Veterans Health Administration and Infectious Disease
The Veterans Health Administration (VHA) has four congressionally mandated missions (Kizer, 1999):
Provide health care services to the nation's veterans.
Conduct educational programs that enhance the quality of care provided.
Conduct research programs that enhance the quality of care provided.
Serve as a backup to the U.S. Department of Defense medical system and assist in the provision of health care during times of emergencies and natural disasters.
One of the largest health care systems in the nation, VHA is the largest component of the U.S. Department of Veterans Affairs (DVA), accounting for half of its budget, approximately $18 billion, and 80 percent of its staff. In addition, certain infectious diseases (Levine, 1998), such as AIDS and tuberculosis, occur at higher rates among the population that it serves, and therefore, VHA can provide unique insights into researching, monitoring, and teaching others about infectious disease.
The VHA is organized into 22 Veterans Integrated Service Networks (VISNs). VISNs are centered around the concept that health care should be based on the population that it serves and not on the facilities in which it is delivered. As a result, each VISN is composed of 7 to 10 hospitals, 25 to 30 ambulatory-care facilities, and is designed to align resources around patients, forcing the VISN to pool and coordinate its resources and services (Kizer, 1997).
VHA's systemwide move to greater efficiency has also included major innovations in the information technology department. Software, such as the Clinical Information Resources Network, allows VHA physicians to view the primary care data for a patient anywhere within their own VISNs and to share
those data with other VISNs. In addition, programs such as the unique Emerging Pathogens Initiative allow VHA to conduct surveillance and monitor emerging pathogens anywhere in the VHA hospital system.
This appendix is intended to acquaint the reader with selected programs and aspects of the VHA which are unique, rather than provide a comprehensive review of all VHA programs that address infectious diseases. The following discussions address the five thematic areas discussed in the workshop summary (i.e., research, clinical practice, surveillance and monitoring, education, and drug formularies) and highlight some of the opportunities presented by the VHA system.
In fiscal year 1997, the VHA research budget totaled more than $900 million. This funding included funds from a congressional appropriation, extramural grants awarded to individual researchers, and indirect support from the medical care budget. The Office of Research and Development (ORD) is the organizational structure responsible for allocating research dollars among the DVA facilities across the nation currently participating in research and development activities. Although the ORD consists of four research branches, the two most relevant to infectious disease are the Cooperative Studies Program (CSP) and the Medical Research Service (MRS).
CSP began in 1946 with landmark research in the treatment of tuberculosis (DVA, Office of Research and Development, 1997). CSP plays the important role of reviewing and providing administrative coordination to researchers nationwide who wish to conduct large, multisite clinical research studies. Indeed, more than 100 DVA hospitals are involved in cooperative studies. CSP provides an opportunity for researchers in infectious disease to coordinate and share resources and patient populations in the course of their investigations.
MRS is the main research branch responsible for biomedical research that enhances the quality of care received by veterans. One of the core research centers is the Center for AIDS and HIV Infection, with locations in Georgia, New York, California, and North Carolina.
Antimicrobial resistance is another research focus in VHA. Current projects include mechanisms of resistance in Mycobacterium tuberculosis , an investigation of the signal pathways in antibiotic resistance, and structure-function relationships of relevant enzymes such as the SHV-1 b-lactamase and amine oxidase.
VHA's Emerging Pathogens Initiative (EPI) has been in operation since 1998, serving as the data source for many research projects. One recent EPI finding showed a concordance between addiction disorders and hepatitis C virus infection, information that is important in designing intervention strategies and therapeutic trials. A second study with EPI data found that group A streptococcus afflicted a younger, disproportionately female population, thereby delineat-
ing a women's health issue that would not otherwise have been recognized. (Refer to Chapter 4 for a more thorough discussion of EPI.)
VHA operates 172 hospitals, 132 nursing homes, 73 home health care programs, and more than 650 outpatient clinics. In 1998, these facilities, along with other contractual programs, served 3.4 million of 9.4 million individuals who qualified for care (Kizer, 1999). However, DVA has experienced dramatic changes in the past few years, eliminating more than half of its acute-care beds and, from 1994 to 1998, increasing by 43 percent the number of ambulatory-care visits per year (Kizer, 1999). Most importantly, the creation of VISNs resulted in a need to integrate clinical data on a VISN-wide basis.
The Computerized Patient Record System (CPRS) allows all individuals on the health care team to view demographic data, future appointments, advanced directives, medications, orders, and progress notes. The Clinical Information Resources Network (CIRN) serves as the means for transmitting those data across the VHA network. CIRN ensures that a patient's primary care provider can receive all data on that patient's care, no matter where it was originally delivered. CIRN presents an opportunity to monitor health care delivery patterns and to allow VHA to modify clinical guidelines on the basis of current physician practices (DVA, Veterans Health Administration, 1998).
VHA is the nation's largest direct provider of services to homeless people, providing health care to more than 80,000 homeless people each year (Robert Rosenheck, Director, Veterans Administration Northeast Program Evaluation Center, personal communication, August 1999). In fact, on any given day in 1996, homeless people accounted for 13.5 percent of all hospital admissions (Wilson and Kizer, 1997).
Homelessness presents a unique set of circumstances for the treatment of infectious diseases. Physician monitoring is limited to the patient's motivation to seek care, and living conditions are often sub-standard. Since these conditions often involve sharing congregate spaces with large numbers of individuals, the transmission of communicable diseases cannot easily be prevented.
However, care of homeless veterans could be improved by use of EPI to identify the most prevalent infections and comorbidities and devise effective prevention strategies. For example, EPI data showed that for fiscal year 1998, 8.1 percent of all patients with hepatitis virus infection were homeless (Kralovic et al., 1999). Since EPI can identify the emerging pathogens that affect homeless
populations the most and VHA treats more homeless individuals than any other healthcare system in the nation, the EPI can also serve as an invaluable public health investigative tool. This information could be very useful to the VHA's Homeless Veterans Treatment and Assistance Program, which seeks to identify and ameliorate the causes and effects of homelessness among veterans.
SURVEILLANCE AND MONITORING
Emerging Pathogens Initiative
EPI has been online since 1998 and is operated by the Program Office for Infectious Diseases. EPI allows VHA to track emerging pathogens on a national level, with no additional labor required at the local level. This automated computer program is an innovative and unique effort capable of searching all VHA inpatient records and retrieving patient-specific information (e.g., age, sex, comorbidities, zip code, and ethnicity) when it identifies a positive laboratory test for a specific pathogen. Identifiable pathogens include hepatitis C virus, M. tuberculosis, penicillin-resistant pneumonococci, vancomycin-resistant enterococci, leishmania, Escherichia coli O157, the virus that causes dengue, Cryptosporidium, CJD, group A streptococcus, Candida in the bloodstream, Clostridium difficile, legionella, and plasmodium, which causes malaria (Roselle et al., 1999).
EPI data are collected once a month and are forwarded to a central processing computer in Austin, Texas. The data are analyzed after a 2-week period, during which hospitals may identify software problems that have resulted in obvious errors. This is intended to serve as a human check on an otherwise automated system. The combination of identifying emerging pathogens and obtaining patient-specific information allows epidemiological analyses, future projections, and outcome assessment.
Annual Infectious Diseases and Infection Control Report
Since 1991, all DVA medical facilities have provided data concerning pathogens and control measures via an electronic survey. These data, including the number of infection control practitioners, physicians, and clerical staff at each facility, as well as information regarding relevant organisms and pathogens, are then analyzed by the Infectious Disease Program Office. For instance, when VHA wanted to determine whether their efforts to reduce M. tuberculosis infection rates via a central planning effort were effective, they analyzed the M. tuberculosis infection rates by use of the data received in the annual survey. Data that were collected between 1992 and 1997 showed that the number of cases of tuberculosis had dropped 44 percent. VHA received confirmation of its effectiveness of their efforts since this decrease was greater than that seen in the U.S. population.
VHA's educational mission is to ensure an adequate supply of clinical care and allied health providers for veterans and the nation. VHA facilities train more than 100,000 individuals from more than 40 health professions every year. VHA directly funds approximately 9,000 physician residency positions and 10 percent of the nation's graduate medical trainees. It is also affiliated with 105 of the nation's 126 medical schools, training 22,000 medical students for at least part of their clinical rotations every year (Kizer, 1997). In addition, the number of ambulatory-care VHA training sites is increasing, providing opportunities not often found at academic health centers.
The sheer number of trainees allows VHA to have a tremendous impact on future medical practice, an impact that is unparalleled by that of any other health care organization in the nation. In addition, the resources at VHA can produce reference manuals and guidebooks that smaller organizations cannot easily provide. One example relevant to infectious disease is the Emerging Pathogens Guidebook. This volume, which serves both as a reference for current practitioners and as a textbook for a workshop in the year 2000, is intended to assist in the prevention of the spread of infectious diseases. In addition, the guidebook serves to provide information and guidance to DVA health care teams. The teams can then modify their health care workplaces to improve infection control practices and minimize the occurrence of nosocomial infections.
The DVA National Formulary, adopted on June 1, 1997, is meant to provide better patient care at a lower cost. Before that date, each VISN was responsible for maintaining its own formulary and making all formulary decisions. The change to the national formulary instituted a tiered system, splitting the decision making process between VHA's Pharmacy Benefits Management Strategic Healthcare Group, each individual VISN, and each facility within a VISN. Each VISN maintains a formulary that provides at least all the drugs on the national level, and facilities maintain formularies that provide at least all the drugs on the VISN and national levels. The tiered system works in conjunction with an ''open" and "closed" drug classification system.
When VHA has secured a national contract with a drug manufacturer to provide particular pharmaceuticals, the drugs are considered to be in "closed" drug classes. In this case, individual VISNs or facilities cannot add additional pharmaceuticals to the formulary. Non-formulary drugs can be prescribed through a procedure used to identify unique clinical circumstances that warrant the use of nonformulary prescriptions, such as the therapeutic failure of all existing formulary pharmaceuticals. The four classes of drugs characterized as "closed" are proton pump inhibitors, alpha-blockers, HMG coeneyme A reductase inhibitors, and angiotensin-converting enzyme inhibitors.
All other drugs listed in the formulary are considered "open" and must be provided by DVA facilities. However, in contrast to the "closed" classes of drugs, local areas may use additional therapeutic agents in an effort to best serve their patient populations. Antibiotics are treated in this manner and are not restricted by the national formulary.
The flexibility offered by a tiered system has allowed certain VHA facilities to design their own procedures for using antibiotics. For instance, the Portland VHA facility uses the services of an infectious diseases team to make an annual review of antimicrobial agents as they pertain to their local patient population. The infectious diseases team consists of clinical microbiologists, physicians, and pharmacists. For any particular drug, the team may allow physicians complete freedom in ordering prescriptions or may require physicians to obtain approval from the team before ordering their use (Larry Strausbaugh, hospital epidemiologist and staff physician, Veterans Administration Hospital Center, personal communication, August 1999).
As indicated in the workshop summary, controversy surrounds the use of formularies and the DVA National Formulary has not been spared. Questions have been raised by both the veterans served by VHA and members of the U.S. Congress who appropriate funds to the VHA. As a result, the Institute of Medicine is currently engaged in a study, mandated by the U.S. Congress, to analyze the DVA National Formulary. Its primary objectives include answering the following the questions:
Is the DVA National Formulary overly restrictive and does it prevent physicians from meeting the unique health care needs of veterans?
What are the potential costs to DVA health care associated with the DVA National Formulary?
What are the effects of the DVA National Formulary and related policies on quality of care?
How does the DVA National Formulary compare with private insurance formularies for drugs and devices and with other government formularies (e.g., that of Medicaid)?
As was the case with VHA's association with educational institutions, the uniqueness of the DVA National Formulary lies in its sheer strength and size. Currently, DVA spends approximately $1 billion on pharmaceuticals annually (Kunzi, 1999), including about $170 million on antimicrobial agents. This provides VHA with a large amount of leverage when contracting for new pharmaceuticals. In addition, the Veterans Health Care Act of 1992 requires pharmaceutical companies to offer selected products to VHA at the Federal Ceiling Price, which is approximately equal to the average nonfederal manufacturer's price plus a 24 percent discount (Kunzi, 1999).