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  • Excess Mortality Rates among Post-9/11 Veterans Compared with General US Population, Particularly among Veterans with TBI
    This study sought to assess the total all-cause and cause-specific mortality burden – and to estimate the total number of excess deaths among post-9/11 Veterans with and without exposure to traumatic brain injury (TBI) compared with the total US population. Findings showed that post-9/11 Veterans experienced excess all-cause and cause-specific mortality compared with the total US population, which was exacerbated by exposure to TBI. While Veterans exposed to moderate/severe TBI accounted for only 3% of the total post-9/11 Veteran population, they accounted for 34% of total excess deaths observed, which was 11-fold higher than would otherwise be expected. The top five causes of death for Veterans were: 1) accident, 2) suicide, 3) cancer, 4) cardiovascular disease, and 5) homicide. Adjusted mortality rates for each were higher among Veterans with mild and moderate/severe TBI, compared with Veterans with no TBI. While excess accident, suicide, and homicide mortality was greater among those with TBI across all age groups, excess mortality from cardiovascular disease and cancer was primarily in Veterans >55 years with moderate/severe TBI. After 20 years of war, it is vital to focus attention on what puts Veterans at risk for accelerated aging and increased mortality, and how it can be mitigated.
    Date: February 11, 2022
  • Increased Risk for Cardiovascular Conditions among Veterans for Up to One Year Following COVID-19 Infection
    This study evaluated the risks and 12-month burdens of cardiovascular outcomes among Veterans who survived the first 30 days of COVID compared to VA healthcare users with no COVID and Veterans who used VA healthcare before the COVID pandemic. Findings showed that COVID-19 increased the risk of developing cardiovascular conditions – spanning several categories – within the first month to one year after infection. The risk increased even in Veterans without previous heart conditions and in those with mild COVID-19 infection. Overall, heart disease was seen in 4% more people who contracted COVID-19 than in those without. COVID-19 patients were 72% more likely to suffer from coronary artery disease, 63% more likely to have a heart attack, and 52% more likely to have a stroke. Health systems should prepare for a significant contribution of COVID-19 to a rise in the burden of cardiovascular diseases and the potential long-lasting consequences for patients and the health system.
    Date: February 7, 2022
  • Women Veterans with Premature Cardiovascular Disease Less Likely than Men to Receive Secondary Prevention Therapy
    This study sought to evaluate sex-based differences in antiplatelet use, any statin and high-intensity statin (HIS) therapy, and statin adherence among patients with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD). Findings showed that women Veterans with premature (age < 55 years) and extremely premature (age < 40 years) ASCVD were less likely to receive antiplatelet agents or statins than men. Premature ASCVD women, compared with men, were significantly less likely to receive antiplatelets (61% vs. 79%), any statin (58% vs. 75%), or HIS therapy (24% vs. 38%). Women with premature ischemic heart disease were comparatively less statin adherent. Relative to women of other races, Black women were less likely to receive some therapies but also more likely to receive others. There was no heterogeneity observed regarding statin adherence. Overall, both sexes received sub-optimal aspirin and statin therapy and had poor statin adherence.
    Date: April 21, 2021
  • Many Veterans Unnecessarily Take Low-Dose Aspirin to Prevent Cardiovascular Disease
    The goal of this study was to investigate the suitability of electronic health records (EHR) to identify patients for deprescribing aspirin based on updated guidelines. Findings showed that many Veterans unnecessarily take low-dose aspirin to prevent cardiovascular disease. Between 2% to 5% of Veterans in this study took low-dose aspirin outside of the guidelines and qualify for the definition of medication overuse as defined by the Institute of Medicine. The percentage of Veterans with low-dose aspirin use was especially high in those aged 50-79. True numbers are likely even higher given the incomplete capture of aspirin use in the EHR.
    Date: December 15, 2020
  • VA HIT-Related Outpatient Diagnostic Delays
    This study evaluated the role of health information technology (HIT) in the root cause analyses (RCAs) of outpatient diagnostic delays submitted to the VA National Center for Patient Safety, which leads patient safety initiatives and uses RCAs of adverse events and close calls to promote learning across the VA healthcare system. Findings showed that of the 214 RCAs included in this study, 88 involved HIT-related safety factors in diagnostic delays. In the majority of these RCAs (n=64), the primary process breakdown was due to inadequate follow-up of one or more abnormal test results. Delays involved the diagnosis of serious conditions, including cancers, infections, and cardiovascular disease. Most safety concerns (83%) involved problems with the safe use of HIT, mainly sociotechnical factors associated with workflow and communication, people, and a poorly designed human-computer interface. Five key high-risk areas for diagnostic delays emerged: 1) managing electronic health record inbox notifications and communication, 2) gathering diagnostic information, 3) technical problems, 4) data entry problems, and 5) failure of a system to track test results. Study findings suggest multiple interventions to reduce outpatient diagnostic delays through improved design, configuration, and use of HIT. Interventions should aim to: 1) Redesign EHR inboxes and message workflow; 2) Develop safety nets to identify missed results; 3) Improve the display of diagnostic information; 4) Track referrals; 5) Optimize order entry design; and 6) Pursue interoperability between VA and non-VA care settings.
    Date: June 25, 2020
  • Cardiovascular Benefits of Intensive Glucose Control in Veterans with Type 2 Diabetes Did Not Persist in Long-term Post-Trial Follow-Up
    Long-term follow-up of glucose lowering in patients with type 2 diabetes may help clarify the duration of any potential cardiovascular disease (CVD) benefit. Investigators here report on the full 15-year follow-up of Veterans with type 2 diabetes who were randomly assigned to receive either intensive or standard glucose control as part of the Veterans Affairs Diabetes Trial. Findings showed that Veterans with type 2 diabetes at high CVD risk, with 5.6 years of intensive glucose lowering to a HbA1c of 6.9%, DID NOT experience reduced major cardiovascular events over 13.6 years of follow-up or reduced total mortality or improved quality of life over 15 years of total follow-up. Although there was a 17% reduction in major CVD events during the approximate 10-year period when HbA1c levels were separated between the intensive and standard therapy groups, there was no evidence of a beneficial legacy effect in the subsequent 5-year period once levels equalized among the groups. Results suggest there are modest long-term cardiovascular benefits of intensive glucose lowering therapy in patients with more advanced diabetes, but that long-term maintenance of lower levels may be required to maintain these improvements.
    Date: June 6, 2019
  • Cardiovascular Care and Research for Women Veterans
    This review presents important information on five areas of cardiovascular disease (CVD) care for women Veterans: 1) rapidly changing demographics; 2) prevalence of traditional risk factors; 3) prevalence of less traditional risk factors (i.e., homelessness, military sexual trauma, and mental health disorders); 4) treatment and outcomes of CVD; and 5) the current state and future directions of women’s health research. The rapidly growing population of women Veterans represents a specific at-risk population with characteristics that set them apart from their male counterparts as well as civilian women regarding CVD risk factors and CVD recognition, diagnosis, treatment, and possibly outcomes. Significant advancements have been made over the past decade in better characterizing CVD in women Veterans, but there remains a large gender gap and paucity of prospective, randomized, interventional clinical trials.
    Date: February 19, 2019
  • Higher Statin Adherence Associated with Lower Mortality in Veterans with Atherosclerotic Cardiovascular Disease
    This analysis sought to determine whether statin adherence is associated with mortality in stable patients with atherosclerotic cardiovascular disease (ASCVD). Findings showed that higher statin adherence was associated with lower mortality in a national sample of Veterans with ACSVD. Also, ischemic heart disease or stroke hospitalizations in the VA healthcare system were more frequent in Veterans who were less adherent to statins. Overall, statin adherence in this cohort on a stable statin intensity was high (88%). Veterans on moderate-intensity statin therapy were more adherent than Veterans on high-intensity statin therapy. Veterans with peripheral artery disease and cerebrovascular disease were less adherent than those with coronary artery disease. Women and minority groups were less adherent to statin therapy, with adherence lowest among black patients. Younger and older patients were less adherent, compared with adults aged 65-74.
    Date: February 13, 2019
  • Substantial Variation in Cardiovascular Mortality Rates across the VA Healthcare System
    This study sought to determine whether there are substantial differences in cardiovascular outcomes across 138 VA medical centers. Findings showed that there is substantial variation in risk-standardized cardiovascular mortality rates across the VA healthcare system, suggesting differences in the quality of cardiovascular healthcare. Ischemic heart disease (IHD) annual death rates at the VAMC with the highest mortality were 3.9 percentage points larger than at the VAMC with the lowest mortality, translating into 1 excess death per year on average among every 26 IHD patients at the highest-mortality VAMC. Similarly, chronic heart failure (CHF) annual death rates were 7.8 percentage points larger, translating into1 excess death per year among every 13 CHF patients at the highest-mortality VAMC compared with CHF patients at the lowest mortality VAMC. Twenty-nine VAMCs had IHD mortality rates that significantly exceeded the national mean, while 35 VAMCs had CHF mortality rates that significantly exceeded the national mean. Cardiovascular mortality in VA medical centers’ chronic cardiovascular disease populations was only modestly correlated with post-hospitalization 30-day outcomes – or with VA’s 5-star quality ratings system.
    Date: July 1, 2018
  • Veterans are Commonly Prescribed Statins for Indications Unsupported by Guidelines for Managing High Cholesterol
    This study of new statin prescriptions in the VA healthcare system examined concordance with ATP-III guidelines (in force in 2102) and ACC-AHA guidelines (updated in 2013). Findings showed that Veterans were commonly prescribed statins for indications not supported by either the ATP-III or the ACC-AHA 2013 guidelines. Of Veterans receiving new statins for primary prevention, 48% did not meet ATP III guidelines; 20% did not fulfill the new ACC-AHA guidelines. Of the Veterans included in the study, 68% of new statins were prescribed for primary prevention and 32% were for secondary prevention of atherosclerotic cardiovascular disease. Nineteen percent of Veterans receiving statins did not meet either set of guidelines.
    Date: September 19, 2017
  • Maximal Doses of High-Intensity Statins Confer Greatest Survival Advantage for Those with Atherosclerotic Cardiovascular Disease
    This study sought to determine one-year cardiovascular mortality for VA patients with atherosclerotic cardiovascular disease by statin intensity – and to assess whether any differences in mortality related to statin intensity, if present, were observed in selected patient sub-groups (i.e., age, gender). Findings showed that high-intensity statins conferred a small but significant survival advantage over moderate intensity statins, even among older adults. Moreover, the maximal doses of high intensity statins conferred a further survival benefit. For example, when the sample was limited to Veterans on high-intensity statins, those treated with maximal doses had a 10% lower mortality when compared with those on sub-maximal doses. There was significant underuse of high-intensity statins and a graded relationship between statin intensity and mortality among Veterans in this study. Only 20% of Veterans received a high-intensity statin, while 43% were on moderate-intensity statins. Older adults (>75 years), women, and some minority groups were less likely to be on a high-intensity statin at baseline. Findings have significant implications for future lipid management practice guidelines.
    Date: November 9, 2016
  • VA Diabetes and Cardiovascular Care Quality Comparable between Physicians and Advanced Practice Providers
    This study assessed the effectiveness of diabetes and cardiovascular disease (CVD) care provided to Veterans in VA primary care by advanced practice providers (APPs) compared to physicians. Findings showed that the quality of diabetes and CVD care delivered in VA primary care settings was mostly comparable between physicians and APPs. However, a majority of Veterans with diabetes and CVD – irrespective of their provider type – did not meet performance measures geared toward control of multiple risk factors. Only 27% and 28% of Veterans with diabetes and 54% and 55% of Veterans with CVD receiving care from physicians and APPs, respectively, met all eligible measures. Thus, regardless of provider type, there is a need to improve performance on all eligible measures among these Veterans.
    Date: November 1, 2016
  • The Gerontologist Supplement Highlights VA Research on Health Issues Affecting Older Women Veterans
    This Supplement includes 13 articles that highlight findings on a range of topics related to women Veterans and aging, such as, menopause, diabetes, cardiovascular disease, chronic pain, and substance use.
    Date: February 1, 2016
  • Sleep Difficulties Associated with Risk Factors for Cardiovascular Disease among Younger Veterans and Active Duty Personnel
    This study examined the relationship between sleep difficulties and several cardiovascular (CVD) risk factors (i.e., smoking status, body mass index, self-reported hypertension, hypertension medication use, clinic-based blood pressure readings, symptoms of depression and PTSD, and diagnosis of depression and PTSD) among relatively younger (mean age, 37 years) Veterans and active duty personnel of the Iraq and Afghanistan wars. Findings showed that 8% of the Veterans in this study endorsed only sleep onset difficulties, 9% endorsed only sleep maintenance difficulties, and 41% endorsed both sleep onset and sleep maintenance difficulties. Study participants with both sleep onset and maintenance difficulties had greater odds of being a current smoker, having a diagnosis of PTSD, having clinically significant PTSD symptoms, having a diagnosis of depression, and having clinically significant depression symptoms. The odds for these risk factors did not differ by race or age. Having the combination of sleep onset and maintenance difficulties also was associated with elevated systolic blood pressure readings and increased likelihood of reporting a hypertension diagnosis among younger white Veterans. Overall, study participants with sleep maintenance difficulties were older, while those having both sleep onset and maintenance difficulties were younger and reported more tours of duty. Veterans reporting sleep difficulties of any kind reported more symptoms of depression and PTSD. Authors note that since sleep difficulties are associated with several CVD risk factors, improving sleep in this younger population may reduce the progression of disease and avert the increased incidence of CVD found in older Veterans.
    Date: March 27, 2015
  • Female Veterans with CVD Less Likely to Receive Statin and High-Intensity Statin Therapy Compared to Male Veterans with CVD
    This study sought to identify the proportion of male and female Veterans with cardiovascular disease (CVD) who received care in any of 130 VA facilities between 10/1/10 and 9/30/11, and who received any statin and high-intensity statin. Findings showed that while evidence-based use of both statin and high-intensity statin therapy remains low in both genders, female Veterans with CVD were less likely to receive evidence-based statins (58% vs. 65%) and high-intensity statins (21% vs. 24%) compared with male Veterans. In fully adjusted analyses, female gender was independently associated with a 32% lower likelihood of receiving any statin therapy and a 24% lower likelihood of receiving high-intensity statin therapy. Mean low-density lipoprotein cholesterol levels were higher in female compared with male Veterans (99 vs. 85 mg/dl) with CVD. The use of statin and high-intensity statin therapy among female Veterans with CVD showed substantial facility-level variation. With the “statin dose-based approach” proposed by the recent cholesterol guidelines, these results highlight areas for quality improvement. It is important to note that despite the observed gender disparity noted in this study, statin and high-intensity statin use remain low in both genders. This is concerning, as the patient population studied in these analyses (i.e., those with established CVD) is the one that derives the most benefit from statin and high-intensity statin therapy.
    Date: January 1, 2015
  • Women Veterans, Particularly Black Veterans, Have Worse Risk Factor Control for Cardiovascular Disease than Male Veterans
    This study compared gender and racial differences in three risk factors that predispose individuals to cardiovascular disease: diabetes, hypertension, and hyperlipidemia. Findings showed that overall, female Veterans had significantly higher LDL cholesterol levels than male Veterans, despite being almost ten years younger, on average. These differences are similar to gender disparities previously reported both within and outside VHA and represent a clinically significant difference. African-American women Veterans had worse blood pressure control than White women Veterans, and among Veterans with diabetes, male African-Americans had worse control of higher blood pressure, LDL, and HbA1c levels than White males.
    Date: September 1, 2014
  • “Tailored” Treatment of Blood Pressure May Prevent Many More Heart Attacks and Strokes than Current Guidelines
    Most current blood pressure (BP) guidelines advocate a treat-to-target (TTT) strategy, which titrates treatment towards intermediate outcomes, notably a BP goal. Benefit-based tailored treatment (BTT) strategies estimate an individual’s net absolute benefit from treatment – taking into account the patient’s estimated risk reduction from treatment, as well as potential harms associated with treatment. This study sought to determine whether a BTT strategy for the treatment of hypertension would prove superior to a traditional TTT strategy. Findings showed that BTT was both more effective and required less antihypertensive medication than current guidelines based on treating to specific blood pressure goals. Over five years, BTT would prevent 900,000 more cardiovascular disease events and save 2.8 million more quality-adjusted life years (QALYs), despite using 6% fewer medications, compared to TTT. While 55% of the 176 million “simulated” patients in this study would be treated identically under the two treatment approaches, in the 45% of the population treated differently by the strategies, BTT would save 159 QALYs per 1,000 treated versus 74 QALYs per 1,000 treated by the TTT approach.
    Date: November 19, 2013
  • Musculoskeletal Conditions, Injuries, and Pain More Prevalent among Patients Using Statins
    This study sought to determine whether statin use was associated with musculoskeletal conditions, including arthropathy (joint disease) and injury. Findings showed that musculoskeletal conditions, injuries, and pain were more common among statin users than similar non-users. In addition, arthropathy was found to be more common among statin users than non-users. Authors note that these findings are concerning, since starting statins at a young age for primary prevention of cardiovascular diseases has been widely advocated.
    Date: July 22, 2013
  • Comparing Cardiovascular Outcomes for Two Common Anti-Diabetes Drugs among Veterans
    This study compared cardiovascular disease (CVD) outcomes and all-cause mortality in a cohort of Veterans who received regular VA healthcare and were prescribed metformin or sulfonylureas – the two most commonly used anti-diabetic drugs. Findings showed a modest but clinically important 21% increased risk of hospitalization for heart attack or stroke, or death from any cause associated with the initiation of sulfonylurea compared with metformin therapy. The sulfonylurea group had higher rates of hospitalizations and deaths due to cardiovascular disease: 18 per 1,000 person years for those taking a sulfonylurea and 10 per 1,000 person years for those taking metformin. These findings suggest that for 1,000 patients who are initiating treatment for diabetes using metformin rather than sulfonylureas, there are 2 fewer heart attacks, strokes, or deaths per year of treatment. The findings do not clarify whether the difference in CVD risk is due to harm from sulfonylureas, benefit from metformin, or both.
    Date: November 6, 2012
  • Construction of a Clinical Indicator for the Risk of Over-Treatment among Elderly Patients with Diabetes
    The publication of three major trials, including the VA Diabetes Trial (VADT), has prompted greater attention to the potential harms of overly tight glycemic control among patients with diabetes, especially in the elderly and those with cardiovascular disease. The high frequency of risk factors for hypoglycemia and its adverse impact, the marginal benefits of tight control in individuals with short life expectancy, and potential for inaccurate measures suggest a need for a quality measure to reduce over-treatment, particularly among elderly patients. This Commentary discusses these issues and explores the construction of a clinical indicator for the risk of over-treatment.
    Date: September 10, 2012
  • Women Veterans Report Poorer Health Outcomes Compared to Civilian and Active Duty Women
    Veteran women reported consistently poorer health compared with other women, including poorer general health, greater likelihood of health risk behaviors (e.g., smoking), and greater likelihood of chronic conditions and mental health disorders. Veterans were most likely – and active duty least likely – to report frequent poor physical health. Veterans were more likely than civilian and active duty women to be obese or overweight – and to have cardiovascular disease. National Guard or Reserves (NG/R) women also were more likely to be overweight or obese than both civilian and active duty women. Veterans were more likely than civilians to report a history of depressive disorder and more likely than active duty women to report a history of anxiety disorder. NG/R women were more likely than civilian and active duty women to report both depression and anxiety. Tobacco use and lack of exercise were most commonly reported among Veterans and least commonly reported among active duty women. Compared to civilians, Veteran women were more highly educated and had higher incomes. Despite these protective factors, Veteran women reported faring better than civilians on only two indicators – health insurance and receiving clinical breast exams.
    Date: May 1, 2012
  • Threshold for Glycemic Control among Veterans with Diabetes
    In 2009, the National Committee for Quality Assurance (NCQA) – Healthcare Employer Information Data Set (HEDIS) measure for good (<7% A1c) glycemic control for individuals with diabetes was revised to apply only to persons younger than 65 years without cardiovascular disease, end-stage diabetes complications, or dementia. However, multiple guidelines recommend that glycemic control targets be individualized, especially in the presence of comorbid medical and mental health conditions. This retrospective study used the NCQA <7% measure to compare overall VA facility rankings with a subset of Veterans receiving complex glycemic treatment regimens (CGR). Findings show that the assessment of the quality of good glycemic control among VA facilities differs using the NCQA-HEDIS measure for the overall study population compared to a subset of patients receiving CGR. For example, the overall top 10% performing facilities achieved a rate of 57% at the <7% A1c threshold compared to 34% for Veterans on CGR using the same measure. Therefore, the authors suggest that reliance upon a <7% A1c threshold measure as the “quality standard” for public reporting or pay-for-performance could have the unintended consequence of adversely impacting patient safety. Moreover, they propose that rather than assessing “good glycemic control” by an all-or-none threshold, developers of measures should provide credit for an A1c result within an acceptable range (e.g. incremental credit for improvement between 7.9% and <7%) in order to balance the trade-offs of benefits, harms, and patient preferences.
    Date: October 1, 2010
  • Mental Health Diagnoses Associated with Cardiovascular Risk Factors among OEF/OIF Veterans
    Studies of Veterans from prior wars found that those with PTSD are at increased risk of developing and dying from cardiovascular disease, but this risk had not yet been evaluated in OEF/OIF Veterans. This article discusses findings from a study on the association between mental health disorders, including PTSD, and cardiovascular risk factors. Findings show that OEF/OIF Veterans (male and female) with mental health diagnoses had a significantly higher prevalence of cardiovascular risk factors (e.g., hypertension, obesity, diabetes, tobacco use). The association between mental health diagnoses and cardiovascular risk factors remained after adjusting for demographics and military factors. The most common mental health diagnosis was PTSD (24%). The majority of Veterans with PTSD had comorbid mental health diagnoses: depression (53%), anxiety disorder (29%), adjustment disorder (26%), alcohol use disorder (22%), substance use disorder (10%), as well as other psychiatric diagnoses (33%).
    Date: August 5, 2009
  • Healthcare Utilization among American Indian and Alaska Native Veterans
    Findings show that like other VA healthcare users, American Indian and Alaska Native (AIAN) patients had the same three most frequent diagnoses associated with healthcare encounters: post-traumatic stress disorder, hypertension, and diabetes. VHA-Indian Health Service (IHS) dual-users were more likely to receive primary care from IHS and to receive diagnostic and behavioral healthcare from VA. Many dual-users who had been diagnosed with diabetes, hypertension, and/or cardiovascular disease received overlapping healthcare services in VA and IHS. Therefore, authors suggest that strategies to improve outcomes among the AIAN Veteran population should target those receiving care in both systems and include information sharing or coordination of clinical care to reduce the potential for duplication and for treatment conflicts.
    Date: June 1, 2009
  • Cardiovascular Risk Reduction Clinic for Veterans with Diabetes
    The Cardiovascular Risk Reduction Clinic (CRRC) is a pharmacist-coordinated clinic at the Providence VAMC designed to treat the four traditional cardiovascular risk factors (diabetes, dyslipidemia, hypertension, and smoking) to attain goals set forth by national guidelines for patients with diabetes or documented cardiovascular disease. Veterans are discharged from the CRRC when guideline-recommended goals for hemoglobin A1c, low-density lipoprotein cholesterol, blood pressure, and smoking are achieved or mostly achieved. This study evaluated the maintenance of these goals for two to three years after discharge from the CRRC. Findings show that Veterans who completed the program maintained two goals – HbA1c and LDL-C – over three years of observation. The effect on blood pressure was less durable, with half of the Veterans who were at target levels at discharge from the CRRC reaching systolic BP >130 within six months after discharge. Results also show that the most important factor to consider for risk of failure after successful attainment of a cardiovascular goal is how poorly controlled the goal was at baseline.
    Date: March 1, 2009

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