quality of care. A lack of information on the cost of these interventions is often cited as a barrier to implementation. In this article, we describe methods for estimating the cost of implementing a complex intervention. We review methods related to the direct measurement of labor, supplies and space, information technology, and research costs. We also discuss several issues that affect cost estimates in implementation studies, including factor prices, fidelity, efficiency and scale of production, distribution, and sunk costs. We examine case studies for stroke and depression, where evidence-based treatments exist and yet gaps in the quality of care remain. Understanding the costs for implementing strategies to reduce these gaps and measuring them consistently will better inform decision makers about an intervention's likely effect on their budget and the expected costs to implement new interventions.

    View details for DOI 10.1177/0272989X20960455

    View details for PubMedID 33078681

  • Estimating Downstream Budget Impacts in Implementation Research. Medical decision making : an international journal of the Society for Medical Decision Making Wagner, T. H., Dopp, A. R., Gold, H. T. 2020: 272989X20954387


    Health care decision makers often request information showing how a new treatment or intervention will affect their budget (i.e., a budget impact analysis; BIA). In this article, we present key topics for considering how to measure downstream health care costs, a key component of the BIA, when implementing an evidence-based program designed to reduce a quality gap. Tracking health care utilization can be done with administrative or self-reported data, but estimating costs for these utilization data raises 2 issues that are often overlooked in implementation science. The first issue has to do with applicability: are the cost estimates applicable to the health care system that is implementing the quality improvement program? We often use national cost estimates or average payments, without considering whether these cost estimates are appropriate. Second, we need to determine the decision maker's time horizon to identify the costs that vary in that time horizon. If the BIA takes a short-term time horizon, then we should focus on costs that vary in the short run and exclude costs that are fixed over this time. BIA is an increasingly popular tool for health care decision makers interested in understanding the financial effect of implementing an evidence-based program. Without careful consideration of some key conceptual issues, we run the risk of misleading decision makers when presenting results from implementation studies.

    View details for DOI 10.1177/0272989X20954387

    View details for PubMedID 32951506

  • Impact of 12 step mutual help groups on drug use disorder patients across six clinical trials. Drug and alcohol dependence Humphreys, K., Barreto, N. B., Alessi, S. M., Carroll, K. M., Crits-Christoph, P., Donovan, D. M., Kelly, J. F., Schottenfeld, R. S., Timko, C., Wagner, T. H. 2020; 215: 108213


    BACKGROUND: 12 step mutual help groups are widely accessed by people with drug use disorder but infrequently subjected to rigorous evaluation. Pooling randomized trials containing a condition in which mutual help group attendance is actively facilitated presents an opportunity to assess the effectiveness of 12 step groups in large, diverse samples of drug use disorder patients.METHODS: Data from six federally-funded randomized trials were pooled (n=1730) and subjected to two-stage instrumental variables modelling, and, fixed and random effects regression models. All trials included a 12 step group facilitation condition and employed the Addiction Severity Index as a core measure.RESULTS: The ability of 12 step facilitation to increase mutual help group participation among drug use disorder patients was minimal, limiting ability to employ two-stage instrumental variable models that correct for selection bias. However, traditional fixed and random effect regression models found that greater 12 step mutual help group attendance by drug use disorder patients predicted reduced use of and problems with illicit drugs and also with alcohol.CONCLUSION: Facilitating significant and lasting involvement in 12 step groups may be more challenging for drug use disorder patients than for alcohol use disorder patients, which has important implications for clinical work and for effectiveness evaluations. Though selection bias could explain part of the results of traditional regression models, the finding that participation in 12 step mutual help groups predicts lower illicit drug and alcohol use and problems in a large, diverse, sample of drug use disorder patients is encouraging.

    View details for DOI 10.1016/j.drugalcdep.2020.108213

    View details for PubMedID 32801112

  • Emergency Medicaid Acquisition Through the Affordable Care Act: The Association Between Hospital Enrollment in California and Hospital Revenue. Medical care Tran, L. D., Knowlton, L. M., Wagner, T. H. 2020; 58 (8): 727–33


    BACKGROUND: Hospital Presumptive Eligibility (HPE) is a national policy stemming from the Affordable Care Act that allows qualified hospitals, working with state officials, to enroll eligible patients for temporary Medicaid coverage. Although all states are required to operate an HPE program, hospital participation is elective and variable. It is unclear which hospitals choose to participate in HPE and how participation affects hospital utilization and revenue.OBJECTIVE: We examined hospital factors associated with HPE participation in the state of California and assessed pre and post changes in hospital revenue and utilization for HPE and non-HPE hospitals.RESEARCH DESIGN: We performed a logistic regression to identify hospital attributes associated with HPE participation. We then used a difference in differences methodology with a hospital fixed effect to test whether HPE enrollment was associated with changes in annual revenues by payer source, uncompensated care costs, outpatient visits, and/or discharges.RESULTS: Three quarters (76%) of qualified hospitals elected to participate in HPE by the end of 2018. Hospitals with 100 or more beds had over 10 times greater odds of participating in HPE compared with smaller hospitals. Hospitals that did not provide outpatient care were significantly less likely to participate. Among hospitals included in trend analyses, enrollment in HPE was associated with increased annual net patient Medicaid revenue and decreased uncompensated care charges. We predicted that HPE enrollment was associated with an average of 9.7% (95% confidence interval: 3.4%-16.4%) increase in annual net patient Medicaid revenue. As of 2018, 33,000 adults and children were enrolled in California's HPE program per month.CONCLUSION: Hospital enrollment in the HPE program shifted costs from uncompensated care to Medicaid.

    View details for DOI 10.1097/MLR.0000000000001352

    View details for PubMedID 32692139

  • Comparing cataract surgery complication rates in veterans receiving VA and community care. Health services research Rosen, A. K., Vanneman, M. E., O'Brien, W. J., Pershing, S., Wagner, T. H., Beilstein-Wedel, E., Lo, J., Chen, Q., Cockerham, G. C., Shwartz, M. 2020


    OBJECTIVES: To compare 90-day postoperative complication rates between Veterans receiving cataract surgery in VA vs Community Care (CC) during the first year of implementation of the Veterans Choice Act.DATA SOURCES: Fiscal Year (FY) 2015 VA and CC outpatient data from VA's Corporate Data Warehouse (CDW) 10/01/14-9/30/15). FY14 data were used to obtain baseline clinical information prior to surgery.STUDY DESIGN: Retrospective one-year study using secondary data to compare 90-day complication rates following cataract surgery (measured using National Quality Forum (NQF) criteria) in VA vs CC. NQF defines major complications from a specified list of Current Procedural Terminology (CPT) codes. We ran a series of logistic regression models to predict 90-day complication rates, adjusting for Veterans' sociodemographic characteristics, comorbidities, preoperative ocular conditions, eye risk group, and type of cataract surgery (classified as routine vs complex).DATA COLLECTION: We linked VA and CC users through patient identifiers obtained from the CDW files. Our sample included all enrolled Veterans who received outpatient cataract surgery either in the VA or through CC during FY15. Cataract surgeries were identified through CPT codes 66984 (routine) and 66982 (complex).PRINCIPAL FINDINGS: Of the 83,879 cataract surgeries performed in FY15, 31 percent occurred through CC. Undergoing complex surgery and having a high-risk eye (based on preoperative ocular conditions) were the strongest clinical predictors of 90-day postoperative complications. Overall, we found low complication rates, ranging from 1.1 percent in low-risk eyes to 3.6 percent in high-risk eyes. After adjustment for important confounders (eg, race, rurality, and preoperative ocular conditions), there were no statistically significant differences in 90-day complication rates between Veterans receiving cataract surgery in VA vs CC.CONCLUSIONS: As more Veterans seek care through CC, future studies should continue to monitor quality of care across the two care settings to help inform VA's "make vs buy decisions."

    View details for DOI 10.1111/1475-6773.13320

    View details for PubMedID 32715468

  • Life expectancy estimates for patients diagnosed with prostate cancer in the Veterans Health Administration. Urologic oncology Sohlberg, E. M., Thomas, I., Yang, J., Kapphahn, K., Daskivich, T. J., Skolarus, T. A., Shelton, J. B., Makarov, D. V., Bergman, J., Bang, C. K., Goldstein, M. K., Wagner, T. H., Brooks, J. D., Desai, M., Leppert, J. T. 2020


    PURPOSE: Accurate life expectancy estimates are required to inform prostate cancer treatment decisions. However, few models are specific to the population served or easily implemented in a clinical setting. We sought to create life expectancy estimates specific to Veterans diagnosed with prostate cancer.MATERIALS AND METHODS: Using national Veterans Health Administration electronic health records, we identified Veterans diagnosed with prostate cancer between 2000 and 2015. We abstracted demographics, comorbidities, oncologic staging, and treatment information. We fit Cox Proportional Hazards models to determine the impact of age, comorbidity, cancer risk, and race on survival. We stratified life expectancy estimates by age, comorbidity and cancer stage.RESULTS: Our analytic cohort included 145,678 patients. Survival modeling demonstrated the importance of age and comorbidity across all cancer risk categories. Life expectancy estimates generated from age and comorbidity data were predictive of overall survival (C-index 0.676, 95% CI 0.674-0.679) and visualized using Kaplan-Meier plots and heatmaps stratified by age and comorbidity. Separate life expectancy estimates were generated for patients with localized or advanced disease. These life expectancy estimates calibrate well across prostate cancer risk categories.CONCLUSIONS: Life expectancy estimates are essential to providing patient-centered prostate cancer care. We developed accessible life expectancy estimation tools for Veterans diagnosed with prostate cancer that can be used in routine clinical practice to inform medical-decision making.

    View details for DOI 10.1016/j.urolonc.2020.05.015

    View details for PubMedID 32674954

  • OUTPATIENT CARE FRAGMENTATION PATTERNS AND ASSOCIATION WITH HOSPITALIZATION IN HIGH-RISK VA PATIENTS Zulman, D. M., Greene, A. L., Wagner, T. H., Maciejewski, M., Singer, S., Slightam, C., Trivedi, R., Vanneman, M., Asch, S., Yoon, J., Goldstein, M. K., Boothroyd, D. SPRINGER. 2020: S216
  • The Urine Albumin-Creatinine Ratio and Kidney Function after Nephrectomy. The Journal of urology Sun, A. J., Thomas, I., Velaer, K. N., Ganesan, C., Song, S., Pao, A. C., Wagner, T. H., Brooks, J. D., Chertow, G. M., Leppert, J. T. 2020: 101097JU0000000000001005


    BACKGROUND: Patients with kidney cancer are at risk of developing chronic kidney disease (CKD) after radical and partial nephrectomy. We sought to determine if the urine albumin-creatinine ratio (UACR) is independently associated with progressive CKD after nephrectomy.METHODS: We performed a cohort study based within a large, integrated health care system. We identified patients who underwent radical or partial nephrectomy from 2004 to 2014 with UACR measured in the 12 months prior to surgery. We fit multivariable models to determine if the UACR was associated with the time to CKD progression (defined as reaching stage 4 or 5 CKD, eGFR <30 mL/min/1.73m2). We performed a parallel analysis measuring the time to stage 3b, 4 or 5 CKD (eGFR <45 mL/min/1.73m2) among patients with normal or near-normal preoperative kidney function (eGFR ≥60 mL/min/1.73 m2). We also examined the association between UACR and survival.RESULTS: 1930 patients underwent radical or partial nephrectomy and had preoperative UACR and pre- and post-operative eGFR. Of these, 658 (34%) and 157 (8%) had moderate (UACR 30-300mg/g) or severe albuminuria (UACR > 300mg/g), respectively. Albuminuria severity was independently associated with progressive CKD after radical (moderate albuminuria HR 1.7, 95%CI 1.4-2.2; severe albuminuria HR 2.3, 95%CI 1.7-3.1) and partial nephrectomy (moderate albuminuria HR 1.8, 95%CI 1.2-2.7; severe albuminuria HR 4.3, 95%CI 2.7-7.0). Albuminuria was also associated with survival following radical and partial nephrectomy.CONCLUSIONS: In patients undergoing radical or partial nephrectomy, the severity of albuminuria can stratify risk of progressive CKD.

    View details for DOI 10.1097/JU.0000000000001005

    View details for PubMedID 32125227

  • Incidence and Prognostic Impact of Incomplete Revascularization Documented by Coronary Angiography 1 Year After Coronary Artery Bypass Grafting. The American journal of cardiology Hattler, B. n., Grover, F. L., Wagner, T. n., Hawkins, R. B., Quin, J. A., Collins, J. F., Bishawi, M. n., Almassi, H. n., Shroyer, A. L. 2020


    Complete revascularization (CR) at the time of coronary artery bypass graft (CABG) surgery improves long-term cardiac outcomes. No studies have previously reported angiographically confirmed CR rates post-CABG. This study's aim was to assess the impact upon long-term outcomes of CR versus incomplete revascularization (IR), confirmed by coronary angiography 1 year after CABG. Randomized On/Off Bypass Study patients who returned for protocol-specified 1-year post-CABG coronary angiograms were included. Patients with a widely patent graft supplying the major diseased artery within each diseased coronary territory were considered to have CR. Outcomes were all-cause mortality and major adverse cardiovascular events (MACE; all-cause mortality, nonfatal myocardial infarction, repeat revascularization) over the 4 years after angiography. Of the 1,276 patients, 756 (59%) had CR and 520 (41%) had IR. MACE was 13% CR versus 26% IR, p <0.001. This difference was driven by fewer repeat revascularizations (5% CR vs 18% IR; p <0.001). There were no differences in mortality (7.1% CR vs 8.1% IR, p = 0.13) or myocardial infarction (4% in both). Adjusted multivariable models confirmed CR was associated with reduced MACE (odds ratio 0.44, 95% confidence interval 0.33 to 0.58, p <0.01), but had no impact on mortality. In conclusion, CR confirmed by post-CABG angiography was associated with improved MACE but not mortality. Repeat revascularization of patients with IR, driven by knowledge of the research angiography results, may have ameliorated potential mortality differences.

    View details for DOI 10.1016/j.amjcard.2020.06.047

    View details for PubMedID 32718555

  • The Association Between Alpha-1 Adrenergic Receptor Antagonists and In-Hospital Mortality from COVID-19. medRxiv : the preprint server for health sciences Rose, L. n., Graham, L. n., Koenecke, A. n., Powell, M. n., Xiong, R. n., Shen, Z. n., Kinzler, K. W., Bettegowda, C. n., Vogelstein, B. n., Athey, S. n., Vogelstein, J. T., Konig, M. F., Wagner, T. H. 2020


    Effective therapies for coronavirus disease 2019 (COVID-19) are urgently needed, and preclinical data suggest alpha-1 adrenergic receptor antagonists (α 1 -AR antagonists) may be effective in reducing mortality related to hyperinflammation. Using a retrospective cohort design with patients in the Department of Veterans Affairs healthcare system, we use doubly robust regression and matching to estimate the association between use of α 1 -AR antagonists at time of hospitalization and likelihood of death due to COVID-19 during an inpatient stay. Having an active prescription for an α 1 -AR antagonist (tamsulosin, silodosin, prazosin, terazosin, doxazosin, or alfuzosin) at the time of admission had a significant negative association with in-hospital mortality (relative risk reduction 14%; odds ratio 0.75; 95% CI 0.66 to 0.86; p ≤ 0.001). These effects were also found in an expanded cohort of suspected COVID-19 patients, supporting the need for clinical trials.

    View details for DOI 10.1101/2020.12.18.20248346

    View details for PubMedID 33398294

    View details for PubMedCentralID PMC7781337

  • Are EMS bypass policies effective implementation strategies for intravenous alteplase for stroke? Implementation science communications Harris, A. H., Barreto, N. B., Trickey, A. W., Bereknyei, S. n., Meng, T. n., Wagner, T. H., Govindarajan, P. n. 2020; 1: 50


    Stroke is a leading cause of disability and the fifth leading cause of death in the USA. Intravenous alteplase is a highly effective clot-dissolving stroke treatment that must be given in a hospital setting within a time-sensitive window. To increase the use of intravenous alteplase in stroke patients, many US counties enacted policies mandating emergency medical service (EMS) paramedics to bypass local emergency departments and instead directly transport patients to specially equipped stroke centers. The objective of this mixed-methods study is to evaluate the effectiveness of policy enactment as an implementation strategy, how differences in policy structures and processes impact effectiveness, and to explore how the county, hospital, and policy factors explain variation in implementation and clinical outcomes. This paper provides a detailed description of an Agency for Healthcare Quality and Research (AHRQ)-funded protocol, including the use of the Consolidated Framework for Implementation Research (CFIR) in the qualitative design.We will construct the largest-ever national stroke database of Medicare enrollees (~ 1.5 million stroke patients) representing 896 policy counties paired with 1792 non-policy counties, then integrate patient-, hospital-, county-, and state-level covariates from eight different data sources. We will use a difference-in-differences analysis to estimate the overall effect of the policy enactment on intravenous alteplase use (implementation outcome) as well as key patient outcomes. We will also quantitatively examine if variation in the context (urban/rural status) and variation in policy features affect outcomes. Finally, a CFIR-informed multiple case study design will be used to interview informants in 72 stakeholders in 24 counties to identify and validate factors that enable policy effects.Policies can be potent implementation strategies. However, the effects of EMS bypass policies to increase intravenous alteplase use have not been rigorously evaluated. By learning how context and policy structures impact alteplase implementation, as well as the barriers and facilitators experienced by stakeholders responsible for policy enactment, the results of this study will inform decisions regarding if and how EMS bypass policies should spread to non-policy counties, and if indicated, creation of a "best practices" toolkit.

    View details for DOI 10.1186/s43058-020-00041-5

    View details for PubMedID 32885206

    View details for PubMedCentralID PMC7427915

  • Acute pain after breast surgery and reconstruction: A two-institution study of surgical factors influencing short-term pain outcomes. Journal of surgical oncology Azad, A. D., Bozkurt, S. n., Wheeler, A. J., Curtin, C. n., Wagner, T. H., Hernandez-Boussard, T. n. 2020


    Acute postoperative pain following surgery is known to be associated with chronic pain development and lower quality of life. We sought to analyze the relationship between differing breast cancer excisional procedures, reconstruction, and short-term pain outcomes.Women undergoing breast cancer excisional procedures with or without reconstruction at two systems: an academic hospital (AH) and Veterans Health Administration (VHA) were included. Average pain scores at the time of discharge and at 30-day follow-up were analyzed across demographic and clinical characteristics. Linear mixed effects modeling was used to assess the relationship between patient/clinical characteristics and interval pain scores with a random slope to account for differences in baseline pain.Our study included 1402 patients at AH and 1435 at VHA, of which 426 AH and 165 patients with VHA underwent reconstruction. Pain scores improved over time and were found to be highest at discharge. Time at discharge, 30-day follow-up, and preoperative opioid use were the strongest predictors of high pain scores. Younger age and longer length of stay were independently associated with worse pain scores.Younger age, preoperative opioid use, and longer length of stay were associated with higher levels of postoperative pain across both sites.

    View details for DOI 10.1002/jso.26070

    View details for PubMedID 32563208

  • Co-Operative Pain Education and Self-management (COPES) Expanding Treatment for Real-World Access (ExTRA): Pragmatic Trial Protocol. Pain medicine (Malden, Mass.) Heapy, A. A., Driscoll, M. A., Buta, E., LaChappelle, K. M., Edmond, S., Krein, S. L., Piette, J. D., Mattocks, K., Murphy, J. L., DeBar, L., MacLean, R. R., Ankawi, B., Kawecki, T., Martino, S., Wagner, T., Higgins, D. M. 2020; 21 (12 Suppl 2): S21–S28


    BACKGROUND: Given access barriers to cognitive behavioral therapy for chronic pain (CBT-CP), this pragmatic superiority trial will determine whether a remotely delivered CBT-CP intervention that addresses these barriers outperforms in-person and other synchronous forms of CBT-CP for veterans with musculoskeletal pain.DESIGN: This pragmatic trial compares an asynchronous form of CBT-CP that uses interactive voice response (IVR) to allow patients to participate from their home (IVR CBT-CP) with synchronous CBT-CP delivered by a Department of Veterans Affairs (VA) clinician. Veterans (n=764; 50% male) with chronic musculoskeletal pain throughout nine VA medical centers will participate. The primary outcome is pain interference after treatment (4months). Secondary outcomes, including pain intensity, depression symptom severity, sleep, self-efficacy, and global impression of change, are also measured after treatment. Where possible, outcomes are collected via electronic health record extraction, with remaining measures collected via IVR calls to maintain blinding. Quantitative and qualitative process evaluation metrics will be collected to evaluate factors related to implementation. A budget impact analysis will be performed.SUMMARY: This pragmatic trial compares the outcomes, cost, and implementation of two forms of CBT-CP as delivered in the real-world setting. Findings from the trial can be used to guide future policy and implementation efforts related to these interventions and their use in the health system. If one of the interventions emerges as superior, resources can be directed to this modality. If both treatments are effective, patient preferences and health care system factors will take precedence when making referrals. Implications of COVID-19 on treatment provision and trial outcomes are discussed.

    View details for DOI 10.1093/pm/pnaa365

    View details for PubMedID 33313733

  • New-onset postoperative atrial fibrillation impact on 5-year clinical outcomes and costs. The Journal of thoracic and cardiovascular surgery Almassi, G. H., Hawkins, R. B., Bishawi, M., Shroyer, A. L., Hattler, B., Quin, J. A., Collins, J. F., Bakaeen, F. G., Ebrahimi, R., Grover, F. L., Wagner, T. H., Veterans Affairs Randomized On/Off Bypass Follow-up Study (ROOBY-FS) Group 2019


    OBJECTIVE: The impact of new-onset postoperative atrial fibrillation (POAF) following coronary artery bypass grafting (CABG) surgery on long-term clinical outcomes and costs is not known. This subanalysis of the Veterans Affairs "Randomized On/Off Bypass Follow-up Study" compared 5-year outcomes and costs between patients with and without POAF.METHODS: Of the 2203 veterans in the study, 100 with pre-CABG atrial fibrillation (93) or missing data (7) were excluded (4.8%). Unadjusted and risk-adjusted outcomes were compared between new-onset POAF (n=551) and patients without POAF (n=1552). Five-year clinical outcomes included mortality, major adverse cardiovascular events (MACE, comprising mortality, repeat revascularization, and myocardial infarction), MACE subcomponents, stroke, and costs. A stringent P value of ≤.01 was required to identify statistical significance.RESULTS: Patients with POAF were older and had more complex comorbidities. Unadjusted 5-year all-cause mortality was 16.3% POAF versus 11.9% no-POAF, P=.008. Unadjusted cardiac-mortality was 7.4% versus 4.8%, P=.022. There were no differences between groups in any other unadjusted outcomes including MACE or stroke. After risk adjustment, there were no significant differences between groups in 5-year all-cause mortality (POAF odds ratio, 1.19; 99% confidence interval, 0.81-1.75) or cardiac mortality (odds ratio, 1.51, 99% confidence interval, 0.88-2.60). Adjusted first-year post-CABG costs were $15,300 greater for patients with POAF, but 2- through 5-year costs were similar.CONCLUSIONS: No 5-year risk-adjusted outcome differences were found between patients with and without POAF after CABG. Although first-year costs were greater in patients with POAF, this difference did not persist in subsequent years.

    View details for DOI 10.1016/j.jtcvs.2019.10.150

    View details for PubMedID 31866082

  • Evaluating the Role of Past Clinical Information on Risk Adjustment. Medical care Lin, J. K., Hong, J., Phibbs, C., Almenoff, P., Wagner, T. 2019


    OBJECTIVE: The objective of this study was to evaluate whether incorporating historical clinical information beyond 1 year improves risk adjustment.DATA SOURCES: Administrative data from the Department of Veterans Affairs and Medicare (for veterans concurrently enrolled in Medicare) for fiscal years (FYs) 2011-2015.STUDY DESIGN: We regressed total annual costs on Medicare hierarchical condition category indicators and risk scores for FY 2015 in both a concurrent and a prospective model using 5-fold cross-validation. Regressions were repeated incorporating clinical information from FY 2011 to 2015. Model fit was appraised using R and mean squared predictive error (MSPE).DATA COLLECTION: All veterans affairs users (n=3,254,783) with diagnostic information FY 2011-2015.PRINCIPAL FINDINGS: In a concurrent model, adding additional years of historical clinical information (FY 2011-2014) did not result in substantive gains in fit (R from 0.671 to 0.673) or predictive capability (MSPE from 1956 to 1950). In a prospective model, adding additional years of historical clinical information also did not result in substantive gains in fit (R from 0.334 to 0.344) or predictive capability (MSPE from 3988 to 3940).CONCLUSION: Incorporating historical clinical information yielded no material gain in risk adjustment fit.

    View details for DOI 10.1097/MLR.0000000000001236

    View details for PubMedID 31688567

  • In-Stent Restenosis in Saphenous Vein Grafts: Insights From the DIVA trial Xenogiannis, I., Rangan, B., Uyeda, L., Banerjee, S., Edson, R., Bhatt, D., Holmes, D., Rao, S., Mavromatis, K., Ramanathan, K., McFalls, E., Garcia, S., Uretsky, B., Latif, F., Armstrong, E., Ortiz, J., Jneid, H., Liu, J., Aggarwal, K., Conner, T., Wagner, T., Karacsonyi, J., Ventura, B., Lu, Y., Shih, M., Brilakis, E. ELSEVIER SCIENCE INC. 2019: B661
  • Association between Timing and Cost of Postoperative Wound Complication Graham, L. A., Wagner, T. H., Sambare, T. D., Hawn, M. T. ELSEVIER SCIENCE INC. 2019: S143
  • Characteristics of mental health trials registered in Psychiatry research Arnow, K. D., King, A. C., Wagner, T. H. 2019; 281: 112552


    The registry was established in 2000 to address concerns about publication bias and public access to information about clinical trials. We aimed to evaluate differences between for-profit and non-profit sponsors of efficacy mental health trials registered in on key trial characteristics that relate to data integrity. We also sought to evaluate whether the registry is fulfilling its purpose as a means of promoting transparency between researchers and the public by providing complete and quality information about the trials it contains. We found that trials tend to be small, use a placebo instead of an active comparator, and employ randomization and blinding. We discuss the implications of these design characteristics and the limitations of the registry.

    View details for DOI 10.1016/j.psychres.2019.112552

    View details for PubMedID 31627072

  • Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer JAMA ONCOLOGY Mor, V., Wagner, T. H., Levy, C., Ersek, M., Miller, S. C., Gidwani-Marszowski, R., Joyce, N., Faricy-Anderson, K., Corneau, E. A., Lorenz, K., Kinosian, B., Shreve, S. 2019; 5 (6): 810–16
  • Resident-Sensitive Processes of Care: Impact of Surgical Residents on Inpatient Testing Sheckter, C. C., Jopling, J., Ding, Q., Trickey, A. W., Wagner, T., Morris, A. M., Hawn, M. T. ELSEVIER SCIENCE INC. 2019: 798-+
  • Overdose Risk Associated with Opioid Use upon Hospital Discharge in Veterans Health Administration Surgical Patients PAIN MEDICINE Mudumbai, S. C., Lewis, E. T., Oliva, E. M., Chung, P. D., Harris, B., Trafton, J., Mariano, E. R., Wagner, T., Clark, J., Stafford, R. S. 2019; 20 (5): 1020–31

    View details for DOI 10.1093/pm/pny150

    View details for Web of Science ID 000479175500018

  • Comparison of a Potential Hospital Quality Metric With Existing Metrics for Surgical Quality-Associated Readmission. JAMA network open Graham, L. A., Mull, H. J., Wagner, T. H., Morris, M. S., Rosen, A. K., Richman, J. S., Whittle, J., Burns, E., Copeland, L. A., Itani, K. M., Hawn, M. T. 2019; 2 (4): e191313


    Importance: The existing readmission quality metric does not meaningfully distinguish readmissions associated with surgical quality from those that are not associated with surgical quality and thus may not reflect the quality of surgical care.Objective: To compare a quality metric that classifies readmissions associated with surgical quality with the existing metric of any unplanned readmission in a surgical population.Design, Setting, and Participants: Cohort study using US nationwide administrative data collected on 4 high-volume surgical procedures performed at 103 Veterans Affairs hospitals from October 1, 2007, through September 30, 2014. Data analysis was conducted from October 1, 2017, to January 24, 2019.Main Outcomes and Measures: Hospital-level rates of unplanned readmission (existing metric) and surgical readmissions associated with surgical quality (new metric) in the 30 days following hospital discharge for an inpatient surgical procedure.Results: The study population included 109 258 patients who underwent surgery at 103 hospitals. Patients were majority male (94.1%) and white (78.2%) with a mean (SD) age of 64.0 (10.0) years at the time of surgery. After case-mix adjustment, 30-day surgical readmissions ranged from 4.6% (95% CI, 4.5%-4.8%) among knee arthroplasties to 11.1% (95% CI, 10.9%-11.3%) among colorectal resections. The new surgical readmission metric was significantly correlated with facility-level postdischarge complications for all procedures, with rho coefficients ranging from 0.33 (95% CI, 0.13-0.51) for cholecystectomy to 0.52 (95% CI, 0.38-0.68) for colorectal resection. Correlations between postdischarge complications and the new surgical readmission metric were higher than correlations between complications and the existing readmission metric for all procedures examined (knee arthroplasty: 0.50 vs 0.48; hip replacement: 0.44 vs 0.18; colorectal resection: 0.52 vs 0.42; and cholecystectomy: 0.33 vs 0.10). When compared with using the existing readmission metric, using the new surgical readmission metric could change hip replacement-associated payment penalty determinations in 28.4% of hospitals and knee arthroplasty-associated penalties in 26.0% of hospitals.Conclusions and Relevance: In this study, surgical quality-associated readmissions were more correlated with postdischarge complications at a higher rate than were unplanned readmissions. Thus, a metric based on such readmissions may be a better measure of surgical care quality. This work provides an important step in the development of future value-based payments and promotes evidence-based quality metrics targeting the quality of surgical care.

    View details for PubMedID 31002316

  • Comparison of a Potential Hospital Quality Metric With Existing Metrics for Surgical Quality-Associated Readmission JAMA NETWORK OPEN Graham, L. A., Mull, H. J., Wagner, T. H., Morris, M. S., Rosen, A. K., Richman, J. S., Whittle, J., Burns, E., Copeland, L. A., Itani, K. F., Hawn, M. T. 2019; 2 (4)
  • Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer. JAMA oncology Mor, V., Wagner, T. H., Levy, C., Ersek, M., Miller, S. C., Gidwani-Marszowski, R., Joyce, N., Faricy-Anderson, K., Corneau, E. A., Lorenz, K., Kinosian, B., Shreve, S. 2019


    Importance: Medicare hospice beneficiaries discontinue disease-modifying treatments because the hospice benefit limits access. While veterans have concurrent access to hospice care and Veterans Affairs (VA) Medical Center (VAMC)-provided treatments, the association of this with changes in treatment and costs of veterans' end-of-life care is unknown.Objective: To determine whether increasing availability of hospice care, without restrictions on disease-modifying treatments, is associated with reduced aggressive treatments and medical care costs at the end of life.Design, Setting, and Participants: A modified difference-in-difference study design, using facility fixed effects, compared patient outcomes during years with relatively high vs lower hospice use. This study evaluated 13 085 veterans newly diagnosed with stage IV non-small cell lung cancer (NSCLC) from 113 VAMCs with a minimum of 5 veterans diagnosed with stage IV NSCLC per year, between 2006 and 2012. Data analyses were conducted between January 2017 and July 2018.Exposures: Using VA inpatient, outpatient, pharmacy claims, and similar Medicare data, we created VAMC-level annual aggregates of all patients who died of cancer for hospice use, cancer treatment, and/or concurrent receipt of both in the last month of life, dividing all VAMC years into quintiles of exposure to hospice availability.Main Outcomes and Measures: Receipt of aggressive treatments (2 or more hospital admissions within 30 days, tube feeding, mechanical ventilation, intensive care unit [ICU] admission) and total costs in the first 6 months after diagnosis.Results: Of the 13 085 veterans included in the study, 12 858 (98%) were men; 10 531 (81%) were white, and 5949 (46%) were older than 65 years. Veterans with NSCLC treated in a VAMC in the top hospice quintile (79% hospice users), relative to the bottom quintile (55% hospice users), were more than twice as likely to have concurrent cancer treatment after initiating hospice care (adjusted odds ratio [AOR], 2.28; 95% CI, 1.67-3.31). Nonetheless, for veterans with NSCLC seen in VAMCs in the top hospice quintile, the AOR of receiving aggressive treatment in the 6 months after diagnosis was 0.66 (95% CI, 0.53-0.81), and the AOR of ICU use was 0.78 (95% CI, 0.62-0.99) relative to patients seen in VAMCs in the bottom hospice quintile. The 6-month costs were lower by an estimated $266 (95% CI, -$358 to -$164) per day for the high-quintile group vs the low-quintile group. There was no survival difference.Conclusions and Relevance: Increasing the availability of hospice care without restricting treatment access for veterans with advanced lung cancer was associated with less aggressive medical treatment and significantly lower costs while still providing cancer treatment.

    View details for PubMedID 30920603

  • A Qualitative Study of Primary Care Providers' Experiences with the Veterans Choice Program. Journal of general internal medicine Nevedal, A. L., Wagner, T. H., Ellerbe, L. S., Asch, S. M., Koenig, C. J. 2019


    BACKGROUND: The Veterans Access, Choice and Accountability Act (hereafter, Choice Program) seeks to improve access to care by enabling eligible Veterans to receive care from community providers. Veterans Affairs (VA) primary care providers (PCPs) play a key role in making referrals to community specialists, but their frontline experiences with referrals are not well understood.OBJECTIVE: To understand VA PCPs' experiences referring patients to community specialists while VA works to expand and refine the implementation of the Choice Program.DESIGN: Qualitative study using interview methods.PARTICIPANTS: Semi-structured telephone interviews were conducted with VA primary care providers (N=72 out of 599 contacted) recruited nationally.APPROACH: Open-ended interview questions elicited PCP perceptions and experiences with referrals to community specialists via the Choice Program. Keywords were identified using automated coding features in ATLAS.ti and evaluated using conventional content analysis to inductively describe the qualitative data.KEY RESULTS: VA PCPs emphasized problems with care coordination and continuity between the VA and community specialists (e.g., "It is extremely difficult for us to obtain and continue continuity of care because there's not much communication with the community specialist"). They described difficulties with tracking the initial referral, coordinating care after receiving community specialty care, accessing community medical records, and aligning community specialists' prescriptions with the VA formulary.CONCLUSIONS: The VA Choice Program provides access to community specialists for VA patients; however, VA primary care providers face challenges tracking referrals to community specialists and in coordinating care. Strategies to improve care coordination between the VA and community providers should focus on providing PCPs with information to follow Veterans throughout the Choice referral process and follow-up.

    View details for PubMedID 30684200

  • Resident Sensitive Processes of Care: the Impact of Surgical Residents on Inpatient Testing. Journal of the American College of Surgeons Sheckter, C. C., Jopling, J., Ding, Q., Trickey, A. W., Wagner, T., Morris, A., Hawn, M. 2019


    INTRODUCTION: Healthcare value is a national priority, and there are substantial efforts to reduce overuse of low-value testing. Residency training programs and teaching hospitals have been implicated in excessive testing. We evaluated the impact of surgery residents on the frequency of inpatient testing and investigated potential inter-resident variation.METHODS: Inpatient laboratory and imaging orders placed on general surgery services were extracted from an academic institution from 2014-2016 and linked to National Surgical Quality Improvement Program data. Using negative binomial mixed effects regression with unstructured covariance, we evaluated the frequency of testing orders compared to median utilization, accounting for case, patient, and attending-level variables.RESULTS: 111,055 laboratory and 7,360 imaging orders were linked with 2,357 patients. Multivariable analysis demonstrated multiple significant predictors of increased testing including: postoperative complications, medical comorbidities, length of stay, relative value units, attending surgeon, and resident surgeon (95% confidence intervals >1, p<0.05). Compared to the median resident physician, 47 residents (37.9%) placed significantly more laboratory orders, and 2 residents (1.6%) placed significantly more imaging orders (95% confidence interval >1, p<0.05). Resident identification explained 3.5% of the total variation in laboratory ordering and 4.9% in imaging orders.CONCLUSIONS: Individual surgical residents had a significant association with the frequency of inpatient testing after adjusting for attending, case, and patient-level variables. There was greater resident variation in laboratory testing compared to imaging, yet surgical residents had small contributions to the total variation in both laboratory and imaging testing. Our models provide a means of identifying high utilizers and could be used to educate residents on their ordering patterns.

    View details for PubMedID 30660819

  • Perioperative Opioid Prescribing Patterns and Readmissions After Total Knee Arthroplasty in a National Cohort of Veterans Health Administration Patients. Pain medicine (Malden, Mass.) Mudumbai, S. C., Chung, P. n., Nguyen, N. n., Harris, B. n., Clark, J. D., Wagner, T. H., Giori, N. J., Stafford, R. S., Mariano, E. R. 2019


    Among Veterans Health Administration (VHA) patients who undergo total knee arthroplasty (TKA) nationally, what are the underlying readmission rates and associations with perioperative opioid use, and are there associations with other factors such as preoperative health care utilization?We retrospectively examined the records of 5,514 TKA patients (primary N = 4,955, 89.9%; revision N = 559, 10.1%) over one fiscal year (October 1, 2010-September 30, 2011) across VHA hospitals nationwide. Opioid use was classified into no opioids, tramadol only, short-acting only, or any long-acting. We measured readmission within 30 days and the number of days to readmission within 30 days. Extended Cox regression models were developed.The overall 30-day hospital readmission rate was 9.6% (N = 531; primary 9.5%, revision 11.1%). Both readmitted patients and the overall sample were similar on types of preoperative opioid use. Relative to patients without opioids, patients in the short-acting opioids only tier had the highest risk for 30-day hospital readmission (hazard ratio = 1.38, 95% confidence interval = 1.14-1.67). Preoperative opioid status was not associated with 30-day readmission. Other risk factors for 30-day readmission included older age (≥66 years), higher comorbidity and diagnosis-related group weights, greater preoperative health care utilization, an urban location, and use of preoperative anticonvulsants.Given the current opioid epidemic, the routine prescribing of short-acting opioids after surgery should be carefully considered to avoid increasing risks of 30-day hospital readmissions and other negative outcomes, particularly in the context of other predisposing factors.

    View details for DOI 10.1093/pm/pnz154

    View details for PubMedID 31309970

  • Health System and Beneficiary Costs Associated With Intensive End-of-Life Medical Services. JAMA network open Gidwani-Marszowski, R. n., Asch, S. M., Mor, V. n., Wagner, T. H., Faricy-Anderson, K. n., Illarmo, S. n., Hsin, G. n., Patel, M. I., Ramchandran, K. n., Lorenz, K. A., Needleman, J. n. 2019; 2 (9): e1912161


    Despite recommendations to reduce intensive medical treatment at the end of life, many patients with cancer continue to receive such services.To quantify expected beneficiary and health system costs incurred in association with receipt of intensive medical services in the last month of life.This retrospective cohort study used data collected nationally from Medicare and the Veterans Health Administration for care provided in fiscal years 2010 to 2014. Participants were 48 937 adults aged 66 years or older who died of solid tumor and were continuously enrolled in fee-for-service Medicare and the Veterans Health Administration in the 12 months prior to death. The data were analyzed from February to August 2019.American Society of Clinical Oncology metrics regarding medically intensive services provided in the last month of life, including hospital stay, intensive care unit stay, chemotherapy, 2 or more emergency department visits, or hospice for 3 or fewer days.Costs in the last month of life associated with receipt of intensive medical services were evaluated for both beneficiaries and the health system. Costs were estimated from generalized linear models, adjusting for patient demographics and comorbidities and conditioning on geographic region.Of 48 937 veterans who received care through the Veterans Health Administration and Medicare, most were white (90.8%) and male (98.9%). More than half (58.9%) received at least 1 medically intensive service in the last month of life. Patients who received no medically intensive service generated a mean (SD) health system cost of $7660 ($1793), whereas patients who received 1 or more medically intensive services generated a mean (SD) health system cost of $23 612 ($5528); thus, the additional financial consequence to the health care system for medically intensive services was $15 952 (95% CI, $15 676-$16 206; P < .001). The biggest contributor to these differences was $21 093 (95% CI, $20 364-$21 689) for intensive care unit stay, while the smallest contributor was $3460 (95% CI, $2927-$3880) for chemotherapy. Mean (SD) expected beneficiary costs for the last month of life were $133 ($50) for patients with no medically intensive service and $1257 ($408) for patients with at least 1 medically intensive service (P < .001).Given the low income of many elderly patients in the United States, the financial consequences of medically intensive services may be substantial. Costs of medically intensive services at the end of life, including patient financial consequences, should be considered by both physicians and families.

    View details for DOI 10.1001/jamanetworkopen.2019.12161

    View details for PubMedID 31560384

  • Assessment of the Medicare Advantage Risk Adjustment Model for Measuring Veterans Affairs Hospital Performance. JAMA network open Wagner, T. H., Almenoff, P., Francis, J., Jacobs, J., Pal Chee, C. 2018; 1 (8): e185993


    Importance: Policymakers and consumers are eager to compare hospitals on performance metrics, such as surgical complications or unplanned readmissions, measured from administrative data. Fair comparisons depend on risk adjustment algorithms that control for differences in case mix.Objective: To examine whether the Medicare Advantage risk adjustment system version 21 (V21) adequately risk adjusts performance metrics for Veterans Affairs (VA) hospitals.Design, Setting, and Participants: This cohort analysis of administrative data from all 5.5 million veterans who received VA care or VA-purchased care in 2012 was performed from September 8, 2015, to October 22, 2018. Data analysis was performed from January 22, 2016, to October 22, 2018.Exposures: A patient's risk as measured by the V21 model.Main Outcomes and Measures: The main outcome was total cost, and the key independent variable was the V21 risk score.Results: Of the 5 472 629 VA patients (mean [SD] age, 63.0 [16.1] years; 5 118 908 [93.5%] male), the V21 model identified 694 706 as having a mental health or substance use condition. In contrast, a separate classification system for psychiatric comorbidities identified another 1 266 938 patients with a mental health condition. The V21 model missed depression not otherwise specified (396 062 [31.3%]), posttraumatic stress disorder (345 338 [27.3%]), and anxiety (129 808 [10.2%]). Overall, the V21 model underestimated the cost of care by $2314 (6.7%) for every person with a mental health diagnosis.Conclusions and Relevance: The findings suggest that current aspirations to engender competition by comparing hospital systems may not be appropriate or fair for safety-net hospitals, including the VA hospitals, which treat patients with complex psychiatric illness. Without better risk scores, which is technically possible, outcome comparisons may potentially mislead consumers and policymakers and possibly aggravate inequities in access for such vulnerable populations.

    View details for PubMedID 30646300

  • Differences in Risk Scores of Veterans Receiving Community Care Purchased by the Veterans Health Administration HEALTH SERVICES RESEARCH Rosen, A. K., Wagner, T. H., Pettey, W. P., Shwartz, M., Chen, Q., Lo, J., O'Brien, W. J., Vanneman, M. E. 2018; 53: 5438–54


    To assess differences in risk (measured by expected costs associated with sociodemographic and clinical profiles) between Veterans receiving outpatient services through two community care (CC) programs: the Fee program ("Fee") and the Veterans Choice Program ("Choice").Administrative data from VHA's Corporate Data Warehouse in fiscal years (FY) 2014-2015.We compared the clinical characteristics of Veterans across three groups (Fee only, Choice only, and Fee & Choice). We classified Veterans into risk groups based on Nosos risk scores and examined the relationship between type of outpatient utilization and risk within each CC group. We also examined changes in utilization of VHA and CC in FY14-FY15. We used chi-square tests, t tests, and ANOVAs to identify significant differences between CC groups.Of the 1,400,977 Veterans using CC in FY15, 91.4 percent were Fee-only users, 4.4 percent Choice-only users, and 4.2 percent Fee & Choice users. Mean concurrent risk scores were higher for Fee only and Fee & Choice (1.9, SD = 2.7; 1.8, SD = 2.2) compared to Choice-only users (1.0, SD = 1.2) (p < .0001). Most CC users were "dual users" of both VHA and CC in FY14-FY15.As care transitions from VHA to CC, VHA should consider how best to coordinate care with community providers to reduce duplication of efforts, improve handoffs, and achieve the best outcomes for Veterans.

    View details for PubMedID 30251367

    View details for PubMedCentralID PMC6235821

  • Exploring Trajectories of Healthcare Utilization Before and After Surgery. Journal of the American College of Surgeons Graham, L. A., Wagner, T. H., Richman, J. S., Morris, M. S., Copeland, L. A., Harris, A. H., Itani, K. M., Hawn, M. T. 2018


    INTRO: Long-term trajectories of healthcare utilization in the context of surgery have not been well characterized. The objective of this study was to examine healthcare utilization trajectories among surgical patients and identify factors associated with high utilization that could possibly be mitigated following surgical admissions.METHODS: Hospital medical-surgical admissions within 2 years of an index inpatient surgery in the Veterans Health Administration (10/1/2007-9/30/2014) were identified. Group-based trajectory analysis identified five distinct trajectories of inpatient admissions around surgery. Characteristics of trajectories of utilization were compared across groups using bivariate statistics and multivariate logistic regression.RESULTS: Of 280,681 surgery inpatients, most underwent orthopedic (29.2%), general (28.4%), or peripheral vascular procedures (12.2%). Five trajectories of healthcare utilization were identified with 5.2% of patients among consistently high inpatient utilizers accounting for 34.0% of inpatient days. Male (95.4% vs. 93.5%, p<0.01), African American (21.6% vs. 17.3%, p<0.01), or unmarried patients (61.6% vs. 52.5%, p<0.01) were more likely to be high utilizers as compared to other trajectories. High utilizers also had a higher comorbidity burden and a strikingly higher burden of mental health diagnoses (depression: 30.3% vs. 16.3%; bipolar disorder: 5.3% vs. 2.1%, p<0.01), social/behavioral risk factors (smoker: 41.1% vs. 33.6%, p<0.01; alcohol use disorder: 28.9% vs. 12.9%, p<0.01), and chronic pain (6.4% vs. 2.8%, p<0.01).CONCLUSION: Mental health, social/behavioral, and pain-related factors are independently associated with high pre- and postoperative healthcare utilization in surgical patients. Connecting patients to social workers and mental health care coordinators around the time of surgery may mitigate the risk of postoperative readmissions related to these factors.

    View details for PubMedID 30359825

  • Persistence of High Health Care Costs among VA Patients HEALTH SERVICES RESEARCH Yoon, J., Chee, C., Su, P., Almenoff, P., Zulman, D. M., Wagner, T. H. 2018; 53 (5): 3898–3916


    To examine high-cost patients in VA and factors associated with persistence in high costs over time.Secondary data for FY2008-2012.We obtained VA and Medicare utilization and cost records for VA enrollees and drew a 20 percent random sample (N = 1,028,568).We identified high-cost patients, defined as those in the top 10 percent of combined VA and Medicare costs, and determined the number of years they remained high cost over 4 years. We compared sociodemographics, clinical characteristics, and baseline utilization by number of high-cost years and conducted a discrete time survival analysis to predict high-cost persistence.Among 105,703 patients with the highest 10 percent of costs at baseline, 68 percent did not remain high cost in subsequent years, 32 percent had high costs after 1 year, and 7 percent had high costs in all four follow-up years. Mortality, which was 47 percent by end of follow-up, largely explained low persistence. The largest percentage of patients who persisted as high cost until end of follow-up was for spinal cord injury (16 percent).Most high-cost patients did not remain high cost in subsequent years, which poses challenges to providers and payers to manage utilization of these patients.

    View details for PubMedID 29862504

    View details for PubMedCentralID PMC6153161

  • Resident Sensitive Processes of Care: The Impact of Individual Surgical Residents on Laboratory Testing Sheckter, C. C., Jopling, J., Ding, Q., Trickey, A. W., Wagner, T., Morris, A. M., Hawn, M. T. ELSEVIER SCIENCE INC. 2018: S228–S229
  • Costs Five Years after Off-Pump or On-pump Coronary Artery Bypass Surgery. The Annals of thoracic surgery Wagner, T. H., Hattler, B., Bakaeen, F. G., Collins, J. F., Almassi, G. H., Quin, J. A., Grover, F. L., Bishawi, M., Shroyer, A. L., VA #517 Randomized On/Off Bypass (ROOBY) Study Group 2018


    BACKGROUND: Coronary artery bypass surgery (CABG) is a common surgical treatment for ischemic heart disease. Little is known about the long-term costs of conducting the surgery on-pump or off-pump.METHODS: As part of the Randomized On/Off Bypass follow-up study, we followed 2,203 participants randomized to on-pump (n = 1,099) and off-pump (n = 1,104) CABG for 5 years using Department of Veterans Affairs and Medicare administrative data. We examined annual costs through 5 years, standardized to 2016 dollars, using multivariate regression models, controlling for site and baseline patient factors.RESULTS: In the first year, including the CABG surgery, annual average costs were $66,599 (standard error $1,946) for the on-pump group and $70,552 (standard error $1,954) for the off-pump group. In years 2-5, average costs ranged from $15,000 to $20,000 per year. There was no significant difference between on-pump and off-pump across the five years. We explored differences among high-risk subgroups (diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, cerebrovascular disease, renal dysfunction, an ejection fraction less 35%, over age 70), and found no treatment assignment by time interactions, except for a non-significant trend in patients with diabetes.CONCLUSIONS: At 5-years, the average costs of off-pump and on-pump CABG patients did not statistically differ. Costs do not favor one approach and the decision should be based on clinical risks, especially in subgroups. Future research is warranted to examine post CABG costs and outcomes for diabetic patients over time.

    View details for PubMedID 30273569

  • Off-Pump versus On-Pump Impact: Diabetic Patient Five-Year Coronary Artery Bypass Clinical Outcomes. The Annals of thoracic surgery Shroyer, A. L., Quin, J. A., Wagner, T. H., Carr, B. M., Collins, J. F., Almassi, G. H., Bishawi, M., Grover, F. L., Hattler, B. 2018


    BACKGROUND: For diabetic patients requiring coronary artery bypass graft (CABG) surgery, controversy persists whether an off-pump or an on-pump approach may be advantageous. As the first US-based, multi-center, randomized, controlled trial, this Department of Veterans Affairs "Randomization On versus Off Bypass Follow-up Study" compared diabetic patients' five-year off-pump versus on-pump clinical outcomes.METHODS: From 2002 to 2008, 835 medically-treated (i.e., oral hypoglycemic and/or insulin-treated) diabetics underwent either off-pump (n = 402) or on-pump (n = 433) CABG. Five-year primary endpoints included all-cause death and major adverse cardiovascular events (MACE; composite included all-cause death, myocardial infarction, or repeat revascularization). Secondary five-year endpoints included cardiac death and MACE-related components. With baseline risks balanced, outcomes were evaluated using a p-value < 0.01; non-significant trends were reported for p-values > 0.01 and < 0.15.RESULTS: Five-year all-cause death rates were 20.2% off-pump versus 14.1% on-pump (p = 0.0198). No differences were seen in MACE (32.6% off-pump versus 28.6% on-pump, p = 0.216), repeat revascularization (12.4% off-pump versus 11.8% on-pump, p = 0.770), and non-fatal myocardial infarction (12.7% off-pump versus 10.4% on-pump, p = 0.299). Cardiac death trended worse with off-pump (9.0%) than with on-pump CABG (6.25%, p = 0.137). Sensitivity analyses removing conversions confirmed these findings.CONCLUSIONS: With a 6.1% absolute difference, a strong trend towards improved five-year survival was observed with on-pump CABG for medically-treated diabetic patients. No off-pump advantage was found for any five-year endpoints. A future clinical trial now appears warranted to rigorously compare off-pump versus on-pump diabetic patients' longer-term outcomes.

    View details for PubMedID 30273568

  • Association Between Preoperative Proteinuria and Postoperative Acute Kidney Injury and Readmission Wahl, T. S., Graham, L. A., Morris, M. S., Richman, J. S., Hollis, R. H., Jones, C. E., Itani, K. M., Wagner, T. H., Mull, H. J., Whittle, J. C., Telford, G. L., Rosen, A. K., Copeland, L. A., Burns, E. A., Hawn, M. T. AMER MEDICAL ASSOC. 2018: e182009


    Proteinuria indicates renal dysfunction and is a risk factor for morbidity among medical patients, but less is understood among surgical populations. There is a paucity of studies investigating how preoperative proteinuria is associated with surgical outcomes, including postoperative acute kidney injury (AKI) and readmission.To assess preoperative urine protein levels as a biomarker for adverse surgical outcomes.A retrospective, population-based study was conducted in a cohort of patients with and without known preoperative renal dysfunction undergoing elective inpatient surgery performed at 119 Veterans Affairs facilities from October 1, 2007, to September 30, 2014. Data analysis was conducted from April 4 to December 1, 2016. Preoperative dialysis, septic, cardiac, ophthalmology, transplantation, and urologic cases were excluded.Preoperative proteinuria as assessed by urinalysis using the closest value within 6 months of surgery: negative (0 mg/dL), trace (15-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-300 mg/dL), 3+ (301-1000 mg/dL), and 4+ (>1000 mg/dL).Primary outcome was postoperative predischarge AKI and 30-day postdischarge unplanned readmission. Secondary outcomes included any 30-day postoperative outcome.Of 346 676 surgeries, 153 767 met inclusion criteria, with the majority including orthopedic (37%), general (29%), and vascular procedures (14%). Evidence of proteinuria was shown in 43.8% of the population (trace: 20.6%, 1+: 16.0%, 2+: 5.5%, 3+: 1.6%) with 20.4%, 14.9%, 4.3%, and 0.9%, respectively, of the patients having a normal preoperative estimated glomerular filtration rate (eGFR). In unadjusted analysis, preoperative proteinuria was significantly associated with postoperative AKI (negative: 8.6%, trace: 12%, 1+: 14.5%, 2+: 21.2%, 3+: 27.6%; P < .001) and readmission (9.3%, 11.3%, 13.3%, 15.8%, 17.5%, respectively, P < .001). After adjustment, preoperative proteinuria was associated with postoperative AKI in a dose-dependent relationship (trace: odds ratio [OR], 1.2; 95% CI, 1.1-1.3, to 3+: OR, 2.0; 95% CI, 1.8-2.2) and 30-day unplanned readmission (trace: OR, 1.0; 95% CI, 1.0-1.1, to 3+: OR, 1.3; 95% CI, 1.1-1.4). Preoperative proteinuria was associated with AKI independent of eGFR.Proteinuria was associated with postoperative AKI and 30-day unplanned readmission independent of preoperative eGFR. Simple urine assessment for proteinuria may identify patients at higher risk of AKI and readmission to guide perioperative management.

    View details for PubMedID 29971429

  • 6th International Consultation on Incontinence. Recommendations of the International Scientific Committee: EVALUATION AND TREATMENT OF URINARY INCONTINENCE, PELVIC ORGAN PROLAPSE AND FAECAL INCONTINENCE NEUROUROLOGY AND URODYNAMICS Abrams, P., Andersson, K., Apostolidis, A., Birder, L., Bliss, D., Brubaker, L., Cardozo, L., Castro-Diaz, D., O'Connell, P. R., Cottenden, A., Cotterill, N., de Ridder, D., Dmochowski, R., Dumoulin, C., Fader, M., Fry, C., Goldman, H., Hanno, P., Homma, Y., Khullar, V., Maher, C., Milsom, I., Newman, D., Nijman, R. M., Rademakers, K., Robinson, D., Rosier, P., Rovner, E., Salvatore, S., Takeda, M., Wagg, A., Wagner, T., Wein, A. 2018; 37 (7): 2271–72

    View details for PubMedID 30106223

  • Estimation of the Prevalence of Amyotrophic Lateral Sclerosis in the United States Using National Administrative Healthcare Data from 2002 to 2004 and Capture-Recapture Methodology. Neuroepidemiology Nelson, L. M., Topol, B., Kaye, W., Williamson, D., Horton, D. K., Mehta, P., Wagner, T. 2018; 51 (3-4): 149–57


    BACKGROUND: National administrative healthcare data may be used as a case-finding method for prevalence studies of chronic disease in the United States, but the completeness of ascertainment likely varies depending on the disease under study.METHODS: We used 3 case-finding sources (Medicare, Medicaid, and Veterans Administration data) to estimate the prevalence of amyotrophic lateral sclerosis (ALS) in the United States for 2002-2004, and applied the capture-recapture methodology to estimate the degree of under-ascertainment when relying solely on these sources for case identification.RESULTS: Case-finding completeness was 76% overall and did not vary by race, but was lower for males (77%) than for females (88%), and lower for patients under age 65 (66%) than patients over age 65 (79%). The uncorrected ALS prevalence ratio was 2.8/100,000 in 2002, 3.3/100,000 in 2003, and 3.7/100,000 in 2004. After correcting for under-ascertainment, the annual prevalence increased by approximately 1 per 100,000 to 3.7/100,000 in 2002 (95% CI 3.66-3.80), 4.4/100,000 in 2003 (95% CI 4.34-4.50), and 4.8/100,000 in 2004 (95% CI 4.76-4.91).CONCLUSIONS: Federal healthcare claims databases ascertained are a very efficient method for identifying the majority of ALS-prevalent cases in the National ALS Registry, and may be enhanced by having patients self-register through the registry web portal.

    View details for DOI 10.1159/000488798

    View details for PubMedID 30092573

  • Costs and Sustainability of a Behavioral Intervention for Urinary Incontinence Prevention UROLOGY PRACTICE Wagner, T. H., Scott, J., Newman, D. K., Miller, J. M., Kirk, K., DiCamillo, M., Raghunathan, T. E., Diokno, A. C., Sampselle, C. M. 2018; 5 (4): 266–71
  • Costs and Sustainability of a Behavioral Intervention for Urinary Incontinence Prevention. Urology practice Wagner, T. H., Scott, J. Y., Newman, D. K., Miller, J. M., Kirk, K., DiCamillo, M. A., Raghunathan, T. E., Diokno, A. C., Sampselle, C. M. 2018; 5 (4): 266-271


    Many women choose behavioral interventions as first line treatment for urinary incontinence. We developed a 20-minute abbreviated video, which proved to be similar to a 2-hour in-person class in a randomized trial. This study examines economic end points for the 20-minute video relative to the 2-hour class.We randomized 332 participants to the 2-hour class and 315 to the 20-minute video. We estimated the cost for the 2-hour class, the 20-minute video and followup health care utilization. Participants were followed for 3, 12 and 24 months, and asked about health care utilization, quality of life and lost productivity. To measure perceived value, we queried each participant regarding willingness to pay. Regression analysis was used for statistical comparisons.The estimated per participant cost for a 2-hour class was $38, which was more than the marginal cost of the video ($0). We found no significant differences between the treatment groups at each followup for quality of life, lost productivity or health care utilization. Women were willing to pay $26, $21 and $30 for a copy of the DVD, video on the Web and in-person class, respectively, all of which were less than the average cost of the in-person class ($38).Poor adherence remains a challenge for many behavioral interventions designed to prevent urinary incontinence. The 20-minute video is less expensive than the 2-hour class and is equally effective. Distributing the video on the Internet will improve access and will be easier to sustain than in-person classes.

    View details for DOI 10.1016/j.urpr.2017.05.003

    View details for PubMedID 37312310

  • Drug-eluting stents versus bare-metal stents in saphenous vein grafts: a double-blind, randomised trial LANCET Brilakis, E. S., Edson, R., Bhatt, D. L., Goldman, S., Holmes, D. R., Rao, S. V., Shunk, K., Rangan, B. V., Mavromatis, K., Ramanathan, K., Bavry, A. A., Garcia, S., Latif, F., Armstrong, E., Jneid, H., Conner, T. A., Wagner, T., Karacsonyi, J., Uyeda, L., Ventura, B., Alsleben, A., Lu, Y., Shih, M., Banerjee, S., DIVA Trial Investigators 2018; 391 (10134): 1997–2007


    Few studies have examined the efficacy of drug-eluting stents (DES) for reducing aortocoronary saphenous vein bypass graft (SVG) failure compared with bare-metal stents (BMS) in patients undergoing stenting of de-novo SVG lesions. We assessed the risks and benefits of the use of DES versus BMS in de-novo SVG lesions.Patients were recruited to our double-blind, randomised controlled trial from 25 US Department of Veterans Affairs centres. Eligible participants were aged at least 18 years and had at least one significant de-novo SVG lesion (50-99% stenosis of a 2·25-4·5 mm diameter SVG) requiring percutaneous coronary intervention with intent to use embolic protection devices. Enrolled patients were randomly assigned, in a 1:1 ratio, by phone randomisation system to receive a DES or BMS. Randomisation was stratified by presence or absence of diabetes and number of target SVG lesions requiring percutaneous coronary intervention (one or two or more) within each participating site by use of an adaptive scheme intended to balance the two stent type groups on marginal totals for the stratification factors. Patients, referring physicians, study coordinators, and outcome assessors were masked to group allocation. The primary endpoint was the 12-month incidence of target vessel failure, defined as the composite of cardiac death, target vessel myocardial infarction, or target vessel revascularisation. The DIVA trial is registered with, number NCT01121224.Between Jan 1, 2012, and Dec 31, 2015, 599 patients were randomly assigned to the stent groups, and the data for 597 patients were used. The patients' mean age was 68·6 (SD 7·6) years, and 595 (>99%) patients were men. The two stent groups were similar for most baseline characteristics. At 12 months, the incidence of target vessel failure was 17% (51 of 292) in the DES group versus 19% (58 of 305) in the BMS group (adjusted hazard ratio 0·92, 95% CI 0·63-1·34, p=0·70). Between-group differences in the components of the primary endpoint, serious adverse events, or stent thrombosis were not significant. Enrolment was stopped before the revised target sample size of 762 patients was reached.In patients undergoing stenting of de-novo SVG lesions, no significant differences in outcomes between those receiving DES and BMS during 12 months of follow-up were found. The study results have important economic implications in countries with high DES prices such as the USA, because they suggest that the lower-cost BMS can be used in SVG lesions without compromising either safety or efficacy.US Department of Veterans Affairs Cooperative Studies Program.

    View details for PubMedID 29759512

  • Reducing Frequent Utilization of Psychiatric Emergency Services Among Veterans While Maintaining Quality of Care. Psychiatric services (Washington, D.C.) Blonigen, D. M., Manfredi, L., Heinz, A., Bi, X., Suarez, P., Nevedal, A. L., Vashi, A. A., Timko, C., Wagner, T. 2018; 69 (4): 438–47


    OBJECTIVE: Use of psychiatric emergency services in emergency departments (EDs) and inpatient psychiatry units contributes substantially to the cost of mental health care. Among patients who utilize psychiatric emergency services, a small percentage ("high utilizers") contributes a disproportionate share of the total cost, yet little is known about the context of care for these patients. This study employed qualitative methods to identify barriers to and facilitators of reducing use of psychiatric emergency services among high utilizers.METHODS: Semistructured phone interviews were conducted with 31 directors of mental health services and providers of psychiatric emergency services across 22 Veterans Health Administration medical centers. The Consolidated Framework for Implementation Research was used to guide the interviews to evaluate the context of care for high utilizers. Thematic coding was used to identify barriers to and facilitators of reducing utilization.RESULTS: Barriers emerged at the patient level (for example, treatment nonadherence and transiency), provider level (for example, stigma toward high utilizers and lack of expertise and training in the management of psychiatric issues among ED staff), and system level (for example, lack of specialized services to address short- and long-term care needs). Facilitators included recovery-oriented care; interdisciplinary care coordination and case management, with emphasis on the role of psychiatric social workers; and predictive analytics to flag high utilizers.CONCLUSIONS: The findings lay the groundwork for the design of novel approaches to care for high utilizers of psychiatric emergency services while limiting provider burnout, managing costs, and optimizing treatment outcomes.

    View details for PubMedID 29385959

  • Economics in dissemination and implementation research Wagner, T. BIOMED CENTRAL LTD. 2018
  • Alcohol use disorder pharmacotherapy and treatment in primary care settings: the adapt-PC trial Hagedorn, H., Brown, R., Dawes, M., Dieperink, E., Myrick, D., Oliva, E., Wagner, T., Wisdom, J., Harris, A. BIOMED CENTRAL LTD. 2018
  • The Predictive Value of Inflammation-Related Peripheral Blood Measurements in Cancer Staging and Prognosis FRONTIERS IN ONCOLOGY Sylman, J. L., Mitrugno, A., Atallah, M., Tormoen, G. W., Shatzel, J. J., Yunga, S., Wagner, T. H., Leppert, J. T., Mallick, P., McCarty, O. T. 2018; 8: 78


    In this review, we discuss the interaction between cancer and markers of inflammation (such as levels of inflammatory cells and proteins) in the circulation, and the potential benefits of routinely monitoring these markers in peripheral blood measurement assays. Next, we discuss the prognostic value and limitations of using inflammatory markers such as neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios and C-reactive protein measurements. Furthermore, the review discusses the benefits of combining multiple types of measurements and longitudinal tracking to improve staging and prognosis prediction of patients with cancer, and the ability of novel in silico frameworks to leverage this high-dimensional data.

    View details for PubMedID 29619344

  • Comparison of Outcomes and Costs Associated With Aspirin +/- Clopidogrel After Coronary Artery Bypass Grafting AMERICAN JOURNAL OF CARDIOLOGY Ebrahimi, R., Gupta, S., Carr, B. M., Bishawi, M., Bakaeen, F. G., Almassi, G., Collins, J., Grover, F. L., Quin, J. A., Wagner, T. H., Shroyer, A. W., Hattler, B. 2018; 121 (6): 709–14


    Optimal antiplatelet therapy after coronary artery bypass graft (CABG) surgery remains controversial. This study evaluated the role of dual antiplatelet therapy using aspirin and clopidogrel (DAPT) versus antiplatelet therapy using aspirin only (ASA) on post-CABG clinical outcomes and costs. In the Department of Veterans Affairs Randomized On/Off Bypass (ROOBY) trial, clopidogrel use after CABG was prospectively collected beginning in year 2 of this study to include 1,525 of the 2,203 original ROOBY patients who received aspirin after CABG. Discretionarily, surgeons after CABG administered either DAPT or ASA treatments. The ROOBY trial's primary 30-day composite (mortality or perioperative morbidity), 1-year composite (all-cause death, repeat revascularization, or nonfatal myocardial infarction), and costs were compared for these 2 strategies. Of the 1,525 subjects, 511 received DAPT and 1,014 received ASA. DAPT subjects, compared with ASA subjects, had lower rates of preoperative left ventricular ejection fraction of ≥45% (78.8% vs 85.7%, p <0.001), on-pump CABG (36.6% vs 57.1%, p = 0.001), and endoscopic vein harvesting (30.0% vs 42.8%, p <0.001). ASA patients were more likely to have earlier aspirin administration and receive 325 versus 81 mg dosages. The 30-day composite outcome rate was significantly lower for DAPT patients compared with ASA patients (3.3% vs 7.1%, p = 0.003), but the 1-year composite outcome was equal between the 2 groups (12.0% vs12.0%, p = 1.0). At 1 year, there were no cost differences between the 2 groups. Propensity analyses did not significantly alter the results. In conclusion, DAPT appeared safe and was associated with fewer 30-day adverse outcomes than aspirin only and with no 1-year outcome or cost differences.

    View details for PubMedID 29402422

  • Employment benefits and job retention: evidence among patients with colorectal cancer CANCER MEDICINE Veenstra, C. M., Abrahamse, P., Wagner, T. H., Hawley, S. T., Banerjee, M., Morris, A. M. 2018; 7 (3): 736–45


    A "health shock," that is, a large, unanticipated adverse health event, can have long-term financial implications for patients and their families. Colorectal cancer is the third most commonly diagnosed cancer among men and women and is an example of a specific health shock. We examined whether specific benefits (employer-based health insurance, paid sick leave, extended sick leave, unpaid time off, disability benefits) are associated with job retention after diagnosis and treatment of colorectal cancer. In 2011-14, we surveyed patients with Stage III colorectal cancer from two representative SEER registries. The final sample was 1301 patients (68% survey response rate). For this study, we excluded 735 respondents who were not employed and 20 with unknown employment status. The final analytic sample included 546 respondents. Job retention in the year following diagnosis was assessed, and multivariable logistic regression was used to evaluate associations between job retention and access to specific employment benefits. Employer-based health insurance (OR = 2.97; 95% CI = 1.56-6.01; P = 0.003) and paid sick leave (OR = 2.93; 95% CI = 1.23-6.98; P = 0.015) were significantly associated with job retention, after adjusting for sociodemographic, clinical, geographic, and job characteristics.

    View details for PubMedID 29473344

  • A Temporal Examination of Platelet Counts as a Predictor of Prognosis in Lung, Prostate, and Colon Cancer Patients. Scientific reports Sylman, J. L., Boyce, H. B., Mitrugno, A. n., Tormoen, G. W., Thomas, I. C., Wagner, T. H., Lee, J. S., Leppert, J. T., McCarty, O. J., Mallick, P. n. 2018; 8 (1): 6564


    Platelets, components of hemostasis, when present in excess (>400 K/μL, thrombocytosis) have also been associated with worse outcomes in lung, ovarian, breast, renal, and colorectal cancer patients. Associations between thrombocytosis and cancer outcomes have been made mostly from single-time-point studies, often at the time of diagnosis. Using laboratory data from the Department of Veterans Affairs (VA), we examined the potential benefits of using longitudinal platelet counts in improving patient prognosis predictions. Ten features (summary statistics and engineered features) were derived to describe the platelet counts of 10,000+ VA lung, prostate, and colon cancer patients and incorporated into an age-adjusted LASSO regression analysis to determine feature importance, and predict overall or relapse-free survival, which was compared to the previously used approach of monitoring for thrombocytosis near diagnosis (Postdiag AG400 model). Temporal features describing acute platelet count increases/decreases were found to be important in cancer survival and relapse-survival that helped stratify good and bad outcomes of cancer patient groups. Predictions of overall and relapse-free survival were improved by up to 30% compared to the Postdiag AG400 model. Our study indicates the association of temporally derived platelet count features with a patients' prognosis predictions.

    View details for PubMedID 29700384

  • Overdose Risk Associated with Opioid Use upon Hospital Discharge in Veterans Health Administration Surgical Patients. Pain medicine (Malden, Mass.) Mudumbai, S. C., Lewis, E. T., Oliva, E. M., Chung, P. D., Harris, B. n., Trafton, J. n., Mariano, E. R., Wagner, T. n., Clark, J. D., Stafford, R. S. 2018


    To determine an association between opioid use upon hospital discharge (ongoing and newly started) in surgical patients and risks of opioid overdose and delirium for the first year.Retrospective, cohort study.Population-level study of Veterans Health Administration patients.All Veterans Health Administration patients (N = 64,391) who underwent surgery in 2011, discharged after one or more days, and without a diagnosis of opioid overdose or delirium from 90 days before admission through 30 days postdischarge (to account for additional opioid dosing in the context of chronic use).Patients' opioid use was categorized as 1) no opioids, 2) tramadol only, 3) short-acting only, 4) long-acting only, 5) short- and long-acting. We calculated unadjusted incidence rates and the incidence rate ratio (IRR) for opioid overdose and drug delirium for two time intervals: postdischarge days 0-30 and days 31-365. We then modeled outcomes of opioid overdose and delirium for postdischarge days 31-365 using a multivariable extended Cox regression model. Sensitivity analysis examined risk factors for overdose for postdischarge days 0-30.Incidence of overdose was 11-fold greater from postdischarge days 0-30 than days 31-365: 26.3 events/person-year (N = 68) vs 2.4 events/person-year (N = 476; IRR = 10.80, 95% confidence interval [CI] = 8.37-13.92). Higher-intensity opioid use was associated with increasing risk of overdose for the year after surgery, with the highest risk for the short- and long-acting group (hazard ratio = 4.84, 95% CI = 3.28-7.14). Delirium (IRR = 10.66, 95% CI = 7.96-14.29) was also associated with higher opioid intensity.Surgical patients should be treated with the lowest effective intensity of opioids and be monitored to prevent opioid-related adverse events.

    View details for PubMedID 30137452

  • Secondary use of electronic medical records for clinical research: Challenges and Opportunities. Convergent science physical oncology Yim, W. W., Wheeler, A. J., Curtin, C. n., Wagner, T. H., Hernandez-Boussard, T. n. 2018; 4 (1)


    With increasingly ubiquitous electronic medical record (EMR) implementation accelerated by the adoption of the HITECH Act, there is much interest in the secondary use of collected data to improve outcomes and promote personalized medicine. A plethora of research has emerged using EMRs to investigate clinical research questions and assess variations in both treatments and outcomes. However, whether because of genuine complexities of modeling disease physiology or because of practical problems regarding data capture, data accuracy, and data completeness, the state of current EMR research is challenging and gives rise to concerns regarding study accuracy and reproducibility. This work explores challenges in how different experimental design decisions can influence results using a specific example of breast cancer patients undergoing excision and reconstruction surgeries from EMRs in an academic hospital and the Veterans Health Administration (VHA) We discuss emerging strategies that will mitigate these limitations, including data sharing, application of natural language processing, and improved EMR user design.

    View details for PubMedID 29732166

    View details for PubMedCentralID PMC5933881

  • Association of Postoperative Readmissions With Surgical Quality Using a Delphi Consensus Process to Identify Relevant Diagnosis Codes. JAMA surgery Mull, H. J., Graham, L. A., Morris, M. S., Rosen, A. K., Richman, J. S., Whittle, J. n., Burns, E. n., Wagner, T. H., Copeland, L. A., Wahl, T. n., Jones, C. n., Hollis, R. H., Itani, K. M., Hawn, M. T. 2018


    Postoperative readmission data are used to measure hospital performance, yet the extent to which these readmissions reflect surgical quality is unknown.To establish expert consensus on whether reasons for postoperative readmission are associated with the quality of surgery in the index admission.In a modified Delphi process, a panel of 14 experts in medical and surgical readmissions comprising physicians and nonphysicians from Veterans Affairs (VA) and private-sector institutions reviewed 30-day postoperative readmissions from fiscal years 2008 through 2014 associated with inpatient surgical procedures performed at a VA medical center between October 1, 2007, and September 30, 2014. The consensus process was conducted from January through May 2017. Reasons for readmission were grouped into categories based on International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes. Panelists were given the proportion of readmissions coded by each reason and median (interquartile range) days to readmission. They answered the question, "Does the readmission reason reflect possible surgical quality of care problems in the index admission?" on a scale of 1 (never related) to 5 (directly related) in 3 rounds of consensus building. The consensus process was completed in May 2017 and data were analyzed in June 2017.Consensus on proportion of ICD-9-coded readmission reasons that reflected quality of surgical procedure.In 3 Delphi rounds, the 14 panelists achieved consensus on 50 reasons for readmission; 12 panelists also completed group telephone calls between rounds 1 and 2. Readmissions with diagnoses of infection, sepsis, pneumonia, hemorrhage/hematoma, anemia, ostomy complications, acute renal failure, fluid/electrolyte disorders, or venous thromboembolism were considered associated with surgical quality and accounted for 25 521 of 39 664 readmissions (64% of readmissions; 7.5% of 340 858 index surgical procedures). The proportion of readmissions considered to be not associated with surgical quality varied by procedure, ranging from to 21% (613 of 2331) of readmissions after lower-extremity amputations to 47% (745 of 1598) of readmissions after cholecystectomy.One-third of postoperative readmissions are unlikely to reflect problems with surgical quality. Future studies should test whether restricting readmissions to those with specific ICD-9 codes might yield a more useful quality measure.

    View details for PubMedID 29710234

  • Quality Of End-Of-Life Care Is Higher In The VA Compared To Care Paid For By Traditional Medicare HEALTH AFFAIRS Gidwani-Marszowski, R., Needleman, J., Mor, V., Faricy-Anderson, K., Boothroyd, D. B., Hsin, G., Wagner, T. H., Lorenz, K. A., Patel, M. I., Joyce, V. R., Murrell, S. S., Ramchandran, K., Asch, S. M. 2018; 37 (1): 95–103


    Congressional and Veterans Affairs (VA) leaders have recommended the VA become more of a purchaser than a provider of health care. Fee-for-service Medicare provides an example of how purchased care differs from the VA's directly provided care. Using established indicators of overly intensive end-of-life care, we compared the quality of care provided through the two systems to veterans dying of cancer in fiscal years 2010-14. The Medicare-reliant veterans were significantly more likely to receive high-intensity care, in the form of chemotherapy, hospital stays, admission to the intensive care unit, more days spent in the hospital, and death in the hospital. However, they were significantly less likely than VA-reliant patients to have multiple emergency department visits. Higher-intensity end-of-life care may be driven by financial incentives present in fee-for-service Medicare but not in the VA's integrated system. To avoid putting VA-reliant veterans at risk of receiving lower-quality care, VA care-purchasing programs should develop coordination and quality monitoring programs to guard against overly intensive end-of-life care.

    View details for PubMedID 29309227

  • Concordance between administrative data and clinical review for mortality in the randomized on/off bypass follow-up study (ROOBY-FS) JOURNAL OF CARDIAC SURGERY Quin, J. A., Hattler, B., Shroyer, A. W., Kemp, D., Almassi, G., Bakaeen, F. G., Carr, B. M., Bishawi, M., Collins, J. F., Grover, F. L., Wagner, T. H., Rooby Followup Study's Endpoints 2017; 32 (12): 751–56


    The optimal methodology to identify cardiac versus non-cardiac cause of death following cardiac surgery has not been determined.The Randomized On/Off Bypass Trial was a multicenter, randomized, controlled clinical trial of 2203 patients (February 2002-May 2008) comparing 1-year cardiac outcomes between off-pump and on-pump bypass surgery. In 2013, the Veterans Affairs (VA) Cooperative Studies Program funded a follow-up study to assess 5-year outcomes including mortality. Deaths were identified and confirmed using the National Death Index (NDI), VA Vital Status file, and medical records. An Endpoints Committee (EC) reviewed patient medical records and classified each cause of death as cardiac, non-cardiac, or unknown. Using pre-determined ICD-10 codes, NDI death certificates were independently used to classify deaths as cardiac or non-cardiac. Cause of death was compared between the NDI and EC classifications and concordance measured, using Kappa statistics.Of the 297 5-year deaths identified by the NDI and/or VA vital status file and confirmed by the EC, 219 had adequate patient records for EC cause of death determination. The EC adjudicated 141 of these deaths as non-cardiac and 78 as cardiac, while the NDI classified 150 as non-cardiac and 69 as cardiac; agreement was 77.6% (kappa 0.500; P < 0.001).Since concordance between EC and NDI cause of death classifications was only moderate, caution should be exercised in relying exclusively on NDI data to determine cause of death. A hybrid approach, integrating multiple information sources, may provide the most accurate approach to classifying cause of death.

    View details for PubMedID 29239024

  • Factors associated with emergency department useamong veteran psychiatric patients PSYCHIATRIC QUARTERLY Blonigen, D. M., Macia, K. S., Bi, X., Suarez, P., Manfredi, L., Wagner, T. H. 2017; 88 (4): 721–32


    Frequent utilization of emergency department (ED) services contributes substantially to the cost of healthcare nationally and is often driven by psychiatric factors. Using national-level data from the Veterans Health Administration (VHA), the present study examined patient-level factors associated with ED use among veteran psychiatric patients. Veterans who had at least one ED visit with a psychiatric diagnosis in fiscal years 2011-2012 (n = 226,122) were identified in VHA administrative records. Andersen's behavioral model of healthcare utilization was used to identify need, enabling, and predisposing factors associated with frequency of ED use (primary outcome) in multivariate regression models. Greater ED use was primarily linked with need (psychotic, anxiety, personality, substance use, and bipolar disorders) and enabling (detoxification-related service utilization and homelessness) factors. Chronic medical conditions, receipt of an opioid prescription, and predisposing factors (e.g., younger age) were also linked to greater ED use; however, the effect sizes for these factors were markedly lower than those of most psychiatric and psychosocial factors. The findings suggest that intensive case management programs aimed reducing frequent ED use among psychiatric patients may require greater emphasis on homelessness and other psychosocial deficits that are common among these patients, and future research should explore cost-effective approaches to implementing these programs.

    View details for PubMedID 28108941

  • Five-Year Outcomes after On-Pump and Off-Pump Coronary-Artery Bypass NEW ENGLAND JOURNAL OF MEDICINE Shroyer, A., Hattler, B., Wagner, T. H., Collins, J. F., Baltz, J. H., Quin, J. A., Almassi, G., Kozora, E., Bakaeen, F., Cleveland, J. C., Bishawi, M., Grover, F. L., Vet Affairs ROOBY-FS Grp 2017; 377 (7): 623–32


    Coronary-artery bypass grafting (CABG) surgery may be performed either with cardiopulmonary bypass (on pump) or without cardiopulmonary bypass (off pump). We report the 5-year clinical outcomes in patients who had been included in the Veterans Affairs trial of on-pump versus off-pump CABG.From February 2002 through June 2007, we randomly assigned 2203 patients at 18 medical centers to undergo either on-pump or off-pump CABG, with 1-year assessments completed by May 2008. The two primary 5-year outcomes were death from any cause and a composite outcome of major adverse cardiovascular events, defined as death from any cause, repeat revascularization (CABG or percutaneous coronary intervention), or nonfatal myocardial infarction. Secondary 5-year outcomes included death from cardiac causes, repeat revascularization, and nonfatal myocardial infarction. Primary outcomes were assessed at a P value of 0.05 or less, and secondary outcomes at a P value of 0.01 or less.The rate of death at 5 years was 15.2% in the off-pump group versus 11.9% in the on-pump group (relative risk, 1.28; 95% confidence interval [CI], 1.03 to 1.58; P=0.02). The rate of major adverse cardiovascular events at 5 years was 31.0% in the off-pump group versus 27.1% in the on-pump group (relative risk, 1.14; 95% CI, 1.00 to 1.30; P=0.046). For the 5-year secondary outcomes, no significant differences were observed: for nonfatal myocardial infarction, the rate was 12.1% in the off-pump group and 9.6% in the on-pump group (P=0.05); for death from cardiac causes, the rate was 6.3% and 5.3%, respectively (P=0.29); for repeat revascularization, the rate was 13.1% and 11.9%, respectively (P=0.39); and for repeat CABG, the rate was 1.4% and 0.5%, respectively (P=0.02).In this randomized trial, off-pump CABG led to lower rates of 5-year survival and event-free survival than on-pump CABG. (Funded by the Department of Veterans Affairs Office of Research and Development Cooperative Studies Program and others; ROOBY-FS number, NCT01924442 .).

    View details for PubMedID 28813218

  • A Randomized Controlled Trial to Compare 2 Scalable Interventions for Lower Urinary Tract Symptom Prevention: Main Outcomes of the TULIP Study. The Journal of urology Sampselle, C. M., Newman, D. K., Miller, J. M., Kirk, K., DiCamillo, M. A., Wagner, T. H., Raghunathan, T. E., Diokno, A. C. 2017; 197 (6): 1480-1486


    We compared 2-year urinary incontinence and urgency scores of older women who attended a 2-hour bladder health class vs those who viewed a 20-minute abbreviated class video for the purpose of urinary incontinence prevention.A randomized, 2-arm, parallel design study was done to test the superiority of the 20-minute video over the 2-hour class. Outcomes at baseline, and 3, 12 and 24 months were the scores on questions 1 to 3 of ICIQ-SF (International Consultation on Incontinence Short Form) as the primary outcome and on IUSS (Indevus Urgency Severity Scale). Intent to treat analysis was done to compare the change from baseline in each intervention group across time and also with each other. Multiple imputation was used for missing data.A total of 647 women participated in the study. Mean age was 63 years and approximately 28% of the participants were African American, primarily from an urban setting. The 2 arms were balanced on body mass index at baseline, age, race/ethnicity, education, employment status, income and marital status. No differences in primary or secondary outcomes were demonstrated between the 2 groups from baseline to the 3, 12 or 24-month visits.The absence of significant differences in the outcome measures of ICIQ-SF and IUSS between the 2-hour class and the 20-minute video groups demonstrates that the 2 interventions were comparable. As urinary incontinence and urgency tend to rise annually in older women, instruction in bladder health self-care provided through either the 2-hour class or the 20-minute video format is a useful intervention to prevent urinary incontinence in older women.

    View details for DOI 10.1016/j.juro.2016.12.099

    View details for PubMedID 28049010

  • Platelet count as a predictor of metastasis and venous thromboembolism in patients with cancer. Convergent science physical oncology Sylman, J. L., Mitrugno, A., Tormoen, G. W., Wagner, T. H., Mallick, P., McCarty, O. J. 2017; 3 (2)


    Platelets are anucleate cells in the blood at concentrations of 150,000 to 400,000 cells/µL and play a key role in hemostasis. Several studies have suggested that platelets contribute to cancer progression and cancer-associated thrombosis. In this review, we provide an overview of the biochemical and biophysical mechanisms by which platelets interact with cancer cells and review the evidence supporting a role for platelet-enhanced metastasis of cancer, and venous thromboembolism (VTE) in patients with cancer. We discuss the potential for and limitations of platelet counts to discriminate cancer disease burden and prognosis. Lastly, we consider more advanced diagnostic approaches to improve studies on the interaction between the hemostatic system and cancer cells.

    View details for DOI 10.1088/2057-1739/aa6c05

    View details for PubMedID 29081989

    View details for PubMedCentralID PMC5658139

  • Déjà Vu: Introducing Operations Research to Health Care. Medical decision making Wagner, T. H., Jopling, J. K. 2017: 272989X17711909-?

    View details for DOI 10.1177/0272989X17711909

    View details for PubMedID 28564550

  • Trends in diagnosis of painful neck and back conditions, 2002 to 2011. Medicine Sinnott, P. L., Dally, S. K., Trafton, J., Goulet, J. L., Wagner, T. H. 2017; 96 (20)


    Neck and back pain are pervasive problems. Some have suggested that rising incidence may be associated with the evidence of rising prevalence.To describe the trends in diagnosis of painful neck and back conditions in a large national healthcare system.A retrospective observational cohort study to describe the incidence and prevalence of diagnosis of neck and back pain in a national cohort.Patients were identified by International Classification of Diseases, 9 Revision (ICD-9) codes in Department of Veterans Affairs (VA) national utilization datasets in calendar years 2002 to 2011.Descriptive statistics were used to analyze the data. Prevalent cases were compared with all veterans who sought health care in each year. Incident cases were identified following a 2 years clean period in which the patient was enrolled and received care, but not services for any back or neck pain conditions.From 2004 to 2011, 3% to 4% of the population was diagnosed with incident back pain problems, the rate increasing on average, 1.75% per year. During the same period, 12.3% to 16.2% of the population was diagnosed with a prevalent back pain problem, the rate increasing on average 4.09% per year.In a national population, the prevalence rate for diagnosis of neck and back pain grew 1.8 to 2.3 times faster than the incidence rate. This suggests that the average duration of episodes of care is increasing. Additional research is needed to understand the influences on the differential rate of change and to develop efficient and effective care systems.

    View details for DOI 10.1097/MD.0000000000006691

    View details for PubMedID 28514286

  • Association between aggressive care and bereaved families' evaluation of end-of-life care for veterans with non-small cell lung cancer who died in Veterans Affairs facilities. Cancer Ersek, M., Miller, S. C., Wagner, T. H., Thorpe, J. M., Smith, D., Levy, C. R., Gidwani, R., Faricy-Anderson, K., Lorenz, K. A., Kinosian, B., Mor, V. 2017


    To the authors' knowledge, little is known regarding the relationship between patients' and families' satisfaction with aggressive end-of-life care. Herein, the authors examined the associations between episodes of aggressive care (ie, chemotherapy, mechanical ventilation, acute hospitalizations, and intensive care unit admissions) within the last 30 days of life and families' evaluations of end-of-life care among patients with non-small cell lung cancer (NSCLC).A total of 847 patients with NSCLC (34% of whom were aged <65 years) who died in a nursing home or intensive care, acute care, or hospice/palliative care (HPC) unit at 1 of 128 Veterans Affairs Medical Centers between 2010 and 2012 were examined. Data sources included Veterans Affairs administrative and clinical data, Medicare claims, and the Bereaved Family Survey. The response rate for the Bereaved Family Survey was 62%.Greater than 72% of veterans with advanced lung cancer who died in an inpatient setting had at least 1 episode of aggressive care and 31% received chemotherapy within the last 30 days of life. For all units except for HPC, when patients experienced at least 1 episode of aggressive care, bereaved families rated care lower compared with when patients did not receive any aggressive care. For patients dying in an HPC unit, the associations between overall ratings of care and ≥2 inpatient admissions or any episode of aggressive care were not found to be statistically significant. Rates of aggressive care were not associated with age, and family ratings of care were similar for younger and older patients.Aggressive care within the last month of life is common among patients with NSCLC and is associated with lower family evaluations of end-of-life care. Specialized care provided within an HPC unit may mitigate the negative effects of aggressive care on these outcomes. Cancer 2017. © 2017 American Cancer Society.

    View details for DOI 10.1002/cncr.30700

    View details for PubMedID 28419414

  • Iraq and Afghanistan Veterans' Use of Veterans Health Administration and Purchased Care Before and After Veterans Choice Program Implementation. Medical care Vanneman, M. E., Harris, A. H., Asch, S. M., Scott, W. J., Murrell, S. S., Wagner, T. H. 2017


    The veterans choice program (VCP), enacted by Congress after concerns surfaced about access, enables veterans to receive care outside Veterans Health Administration (VHA) facilities. Veterans who face long wait times, large driving distances, or particular hardships are eligible for VCP. Prior purchased care programs were comparatively limited in scope.We sought to describe utilization of VHA-provided and purchased outpatient care by veterans eligible for VCP before and after VCP implementation. We focused on veterans recently eligible for VHA as they are of particular policy relevance and might have less established care patterns.We identified all Iraq and Afghanistan veterans who were eligible for VCP in 2015. We tabulated their use of VHA and purchased outpatient care for 3 years before (FY2012-2014) and 1 year after VCP implementation (FY2015).Our study population consisted of 214,449 Iraq and Afghanistan veterans who were eligible for VCP due to wait-time, distance, or hardship issues.In the first year of the program, 3821 (2%) of these Iraq and Afghanistan veterans used non-VHA services through VCP. Per capita VHA utilization tended to decline slightly after VCP implementation, but these changes varied by type of outpatient care.There was low uptake of VCP services in the first year of the program. Data from additional years are needed to better understand the impact of this policy.

    View details for DOI 10.1097/MLR.0000000000000678

    View details for PubMedID 28146036

  • Contemporary Use of Partial Nephrectomy: Are Older Patients With Impaired Kidney Function Being Left Behind? UROLOGY Leppert, J. T., Mittakanti, H. R., Thomas, I., Lamberts, R. W., Sonn, G. A., Chung, B. I., Skinner, E. C., Wagner, T. H., Chertow, G. M., Brooks, J. D. 2017; 100: 65-71
  • Hospital Readmissions after Surgery: How Important Are Hospital and Specialty Factors? Journal of the American College of Surgeons Hollis, R. H., Graham, L. A., Richman, J. S., Morris, M. S., Mull, H. J., Wahl, T. S., Burns, E., Copeland, L. A., Telford, G. L., Rosen, A. K., Itani, K. F., Whittle, J., Wagner, T. H., Hawn, M. T. 2017


    Hospital readmission rates after surgery can represent an overall hospital effect or a combination of specialty and patient effects. We hypothesized that hospital readmission rates for procedures within specialties were more strongly correlated than rates across specialties within the same hospital.For general, orthopaedic, and vascular specialties at Veterans Affairs hospitals during 2008 to 2014, 30-day risk-adjusted readmission rates were estimated for 6 high-volume procedures and each specialty. Relationships were assessed using the Pearson correlation coefficient.At 84 hospitals, 64,724 orthopaedic, 24,963 general, and 10,399 vascular inpatient procedures were performed; mean readmission rates were 6.3%, 13.6%, and 16.4%, respectively. There was no correlation between specialty-specific adjusted hospital readmission rates: general and orthopaedic (r = 0.21; p = 0.06), general and vascular (r = 0.15; p = 0.19), and vascular and orthopaedic surgery (r = 0.07; p = 0.55). Within specialties, we found modest correlations between knee and hip arthroplasty readmission rates (r = 0.39; p < 0.01) and colectomy and ventral hernia repair (r = 0.24; p = 0.03), but not between lower-extremity bypass and endovascular aortic repair (r = 0.13; p = 0.26). Overall, controlling for patient-level factors, 1.9% of the variation in readmissions was attributable to specialty-level factors; only 0.6% was attributable to hospital-level factors.Hospital readmission rates for orthopaedic, vascular, and general surgery were not correlated between specialties; within each of the 3 specialties, modest correlations were found between 2 procedures within 2 of these specialties. These findings suggest that hospital surgical readmission rates are primarily explained by patient- and procedure-specific factors and less by broader specialty and/or hospital effects.

    View details for DOI 10.1016/j.jamcollsurg.2016.12.034

    View details for PubMedID 28088603

  • Incident CKD after Radical or Partial Nephrectomy. Journal of the American Society of Nephrology : JASN Leppert, J. T., Lamberts, R. W., Thomas, I. C., Chung, B. I., Sonn, G. A., Skinner, E. C., Wagner, T. H., Chertow, G. M., Brooks, J. D. 2017


    The comparative effectiveness of partial nephrectomy versus radical nephrectomy to preserve kidney function has not been well established. We determined the risk of clinically significant (stage 4 and higher) CKD after radical or partial nephrectomy among veterans treated for kidney cancer in the Veterans Health Administration (2001-2013). Among patients with preoperative eGFR≥30 ml/min per 1.73 m(2), the incidence of CKD stage 4 or higher after radical (n=9759) or partial nephrectomy (n=4370) was 7.9% overall. The median time to stage 4 or higher CKD after surgery was 5 months, after which few patients progressed. In propensity score-matched cohorts, partial nephrectomy associated with a significantly lower relative risk of incident CKD stage 4 or higher (hazard ratio, 0.34; 95% confidence interval [95% CI], 0.26 to 0.43, versus radical nephrectomy). In a parallel analysis of patients with normal or near-normal preoperative kidney function (eGFR≥60 ml/min per 1.73 m(2)), partial nephrectomy was also associated with a significantly lower relative risk of incident CKD stage 3b or higher (hazard ratio, 0.15; 95% CI, 0.11 to 0.19, versus radical nephrectomy) in propensity score-matched cohorts. Competing risk regression models produced consistent results. Finally, patients treated with a partial nephrectomy had reduced risk of mortality (hazard ratio, 0.55; 95% CI, 0.49 to 0.62). In conclusion, compared with radical nephrectomy, partial nephrectomy was associated with a marked reduction in the incidence of clinically significant CKD and with enhanced survival. Postoperative decline in kidney function occurred mainly in the first year after surgery and appeared stable over time.

    View details for PubMedID 29018140

  • Detecting organisational innovations leading to improved ICU outcomes: a protocol for a double-blinded national positive deviance study of critical care delivery. BMJ open Chiou, H. n., Jopling, J. K., Scott, J. Y., Ramsey, M. n., Vranas, K. n., Wagner, T. H., Milstein, A. n. 2017; 7 (6): e015930


    There is substantial variability in intensive care unit (ICU) utilisation and quality of care. However, the factors that drive this variation are poorly understood. This study uses a novel adaptation of positive deviance approach-a methodology used in public health that assumes solutions to challenges already exist within the system to detect innovations that are likely to improve intensive care.We used the Philips eICU Research Institute database, containing 3.3 million patient records from over 50 health systems across the USA. Acute Physiology and Chronic Health Evaluation IVa scores were used to identify the study cohort, which included ICU patients whose outcomes were felt to be most sensitive to organisational innovations. The primary outcomes included mortality and length of stay. Outcome measurements were directly standardised, and bootstrapped CIs were calculated with adjustment for false discovery rate. Using purposive sampling, we then generated a blinded list of five positive outliers and five negative comparators.Using rapid qualitative inquiry (RQI), blinded interdisciplinary site visit teams will conduct interviews and observations using a team ethnography approach. After data collection is completed, the data will be unblinded and analysed using a cross-case method to identify themes, patterns and innovations using a constant comparative grounded theory approach. This process detects the innovations in intensive care and supports an evaluation of how positive deviance and RQI methods can be adapted to healthcare.The study protocol was approved by the Stanford University Institutional Review Board (reference: 39509). We plan on publishing study findings and methodological guidance in peer-reviewed academic journals, white papers and presentations at conferences.

    View details for PubMedID 28615274

  • Rationale and design of the Drug-Eluting Stents vs Bare-Metal Stents in Saphenous Vein Graft Angioplasty (DIVA) Trial. Clinical cardiology Brilakis, E. S., Banerjee, S. n., Edson, R. n., Shunk, K. n., Goldman, S. n., Holmes, D. R., Bhatt, D. L., Rao, S. V., Smith, M. W., Sather, M. n., Colling, C. n., Kar, B. n., Nielsen, L. n., Conner, T. n., Wagner, T. n., Rangan, B. V., Ventura, B. n., Lu, Y. n., Holodniy, M. n., Shih, M. C. 2017


    VA Cooperative Studies Program #571 (DIVA) was designed to evaluate the efficacy of drug-eluting stents (DES) for reducing aortocoronary saphenous vein bypass graft (SVG) failure when compared with bare-metal stents (BMS) in participants undergoing stenting of de novo SVG lesions. Participants undergoing clinically indicated stenting of de novo SVG lesions were randomized in a 1:1 ratio to DES or BMS. Randomization was stratified by presence/absence of diabetes mellitus and the number of target SVG lesions (1 vs ≥2) within each participating site. At sites that did not routinely administer 12-months of dual antiplatelet therapy after SVG stenting participants without acute coronary syndromes received 1 month of open-label clopidogrel, followed by 11 months of clopidogrel for those assigned to DES and 11 months of placebo for those assigned to BMS. The primary endpoint was the 12-month incidence of target-vessel failure (defined as the composite of cardiac death, target-vessel myocardial infarction, or target-vessel revascularization). Secondary endpoints included the incidence of other clinical endpoints and the incremental cost-effectiveness of DES relative to BMS. Due to lower-than-anticipated target-vessel failure rates, target enrollment was increased from 519 to 762. The study had randomized 599 participants when recruitment ended in December 2015. The DIVA trial will provide clarity on the appropriate stent type for de novo SVG lesions.

    View details for PubMedID 28841230

  • Evaluating the implementation of a national disclosure policy for large-scale adverse events in an integrated health care system: identification of gaps and successes BMC HEALTH SERVICES RESEARCH Maguire, E. M., Bokhour, B. G., Wagner, T. H., Asch, S. M., Gifford, A. L., Gallagher, T. H., Durfee, J. M., Martinello, R. A., Elwy, A. R. 2016; 16


    Many healthcare organizations have developed disclosure policies for large-scale adverse events, including the Veterans Health Administration (VA). This study evaluated VA's national large-scale disclosure policy and identifies gaps and successes in its implementation.Semi-structured qualitative interviews were conducted with leaders, hospital employees, and patients at nine sites to elicit their perceptions of recent large-scale adverse events notifications and the national disclosure policy. Data were coded using the constructs of the Consolidated Framework for Implementation Research (CFIR).We conducted 97 interviews. Insights included how to handle the communication of large-scale disclosures through multiple levels of a large healthcare organization and manage ongoing communications about the event with employees. Of the 5 CFIR constructs and 26 sub-constructs assessed, seven were prominent in interviews. Leaders and employees specifically mentioned key problem areas involving 1) networks and communications during disclosure, 2) organizational culture, 3) engagement of external change agents during disclosure, and 4) a need for reflecting on and evaluating the policy implementation and disclosure itself. Patients shared 5) preferences for personal outreach by phone in place of the current use of certified letters. All interviewees discussed 6) issues with execution and 7) costs of the disclosure.CFIR analysis reveals key problem areas that need to be addresses during disclosure, including: timely communication patterns throughout the organization, establishing a supportive culture prior to implementation, using patient-approved, effective communications strategies during disclosures; providing follow-up support for employees and patients, and sharing lessons learned.

    View details for DOI 10.1186/s12913-016-1903-7

    View details for Web of Science ID 000387540000003

    View details for PubMedID 27835983

    View details for PubMedCentralID PMC5106838

  • Risk Adjustment Tools for Learning Health Systems: A Comparison of DxCG and CMS-HCC V21. Health services research Wagner, T. H., Upadhyay, A., Cowgill, E., Stefos, T., Moran, E., Asch, S. M., Almenoff, P. 2016; 51 (5): 2002-2019


    To compare risk scores computed by DxCG (Verisk) and Centers for Medicare and Medicaid Services (CMS) V21.Analysis of administrative data from the Department of Veterans Affairs (VA) for fiscal years 2010 and 2011.We regressed total annual VA costs on predicted risk scores. Model fit was judged by R-squared, root mean squared error, mean absolute error, and Hosmer-Lemeshow goodness-of-fit tests. Recalibrated models were tested using split samples with pharmacy data.We created six analytical files: a random sample (n = 2 million), high cost users (n = 261,487), users over age 75 (n = 644,524), mental health and substance use users (n = 830,832), multimorbid users (n = 817,951), and low-risk users (n = 78,032).The DxCG Medicaid with pharmacy risk score yielded substantial gains in fit over the V21 model. Recalibrating the V21 model using VA pharmacy data-generated risk scores with similar fit statistics to the DxCG risk scores.Although the CMS V21 and DxCG prospective risk scores were similar, the DxCG model with pharmacy data offered improved fit over V21. However, health care systems, such as the VA, can recalibrate the V21 model with additional variables to develop a tailored risk score that compares favorably to the DxCG models.

    View details for DOI 10.1111/1475-6773.12454

    View details for PubMedID 26839976

    View details for PubMedCentralID PMC5034200

  • Contemporary Use of Partial Nephrectomy: Are Older Patients With Impaired Kidney Function Being Left Behind? Urology Leppert, J. T., Mittakanti, H. R., Thomas, I., Lamberts, R. W., Sonn, G. A., Chung, B. I., Skinner, E. C., Wagner, T. H., Chertow, G. M., Brooks, J. D. 2016


    To assess whether patient factors, such as age and preoperative kidney function, were associated with receipt of partial nephrectomy in a national integrated healthcare system.We identified patients treated with a radical or partial nephrectomy from 2002 to 2014 in the Veterans Health Administration. We examined associations among patient age, sex, race or ethnicity, multimorbidity, baseline kidney function, tumor characteristics, and receipt of partial nephrectomy. We estimated the odds of receiving a partial nephrectomy and assessed interactions between covariates and the year of surgery to explore whether patient factors associated with partial nephrectomy changed over time.In our cohort of 14,186 patients, 4508 (31.2%) received a partial nephrectomy. Use of partial nephrectomy increased from 17% in 2002 to 32% in 2008 and to 38% in 2014. Patient race or ethnicity, age, tumor stage, and year of surgery were independently associated with receipt of partial nephrectomy. Black veterans had significantly increased odds of receipt of partial nephrectomy, whereas older patients had significantly reduced odds. Partial nephrectomy utilization increased for all groups over time, but older patients and patients with worse baseline kidney function showed the least increase in odds of partial nephrectomy.Although the utilization of partial nephrectomy increased for all groups, the greatest increase occurred in the youngest patients and those with the highest baseline kidney function. These trends warrant further investigation to ensure that patients at the highest risk of impaired kidney function are considered for partial nephrectomy whenever possible.

    View details for DOI 10.1016/j.urology.2016.08.044

    View details for PubMedID 27634733

  • Gap between Recommendations and Practice of Palliative Care and Hospice in Cancer Patients. Journal of palliative medicine Gidwani, R., Joyce, N., Kinosian, B., Faricy-Anderson, K., Levy, C., Miller, S. C., Ersek, M., Wagner, T., Mor, V. 2016; 19 (9): 957-963


    Specialty societies recommend patients with advanced cancer receive early exposure to palliative care and exposure to hospice care.We sought to understand real-world practice of care, specifically, the timing of palliative care, and how timing and duration of hospice care varied across Medicare, VA, and VA-Purchased care.We conducted a retrospective analysis of administrative data for veterans aged 65 years or older who died with cancer in 2012. Multilevel logistic regression was used to evaluate the likelihood of receiving palliative care, receiving hospice care, and receiving hospice care for at least three days.Medicare, VA, and VA-Purchased care environments.The receipt and timing of palliative care within VA and the receipt and timing of hospice care across three healthcare environments.Most veterans received hospice care (71%), whereas fewer received palliative care (52%). Among all cancer decedents, 59% received hospice care for their last three days of life. Patients who received hospice care did so a median of 20 days before death (interquartile range [IQR]: 7-46). Patients who received palliative care did so a median of 38 days before death (IQR: 13-94). Adjusted analyses revealed significant differences in receipt of palliative care across cancer type, and significant differences in receipt of hospice care across cancer type. After adjusting for age and cancer type, patients who received VA hospice care were significantly less likely to receive it for at least three days compared with patients who received VA-Purchased or Medicare hospice care.There remains a gap between recommended timing of supportive services and real-world practice of care. Results suggest that difficulties in prognosticating death are not fully responsible for underexposure to hospice.

    View details for DOI 10.1089/jpm.2015.0514

    View details for PubMedID 27228478

  • Time-to-Cessation of Postoperative Opioids: A Population-Level Analysis of the Veterans Affairs Health Care System. Pain medicine Mudumbai, S. C., Oliva, E. M., Lewis, E. T., Trafton, J., Posner, D., Mariano, E. R., Stafford, R. S., Wagner, T., Clark, J. D. 2016; 17 (9): 1732-1743


    This study aims to determine 1) the epidemiology of perioperative opioid use; and 2) the association between patterns of preoperative opioid use and time-to-cessation of postoperative opioids.Retrospective, cohort study.National, population-level study of Veterans Healthcare Administration (VHA) electronic clinical data.All VHA patients (n = 64,391) who underwent surgery in 2011, discharged after stays of ≥1 day, and receiving ≥1 opioid prescription within 90 days of discharge.Patients' preoperative opioid use were categorized as 1) no opioids, 2) tramadol only, 3) short-acting (SA) acute/intermittent (≤ 90 days fill), 4) SA chronic (> 90 days fill), or 5) any long-acting (LA). After defining cessation as 90 consecutive, opioid-free days, the authors calculated time-to-opioid-cessation (in days), from day 1 to day 365, after hospital discharge. The authors developed extended Cox regression models witha prioriidentified predictors. Sensitivity analyses used alternative cessation definitions (30 or 180 consecutive days).Almost 60% of the patients received preoperative opioids: tramadol (7.5%), SA acute/intermittent (24.1%), SA chronic (17.5%), and LA (5.2%). For patients opioid-free preoperatively, median time-to-cessation of opioids postoperatively was 15 days. The SA acute/intermittent cohort (HR =1.96; 95% CI =1.92-2.00) had greater risk for prolonged time-to-cessation than those opioid-free (reference), but lower risk than those taking tramadol only, SA chronic (HR = 9.09; 95% CI = 8.33-9.09), or LA opioids (HR = 9.09; 95% CI = 8.33-10.00). Diagnoses of chronic pain, substance-use, or affective disorders were weaker positive predictors. Sensitivity analyses maintained findings.Greater preoperative levels of opioid use were associated with progressively longer time-to-cessation postoperatively.

    View details for DOI 10.1093/pm/pnw015

    View details for PubMedID 27084410

  • Overall Survival in Patients with Localized Prostate Cancer in the US Veterans Health Administration: Is PIVOT Generalizable? EUROPEAN UROLOGY Barbosa, P. V., Thomas, I., Srinivas, S., Buyyounouski, M. K., Chung, B. I., Chertow, G. M., Asch, S. M., Wagner, T. H., Brooks, J. D., Leppert, J. T. 2016; 70 (2): 227-230


    A better understanding of overall survival among patients with clinically localized prostate cancer (PCa) in the US Veterans Health Administration (VHA) is critical to inform PCa treatment decisions, especially in light of data from the Prostate Intervention Versus Observation Trial (PIVOT). We sought to describe patterns of survival for all patients with clinically localized PCa treated by the VHA. We created an analytic cohort of 35 954 patients with clinically localized PCa diagnosed from 1995 to 2001, approximating the PIVOT inclusion criteria (age of diagnosis ≤75 yr and clinical stage T2 or lower). Mean patient age was 65.9 yr, and median follow-up was 161 mo. Overall, 22.5% of patients were treated with surgery, 16.6% were treated with radiotherapy, and 23.1% were treated with androgen deprivation. Median survival of the entire cohort was 14 yr (25th, 75th percentiles, range: 7.9-20 yr). Among patients who received treatment with curative intent, median survival was 17.9 yr following surgery and 12.9 yr following radiotherapy. One-third of patients died within 10 yr of diagnosis compared with nearly half of the participants in PIVOT. This finding sounds a note of caution when generalizing the mortality data from PIVOT to VHA patients and those in the community.More than one-third of patients diagnosed with clinically localized prostate cancer treated through the US Veterans Health Administration from 1995 to 2001 died within 10 yr of their diagnosis. Caution should be used when generalizing the estimates of competing mortality data from PIVOT.

    View details for DOI 10.1016/j.eururo.2016.02.037

    View details for PubMedID 26948397

  • Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses PUBLIC HEALTH Maguire, E. M., Bokhour, B. G., Asch, S. M., Wagner, T. H., Gifford, A. L., Gallagher, T. H., Durfee, J. M., Martinello, R. A., Elwy, A. R. 2016; 135: 75-82


    We examined print, broadcast and social media reports about health care systems' disclosures of large scale adverse events to develop future effective messaging.Directed content analysis.We systematically searched four communication databases, YouTube and Really Simple Syndication (RSS) feeds relating to six disclosures of lapses in infection control practices in the Department of Veterans Affairs occurring between 2009 and 2012. We assessed these with a coding frame derived from effective crisis and risk communication models.We identified 148 unique media reports. Some components of effective communication (discussion of cause, reassurance, self-efficacy) were more present than others (apology, lessons learned). Media about 'promoting secrecy' and 'slow response' appeared in reports when time from event discovery to patient notification was over 75 days. Elected officials' quotes (n = 115) were often negative (83%). Hospital officials' comments (n = 165) were predominantly neutral (92%), and focused on information sharing.Health care systems should work to ensure that they develop clear messages focused on what is not well covered by the media, including authentic apologies, remedial actions taken, and shorten the timeframe between event identification and disclosure to patients.

    View details for DOI 10.1016/j.puhe.2015.10.016

    View details for Web of Science ID 000377414200010

    View details for PubMedID 27026251

  • Enhancing access to alcohol use disorder pharmacotherapy and treatment in primary care settings: ADaPT-PC IMPLEMENTATION SCIENCE Hagedorn, H. J., Brown, R., Dawes, M., Dieperink, E., Myrick, D. H., Oliva, E. M., Wagner, T. H., Wisdom, J. P., Harris, A. H. 2016; 11


    Only 7.8 % of individuals meeting diagnostic criteria for alcohol use disorder (AUD) receive treatment in a given year. Most individuals with AUDs are identified in primary care (PC) settings and referred to substance use disorders (SUD) clinics; however, only a minority of those referred attend treatment services. Safe and effective pharmacological treatments for AUD exist, but they are rarely prescribed by PC providers. The objective of this study is to refine, implement, and evaluate an intervention to integrate pharmacological AUD treatment options into PC settings. This paper provides a detailed description of the intervention design and the evaluation components.Three large Veterans Health Administration (VHA) facilities are participating in the intervention. The intervention targets stakeholder groups with tailored strategies based on implementation theory and prior research identifying barriers to implementation of AUD pharmacotherapy. Local SUD providers and primary care mental health integration (PCMHI) providers are trained to serve as local implementation/clinical champions and receive external facilitation. PC providers receive access to consultation from local and national clinical champions, educational materials, and a dashboard of patients with AUD on their caseloads for case identification. Veterans with AUD diagnoses receive educational information in the mail just prior to a scheduled PC visit. Effectiveness of the intervention will be evaluated through an interrupted time series with matched controls to monitor change in facility level AUD pharmacotherapy prescribing rates. Following Stetler's four-phase formative evaluation (FE) strategy, FE methods include (1) developmental FE (pre-implementation interviews with champions, PC providers, and Veterans), (2) implementation-focused FE (tracking attendance at facilitation meetings, academic detailing efforts by local champions, and patient dashboard utilization), (3) progress-focused FE (tracking rates of AUD pharmacotherapy prescribing and rates of referral to PCMHI and SUD specialty care), and (4) interpretive FE (post-implementation interviews with champions and PC providers). Analysis of FE data will be guided by the Consolidated Framework for Implementation Research (CFIR).If demonstrated to be successful, this implementation strategy will provide a replicable, feasible, and relative low-cost method for integrating AUD treatment services into PC settings, thereby increasing access to AUD treatment.

    View details for DOI 10.1186/s13012-016-0431-5

    View details for PubMedID 27164835

  • Opportunities to Enhance Value-Related Research in the US Department of Veterans Affairs JOURNAL OF GENERAL INTERNAL MEDICINE Wagner, T. H., Burstin, H., Frakt, A. B., Krein, S. L., Lorenz, K., Maciejewski, M. L., Pizer, S. D., Weiner, M., Yoon, J., Zulman, D. M., Asch, S. M. 2016; 31: 78-83
  • Costs for a Health Coaching Intervention for Chronic Care Management AMERICAN JOURNAL OF MANAGED CARE Wagner, T. H., Willard-Grace, R., Chen, E., Bodenheimer, T., Thom, D. H. 2016; 22 (4): E141-E146


    Health coaches can help patients gain knowledge, skills, and confidence to manage their chronic conditions. Coaches may be particularly valuable in resource-poor settings, but they are not typically reimbursed by insurance, raising questions about their budgetary impact.The Health Coaching in Primary Care (HCPC) study was a randomized controlled trial that showed health coaches were effective at helping low-income patients improve control of their type 2 diabetes, hypertension, and/or hyperlipidemia at 12 months compared with usual care.We estimated the cost of employing 3 health coaches and mapped these costs to participants. We tested whether the added costs of the coaches were offset by any savings in healthcare utilization within 1 year. Healthcare utilization data were obtained from 5 sources. Multivariate models assessed differences in costs at 1 year controlling for baseline characteristics.Coaches worked an average of 9 hours with each participant over the length of the study. On average, the health coach intervention cost $483 per participant per year. The average healthcare costs for the coaching group was $3207 compared with $3276 for the control group (P = .90). There was no evidence that the coaching intervention saved money at 1 year.Health coaches have been shown to improve clinical outcomes related to chronic disease management. We found that employing health coaches adds an additional cost of $483 per patient per year. The data do not suggest that health coaches pay for themselves by reducing healthcare utilization in the first year.

    View details for Web of Science ID 000375069400004

    View details for PubMedID 27143350

  • Opportunities to Enhance Value-Related Research in the U.S. Department of Veterans Affairs. Journal of general internal medicine Wagner, T. H., Burstin, H., Frakt, A. B., Krein, S. L., Lorenz, K., Maciejewski, M. L., Pizer, S. D., Weiner, M., Yoon, J., Zulman, D. M., Asch, S. M. 2016; 31: 78-83

    View details for DOI 10.1007/s11606-015-3538-5

    View details for PubMedID 26951279

  • The rise of concurrent care for veterans with advanced cancer at the end of life CANCER Mor, V., Joyce, N. R., Cote, D. L., Gidwani, R. A., Ersek, M., Levy, C. R., Faricy-Anderson, K. E., Miller, S. C., Wagner, T. H., Kinosian, B. P., Lorenz, K. A., Shreve, S. T. 2016; 122 (5): 782-790


    Unlike Medicare, the Veterans Health Administration (VA) health care system does not require veterans with cancer to make the "terrible choice" between receipt of hospice services or disease-modifying chemotherapy/radiation therapy. For this report, the authors characterized the VA's provision of concurrent care, defined as days in the last 6 months of life during which veterans simultaneously received hospice services and chemotherapy or radiation therapy.This retrospective cohort study included veteran decedents with cancer during 2006 through 2012 who were identified from claims with cancer diagnoses. Hospice and cancer treatment were identified using VA and Medicare administrative data. Descriptive statistics were used to characterize the changes in concurrent care, hospice, palliative care, and chemotherapy or radiation treatment.The proportion of veterans receiving chemotherapy or radiation therapy remained stable at approximately 45%, whereas the proportion of veterans who received hospice increased from 55% to 68%. The receipt of concurrent care also increased during this time from 16.2% to 24.5%. The median time between hospice initiation and death remained stable at around 21 days. Among veterans who received chemotherapy or radiation therapy in their last 6 months of life, the median time between treatment termination and death ranged from 35 to 40 days. There was considerable variation between VA medical centers in the use of concurrent care (interquartile range, 16%-34% in 2012).Concurrent receipt of hospice and chemotherapy or radiation therapy increased among veterans dying from cancer without reductions in the receipt of cancer therapy. This approach reflects the expansion of hospice services in the VA with VA policy allowing the concurrent receipt of hospice and antineoplastic therapies. Cancer 2016;122:782-790. © 2015 American Cancer Society.

    View details for DOI 10.1002/cncr.29827

    View details for Web of Science ID 000371166300019

    View details for PubMedID 26670795

  • Resident versus attending surgeon graft patency and clinical outcomes in on- versus off-pump coronary artery bypass surgery JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Almassi, G. H., Carr, B. M., Bishawi, M., Shroyer, A. L., Quin, J. A., Hattler, B., Wagner, T. H., Collins, J. F., Ravichandran, P., Cleveland, J. C., Grover, F. L., Bakaeen, F. G. 2015; 150 (6): 1428-?


    Controversy exists regarding ideal approaches in teaching residents complex and/or new surgical techniques in part because consequences on patient outcomes are largely unknown. This study compared patient outcomes for cases in which residents (rather than attending surgeons) performed most of the distal anastomoses as primary surgeons, during on- and off-pump coronary artery bypass grafting (CABG).This preapproved substudy of the Randomized On/Off Bypass (ROOBY) trial compared clinical outcomes and 1-year graft patency for cases in which residents versus attending surgeons were the primary operator. Comparisons were made between on-pump and off-pump techniques.From July 2003 through May 2007, a total of 1272 ROOBY nonemergent CABG patients were randomized at 16 Veterans Affairs centers where residents were active participants. Residents were the primary surgeon (ie, performed ≥50% of the distal anastomoses) more frequently in on-pump (77.9%) than in off-pump (67.4%) cases. Between these 2 techniques, no differences were found [corrected] in baseline patient characteristics; short-term and 1-year morbidity and mortality rates were no different for residents versus attendings in CABG cases. FitzGibbon A graft patency rates were similar for resident versus attendings completed distal anastomoses for on-pump (83.0% vs 82.4%) compared with off-pump (77.2% vs 76.6%) procedures.In the ROOBY trial, short-term and 1-year patient outcomes and graft patency rates did not differ between resident and attending surgeons, demonstrating that with appropriate patient selection and resident supervision, residents can perform advanced, novel surgical techniques with outcomes similar to those of attending surgeons.

    View details for DOI 10.1016/j.jtcvs.2015.08.124

    View details for PubMedID 26470910

  • Invasive Mechanical Ventilation in California Over 2000-2009: Implications for Emergency Medicine. The western journal of emergency medicine Mudumbai, S. C., Barr, J., Scott, J., Mariano, E. R., Bertaccini, E., Nguyen, H., Memtsoudis, S. G., Cason, B., Phibbs, C. S., Wagner, T. 2015; 16 (5): 696-706


    Patients who require invasive mechanical ventilation (IMV) often represent a sequence of care between the emergency department (ED) and intensive care unit (ICU). Despite being the most populous state, little information exists to define patterns of IMV use within the state of California.We examined data from the masked Patient Discharge Database of California's Office of Statewide Health Planning and Development from 2000-2009. Adult patients who received IMV during their stay were identified using the International Classification of Diseases 9th Revision and Clinical Modification procedure codes (96.70, 96.71, 96.72). Patients were divided into age strata (18-34yr, 35-64yr, and >65yr). Using descriptive statistics and regression analyses, for IMV discharges during the study period, we quantified the number of ED vs. non-ED based admissions; changes in patient characteristics and clinical outcome; evaluated the marginal costs for IMV; determined predictors for prolonged acute mechanical ventilation (PAMV, i.e. IMV>96hr); and projected the number of IMV discharges and ED-based admissions by year 2020.There were 696,634 IMV discharges available for analysis. From 2000-2009, IMV discharges increased by 2.8%/year: n=60,933 (293/100,000 persons) in 2000 to n=79,868 (328/100,000 persons) in 2009. While ED-based admissions grew by 3.8%/year, non-ED-based admissions remained stable (0%). During 2000-2009, fastest growth was noted for 1) the 35-64 year age strata; 2) Hispanics; 3) patients with non-Medicare public insurance; and 4) patients requiring PAMV. Average total patient cost-adjusted charges per hospital discharge increased by 29% from 2000 (from $42,528 to $60,215 in 2014 dollars) along with increases in the number of patients discharged to home and skilled nursing facilities. Higher marginal costs were noted for younger patients (ages 18-34yr), non-whites, and publicly insured patients. Some of the strongest predictors for PAMV were age 35-64 years (OR=1.12; 95% CI [1.09-1.14], p<0.05); non-Whites; and non-Medicare public insurance. Our models suggest that by 2020, IMV discharges will grow to n=153,153 (377 IMV discharges/100,000 persons) with 99,095 admitted through the ED.Based on sustained growth over the past decade, by the year 2020, we project a further increase to 153,153 IMV discharges with 99,095 admitted through the ED. Given limited ICU bed capacities, ongoing increases in the number and type of IMV patients have the potential to adversely affect California EDs that often admit patients to ICUs.

    View details for DOI 10.5811/westjem.2015.6.25736

    View details for PubMedID 26587094

  • Intended and unintended effects of large-scale adverse event disclosure: a controlled before-after analysis of five large-scale notifications BMJ QUALITY & SAFETY Wagner, T. H., Taylor, T., Cowgill, E., Asch, S. M., Su, P., Bokhour, B., Durfee, J., Martinello, R. A., Maguire, E., Elwy, A. R. 2015; 24 (5): 295-302


    How patients respond to being notified of a large-scale adverse event (LSAE), such as improper sterilisation of medical equipment that exposes them to bloodborne pathogens, is not well known. The objective of this study was to determine, using administrative data, the intended and unintended consequences of patient notification following a LSAE.We examined five LSAEs where patients may have been inadvertently exposed to hepatitis C virus (HCV), HIV, and hepatitis B virus (HBV). A total of 9638 cases were identified at five Department of Veteran Affairs (VA) medical facilities between 2009 and 2012. We identified controls at the same facility prior to the exposure period and at neighbouring facilities (n=45 274). Difference-in-differences models were used with Veterans Health Administration (VHA) and Medicare data to examine infectious disease testing rates and subsequent utilisation patterns.Receipt of a LSAE notification was associated with a 73.2, 76.8 and 77.1 adjusted percentage point increase for HCV, HIV and HBV testing, respectively (all p<0.001). Compared with white patients, African-American patients were significantly less likely to return to VHA for follow-up testing. Patients exposed to a dental LSAE reduced their use of preventive and restorative dental care over the subsequent year, but they eventually came back to VHA for dental services 18-months post exposure.The majority of patients notified of a LSAE responded by getting tested for HCV, HIV and HBV, although there remains room for improvement. Potential exposure to a LSAE was associated with increased odds of subsequently using non-VA facilities, but the size and timing of the shift depended on the type of care.

    View details for DOI 10.1136/bmjqs-2014-003800

    View details for Web of Science ID 000353038100002

    View details for PubMedID 25882785

  • Treating age-related macular degeneration: comparing the use of two drugs among medicare and veterans affairs populations. Health affairs Pershing, S., Pal Chee, C., Asch, S. M., Baker, L. C., Boothroyd, D., Wagner, T. H., Bundorf, M. K. 2015; 34 (2): 229-238


    While new biologics have revolutionized the treatment of age-related macular degeneration-the leading cause of severe vision loss among older adults-these new drugs have also raised concerns over the economic impact of medical innovation. The two leading agents are similar in effectiveness but vary greatly in price-up to $2,000 per injection for ranibizumab compared to $50 for bevacizumab. We examined the diffusion of these drugs in fee-for-service Medicare and Veterans Affairs (VA) systems during 2005-11, in part to assess the impact that differing financial incentives had on prescribing. Physicians treating Medicare patients have a direct financial incentive to prescribe the more expensive agent (ranibizumab), while VA physicians do not. Medicare injections of the more expensive ranibizumab peaked in 2007 at 47 percent. Beginning in 2009 the less expensive bevacizumab became the predominant therapy for Medicare patients, accounting for more than 60 percent of injections. For VA patients, the distribution of injections across the two drugs was relatively equal, particularly from 2009 to 2011. Our analysis indicates that there are opportunities in both the VA and Medicare to adopt more value-conscious treatment patterns and that multiple mechanisms exist to influence utilization.

    View details for DOI 10.1377/hlthaff.2014.1032

    View details for PubMedID 25646102

  • Treating age-related macular degeneration: comparing the use of two drugs among medicare and veterans affairs populations. Health affairs Pershing, S., Pal Chee, C., Asch, S. M., Baker, L. C., Boothroyd, D., Wagner, T. H., Bundorf, M. K. 2015; 34 (2): 229-238

    View details for DOI 10.1377/hlthaff.2014.1032

    View details for PubMedID 25646102

  • Postoperative Atrial Fibrillation Impacts on Costs and One-Year Clinical Outcomes: The Veterans Affairs Randomized On/Off Bypass Trial ANNALS OF THORACIC SURGERY Almassi, G. H., Wagner, T. H., Carr, B., Hattler, B., Collins, J. F., Quin, J. A., Ebrahimi, R., Grover, F. L., Bishawi, M., Shroyer, A. L. 2015; 99 (1): 109-114


    New-onset postoperative atrial fibrillation (POAF) after coronary artery bypass graft surgery (CABG) is associated with worse in-hospital morbidity and mortality, extended hospital stays, and higher costs. Beyond the initial hospital discharge, the cost and outcomes of POAF have not been well studied.For CABG patients with and without new-onset POAF, a retrospective propensity-matched, multivariable regression analysis was performed to compare 1-year outcomes (including health-related quality of life [HRQoL] scores and mortality rates) and costs (standardized to 2010 dollars). Regression models controlled for site and patient factors, with propensity matching used to adjust for differences in POAF versus no-POAF patients' risk profiles.Using the existing CABG trial database, 2,096 patient records were analyzed, including POAF patients (n = 549) versus no-POAF patients (n = 1,547). For the index CABG hospitalization, POAF patients had longer postoperative length of stay (+3.9 days) and higher discharge costs (+$13,993) than no-POAF patients. At 1 year, POAF patients had more than twice the adjusted odds of dying (p < 0.01), with higher 1-year total cumulative costs. This 1-year cost difference (+$15,593) was largely attributable to hospital-based costs during the index surgery hospitalization. There was no difference in 1-year HRQoL scores (or HRQoL score changes) between POAF patients and no-POAF patients.Compared with no-POAF patients, POAF patients had higher discharge and 1-year costs along with higher 1-year mortality rates, but no differences were observed in 1-year HRQoL scores. Additional research appears warranted to improve the longer-term survival rates for POAF CABG patients, targeting future POAF-specific postdischarge interventions.

    View details for DOI 10.1016/j.athoracsur.2014.07.035

    View details for Web of Science ID 000347030800032

    View details for PubMedID 25442992

  • Multimorbidity and healthcare utilisation among high-cost patients in the US Veterans Affairs Health Care System. BMJ open Zulman, D. M., Pal Chee, C., Wagner, T. H., Yoon, J., Cohen, D. M., Holmes, T. H., Ritchie, C., Asch, S. M. 2015; 5 (4)

    View details for DOI 10.1136/bmjopen-2015-007771

    View details for PubMedID 25882486

  • Multimorbidity and healthcare utilisation among high-cost patients in the US Veterans Affairs Health Care System. BMJ open Zulman, D. M., Pal Chee, C., Wagner, T. H., Yoon, J., Cohen, D. M., Holmes, T. H., Ritchie, C., Asch, S. M. 2015; 5 (4)


    To investigate the relationship between multimorbidity and healthcare utilisation patterns among the highest cost patients in a large, integrated healthcare system.In this retrospective cross-sectional study of all patients in the U.S. Veterans Affairs (VA) Health Care System, we aggregated costs of individuals' outpatient and inpatient care, pharmacy services and VA-sponsored contract care received in 2010. We assessed chronic condition prevalence, multimorbidity as measured by comorbidity count, and multisystem multimorbidity (number of body systems affected by chronic conditions) among the 5% highest cost patients. Using multivariate regression, we examined the association between multimorbidity and healthcare utilisation and costs, adjusting for age, sex, race/ethnicity, marital status, homelessness and health insurance status.USA VA Health Care System.5.2 million VA patients.Annual total costs; absolute and share of costs generated through outpatient, inpatient, pharmacy and VA-sponsored contract care; number of visits to primary, specialty and mental healthcare; number of emergency department visits and hospitalisations.The 5% highest cost patients (n=261 699) accounted for 47% of total VA costs. Approximately two-thirds of these patients had chronic conditions affecting ≥3 body systems. Patients with cancer and schizophrenia were less likely to have documented comorbid conditions than other high-cost patients. Multimorbidity was generally associated with greater outpatient and inpatient utilisation. However, increased multisystem multimorbidity was associated with a higher outpatient share of total costs (1.6 percentage points per affected body system, p<0.01) but a lower inpatient share of total costs (-0.6 percentage points per affected body system, p<0.01).Multisystem multimorbidity is common among high-cost VA patients. While some patients might benefit from disease-specific programmes, for most patients with multimorbidity there is a need for interventions that coordinate and maximise efficiency of outpatient services across multiple conditions.

    View details for DOI 10.1136/bmjopen-2015-007771

    View details for PubMedID 25882486

    View details for PubMedCentralID PMC4401870

  • Improving healthcare systems' disclosures of large-scale adverse events: a Department of Veterans Affairs leadership, policymaker, research and stakeholder partnership. Journal of general internal medicine Elwy, A. R., Bokhour, B. G., Maguire, E. M., Wagner, T. H., Asch, S. M., Gifford, A. L., Gallagher, T. H., Durfee, J. M., Martinello, R. A., Schiffner, S., Jesse, R. L. 2014; 29: 895-903


    The Department of Veterans Affairs (VA) mandates disclosure of large-scale adverse events to patients, even if risk of harm is not clearly present. Concerns about past disclosures warranted further examination of the impact of this policy.Through a collaborative partnership between VA leaders, policymakers, researchers and stakeholders, the objective was to empirically identify critical aspects of disclosure processes as a first step towards improving future disclosures.Semi-structured interviews were conducted with participants at nine VA facilities where recent disclosures took place.Ninety-seven stakeholders participated in the interviews: 38 employees, 28 leaders (from facilities, regions and national offices), 27 Veteran patients and family members, and four congressional staff members.Facility and regional leaders were interviewed by telephone, followed by a two-day site visit where employees, patients and family members were interviewed face-to-face. National leaders and congressional staff also completed telephone interviews. Interviews were analyzed using rapid qualitative assessment processes. Themes were mapped to the stages of the Crisis and Emergency Risk Communication model: pre-crisis, initial event, maintenance, resolution and evaluation.Many areas for improvement during disclosure were identified, such as preparing facilities better (pre-crisis), creating rapid communications, modifying disclosure language, addressing perceptions of harm, reducing complexity, and seeking assistance from others (initial event), managing communication with other stakeholders (maintenance), minimizing effects on staff and improving trust (resolution), and addressing facilities' needs (evaluation).Through the partnership, five recommendations to improve disclosures during each stage of communication have been widely disseminated throughout the VA using non-academic strategies. Some improvements have been made; other recommendations will be addressed through implementation of a large-scale adverse event disclosure toolkit. These toolkit strategies will enable leaders to provide timely and transparent information to patients and families, while reducing the burden on employees and the healthcare system during these events.

    View details for DOI 10.1007/s11606-014-3034-3

    View details for PubMedID 25355090

  • Improving Healthcare Systems' Disclosures of Large-Scale Adverse Events: A Department of Veterans Affairs Leadership, Policymaker, Research and Stakeholder Partnership JOURNAL OF GENERAL INTERNAL MEDICINE Elwy, A. R., Bokhour, B. G., Maguire, E. M., Wagner, T. H., Asch, S. M., Gifford, A. L., Gallagher, T. H., Durfee, J. M., Martinello, R. A., Schiffner, S., Jesse, R. L. 2014; 29: S895-S903


    The Department of Veterans Affairs (VA) mandates disclosure of large-scale adverse events to patients, even if risk of harm is not clearly present. Concerns about past disclosures warranted further examination of the impact of this policy.Through a collaborative partnership between VA leaders, policymakers, researchers and stakeholders, the objective was to empirically identify critical aspects of disclosure processes as a first step towards improving future disclosures.Semi-structured interviews were conducted with participants at nine VA facilities where recent disclosures took place.Ninety-seven stakeholders participated in the interviews: 38 employees, 28 leaders (from facilities, regions and national offices), 27 Veteran patients and family members, and four congressional staff members.Facility and regional leaders were interviewed by telephone, followed by a two-day site visit where employees, patients and family members were interviewed face-to-face. National leaders and congressional staff also completed telephone interviews. Interviews were analyzed using rapid qualitative assessment processes. Themes were mapped to the stages of the Crisis and Emergency Risk Communication model: pre-crisis, initial event, maintenance, resolution and evaluation.Many areas for improvement during disclosure were identified, such as preparing facilities better (pre-crisis), creating rapid communications, modifying disclosure language, addressing perceptions of harm, reducing complexity, and seeking assistance from others (initial event), managing communication with other stakeholders (maintenance), minimizing effects on staff and improving trust (resolution), and addressing facilities' needs (evaluation).Through the partnership, five recommendations to improve disclosures during each stage of communication have been widely disseminated throughout the VA using non-academic strategies. Some improvements have been made; other recommendations will be addressed through implementation of a large-scale adverse event disclosure toolkit. These toolkit strategies will enable leaders to provide timely and transparent information to patients and families, while reducing the burden on employees and the healthcare system during these events.

    View details for DOI 10.1007/s11606-014-3034-3

    View details for Web of Science ID 000345410200014

    View details for PubMedCentralID PMC4239293

  • Estimating the Efficacy of Alcoholics Anonymous without Self-Selection Bias: An Instrumental Variables Re-Analysis of Randomized Clinical Trials ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH Humphreys, K., Blodgett, J. C., Wagner, T. H. 2014; 38 (11): 2688-2694


    Observational studies of Alcoholics Anonymous' (AA) effectiveness are vulnerable to self-selection bias because individuals choose whether or not to attend AA. The present study, therefore, employed an innovative statistical technique to derive a selection bias-free estimate of AA's impact.Six data sets from 5 National Institutes of Health-funded randomized trials (1 with 2 independent parallel arms) of AA facilitation interventions were analyzed using instrumental variables models. Alcohol-dependent individuals in one of the data sets (n = 774) were analyzed separately from the rest of sample (n = 1,582 individuals pooled from 5 data sets) because of heterogeneity in sample parameters. Randomization itself was used as the instrumental variable.Randomization was a good instrument in both samples, effectively predicting increased AA attendance that could not be attributed to self-selection. In 5 of the 6 data sets, which were pooled for analysis, increased AA attendance that was attributable to randomization (i.e., free of self-selection bias) was effective at increasing days of abstinence at 3-month (B = 0.38, p = 0.001) and 15-month (B = 0.42, p = 0.04) follow-up. However, in the remaining data set, in which preexisting AA attendance was much higher, further increases in AA involvement caused by the randomly assigned facilitation intervention did not affect drinking outcome.For most individuals seeking help for alcohol problems, increasing AA attendance leads to short- and long-term decreases in alcohol consumption that cannot be attributed to self-selection. However, for populations with high preexisting AA involvement, further increases in AA attendance may have little impact.

    View details for DOI 10.1111/acer.12557

    View details for Web of Science ID 000345620400001

    View details for PubMedID 25421504

    View details for PubMedCentralID PMC4285560

  • Cost-Effectiveness of Supported Employment for Veterans With Spinal Cord Injuries ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Sinnott, P. L., Joyce, V., Su, P., Ottomanelli, L., Goetz, L. L., Wagner, T. H. 2014; 95 (7): 1254-1261


    To estimate the cost-effectiveness of a supported employment (SE) intervention that had been previously found effective in veterans with spinal cord injuries (SCIs).Cost-effectiveness analysis, using cost and quality-of-life data gathered in a trial of SE for veterans with SCI.SCI centers in the Veterans Health Administration.Subjects (N=157) who completed a study of SE in 6 SCI centers. Subjects were randomly assigned to the intervention of SE (n=81) or treatment as usual (n=76).A vocational rehabilitation program of SE for veterans with SCI.Costs and quality-adjusted life years, which were estimated from the Veterans Rand 36-Item Health Survey, extrapolated to Veterans Rand 6 Dimension utilities.Average cost for the SE intervention was $1821. In 1 year of follow-up, estimated total costs, including health care utilization and travel expenses, and average quality-adjusted life years were not significantly different between groups, suggesting the Spinal Cord Injury Vocational Integration Program intervention was not cost-effective compared with usual care.An intensive program of SE for veterans with SCI, which is more effective in achieving competitive employment, is not cost-effective after 1 year of follow-up. Longer follow-up and a larger study sample will be necessary to determine whether SE yields benefits and is cost-effective in the long run for a population with SCI.

    View details for DOI 10.1016/j.apmr.2014.01.010

    View details for Web of Science ID 000338479700005

    View details for PubMedID 24486426

  • Comparing Off-Pump and On-Pump Clinical Outcomes and Costs for Diabetic Cardiac Surgery Patients ANNALS OF THORACIC SURGERY Shroyer, A. L., Hattler, B., Wagner, T. H., Baltz, J. H., Collins, J. F., Carr, B. M., Almassi, G. H., Quin, J. A., Hawkins, R. B., Kozora, E., Bishawi, M., Ebrahimi, R., Grover, F. L. 2014; 98 (1): 38-44


    Observational studies have documented an off-pump over on-pump advantage for high-risk patients, including diabetic patients. Randomized trials have not confirmed this advantage. The VA Randomization On Versus Off Bypass (ROOBY) trial randomly assigned 2,203 coronary artery bypass graft surgery (CABG) patients at 18 sites to either on-pump (n=1,099) or off-pump (n=1,104) procedures. An a priori ROOBY aim was to evaluate treatment impact on diabetic patients.Actively treated diabetic patients (n=835, receiving oral hypoglycemic or insulin medications) received off-pump CABG (n=402) or on-pump CABG (n=433). The primary ROOBY trial endpoints were a short-term composite (30-day operative death or major complications) and a 1-year composite (death, nonfatal acute myocardial infarction, or repeat revascularization). Secondary ROOBY endpoints included 1-year all-cause death, 1-year graft patency, 1-year changes from baseline in neurocognitive status and health-related quality of life, and costs.Diabetic patients' risk factors at baseline were balanced across treatments. For diabetic patients, the primary short-term composite outcome rate showed a worse trend for off-pump (8.0%) than on-pump (3.9%, p=0.013), with no difference in the 1-year primary composite outcome or 1-year death rate. One-year patency was 83.1% off-pump versus 88.4% on-pump (p=0.004). No differences were found in neurocognitive, health-related quality of life, discharge cost, and 1-year cumulative cost.Concordant with the ROOBY trial's overall findings, off-pump CABG yielded no advantage over on-pump CABG for actively treated diabetic patients. The 1-year graft patency was lower and the short-term composite trended higher for off-pump CABG, with no other significant outcome or cost differences.

    View details for DOI 10.1016/j.athoracsur.2014.03.042

    View details for Web of Science ID 000338432600017

    View details for PubMedID 24841548

  • KRAS mutation confers resistance to antibody-dependent cellular cytotoxicity of cetuximab against human colorectal cancer cells INTERNATIONAL JOURNAL OF CANCER Conti, S. L., Thomas, I., Hagedorn, J. C., Chung, B. I., Chertow, G. M., Wagner, T. H., Brooks, J. D., Srinivas, S., Leppert, J. T. 2014; 134 (9): 2245-2252


    We sought to analyze utilization and survival outcomes of cytoreductive nephrectomy in patients with metastatic renal cell carcinoma (RCC) before and after introduction of targeted therapy. We identified patients with metastatic RCC between 1993 and 2010 in the SEER registry and examined temporal trends in utilization. We performed a joinpoint regression to determine when changes in utilization of cytoreductive nephrectomy occurred. We fitted multivariable proportional hazard models in full and propensity score-matched cohorts. We performed a difference-in-difference analysis to compare survival outcomes before and after introduction of targeted therapy. The proportion of patients undergoing cytoreductive nephrectomy increased from 1993 to 2004, from 29% to 39%. We identified a primary joinpoint of 2004, just prior to the introduction of targeted therapy. Beginning in 2005, there was a modest decrease in utilization of cytoreductive nephrectomy. Cytoreductive nephrectomy was associated with a lower adjusted relative hazard (0.41, 95% confidence interval 0.34 to 0.43). Median survival among patients receiving cytoreductive nephrectomy increased in the targeted therapy era (19 versus 13 months), while median survival among patients not receiving cytoreductive nephrectomy increased only slightly (4 versus 3 months). Difference-in-difference analysis showed a significant decrease in hazard of death among patients who received cytoreductive nephrectomy in the targeted therapy era. Despite decreased utilization in the targeted therapy era, cytoreductive nephrectomy remains associated with improved survival. Prospective randomized trials are needed to confirm the benefit of cytoreductive nephrectomy among patients with metastatic RCC treated with novel targeted therapies. © 2013 Wiley Periodicals, Inc.

    View details for DOI 10.1002/ijc.28550

    View details for Web of Science ID 000331006600013

  • Facility-Level Analysis of PET Scanning for Staging Among US Veterans With Non-small Cell Lung Cancer CHEST Gould, M. K., Wagner, T. H., Schultz, E. M., Xu, X., Ghaus, S. J., Provenzale, D., Au, D. H. 2014; 145 (4): 839-847


    PET scanning has been shown in randomized trials to reduce the frequency of surgery without cure among patients with potentially resectable non-small cell lung cancer (NSCLC). We examined whether more frequent use of PET scanning at the facility level improves survival among patients with NSCLC in real-world practice.In this prospective cohort study of 622 US veterans with newly diagnosed NSCLC, we compared groups defined by the frequency of PET scan use measured at the facility level and categorized as low (<25%), medium (25%-60%), or high (>60%).The median age of the sample was 69 years. Ninety-eight percent were men, 36% were Hispanic or nonwhite, and 54% had moderate or severe comorbidities. At low-, medium-, and high-use facilities, PET scan was performed in 13%, 40%, and 72% of patients, respectively (P<.0001). Baseline characteristics were similar across groups, including clinical stage based on CT scanning. More frequent use of PET scanning was associated with more frequent invasive staging (P<.001) and nonsignificant improvements in downstaging (P=.13) and surgery without cure (P=.12). After a median of 352 days of follow-up, 22% of the sample was still alive, including 22% at low- and medium-use facilities and 20% at high-use facilities. After adjustment and compared with patients at low-use facilities, the hazard of death was greater for patients at high-use facilities (adjusted hazard ratio [HR], 1.35; 95% CI, 1.05-1.74) but not different for patients at medium-use facilities (adjusted HR, 1.14; 95% CI, 0.88-1.46).In this study of veterans with NSCLC, markedly greater use of PET scanning at the facility level was associated with more frequent use of invasive staging and possible improvements in downstaging and surgery without cure, but greater use of PET scanning was not associated with better survival.

    View details for DOI 10.1378/chest.13-1073

    View details for Web of Science ID 000334097700029

    View details for PubMedID 24306819

    View details for PubMedCentralID PMC3971972

  • Utilization of renal mass biopsy in patients with renal cell carcinoma. Urology Leppert, J. T., Hanley, J., Wagner, T. H., Chung, B. I., Srinivas, S., Chertow, G. M., Brooks, J. D., Saigal, C. S. 2014; 83 (4): 774-780


    To examine the patient, tumor, and temporal factors associated with receipt of renal mass biopsy (RMB) in a contemporary nationally representative sample.We queried the Surveillance, Epidemiology, and End Results-Medicare data set for incident cases of renal cell carcinoma diagnosed between 1992 and 2007. We tested for associations among receipt of RMB and patient and tumor characteristics, type of therapy, and procedure type. Temporal trends in receipt of RMB were characterized over the study period.Approximately 1 in 5 (20.7%) patients diagnosed with renal cell carcinoma (n = 24,702) underwent RMB before instituting therapy. There was a steady and modest increase in RMB utilization, with the highest utilization (30%) occurring in the final study year. Of patients who underwent radical (n = 15,666) or partial (n = 2211) nephrectomy, 17% and 20%, respectively, underwent RMB in advance of surgery. Sixty-five percent of patients who underwent ablation (n = 314) underwent RMB before or in conjunction with the procedure. Roughly half of patients (50.4%) treated with systemic therapy alone underwent RMB. Factors independently associated with use of RMB included younger age, black race, Hispanic ethnicity, tumor size <7 cm, and metastatic disease at presentation.At present, most patients who eventually undergo radical or partial nephrectomy do not undergo RMB, whereas most patients who eventually undergo ablation or systemic therapy do. The optimal use of RMB in the evaluation of kidney tumors has yet to be determined.

    View details for DOI 10.1016/j.urology.2013.10.073

    View details for PubMedID 24529579

  • Reply. Urology Leppert, J. T., Hanley, J., Wagner, T. H., Chung, B. I., Brooks, J. D., Srinivas, S., Chertow, G. M., Saigal, C. S. 2014; 83 (4): 779-780

    View details for DOI 10.1016/j.urology.2013.10.077

    View details for PubMedID 24529590

  • Utilization of Renal Mass Biopsy in Patients With Renal Cell Carcinoma Reply UROLOGY Leppert, J. T., Hanley, J., Wagner, T. H., Chung, B. I., Brooks, J. D., Srinivas, S., Chertow, G. M., Saigal, C. S. 2014; 83 (4): 779-780
  • Effect of Clopidogrel Use Post Coronary Artery Bypass Surgery on Graft Patency 49th Annual Meeting of the Society-of-Thoracic-Surgeons Ebrahimi, R., Bakaeen, F. G., Uberoi, A., Ardehali, A., Baltz, J. H., Hattler, B., Almassi, G. H., Wagner, T. H., Collins, J. F., Grover, F. L., Shroyer, A. L. ELSEVIER SCIENCE INC. 2014: 15–21


    Clopidogrel use post coronary artery bypass grafting (CABG) has become more popular under the assumption that it improves graft patency. The purpose of this sub-analysis from the Randomized On and Off-Pump Bypass (ROOBY) trial is to evaluate the role of clopidogrel use post CABG to improve graft patency when added to standard aspirin therapy.The ROOBY trial was a multi-center, randomized, controlled clinical trial that compared on-pump versus off-pump coronary artery bypass grafting (CABG). Clopidogrel use post CABG was left at the discretion of the operator. Detailed data regarding the use and timing of clopidogrel post CABG were collected prospectively, along with 1-year angiograms to evaluate graft status.Of the 2,203 subjects undergoing CABG, 953 patient records had complete clopidogrel use and 1-year angiographic data. Of these, 345 (36.2%) received clopidogrel post CABG prior to discharge. Compared with patients with no post-CABG clopidogrel use, baseline characteristics were similar for the clopidogrel group except for the following: lower preoperative aspirin use (80.2% vs 86.7%, p = 0.009); higher preoperative clopidogrel use (23.5% vs 14.0%, p < 0.001), less on-pump (35.9% vs 55.9%, p < 0.0001); and lower endoscopic vein harvesting (30.8% vs 42.5%, p < 0.001) rates. Overall 1-year graft patency rates were not different between the clopidogrel and no-clopidogrel groups (86.5% vs 85.3%, p = 0.43). Multivariable analyses did not alter these findings.This study suggests that routine post-CABG clopidogrel use may not translate to improved 1-year graft patency. Future studies appear warranted to better define the role of more aggressive antiplatelet therapy post CABG on graft patency and clinical outcomes.

    View details for DOI 10.1016/j.athoracsur.2013.08.058

    View details for Web of Science ID 000329155900013

    View details for PubMedID 24206971

  • Effectiveness of preoperative beta-blockade on intra-operative heart rate in vascular surgery cases conducted under regional or local anesthesia. SpringerPlus Mudumbai, S. C., Wagner, T., Mahajan, S., King, R., Heidenreich, P. A., Hlatky, M., Wallace, A. W., Mariano, E. R. 2014; 3: 227-?

    View details for DOI 10.1186/2193-1801-3-227

    View details for PubMedID 24855591

  • Effectiveness of preoperative beta-blockade on intra-operative heart rate in vascular surgery cases conducted under regional or local anesthesia. SpringerPlus Mudumbai, S. C., Wagner, T., Mahajan, S., King, R., Heidenreich, P. A., Hlatky, M., Wallace, A. W., Mariano, E. R. 2014; 3: 227-?


    Preoperative β-blockade has been posited to result in better outcomes for vascular surgery patients by attenuating acute hemodynamic changes associated with stress. However, the incremental effectiveness, if any, of β-blocker usage in blunting heart rate responsiveness for vascular surgery patients who avoid general anesthesia remains unknown.We reviewed an existing database and identified 213 consecutive vascular surgery cases from 2005-2011 conducted without general anesthesia (i.e., under monitored anesthesia care or regional anesthesia) at a tertiary care Veterans Administration medical center and categorized patients based on presence or absence of preoperative β-blocker prescription. For this series of patients, with the primary outcome of maximum heart rate during the interval between operating room entry to surgical incision, we examined the association of maximal heart rate and preoperative β-blocker usage by performing crude and multivariate linear regression, adjusting for relevant patient factors.Of 213 eligible cases, 137 were prescribed preoperative β-blockers, and 76 were not. The two groups were comparable across baseline patient factors and intraoperative medication doses. The β-blocker group experienced lower maximal heart rates during the period of evaluation compared to the non-β-blocker group (85 ± 22 bpm vs. 98 ± 36 bpm, respectively; p = 0.002). Adjusted linear regression confirmed a statistically-significant association between lower maximal heart rate and the use of β-blockers (Beta = -11.5; 95% CI [-3.7, -19.3] p = 0.004).The addition of preoperative β-blockers, even when general anesthesia is avoided, may be beneficial in further attenuating stress-induced hemodynamic changes for vascular surgery patients.

    View details for DOI 10.1186/2193-1801-3-227

    View details for PubMedID 24855591

    View details for PubMedCentralID PMC4024108

  • The Challenges with Interpreting Cost-Effectiveness Data SCANDINAVIAN CARDIOVASCULAR JOURNAL Wagner, T. H., Shroyer, A. L., Hattler, B., Collins, J. F., Grover, F. L. 2013; 47 (6): 383-383

    View details for DOI 10.3109/14017431.2013.851413

    View details for Web of Science ID 000327848900009

    View details for PubMedID 24200227

  • Utilization of renal mass biopsy in patients with renal cell carcinoma 12th International Kidney Cancer Symposium Leppert, J. T., Hanley, J., Wagner, T. H., Chung, B. I., Srinivas, S., Chertow, G. M., Brooks, J. D., Saigal, C. S. WILEY-BLACKWELL. 2013: 14–14
  • Consequences of Radial Artery Harvest Results of a Prospective, Randomized, Multicenter Trial JAMA SURGERY Holman, W. L., Davies, J. E., Lin, J. Y., Wang, Y., Goldman, S., Bakaeen, F. G., Kelly, R., Fremes, S. E., Lee, K. K., Wagner, T. H., Sethi, G. K. 2013; 148 (11): 1020-1023


    To date, no study has defined the consequences of radial artery harvest based on a large number of patients in a prospective randomized trial.To compare pain at the harvest site and functional changes associated with harvesting the radial artery vs saphenous vein for coronary artery bypass grafting.This study compares the consequences of radial artery harvest with saphenous vein harvest in patients undergoing elective coronary artery bypass grafting procedures in Veterans Affairs hospitals.Eleven hospitals screened 6148 patients, of whom 751 were included in this trial. We analyzed 2 variables: pain at the harvest site as measured on a scale of 0 to 100 (least to most painful) and hand performance testing. Patients included in this analysis had radial artery only (n = 80) or saphenous vein only (n = 337) harvest. Pain score, grip strength, and dexterity were measured before surgery and at 3 and 12 months after surgery. We adjusted for pain scores of the nonharvested extremity, age, whether the patient underwent endoscopic vein harvesting, and comorbid health conditions (smoking history, type 2 diabetes mellitus, hypertension, and heart failure).There was a significant difference in change of pain score at 3 months from the preoperative baseline between radial artery and saphenous vein groups after adjusting for covariates (P < .001) but not at 12 months (P = .07). No significant changes occurred in grip strength or dexterity from preoperative baseline to 3 and 12 months after surgery (P > .05).The radial artery group reported significantly more pain than the saphenous vein group 3 months after surgery; however, similar levels of pain were observed in both groups at 12 months after surgery. Grip strength and manual dexterity were not changed by radial artery harvesting at 3 and 12 months.

    View details for DOI 10.1001/jamasurg.2013.3721

    View details for Web of Science ID 000330116000005

    View details for PubMedID 24068158

  • Utilization of cytoreductive nephrectomy and patient survival in the targeted therapy era 12th International Kidney Cancer Symposium Conti, S. L., Thomas, I., Hagedorn, J. C., Chung, B. I., Chertow, G. M., Wagner, T. H., Brooks, J. D., Srinivas, S., Leppert, J. T. WILEY-BLACKWELL. 2013: 14–16
  • On-Pump versus Off-Pump Coronary Artery Bypass Surgery: Cost-Effectiveness Analysis Alongside a Multisite Trial 49th Annual Meeting of the Society-of-Thoracic-Surgeons Wagner, T. H., Hattler, B., Bishawi, M., Baltz, J. H., Collins, J. F., Quin, J. A., Grover, F. L., Shroyer, A. L. ELSEVIER SCIENCE INC. 2013: 770–77


    Questions have been raised about the costs and outcomes for patients receiving on-pump and off-pump coronary artery bypass graft surgery. As part of the Department of Veterans Affairs Randomized On/Off Bypass (ROOBY) multisite trial, a cost-effectiveness analysis was performed to compare on-pump versus off-pump patients' quality-adjusted life-years and costs at 1 year.One-year outcomes and costs (standardized to 2010 dollars) were estimated in multivariate regression models, controlling for site and baseline patient factors. The 1-year incremental cost-effectiveness analysis ratio with 95% confidence intervals was calculated using bootstrapping.Eighteen centers randomly assigned 2,203 participants to on-pump (n=1,099) versus off-pump (n=1,104) coronary artery bypass graft surgery. Both groups' quality of life improved significantly after surgery (p<0.01) compared with baseline, but no differences were found between treatment groups. Adjusted cost of the index coronary artery bypass graft surgery hospitalization was $36,046 on-pump and $36,536 off-pump (p=0.16). At 1 year, on-pump adjusted cost was $56,023 versus $59,623 off-pump (p=0.046). Off-pump-to-on-pump conversions after first distal anastomosis (4.8%) had significantly higher 1-year costs. Excluding conversions, there were no significant differences between treatments for index hospitalization or 1-year total costs.At 1 year, off-pump coronary artery bypass graft surgery was more expensive than on-pump when late off-pump-to-on-pump conversions were included. Excluding late conversions, there was no difference in quality-adjusted life-years or identifier NCT00032630;

    View details for DOI 10.1016/j.athoracsur.2013.04.074

    View details for Web of Science ID 000323940200014

    View details for PubMedID 23916805

  • Association of age and packed red blood cell transfusion to 1-year survival - an observational study of ICU patients TRANSFUSION MEDICINE Mudumbai, S. C., Cronkite, R., Hu, K. U., Heidenreich, P. A., Gonzalez, C., Bertaccini, E., Stafford, R. S., Cason, B. A., Mariano, E. R., Wagner, T. 2013; 23 (4): 231-237


    OBJECTIVES: To compare the 1-year survival for different age strata of intensive care unit (ICU) patients after receipt of packed red blood cell (PRBC) transfusions. BACKGROUND: Despite guidelines documenting risks of PRBC transfusion and data showing that increasing age is associated with ICU mortality, little data exist on whether age alters the transfusion-related risk of decreased survival. METHODS: We retrospectively examined data on 2393 consecutive male ICU patients admitted to a tertiary-care hospital from 2003 to 2009 in age strata: 21-50, 51-60, 61-70, 71-80 and >80 years. We calculated Cox regression models to determine the modifying effect of age on the impact of PRBC transfusion on 1-year survival by using interaction terms between receipt of transfusion and age strata, controlling for type of admission and Charlson co-morbidity indices. We also examined the distribution of admission haematocrit and whether transfusion rates differed by age strata. RESULTS: All age strata experienced statistically similar risks of decreased 1-year survival after receipt of PRBC transfusions. However, patients age >80 were more likely than younger cohorts to have haematocrits of 25-30% at admission and were transfused at approximately twice the rate of each of the younger age strata. DISCUSSION: We found no significant interaction between receipt of red cell transfusion and age, as variables, and survival at 1 year as an outcome.

    View details for DOI 10.1111/tme.12010

    View details for Web of Science ID 000321975300005

    View details for PubMedID 23480030

  • MULTIMORBIDITY AND HEALTH CARE UTILIZATION AMONG HIGH-COST PATIENTS: IMPLICATIONS FOR CARE COORDINATION 36th Annual Meeting of the Society-of-General-Internal-Medicine Zulman, D., Yoon, J., Cohen, D. M., Wagner, T. H., Ritchie, C., Asch, S. SPRINGER. 2013: S123–S124
  • Sponsorship and design characteristics of trials registered in CONTEMPORARY CLINICAL TRIALS Roumiantseva, D., Carini, S., Sim, I., Wagner, T. H. 2013; 34 (2): 348-355


    We examine the extent to which is meeting its goal of providing oversight and transparency of clinical trials with human subjects. We analyzed the database contents as of June 2011, comparing interventions, medical conditions, and trial characteristics by sponsor type. We also conducted a detailed analysis of incomplete data.Among trials with only government sponsorship (N=9252), 36% were observational and 64% interventional; in contrast, almost all (90%) industry-only sponsored trials were interventional. Industry-only sponsored interventional trials (N=30,036) were most likely to report a drug intervention (81%), followed by biologics (9%) and devices (8%). Government-only interventional trials (N=5886) were significantly more likely to test behavioral interventions (28%) and procedures (13%) than industry-only trials (p<0.001). Medical conditions most frequently studied in industry-only trials were cancer (19%), cardiovascular conditions (12%) and endocrine/metabolic disorders (11%). Government-only funded trials were more likely to study mental health (19% vs. 7% for industry, p<.001), and viral infections, including HIV (15% vs 7% for industry, p<.001). Government-funded studies are significantly more likely to be missing data about study design and intervention arms in the registry. For all studies, we report ambiguous and contradictory data entries.Industry-sponsored studies differ systematically from government-sponsored studies in study type, choice of interventions, conditions studied, and completeness of submitted information. Imprecise study design information, incomplete coding of conditions, out-of-date or unspecified enrollment numbers, and other missing data continue to hinder robust analyses of trials registered in

    View details for DOI 10.1016/j.cct.2013.01.004

    View details for Web of Science ID 000317169100020

    View details for PubMedID 23380028

  • Are Central Institutional Review Boards the Solution? The National Heart, Lung, and Blood Institute Working Group's Report on Optimizing the IRB Process ACADEMIC MEDICINE Mascette, A. M., Bernard, G. R., DiMichele, D., Goldner, J. A., Harrington, R., Harris, P. A., Leeds, H. S., Pearson, T. A., Ramsey, B., Wagner, T. H. 2012; 87 (12): 1710-1714


    The National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health convened a working group in June 2011 to examine alternative institutional review board (IRB) models. The working group was held in response to proposed changes in the regulations for government-supported research and the proliferation of multicenter clinical trials where multiple individual reviews may be inefficient. Group members included experts in heart, lung, and blood research, research oversight, bioethics, health economics, regulations, and information technology (IT). The group discussed alternative IRB models, ethical concerns, metrics for evaluating IRBs, IT needs, and economic considerations. Participants noted research gaps in IRB best practices and in metrics. The group arrived at recommendations for process changes, such as defining specific IRB performance requirements in funding announcements, requiring funded researchers to use more efficient alternative IRB models, and developing IT systems to facilitate information sharing and collaboration among IRBs. Despite the success of the National Cancer Institute's central IRB (CIRB), the working group, concerned about the creation costs and unknown cost-efficiency of a new CIRB, and about the risk of shifting the burden of dealing with multiple IRBs from sponsors to research institutions, did not recommend the creation of an NHLBI-funded CIRB.

    View details for DOI 10.1097/ACM.0b013e3182720859

    View details for Web of Science ID 000311836800021

    View details for PubMedID 23095928

  • One-year outcomes of telephone case monitoring for patients with substance use disorder ADDICTIVE BEHAVIORS McKellar, J., Wagner, T., Harris, A., Oehlert, M., Buckley, S., Moos, R. 2012; 37 (10): 1069-1074


    Many patients treated for substance use disorder (SUD) do not achieve lasting recovery from a single episode of treatment and require continuing care. The current randomized clinical trial investigated whether in-person continuing care as usual (CCAU) following intensive outpatient SUD treatment leads to better SUD outcomes when compared with telephone case monitoring (TCM).This study randomized 667 intensive SUD outpatients to telephone case monitoring versus face-to-face continuing care as usual at two sites. Patients completed data at baseline, 3 and 12months with telephone interviews. Data of interest include self-report of substance use, psychiatric symptoms, quality of life, and treatment satisfaction. We also evaluated potential interaction effects for distance to VA provider, SUD severity, and presence of co-morbid psychiatric disorder.Participants randomized to the telephone case monitoring condition substantially engaged with face-to-face continuing care resulting in cross-over contamination. We addressed this issue by using randomization as an instrumental variable to evaluate the impact of telephone case monitoring (contamination adjusted, intent to treat analysis). Instrumental variable analyses indicated significant benefit of telephone case monitoring for drug and alcohol percent days abstinent and psychiatric symptom outcomes at 3-months follow-up, but not at 12-month follow-up. No interaction analyses were significant.Participants receiving telephone case monitoring achieved better short term outcomes in terms of substance use and psychiatric symptoms. The "on treatment" effects suggests the need for future studies to investigate consumer (patient) perspectives on the optimal duration of telephone case monitoring and use of alternative monitoring methods such as text messaging.

    View details for DOI 10.1016/j.addbeh.2012.03.009

    View details for Web of Science ID 000307205200001

    View details for PubMedID 22651986

  • Coronary artery bypass graft patency: residents versus attending surgeons. Annals of thoracic surgery Bakaeen, F. G., Sethi, G., Wagner, T. H., Kelly, R., Lee, K., Upadhyay, A., Thai, H., Juneman, E., Goldman, S., Holman, W. L. 2012; 94 (2): 482-488


    Data are limited regarding the patency of coronary artery bypass grafts performed by residents versus attending surgeons.We analyzed data from a multicenter, randomized Veterans Affairs Cooperative Study in which the left internal mammary artery was used preferentially to graft the left anterior descending coronary artery, and the best remaining coronary vessel received (per random assignment) either a radial artery or a saphenous vein graft. The study vessel's 1-year graft patency was the primary outcome measure. Secondary outcomes included operative times, operative morbidity, mortality, repeat revascularization, cost, angina symptoms, and quality of life. Multivariate analyses were used to compare patient outcomes for residents versus attendings.Residents were designated as primary surgeons in 23% of cases (167 of 725). Among the 531 patients who had a 1-year angiogram, study graft patency rates for resident cases (n=122) and attending cases (n=409) were not significantly different (86% versus 90%, p=0.22). Residents' cases had longer perfusion time (119 versus 105 minutes, p<0.0001) and cross-clamp time (84 versus 68 minutes, p<0.0001). After risk adjustment, all outcome measures did not differ between the two groups, and there was no apparent interaction effect between resident/attending designation and radial artery versus saphenous vein use or on-pump versus off-pump approach.Surgeons in training perform coronary artery bypass surgery without compromising graft patency or patient outcomes. Ongoing evaluation of residents' performance and surgical outcomes is needed, given the major changes that are occurring in residency training.

    View details for DOI 10.1016/j.athoracsur.2012.04.039

    View details for PubMedID 22698772

  • Coronary Artery Bypass Graft Patency: Residents Versus Attending Surgeons Late-Breaking Clinical Trial Abstract Session on Congenital Heart Surgery at the 48th Annual Meeting of the Society-of-Thoracic-Surgeons / Surgical Motion Picture Session Bakaeen, F. G., Sethi, G., Wagner, T. H., Kelly, R., Lee, K., Upadhyay, A., Hoang Thai, H., Juneman, E., Goldman, S., Holman, W. L. ELSEVIER SCIENCE INC. 2012: 482–88
  • Vascular Surgery Patients Prescribed Preoperative beta-Blockers Experienced a Decrease in the Maximal Heart Rate Observed During Induction of General Anesthesia JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA Mudumbai, S. C., Wagner, T., Mahajan, S., King, R., Heidenreich, P. A., Hlatky, M., Wallace, A., Mariano, E. R. 2012; 26 (3): 414-419


    To investigate the association of preoperative β-blocker usage and maximal heart rates observed during the induction of general anesthesia.Retrospective descriptive, univariate, and multivariate analyses of electronic hospital and anesthesia medical records.A tertiary-care medical center within the Veterans Health Administration.Consecutive adult elective and emergent patients presenting for vascular surgery during calendar years 2005 to 2011.None.Of the 430 eligible cases, 218 were prescribed β-blockers, and 212 were not taking β-blockers. The two groups were comparable across baseline patient factors (ie, demographic, morphometric, surgical duration, and surgical procedures) and induction medication doses. The β-blocker group experienced a lower maximal heart rate during the induction of general anesthesia compared with the non-β-blocker group (105 ± 41 beats/min v 115 ± 45 beats/min, respectively; p < 0.01). Adjusted linear regression found a statistically significant association between lower maximal heart rate and the use of β-blockers (β = -11.1 beats/min, p < 0.01). There was no difference between groups in total intraoperative β-blocker administration.Preoperative β-blockade of vascular surgery patients undergoing general anesthesia is associated with a lower maximal heart rate during anesthetic induction. There may be potential benefits in administering β-blockers to reduce physiologic stress in this surgical population at risk for perioperative cardiac morbidity. Future research should further explore intraoperative hemodynamic effects in light of existing practice guidelines for optimal medication selection, dosage, and heart rate control.

    View details for DOI 10.1053/j.jvca.2011.09.027

    View details for Web of Science ID 000304215800011

    View details for PubMedID 22138312

  • A Comprehensive Care Management Program to Prevent Chronic Obstructive Pulmonary Disease Hospitalizations A Randomized, Controlled Trial ANNALS OF INTERNAL MEDICINE Fan, V. S., Gaziano, J. M., Lew, R., Bourbeau, J., Adams, S. G., Leatherman, S., Thwin, S. S., Huang, G. D., Robbins, R., Sriram, P. S., Sharafkhaneh, A., Mador, M. J., Sarosi, G., Panos, R. J., Rastogi, P., Wagner, T. H., Mazzuca, S. A., Shannon, C., Colling, C., Liang, M. H., Stoller, J. K., Fiore, L., Niewoehner, D. E. 2012; 156 (10): 673-U46


    Improving a patient's ability to self-monitor and manage changes in chronic obstructive pulmonary disease (COPD) symptoms may improve outcomes.To determine the efficacy of a comprehensive care management program (CCMP) in reducing the risk for COPD hospitalization.A randomized, controlled trial comparing CCMP with guideline-based usual care. ( registration number: NCT00395083) SETTING: 20 Veterans Affairs hospital-based outpatient clinics.Patients hospitalized for COPD in the past year.The CCMP included COPD education during 4 individual sessions and 1 group session, an action plan for identification and treatment of exacerbations, and scheduled proactive telephone calls for case management. Patients in both the intervention and usual care groups received a COPD informational booklet; their primary care providers received a copy of COPD guidelines and were advised to manage their patients according to these guidelines. Patients were randomly assigned, stratifying by site based on random, permuted blocks of variable size.The primary outcome was time to first COPD hospitalization. Staff blinded to study group performed telephone-based assessment of COPD exacerbations and hospitalizations, and all hospitalizations were blindly adjudicated. Secondary outcomes included non-COPD health care use, all-cause mortality, health-related quality of life, patient satisfaction, disease knowledge, and self-efficacy.Of the eligible patients, 209 were randomly assigned to the intervention group and 217 to the usual care group. Citing serious safety concerns, the data monitoring committee terminated the intervention before the trial's planned completion after 426 (44%) of the planned total of 960 patients were enrolled. Mean follow-up was 250 days. When the study was stopped, the 1-year cumulative incidence of COPD-related hospitalization was 27% in the intervention group and 24% in the usual care group (hazard ratio, 1.13 [95% CI, 0.70 to 1.80]; P= 0.62). There were 28 deaths from all causes in the intervention group versus 10 in the usual care group (hazard ratio, 3.00 [CI, 1.46 to 6.17]; P= 0.003). Cause could be assigned in 27 (71%) deaths. Deaths due to COPD accounted for the largest difference: 10 in the intervention group versus 3 in the usual care group (hazard ratio, 3.60 [CI, 0.99 to 13.08]; P= 0.053).Available data could not fully explain the excess mortality in the intervention group. Ability to assess the quality of the educational sessions provided by the case managers was limited.A CCMP in patients with severe COPD had not decreased COPD-related hospitalizations when the trial was stopped prematurely. The CCMP was associated with unanticipated excess mortality, results that differ markedly from similar previous trials. A data monitoring committee should be considered in the design of clinical trials involving behavioral interventions.

    View details for Web of Science ID 000304193400013

    View details for PubMedID 22586006

  • Identifying Neck and Back Pain in Administrative Data Defining the Right Cohort SPINE Sinnott, P. L., Siroka, A. M., Shane, A. C., Trafton, J. A., Wagner, T. H. 2012; 37 (10): 860-874


    We reviewed existing methods for identifying patients with neck and back pain in administrative data. We compared these methods using data from the Department of Veterans Affairs.To answer the following questions: (1) what diagnosis codes should be used to identify patients with neck pain and back pain in administrative data; (2) because the majority of complaints are characterized as nonspecific or mechanical, what diagnosis codes should be used to identify patients with nonspecific or mechanical problems in administrative data; and (3) what procedure and surgical codes should be used to identify patients who have undergone a surgical procedure on the neck or back.Musculoskeletal neck and back pain are pervasive problems, associated with chronic pain, disability, and high rates of health care utilization. Administrative data have been widely used in formative research, which has largely relied on the original work of Volinn, Cherkin, Deyo, and Einstadter and the Back Pain Patient Outcomes Assessment Team first published in 1992. Significant variation in reports of incidence, prevalence, and morbidity associated with these problems may be due to nonstandard or conflicting methods to define study cohorts.A literature review produced 7 methods for identifying neck and back pain in administrative data. These code lists were used to search Veterans Health Administration data for patients with back and neck problems, and to further categorize each case by spinal segment involved, as nonspecific/mechanical and as surgical or not.There is considerable overlap in most algorithms. However, gaps persist.Gaps are evident in existing methods and a new framework to identify patients with neck pain and back pain in administrative data is proposed.

    View details for DOI 10.1097/BRS.0b013e3182376508

    View details for Web of Science ID 000303499400017

    View details for PubMedID 22127268

  • Access to the Medical Record ANNALS OF INTERNAL MEDICINE Zulman, D. M., Nazi, K. M., Asch, S. M., Wagner, T. H. 2012; 156 (9): 668-668
  • Patient Interest in Sharing Personal Health Record Information A Web-Based Survey ANNALS OF INTERNAL MEDICINE Zulman, D. M., Nazi, K. M., Turvey, C. L., Wagner, T. H., Woods, S. S., An, L. C. 2011; 155 (12): 805-U46


    Electronic personal health record (PHR) systems are proliferating but largely have not realized their potential for enhancing communication among patients and their network of care providers.To explore preferences about sharing electronic health information among users of the U.S. Department of Veterans Affairs (VA) PHR system, My HealtheVet.Web-based survey of a convenience sample.My HealtheVet Web site from 7 July through 4 October 2010.18 471 users of My HealtheVet.Interest in shared PHR access and preferences about who would receive access, the information that would be shared, and the activities that users would delegate.Survey respondents were predominantly men (92%) and aged 50 to 64 years (51%) or 65 years or older (39%); approximately 39% reported poor or fair health status. Almost 4 of 5 respondents (79%) were interested in sharing access to their PHR with someone outside of their health system (62% with a spouse or partner, 23% with a child, 15% with another family member, and 25% with a non-VA health care provider). Among those who selected a family member other than a spouse or partner, 47% lived apart from the specified person. Preferences about degree of access varied on the basis of the type of information being shared, the type of activity being performed, and the respondent's relationship with the selected person.The survey completion rate was 40.8%. Results might not be generalizable to all My HealtheVet users.In a large survey of PHR users in the VA system, most respondents were interested in sharing access to their electronic health information with caregivers and non-VA providers. Existing and evolving PHR systems should explore secure mechanisms for shared PHR access to improve information exchange among patients and the multiple persons involved in their health care.Veterans Health Administration and The Robert Wood Johnson Foundation Clinical Scholars Program.

    View details for DOI 10.1059/0003-4819-155-12-201112200-00002

    View details for Web of Science ID 000298280500014

    View details for PubMedID 22184687

  • Recent Trends in Veterans Affairs Chronic Condition Spending POPULATION HEALTH MANAGEMENT Yoon, J., Scott, J. Y., Phibbs, C. S., Wagner, T. H. 2011; 14 (6): 293-298


    The change in prevalence and total Veterans Affairs (VA) spending were estimated for 16 chronic condition categories between 2000 and 2008. The drivers of changes in spending also were examined. Chronic conditions were identified through diagnoses in encounter records, and treatment costs per patient were estimated using VA cost data and regression models. The estimated differences in total VA spending between 2000 and 2008 and the contributions of population increase, differences in prevalence, and differences in treatment costs were evaluated. Most of the spending increases during the study period were driven by the increase in the VA patient population from 3.3 million in 2000 to 4.9 million in 2008. Spending on renal failure increased the most, by more than $1.5 billion, primarily because of higher prevalence. Higher treatment costs did not contribute much to higher spending; lower costs per patient for several conditions may have helped to slow spending for diabetes, chronic obstructive pulmonary disease, heart conditions, renal failure, dementia, and stroke. Lowering treatment costs per patient for common conditions can help slow spending for chronic conditions, but most of the increase in spending in the study period was the result of more patients seeking care from VA providers and the higher prevalence of conditions among patients. As the VA patient population continues to age and to develop more co-morbidities, and as returning veterans seek care for service-related problems, higher spending on chronic conditions will become a more prominent issue for the VA health care system.

    View details for DOI 10.1089/pop.2010.0079

    View details for Web of Science ID 000298292600004

    View details for PubMedID 22044350

  • Robot-Assisted Therapy for Long-Term Upper-Limb Impairment after Stroke (vol 362, pg 1772, 2010) NEW ENGLAND JOURNAL OF MEDICINE Lo, A. C., Guarino, P. D., Richards, L. G., Haselkorn, J. K., Wittenberg, G. F., Federman, D. G., RINGER, R. J., Wagner, T. H., Krebs, H., Volpe, B. T., CT, B., Bravata, D. M., Duncan, P. W., Corn, B. H., Maffucci, A. D., Nadeau, S. E., Conroy, S. S., Powell, J. M., Huang, G. D., Peduzzi, P. 2011; 365 (18): 1749-1749
  • Costs and quality of life associated with radial artery and saphenous vein cardiac bypass surgery: results from a Veterans Affairs multisite trial 35th Annual Meeting for the Association-of-VA-Surgeons Wagner, T. H., Sethi, G., Holman, W., Lee, K., Bakaeen, F. G., Upadhyay, A., McFalls, E., Tobler, H. G., Kelly, R. F., Crittenden, M. D., Thai, H., Goldman, S. EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC. 2011: 532–35


    In coronary artery bypass grafting (CABG) surgery, there is uncertainty about whether the radial artery affects quality of life or costs relative to the saphenous vein. This study compared the cost and quality of life for patients randomized to either radial artery or saphenous vein grafts.We analyzed the duration and cost of the index surgery and costs and quality of life (Seattle Angina Questionnaire and Health Utility Index) at 1 year for 726 participants.The 2 treatment groups had similar baseline characteristics. Using the radial artery added approximately 31 minutes to the surgery (from skin incision to skin closure; P < .001) compared with a saphenous vein graft. There were no significant differences in terms of costs and quality of life after the index hospitalization or at 1 year.Coronary artery bypass grafting with the radial artery lasts approximately 31 minutes longer than with the saphenous vein. However, costs and the quality of life were not statistically different.

    View details for DOI 10.1016/j.amjsurg.2011.06.011

    View details for Web of Science ID 000297025700010

    View details for PubMedID 21872209

  • Association of admission hematocrit with 6-month and 1-year mortality in intensive care unit patients TRANSFUSION Mudumbai, S. C., Cronkite, R., Hu, K. U., Wagner, T., Hayashi, K., Ozanne, G. M., Davies, M. F., Heidenreich, P., Bertaccini, E. 2011; 51 (10): 2148-2159


    This study examined the association of hematocrit (Hct) levels measured upon intensive care unit (ICU) admission and red blood cell transfusions to long-term (1-year or 180-day) mortality for both surgical and medical patients.Administrative and laboratory data were collected retrospectively on 2393 consecutive medical and surgical male patients admitted to the ICU between 2003 and 2009. We stratified patients based on their median Hct level during the first 24 hours of their ICU stay (Hct < 25.0%, 25% ≤ Hct < 30%, 30% ≤ Hct < 39%, and 39.0% and higher). An extended Cox regression analysis was conducted to identify the time period after ICU admission (0 to <180, 180 to 365 days) when low Hct (<25.0) was most strongly associated with mortality. The unadjusted and adjusted relationship between admission Hct level, receipt of a transfusion, and 180-day mortality was assessed using Cox proportional hazards regression modeling.Patients with an Hct level of less than 25% who were not transfused had the worst mortality risk overall (hazard ratio [HR], 6.26; 95% confidence interval [CI], 3.05-12.85; p < 0.001) during the 6 months after ICU admission than patients with a Hct level of 39.0% or more who were not transfused. Within the subgroup of patients with a Hct level of less than 25% only, receipt of a transfusion was associated with a significant reduction in the risk of mortality (HR, 0.40; 95% CI, 0.19-0.85; p = 0.017).Anemia of a Hct level of less than 25% upon admission to the ICU, in the absence of a transfusion, is associated with long-term mortality. Our study suggests that there may be Hct levels below which the transfusion risk-to-benefit imbalance reverses.

    View details for DOI 10.1111/j.1537-2995.2011.03134.x

    View details for Web of Science ID 000295917700014

    View details for PubMedID 21985048

  • If substance use disorder treatment more than offsets its costs, why don't more medical centers want to provide it? A budget impact analysis in the Veterans Health Administration JOURNAL OF SUBSTANCE ABUSE TREATMENT Humphreys, K., Wagner, T. H., Gage, M. 2011; 41 (3): 243-251


    Given that many studies have reported that the costs of substance use disorder (SUD) treatment are more than offset by other savings (e.g., in health care, in criminal justice, in foster care), why haven't health care system managers rushed to expand treatment? This article attempts to explain this puzzling discrepancy by analyzing 1998-2006 data from the national Veterans Affairs (VA) health care system. The main outcome measures were annual cost and utilization for VA SUD-diagnosed patients. The key independent variable was the medical centers' annual spending for SUD treatment. There was no evidence that SUD spending was associated with lower medical center costs over time within the medical center that paid for the treatment. Health care system managers may not be influenced by research suggesting that the costs of SUD treatment are more than fully offset because they bear the cost of providing treatment while the savings largely accrue to other systems.

    View details for DOI 10.1016/j.jsat.2011.04.006

    View details for Web of Science ID 000294982100004

    View details for PubMedID 21664790

  • An Economic Analysis of Robot-Assisted Therapy for Long-Term Upper-Limb Impairment After Stroke STROKE Wagner, T. H., Lo, A. C., Peduzzi, P., Bravata, D. M., Huang, G. D., Krebs, H. I., Ringer, R. J., Federman, D. G., Richards, L. G., Haselkorn, J. K., Wittenberg, G. F., Volpe, B. T., Bever, C. T., Duncan, P. W., Siroka, A., Guarino, P. D. 2011; 42 (9): 2630-U422


    Stroke is a leading cause of disability. Rehabilitation robotics have been developed to aid in recovery after a stroke. This study determined the additional cost of robot-assisted therapy and tested its cost-effectiveness.We estimated the intervention costs and tracked participants' healthcare costs. We collected quality of life using the Stroke Impact Scale and the Health Utilities Index. We analyzed the cost data at 36 weeks postrandomization using multivariate regression models controlling for site, presence of a prior stroke, and Veterans Affairs costs in the year before randomization.A total of 127 participants were randomized to usual care plus robot therapy (n=49), usual care plus intensive comparison therapy (n=50), or usual care alone (n=28). The average cost of delivering robot therapy and intensive comparison therapy was $5152 and $7382, respectively (P<0.001), and both were significantly more expensive than usual care alone (no additional intervention costs). At 36 weeks postrandomization, the total costs were comparable for the 3 groups ($17 831 for robot therapy, $19 746 for intensive comparison therapy, and $19 098 for usual care). Changes in quality of life were modest and not statistically different.The added cost of delivering robot or intensive comparison therapy was recuperated by lower healthcare use costs compared with those in the usual care group. However, uncertainty remains about the cost-effectiveness of robotic-assisted rehabilitation compared with traditional rehabilitation. Clinical Trial Registration- URL: Unique identifier: NCT00372411.

    View details for DOI 10.1161/STROKEAHA.110.606442

    View details for Web of Science ID 000294342800056

    View details for PubMedID 21757677

  • Disparities in Lung Cancer Staging with Positron Emission Tomography in the Cancer Care Outcomes Research and Surveillance (CanCORS) Study JOURNAL OF THORACIC ONCOLOGY Gould, M. K., Schultz, E. M., Wagner, T. H., Xu, X., Ghaus, S. J., Wallace, R. B., Provenzale, D., Au, D. H. 2011; 6 (5): 875-883


    Disparities in treatment exist for nonwhite and Hispanic patients with non-small cell lung cancer, but little is known about disparities in the use of staging tests or their underlying causes.Prospective, observational cohort study of 3638 patients with newly diagnosed non-small cell lung cancer from 4 large, geographically defined regions, 5 integrated health care systems, and 13 VA health care facilities.Median age was 69 years, 62% were men, 26% were Hispanic or nonwhite, 68% graduated high school, 50% had private insurance, and 41% received care in the VA or another integrated health care system. After adjustment, positron emission tomography (PET) use was 13% lower among nonwhites and Hispanics than non-Hispanic whites (risk ratio [RR] 0.87, 95% confidence interval [CI] 0.77-0.97), 13% lower among those with Medicare than those with private insurance (RR 0.87, 95% CI 0.76-0.99), and 24% lower among those with an elementary school education than those with a graduate degree (RR 0.76, 95% CI 0.57-0.98). Disparate use of PET was not observed among patients who received care in an integrated health care setting, but the association between race/ethnicity and PET use was similar in magnitude across all other subgroups. Further analysis showed that income, education, insurance, and health care setting do not explain the association between race/ethnicity and PET use.Hispanics and nonwhites with non-small cell lung cancer are less likely to receive PET imaging. This finding is consistent across subgroups and not explained by differences in income, education, or insurance coverage.

    View details for DOI 10.1097/JTO.0b013e31821671b6

    View details for Web of Science ID 000289554100006

    View details for PubMedID 21572580

    View details for PubMedCentralID PMC3092472

  • Mental Health and Substance Use Disorder Spending in the Department of Veterans Affairs, Fiscal Years 2000-2007 PSYCHIATRIC SERVICES Wagner, T. H., Sinnott, P., Siroka, A. M. 2011; 62 (4): 389-395


    This study analyzed spending for treatment of mental health and substance use disorders in the Department of Veterans Affairs (VA) in fiscal years (FYs) 2000 through 2007.VA spending as reported in the VA Decision Support System was linked to patient utilization data as reported in the Patient Treatment Files, the National Patient Care Database, and the VA Fee Basis files. All care and costs from FY 2000 to FY 2007 were analyzed.Over the study period the number of veterans treated at the VA increased from 3.7 million to over 5.1 million (an average increase of 4.9% per year), and costs increased .7% per person per year. For mental health and substance use disorder treatment, the volume of inpatient care decreased markedly, residential care increased, and spending decreased on average 2% per year (from $668 in FY 2000 to $578 per person in FY 2007). FY 2007 saw large increases in mental health spending, bucking the trend from FY 2000 through FY 2006.VA's continued emphasis on outpatient and residential care was evident through 2007. This trend in spending might be unimpressive if VA were enrolling healthier Veterans, but the opposite seems to be true: over this time period the prevalence of most chronic conditions, including depression and posttraumatic stress disorder, increased. VA spending on mental health care grew rapidly in 2007, and given current military activities, this trend is likely to increase.

    View details for Web of Science ID 000289060200010

    View details for PubMedID 21459990

  • The generalizability of participants in Veterans Affairs Cooperative Studies Program 474, a multi-site randomized cardiac bypass surgery trial CONTEMPORARY CLINICAL TRIALS Wagner, T. H., Holman, W., Lee, K., Sethi, G., Ananth, L., Hoang Thai, T., Goldman, S. 2011; 32 (2): 260-266


    The Department of Veterans Affairs (VA) Cooperative Studies Program (CSP) initiated a multi-site randomized trial (CSP 474) to determine graph patency between radial artery or saphenous vein grafts in coronary artery bypass surgery (CABG). In this paper, we describe the study and compare participants' baseline characteristics to non-participants who received CABG surgery in the VA.We identified our participants in the VA administrative databases along with all other CABG patients who did not have a concomitant valve procedure between FY2003 and FY2008. We extracted demographic, clinical information and organizational information at the time of the surgery from the databases. We conducted multiple logistic regression to determine characteristics associated with participation at three levels: between participants and non-participants within participating sites, between participating sites and non-participating sites, between participants and all non-participants.Enrollment ended in early 2008. Participants were similar to non-participants across many parameters. Likewise, participating sites were also quite similar to non-participating sites, although participating sites had a higher volume of CABG surgery, a lower percentage of CABG patients with a prior inpatient mental health admission than non-participating sites. After controlling for site differences, CSP 474 participants were younger and had fewer co-morbid conditions than non-participants.Participants were significantly younger than non-participants. Participants also had lower rates of some cardiac-related illness including, congestive heart failure, peripheral vascular disease, and cerebrovascular disease than non-participants.

    View details for DOI 10.1016/j.cct.2010.11.008

    View details for Web of Science ID 000288056700016

    View details for PubMedID 21078416

  • Radial Artery Grafts vs Saphenous Vein Grafts in Coronary Artery Bypass Surgery A Randomized Trial JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Goldman, S., Sethi, G. K., Holman, W., Thai, H., McFalls, E., Ward, H. B., Kelly, R. F., Rhenman, B., Tobler, G. H., Bakaeen, F. G., Huh, J., Soltero, E., Moursi, M., Haime, M., Crittenden, M., Kasirajan, V., Ratliff, M., Pett, S., Irimpen, A., Gunnar, W., Thomas, D., Fremes, S., Moritz, T., Reda, D., Harrison, L., Wagner, T. H., Wang, Y., Planting, L., Miller, M., Rodriguez, Y., Juneman, E., Morrison, D., Pierce, M. K., Kreamer, S., Shih, M., Lee, K. 2011; 305 (2): 167-174


    Arterial grafts are thought to be better conduits than saphenous vein grafts for coronary artery bypass grafting (CABG) based on experience with using the left internal mammary artery to bypass the left anterior descending coronary artery. The efficacy of the radial artery graft is less clear.To compare 1-year angiographic patency of radial artery grafts vs saphenous vein grafts in patients undergoing elective CABG.Multicenter, randomized controlled trial conducted from February 2003 to February 2009 at 11 Veterans Affairs medical centers among 757 participants (99% men) undergoing first-time elective CABG.The left internal mammary artery was used to preferentially graft the left anterior descending coronary artery whenever possible; the best remaining recipient vessel was randomized to radial artery vs saphenous vein graft.The primary end point was angiographic graft patency at 1 year after CABG. Secondary end points included angiographic graft patency at 1 week after CABG, myocardial infarction, stroke, repeat revascularization, and death.Analysis included 733 patients (366 in the radial artery group, 367 in the saphenous vein group). There was no significant difference in study graft patency at 1 year after CABG (radial artery, 238/266; 89%; 95% confidence interval [CI], 86%-93%; saphenous vein, 239/269; 89%; 95% CI, 85%-93%; adjusted OR, 0.99; 95% CI, 0.56-1.74; P = .98). There were no significant differences in the secondary end points.Among Veterans Affairs patients undergoing first-time elective CABG, the use of a radial artery graft compared with saphenous vein graft did not result in greater 1-year Identifier: NCT00054847.

    View details for Web of Science ID 000286103400022

    View details for PubMedID 21224458

  • Patient interest in sharing personal health record information: A Web-Based Survey Ann of Intern Med Zulman DM, Nazi KM, Turvey CL, Wagner TH, Woods SS, An LC 2011; 155: 805-810
  • Returns to physician human capital Evidence from patients randomized to physician teams JOURNAL OF HEALTH ECONOMICS Doyle, J. J., Ewer, S. M., Wagner, T. H. 2010; 29 (6): 866-882


    Physicians play a major role in determining the cost and quality of healthcare, yet estimates of these effects can be confounded by patient sorting. This paper considers a natural experiment where nearly 30,000 patients were randomly assigned to clinical teams from one of two academic institutions. One institution is among the top medical schools in the U.S., while the other institution is ranked lower in the distribution. Patients treated by the two programs have similar observable characteristics and have access to a single set of facilities and ancillary staff. Those treated by physicians from the higher ranked institution have 10-25% less expensive stays than patients assigned to the lower ranked institution. Health outcomes are not related to the physician team assignment. Cost differences are most pronounced for serious conditions, and they largely stem from diagnostic-testing rates: the lower ranked program tends to order more tests and takes longer to order them.

    View details for DOI 10.1016/j.jhealeco.2010.08.004

    View details for Web of Science ID 000284671600008

    View details for PubMedID 20869783

  • Introduction of a Rapid Response System at a United States Veterans Affairs Hospital Reduced Cardiac Arrests ANESTHESIA AND ANALGESIA Lighthall, G. K., Parast, L. M., Rapoport, L., Wagner, T. H. 2010; 111 (3): 679-686


    We sought to determine the impact of a rapid response system on cardiac arrest rates and mortality in a United States veteran population.We describe a prospective analysis of cardiac arrests in 9 months before and 27 months after institution of a rapid response system, and retrospective analysis of mortality 3.5 years before the intervention and 27 months after the intervention. The study included all inpatients from a university-affiliated United States Veterans Affairs Medical Center, before and after implementation of a rapid response system, including an educational program, patient calling criteria, and a physician-led medical emergency team. Primary end points were hospital-wide cardiac arrests and mortality rates normalized to hospital discharges. Comparisons of event rates between various time points during the implementation process were made by analysis of variance.Three hundred seventy-eight calls were made to the medical emergency team in the time period studied. Compared with preintervention time points, cardiac arrests were reduced by 57%, amounting to a reduction of 5.6 cardiac arrests per 1000 hospital discharges (P < 0.01). Mortality was reduced during the intervention, but this was attributable to a natural decrease occurring over all phases of the study.A significant reduction in the rate of cardiac arrests was realized with this intervention, as well as a trend toward lower mortality. We estimate that 51 arrests were prevented in the timeframe studied. Our results suggest that further reductions in morbidity can be realized by expansion of rapid response systems throughout the Veterans Affairs network.

    View details for DOI 10.1213/ANE.0b013e3181e9c3f3

    View details for Web of Science ID 000281150100015

    View details for PubMedID 20624835

  • Talking About Incontinence The First Step Toward Prevention and Treatment JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Wagner, T. H., Subak, L. L. 2010; 303 (21): 2184–85

    View details for PubMedID 20516420

  • Robot-Assisted Therapy for Long-Term Upper-Limb Impairment after Stroke NEW ENGLAND JOURNAL OF MEDICINE Lo, A. C., Guarino, P. D., Richards, L. G., Haselkorn, J. K., Wittenberg, G. F., Federman, D. G., Ringer, R. J., Wagner, T. H., Krebs, H. I., Volpe, B. T., Bever, C. T., Bravata, D. M., Duncan, P. W., Corn, B. H., Maffucci, A. D., Nadeau, S. E., Conroy, S. S., Powell, J. M., Huang, G. D., Peduzzi, P. 2010; 362 (19): 1772-1783


    Effective rehabilitative therapies are needed for patients with long-term deficits after stroke.In this multicenter, randomized, controlled trial involving 127 patients with moderate-to-severe upper-limb impairment 6 months or more after a stroke, we randomly assigned 49 patients to receive intensive robot-assisted therapy, 50 to receive intensive comparison therapy, and 28 to receive usual care. Therapy consisted of 36 1-hour sessions over a period of 12 weeks. The primary outcome was a change in motor function, as measured on the Fugl-Meyer Assessment of Sensorimotor Recovery after Stroke, at 12 weeks. Secondary outcomes were scores on the Wolf Motor Function Test and the Stroke Impact Scale. Secondary analyses assessed the treatment effect at 36 weeks.At 12 weeks, the mean Fugl-Meyer score for patients receiving robot-assisted therapy was better than that for patients receiving usual care (difference, 2.17 points; 95% confidence interval [CI], -0.23 to 4.58) and worse than that for patients receiving intensive comparison therapy (difference, -0.14 points; 95% CI, -2.94 to 2.65), but the differences were not significant. The results on the Stroke Impact Scale were significantly better for patients receiving robot-assisted therapy than for those receiving usual care (difference, 7.64 points; 95% CI, 2.03 to 13.24). No other treatment comparisons were significant at 12 weeks. Secondary analyses showed that at 36 weeks, robot-assisted therapy significantly improved the Fugl-Meyer score (difference, 2.88 points; 95% CI, 0.57 to 5.18) and the time on the Wolf Motor Function Test (difference, -8.10 seconds; 95% CI, -13.61 to -2.60) as compared with usual care but not with intensive therapy. No serious adverse events were reported.In patients with long-term upper-limb deficits after stroke, robot-assisted therapy did not significantly improve motor function at 12 weeks, as compared with usual care or intensive therapy. In secondary analyses, robot-assisted therapy improved outcomes over 36 weeks as compared with usual care but not with intensive therapy. ( number, NCT00372411.)

    View details for DOI 10.1056/NEJMoa0911341

    View details for Web of Science ID 000277555500004

    View details for PubMedID 20400552

  • Costs and Benefits of the National Cancer Institute Central Institutional Review Board JOURNAL OF CLINICAL ONCOLOGY Wagner, T. H., Murray, C., Goldberg, J., Adler, J. M., Abrams, J. 2010; 28 (4): 662-666


    In 2001, the National Cancer Institute (NCI) formed the Central Institutional Review Board (CIRB) to conduct a single human subjects review for its multisite phase III oncology trials. The goal of this study was to assess whether NCI's CIRB was associated with lower effort, time, and cost in processing adult phase III oncology trials.We conducted an observational study and compared sites affiliated with the NCI CIRB to unaffiliated sites that used their local IRB for review. Oncology research staff and IRB staff were surveyed to understand effort and timing. Response rates were 60% and 42%, respectively. Analysis of these survey data yielded information on effort, timing, and costs. We combined these data with CIRB operational data to determine the net savings of the CIRB using a societal perspective.CIRB affiliation was associated with faster reviews (33.9 calendar days faster on average), and 6.1 fewer hours of research staff effort. CIRB affiliation was associated with a savings of $717 per initial review. The estimated cost of running the CIRB was $161,000 per month. The CIRB yielded a net cost of approximately $55,000 per month from a societal perspective. Whether the CIRB results in higher or lower quality reviews was not assessed because there is no standard definition of review quality.The CIRB was associated with decreases in investigator and IRB staff effort and faster protocol reviews, although savings would be higher if institutions used the CIRB as intended.

    View details for DOI 10.1200/JCO.2009.23.2470

    View details for Web of Science ID 000274138800023

    View details for PubMedID 19841324

    View details for PubMedCentralID PMC2816001

  • Disparities in health-related internet use by US veterans: results from a national survey. Informatics in primary care McInnes, D. K., Gifford, A. L., Kazis, L. E., Wagner, T. H. 2010; 18 (1): 59-68


    The internet can contribute to improved access to information and services among underserved populations. Little is known about veterans' use of the internet for health, and how it is affected by socio-demographic characteristics. This knowledge gap is acute given the US Department of Veterans Affairs' (VA's) deployment of a major patient portal/personal health record system.To assess the frequency and correlates of veterans' use of the internet and identify personal characteristics impeding veterans' health-related internet use.Survey of 12 878 randomly selected adults from a panel of 60 000 US households. Veterans were oversampled.Of the 3408 veterans responding, 54% had used the internet and 29% had used the internet specifically for health. In multi-variable analyses, general internet use was positively associated with younger age (OR = 0.03, CI = 0.01-0.06, oldest versus youngest group), higher income (OR = 3.12, CI = 2.10-4.63, > or =$75 000 versus <$25 000), more education (OR = 4.2, CI = 2.92-6.02, most versus least educated group), and better health (OR = 0.59, CI = 0.42-83, fair/poor versus very good/excellent). Health-related internet use was positively associated with more education (OR = 2.32, CI = 1.45-3.74, most versus least educated group), urban location (OR = 2.41, CI = 1.66-3.50), and worse health (OR = 1.85, CI = 1.16-2.95, fair/poor versus very good/excellent).In the first large, systematic survey of veterans' internet use we found that more education and urban location were strongly, and positively, associated with veterans' health-related internet use, even after controlling for multiple socio-demographic characteristics. Interventions may be needed for less educated and rural veterans, e.g. by providers discussing internet use with their patients, or by the VA training veterans in health-related internet use.

    View details for PubMedID 20429979

  • Racial and ethnic disparities in the use of positron emission tomography for patients with non-small cell lung cancer Gould, M. K., SCHULTZ, E. M., Wagner, T. H., Xu, X., Ghaus, S. J., Wallace, R. B., Provenzale, D., Au, D. H. AMER THORACIC SOC. 2010
  • Embracing a Health Services Research Perspective on Personal Health Records: Lessons Learned from the VA My HealtheVet System JOURNAL OF GENERAL INTERNAL MEDICINE Nazi, K. M., Hogan, T. P., Wagner, T. H., McInnes, D. K., Smith, B. M., Haggstrom, D., Chumbler, N. R., Gifford, A. L., Charters, K. G., Saleem, J. J., Weingardt, K. R., Fischetti, L. F., Weaver, F. M. 2010; 25: 62-67


    Personal health records (PHRs) are designed to help people manage information about their health. Over the past decade, there has been a proliferation of PHRs, but research regarding their effects on clinical, behavioral, and financial outcomes remains limited. The potential for PHRs to facilitate patient-centered care and health system transformation underscores the importance of embracing a broader perspective on PHR research.Drawing from the experiences of VA staff to evaluate the My HealtheVet (MHV) PHR, this article advocates for a health services research perspective on the study of PHR systems.We describe an organizing framework and research agenda, and offer insights that have emerged from our ongoing efforts regarding the design of PHR-related studies, the need to address PHR data ownership and consent, and the promotion of effective PHR research collaborations.These lessons are applicable to other PHR systems and the conduct of PHR research across different organizational contexts.

    View details for DOI 10.1007/s11606-009-1114-6

    View details for Web of Science ID 000273667000011

    View details for PubMedID 20077154

  • Multicenter Randomized Trial of Robot-Assisted Rehabilitation for Chronic Stroke: Methods and Entry Characteristics for VA ROBOTICS NEUROREHABILITATION AND NEURAL REPAIR Lo, A. C., Guarino, P., Krebs, H. I., Volpe, B. T., Bever, C. T., Duncan, P. W., Ringer, R. J., Wagner, T. H., Richards, L. G., Bravata, D. M., Haselkorn, J. K., Wittenberg, G. F., Federman, D. G., Corn, B. H., Maffucci, A. D., Peduzzi, P. 2009; 23 (8): 775-783


    Chronic upper extremity impairment due to stroke has significant medical, psychosocial, and financial consequences, but few studies have examined the effectiveness of rehabilitation therapy during the chronic stroke period.. To test the safety and efficacy of the MIT-Manus robotic device for chronic upper extremity impairment following stroke.. The VA Cooperative Studies Program initiated a multicenter, randomized, controlled trial in November 2006 (VA ROBOTICS). Participants with upper extremity impairment >/=6 months poststroke were randomized to robot-assisted therapy (RT), intensive comparison therapy (ICT), or usual care (UC). RT and ICT consisted of three 1-hour treatment sessions per week for 12 weeks. The primary outcome was change in the Fugl-Meyer Assessment upper extremity motor function score at 12 weeks relative to baseline. Secondary outcomes included the Wolf Motor Function Test and the Stroke Impact Scale.. A total of 127 participants were randomized: 49 to RT, 50 to ICT, and 28 to UC. The majority of participants were male (96%), with a mean age of 65 years. The primary stroke type was ischemic (85%), and 58% of strokes occurred in the anterior circulation. Twenty percent of the participants reported a stroke in addition to their index stroke. The average time from the index stroke to enrollment was 56 months (range, 6 months to 24 years). The mean Fugl-Meyer score at entry was 18.9.. VA ROBOTICS demonstrates the feasibility of conducting multicenter clinical trials to rigorously test new rehabilitative devices before their introduction to clinical practice. The results are expected in early 2010.

    View details for DOI 10.1177/1545968309338195

    View details for Web of Science ID 000269856900001

    View details for PubMedID 19541917

  • New, but Not Improved? Incorporating Comparative-Effectiveness Information into FDA Labeling NEW ENGLAND JOURNAL OF MEDICINE Stafford, R. S., Wagner, T. H., Lavori, P. W. 2009; 361 (13): 1230-1233

    View details for DOI 10.1056/NEJMp0906490

    View details for Web of Science ID 000270078700003

    View details for PubMedID 19675326

  • Low Back Pain in VA Users ARCHIVES OF INTERNAL MEDICINE Sinnott, P., Wagner, T. H. 2009; 169 (14): 1338-1339

    View details for Web of Science ID 000268373000018

    View details for PubMedID 19636039

  • Re: Practice Patterns in Benign Prostatic Hyperplasia Surgical Therapy: The Dramatic Increase in Minimally Invasive Technologies JOURNAL OF UROLOGY Wagner, T. H. 2009; 181 (6): 2829-2830

    View details for Web of Science ID 000266020500154

    View details for PubMedID 19376534

  • Impact of overactive bladder on work productivity in the United States: results from EpiLUTS. American journal of managed care Sexton, C. C., Coyne, K. S., Vats, V., Kopp, Z. S., Irwin, D. E., Wagner, T. H. 2009; 15 (4): S98-S107


    Little research has focused on the impact of overactive bladder (OAB) on work productivity. Consequently, the impact of OAB and other lower urinary tract symptoms (LUTS) on work productivity was evaluated in employed men and women aged 40 to 65 in the United States.Data from a population-based, cross-sectional Internet survey were used to examine the impact of OAB symptoms on work productivity. US participants aged 40 to 65 working full- or part-time were included in the analysis. Participants were asked about the incidence of OAB and other LUTS and a series of questions about work productivity.Descriptive statistics and linear and logistic regressions were used to evaluate outcome differences for men and women by the OAB groups of no/minimal symptoms, continent OAB, and incontinent OAB.The response rate was 60%, and a total of 2876 men and 2820 women were analyzed. Men and women with incontinent OAB reported the lowest levels of work productivity and highest rates of daily work interference. Storage symptoms associated with OAB were most consistently associated with work productivity outcomes; however, significant associations were also found for other storage, voiding, and postmicturition LUTS.In this large US population-based study, OAB was highly prevalent and was associated with lower levels of work productivity. These findings add to the literature documenting the burden of OAB and other LUTS, underscoring the need for increased screening and treatment.

    View details for PubMedID 19355804

  • Description of outpatient utilization and costs in group of veterans with traumatic brain injury JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT Homaifar, B. Y., Harwood, J. E., Wagner, T. H., Brenner, L. A. 2009; 46 (8): 1003-1010


    In an attempt to increase understanding regarding the nonacute healthcare needs of veterans with traumatic brain injury (TBI), we examined the outpatient utilization and cost patterns of 72 patients with TBI who were at least 4 years postinjury. We selected participants from a clinical database of veterans receiving care at a western Department of Veterans Affairs (VA) medical center. We extracted data from national utilization databases maintained by the VA and examined data from primary care and internal medicine, psychiatry and substance use, rehabilitation, and other services (e.g., ancillary, diagnostic, prosthetic, dental, nursing home, and home care). We extracted data for fiscal years 2002 to 2007. In addition to descriptive statistics, we modeled visits per year as a function of time since injury. The data show that this sample of patients with TBI consistently used a wide array of outpatient services over time with considerable variation in cost. Further study regarding economic aspects of care for patients with TBI is warranted.

    View details for DOI 10.1682/JRRD.2008.12.0166

    View details for Web of Science ID 000274171000003

    View details for PubMedID 20157857

  • Methods of a multisite randomized clinical trial of supported employment among veterans with spinal cord injury JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT Ottomanelli, L., Goetz, L., McGeough, C., Suris, A., Sippel, J., Sinnott, P., Wagner, T. H., Cipher, D. J. 2009; 46 (7): 919-930


    This article compares the methods of a randomized multisite clinical trial of evidence-based supported employment with conventional vocational rehabilitation among veterans with spinal cord injury (SCI). The primary hypothesis is that, compared with conventional vocational rehabilitation (i.e., standard care), evidence-based supported employment will significantly improve competitive employment outcomes and general rehabilitation outcomes. The secondary hypothesis is that evidence-based supported employment in SCI will be more cost-effective than standard care. The current article describes the clinical trial and presents baseline data. The present sample includes 301 veterans with SCI, which includes paraplegia (50%), high tetraplegia (32%), and low tetraplegia (18%). Baseline data indicate that 65% of this sample of employment-seeking veterans with SCI had never been employed postinjury, despite the fact that nearly half (41%) had received some type of prior vocational rehabilitation. These rates of unemployment for veterans with SCI are consistent with the rates reported for community samples of persons with SCI. Forthcoming outcome data will provide much needed insights into the best practices for helping these veterans restore vocational goals and improve overall quality of life.

    View details for DOI 10.1682/JRRD.2008.10.0145

    View details for Web of Science ID 000273443700003

    View details for PubMedID 20104414

  • Prescription drug co-payments and cost-related medication underuse HEALTH ECONOMICS POLICY AND LAW Wagner, T. H., Heisler, M., Piette, J. D. 2008; 3 (1): 51-67


    Co-payments have been linked to the slowing growth in pharmaceutical spending over the last five years. However, patients with health problems frequently have difficulty affording their pharmacotherapy and fail to take their medication as prescribed. We examine the relationship between co-payment amounts and four types of cost-related underuse: taking fewer doses, postponing taking a medication, failing to fill a prescription at all, and taking medication less frequently than prescribed. We conducted a nationwide survey of US adults age 50 and over who take medication for a chronic condition. Participants provided information on 17 chronic conditions, medication they take for those conditions, and whether they underused any medication due to cost. We analyzed those who reported paying co-payments for their prescriptions (n = 2,869). Analysis involved multivariate logistic regression, with adjustments for survey weights and clustering. Our data show a strong positive association between co-payments and cost-related medication underuse. Although people differ in how they underuse medications, these behaviours are strongly associated with co-payment amount. Realigning the co-payments with cost-effectiveness data, also known as value-based insurance design, warrants further investigation.

    View details for DOI 10.1017/S1744133107004380

    View details for Web of Science ID 000208039600004

    View details for PubMedID 18634632

  • The costs of an outreach intervention for low-income women with abnormal Pap smears. Preventing chronic disease Wagner, T. H., Engelstad, L. P., McPhee, S. J., Pasick, R. J. 2007; 4 (1): A11-?


    Follow-up among women who have had an abnormal Papanicolaou (Pap) smear is often poor in public hospitals that serve women at increased risk for cervical cancer. This randomized controlled trial evaluated and compared the total cost and cost per follow-up of a tailored outreach intervention plus usual care with the total cost and cost per follow-up of usual care alone.Women with an abnormal Pap smear (n = 348) receiving care at Alameda County Medical Center (Alameda County, California) were randomized to intervention or usual care. The intervention used trained community health advisors to complement the clinic's protocol for usual care. We assessed the costs of the intervention and the cost per follow-up within 6 months of the abnormal Pap smear test result.The intervention increased the rate of 6-month follow-up by 29 percentage points, and the incremental cost per follow-up was 959 dollars (2005 dollars). The cost per follow-up varied by the severity of the abnormality. The cost per follow-up for the most severe abnormality (high-grade squamous intraepithelial lesion) was 681 dollars, while the cost per follow-up for less severe abnormalities was higher.In a health care system in which many women fail to get follow-up care for an abnormal Pap smear, outreach workers were more effective than usual care (mail or telephone reminders) at increasing follow-up rates. The results suggest that outreach workers should manage their effort based on the degree of abnormality; most effort should be placed on women with the most severe abnormality (high-grade squamous intraepithelial lesion).

    View details for PubMedID 17173719

  • Prevalence of substance use disorders among veterans and comparable nonveterans from the National Survey on Drug Use and Health. Psychological Services Todd, W. H., Katherine, H. M., Belle, F., Dai, L., Yesenia, L., Keith, H. 2007; 4 (3): 149
  • Cost of inpatient rehabilitation care in the Department of Veterans Affairs JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT Wagner, T. H., Richardson, S. S., Vogel, B., Wing, K., Smith, M. W. 2006; 43 (7): 929-937


    We investigated the determinants of inpatient rehabilitation costs in the Department of Veterans Affairs (VA) and examined the relationship between length of stay (LOS) and discharge costs using data from VA and community rehabilitation hospitals. We estimated regression models to identify patient characteristics associated with specialized inpatient rehabilitation costs. VA data included 3,535 patients discharged from 63 facilities in fiscal year 2001. We compared VA costs to community rehabilitation hospitals using a sample from the Uniform Data System for Medical Rehabilitation of 190,112 patients discharged in 1999 from 697 facilities. LOS was a strong predictor of cost for VA and non-VA hospitals. Functional status, measured by Functional Independence Measure (FIM) scores at admission, was statistically significant but added little explanatory value after controlling for LOS. Although FIM scores were associated with LOS, FIM scores accounted for little variance in cost after controlling for LOS. These results are most applicable to researchers conducting cost-effectiveness analyses.

    View details for DOI 10.1682/JRRD.2005.10.0162

    View details for Web of Science ID 000245633700014

    View details for PubMedID 17436178

  • Determinants of cost among people who died in VA nursing homes MEDICAL CARE RESEARCH AND REVIEW Yu, W., Wagner, T. H., Barnett, P. G. 2006; 63 (4): 477-498


    We examined final stays of elderly patients (65 or more years of age) who died in 111 VA nursing homes in fiscal year 2000 (N = 4,897) to evaluate determinants of the cost of final nursing home stays. We analyzed cost and its two main components (length of stay and intensity of care) by primary disease, age, race or ethnicity, gender, and benefit-eligibility type. We found that disease rather than age was the dominant factor influencing the cost of final nursing home stays. After controlling for six common diagnoses, age was not associated with cost. Marital status and race or ethnicity were also significant predictors but accounted for less variation than illnesses. Incorporating illness into models that predict future demand for nursing home use provides greater precision than using age alone, especially as diseases and their treatments change through time.

    View details for DOI 10.1177/1077558706288843

    View details for Web of Science ID 000239206300004

    View details for PubMedID 16847074

  • Medication characteristics beyond cost alone influence decisions to underuse pharmacotherapy in response to financial pressures JOURNAL OF CLINICAL EPIDEMIOLOGY Piette, J. D., Heisler, M., Wagner, T. H. 2006; 59 (7): 739-746


    Little is known about how patients facing medication cost pressures make choices about whether to underuse one or more of their prescription drugs. We calculated the probability that older adults would underuse prescription medications for common chronic illnesses because of cost concerns. We also identified differences in cost-related underuse between symptom-relief medications (e.g., analgesics) and primarily "preventive" medications (e.g., antihypertensives).Older chronically ill patients using both symptom-relief and preventive medications (N = 2,008) were identified as part of a nationwide survey in the United States and reported information about their cost-related underuse of 16 medication types. We used regression models to estimate the probability of underuse for each medication type, assuming average out-of-pocket costs, no prescription coverage, and the sociodemographic characteristics of a typical American aged 50+.23% of respondents reported forgoing medication in the prior year due to cost. The likelihood of cost-related underuse was higher for symptom-relief medications (27%) than for primarily preventive medications (20%, P < .001). Among the subset of patients who cut back on adherence due to cost, the likelihood of forgoing symptom-relief medication (69%) was higher than that for preventive drugs (54%, P < .001).Medication characteristics beyond cost alone influence decisions to underuse treatment in response to financial pressures.

    View details for DOI 10.1016/j.jclinepi.2005.11.023

    View details for Web of Science ID 000238427600012

    View details for PubMedID 16765278

  • Who searches the internet for health information? 4th World Conference of the International-Health-Economics-Association (iHEA) Bundorf, M. K., Wagner, T. H., Singer, S. J., Baker, L. C. WILEY-BLACKWELL PUBLISHING, INC. 2006: 819–36


    To determine what types of consumers use the Internet as a source of health information.A survey of consumer use of the Internet for health information conducted during December 2001 and January 2002.We estimated multivariate regression models to test hypotheses regarding the characteristics of consumers that affect information seeking behavior.Respondents were randomly sampled from an Internet-enabled panel of over 60,000 households. Our survey was sent to 12,878 panel members, and 69.4 percent of surveyed panel members responded. We collected information about respondents' use of the Internet to search for health information and to communicate about health care with others using the Internet or e-mail within the last year.Individuals with reported chronic conditions were more likely than those without to search for health information on the Internet. The uninsured, particularly those with a reported chronic condition, were more likely than the privately insured to search. Individuals with longer travel times for their usual source of care were more likely to use the Internet for health-related communication than those with shorter travel times.Populations with serious health needs and those facing significant barriers in accessing health care in traditional settings turn to the Internet for health information.

    View details for DOI 10.1111/j.1475-6773.2006.00510.x

    View details for PubMedID 16704514

  • Self-reported utilization of health care services: Improving measurement and accuracy MEDICAL CARE RESEARCH AND REVIEW Bhandari, A., Wagner, T. 2006; 63 (2): 217-235


    Self-report is often used to estimate health care utilization. However, the accuracy of such data is of paramount concern. The authors conducted a systematic review of 42 studies that evaluated the accuracy of self-report utilization data, where utilization was defined as a visit to a clinical provider or entity. They also present a broad conceptual model that identifies major issues to consider when collecting, analyzing, and reporting such data. The results show that self-report data are of variable accuracy. Factors that affect accuracy include (1) sample population and cognitive abilities, (2) recall time frame, (3) type of utilization, (4) utilization frequency, (5) questionnaire design, (6) mode of data collection, and (7) memory aids and probes.

    View details for DOI 10.1177/1077558705285298

    View details for Web of Science ID 000236280900004

    View details for PubMedID 16595412

  • Internet use and stigmatized illness SOCIAL SCIENCE & MEDICINE Berger, M., Wagner, T. H., Baker, L. C. 2005; 61 (8): 1821-1827


    People with stigmatized illnesses often avoid seeking health care and education. The internet may be a useful health education and outreach tool for this group. This study examined patterns of internet use for health information among those with and without stigmatized illnesses. A national survey of internet users in the USA was conducted. Respondents who self-reported a stigmatized condition-defined as anxiety, depression, herpes, or urinary incontinence-were compared to respondents who reported having at least one other chronic illness, such as cancer, heart problems, diabetes, and back pain. The analytical sample consisted of 7014 respondents. Cross-sectional associations between stigmatized illness and frequency of internet use for information about health care, use of the internet for communication about health, changes in health care utilization after internet use, and satisfaction with the internet were determined. After controlling for a number of potential confounders, those with stigmatized illnesses were significantly more likely to have used the internet for health information, to have communicated with clinicians about their condition using the internet, and to have increased utilization of health care based on information found on the internet, than those with non-stigmatized conditions. Length of time spent online, frequency of internet use, satisfaction with health information found on the internet, and discussion of internet findings with health care providers did not significantly differ between the two groups. Results from this survey suggest that the internet may be a valuable health communication and education tool for populations who are affected by stigmatized illnesses.

    View details for DOI 10.1016/j.socsimed.2005.03.025

    View details for Web of Science ID 000231462700020

    View details for PubMedID 16029778

  • Health-related consequences of overactive bladder: an economic perspective BJU INTERNATIONAL Hu, T. W., Wagner, T. H. 2005; 96: 43-45


    About 34 million people in the USA have an overactive bladder (OAB), a condition characterized by urinary urgency, with or without urinary incontinence, and usually frequency and nocturia. This condition is associated with increased health risks (e.g. urinary tract infection, falls and fall-related injuries, including broken bones), as well as admission to nursing homes and prolonged hospital stays. The annual costs associated with OAB in the community setting are >9 billion dollars, including 2.9 billion dollars for diagnosis and treatment, 1.5 billion dollars for routine care, 3.9 billion dollars for treatment of health-related consequences, and 841 million dollars in lost productivity. These cost patterns raise the possibility that treating OAB at an early stage may both improve patient care and minimize overall use of healthcare resources. However, before a thorough economic analysis of OAB can be undertaken, more data are needed about the long-term costs and the pathogenesis of OAB-related conditions.

    View details for DOI 10.1111/j.1464-410X.2005.05654.x

    View details for Web of Science ID 000231741900008

    View details for PubMedID 16086679

  • An economic evaluation of inpatient residential treatment programs in the department of veterans affairs Annual Meeting of the Veterans-Administration-Health-Services-Research-and-Development-Service (HSR&D) Wagner, T. H., Chen, S. SAGE PUBLICATIONS INC. 2005: 187–204


    The Veterans Health Administration (VA) established psychosocial residential rehabilitation treatment programs (RTPs) to treat eligible veterans who have psychiatric and substance use disorders in a less intensive and more self-reliant inpatient setting. Forty-two (25 percent) VA medical centers adopted RTPs in 1995. Panel regression models using data from 1993 through 1999 indicated that RTPs were associated with 8.6 and 24.4 percent decreases in the average cost per day for inpatient psychiatry and substance use care, respectively. During this time, VA transitioned much of the inpatient mental health care to ambulatory services. Yet medical centers with RTPs had smaller decreases in the number of inpatient patient days than those without RTPs. Because medical centers with RTPs provided more services, this offset the per diem savings, resulting in no significant differences in total costs between medical centers with and without RPTs.

    View details for DOI 10.1177/1077558704273804

    View details for Web of Science ID 000227762500003

    View details for PubMedID 15750176

  • Free Internet access, the digital divide, and health information MEDICAL CARE Wagner, T. H., Bundorf, M. K., Singer, S. J., Baker, L. C. 2005; 43 (4): 415-420


    The Internet has emerged as a valuable tool for health information. Half of the U.S. population lacked Internet access in 2001, creating concerns about those without access. Starting in 1999, a survey firm randomly invited individuals to join their research panel in return for free Internet access. This provides a unique setting to study the ways that people who had not previously obtained Internet access use the Internet when it becomes available to them.In 2001-2002, we surveyed 12,878 individuals 21 years of age and older on the research panel regarding use of the Internet for health; 8935 (69%) responded. We analyzed respondents who had no prior Internet access, and then compared this group to those who had prior Internet access.Among those newly provided free Internet access, 24% had used the Internet for health information in the past year, and users reported notable benefits, such as improved knowledge and self-care abilities. Not surprisingly, the no-prior-Internet group reported lower rates of using the Internet (24%) than the group that had obtained Internet access prior to joining the research panel (40%), but the 2 groups reported similar perceptions of the Internet and self-reported effects.Those who obtained Internet access for the first time by joining the panel used the Internet for health and appeared to benefit from it. Access helps explain the digital divide, although most people given free access do not use the Internet for health information.

    View details for Web of Science ID 000227914000013

    View details for PubMedID 15778645

  • Patient strategies to cope with high prescription medication costs: Who is cutting back on necessities, increasing debt, or underusing medications? JOURNAL OF BEHAVIORAL MEDICINE Heisler, M., Wagner, T. H., Piette, J. D. 2005; 28 (1): 43-51


    Many chronically ill adults in the United States face high prescription medication costs, yet little is known about the strategies patients adopt to cope with these costs. Through a national survey of 4,055 adults taking prescription medications for one of five chronic diseases, we compared whether respondents cut back on necessities such as food or heat to pay for medications, increased debt, or underused medications because of cost. We also examined the sociodemographic and clinical correlates and differential use by different sub-groups of these three strategies. Overall, 31% of respondents reported pursuing at least one of the strategies over the prior 12 months. Twenty-two percent had cut back on necessities, 16% had increased their debt burden, and 18% had underused prescription drugs. Among patients who underused their medication, 67% also had cut necessities or increased debt. Although we found significant differences in the way patients with varying socio-demographic characteristics responded to medication cost pressures, use of all these strategies was especially common among patients who were low-income, in poor health, and taking multiple medications.

    View details for DOI 10.1007/s10865-005-2562-z

    View details for Web of Science ID 000228014200005

    View details for PubMedID 15887875

  • Economics of incontinence 3rd International Consultation on Incontinence Hu, T. W., Wagner, T. H., Hawthorne, G., Moore, K., Subak, L. L., Versi, E. HEALTH PUBL LTD C/O PLYMBRIDGEDISTRIBUTORS LTD. 2005: 73–95
  • The relationships among age, chronic conditions, and healthcare costs AMERICAN JOURNAL OF MANAGED CARE Yu, W., Ravelo, A., Wagner, T. H., Barnett, P. G. 2004; 10 (12): 909-916


    To learn how age and chronic illness affect costs in the Veterans Affairs healthcare system.Veterans Affairs patients 65 years or older were identified from administrative data. We noted their healthcare utilization, cost, and diagnosis of any of 29 common chronic conditions (CCs). We examined how those 80 years or older differed from the younger patients.The Department of Veterans Affairs spent dollars 8.5 billion to treat 1.6 million older patients in fiscal year 2000. Age was less important than chronic illness in explaining cost differences. The oldest patients incurred a mean of dollars 1295 greater costs than the younger patients, primarily because they were more likely to have a high-cost CC. The oldest patients incurred higher total costs than the younger patients in only 14 of 29 groups defined by CC. Long-term care accounted for most of the extra cost of the oldest patients. When this cost was excluded, the oldest patients incurred only dollars 266 more cost than the younger patients.Growth in the population of the oldest patients will increase the number of individuals with CCs requiring long-term care. With its limited long-term care benefit, Medicare will avoid much of this financial consequence. In contrast, the financial risk of acute and long-term care gives the Department of Veterans Affairs an incentive to develop strategies to prevent CCs associated with long-term care.

    View details for Web of Science ID 000225627700002

    View details for PubMedID 15617366

  • Behavioral interventions and cost-effectiveness analysis PREVENTIVE MEDICINE Wagner, T. H., Goldstein, M. K. 2004; 39 (6): 1208-1214


    Behavioral health interventions are often gauged with a dichotomous outcome, "success" or "failure." Hidden by this dichotomy is a series of behavior changes that can be followed with the Transtheoretical Model (stages of change). There has been little consideration, however, about whether this information can and should be used in cost-effectiveness analysis. We review the stages of change model and its applications to behavioral health interventions. We then discuss analytical methods for including stages of change, or similar behavior change models, in cost-effectiveness analysis (CEA). This is typically not done but it may be critical for study design and for interpreting CEA results.

    View details for DOI 10.1016/j.ypmed.2004.04.052

    View details for Web of Science ID 000225496200021

    View details for PubMedID 15539057

  • Use of the Internet for health information by the chronically ill. Preventing chronic disease Wagner, T. H., Baker, L. C., Bundorf, M. K., Singer, S. 2004; 1 (4): A13-?


    Chronic conditions are among the leading causes of death and disability in the United States. The Internet is a source of health information and advice for individuals with chronic conditions and shows promise for helping individuals manage their conditions and improve their quality of life.We assessed Internet use for health information by people who had one or more of five common chronic conditions. We conducted a national survey of adults aged 21 and older, then analyzed data from 1980 respondents who had Internet access and who reported that they had hypertension, diabetes, cancer, heart problems, and/or depression.Adjusted rates for any Internet use for health information ranged from 33.8% (heart problems only) to 52.0% (diabetes only). A sizable minority of respondents - particularly individuals with diabetes - reported that the Internet helped them to manage their condition themselves, and 7.9% said information on the Internet led them to seek care from a different doctor.Use of the Internet for health information by chronically ill patients is moderate. Self-reported effects on choice of treatment or provider are small but noteworthy.

    View details for PubMedID 15670445

    View details for PubMedCentralID PMC1277953

  • Cost-related medication underuse among chronically ill adults: The treatments people forgo, how often, and who is at risk AMERICAN JOURNAL OF PUBLIC HEALTH Piette, J. D., Heisler, M., Wagner, T. H. 2004; 94 (10): 1782-1787


    We sought information about the cost-related underuse of medications-which medications are underused, by whom, and how often.Chronically ill adults were asked to identify how often they underused prescription medication for 16 health conditions because of the cost.Eighteen percent of respondents cut back on medication use owing to cost in the previous year, and 14% used less medication at least monthly. Although rates of underuse varied substantially across treatments, prescription coverage and out-of-pocket costs were determinants of underuse across medication types.Many chronically ill adults frequently cut back on medications owing to cost. Patients are selective about the treatments they forgo. Out-of-pocket costs and inadequate prescription coverage may lead to adherence problems for many important medication types.

    View details for Web of Science ID 000224309900030

    View details for PubMedID 15451750

  • Cost-related medication underuse - Do patients with chronic illnesses tell their doctors? ARCHIVES OF INTERNAL MEDICINE Piette, J. D., Heisler, M., Wagner, T. H. 2004; 164 (16): 1749-1755


    Although many chronically ill patients underuse prescription medications because of cost concerns, we know little about their discussions with clinicians about this issue.Nationwide survey of 660 older adults with chronic illnesses who reported underusing medication in the prior year because of cost. We assessed whether patients discussed cost-related medication underuse with clinicians, reasons that some patients did not talk with clinicians about this problem, how clinicians responded when this issue was raised, and how helpful patients perceived clinicians to be.Two thirds of respondents never told a clinician in advance that they planned to underuse medication because of the cost, and 35% never discussed the issue at all. Of those who did not tell a clinician, 66% reported that nobody asked them about their ability to pay for prescriptions and 58% reported that they did not think providers could help them. When patients talked with clinicians about medication costs, 72% found those conversations helpful. However, 31% reported that their medications were never changed to a generic or less expensive alternative, and few patients were given other forms of assistance such as information about programs that help pay drug costs (30%) or where to purchase less expensive medication (28%). Patients were most likely to find clinicians helpful if clinicians provided free samples, asked about problems paying for prescriptions, and offered advice about how to pay for patients' current regimens.About one third of chronically ill adults who underuse prescription medication because of the cost never talk with clinicians in advance, and many never raise this issue at all. Clinicians should take a more proactive role in identifying and assisting patients who have problems paying for prescription drugs.

    View details for Web of Science ID 000223831900005

    View details for PubMedID 15364667

  • Consumers' use of the Internet for health insurance AMERICAN JOURNAL OF MANAGED CARE Bundorf, M. K., Singer, S. J., Wagner, T. H., Baker, L. 2004; 10 (9): 609-616


    We examined consumers' search for information about health insurance choices and their use of the Internet for that search and to manage health benefits.We surveyed a random sample of more than 4500 individuals aged 21 years and older who were members of a survey research panel during December 2001 and January 2002.The survey included questions about searching for health insurance information in 3 health insurance markets: Medicare, individual or nongroup, and employer-sponsored group. We also asked questions about use of the Internet to manage health benefits. We tabulated means of responses to each question by market and tested for independence across demographic groups using the Pearson chi-square test.We identified important differences across and within markets in the extent to which people look for information about health insurance alternatives and the role of the Internet in their search. Although many individuals were unaware of whether their employer or health plan provided a website to manage health benefits, those who used the sites generally evaluated them favorably.Our results suggest that the Internet is an important source of health insurance information, particularly for individuals purchasing coverage individually in the nongroup and Medicare markets relative to those obtaining coverage from an employer. In the case of Medicare coverage, studies focusing on beneficiaries' use of Internet resources may underestimate the Internet's importance by neglecting caregivers who use the Internet. Many individuals may be unaware of the valuable resources available through employers or health plans.

    View details for PubMedID 15515993

  • Economies of scale in institutional review boards MEDICAL CARE Wagner, T. H., Cruz, A. M., Chadwick, G. L. 2004; 42 (8): 817-823


    Research with human subjects is essential for most clinical and social science research. As such, the ethical treatment of subjects, including the role of Institutional Review Boards (IRBs), is of paramount concern. The prevailing system of IRBs in the United States reflects an integrated approach in which research organizations have their own local IRB. Recent regulatory changes and a few high-profile problems have prompted proposals for greater investments in IRBs.We conducted regression analyses, looking at how IRB size was associated with IRB costs (economies of scale).We studied data from a cross-sectional survey.We studied IRBs at Veterans Affairs (VA) and VA-affiliated medical centers (n = 109); 81 (73%) IRB administrators completed the survey. Fourteen of the administrators had missing data and were excluded from final analysis, leaving a sample of 67.The primary dependent variable was IRB costs in 2001, which we estimated from the survey. Independent variables included IRB size measured as the number of actions (ie, number of initial reviews, amendments, continuing/annual reviews, and harms/adverse event reports) reviewed by the IRB in the last year.The results indicate that very large economies of scale exist, especially for IRBs that handle fewer than 150 actions per year.A discussion of the costs of benefits of having 3000 to 5000 local IRBs in the United States is warranted because other organizational arrangements could be economically and socially advantageous.

    View details for DOI 10.1097/01.mlr.0000132395.32967.d4

    View details for Web of Science ID 000222962100013

    View details for PubMedID 15258484

  • Clinician identification of chronically ill patients who have problems paying for prescription medications AMERICAN JOURNAL OF MEDICINE Heisler, M., Wagner, T. H., Piette, J. D. 2004; 116 (11): 753-758


    Little is known about whether health care providers are effectively identifying patients who have difficulty covering the costs of out-of-pocket prescription medications. We examined whether and how providers are identifying chronically ill adults who have potential problems paying for prescription medications.We conducted a cross-sectional survey of a national sample of 4050 adults aged 50 years or older who use prescription medications for at least one of five chronic health conditions. The primary outcome measure was patient report of being asked by a doctor or nurse in the prior 12 months whether the patient could afford the prescribed medication. The measures of prescription cost burden were cost-related underuse of medications, cutting back on other necessities to pay for medications, and worries about medication costs. We adjusted for patient income, education, race/ethnicity, age, sex, health status, number of prescribed medications, pharmacy benefits, frequency of outpatient visits, having a regular health care provider, and sampling weights.In the weighted analyses, 16% (547/4050) of respondents reported that they had been asked about potential problems paying for a prescribed medication. Only 360 (24%) of the 1499 respondents who reported one or more burdens from out-of-pocket medication costs reported being asked this question. After adjusting for potential confounders, patients who had cut back on medication use or other necessities to cover payments were no more likely than other patients to be asked about the ability to pay for prescription medications. Concerns about medication costs, being a racial/ethnic minority, taking seven or more prescription medications, and having no prescription coverage were independently associated with a greater likelihood of being asked about possible problems with prescription costs.Few chronically ill patients who are at risk of or experiencing problems related to prescription medication costs report that their clinicians had asked them about possible medication payment difficulties.

    View details for DOI 10.1016/j.amjmed.2004.01.013

    View details for Web of Science ID 000221463000005

    View details for PubMedID 15144912

  • Improving the decision processes of institutional review boards JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Wagner, T. H. 2004; 291 (14): 1698-1698

    View details for Web of Science ID 000220788700023

    View details for PubMedID 15082694

  • Cost-related medication under-use: An analysis of tough choices by chronically-ill adults. 27th Annual Meeting of the Society-of-General-Internal-Medicine Piette, J. D., Heisler, M., Wagner, T. H. SPRINGER. 2004: 133–134
  • Costs of urinary incontinence and overactive bladder in the United States: A comparative study UROLOGY Hu, T. W., Wagner, T. H., Bentkover, J. D., LeBlanc, K., Zhou, S. Z., Hunt, T. 2004; 63 (3): 461-465


    To update the cost of urinary incontinence (UI) for year 2000 and compare it with the cost of overactive bladder (OAB).Using the cost-of-illness framework, disease epidemiologic data were combined with treatment rates, consequence probabilities, and average cost estimates. All costs reflect the costs during 2000.The total cost of UI and OAB was 19.5 billion dollars and 12.6 billion dollars, respectively (year 2000 dollars). With UI, 14.2 billion dollars was borne by community residents and 5.3 billion dollars by institutional residents. With OAB, 9.1 and 3.5 billion dollars, respectively, was incurred by community and institutional residents.OAB affected 34 million individuals compared with 17 million with UI. Despite the differences in epidemiology, the total and per-person costs of UI were higher than the OAB costs because OAB individuals without incontinent episodes incurred fewer costs, on average.

    View details for DOI 10.1016/j.urology.2003.10.037

    View details for Web of Science ID 000220223500009

    View details for PubMedID 15028438

  • Health insurance status, cost-related medication underuse, and outcomes among diabetes patients in three systems of care MEDICAL CARE Piette, J. D., Wagner, T. H., Potter, M. B., Schillinger, D. 2004; 42 (2): 102-109


    Chronically ill patients often experience difficulty paying for their medications and, as a result, use less than prescribed.The objectives of this study were to determine the relationship between patients with diabetes' health insurance coverage and cost-related medication underuse, the association between cost-related underuse and health outcomes, and the role of comorbidity in this process.We used a patient survey with linkage to insurance information and hemoglobin A1C (A1C) test results.We studied 766 adults with diabetes recruited from 3 Veterans Affairs (VA), 1 county, and 1 university healthcare system.Main outcomes consisted of self-reported medication underuse as a result of cost, A1C levels, symptom burden, and Medical Outcomes Study 12-Item Short-Form physical and mental functioning scores.Fewer VA patients reported cost-related medication underuse (9%) than patients with private insurance (18%), Medicare (25%), Medicaid (31%), or no health insurance (40%; P <0.0001). Underuse was substantially more common among patients with multiple comorbid chronic illnesses, except those who used VA care. The risk of cost-related underuse for patients with 3+ comorbidities was 2.8 times as high among privately insured patients as VA patients (95% confidence interval, 1.2-6.5), and 4.3 to 8.3 times as high among patients with Medicare, Medicaid, or no insurance. Individuals reporting cost-related medication underuse had A1C levels that were substantially higher than other patients (P <0.0001), more symptoms, and poorer physical and mental functioning (all P <0.05).Many patients with diabetes use less of their medication than prescribed because of the cost, and those reporting cost-related adherence problems have poorer health. Cost-related adherence problems are especially common among patients with diabetes with comorbid diseases, although the VA's drug coverage may protect patients from this increased risk.

    View details for DOI 10.1097/01.mlr.0000108742.26446.17

    View details for Web of Science ID 000188432100002

    View details for PubMedID 14734946

  • Problems paying out-of-pocket medication costs among older adults with diabetes DIABETES CARE Piette, J. D., Heisler, M., Wagner, T. H. 2004; 27 (2): 384-391


    To identify problems faced by older adults with diabetes due to out-of-pocket medication costs.In this cross-sectional national survey of 875 adults with diabetes treated with hypoglycemic medication, respondents reported whether they had underused prescription medications due to cost pressures or had experienced other financial problems associated with medication costs such as forgoing basic necessities. Respondents also described their interactions with clinicians about medication costs.A total of 19% of respondents reported cutting back on medication use in the prior year due to cost, 11% reported cutting back on their diabetes medications, and 7% reported cutting back on their diabetes medications at least once per month. Moreover, 28% reported forgoing food or other essentials to pay medication costs, 14% increased their credit card debt, and 10% borrowed money from family or friends to pay for their prescriptions. Medication cost problems were especially common among respondents who were younger, had higher monthly out-of-pocket costs, and had no prescription drug coverage. In general, few respondents, including those reporting medication cost problems, reported that their health care providers had given them information or other assistance to address medication cost pressures.Out-of-pocket medication costs pose a significant burden to many adults with diabetes and contribute to decreased treatment adherence. Clinicians should actively identify patients with diabetes who are facing medication cost pressures and assist them by modifying their medication regimens, helping them understand the importance of each prescribed medication, providing information on sources of low-cost drugs, and linking patients with coverage programs.

    View details for Web of Science ID 000188739900016

    View details for PubMedID 14747218

  • Use of the Internet for health information and communication - Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Baker, L., Wagner, T. H., Bundorf, M. K., Singer, S. 2003; 290 (17): 2257-2258
  • New opportunities for integrated child health systems: Results from the multifaceted Pre-to-Three program AMERICAN JOURNAL OF PUBLIC HEALTH Cuellar, A. E., Wagner, T. H., Hu, T. W., Peifer, K., Kitzman, H., Tobin, S. J., Shih, V., Morrow, S. 2003; 93 (11): 1889-1890

    View details for Web of Science ID 000186307900024

    View details for PubMedID 14600059

  • Spending for specialized mental health treatment in the VA: 1995-2001 HEALTH AFFAIRS Chen, S., Smith, M. W., Wagner, T. H., Barnett, P. G. 2003; 22 (6): 256-263


    The mid-1990s saw dramatic changes in mental health care in the Department of Veterans Affairs (VA), the largest provider of such care in the United States. Spending for specialized inpatient mental health care fell 21 percent from 1995 to 2001, while spending for specialized outpatient care rose 63 percent. The shift from inpatient to outpatient care was accompanied by rapid increases in outpatient medication costs. Overall, the VA reduced the average cost (per VA user) of specialized mental health care by 22 percent while it increased the number of users of these services by 35 percent.

    View details for Web of Science ID 000186632200033

    View details for PubMedID 14649454

  • Using average cost methods to estimate encounter-level costs for medical-surgical stays in the VA MEDICAL CARE RESEARCH AND REVIEW Wagner, T. H., Chen, S., Barnett, P. G. 2003; 60 (3): 15S-36S


    The U.S. Department of Veterans Affairs (VA) maintains discharge abstracts, but these do not include cost information. This article describes the methods the authors used to estimate the costs of VA medical-surgical hospitalizations in fiscal years 1998 to 2000. They estimated a cost regression with 1996 Medicare data restricted to veterans receiving VA care in an earlier year. The regression accounted for approximately 74 percent of the variance in cost-adjusted charges, and it proved to be robust to outliers and the year of input data. The beta coefficients from the cost regression were used to impute costs of VA medical-surgical hospital discharges. The estimated aggregate costs were reconciled with VA budget allocations. In addition to the direct medical costs, their cost estimates include indirect costs and physician services; both of these were allocated in proportion to direct costs. They discuss the method's limitations and application in other health care systems.

    View details for DOI 10.1177/1077558703256485

    View details for Web of Science ID 000184825000003

    View details for PubMedID 15095543

  • Average cost of VA rehabilitation, mental health, and long-term hospital stays MEDICAL CARE RESEARCH AND REVIEW Yu, W., Wagner, T. H., Chen, S., Barnett, P. G. 2003; 60 (3): 40S-53S


    This article describes the development of a database for the cost of inpatient rehabilitation, mental health, and long-term care stays in the Department of Veterans Affairs from fiscal year 1998 forward. Using "bedsection," which is analogous to a hospital ward, the authors categorize inpatient services into nine categories: rehabilitation, blind rehabilitation, spinal cord injury, psychiatry, substance abuse, intermediate medicine, domiciliary, psychosocial residential rehabilitation, and nursing home. For each of the nine categories, they estimated a national and a local (i.e., medical center) average per diem cost. The nursing home average per diem costs were adjusted for case mix using patient assessment information. Encounter-level costs were then calculated by multiplying the average per diem cost by the number of days of stay in the fiscal year. The national cost estimates are more reliable than the local cost estimates.

    View details for DOI 10.1177/1077558703256724

    View details for Web of Science ID 000184825000005

    View details for PubMedID 15095545

  • Prevalence and costs of chronic conditions in the VA health care system MEDICAL CARE RESEARCH AND REVIEW Yu, W., Ravelo, A., Wagner, T. H., Phibbs, C. S., Bhandari, A., Chen, S., Barnett, P. G. 2003; 60 (3): 146S-167S


    Chronic conditions are among the most common causes of death and disability in the United States. Patients with such conditions receive disproportionate amounts of health care services and therefore cost more per capita than the average patient. This study assesses the prevalence among the Department of Veterans Affairs (VA) health care users and VA expenditures (costs) of 29 common chronic conditions. The authors used regression to identify the marginal impact of these conditions on total, inpatient, outpatient, and pharmacy costs. Excluding costs of contracted medical services at non-VA facilities, total VA health care expenditures in fiscal year 1999 (FY1999) were $14.3 billion. Among the 3.4 million VA patients in FY1999, 72 percent had 1 or more of the 29 chronic conditions, and these patients accounted for 96 percent of the total costs ($13.7 billion). In addition, 35 percent (1.2 million) of VA health care users had 3 or more of the 29 chronic conditions. These individuals accounted for 73 percent of the total cost. Overall, VA health care users have more chronic diseases than the general population.

    View details for DOI 10.1177/1077558703257000

    View details for Web of Science ID 000184825000011

    View details for PubMedID 15095551

  • Use of the Internet and e-mail for health care information: Results from a national survey (vol 289, pg 2400, 2003) JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Baker, L. 2003; 290 (3): 334-334
  • The cost of institutional review board procedures in Multicenter Observational Research ANNALS OF INTERNAL MEDICINE Humphreys, K., Trafton, J., Wagner, T. H. 2003; 139 (1): 77-77

    View details for Web of Science ID 000183823200014

    View details for PubMedID 12834327

  • Estimated economic costs of overactive bladder in the United States UROLOGY Hu, T. W., Wagner, T. H., Bentkover, J. D., LeBlanc, K., Piancentini, A., Stewart, W. F., Corey, R., Zhou, S. Z., Hunt, T. L. 2003; 61 (6): 1123-1128


    To estimate the economic costs of overactive bladder (OAB), including community and nursing home residents, and to compare the costs in male versus female and older versus younger populations.The National Overactive Bladder Evaluation Program included a representative telephone survey of 5204 community-dwelling adults 18 years and older in the United States and a follow-up postal survey of all individuals with OAB identified and age and sex-matched controls. The postal survey asked respondents about bladder symptoms, self-care use, treatment use, work loss, and OAB-related health consequences. Survey data estimates were combined with year 2000 average cost data to calculate the cost of OAB in the community. Institutional costs were estimated from the costs of urinary incontinence in nursing homes, limited to only those with urge incontinence or mixed incontinence (urge and stress).The estimated total economic cost of OAB was 12.02 billion dollars in 2000, with 9.17 and 2.85 billion dollars incurred in the community and institutions, respectively. Community female and male OAB costs totaled 7.37 and 1.79 billion dollars, respectively. The estimated total cost was sensitive to the estimated prevalence of OAB; therefore, we calculated the average cost per community-dwelling person with OAB, which was 267 dollars per year.By quantifying the total economic costs of OAB, this study-the first obtained from national survey data-provides an important perspective of this condition in society. The conservative estimates of the total cost of OAB were comparable to those of osteoporosis and gynecologic and breast cancer. Although this provides information on the direct and indirect costs of OAB, quality-of-life issues must be taken into account to gain a better understanding of this condition.

    View details for DOI 10.1016/S0090-4295(03)00009-8

    View details for Web of Science ID 000183547000014

    View details for PubMedID 12809878

  • The effect of age on the use of health and self-care information: Confronting the stereotype GERONTOLOGIST Wagner, L. S., Wagner, T. H. 2003; 43 (3): 318-324


    Given stereotypes of older adults, there is the perception that older adults will not use health information technologies. One concern is that practitioners might shy away from providing older patients with health information, and in particular, computerized information. The study's primary objective was to evaluate whether a health information intervention had a differential effect for people of different ages.Quasi-experimental survey data from an assessment of a communitywide informational intervention were used. People were asked about their use of medical reference books, telephone advice nurses, or computers for health information in the past few months. In total, 5,909 surveys were completed.The data show that older adults were no less likely (and were sometimes more likely) to use health information as a result of the intervention than younger adults. For telephone advice nurses and computers, the effect of the intervention was not significantly different for the different age groups. Yet, compared with persons 18-29 years of age, those over the age of 65 had a 17-percentage point increase in using a self-care book.We find convincing evidence to counter the stereotype that older adults are resistant to trying new health information technologies.

    View details for Web of Science ID 000183603900005

    View details for PubMedID 12810895

  • The cost of operating institutional review boards (IRBs) ARENA 2001 National Conference Wagner, T. H., Bhandari, A., Chadwick, G. L., Nelson, D. K. LIPPINCOTT WILLIAMS & WILKINS. 2003: 638–44


    Recent reports have claimed that institutional review boards (IRBs) are underfunded, yet little is known about the costs of operating IRBs. This study estimated the costs for operating high-volume and low-volume IRBs.IRB costs were calculated from published summary data. Costs were standardized to reflect 2001 dollars.Total estimated costs for operating high-volume and low-volume IRBs were $770,674 and $76,626, respectively. The average cost per action, a measure of economic efficiency, was lower for high-volume IRBs ($277 per action) than it was for low-volume IRBs ($799 per action).Although high-volume IRBs are more expensive than are low-volume IRBs in absolute terms, they are more economically efficient. Policy debates should consider the potential savings from large IRBs, perhaps by encouraging small IRBs to merge, although this may result in less local review, control, and oversight.

    View details for Web of Science ID 000184741400014

    View details for PubMedID 12805049

  • Use of the Internet and e-mail for health care information - Results from a national survey JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Baker, L., Wagner, T. H., Singer, S., Bundorf, M. K. 2003; 289 (18): 2400-2406


    The Internet has attracted considerable attention as a means to improve health and health care delivery, but it is not clear how prevalent Internet use for health care really is or what impact it has on health care utilization. Available estimates of use and impact vary widely. Without accurate estimates of use and effects, it is difficult to focus policy discussions or design appropriate policy activities.To measure the extent of Internet use for health care among a representative sample of the US population, to examine the prevalence of e-mail use for health care, and to examine the effects that Internet and e-mail use has on users' knowledge about health care matters and their use of the health care system.Survey conducted in December 2001 and January 2002 among a sample drawn from a research panel of more than 60 000 US households developed and maintained by Knowledge Networks. Responses were analyzed from 4764 individuals aged 21 years or older who were self-reported Internet users.Self-reported rates in the past year of Internet and e-mail use to obtain information related to health, contact health care professionals, and obtain prescriptions; perceived effects of Internet and e-mail use on health care use.Approximately 40% of respondents with Internet access reported using the Internet to look for advice or information about health or health care in 2001. Six percent reported using e-mail to contact a physician or other health care professional. About one third of those using the Internet for health reported that using the Internet affected a decision about health or their health care, but very few reported impacts on measurable health care utilization; 94% said that Internet use had no effect on the number of physician visits they had and 93% said it had no effect on the number of telephone contacts. Five percent or less reported use of the Internet to obtain prescriptions or purchase pharmaceutical products.Although many people use the Internet for health information, use is not as common as is sometimes reported. Effects on actual health care utilization are also less substantial than some have claimed. Discussions of the role of the Internet in health care and the development of policies that might influence this role should not presume that use of the Internet for health information is universal or that the Internet strongly influences health care utilization.

    View details for PubMedID 12746364

  • Health insurance status, medication self-restriction due to cost, and outcomes among diabetes patients in three systems of care. 26th Annual Meeting of the Society-of-General-Internal-Medicine Piette, J., Wagner, T. H., Potter, M. B., Schillinger, D. SPRINGER. 2003: 213–213
  • Evaluating an incontinence intervention in nursing home residents JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Wagner, T. H., Subak, L. L. 2003; 51 (2): 275-276

    View details for Web of Science ID 000180605400020

    View details for PubMedID 12558729

  • Computerized health information and the demand for medical care VALUE IN HEALTH Wagner, T. H., Jimison, H. B. 2003; 6 (1): 29-39


    Consumer health information, once the domain of books and booklets, has become increasingly digitized and available on the Internet. This study assessed the effect of using computerized health information on consumers' demand for medical care.The dependent variable was self-reported number of visits to the doctor in the past year. The key independent variable was the use of computerized health information, which was treated as endogenous. We tested the effect of using computerized health information on physician visits using ordinary least squares, instrumental variables, fixed effects, and fixed-effects instrumental variables models. The instrumental variables included exposure to the Healthwise Communities Project, a community-wide health information intervention; computer ownership; and Internet access. Random households in three cities were mailed questionnaires before and after the Healthwise Communities Project. In total, 5909 surveys were collected for a response rate of 54%.In both the bivariate and the multivariate analyses, the use of computerized health information was not associated with self-reported entry into care or number of visits. The instrumental variables models also found no differences, with the exception that the probability of entering care was significantly greater with the two-stage conditional logit model (P <.05).Although providing people with health information is intuitively appealing, we found little evidence of an association between using a computer for health information and self-reported medical visits in the past year. This study used overall self-reported utilizations as the dependent variable, and more research is needed to determine whether health information affects the health production function in other important ways, such as the location of care, the timing of getting care, or the intensity of treatment.

    View details for Web of Science ID 000180811300006

    View details for PubMedID 12535236

  • Health-related consequences of overactive bladder AMERICAN JOURNAL OF MANAGED CARE Wagner, T. H., Hu, T. W., Bentkover, J., LeBlanc, K., Stewart, W., Corey, R., Zhou, Z. Y., Hunt, T. 2002; 8 (19): S598-S607


    Overactive bladder (OAB) is a condition of urgency, with or without urge incontinence, usually with frequency and nocturia. This study assesses whether people with OAB are at greater risk for urinary tract infections (UTIs), falls and injuries, and increased number of visits to the doctor compared to age- and gender-matched controls. The study also estimates costs associated with these health-related consequences.A US representative telephone survey under the National Overactive Bladder Evaluation (NOBLE) Program was conducted with 5204 English-speaking adults older than 18 years. The survey asked respondents about bladder symptoms. Based on the telephone survey, 865 symptom-identified OAB cases and 903 age- and gender-matched controls were sent a postal questionnaire. A total of 397 cases and 522 controls returned the questionnaires. Nonrespondent cases and controls did not differ with regard to age, gender, educational status, diabetes, congestive heart failure, and self-rated health status. Regression analyses were conducted to assess the effect of OAB on health-related consequences, controlling for age, gender, race, education, marital status, number of previous births, self-reported health status, diabetes, and congestive heart failure.People with OAB reported 0.84 (20%) more visits to the physician (P < .05) and 0.21 (138%) more UTIs in the last year than people without OAB (P < .001). Overactive bladder cases also had over twice the odds of being injured in a fall than people without OAB (odds ratio = 2.26; 95% confidence interval 1.46, 3.51). Consistent with having more falls, OAB cases had an increased risk of bone fracture (P < .1). This effect, however, was not statistically significant (at alpha level 0.05) due to the limited sample size. The estimated cost of UTIs associated with OAB was approximately $1.37 billion US dollars in year 2000. The cost of falls without bone fracture due to OAB was $55 million. Falls with bone fracture accounted for approximately $386 million; however, further research with a larger sample is needed to accurately estimate these costs.People with OAB self-report significantly more UTIs and a greater risk of being injured in a fall. Given the large prevalence of UTIs and concerns of overprescribing antibiotics, these results are important for health plans and policy makers. In addition, people with OAB visit their physicians more often than people without OAB. These consequences entail significant economic costs, of which a large percentage will be incurred by health plans. To the extent that OAB causes these consequences, there may be significant savings from effectively treating OAB.

    View details for Web of Science ID 000180217300002

    View details for PubMedID 12516954

  • Does willingness to pay vary by race/ethnicity? An analysis using mammography among low-income women HEALTH POLICY Wagner, T. H., Hu, T. W., Duenas, G. V., Kaplan, C. P., Nguyen, B. H., Pasick, R. J. 2001; 58 (3): 275-288


    As part of a population-based intervention to improve periodic mammogram screening, we examined WTP for mammography in five ethnic groups. Through random digit dialing, we contacted households in low-income census tracts of Alameda County, California (San Francisco Bay area). Women who met the ethnicity, age and cancer-free eligibility criteria were invited to participate. For the baseline assessment, women were surveyed over the phone in their preferred language. Of the 1465 surveyed women, 499 identified themselves as African-American, 199 were Chinese, 167 were Filipino, 300 were Latina, and 300 were non-Hispanic white. Bivariate and multivariate analysis showed that WTP varied significantly by ethnicity (P<0.05). We also found that when Filipino and Chinese women had a female relative with breast cancer, they were willing to pay less money for a mammogram. African-American, Latino, and non-Hispanic white women, however, were willing to pay more money for a mammogram if a female relative had had breast cancer. This ethnic difference, when there is a familial link to breast cancer, needs further study as it has implication for genetic testing. Nevertheless, WTP studies that do not account for ethnic differences may be overstating net benefits to society.

    View details for Web of Science ID 000172122700006

    View details for PubMedID 11641004

  • The demand for consumer health information JOURNAL OF HEALTH ECONOMICS Wagner, T. H., Hu, T. W., Hibbard, J. H. 2001; 20 (6): 1059-1075


    Using data from an evaluation of a community-wide informational intervention, we modeled the demand for medical reference books, telephone advice nurses, and computers for health information. Data were gathered from random household surveys in Boise, ID (experimental site), Billings, MT, and Eugene, OR (control sites). Conditional difference-in-differences show that the intervention increased the use of medical reference books, advice nurses, and computers for health information by approximately 15, 6, and 4%. respectively. The results also suggest that the intervention was associated with a decreased reliance on health professionals for information.

    View details for Web of Science ID 000172086400009

    View details for PubMedID 11758048

  • Who uses self-care books, advice nurses, and computers for health information? INTERNATIONAL JOURNAL OF TECHNOLOGY ASSESSMENT IN HEALTH CARE Wagner, T. H., Hibbard, J. H. 2001; 17 (4): 590-600


    While evaluating the effect of a community-wide informational intervention, this study explored access, health, and demographic factors related to the use of medical reference books, telephone advice nurses, and computers for health information.A random sample of households in the intervention city (Boise, Idaho) and two control cities were surveyed about their use of health information in 1996. Shortly thereafter, the Healthwise Communities Project (HCP) distributed health information to all Boise residents. A follow-up survey was conducted in 1998. Overall, 5,909 surveys were completed for a 54% response rate.The HCP intervention was associated with statistically significant increases in the use of medical reference books and telephone advice nurses. The increased use of computers for health information was marginally significant. Few access, health, or demographic factors were consistently associated with using the different resources, except that people with depression used more of all three information resources, and income was not a significant predictor.Providing free health information led to an increase in use, but access, health, and demographic factors were also important determinants. In particular, poor health status and presence of a chronic illness were associated with health information use. These results suggest that healthy consumers are less interested in health information, and it may take other incentives to motivate them to learn about prevention and healthy behaviors.

    View details for Web of Science ID 000172329500013

    View details for PubMedID 11758302

  • Does providing consumer health information affect self-reported medical utilization? Evidence from the Healthwise Communities Project MEDICAL CARE Wagner, T. H., Hibbard, J. H., Greenlick, M. R., Kunkel, L. 2001; 39 (8): 836-847


    To determine whether providing health information to residents of Boise ID had an effect on their self-reported medical utilization.The Healthwise Communities Project (HCP) evaluation followed a quasi-experimental design.Random households in metropolitan zip codes were mailed questionnaires before and after the HCP. A total of 5,909 surveys were returned.The dependent variable was self-reported number of visits to the doctor in the past year. A difference-in-differences estimator was used to assess the intervention's community-level effect. We also assessed the intervention's effect on the variance of self-report utilization.Boise residents had a higher adjusted odds of entering care (OR = 1.27, 95% CI 0.88, 1.85) and 0.1 more doctor visits compared with residents in the control cities; however, for both outcomes, the effects were small and not significant. Although the means changed little, the data suggest that the variance of utilization in Boise decreased.The HCP had a small effect on overall self-reported utilization. Although the findings were not statistically significant, a posthoc power analysis revealed that the study was underpowered to detect effects of this magnitude. It may be possible to achieve larger effects by enrolling motivated people into a clinical trial. However, these data suggest that population-based efforts to provide health information have a small effect on self-reported utilization.

    View details for Web of Science ID 000170238200009

    View details for PubMedID 11468502

  • When parents are given greater access to health information, does it affect pediatric utilization? MEDICAL CARE Wagner, T. H., Greenlick, M. R. 2001; 39 (8): 848-855


    Most studies assessing the effects of consumer health information on medical utilization have used randomized controlled clinical trials with the chronically ill. In this paper, we analyze the effect of the Healthwise Communities Project, a natural experiment that provided free self-care resources, on reported pediatric utilization.Random household surveys were collected before and after the intervention in Boise, Idaho and in two control communities.A total of 5,909 surveys were completed, representing an overall response rate of 54%. Of these, 1,812 respondents were between 18 and 55 years of age and had children under 18 years of age living in the home. All analyses were restricted to these 1,812 persons.Parents were asked how many times their children visited a physician in the last year. Responses were gathered with a categorical response scale, which was then transformed into a continuous variable (number of pediatric visits).The intervention was associated with a decrease in reported pediatric utilization rates. The decrease in visits ranged from -0.72 to -0.66 (P approximately 0.05), depending on the statistical model used. Further analyses of 423 families followed over time found a more modest decrease (-0.19) that was not statistically significant.This study found that increasing access to self-care books, telephone advice nurses, and Internet-based health information is associated with decreases in reported pediatric utilization. However, the significance of the results was sensitive to the statistical model. More research is needed to understand the average and marginal costs of providing health information to consumers.

    View details for Web of Science ID 000170238200010

    View details for PubMedID 11468503

  • The effect of reforms on spending for veterans' substance abuse treatment, 1993-1999 HEALTH AFFAIRS Chen, S., Wagner, T. H., Barnett, P. G. 2001; 20 (4): 169-175

    View details for Web of Science ID 000169925400017

    View details for PubMedID 11463073

  • Willingness to pay for mammography: item development and testing among five ethnic groups HEALTH POLICY Wagner, T. H., Hu, T. W., Duenas, G. V., Pasick, R. J. 2000; 53 (2): 105-121


    The goal of this study was to develop a willingness to pay (WTP) question for mammography that is appropriate for low income, ethnically-diverse women. Through qualitative research with 50 low income women of five ethnic groups we developed both a WTP question and a willingness to travel question (WTT). After being refined through interviews with 41 women, these questions were pilot tested on a random sample of 52 low income, ethnically-diverse women in the San Francisco area. Results show that the concepts underlying WTP and WTT were culturally appropriate to the five ethnicities in this study. Analyses generally confirm the validity of the WTP and WTT questions. As expected, WTP was associated with household income, perceived risk of cancer, and knowledge that one needs a mammogram even after a clinical breast examination. Despite the small samples, WTP varied among the ethnic groups. Additionally, WTT was moderately correlated with the natural log of WTP (r = 0.58, P < 0.001). These questions are now in use in a larger clinical trial and future analyses will explore willingness to pay and willingness to travel within and across the ethnic groups.

    View details for Web of Science ID 000088596300003

    View details for PubMedID 11014787

  • Economic considerations in overactive bladder Workshop on Overactive Bladder: Examining the Burden of Disease Hu, T. W., Wagner, T. H. MANAGED CARE & HEALTHCARE COMMUNICATIONS LLC. 2000: S591–S598


    Many costs are associated with overactive bladder (OAB). They include direct costs, such as those associated with treatment, diagnosis, routine care, and the consequences of the disease; indirect costs of lost wages and productivity; and intangible costs associated with pain, suffering, and decreased quality of life. Quantification of all these costs is essential for establishing the total economic burden of a disease on society. Currently, the total economic burden of OAB is unknown. However, various studies have determined that the economic burden of urinary incontinence, one of the symptoms of OAB, is substantial. It is also important to establish the economic impact of various interventions for OAB. Cost-minimization, cost-outcome, cost-utility, and cost-benefit models can be used for these analyses. The most difficult aspect of evaluating the economic impact of a treatment is estimating the intangible costs.

    View details for Web of Science ID 000088759100005

    View details for PubMedID 11183902

  • Health services utilization among Latinos and white non-Latinos: Results from a national survey JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Guendelman, S., Wagner, T. H. 2000; 11 (2): 179-194


    Utilization patterns may be changing as managed care organizations actively market services to Latinos. This study compares use of any care, emergency services, inpatient hospitalization, nonemergency outpatient care only, and preventive care among 1,001 self-identified Latino and 1,107 white non-Latino adults. Data were from the 1994 Commonwealth Fund Survey of Minority Health. Latinos were less likely than white non-Latinos to have entered the health system for any type of care, to have been admitted to a hospital, or to have used preventive care. Access to a regular source of care along with financial factors reduced the ethnic/racial gap in the use of any care and preventive care, yet cultural and behavioral factors contributed little. Latinos in managed care plans, compared with fee-for-service systems, were twice as likely to receive preventive care. This suggests that managed care has the potential to reduce inequities in preventive care utilization.

    View details for Web of Science ID 000086592400006

    View details for PubMedID 10793514

  • Healthcare utilization among Hispanics: Findings from the 1994 minority health survey AMERICAN JOURNAL OF MANAGED CARE Wagner, T. H., Guendelman, S. 2000; 6 (3): 355-364


    To assess the effects of health need, enabling factors, and predisposing factors on entry into any type of care, volume of care, use of emergency services, hospitalization, and receipt of preventive services.Multiple regression analysis with cross-sectional data.Participants were the 1001 adults who identified themselves as Hispanic in the Commonwealth Fund Minority Health Survey; a telephone survey of noninstitutionalized persons designed to oversample minorities was conducted.The 3 Hispanic subpopulations had similar sociodemographic profiles and similar patterns of healthcare utilization, except that Hispanics of other national origins were more likely to use preventive care compared with Mexican Americans and Puerto Ricans. Overall, 78% of the Hispanics surveyed entered the healthcare system in the past year, making an average of 5.25 visits. After controlling for other factors, immigrants had fewer visits and were less likely to have received preventive care. A regular source of care and insurance coverage influenced entry and volume of care, but was not associated with emergency services or hospitalizations.Access to care for Hispanics remains a major problem, significantly affected by structural and financial factors, personal experiences with the healthcare system, and predisposing factors. Policy solutions that address the health service needs of the uninsured will largely benefit Hispanics. In addition, as managed care plans compete for contracts and become more multicultural, access to care for Hispanics, including the uninsured, may improve through market forces.

    View details for Web of Science ID 000085952500005

    View details for PubMedID 10977435

  • Who gets second opinions? HEALTH AFFAIRS Wagner, T. H., Wagner, L. S. 1999; 18 (5): 137-145


    Six states require health plans to provide or authorize second medical opinions (SMOs). The intent of such legislation is to preserve consumer choice, to improve the flow of information, and to improve health outcomes in this era of managed care. However, it is unclear who benefits from these laws. This paper reviews the changing role of second opinions and, using a nationally representative data set from the Commonwealth Fund, examines who gets them. Of persons who had visited a doctor in the previous year, 19 percent received a second opinion, for an estimated cost of $3.2 billion in 1994. Findings suggest that cultural norms and sociocultural factors may partially determine who may benefit from SMO legislation.

    View details for Web of Science ID 000082646600015

    View details for PubMedID 10495601

  • Quality of life of women with urinary incontinence: Further development of the incontinence quality of life instrument (I-QOL) (vol 53, pg 71, 1999) UROLOGY Patrick, D. L., MARTIN, M. L., Bushnell, D. M., Yalcin, I., Wagner, T. H., Buesching, D. P. 1999; 53 (5): 1072-1072
  • Quality of life of women with urinary incontinence: Further development of the Incontinence Quality of Life Instrument (I-QOL) UROLOGY Patrick, D. L., MARTIN, M. L., Bushnell, D. M., Yalcin, I., Wagner, T. H., Buesching, D. P. 1999; 53 (1): 71-76


    To report on the further development of the Incontinence Quality of Life Instrument (I-QOL), a self-report quality of life measure specific to urinary incontinence (UI), including its measurement model, responsiveness, and effect size.Incontinent female patients (141 with stress, 147 with mixed UI) completed the I-QOL and comparative measures at screening, pretreatment, and four subsequent follow-up visits during participation in a multicenter, double-blind, placebo-controlled, randomized trial assessing the efficacy of duloxetine. Psychometric testing followed standardized procedures.Factor analysis confirmed an overall score and three subscale scores (avoidance and limiting behaviors, psychosocial impacts, and social embarrassment). All scores were internally consistent (alpha = 0.87 to 0.93) and reproducible (ICC = 0.87 to 0.91). The pattern of previously reported correlations with the Short-Form 36-item Health Survey and Psychological Well-Being Schedule were confirmed. Responsiveness statistics using changes in the independent measures of stress test pad weight, number of incontinent episodes, and patient global impression of improvement ranged from 0.4 to 0.8. Minimally important changes ranged from 2% to 5% in association with these measures and effect sizes.In a clinical trial, the I-QOL proved to be valid, reproducible, and responsive to treatment for UI in women.

    View details for Web of Science ID 000077739500013

    View details for PubMedID 9886591

  • Economic costs of urinary incontinence in 1995 - Reply by the authors UROLOGY Anonymous 1998; 51 (3): 360-361
  • Economic costs of urinary incontinence in 1995 UROLOGY Wagner, T. H., Hu, T. W. 1998; 51 (3): 355-360


    Urinary incontinence imposes a significant financial burden on individuals, their families, and healthcare organizations. For individuals 65 years of age and older these costs are substantial, increasing from $8.2 billion (1984 dollars) to $16.4 billion (1993 dollars). Both of these cost-of-illness estimates, however, relied on data and factors that have changed over time. This study updates these cost estimates. The 1995 societal cost of incontinence for individuals aged 65 years and older was $26.3 billion, or $3565 per individual with urinary incontinence. Limitations, implications, and directions for future research are also discussed.

    View details for Web of Science ID 000072414900001

    View details for PubMedID 9510336

  • Economic costs of urinary incontinence. International urogynecology journal and pelvic floor dysfunction Wagner, T. H., Hu, T. W. 1998; 9 (3): 127-128

    View details for PubMedID 9745968

  • The effectiveness of mailed patient reminders on mammography screening: A meta-analysis AMERICAN JOURNAL OF PREVENTIVE MEDICINE Wagner, T. H. 1998; 14 (1): 64-70


    Researchers have tried to increase mammography screening rates by using patient-oriented reminders. This paper compares the effectiveness of mailed patient reminders at increasing mammography screening.Sixteen published articles met the inclusion criteria and were included in the meta-analysis. To assess the association between reminders and mammography screening, the Mantel-Haenszel odds ratio (OR) was calculated.Among U.S. studies in which controls did not receive any type of reminder, women who received reminders were approximately 50% more likely to get a mammogram (OR 1.48; chi(2)MH(1) = 38.27, P < .001). In addition, tailored letters were found to be more effective than generic reminders (OR 1.87; chi(2)MH(1) = 4.70, P < .05). Combining cost and effectiveness data allowed for estimates of cost per woman screened, which ranged from $0.96 to $5.88.Patient reminders are effective at increasing mammography screening. More research is needed to assess (1) the cost-effectiveness of patient reminders and (2) their effectiveness across race, education, income, and type of insurance.

    View details for Web of Science ID 000071736500008

    View details for PubMedID 9476837

  • A new instrument to assess the long-term quality of life effects from migraine: Development and psychometric testing of the MSQOL HEADACHE Wagner, T. H., Patrick, D. L., Galer, B. S., BERZON, R. A. 1996; 36 (8): 484-492


    Quality of life is important to persons experiencing migraine. This study discusses the development of a migraine-specific quality-of-life measure (MSQOL). Participants, who included migraineurs from both tertiary care centers and the community, were screened using the International Headache Society migraine criteria prior to enrollment. Internal consistency of the MSQOL was high (alpha 0.92). Reproducibility over an average of 24 days was high (intraclass correlation 0.90). Construct validity was determined by convergent validity and known groups validity. The MSQOL was compared to two other frequently used health status questionnaires; results indicate that the MSQOL more closely resembles well-being than functional status. Results also indicate that migraineurs with more symptoms, medical appointments per year to treat migraines, and migraine episodes per year have a significantly worse quality of life. The MSQOL proved valid and reliable as a self-administered measure and will be a useful tool in clinical migraine research. The information gained from its use in the clinical environment should provide important additional information about the impact of migraine on quality of life and the potential benefits of therapeutic interventions.

    View details for Web of Science ID A1996VE85200007

    View details for PubMedID 8824004

  • Cross-cultural development of a quality of life measure for men with erection difficulties QUALITY OF LIFE RESEARCH Wagner, T. H., Patrick, D. L., McKenna, S. P., Froese, P. S. 1996; 5 (4): 443-449


    Erection difficulties have a profound effect on a man's quality of life, however, the emotional consequences are often overlooked in quantitative research where most sex-related questionnaires focus on a man's functional ability. Consequently, we developed a cross-cultural instrument to measure quality of life specific to male erection difficulties (QOL-MED). The items in the QOL-MED originated from interviewing forty men with erection difficulties In Seattle and Boston. Twelve men in the USA and 29 men in England helped us refine the instrument. Testing the QOL-MED's psychometric properties involved two administrations over a two-week period in the USA (n = 40) and the UK (n = 29). For discriminant validity, we predicted quality of life would worsen with increased self-perceived severity of the condition. After controlling for years with erection difficulties in a linear regression model, we found a significant negative association between self-perceived severity and quality of life for men in the UK only (p < 0.01). The expectation that the measure would produce evidence for convergent validity by being more closely correlated to well-being than functional status was not confirmed. Both the USA and UK instruments were internally consistent (Cronbach's alpha = 0.94 and 0.96, respectively), and reproducible (0.78 and 0.95, respectively). This instrument provides a promising tool for studying therapies and understanding quality of life in patients with erectile dysfunction.

    View details for Web of Science ID A1996VE41700005

    View details for PubMedID 8840824

  • Quality of life of persons with urinary incontinence: Development of a new measure UROLOGY Wagner, T. H., Patrick, D. L., BAVENDAM, T. G., MARTIN, M. L., Buesching, D. P. 1996; 47 (1): 67-71


    Our objective was to develop a self-report quality of life measure specific to urinary incontinence (I-QOL) that could be used as an outcome measure in clinical trials and in patient care centers.The I-QOL was developed from interviews of 20 individuals with urinary incontinence. Refining the questionnaire was accomplished by structured interviews of 17 individuals with urinary incontinence. Testing the I-QOL's psychometric properties involved two administrations (n = 62) along with measures of psychologic well-being and functional status.The rigorous development process ensured that the measure was complete and understandable. The I-QOL proved to be internally consistent (alpha 0.95) and highly reproducible (r = 0.93; 18 days; SD 4). For discriminant validity, severity of incontinence (P < 0.0001) and number of medical appointments in the past year to treat incontinence (P < 0.0001) significantly predicted I-QOL scores. Convergent validity analyses confirmed our predictions that the I-QOL scores were more closely related to overall well-being than bodily pain.The I-QOL proved to be valid and reproducible as a self-administered measure for assessing quality of life of patients with urinary incontinence.

    View details for Web of Science ID A1996TR21500012

    View details for PubMedID 8560665

  • Estimated costs of treating stress urinary incontinence in elderly women according to the AHCPR clinical practice guidelines Am J Manag Care Scott, R., Todd H, W., Tamara, B. 1996; 2