Examples of Scholar Research Projects

After hospitalization, many patients wind up back in the Emergency Room (Anita Vashi, CSP 11-13)

Following a hospitalization, patients face many challenges as they transition home. Current efforts to improve and coordinate healthcare rely on hospital readmission rates as a marker of quality and transitions in care during the post acute care period. Dr. Vashi, a VA Clinical Scholar, and colleagues conducted a study to determine the degree to which ED visits (treat-and-release encounters) contributed to overall use of acute care services within 30 days of hospital discharge. In a study of 5,032,254 index hospitalizations among 4,028,555 adult patients, the team found that of all the hospitalizations in the study, 17.9 percent resulted in at least 1 acute care encounter in the 30 days following discharge; 7.5 percent of discharges were followed by at least 1 ED encounter; and 12.3 percent by at least 1 readmission. For every 1,000 discharges, there were 97.5 ED treat-and-release visits and 147.6 hospital readmissions in the 30 days following discharge. Visits to the ED comprised nearly 40 percent of the post-discharge acute care encounters. Moreover, patients commonly returned to the ED for reasons related to their index hospitalization. This study raises concerns that many more patients require acute medical care after hospital discharge than previously recognized. The use of hospital readmissions as a lone metric for post-discharge health care quality may be incomplete without considering the role of the ED.

JAMA, 309(4):364-71, 2013.

Higher opioid analgesic receipt among HIV+ veterans (E. Jennifer Edelman, CSP 09-12)

Dr. Edelman and colleagues investigated patterns of opioid receipt across 78,738 HIV infected and uninfected patients using 2005-2006 data from the Veterans Aging Cohort Study-Virtual Cohort (VACS-VC). Since patients with HIV are more likely to have substance use disorders, and opioids may be detrimental to the immune system and interact with antiretroviral treatments, opioid analgesics could present a greater risk to these patients than their uninfected counterparts. Dr. Edelman and her colleagues found that over 1 in 3 patients had received at least one opioid prescription during the study period. They also found that after controlling for factors known to be associated with opioid receipt, HIV-infected patients had 40 percent higher odds of receiving opioids than uninfected patients. As HIV is now a chronic disease, these findings underscore the need for further research examining the long-term risks and benefits of opioid analgesics in HIV-infected patients. The VACS-VC data provides an opportunity to examine these effects, and Dr. Edelman is pursuing this line of inquiry.

J Gen Intern Med, 28(1):82-90, 2013.

Coordination of care between hospitals and homeless shelters in New Haven (S. Ryan Greysen, CSP 09-11)

The higher use of acute care services, inpatient admissions, and ED visits among the homeless population reflects a high degree of health disparity across the nation and is a significant health care burden. Dr. Greysen and colleagues used a community-based participatory research approach to include input from the Columbus House shelter staff, case managers, and social workers; homeless individuals; city and state officials; and clinicians and administrators at Y-NHH as well as those from the health center closest to Columbus House. Of 98 shelter clients surveyed, 60 percent delayed seeking care because they were concerned they wouldn’t get the care they needed or wouldn’t be able to find a shelter the night after discharge. Study participants also identified three areas for improvement: 1) hospital providers should consider housing a health concern, 2) hospital and shelter providers should communicate during discharge, and 3) discharge planning should include safe transportation. Forming a partnership between the hospital and community shelter is a Medicare innovation funded by the ACA.

J Gen Intern Med, 27(11):1484-91, 2012.

Many out-of-network physician services lack transparency (Kelly Kyanko, CSP 09-11)

Private insurance plans that offer reimbursement for out-of-network physician services are popular. However, the additional costs of using an out-of-network physician may be unexpected if patients involuntarily use out-of-network physicians or costs are not transparent. In an online survey, Kyanko and coworkers found that of 7,812 respondents with private health insurance, 8.3 percent used an out of network physician in the past 12 months. 40 percent who used out-of-network physicians did so involuntarily due to medical emergency or lack of knowledge of the physician’s out-of-network status. In comparison to those who use out-of-network physicians voluntarily, involuntary use was more likely to involve single marital status, low (<$35,000) income, and was usually for primary care services. About half of those who used out-of-network physicians noted nontransparent costs. Several states have already begun to address price transparency by mandating disclosure of out-of-network status.

Health Serv Res. 2012 Oct 22.

Inappropriate and appropriate use of prostate cancer imaging are linked and vary by region (Danil Makarov, CSP 08-10)

Dr. Makarov, a VA Clinical Scholar, and colleagues sought to verify if the “thermostat model” can be used to describe prostate cancer imaging use. The SEER-Medicare linked database was consulted to determine rates of appropriate and inappropriate imaging in a sample of 29,053 men diagnosed with prostate cancer in 2004-2005 across 16 regions. There was a significant variation by registry site and a correlation between high appropriate imaging and high inappropriate imaging. This study suggests that efforts to lower inappropriate use of imaging could also lower appropriate use of imaging. Dr. Makarov recently received a VA Career Development Award to further our understanding of factors driving use—and overuse—of imaging tests.

Health Affairs, 31(4):730-40, 2012.