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CDA 07-020 – HSR&D Study

 
CDA 07-020
Appropriateness of Diagnostic and Therapeutic Interventions for Veterans with Stroke
Salomeh Keyhani MD MPH
San Francisco VA Medical Center, San Francisco, CA
San Francisco, CA
Funding Period: February 2008 - January 2013

BACKGROUND/RATIONALE:
Within the Veterans Health Administration (VHA), approximately 6000 veterans are hospitalized with acute ischemic stroke annually. Tissue plasminogen activator (tPA) is the only medication that is Food and Drug Administration (FDA) approved for the treatment of acute ischemic stroke. Guidelines support the use of tPA in eligible patients with acute ischemic stroke for the reduction of stroke symptom severity.

OBJECTIVE(S):
To examine the use and misuse of thrombolytic therapy in a national sample of veterans who were admitted to a VHA Medical Center (VAMC) with acute ischemic stroke.

METHODS:
Medical record reviews were conducted on 5000 acute stroke patients who were admitted to a VAMC in 2007. Patients were defined as eligible to receive tPA if they arrived at the hospital within 3 hours of stroke symptom onset and had no contraindications to tPA. We compared eligible patients who received tPA to those who did not and examined the distribution of eligible patients across the 130 VAMCs included in this study.


FINDINGS/RESULTS:
Not yet available.

IMPACT:
We found that relatively few eligible veterans receive thrombolysis across the VHA system and that strategies to improve thrombolysis delivery will have to account for the low annual volume of eligible stroke patients cared for at individual VAMCs. This work has informed our on-going work to assist VA policymakers to better plan VA stroke care. Our stroke make-buy model, allows the leadership of each VAMC to individually assess the costs of internal versus outsourced stroke care.


External Links for this Project

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PUBLICATIONS:

Journal Articles

  1. Keyhani S, Kim A, Mann M, Korenstein D. A new independent authority is needed to issue National Health Care guidelines. Health affairs (Project Hope). 2011 Feb 1; 30(2):256-65. [view]
  2. Korenstein D, Keyhani S, Mendelson A, Ross JS. Adherence of pharmaceutical advertisements in medical journals to FDA guidelines and content for safe prescribing. PLoS ONE. 2012 Feb 15; 6(8):e23336. [view]
  3. Ross JS, Keyhani S, Korenstein D. Appropriateness of collaborations between industry and the medical profession: physicians' perceptions. The American journal of medicine. 2009 Oct 1; 122(10):955-60. [view]
  4. Ross JS, Arling G, Ofner S, Roumie CL, Keyhani S, Williams LS, Ordin DL, Bravata DM. Correlation of inpatient and outpatient measures of stroke care quality within veterans health administration hospitals. Stroke. 2011 Aug 1; 42(8):2269-75. [view]
  5. Bishop TF, Federman AD, Keyhani S. Declines in physician acceptance of Medicare and private coverage. Archives of internal medicine. 2011 Jun 27; 171(12):1117-9. [view]
  6. Keyhani S, Federman A. Doctors on coverage--physicians' views on a new public insurance option and Medicare expansion. The New England journal of medicine. 2009 Oct 1; 361(14):e24. [view]
  7. Ross JS, Keyhani S, Keenan PS, Bernheim SM, Penrod JD, Boockvar KS, Krumholz HM, Siu AL. Dual use of Veterans Affairs services and use of recommended ambulatory care. Medical care. 2008 Mar 1; 46(3):309-16. [view]
  8. Arling G, Reeves M, Ross J, Williams LS, Keyhani S, Chumbler N, Phipps MS, Roumie C, Myers LJ, Salanitro AH, Ordin DL, Myers J, Bravata DM. Estimating and reporting on the quality of inpatient stroke care by Veterans Health Administration Medical Centers. Circulation. Cardiovascular quality and outcomes. 2012 Jan 1; 5(1):44-51. [view]
  9. Korenstein D, Falk R, Howell EA, Bishop T, Keyhani S. Overuse of health care services in the United States: an understudied problem. Archives of internal medicine. 2012 Jan 23; 172(2):171-8. [view]
  10. Korenstein D, Keyhani S, Ross JS. Physician attitudes toward industry: a view across the specialties. Archives of surgery (Chicago, Ill. : 1960). 2010 Jun 1; 145(6):570-7. [view]
  11. Federman AD, Woodward M, Keyhani S. Physicians' opinions about reforming reimbursement: results of a national survey. Archives of internal medicine. 2010 Oct 25; 170(19):1735-42. [view]
  12. Federman AD, Keyhani S. Physicians' participation in the Physicians' Quality Reporting Initiative and their perceptions of its impact on quality of care. Health policy (Amsterdam, Netherlands). 2011 Oct 1; 102(2-3):229-34. [view]
  13. Neuman J, Korenstein D, Ross JS, Keyhani S. Prevalence of financial conflicts of interest among panel members producing clinical practice guidelines in Canada and United States: cross sectional study. BMJ (Clinical research ed.). 2011 Oct 11; 343:d5621. [view]
  14. Keyhani S, Falk R, Bishop T, Howell E, Korenstein D. The relationship between geographic variations and overuse of healthcare services: a systematic review. Medical care. 2012 Mar 1; 50(3):257-61. [view]
  15. Keyhani S, Arling G, Williams LS, Ross JS, Ordin DL, Myers J, Tyndall G, Vogel B, Bravata DM. The use and misuse of thrombolytic therapy within the Veterans Health Administration. Medical care. 2012 Jan 1; 50(1):66-73. [view]
  16. Keyhani S, Wang S, Hebert P, Carpenter D, Anderson G. US pharmaceutical innovation in an international context. American journal of public health. 2010 Jun 1; 100(6):1075-80. [view]
Journal Other

  1. Kale MS, Bishop TF, Federman AD, Keyhani S. "Top 5" lists top $5 billion. [Letter to the Editor]. Archives of internal medicine. 2011 Nov 14; 171(20):1856-8. [view]
  2. Keyhani S, Federman A. Health care reform and the AMA. [Letter to the Editor]. The New England journal of medicine. 2010 Jun 10; 362(23):2230-2. [view]
  3. Bishop TF, Federman AD, Keyhani S. Physicians' views on defensive medicine: a national survey. [Letter to the Editor]. Archives of internal medicine. 2010 Jun 28; 170(12):1081-3. [view]
Conference Presentations

  1. Keyhani S. Adherence of Pharmaceutical Ads in Medical Journals to FDA Standards. Paper presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 28; Minneapolis, MN. [view]
  2. Keyhani S. Did the American Medical Association Represent Physician Views in Health Care Reform? Poster session presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 28; Minneapolis, MN. [view]
  3. Keyhani S, Cheng E, Li X, Arling G, Williams LS, Phipps M, Bravata DM. Does inclusion of NIH stroke scale in a 30-day mortality model impact VAMC rankings? Paper presented at: American Heart Association Quality of Care and Outcomes Research Council Annual Scientific Session; 2011 May 13; Washington, DC. [view]
  4. Keyhani S, Falk R, Bishop T, Howell EA, Korenstein D. Geographic Variations and Overuse: A Systematic Review. Poster session presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA. [view]
  5. Keyhani S, Falk R, Bishop T, Howell EA, Korenstein D. Overuse and Systems of Care: Implications for Accountable Care Organizations. Poster session presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA. [view]
  6. Keyhani S. Physician Views on Comparative Effectiveness Research: A National Survey. Paper presented at: AcademyHealth Annual Research Meeting; 2010 Jun 27; Boston, MA. [view]
  7. Keyhani S, Allen K, Hebert PL, Penrod JD, Federman A, Siu AL. Self Reported Health Characteristics of Veterans who use the VA and Medicare FFS. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD. [view]
  8. Keyhani S, Cheng E, Ofner S, Williams L, Halm E, Bravata DM. The Underuse of Carotid Imaging in the VHA. Poster session presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2011 May 14; Washington, DC. [view]


DRA: Aging, Older Veterans' Health and Care, Health Systems, Brain and Spinal Cord Injuries and Disorders, Cardiovascular Disease
DRE: Treatment - Observational, Prevention
Keywords: none
MeSH Terms: none

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