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Publication Briefs

Study Examines the Consequences of Notifying VA Patients about Potential Exposure to Large-Scale Adverse Events

Communicating medical or healthcare system errors to patients in a way that guides them to appropriate action is one of the more difficult challenges in medicine, particularly in regard to large-scale adverse events (LSAEs) in which patients are exposed to an adverse event that raises the risk of infection. As organizations develop best practices, there are often questions about how to measure the damage created by an LSAE or, conversely, the benefit that better communication about LSAEs might engender. This study sought to determine the intended and unintended consequences of patient notification following an LSAE within the VA healthcare system, which systematically looks for LSAEs, tracks potentially exposed patients, and communicates with them after LSAE notification. Using VA data, investigators examined six LSAEs where Veterans may have been inadvertently exposed to hepatitis C virus (HCV), hepatitis B virus (HBV), and HIV. Cases (n=9,638) and controls (n=45,274) were identified at five VAMCs between 2009 and 2012 based on exposure dates, clinical and procedure codes. Outcomes included: receipt of testing for HCV, HBV, and HIV following notification; number of days between notification and testing; and location of testing (VA vs. non-VA healthcare facility). Veterans were categorized into younger (<65) and older (>65) patient segments to account for age-related Medicare eligibility. Demographics also were examined.


  • More than two-thirds of potentially exposed patients returned for HCV, HBV, and HIV testing following the receipt of an LSAE notification letter, which was associated with a 72 to 76 percentage point increase in testing.
  • Among Veterans who sought testing, 57% were tested in the 30 days following notification, and 74% were tested within 60 days. The vast majority (>98%) completed testing in a VA facility; less than 2% were tested at a non-VA facility paid by purchased care or Medicare (when eligible).
  • Among older Veterans, notification was associated with higher odds of increased VA outpatient use in the following 3 months, but decreased odds of using VA healthcare in the subsequent 9 months.
  • Compared to white Veterans, African American Veterans were significantly less likely to return to VA for follow-up testing.


  • The cohort used for this study might exclude notified patients or include unaffected patients because investigators did not have the list of specific patients who were notified.
  • There was a lack of non-VA data for patients under age 65.

This study was funded by HSR&D (SDR 11-440). Drs. Wagner, Taylor, and Asch, and Ms. Cowgill are part of HSR&D's Center for Innovation to Implementation; Dr. Wagner, Mr. Su, and Ms. Cowgill also are part of HSR&D's Health Economics Resource Center, both located in Palo Alto, CA. Drs. Bokhour and Elwy and Ms. Maguire are with HSR&D's Center for Healthcare Organization and Implementation Research, Bedford/Boston, MA.

PubMed Logo Wagner T, Taylor T, Cowgill E, Asch S, Su P, Bokhour B, Durfee J, Martinello R, Maguire E, Elwy R. Intended and Unintended Effects of Large-Scale Adverse Event Disclosure: A Controlled Before-After Analysis of Five Large-Scale Notifications. BMJ Quality & Safety. May 2015;24(5):295-302.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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