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Reasons for acquiring insurance outside Department of Veterans Affairs (VA) health care coverage among VA enrollees are incompletely understood. To assess Veterans' decision-making and acquisition of non-VA health care insurance in the Affordable Care Act era, we used mailed questionnaires and semistructured interviews in a stratified random sample of VA enrollees <65 years in the Midwest. Of the 3,666 survey participants, 32.1% reported non-VA insurance. Frequently reported reasons included wanting coverage for emergency situations or family members. Those without non-VA insurance cited unaffordability as the main obstacle. Analysis of the semistructured interview data revealed similar findings. In multivariable logistic regression analyses, characteristics associated with non-VA insurance included higher income (>$50,000 vs. <$10,000, odds ratio [OR] = 5.95, 95% confidence interval [CI]: 3.45-10.3, p < .001). As financial barriers exist for acquisition of non-VA insurance and hence community care, it is critically important that VA enrollees' health care needs are met through VA or community providers financed through VA.

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BACKGROUND: Provisions of the Affordable Care Act (ACA) provided nonelderly individuals, including Veterans, with additional health care coverage options. This may impact enrollment for health care through the Veterans Health Administration (VHA). National enrollment data was used to: (1) compare characteristics of enrollees at 3 time points in relation to the implementation of ACA insurance provisions (2012); and (2) examine enrollment trends. METHODS: The study population included a 10% sample of Veterans under age 65 who were VHA enrollees between January 2012 and September 2015. Demographic and baseline characteristics were compared between 3 enrollment groups: pre-2012, pre-ACA (2012-2013), and post-ACA (2014-2015). Using an interrupted time series approach, we employed pooled logistic regression to assess trends in new VHA enrollment, overall, and by select enrollee characteristics. RESULTS: A total of 429,833 enrollees were identified. Compared with pre-ACA enrollees, post-ACA enrollees were more likely to be older, have a service-connected disability, live further away from a VHA medical center, but less likely to use primary care within 6 months. The post-ACA quarterly trend in the odds of being a new enrollee was 3% lower (95% confidence interval: 0.96, 0.98) as compared with the pre-ACA trend. This decline was consistent across sex, geography, (all but 1) priority group, and state Medicaid-expansion subgroups. CONCLUSIONS: The ACA appears to have contributed to a decline in new VHA enrollment. In addition, the profile of newer enrollees differs from that of pre-ACA enrollees. The VHA must continue to monitor trends in demand in order to continue delivering high-quality, efficient care.

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OBJECTIVE: To compare the complications, healthcare utilization and costs following DBS or medical management for patients with Parkinson's disease (PD). METHODS: We examined healthcare utilization and costs for up to 5 years between veterans with DBS and those with medical management for PD. Veterans who received DBS between 2007 and 2013 were matched with veterans who received medical management using propensity score approaches. Healthcare utilization and costs were obtained from national VA and Medicare data sources and compared using procedures to adjust for potential differences in length of follow-up. RESULTS: We identified 611 veterans who had received DBS and a matched group of 611 veterans who did not undergo DBS. Among DBS patients, 59% had the electrodes and generator implanted during separate admissions. After 5 years of follow-up, average total healthcare costs, including DBS procedures and complications, were $77,131 (95% confidence interval: $66,095-$88,168; P < 0.001) higher per person for patients who received DBS ($162,489) than patients who received medical management ($85,358). In contrast, excluding the costs of the DBS procedures and complications, average total costs were not significantly different between patients who received DBS and patients who received medical management after 5 years of follow-up. CONCLUSIONS: Healthcare costs over 5 years were higher for veterans who received DBS. These higher healthcare costs may reflect the costs of DBS procedures and any follow-up required plus greater surveillance by healthcare professionals following DBS as well as unobserved differences in the patients who received medical management or DBS.

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OBJECTIVE: Deep brain stimulation has been shown to have a significant long-term beneficial effect on motor function. However, whether it affects survival is not clear. In this study, we compared survival rates for Parkinson's disease (PD) patients who underwent deep brain stimulation (DBS) with those who were medically managed. METHODS: A retrospective analysis of Veterans Affairs and Medicare administrative data of veterans with PD who received DBS and were propensity score matched to a cohort of veterans with PD who did not receive DBS between 2007-2013. RESULTS: Veterans with PD who received DBS had a longer survival measured in days than a matched group of veterans who did not undergo DBS (mean = 2291.1 [standard error = 46.4] days [6.3 years] vs 2063.8 [standard error = 47.7] days [5.7 years]; P = .006; hazard ratio = 0.69 [95% confidence interval 0.56-0.85]). Mean age at death was similar for both groups (76.5 [standard deviation = 7.2] vs 75.9 [standard deviation = 8.4] years, P = .67), respectively, and the most common cause of death was PD. CONCLUSIONS: DBS is associated with a modest survival advantage when compared with a matched group of patients who did not undergo DBS. Whether the survival advantage reflects a moderating influence of DBS on PD or on comorbidities that might shorten life or whether differences may be a result of unmeasured differences between groups is not known. © 2017 International Parkinson and Movement Disorder Society.

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BACKGROUND: The subthalamic nucleus (STN) and the globus pallidus internus (GPi) are both effective targets for deep brain stimulation (DBS) to relieve motor symptoms of Parkinson's disease. However, studies have reported varied effects on mental health-related adverse events and depressed mood following DBS. OBJECTIVE: The current observational study sought to compare mental health healthcare utilization and costs for three years following STN or GPi DBS. METHODS: For a cohort of Veterans (n = 161) with Parkinson's disease who participated in a larger multi-site randomized trial, we compared mental health outpatient visits, medication use, inpatient admissions, and associated costs by DBS target site (STN vs. GPi). RESULTS: Neither group nor time differences were significant for mental health outpatient or inpatient utilization following DBS. Overall costs associated with mental health visits and medications did not differ by time or by group. However, the percentage of patients with mental health medication use increased in the 6-month and 6 to 12 month periods post-surgery. The STN group had significantly greater increase in medication use at 6 to 12 months post-surgery compared to the GPi group (p <  0.05). CONCLUSION: Despite a brief increase in medication use following surgery, this study suggests that mental health healthcare use and costs are stable over time and similar between DBS targets. Prior research findings of mental health-related adverse events and mood following DBS did not translate to greater mental health service utilization in our cohort. The changes seen in the year following surgery may reflect temporary adjustments with stabilization over time.

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OBJECTIVE: To assess costs and effectiveness of deep brain stimulation (DBS) of the internal globus pallidum (GPi) versus subthalamic nucleus (STN) from the provider and societal perspectives for Parkinson's disease (PD) patients in a multicenter randomized trial. METHODS: All costs from randomization to 36 months were included. Costs were from Department of Veterans Affairs (VA) and Medicare databases and clinical trial data. Quality adjusted life years (QALYs) were from Quality of Well Being questionnaires. RESULTS: Provider costs were similar for the 144 GPi and 130 STN patients (GPi: $138,044 vs. STN: $131,822; difference = $6,222, 95% confidence interval [CI]: -$42,125 to $45,343). Societal costs were also similar (GPi: $171,061 vs. STN: $167,706; difference = $3,356, 95% CI: -$57,371 to $60,294). The GPi patients had nonsignificantly more QALYs. CONCLUSIONS: The QALYs and costs were similar; the level of uncertainty given the sample size suggests that these factors should not direct treatment or resource allocation decisions in selecting or making available either procedure for eligible PD patients.

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The costs of treating Parkinson's disease (PD) are significant. Medication reductions usually occur following deep brain stimulation (DBS), but less is known about the relative costs of DBS targets, the globus pallidum (GPi) or the subthalamic nucleus (STN). This article reports medication costs between best medical therapy (BMT) and DBS over 6 months postintervention and by DBS target over 36 months postsurgery. Prescription use and costs for patients (n = 161) with advanced PD from a multisite randomized trial of BMT and DBS were examined overall and by drug category. Medication adjustment occurred at the discretion of the neurologists. PD medications were extracted from the Department of Veterans Affairs Decision Support System database. Levodopa equivalents (LEDD) were significantly lower for DBS than for BMT patients at 6 months (1101 vs 1398 mg; P = .005), but costs were similar (US$1750 vs US$1589; P = .55). LEDD decreased following GPi and STN DBS (1395-1161 mg, P = .014; and 1347-891 mg, P < .0001, respectively) in the first 6 months, but was lower for STN than for GPi over 36 months following DBS (P = .03). Total PD medication costs per 6-month intervals decreased over 36 months (P < .0001), but did not differ by target (P = .50) in the mixed-model analysis. However, cumulative medication costs over 36 months were lower for the STN than for GPi patients. PD medication use and costs decreased following DBS in either target over 36 months, but cumulative costs were less for STN than for GPi.

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OBJECT: Deep brain stimulation (DBS) to treat advanced Parkinson disease (PD) has been focused on one of two anatomical targets: the subthalamic nucleus (STN) and the globus pallidus internus (GPI). Authors of more than 65 articles have reported on bilateral DBS outcomes. With one exception, these studies involved pre- and postintervention comparisons of a single target. Despite the paucity of data directly comparing STN and GPI DBS, many clinicians already consider the STN to be the preferred target site. In this study the authors conducted a metaanalysis of the existing literature on patient outcomes following DBS of the STN and the GPI. METHODS: This metaanalysis includes 31 STN and 14 GPI studies. Motor function improved significantly following stimulation (54% in patients whose STN was targeted and 40% in those whose GPI was stimulated), with effect sizes (ESs) of 2.59 and 2.04, respectively. After controlling for participant and study characteristics, patients who had undergone either STN or GPI DBS experienced comparable improved motor function following surgery (p = 0.094). The performance of activities of daily living improved significantly in patients with either target (40%). Medication requirements were significantly reduced following stimulation of the STN (ES = 1.51) but did not change when the GPI was stimulated (ES = -0.02). CONCLUSIONS: In this analysis the authors highlight the need for uniform, detailed reporting of comprehensive motor and nonmotor DBS outcomes at multiple time points and for a randomized trial of bilateral STN and GPI DBS.

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BACKGROUND: This study examined trends and outcomes for breast cancer surgery performed at Department of Veterans Affairs (VA) hospitals. STUDY DESIGN: We examined breast cancer operations performed in VA hospitals from October 1991 to September 1997. Data from the VA National Surgical Quality Improvement Program, surgical pathology reports, discharge data, and outpatient data were used. Surgical outcomes included postoperative length of stay, 30-day morbidity rates, 1-year surgery-related readmission rates, and mortality. An expert panel of breast cancer clinicians identified surgery-related hospital readmissions. Hierarchical regression analysis was used to identify patient, provider, and hospital characteristics associated with postoperative length of stay, and 30-day morbidity. RESULTS: From October 1991 to September 1997 1,333 breast operations were performed, ranging from 1 to 38 on average per hospital; 478 operations were for breast cancer. Among breast cancer surgery patients, 25% were men. Thirty-day morbidity rates, 1-year hospital readmission rates, and mortality were very low for both men and women. Postoperative length of stay averaged 6.8 days. Lower income, longer operation times, and older age increased the likelihood of 30-day morbidity. Lower functional status, older age, longer operation time, and lower average annual volume of procedures increased postoperative length of stay. Documentation of the extent of disease and surgical margin in pathology reports was poor in medical records. CONCLUSIONS: Hospital stays were longer, and morbidity and readmission rates for patients having breast cancer operations at VA hospitals were comparable to those reported for private sector hospitals.

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