VA has a nationwide cadre of health services researchers who examine health care itself. They look at everything from the computer technology used in health care to small talk between doctors and patients during office visits.
These health services researchers play a vital role in shaping the delivery of health care. They focus on access, cost, and quality. They work to identify and assess vital signs of a well-functioning health care system and develop performance measures for examining aspects of such a system. They also seek to improve the system by identifying gaps in quality and then testing and disseminating solutions to those problems.
Most of this research is undertaken by VA (HSR&D), which works to identify and evaluate innovative strategies that lead to accessible, high, quality, cost-effective care for Veterans and the nation.
HSR&D's 19 Centers of Innovation and four resource centers support innovative research that advances the understanding of the VA health care system, and promote research in targeted areas that contribute to short- and long-term improvements in VA care.
The Collaborative Research to Enhance Transformation and Excellence(CREATE) initiative encourages HSR&D investigators to collaborate with others within VA to conduct research on high-priority issues that affect the health and health care of Veterans.
The Quality Enhancement Research Initiative (QUERI), also under HSR&D auspices, enhances the quality and outcomes of VA health care by systematically implementing clinical research findings and evidence-based recommendations into routine clinical practice.
Another HSR&D initiative, the Evidence-based Synthesis Program, provides timely and accurate syntheses of research findings on targeted health care topics of particular importance to VA clinicians, managers, and policymakers.
The VA Technology Transfer Program translates the results of worthy discoveries made by employees in all areas of VA research into medical practice in VA and beyond. It educates VA inventors concerning their rights and obligations, rigorously evaluates their inventions, obtains patents, and helps in the commercialization of new products.
Many VA research projects do not relate to a specific health condition.
Some VA researchers work on ways to measure performance and improve the quality of the health care VA provides. Others look at technologies involved with connected health, changing the locations where health care is being provided, or the methods through with Veterans can access care. Still others look at patient-safety issues, working to reduce and prevent inadvertent harm to Veterans as a result of the health care VA provides.
Some VA researchers work in the area of health care informatics, finding ways to use the power of information technology (IT) to benefit both science and communications. Others look at ways Veterans use the Internet as it relates to health care.
Researchers also explore new models of providing care to patients, such as VA's Patient Aligned Care Teams (PACT) initiative. They look at ways to provide more data about the quality of VA's care to patients and others, and study interactions between patients and clinicians to improve patients' abilities to understand what their providers tell them. And they study the economics of providing health care, in hopes of reducing the taxpayer burden associated with the VA health care system.
Finally, some VA researchers are looking at new ways to accomplish research itself, including reducing the time it takes to conduct research projects and have the results adopted into everyday care; creating partnerships with other research groups; and finding new, more efficient and accurate ways to conduct clinical trials.
VA investigators have been involved in a number of initiatives focused on improving access to care for Veterans, as well as improving the quality of the care Veterans receive.
These initiatives include developing and implementing effective treatments and programs that take place outside of hospitals and clinics, getting health care providers and Veterans involved in designing ways to improve access to care, and identifying the best strategies for implementing effective treatments or programs.
Shared medical appointments (SMAs), for example, are becoming a popular way for Americans to see their doctors. Group visits provide patients with a sense of comfort, support, and even motivation, which comes from sharing similar experiences with others in the same situation.
Videoconferencing for diabetes management—Diabetes management is one of the areas in which SMAs are often used. Researchers conducting an ongoing VA study are looking at whether videoconferencing can be used to conduct SMAs for diabetes care. If videoconferencing is found effective, it will help overcome the problem of finding health care specialists in rural areas who have the skills to conduct these group visits in person.
Group therapy for Veterans at risk of suicide—Researchers at the Robley Rex VA Medical Center in Louisville, Kentucky., are conducting a three-year study into the use of group therapy visits for Veterans at risk of suicide. They hope to learn whether group therapy will provide these Veterans with an opportunity to develop relationships while contributing to one another's efforts at rehabilitation. The hope is that Veterans participating in these sessions will build interpersonal connections that may increase their motivation to live, rekindling the camaraderie and sense of mutual responsibility that was ingrained in them through their military service.
Re-engaging Veterans with mental illness—VA has found that Veterans with serious mental illness who re-engaged in VA health care have a 12-fold decreased risk of mortality compared with Veterans who were not brought back into care. VA researchers are therefore seeking ways to re-engage Veterans with serious mental illness who are homeless or at risk of homelessness to get them back into the VA health care system.
Along these lines, a study at the VA Ann Arbor Healthcare System is evaluating a program to identify Veterans with a history of homelessness and a diagnosis of serious mental illness who have stopped coming to VA for care. The researchers hope to determine whether a centralized program can help local homeless coordinators and others re-engage these Veterans with the health care, housing, and other social services VA offers.
VA's National Center for Patient Safety (NCPS) was established in 1999 to develop and nurture a culture of safety throughout VHA. The center's goal is the nationwide reduction and prevention of inadvertent harm to Veterans as a result of their care.
NCPS operates Patient Safety Centers of Inquiry (PSCI) at a number of VA medical centers throughout the nation. PSCIs research specific areas of patient safety and develop and provide practical tools to improve patient safety. PSCIs have contributed to teamwork and simulation training; safe patient handling and movement; and patient fall prevention and management.
VA has developed a campaign, called "No Preventable Harms", that aims to "create the safest health care system in the world" by reducing and eliminating occurrences such as infections, medication-related errors, and blood clots in the extremities.
Reducing catheter-associated urinary tract infections—The first focus of the campaign is to reduce the number of catheter-associated urinary tract infections. These infections are common, costly, and dangerous, affecting about 1 in 20 patients admitted to hospitals every year.
The infections increase Veterans' length of stay, overall health costs, and their risk of dying. The researchers found that, although only 25 percent of hospital patients have a urinary catheter at any given time, patients with such catheters accounted for around one-third of all infections.
By ensuring that catheters were used only for patients who really needed them, and that nurses used proper hygiene when inserting them, and by preventing exposure to bacteria, VA's Ann Arbor facility saw a 39 percent decrease in infections. The program has now been expanded to the entire VA region, and will soon be used nationwide.
The results of the effort, conducted by researchers at the Ann Arbor VA and the University of Michigan, were published in 2015.
Contamination while removing protective gear—Researchers at the Louis Stokes VA Medical Center in Cleveland and their colleagues used fluorescent lotion and black light in a 2015 study that showed that health care workers often contaminate their skin and clothing while removing their protective gear. This contamination can spread germs and place the workers and patients at risk of infection. Contaminated personnel can also spread pathogens to other susceptible patients.
Doctors, nurses, and other health care personnel at four VA and non-VA Cleveland-area hospitals were asked to participate in simulations in which they put on and removed protective gowns and gloves. A small amount of fluorescent lotion was then placed in the palm of their hands, which they rubbed between their hands and smeared on their gowns.
The investigators checked the skin and clothing of the study participants for the lotion after the participants removed those gowns and gloves, and found that either their skin or their clothing was contaminated 46 percent of the time—70 percent of the time when the protective equipment was removed improperly.
Reducing diagnostic errors—In a 2015 editorial in the New England Journal of Medicine, Dr. Hardeep Singh of the VA Center for Innovations in Quality, Effectiveness, and Safety at the Michael E. DeBakey VA Medical Center in Houston, issued a call to action to reduce the number of diagnostic errors made by clinicians nationwide. According to Singh, diagnostic errors affect 12 million American adults per year, or 1 in 20 adults. Common diagnoses such as infections, heart disease, and cancer are among those that are often missed.
Dr. Singh and his co-author suggest recommendations for systems and process changes such as making patients a part of the diagnostic team, reforming the way in which diagnosis is taught, strengthening teamwork, and promoting a culture of diagnostic safety.
They argued that one of the first steps should be for researchers and safety professionals to develop resources to help institutions and clinicians identify and measure diagnostic errors accurately.
Patient Aligned Care Teams (PACTs) have transformed how primary care is delivered in VA. These integrated teams aim to deliver care that is patient-driven, team-based, comprehensive, and coordinated. Researchers have looked at how this transformation has been implemented in VA, and how PACTs have influenced Veterans' health.
PACTs are teams of health care professionals that provide comprehensive care in partnership with the patient and his or her caregivers, and manages and coordinates comprehensive health care services consistent with agreed-on goals of care..
One of VA's CREATE initiatives looks at improving quality and safety through better communications in PACTs. This CREATE is now funding studies to look at the development of PACT interventions that improve health care quality and safety, to deliver timely and team members with understandable information that can be used to improve clinical outcomes.
Rapid PACT implementation—A study at the Ann Arbor VA evaluated changes in VA care since the implementation of PACT, and found that VA achieved rapid progress in building a PACT infrastructure in the first 30 months of a four-year implementation plan. The study also found that, throughout VA, in-person primary care provider visit rates decreased slightly; health care provided via telephone and the Internet increased dramatically; and post-hospitalization follow-up improved substantially. All of this was the result of VA's adoption of PACT teams.
The July 2014 supplement to the Journal of General Internal Medicine focused on the initial implementation of PACT in VA. The supplement included 19 peer-reviewed articles that reflected on lessons learned by researchers and their clinical and policy partners during early stages of the PACT implementation.
The 19 published articles touched upon virtually all facets of PACT, including implementation strategies, performance measurement, care transitions, team development, mental health and pharmacy integration, and quality improvement.
PACT model for mental illness—An ongoing study, set to conclude in 2018, is looking at the effects of moving to a PACT model for Veterans with serious mental illnesses. The study is addressing whether PACTs can provide seriously mentally ill Veterans with appropriate preventive and medical treatments and improve their quality of life, and whether PACTs for this population can reduce medical and mental health treatment usage and costs.
About three-quarters of Veterans enrolled in VA health care also have another form of health coverage, and the Veterans Choice program allows eligible Veterans to receive health care within their communities. While this raises the possibility of better, more comprehensive care, it may also lead to some adverse outcomes, such as incomplete communication among providers; duplicative, competing, or incomplete diagnosis and treatment plans; and unnecessary high costs.
VA researchers work to understand the scope of multi-system health care use, its impact on the quality, costs, and efficiency of patient care.
VA health care and Medicare—A study by researchers at the Providence, Rhode Island, VA Medical Center, published in 2015, provided an assessment of VA and non-VA health services, VA-financed costs, and quality of care for all VA enrollees who are also enrolled in a Medicare Advantage Plan.
The study looked at 6,643 older, chronically ill Veterans who were enrolled during 2008 or 2009 in both VA and a Medicare Advantage plan, and focused on measures of good care for diabetes, hypertension, and high cholesterol. It found that those who used both plans did no better or worse than those who used only VA care.
Investigators did find some duplicate spending, but noted that among the 5,000 or so Veterans who used both systems to some extent, most relied more heavily on VA, with relatively few Medicare Advantage visits.
A 2014 study by a team at VA's Center for Health Equity Research and Promotion, based in Philadelphia and Pittsburgh, found that many Veterans with diabetes received blood sugar testing strips from both VA and Medicare.
The investigators studied data from 363,996 Veterans with type 2 diabetes, all age 64 or older, who used the VA health care system in 2009 and received test strips from either VA or Medicare. They found that overall, about 20 percent of the 157 million strips dispensed to all the Veterans were possibly unnecessary.
On average, they found, 72 percent of the Veterans studied received an average of 200 strips from VA; 23 percent received an average of 400 strips from Medicare; and 6 percent received strips from both programs—an average of 600 per year. According to the authors, patients should receive no more than one strip per day, so receiving more than 365 strips a year was defined as overuse.
The spread of high-speed Internet access and the use of mobile technologies allow Veterans many new ways to connect with their VA health care team. VA researchers have led the way in exploring how care can be enhanced by the use of telephone, Internet, videoconferencing, email, and text messaging.
Home-based telehealth—In a paper presented in 2014 during a Government Health IT conference, VA reported that Veterans enrolled in home-based telehealth programs received higher quality care at lower costs, compared with those receiving traditional in-person care.
According to the paper, the number of Veterans receiving telehealth care is increasing by about 22 percent each year, and, in fiscal year 2013, nearly 610,000 Veterans received care through one or more of VA's methods of providing connected health.
Homeless Veterans and mobile phones—VA researchers have conducted a number of studies comparing these technologies to standard care. A 2014 study by researchers at the Edith Nourse Rogers VA Hospital in Bedford, Massachusetts, surveyed 106 homeless Veterans and found that 89 percent of them had a mobile phone (one third of which were smartphones) and that 76 percent of them used the Internet.
Nearly all of the homeless Veterans surveyed (93 percent) were interested in receiving mobile phone reminders about upcoming medical appointments, and 88 percent wanted to be asked by mobile phone if they would like to schedule an appointment if they had not been seen by a health provider in over a year.
Online access to health records—In another VA-sponsored study, Veterans with online access to their health records reported they communicated better with their doctors, and that they had higher levels of overall satisfaction with their care. The findings confirmed previous research that showed the benefits of shared electronic health records for patients and their caregivers.
Researchers at the VA Portland Healthcare System conducted five focus groups with patients and family members who had enrolled in a VA pilot program that allowed patients and caregivers to view and download content in their electronic health record, including clinical notes, laboratory tests, and imaging reports.
The researchers found that patients overwhelmingly felt that having more, rather than less, information about their health was helpful. Some Veterans, however, reported difficulties in viewing their records, and others indicated they were stressed by reading medical information they might not fully understand, or a doctor's comment to which they took offense.
Telehealth and multiple sclerosis—Researchers at the Baltimore VA Medical Center and the University of Maryland are currently studying whether telehealth can help Veterans with multiple sclerosis (MS) to exercise regularly. Exercise helps speed recovery after MS flare-ups, and provides all MS patients with the opportunity to maintain or improve their power and functioning, including their brain functioning.
The Internet-based technology being tested includes the ability to do standardized surveys, ask questions, give patients educational modules, and provide patients with feedback and messages. It also allows for other kinds of assessments including measuring the air flow through the lungs, and monitoring blood glucose levels.
Telehealth and diabetes—Investigators in a 2015 study looked at a new telehealth program developed at the Durham VA Medical Center for Veterans whose diabetes has not responded to standard care.
The program, called Advanced Comprehensive Diabetes Care (ACDC), showed favorable results in a small trial that included 50 Veterans with persistently poor diabetes care. It yielded better results than standard clinic-based care in nudging blood sugar levels toward normal.
Patients using the program were asked to check their blood sugar before each meal and at bedtime, and used an interactive voice system to transmit their readings to the clinic. Every two weeks, they spoke with a nurse on topics related to controlling their blood sugar, and had their cases reviewed by physicians to see if medication tweaks were needed. Physicians also regularly reviewed the Veterans' care.
Over six months, the group receiving usual care saw a slight reduction in their average blood sugar levels, from 10.5 to 10.2. The ACDC group, however, saw a larger reduction, from 10.5 to 9.2. The researchers now plan to study the program across several sites of care.
Point-of-care studies are a unique new approach to make clinical trials a part of routine care. These studies allow researchers to make randomized comparisons within VA's health are system without the need for special study visits.
This approach embeds research into routine clinical care, by comparing established treatments that doctors are already using, and collects data on which treatments work best within the context of real-world, everyday health care.
In a point-of-care study, volunteers are enrolled within the framework of their visits to their regular health care providers. The providers draw on data from electronic medical records to determine if a patient is right for a study. Patients who consent to take part are randomized into one of the study's treatment arms, and continue to receive care from their usual providers.
Comparing two insulin administration methods—A team of VA and Stanford University researchers is currently conducting a point of care study involving 3,000 Veterans with diabetes. The study compares two methods of administering insulin to hospitalized Veterans, and is tracking which of the two treatments is associated with better outcomes. In this case, the better outcome would involve shorter hospital stays.
Eventually, the system's software will begin to preferentially direct more patients to the treatment that is proving more effective. The ideal end result will be that evidence from the trial will be incorporated into everyday practice quickly and inexpensively.
Comparing diuretics—Another point-of-care study will look at which of two kinds of diuretics (water pills) are more effective at preventing cardiovascular outcomes such as heart attacks, strokes, and coronary artery disease. The two medications, chlorthalidone (sold as Thalitone in the U.S.), and hydrochlorothiazide (sold as esidrix or microzide) have both been used for more than 50 years and are considered as first-line treatments for hypertension.
Patients selected for the study will be those who are currently taking hydrochlorothiazide. They will be randomly selected to either continue taking that drug or to receive chlorthalidone, and will be followed for major cardiovascular events, such as heart attacks or strokes. Data from the study will be collected through VA's electronic health record system.
It typically takes several years between the time researchers first decide to study a problem, and the time their findings are published and disseminated. In cases where findings are implemented into everyday medical practice, that stage can take an additional few years. By this time, some of the factors considered in the original study design and plan may have changed, making the final results less applicable or relevant.
VA Research is looking at a number of ways to shorten this cycle. Given VA's unique research infrastructure, the program is ideally positioned to be a pioneer in this area.
In one initiative already underway, VA provides pilot funding so that researchers can begin collecting preliminary data even while submitting their initial proposals. VA is also offering sequential funding when timing is critical, by funding the first phase of data collection with an implicit promise to fund subsequent research phases if the initial data address the concerns the study proposal raises.
For issues of particular urgency to Veterans and their health care, VA reviewers are working with applicants to help ensure that proposals are written in a scientifically sound and "fundable" format, thus avoiding the need for many cycles of revisions.
VA is also encouraging researchers to involve interested parties at the outset of studies to identify important issues that may later impact whether findings can be used. These issues can include feasibility, costs, and value.
In clinical trials research, VA is exploring designs that allow investigators to change the size of their samples and other elements in response to data they accumulate during the trial itself. VA hopes this approach may also serve health services researchers.
Finally, health services researchers may be reluctant to study health system areas undergoing rapid change, such as drug therapies and health information technology, because changes due to initiatives throughout the VA system will complicate their analysis. Because of this, VA plans to experiment with statistical methods and research processes that will allow researchers to make changes as needed to studies in progress.
The Health information technology (HIT) landscape is changing rapidly as a result of increased computing power, changing computer platforms, and new expectations on the part of patients, providers, and other stakeholders. To capitalize on this digital environment, VA invests significant resources in supporting health care informatics and "big data" research.
A critical foundation to HIT research in VA is the Veterans Informatics and Computing Infrastructure (VINCI). Funded by VA Research and VA's Office of Information and Technology, VINCI provides a secure high-performance computing environment and access to comprehensive VHA data.
This infrastructure helps researchers access national data on the entire VA population and makes it easier to create sophisticated analytic tools, which are used in research addressing a broad array of issues.
One study is using VINCI to develop an automated surveillance intervention to improve diagnosis and clinical care for five common cancers. The goal is to reduce cancer-related diagnostic delays and thereby improve care.
A CREATE group, Improving Therapeutic Decision-Making through Veteran-Centered Population Analytics, hopes to use population informatics methods and tools to make VA medication management data accessible to clinical providers and teams. The projects within this program will use data within VA's electronic health record and administrative records to help improve diagnosis and prescribing.
VA researchers have invented many notable new drugs and technologies—but these inventions have little value unless they are made available to those who would be helped by them.
VA's Technology Transfer Program (TTP) works to protect intellectual property developed within the department. The program finds private industry partners willing to invest in new technology and conduct further development and commercialization activities.
A recent example of the use of the program involves a new tissue preservation solution formulated by VA scientists, to be used for the stabilization of veins and arteries in coronary bypass surgeries or other procedures. VA has licensed the technology and the company is in the process of clinical trials required for FDA approval.
A White House directive issued in February 2013 required VA to develop plans to make the published results of its research freely available to the public within one year of publication.
VA has prepared a new plan to ensure peer-reviewed full-text articles resulting from VA-funded research are available to the public through PubMed Central, a National Library of Medicine database. The plan was published in the Federal Register on Oct. 7, 2015, and VA is now in the process of reviewing and analyzing public input.
Under the plan, VA will also be expanding access to the data supporting researchers' conclusions, with an overarching goal of allowing wider access to information developed by researchers while keeping strong safeguards in place on Veterans' privacy and data confidentiality.
VA Research has always encouraged and promoted the free exchange of scientific and medical information. Investigators are expected to report their results at professional meetings and in scientific and medical journals. Those results will now be more accessible to the general public.
A new approach to health services research. Kupersmith J, Eisen S. Certain characteristics of health services research have hindered accumulation of evidence and impaired the ability to translate research findings into care. VA's CREATE approach holds great promise for filling gaps in health services research coordination and communication. Arch Intern Med. 2012 July 9;172(13):1033-4.
Patient experiences with full electronic access to health records and clinical notes through the My HealtheVet Personal Health Record Pilot: qualitative study. Woods SS, Schwartz E, Tuepker A, Press NA, Nazi KM, Turvey CL, Nichol WP. Patients and their delegates had predominantly positive experiences with health record transparency and the open sharing of notes and test results. Viewing their records appears to empower patients and enhance their contributions to care, calling into question common provider concerns about the effect of full record access on patient well-being. J Med Internet Res. 2013 Mar 27;15(3):e65.
Medical Home Features of VHA Primary Care Clinics and Avoidable Hospitalizations . Yoon J, Rose DE, Canelo I, Upadhyay AS, Schectman G, Stark R, Rubenstein LV, Yano EM. Greater adoption of medical home features by VHA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations with access and scheduling and care coordination/transitions in care as key factors. J Gen Intern Med. 2013 Sep;28(9):1188-94.
Patient Aligned Care Teams (PACT): VA's journey to implement patient-centered medical homes. Yano EM, Bair MJ, Carrasquillo O, Krein SL, Rubenstein LV Introduction to an open-access supplement of 19 peer-reviewed articles that reflect on lessons learned by researchers and their partners during early stages of the PACT implementation. J Gen Intern Med. 2014 Jul;29 Suppl 2:S547-9.
The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. Singh H, Meyer AN, Thomas EJ. Diagnostic errors affect at least 1 in 20 US adults. This foundational evidence should encourage policymakers, healthcare organizations, and researchers to start measuring and reducing diagnostic errors. BMJ Qual Saf. 2014 Sep;23(9):727-31.
The Potential for Health-Related Uses of Mobile Phones and Internet with Homeless Veterans: Results from a Multisite Survey. McInnes DK, Sawh L, Petrakis BA, Rao S, Shimda SL, Eyrich-Garg KM, Gifford AL, Anaya HD, Smelson DA. These findings suggest new avenues for communication and health interventions (mobile phones and the Internet) for hard-to-reach homeless Veterans. Telemed J E Health. 2014 Sep;20(9):801-9.
Dual use of Department of Veterans Affairs and medicare benefits and use of test strips in Veterans with type 2 diabetes mellitus. Gellad WF, Zhao X, Thorpe CT, Mor MK, Good CB, Fine MJ. Veterans who receive glucose test strips through both VA and Medicare use more strips and are more likely to potentially overuse strips. JAMA Intern Med. 2015 Jan;175(1):26-34.
Introducing the No Preventable Harms campaign: creating the safest health care system in the world, starting with catheter-associated urinary tract infection prevention. Saint S, Fowler KE, Sermak K, Gales E, Harrod M, Holland P, Bradley SF, Hancock JB, Krein SL. A regional collaborative can be a valuable strategy for addressing important endemic patient safety problems. Am J Infect Control, 2015 Mar 1;43(3):254-9.
Dual-system use and intermediate health outcomes among Veterans enrolled in Medicare Advantage Plans. Cooper AL, Jiang L, Yoon J, Charlton ME, Wilson IB, Mor V, Kizer KW, Trivedi AN. There is no evidence that Veterans with dual use of VA and Medicare Advantage experienced improved or worsened outcomes as compared with Veterans who exclusively used VA care. Health Serv Res. 2015 Apr 6. (Epub ahead of print.)
Practical telemedicine for Veterans with persistently poor diabetes control: a randomized pilot trial. Crowley MJ, Edelman D, McAndrew AT, Kistler S, Danus S, Webb JA, Zanga J, Sanders LL, Coffman CJ, Jackson Gl, Bosworth HB. A comprehensive telemedicine intervention improved outcomes among Veterans with persistently poor diabetes control despite clinic-based care. Telemed J E Health. 2015 Nov 5. (Epub ahead of print.)
Contamination of health care personnel during removal of personal protective equipment. Tomas ME, Kundrapu S, Thota P, Sunkesula VA, Cadnum JL, Mana TS, Jencson A, O'Donnell M, Zabarsky TF, Hecker MT, Ray AJ, Wilson BM, Donskey CJ. Contamination of the skin and clothing of health care personnel occurs frequently during removal of contaminated gloves or gowns. JAMA Intern Med. 2015 Dec 1; 175(12):1904-10.
Improving diagnosis in health care-the next imperative for patient safety. Singh H, Graber ML. The recent Institute of Medicine report on "Improving Diagnosis in Health Care" requires individual and collaborative action from all health care stakeholders nationwide. N Engl J Med. 2015 Dec 24;373(26):2493-5.