Biomedical subjects

Michael K Chapko

Publications and source records attributed to Michael K Chapko.

10 recordsLinked to original sources

PubMed2006

Randomized trial of onsite versus referral primary medical care for veterans in addictions treatment.

BACKGROUND: Patients presenting for treatment of substance use disorders (SUDs) often exhibit medical comorbidities that affect functional health status and healthcare costs. Providing primary care within addictions clinics (onsite care) may improve medical and SUD treatment outcomes in this population. OBJECTIVE: The objective of this study was to compare outcomes among Veterans' Administration (VA) patients who receive medical care within the SUD clinic and those referred to a general medicine clinic at the same facility. METHODS: Veterans entering SUD treatment with a chronic medical condition and no current primary care were randomized to receive primary medical care: 1) onsite in the VA SUD clinic (n = 358), or 2) in the VA general internal medicine clinic (n = 362). Subjects were assessed at baseline and at 3, 6, and 12 months postrandomization. Intention-to-treat analyses used random-effects regression. MEASURES: Measures included SF-36 Physical and Mental Component Summaries (PCS, MCS), VA service utilization, SUD treatment retention, Addiction Severity Index (ASI) scores, 30-day abstinence, and total VA healthcare costs. RESULTS: Over the study year, patients assigned to onsite care were more likely to attend primary care (adjusted odds ratio [OR] = 2.20; 95% confidence interval [CI] = 1.53-3.15) and to remain engaged in SUD treatment at 3 months (adjusted OR = 1.36; 1.00-1.84). Overall, outcomes on the MCS (but not the PCS) and the ASI improved significantly over time but did not differ by treatment condition. Total VA healthcare costs did not differ reliably across conditions. CONCLUSIONS: Compared with referral care, providing primary care within a VA addiction clinic increased primary care access and initial SUD treatment retention but showed no effect on overall health status or costs.

Adult↗

PubMed2005

The association between health insurance coverage and diabetes care; data from the 2000 Behavioral Risk Factor Surveillance System.

OBJECTIVE: To describe the association between type of health insurance coverage and the quality of care provided to individuals with diabetes in the United States. DATA SOURCE: The 2000 Behavioral Risk Factor Surveillance System. STUDY DESIGN: Our study cohort included individuals who reported a diagnosis of diabetes (n=11,647). We performed bivariate and multivariate logistic regression analyses by age greater or less than 65 years to examine the association of health insurance coverage with diabetes-specific quality of care measures, controlling for the effects of race/ethnicity, annual income, gender, education, and insulin use. PRINCIPAL FINDINGS: Most individuals with diabetes are covered by private insurance (39 percent) or Medicare (44 percent). Among persons under the age of 65 years, 11 percent were uninsured. The uninsured were more likely to be African American or Hispanic and report low incomes. The uninsured were less likely to report annual dilated eye exams, foot examinations, or hemoglobin A1c (HbA1c) tests and less likely to perform daily blood glucose monitoring than those with private health insurance. We found few differences in quality indicators between Medicare, Medicaid, or the Department of Veterans Affairs (VA) as compared with private insurance coverage. Persons who received care through the VA were more likely to report taking a diabetes education class and HbA1c testing than those covered by private insurance. CONCLUSIONS: Uninsured adults with diabetes are predominantly minority and low income and receive fewer preventive services than individuals with health insurance. Among the insured, different types of health insurance coverage appear to provide similar levels of care, except for higher rates of diabetes education and HbA1c testing at the VA.

Adult↗

PubMed2005

Cost effectiveness of testing strategies for chronic hepatitis C.

OBJECTIVE: This paper compares nine strategies for determining hepatitis C antibody and viral status. They combine two tests for antibodies (enzyme immunoassays (EIA), recombinant immunoblot assays (RIBA)) and one for viremia (reverse transcription polymerase chain reaction (PCR)). Using optical density to divide EIA results into three categories (high positive, low positive, negative) was also considered. METHODS: Decision analysis compared strategies on cost as well as sensitivity and specificity with regard to antibody and viral status. Parameters in the decision tree included antibody prevalence, proportion viremic, sensitivity, specificity, and cost of individual tests. RESULTS: The two best strategies are EIA followed by PCR (EIA-->PCR); and EIA with three levels of optical density (EIA-OD), followed by RIBA for EIA-OD low positives, and then PCR for all positives (EIA-OD-->RIBA-->PCR). EIA-->PCR has equal viral sensitivity, slightly lower cost, slightly higher antibody sensitivity, but lower antibody specificity compared to EIA-OD-->RIBA-->PCR. The cost per false antibody positive avoided using EIA-OD-->RIBA-->PCR rather than EIA-->PCR is $36 when prevalence is 5%, and $193 when prevalence is 50%. Using EIA-OD-->RIBA-->PCR rather than EIA-->PCR results in 112 false antibody positives avoided for every true antibody positive missed when prevalence is 5%; this ratio is 18:1 when prevalence is 25%; and 6:1 when prevalence is 50%. CONCLUSIONS: EIA-OD-->RIBA-->PCR is the best choice when prevalence in the tested group is below 20%. As prevalence increases, the choice of EIA-OD-->RIBA-->PCR versus EIA-->PCR will depend on the relative importance of avoiding false antibody positives versus missing true antibody positives. Our analysis makes explicit the magnitude of this trade-off.

Cost-Benefit Analysis↗

PubMed2004

Data resources in the Department of Veterans Affairs.

OBJECTIVE: To provide an overview of databases that are maintained by the Department of Veterans Affairs (VA) and are of relevance to investigators involved in epidemiologic, clinical, and health services research. RESEARCH DESIGN AND METHODS: We reviewed both national and local VA databases and identified their strengths and limitations. We also referenced specific studies that have assessed the validity and reliability of VA databases. RESULTS: There are numerous national databases housed at the Austin Automation Center in Austin, Texas. These include the Patient Treatment File (hospital abstracts), the Outpatient Care File, the Beneficiary Identification Record Locator System death file for assessing vital status, and the Decision Support System, which provides integrated clinical and financial information for managerial decision making. The major limitation of these databases is that clinical detail below the level of ICD-9-CM diagnosis and procedure codes is not uniformly available nationally. These databases offer an excellent opportunity to monitor the health of veterans over time because they track all inpatient and outpatient utilization in the VA. However, at the local or medical center level, the Veterans Health Information and Systems and Technology Architecture contains extensive clinical information, but has fewer patients, varies in format across medical centers, and poses difficulties with data extraction for statistical analysis. CONCLUSIONS: Both local and national VA databases are valuable resources for investigators who have interests in a wide array of research topics, including diabetes. The potential for investigating important scientific questions with VA databases becomes greater as communications and database management technologies improve.

Confidentiality↗

PubMed2003

Predictors of colorectal cancer screening participation in the United States.

OBJECTIVE: Our aim was to identify predictors of colorectal cancer screening in the United States and subgroups with particularly low rates of screening. METHODS: The responses to a telephone-administered questionnaire of a nationally representative sample of 61,068 persons aged >/=50 yr were analyzed. Current screening was defined as either sigmoidoscopy/colonoscopy in the preceding 5 years or fecal occult blood testing (FOBT) in the preceding year, or both. RESULTS: Overall, current colorectal cancer screening was reported by 43.4% (sigmoidoscopy/colonoscopy by 22.8%, FOBT by 9.9%, and both by 10.7%). The lowest rates of screening were reported by the following subgroups: those aged 50-54 yr (31.2%), Hispanics (31.2%), Asian/Pacific Islanders (34.8%), those with education less than the ninth grade (34.4%), no health care coverage (20.4%), or coverage by Medicaid (29.2%), those who had no routine doctor's visit in the last year (20.3%), and every-day smokers (32.1%). The most important modifiable predictors of current colorectal cancer screening were health care coverage (OR = 1.7, 95% CI = 1.5-1.9) and a routine doctor's visit in the last year (OR = 3.5, 95% CI = 3.2-3.8). FOBT was more common in women than in men (OR = 1.8, 95% CI = 1.6-2.0); sigmoidoscopy/colonoscopy was more common in Hispanics (OR = 1.4, 95% CI = 1.1-1.7) and Asian/Pacific Islanders (OR = 2.4, 95% = CI 1.5-3.9) relative to whites, in persons without routine doctor's visits in the preceding year (OR = 3.3, 95% CI = 2.8-4), and in persons with poor self-reported health (OR = 1.3, 95% CI = 1.2-1.5). CONCLUSIONS: Interventions should be developed to improve screening for the subgroups who reported the lowest screening rates. Such interventions may incorporate individual screening strategy preferences.

Aged↗

PubMed2002

Evaluation of the Department of Veterans Affairs community-based outpatient clinics.

OBJECTIVE: This paper describes the history of the Department of Veterans Affairs (VA) Community-Based Outpatient Clinics (CBOCs), CBOC Performance Evaluation Project, and characteristics of CBOCs within the VA, and summarizes the findings and implications of the CBOC Performance Evaluation Project. SUBJECTS: There were 139 CBOCs in operation at the end of fiscal year 1998. Ninety-eight percent of CBOCs offered primary health care, and 28% offered primary health care and primary mental health care. The average CBOC was 70.7 miles from its parent VAMC. Sixty-one percent of the CBOCs were located in urban areas and 39% were in rural areas. Sixty-four percent of the CBOCs were VA-staff and 36% were contract. RESULTS: The details of the project's findings are reported in four companion papers that describe, respectively, health care access and utilization, cost of care, patient perceptions of care, and quality of care in VA CBOCs. For most measures, CBOC performance was equivalent to their parent VAMCs. However, there were a few areas of potential concern: CBOCs had fewer patients that reported having one provider or team in charge of care; CBOC patients had fewer specialty visits; and CBOCs served a smaller percent of women and black persons. CONCLUSION: CBOCs appear to be performing comparably to their parent medical centers but will benefit from ongoing monitoring.

Community Health Centers↗

PubMed2002

VA community-based outpatient clinics: access and utilization performance measures.

OBJECTIVES: The purpose of this study was to compare access and utilization performance measures between Community-Based Outpatient Clinics (CBOC) and primary care clinics at parent VA Medical Centers (VAMC) and between VA-staff CBOCs and contract CBOCs. METHODS: The study design was cross-sectional and retrospective. Performance measures were based on data routinely collected for administrative and research purposes by the VA. The sample included all primary care patients (n = 37,084) treated at the 38 CBOCs opened before 4/1/98 (30 VA-staff and 8 contract) and all primary care patients (n = 318,369) treated at the 32 parent VAMCs. Six months of service use data were used to derive the access and utilization performance measures. Multivariate regression analyses were used to control for observable casemix differences. RESULTS: CBOCs are attracting new high priority patients to the VA health care system. CBOC patients had more primary care encounters and fewer specialty encounters than patients in the primary care clinics of the parent VAMCs. VA-staffed CBOC patients had more primary care encounters and fewer specialty encounters than contract CBOC patients. CONCLUSIONS: CBOCs are helping the VA achieve its goals of attracting new patients and shifting the focus of care from the specialty to the primary care setting.

Community Health Centers↗

PubMed2002

VA community-based outpatient clinics: quality of care performance measures.

BACKGROUND: The Veterans Health Administration (VHA) recently initiated a system of Community-Based Outpatient Clinics (CBOCs) to enhance delivery of primary care to veterans. OBJECTIVE: The objective of this study was to compare quality of care provided to veterans at CBOCs and at traditional hospital-based VA Medical Center (VAMC) clinics. RESEARCH DESIGN: Quality of care was assessed using medical record data abstracted at CBOCs and VAMCs. The analysis used a logistic regression model that allowed for possible within-facility correlation and controlled for patient differences between facilities. SUBJECTS: The study included 4768 patients from 20 geographically diverse CBOCs and 2433 patients from the 20 VAMCs associated with these CBOCs. MEASURES: Quality of care was measured using 7 Prevention Index (PI) indicators and 9 Chronic Disease Care Index (CDCI) indicators, which assess compliance with nationally recognized guidelines for primary prevention, early disease detection, and care of patients with chronic disease. RESULTS: In the overall CBOC versus VAMC comparisons, performance was not significantly different on 15 of the 16 PI and CDCI indicators. In the comparisons between individual CBOCs and VAMCs pairs, 5 out of 20 CBOCs performed significantly below the affiliated VAMC on 4 or more indicators. CONCLUSIONS: These results suggest that CBOCs overall are providing a similar level of quality of care as VAMCs based on the PI and CDCI, although performance at several individual CBOCs fell below their affiliated VAMC on some indicators. Therefore, it appears that CBOCs are a valid approach for providing quality primary care to veterans.

Aged↗

PubMed2002

VA community-based outpatient clinics: performance measures based on patient perceptions of care.

BACKGROUND: The Department of Veterans Affairs (VA) recently initiated a system of Community- Based Outpatient Clinics (CBOCs) to enhance delivery of primary care to veterans. OBJECTIVE: The objective of this study was to determine the effect of CBOCs on patients' perceptions of care. RESEARCH DESIGN: The study design is a cross-sectional survey. SUBJECTS: This study compares 4,980 patients from 44 geographically diverse CBOCs to 4,159 patients from 36 parent VA Medical Center primary care clinics administratively and geographically associated with the CBOCs studied. MEASURES: Survey data were obtained from the 1998 VA National Outpatient Customer Satisfaction Survey which assesses eight multiitem scales addressing access and timeliness of care, education/information, patient preferences, emotional support, coordination of care, courtesy, and specialty care access. Each scale was evaluated based upon item responses that indicate a problem with care. The survey also contained SF-12 health status measures used for case-mix adjustment. RESULTS: Multivariate logistic regression controlling for patient health status measures revealed that CBOC patients reported fewer problems with care than VA-based patients on 7 of 8 scales though the absolute differences were small for most of the scales. The largest difference was observed for the access/timeliness scale. Significant differences between VA-staff and contract CBOCs were not observed. CONCLUSIONS: These results suggest that veterans participating in VA's initiative to provide primary care in community-based settings report no more than, and in some dimensions fewer problems with care compared with veterans who receive care in VAMC clinics.

Aged↗

PubMed2002

VA community-based outpatient clinics: cost performance measures.

OBJECTIVE: To examine the direct costs of treating veterans in Community-Based Outpatient Clinics (CBOC) and primary care clinics operated by VA medical centers (VAMCs) between April 1998 and September 1998. RESEARCH DESIGN: In a retrospective observational study of patients in eighteen CBOCs and fourteen VAMCs, direct costs were compared. In addition, the costs of treating patients in new and established CBOCs were also examined. MEASURES: The three types of costs examined include direct cost per primary care visit, direct primary care cost per patient, and total direct cost per patient in ordinary least squares regressions with facility-specific random effects. Indirect costs for overhead and administration were excluded. All cost comparisons controlled for patient characteristics and case-mix differences via the Diagnostic Cost Group methodology. RESULTS: Results indicate that CBOC patients and VAMC patients had similar direct primary care costs on a per visit and per patient basis. Total direct costs for CBOC patients were lower compared with VAMC patients, because of lower specialty and ancillary care costs. Patients in new CBOCs had similar primary, specialty, ancillary and inpatient care costs when compared with patients in established CBOCs. CONCLUSION: Lower total costs for CBOC patients may be a consequence of substituting primary care at CBOCs for expensive specialty and ancillary care at VAMCs. CBOCs may be an alternative approach to providing care to veterans at a lower cost than traditional delivery models based in VA Medical Centers.

Aged↗