We surveyed 700 veterans who were outpatients in a non–Veterans Affairs (VA) multihospital system. Our objective was to assess the prevalence of mental disorders and service use among these veterans. The majority were Vietnam veterans (72.0%), and male (95.9%), and 40.4% reported recently using the VA for care. The prevalence of lifetime post-traumatic stress disorder (PTSD) was 9.6%, lifetime depression 18.4%, and lifetime mental health service use 50.1%. In multivariate analyses, significant factors associated with PTSD, depression, and mental health service use were low self-esteem, use of alcohol/drugs to cope, history of childhood adversity, high combat exposure, and low psychological resilience. VA service use was associated with greater mental health service use and combat exposure. With the exception of alcohol misuse, the mental health status of veterans seen in non-VA facilities appeared to be better than reported in past studies. Because most veterans have access to both VA and non-VA services, these findings have implications for veterans and outcomes research.

ObjectiveOpioid overdoses (ODs) have been increasing, and harm reduction efforts are a priority. The success of these efforts will be dependent on the identification of at-risk patients and improved access to the antidote naloxone. Therefore, to identify access to naloxone and factors associated with negative health outcomes, we conducted a retrospective study of patients with OD to identify those at highest risk of adverse outcomes and to assess the use of naloxone.MethodsWe conducted a study of electronic health records for patients admitted to the largest multihospital system in the region – the Geisinger Health System (GHS) for ODs – from April 2005 through March 2015. ODs were defined by International Classification of Diseases-9 codes (age range: 10–95 years). Bivariate analyses and multiple logistic regressions were conducted to identify pre-OD factors associated with adverse health outcomes post-OD.ResultsWe identified 2,039 patients with one or more ODs, of whom 9.4% were deceased within 12 months. Patient demographics suggest that patients with OD had a mean age of 52 years, were not married (64%), and were unemployed (78%). Common comorbidities among patients with OD include cardiovascular disease (22%), diabetes (14%), cancer (13%), and the presence of one or more mental health disorders (35%). Few patients had a prescription order for naloxone (9%) after their OD. The majority of patients with OD were in proximity to GHS health care facilities, with 87% having a GHS primary care provider. In multiple logistic regressions, common predictors of adverse outcomes, including death, repeated ODs, frequent service use, and high service cost, were higher prescription opioid use, comorbid medical conditions, comorbid mental disorders, and concurrent use of other psychotropic medications.ConclusionThis study suggests opportunities for improving OD outcomes. Those who receive higher quantities of prescription opioids concurrent with other psychotropic medicines may need closer monitoring to avoid death, repeated OD events, higher service use, and higher service costs. Other opportunities for improving OD outcomes include the use of electronic health records to notify physicians of high-risk patients and updating of guidelines/operation manuals focused on the distribution of naloxone to those in highest need.

Readmission among patients with CLI is high, the majority of them being unplanned readmissions. Several demographic, clinical, and socioeconomic factors play important roles in predicting readmissions.

Background: Informed consent requirements generally require a lengthy process and signed documentation for patients to participate in clinical research. With growing interest in comparative effectiveness research (CER), whereby patients receive approved (nonexperimental) medicines for their medical condition, questions have been raised whether the same consent requirements should apply. Little input from patients has been part of these debates. Methods: We conducted two "deliberative engagement sessions" with patients from Johns Hopkins Community Physicians (JHCP) and Geisinger Health System (GHS). Full-day sessions introduced participants to two different CER designs (observational vs. randomized) comparing two antihypertensive medications and three disclosure or consent approaches: Opt-In, Opt-Out, and "General Approval." Sessions consisted of presentations and extensive discussion at small group tables. Pre-and posttest surveys were completed by participants before and after all-day discussions measuring attitudes about research and about each of the three disclosure/ consent options. Results: One hundred thirty-seven adults over age 40 years participated. Attitudes were similar between JHCP and GHS. Participants strongly preferred Opt-In or Opt-Out consent options to General Approval for both observational and randomized designs. For the randomized CER study, 70% liked Opt-In, 65% liked Opt-Out, and 40% liked General Approval. In discussing disclosure/consent options, patients cared most about choice, information, privacy and confidentiality, quality of the research, trust, respect, and impact of the study on patient care. Conclusions: The majority of participants from two different types of health systems liked both Opt-In and Opt-Out approaches for observational and randomized designs for low-risk CER. There were no posttest differences in the proportion liking Opt-In versus Opt-Out. Patients in this study wanted to be told about research and have a choice, but were very open to such disclosures being streamlined. Policymakers may find patients' views about what matters to them in the context of consent and CER relevant.

Improving the quality of care for chronic diseases is an important issue for most health care systems in industrialized nations. One widely adopted approach is the Chronic Care Model (CCM), which was first developed in the late 1990s. In this article we present the results from two large surveys in the United States and Germany that report patients' experiences in different models of patient-centered diabetes care, compared to the experiences of patients who received routine diabetes care in the same systems. The study populations were enrolled in either Geisinger Health System in Pennsylvania or Barmer, a German sickness fund that provides medical insurance nationwide. Our findings suggest that patients with type 2 diabetes who were enrolled in the care models that exhibited key features of the CCM were more likely to receive care that was patient-centered, high quality, and collaborative, compared to patients who received routine care. This study demonstrates that quality improvement can be realized through the application of the Chronic Care Model, regardless of the setting or distinct characteristics of the program.