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  • Difficulty of Diagnosing and Treating Veterans Suspected of Having Long COVID
    Using data from VA’s electronic health record (EHR), investigators identified a random, nation-wide sample of 200 VA patients who were assigned a new ICD-10 diagnostic code for long COVID between October 1, 2021, and March 1, 2022. Investigators then conducted a text word search and qualitative analysis of Veterans’ EHRs to identify dominant themes pertaining to the diagnosis and management of long COVID. Findings showed that there was substantial clinical uncertainty around the diagnosis and management of long COVID; most Veterans had one or more comorbid conditions with symptoms that might overlap those of long COVID. Some patients had prolonged or repeated hospital admissions or nursing home stays, blurring the boundaries between outcomes associated with acute infection, prolonged hospitalization, and long COVID. Patients’ own reports of how they had been impacted by COVID often referenced an exacerbation of pre-existing symptoms rather than an entirely new set of symptoms. Uncertainty about the etiology of patients’ symptoms led to ongoing monitoring, diagnostic testing, and specialist referral. Long COVID-specific care processes were often siloed and poorly coordinated with the care patients were already receiving for other health conditions and could lead to care that was burdensome and even unwanted, particularly among those with complex medical conditions and functional limitations.
    Date: November 3, 2022
  • Early Temperature Trends May Identify COVID-19 Infection in Pre-Symptomatic Long-Term Care Residents
    Pre-symptomatic COVID-19 transmission in nursing homes is common and older patients often have blunted febrile response to infection. As a result, current clinical screening for temperature above 38°C may not identify infected subclinical cases that risk transmission until later. This study sought to determine whether early temperature trends in the course of COVID-19 infection could identify pre-symptomatic Veterans in nursing homes. Findings showed that a change in temperature of 0.4°C from baseline identified 47% of VA nursing home residents who became COVID positive, earlier than standard testing by an average of 42 hours. Temperature variability of 0.5°C over three days, when paired with a 37.2°C temperature cutoff (instead of the VA standard of 38°C), identified 55% of VA nursing home residents who became COVID positive earlier than standard testing by an average of 44 hours. A change from baseline temperature of 0.4°C, when combined with temperature variability of 0.7°C over three days, identified 52% of VA nursing home residents who became COVID positive, earlier than standard testing by an average of 40 hours, and by more than 3 days in 22% of Veterans.
    Date: August 4, 2022
  • Antipsychotic Prescribing Decreased in VA Nursing Homes, but Prescribing Alternative Drugs, such as Opioids, Increased
    This study sought to evaluate national trends in prescribing antipsychotic and other central nervous system (CNS)-active medications for Veterans with dementia residing in VA nursing homes, as well as how use has changed over time. Findings showed that antipsychotic use steadily decreased between FY2009 and FY2018 (from 34% to 28%), with similar declines in anxiolytic prescribing (from 34% to 27%). Over the same period, prescribing of antiepileptics, antidepressants, and opioids increased significantly: from 27% to 43%, 57% to 63%, and 33% to 41%, respectively. The decline in prescribing antipsychotics was most significant following VA’s Psychotropic Drug Safety Initiative (2013-2018). The overall prescribing of non-antipsychotic psychotropic medications grew from 75% to 81%. Prescribing of memory medications declined throughout the study – from 32% to 22%, representing an 11% absolute decline. Memory medications were the least prescribed medication class for Veterans with dementia throughout the study period. Initiatives focused on improving care for nursing home residents should: 1) monitor the use of all CNS-active medication and other potentially sedating treatments used for sedation in dementia; and 2) consider how to incentivize the use of evidence-based non-pharmacological alternatives.
    Date: May 26, 2022
  • Two Studies Show Positive Impact of COVID-19 Vaccinations on VA and Community Nursing Home Residents
    U.S. nursing homes incurred more than one-third of COVID-19 fatalities in the United States and began vaccine clinics in mid-December. The first study describes the proportion of COVID-19 positive tests among 130 VA Community Living Centers (CLCs) before and after COVID-19 vaccination. Findings showed that the number of COVID-19 positive tests dropped among all CLC residents in the fourth week after vaccination, with an approximately 75% drop in the proportion of COVID-19 positive tests. The second study compared incident COVID-19 infection and 30-day hospitalization or death among residents with COVID-19 between non-VA nursing homes with earlier versus later vaccine clinics. Findings showed that one week after their initial vaccine clinics, nursing homes with earlier vaccination had 2.5 fewer new COVID-19 infections per 100 at-risk residents than expected relative to facilities with later vaccination. Cumulatively over 7 weeks, earlier vaccination facilities had 5.2 fewer infections per 100 at-risk residents and 5 fewer hospitalizations and/or deaths per 100 infected residents. These results suggest that COVID-19 vaccines accelerated the rate of decline of incident infections, morbidity, and mortality.
    Date: April 16, 2021
  • Repeated Temperature Readings with Patient Baseline Increases Sensitivity for COVID-19 Detection among Elderly Veterans
    The purpose of this study was to compare temperature trends and identify maximum temperatures in Community Living Center (CLC) residents 14 days prior to and following systematic testing for COVID-19. Findings showed that a single temperature screening is unlikely to accurately detect COVID-19 in nursing home residents. Only 27% of residents who tested positive for the virus met the temperature threshold (38°C or 100.4°F) during the study period. While most nursing home residents (63%) with confirmed COVID-19 experienced two or more 0.5°C elevations above their baseline temperatures, there also was a group (20%) that was persistently cooler and had no temperature deviation from baseline. Temperatures in elderly Veterans with COVID-19 began rising 7 days prior to testing for the virus – and remained elevated during the 14-day follow-up. The average maximum temperature in COVID-19 positive patients was 37.66°C (99.8°F) compared to 37.11°C (98.8°F) in patients who were COVID-19 negative. Study findings suggest that the current fever threshold for COVID-19 screening should be reconsidered. Repeated temperature measurement with a patient-derived baseline could increase sensitivity for surveillance purposes when applied to a nursing home population.
    Date: June 8, 2020
  • Strategy in a VA Skilled Nursing Facility Minimizes Both Asymptomatic and Pre-Symptomatic Transmission of COVID-19
    Universal and serial COVID-19 testing in skilled nursing facilities can identify cases during an outbreak, and rapid isolation and cohorting can minimize ongoing transmission. This outbreak report demonstrates the utility of universal serial laboratory screening to identify cases to rapidly isolate or cohort to reduce transmission in a VA skilled nursing facility. This strategy limited potential asymptomatic and pre-symptomatic transmission of COVID-19, allowing for successful containment. The outbreak in one ward was suppressed within 1 week, the outbreak in a second ward was suppressed within 2 weeks, and no cases occurred in a third ward.
    Date: May 29, 2020
  • Nurse Practitioners as Primary Care Providers May Be a High-Value Solution to Increasing Access to Care for All Veterans
    Investigators in this study assessed patient outcomes between primary care nurse practitioners (NPs) and MDs, including utilization, costs, and quality of care – one year after patient reassignment to a new primary care provider (due to a Veteran’s prior MD PCP leaving VA). Findings showed that compared to Veterans newly assigned to MDs, those newly assigned to NPs were less likely to use primary care and specialty care services – and incurred fewer hospitalizations. Further, Veterans assigned to NPs achieved similar quality of care in the management of chronic disease compared to those assigned to MDs. Differences in costs, clinical outcomes, and the receipt of diagnostic tests between NP and MD groups were not statistically significant. Findings suggest that the general use of nurse practitioners as primary care providers may be a high-value solution to increasing access to care for all Veterans. Also, comparable or better outcomes achieved at similar costs for patients across differing levels of comorbidity suggest NPs as primary care providers need not be limited to less complex patients.
    Date: April 1, 2020
  • JGIM Supplement Features VA Research on Care Coordination Both within VA and with Non-VA Healthcare Providers
    In March 2018, a state-of-the-art (SOTA) conference on care coordination was jointly planned by VA HSR&D and the Offices of Primary Care, Community Care, Nursing Services, and Care Management and Social Work. The SOTA was organized into three workgroups: 1) measures and models of care coordination; 2) care coordination within the VA system; and 3) care coordination between VA and non-VA providers for care paid for by VA. SOTA participants included VA and non-VA health services researchers, clinicians, and policymakers. Funded by HSR&D, this JGIM Supplement presents recommendations from the SOTA, as well as original research papers on care coordination strategies within VA and between VA and non-VA providers.
    Date: May 1, 2019
  • Antihypertensive Deintensification Associated with Fewer Falls among Older VA Nursing Home Residents
    This study sought to: 1) describe the frequency of antihypertensive de-intensification during scenarios suggesting over-aggressive treatment, 2) identify characteristics of residents associated with antihypertensive de-intensification, and 3) examine the association between antihypertensive de-intensification and subsequent falls. Findings showed that among Veterans with possibly over-aggressive antihypertensive treatment, just 11% underwent antihypertensive de-intensification. Among Veterans with low systolic blood pressure (SBP 80-100), antihypertensive de-intensification was associated with a lower risk of falling, but was not associated with risk of hospitalization or death. Among Veterans with possibly low SBP (101-120), antihypertensive de-intensification was associated with a higher risk of death, but not with risk of falling or hospitalization. In frail older adults, clinicians should repeatedly re-evaluate intensity of blood pressure management, taking into account the individual’s prognosis, goals of care, and an individualized estimate of the benefits and harms associated with the intensity of antihypertensive medication.
    Date: December 1, 2018
  • High-Risk Veterans with Access to Primary Care Intensive Management Receive Increased Outpatient Care without Increased Cost
    Intensive Management (IM) models aim to proactively reduce complex patients’ deteriorations in health and resultant high-cost hospitalizations through interdisciplinary teams, care coordination, and support for care transitions. This study evaluated the impact of outpatient primary care IM programs on health care utilization and cost at five VA medical centers. Findings showed that Veterans receiving IM care had higher utilization of outpatient care without an increase in total costs (including costs of the IM program) or differences in mortality over a 12-month period. Veterans in IM care had greater use of outpatient services such as mental health/substance abuse care, home care, and palliative/hospice care both in person and by telephone. Increased outpatient costs were attributed to higher use of these services. Veterans in IM care had a statistically significant reduction in nursing home days and non-significant trends toward lower mean inpatient costs, number of inpatient stays, and number of hospital days. IM programs appeared to improve access to necessary outpatient services and improve engagement in care.
    Date: June 19, 2018
  • VA and Non-VA Nursing Homes Differ in CAUTI Prevention Methods
    This study sought to compare infection prevention resources and practices between VA and non-VA nursing homes from 41 states that were participating as part of a national initiative to reduce catheter-associated urinary tract infections (CAUTIs), enhance frontline healthcare professional knowledge about infection prevention, and improve the safety culture in nursing homes. Findings showed that VA and non-VA nursing homes differed in their approach to CAUTI prevention: VA nursing homes reported more hours/week devoted to infection prevention-related activities (31 vs. 12 hours), and were more likely to have committees that reviewed healthcare-associated infections; VA nursing homes had substantially higher physician and nurse staffing to bed ratios compared with non-VA nursing homes; a higher percentage of VA nursing homes reported having 24-hour registered nurse supervision compared to non-VA nursing homes (96% vs. 56%); and most VA nursing home infection prevention programs were integrated within their VA acute care infection prevention programs, and they had more infection prevention related resources. In addition, a higher percentage of VA nursing homes reported tracking CAUTI rates (94% vs. 66%) and sharing CAUTI data with leadership and nursing personnel.
    Date: December 5, 2016
  • Study Compares Stroke Care in VA Community Living Centers with Private, VA-Contracted Nursing Homes
    This study is part of a larger investigation comparing the use and functional outcomes between Veterans in VA community living centers (CLCs) and VA-contracted community nursing homes (CNHs). Findings showed that compared with Veterans residing at CNHs, Veterans residing at CLCs had fewer average rehabilitation therapy days (both adjusted and unadjusted), but were significantly more likely to receive restorative nursing care. For rehabilitation therapy, Veterans in CLCs had lower user rates (75% vs. 76%) and fewer observed therapy days (4.9 vs. 6.4) compared to Veterans in CNHs. For restorative nursing care, Veterans in CLCs had higher user rates (34% vs. 31%), more observed average care days (9.4 vs. 5.9), and more adjusted days for restorative nursing care.
    Date: March 1, 2016
  • Rehabilitation Settings for Veterans Following Hospital Discharge for Hip Fracture
    This study explored the factors that impact choice of VA rehabilitation setting after acute hip fracture repair procedures. Findings showed that following hospitalization for hip fracture, nearly half (48%) of the Veterans in this study were discharged directly home – without VA-paid rehabilitation. Few Veterans (0.8%) were discharged with home health, with higher proportions discharged to a nursing home (15%), outpatient rehabilitation (19%), or inpatient rehabilitation (17%). Veterans with higher comorbidity scores were less likely to be discharged to inpatient rehabilitation. Veterans were more likely to be discharged to non-home settings if they had total functional dependence, had high American Society of Anesthesiology (ASA) class scores, had one or more surgical complications, or lived in counties with lower nursing home bed occupancy rates. Thus, it appeared that the most vulnerable patients were provided inpatient care. Surgical complications were the most significant predictor of discharge setting, but the availability of community resources also was an important predictor.
    Date: January 1, 2014
  • Publicly Reported Quality Ratings have Small but Positive Effect on Patient Choice of Nursing Home for Post-Acute Care
    Patients were more likely to choose facilities with higher reported post-acute care quality related to resident pain control after public reporting was initiated; however, the magnitude of the effect was small. No changes in nursing home choice related to report card scores were seen in facilities not exposed to public reporting. A better pain score (less pain experienced by the patient) was associated with an increase in consumer demand after public reporting was initiated; for delirium, there was no significant effect, and for improved walking, the effect was unexpectedly negative. There was a differential response across patients by education level, which raises the possibility that the format and distribution of this information matters. Authors suggest that this information may be more influential if it is delivered to consumers in a more user-friendly format, or if it is delivered to patient advocates or surrogate decision-makers.
    Date: January 10, 2012
  • Evidence-Based Staffing Methodology to Predict Nurse Staffing Needs
    This article describes a process used to identify indicators of nursing workload and develop an evidence-based nurse-staffing methodology that could be used to predict staffing needs and eventually link to nursing outcomes in the VA healthcare system. The final set of indicators included: 1) average length of stay (surrogate marker for patient severity of illness); 2) average number of medication doses administered daily; 3) percentage of patients with age >70; 4) percentage of patients with a BMI >25; 5) top three diagnostic categories on the unit (surrogate for complexity/scope of care required); 6) average daily census (patient volume and nursing workload); and 7) daily patient turnover (admissions, transfers, discharges). Following successful evaluation, the Office of Nursing Services introduced a national VA policy that directed all facilities to implement the new evidence-based, nationally standardized staffing methodology by September 2011. A formal evaluation will begin in October 2011.
    Date: October 1, 2011
  • Potential Problems with the Use of Antidepressants among Older Veterans Residing in VA Nursing Homes
    This study examined the prevalence and patient/site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants among Veterans aged 65 years and older that were admitted to any one of 133 VA Community Living Centers (CLC, previously called Nursing Home Care Units). Findings suggest potential problems with the use of antidepressants in older Veterans that reside in VA CLCs. Overall, only 18% of antidepressant use was optimal. Of the 877 Veterans with depression, 25% did not receive an antidepressant, suggesting potential underuse. Among depressed Veterans who received antidepressants, 43% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. In addition, of the 2,815 Veterans who did not have depression, 42% were prescribed one or more antidepressants; of these, only 4% had an FDA-approved labeled indication, suggesting potential overuse. Also, the co-prescribing of antipsychotics (in patients without schizophrenia) among those without depression was associated with an increased risk of antidepressant overuse.
    Date: August 1, 2011
  • Nurse Case Management Decreases Cardiovascular Risk Factors among Veterans with Diabetes Compared to Usual Care
    This study sought to determine if nurse case management could effectively improve rates of control for hypertension, hyperglycemia, and hyperlipidemia among Veterans with diabetes compared to usual care. Findings showed that involving a nurse case manager in the care of patients with diabetes can significantly improve the number of individuals achieving target values for glycemia, lipids, and blood pressure compared to usual care. In this study, a greater number of Veterans in the intervention group had all three outcome measures under control compared to Veterans in the usual care group. In addition, a greater number of Veterans in the nurse case management group achieved individual treatment goals for blood pressure, lipids, and blood sugar compared to Veterans receiving usual care. Observed differences between groups were likely mediated both by enhanced lifestyle changes and a greater intensity of pharmacological treatment among Veterans in the intervention group.
    Date: June 2, 2011
  • Pain Screening Implementation for Veterans Falls Short
    This study included surveys of Veteran outpatients and nursing staff who screened for pain during normal vital sign intake. Investigators compared pain levels documented by the nursing staff with those reported by Veterans during the study survey. Findings show that despite a longstanding mandate, pain screening implementation falls short, and informal screening is common. Although pain was evaluated in all patient encounters, less than half of the Veterans reported that the nursing staff formally rated their pain. However, the majority of the time the nursing staff’s pain documentation matched the Veteran’s subsequent report within one point on the rating scale. When differences did occur, the nursing staff under-estimated pain in 25% of the cases, and overestimated pain in 7% of the cases. Veterans with PTSD or another anxiety disorder were almost twice as likely to report higher pain levels than those documented by the nursing staff. Additionally, nursing staff were less likely to underestimate pain when the patient self-reported excellent, very good, or good health status (relative to fair or poor health status).
    Date: August 6, 2010
  • Rates of Depression Rise among VA Nursing Home Residents
    Prevalence rates for dementia and schizophrenia fluctuated moderately from 1990 to 2006, but rates for depression were substantially higher in 2006 than in 1998. Results also show that PTSD was more prevalent, while the prevalence of alcohol use disorders declined. The prevalence of serious mental illness (e.g., schizophrenia, bipolar and manic disorders) was relatively stable over this time period, except for increases among the oldest residents. Understanding recent changes in the prevalence of mental health disorders among VA nursing home residents can contribute to optimal planning to meet their treatment needs.
    Date: April 1, 2010
  • Addressing Psychosocial Needs of Cancer Patients
    This Commentary discusses the nursing challenges of assessing and managing cancer-related distress, in addition to recommending assessment tools and further research. Measurement tools are available that are both well-established and feasible for nurses working within time-constrained environments.
    Date: April 1, 2010
  • More than One-Quarter of Elderly Individuals Require Surrogate Decision-Making Near the End of Life
    Of the 3,746 elderly adults (non-Veterans) in this study, 26.8% required decision-making at the end of life and lacked decision-making capacity. Thus, surrogate decision-making was often required. Of those requiring surrogate decision-making, 67.6% had advance directives. Individuals who authored advance directives received care that was strongly associated with their preferences. And those who requested all care possible were far more likely to receive aggressive care compared to those who did not request it. Individuals with advance directives preferred limited and comfort care more than all care possible. Cognitive impairment, cerebrovascular disease, and nursing home status were associated with the need for decision-making and lost decision-making capacity before death; but these characteristics were so common (present in 65.3% of the study population) as to not be clinically useful risk factors.
    Date: April 1, 2010
  • Nursing Homes’ Disaster Response Activities Following Hurricanes Katrina and Rita
    Hurricanes Katrina and Rita exposed significant flaws in the U.S. preparedness for catastrophic events – and in the nation’s capacity to respond to them. This article reviews VA’s response to these hurricanes, in regard to nursing home evacuation, and the literature on nursing home evacuation. Authors also propose a conceptual model to help guide decision-making for future evacuations.
    Date: March 24, 2010
  • Aggression is Common among Veterans with Dementia
    Findings showed that 41% of Veterans with newly diagnosed dementia became aggressive within 24 months, corroborating the findings of previous studies that aggression is common in persons with dementia. The use of antipsychotic medications increased significantly in Veterans after they became aggressive, and this group also had a ten-fold greater occurrence of injuries. In addition, almost twice as many aggressive Veterans were admitted to nursing homes. There were no differences in rates of restraint use or in- and outpatient visits between Veterans who became aggressive and those who did not.
    Date: March 1, 2010
  • Nursing’s Role in Healthcare and Advancement in Evolving Healthcare Environment
    In a recent national survey, although 77% of nurses reported that they were satisfied with their jobs, only 18% of nurses reported that they were actively engaged (defined as psychological commitment to job and workplace) in their work. Therefore, efforts to improve the clinical work environment, the safety culture, and the nursing education infrastructure are necessary. This article explores the opportunity for change by: 1) examining nursing’s history in professional practice and its journey as an evolving profession, and 2) mapping the growth of hospitals and the advancement of nursing’s role in the US, specifically in the context of the healthcare organization.
    Date: January 1, 2010
  • Drugs-to-Avoid Criteria for the Elderly have Limited Value
    Drugs-to-avoid criteria are lists of drugs considered to be potentially inappropriate for the elderly due to adverse effects, limited effectiveness, or both. For example, the Centers for Medicare and Medicaid Services use a version of the criteria of Beers et al. in nursing homes, and the National Committee for Quality Assurance uses the criteria of Zhan et al. to compare the quality of U.S. health plans. This study compared the Beers and Zhan criteria with individualized expert assessment of patients’ medications in 256 elderly Veterans from the Iowa City VAMC who were taking five or more medications. Findings show that the drugs-to-avoid criteria performed poorly when used as quality measures to assess the current state of a patient’s drug therapy. For example, half or more of the drugs flagged by the Beers and Zhan criteria were not considered problematic upon individualized expert review. In addition, the Beers and Zhan criteria identified only 8-15% of drugs that experts judged to be problematic. Therefore, authors suggest that while these criteria are useful as guides for initial prescribing decisions, they are insufficiently accurate to use as stand-alone measures for the quality of prescribing.
    Date: July 27, 2009
  • Prescribing Discrepancies during Patient Transfer May Result in Adverse Drug Events
    The objective of this study was to examine medication discrepancies related to adverse drug events (ADEs) in nursing home patients transferred to and from the hospital. Findings show that less than 5% of discrepancies caused ADEs, which is consistent with reviews that suggest only a small fraction of errors result in harm. Authors note that information about ADEs caused by medication discrepancies can be used to enhance measurement of care quality, identify high-risk patients, and inform the development of decision-support tools at the time of patient transfer.
    Date: February 1, 2009
  • Physicians May Need More Education about Long-Term Care Options for Veterans
    The purpose of this study was to obtain information about VA long-term care (LTC) referrals that could be used to develop interventions that increase the likelihood of referrals to home and community-based services (HCBS) instead of institutional care. Findings indicate that physicians are often seen as having limited familiarity with HCBS options and tend to refer Veterans with LTC needs to nursing homes. Training physicians about LTC referral options, with particular focus on how HCBS can be used to meet Veteran and caregiver needs, may help to increase those referrals.
    Date: February 1, 2009
  • Veterans Using Home Healthcare have Higher Rates of Outpatient, Inpatient, and Nursing Home Care
    Veterans receiving VA home health care in 2002 increased their absolute chance of using VA outpatient care by 3%, inpatient care by nearly 12%, and nursing home care by 5% in 2003. Moreover, although utilization rates were low, VA HHC users were about 10 times more likely to have used hospice, adult day health care, or respite care in the VA system than non-users.
    Date: October 1, 2008
  • Association between Nurse Staffing Levels and Patient Mortality in VA Hospitals
    RN staffing was not significantly associated with in-hospital mortality for veterans with an ICU stay; however, increased RN staffing was significantly associated with decreased mortality among non-ICU patients. Continuing to estimate the effect of RN staffing and skill mix on patient outcomes using hospital-level data will provide poor estimates of outcome associations, such as in-hospital mortality.
    Date: September 1, 2008
  • VA Nurse Burnout and Patient Safety Outcomes
    Among VA nurses at one Midwestern location, burnout was associated with perceptions of a less safe environment. While burnout was not associated with event-reporting behavior, it was negatively associated with reporting of near misses (mistakes that did not lead to adverse events). The finding that higher burnout was associated with lower incidence of near-miss reports is of concern because these reports are essential to addressing safety concerns in the environment.
    Date: August 1, 2008

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