Vets Getting a Raw Deal

[swatsurgeon]

The VA system could be so good and articles continue to be written about the care received at VA hospitals....not so good. Our vets deserve the best care and if you are getting operated on later in the day, this is what they write about:

Time of Day Is Associated With Postoperative Morbidity: An Analysis of the National Surgical Quality Improvement Program Data CME
Posted 04/30/2008

Rachel R. Kelz, MD, MSCE; Kathryn M. Freeman, BA; Patrick W. Hosokawa, MS; David A. Asch, MD, MBA; Francis R. Spitz, MD; Miriam Moskowitz, RN, MSN; William G. Henderson, MPH, PhD; Marc E. Mitchell, MD; Kamal M. F. Itani, MD, FACS
Disclosures

Abstract and Introduction
Abstract
Objective: To examine the association between surgical start time and morbidity and mortality for nonemergent procedures.
Summary Background Data: Patients require medical services 24 hours a day. Several studies have demonstrated a difference in outcomes over the course of the day for anesthetic adverse events, death in the ICU, and dialysis care. The relationship between operation start time and patient outcomes is yet undefined.
Methods: We performed a retrospective cohort study of 144,740 nonemergent general and vascular surgical procedures performed within the VA Medical System 2000-2004 and entered into the National Surgical Quality Improvement Program Database. Operation start time was the independent variable of interest. Logistic regression was used to adjust for patient and procedural characteristics and to determine the association between start time and, in 2 independent models, mortality and morbidity.
Results: Unadjusted later start time was significantly associated with higher surgical morbidity and mortality. After adjustment for patient and procedure characteristics, mortality was not significantly associated with start time. However, after appropriate adjustment, operations starting between 4 pm and 6 pm were associated with an elevated risk of morbidity (OR = 1.25, P ≤ 0.005) over those starting between 7 am and 4 pm as were operations starting between 6 pm and 11 pm (OR = 1.60, P ≤ 0.005).
Conclusions: When considering a nonemergent procedure, surgeons must bear in mind that cases that start after routine “business” hours within the VA System may face an elevated risk of complications that warrants further evaluation.


Gentlemen and ladies...start asking questions and insist on the high quality you deserve.

ss

[Jack Moroney (RIP)]

Well Damn, aren't you a morale builder:D

Have they looked at patient load, locations of hospitals, and staffing levels or is this just another one of those shots in the dark? I think I have been very fortunate, to date-more to follow, with the facility at White River Junction, Vermont, and the post operative care and rehabilitation was pretty good in Manchester, NH, but the staffing was low and some of the patients were pure assholes placing more demand on the system than necessary would whine about the dumbest things.

[Semper gumby]

I happen to work in a VA medical center as a contract worker. It's my first time working for the VA. I know that after 4 pm, most ancillary services close down, other than the wards. (Not sure about lab...) Are there any VA hospitals that are staffed 24/7, like a real hospital?

[Doczilla]

Correct me if I'm wrong, but didn't we find increases in morbidity/mortality with off-hours surgery in civilian hospitals as well? I have often heard surgeons citing this difference as a reason to admit the patient and schedule a non-elective surgery for a day or two later.

'zilla

[The Reaper]

The VA hospital in Fayetteville looks to be at least 20 years behind current facilities, and has some of the worst attitudes among the staff you can imagine.

Given that the bulk of their patients are old, suffering from multiple maladies, have an above average percentage of smokers, are already disabled, and were treated by the military prior to the VA system, I can see why the increased mortality would occur.

TR

[CPTAUSRET]

Correct me if I'm wrong, but didn't we find increases in morbidity/mortality with off-hours surgery in civilian hospitals as well?

'zilla

That's probably correct!

Slightly off topic...My wife chaired an IOM committee looking at PTSD compensation from the VA.


News from the National Academies


Date: May 8, 2007



FOR IMMEDIATE RELEASE



VA Should Revise its Methods for Evaluating and Rating PTSD in Veterans

To Eliminate Inconsistencies and Ensure Appropriate Compensation



WASHINGTON -- To ensure more consistent and appropriate disability compensation for veterans, the U.S. Department of Veterans Affairs (VA) needs to revise how it evaluates former military personnel for service-connected post-traumatic stress disorder (PTSD) and determines the payment amounts they merit, says a new report from the Institute of Medicine and National Research Council. A surge in the number of disability claims for PTSD has revealed inconsistencies in compensation levels awarded across the country, raising questions about the effectiveness of the VA's current ways of assessing and rating this condition, and whether some veterans are getting payments that are too low, too high, or unmerited.



The agency should develop new evaluation methods and rating criteria specific to PTSD to replace current standards that yield a crude and overly general assessment of PTSD disability, said the committee that wrote the report. It urged the VA to base compensation decisions on how greatly PTSD affects all aspects of a veteran's daily life, not just his or her ability to be gainfully employed.



The agency also should ensure that all veterans applying for PTSD compensation receive a thorough, initial evaluation by an experienced clinical professional. These exams should be of sufficient duration to provide a detailed picture of each veteran's condition so that disability raters -- non-clinical personnel who determine whether a disability is connected to military service and the level of impairment it entails -- can make more consistent and better informed decisions about the level of compensation each veteran merits. More thorough evaluations also would enhance VA's ability to detect inappropriate claims, though the committee confirmed that PTSD symptoms can manifest many years after a traumatic event or may interfere with a veteran's ability to function only later in life.



"As the increasing number of claims to the VA shows, PTSD has become very significant public health problem, particularly for veterans of current and past conflicts," said committee chair Nancy Andreasen, Andrew H. Woods Chair of Psychiatry and director, Psychiatric Neuroimaging Research Center, Carver College of Medicine, University of Iowa, Iowa City. "Our review of the current methods for evaluating PTSD disability claims and determining compensation indicates that a comprehensive revision is needed."



Recent years have seen a spike in PTSD claims and a significant increase in disability payments for the condition. The number of cases jumped almost 80 percent between fiscal years 1999 and 2004, growing from 120,265 cases to 215,871. Payments for PTSD increased almost 150 percent over the same period, rising from $1.72 billion to $4.28 billion. The bulk of claims for PTSD compensation currently are coming from Vietnam War veterans who comprise the majority of living veterans, but claims also are being made by former service personnel of earlier conflicts as well as personnel who served in the first Gulf War and in the current conflicts in Iraq and Afghanistan. There likely will be many more claims from the latter group in the future, so how this issue is resolved now will eventually affect many active duty personnel.



A thorough, initial evaluation by an experienced professional is crucial to improving PTSD compensation decisions, the committee said. These exams determine whether former service members are experiencing PTSD and how severe it is. Currently, the time devoted to the evaluations varies widely as does the amount of detail examiners provide to the raters who determine the appropriate level of compensation. Moreover, many veterans denied compensation eventually receive it after applying for re-evaluation, sometimes multiple times. Ensuring that every veteran making a claim receives a comprehensive evaluation could make the process more efficient.



The report offers a starting point to help VA devise new ratings criteria specific to PTSD. The committee emphasized the need to rate PTSD disability based on a fuller range of an individual's capacity to function, not just on his or her ability to work. The focus on occupational impairment in the current rating scheme penalizes veterans who can and do work despite their symptoms, and may serve as a disincentive to work, the report says.



Many disability claims are being submitted by veterans who have been out of military service for several years, which has prompted questions about how long after a traumatic event PTSD can manifest and whether standardized tests could detect dissembling if someone tried to make a fraudulent claim. The committee found abundant evidence that PTSD can develop at any time after exposure to trauma. It also can manifest as a relapsing condition or flare up after being suppressed and undiagnosed. Aging, loss of mental acuity, the death of friends or spouses, and other factors can trigger or exacerbate symptoms as well. Standardized tests can be a useful part of an assessment, but they are no substitute for a thorough clinical assessment by a trained professional, the committee concluded.



Combat exposure is not the only potential trigger for PTSD among service members; sexual assault is another form of trauma. The available information suggests that female veterans are less likely to receive compensation for PTSD, which may in part be due to the difficulty of substantiating exposure to traumatic events unrelated to combat, including sexual harassment or assaults that occurred during service. VA should make a concerted effort to gather data and provide reference materials to help disability raters better address the management of PTSD claims related to sexual assault during military service, the report says.



The study was sponsored by the U.S. Department of Veterans Affairs. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Research Council is the principal operating agency of the National Academy of Sciences and National Academy of Engineering. A committee roster follows.







# # #



[ This news release and report are available at http://national-academies.org ]



INSTITUTE OF MEDICINE

Board on Military and Veterans Health

and

NATIONAL RESEARCH COUNCIL

Division of Behavioral and Social Sciences and Education

Center for Studies of Behavior and Development



Committee on Veterans' Compensation for Post Traumatic Stress Disorder



Nancy C. Andreasen, M.D., Ph.D. (chair)

Andrew H. Woods Chair of Psychiatry, and

Director

Neuroimaging Research Center

Carver College of Medicine

University of Iowa

Iowa City



Jacquelyn C. Campbell, Ph.D., R.N.

Anna D. Wolf Chair

School of Nursing

The Johns Hopkins University

Baltimore



Judith A. Cook, Ph.D.

Professor of Psychiatry, and

Director

Center on Mental Health Services Research and Policy

University of Illinois

Chicago



John A. Fairbank, Ph.D.

Associate Professor of Medical Psychology

Duke University Medical Center, and

Co-director

National Center for Child Traumatic Stress

Durham, N.C.



Bonnie L. Green, Ph.D.

Professor of Psychiatry, and

Director of Research

Department of Psychiatry

Georgetown University Medical School

Washington, D.C.



Dean G. Kilpatrick, Ph.D.

Distinguished University Professor

Department of Psychiatry and Behavioral Sciences, and

Director

National Crime Victims Research and Treatment Center

Medical University of South Carolina

Charleston



Kurt Kroenke, M.D.

Professor of Medicine

Division of General Internal Medicine and Geriatrics

Indiana University, and

Senior Research Scientist and Director of Fellowship Training

Regenstrief Institute Inc.

Indianapolis



Richard A. Kulka, Ph.D.

Senior Vice President of Strategic Business Development

Abt Associates Inc., and

Senior Research Scientist

Center for Demographic Studies

Duke University

Durham, N.C.



Patricia M. Owens, M.P.A.

Independent Consultant

Minisink Hills, Pa.



Robert T. Reville, Ph.D.

Director

RAND Institute of Civil Justice

Santa Monica, Calif.



David S. Salkever, Ph.D.

Professor

Department of Public Policy

University of Maryland, Baltimore County, and

Research Associate

National Bureau of Economic Research

Cambridge, Mass.



Robert J. Ursano, M.D.

Professor of Psychiatry and Neuroscience;

Chair

Department of Psychiatry; and

Director

Center for the Study of Traumatic Stress

Uniformed Services University of the Health Sciences

Bethesda, Md.





STAFF



David A. Butler, Ph.D.

Study Director

[Jack Moroney (RIP)]

The VA hospital in Fayetteville looks to be at least 20 years behind current facilities, and has some of the worst attitudes among the staff you can imagine. TR


I have heard that about many VA facilities, but fortunately White River Junction seems to have their stuff in order. Yes, they do not have all the bells and whistles of a Duke or major medical center but they are in close cooperation with Dartmouth-Hitchcock which is an excellent facility and whose folks come through on rotation. When I went through the cancer bit I was able to go to Dartmouth-Hitchcock for the follow up radiation procedures rather than having to go to Boston VA, which was a good deal for me. I have found the folks here to be polite, professional, and no nonsense. That is a good thing because I would not expect nor accept anything else. White River also just got their own MRI, but like all thinks VA, I have an appointment in two months time rather than the same day. Then, that is my choice. I have no complaints with the system up here sorry to hear about the situation in your area.