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Farag A, Wakefield BJ, Jaske E, Paez M, Stewart G. Determinants of Patient Aligned Care Team (PACT) members' burnout and its relationship with patient-centered care. Appl Ergon 2024; 118:104272. [PMID: 38537519 DOI: 10.1016/j.apergo.2024.104272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/11/2024] [Accepted: 03/15/2024] [Indexed: 05/03/2024]
Abstract
Burnout is a prevalent issue among healthcare providers affecting up to 54% of physicians and 35% of nurses. Patient Aligned Care Teams (PACT) is a team-based primary care delivery model designed to assure the delivery of high-quality care while improving clinicians' well-being. Limited studies evaluated the relationship between work environment variables and PACT members' burnout and the relationship between PACT members' burnout and patient-centered care. This cross-sectional study is based on the 2018 Veterans Health Administration (VHA) national web-based PACT survey. Burnout was measured using a single-item question that was validated in previous studies. Descriptive statistics and logistic regression were used to analyze the data. Fifty-one percent of primary care providers and 40.12% of nurses reported high burnout. PACT members with a work environment characterized by high-quality team interaction, leadership support, and psychological safety experienced lower levels of burnout. PACT members' burnout explained 6% of the variance in PACT members' ability to deliver patient-centered care. Burnout among PACT members is attributed to multiple personal and occupational variables. This study identified modifiable work environment variables that can be used to inform burnout interventions.
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Affiliation(s)
- Amany Farag
- University of Iowa, College of Nursing, Iowa City, IA, USA.
| | | | - Erin Jaske
- VA Puget Sound Health Care System, Seattle, WA, USA
| | | | - Greg Stewart
- University of Iowa, Tippie College of Business, Iowa City, IA, USA
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2
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Hausmann LRM, Goodrich DE, Rodriguez KL, Beyer N, Michaels Z, Cantor G, Armstrong N, Eliacin J, Gurewich DA, Cohen AJ, Mor MK. Participation of Veterans Affairs Medical Centers in veteran-centric community-based service navigation networks: A mixed methods study. Health Serv Res 2024; 59:e14286. [PMID: 38258302 PMCID: PMC11063092 DOI: 10.1111/1475-6773.14286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVE To understand the determinants and benefits of cross-sector partnerships between Veterans Affairs Medical Centers (VAMCs) and geographically affiliated AmericaServes Network coordination centers that address Veteran health-related social needs. DATA SOURCES AND SETTING Semi-structured interviews were conducted with AmericaServes and VAMC staff across seven regional networks. We matched administrative data to calculate the percentage of AmericaServes referrals that were successfully resolved (i.e., requested support was provided) in each network overall and stratified by whether clients were also VAMC patients. STUDY DESIGN Convergent parallel mixed-methods study guided by Himmelman's Developmental Continuum of Change Strategies (DCCS) for interorganizational collaboration. DATA COLLECTION Fourteen AmericaServes staff and 17 VAMC staff across seven networks were recruited using snowball sampling and interviewed between October 2021 and April 2022. Rapid qualitative analysis methods were used to characterize the extent and determinants of VAMC participation in networks. PRINCIPAL FINDINGS On the DCCS continuum of participation, three networks were classified as networking, two as coordinating, one as cooperating, and one as collaborating. Barriers to moving from networking to collaborating included bureaucratic resistance to change, VAMC leadership buy-in, and not having VAMCs staff use the shared technology platform. Facilitators included ongoing communication, a shared mission of serving Veterans, and having designated points-of-contact between organizations. The percentage of referrals that were successfully resolved was lowest in networks engaged in networking (65.3%) and highest in cooperating (85.6%) and collaborating (83.1%) networks. For coordinating, cooperating, and collaborating networks, successfully resolved referrals were more likely among Veterans who were also VAMC patients than among Veterans served only by AmericaServes. CONCLUSIONS VAMCs participate in AmericaServes Networks at varying levels. When partnerships are more advanced, successful resolution of referrals is more likely, especially among Veterans who are dually served by both organizations. Although challenges to establishing partnerships exist, this study highlights effective strategies to overcome them.
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Affiliation(s)
- Leslie R. M. Hausmann
- Center for Health Equity Research and PromotionVeterans Affairs (VA) Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
- Division of General Internal Medicine, Department of MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - David E. Goodrich
- Center for Health Equity Research and PromotionVeterans Affairs (VA) Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
| | - Keri L. Rodriguez
- Center for Health Equity Research and PromotionVeterans Affairs (VA) Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
| | - Nicole Beyer
- Center for Health Equity Research and PromotionVeterans Affairs (VA) Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
| | - Zachary Michaels
- Center for Health Equity Research and PromotionVeterans Affairs (VA) Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
| | - Gilly Cantor
- D'Aniello Institute for Veterans and Military FamiliesSyracuse UniversitySyracuseNew YorkUSA
| | - Nicholas Armstrong
- D'Aniello Institute for Veterans and Military FamiliesSyracuse UniversitySyracuseNew YorkUSA
| | - Johanne Eliacin
- National Center for PTSDVA Boston Healthcare SystemBostonMassachusettsUSA
- Center for Health Information and CommunicationRichard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
- Department of Internal Medicine and GeriatricsIndiana University School of MedicineIndianapolisIndianaUSA
| | - Deborah A. Gurewich
- Center for Healthcare Implementation and Research (CHOIR)VA Boston Health Care SystemBedfordMassachusettsUSA
- Section of Internal MedicineBoston University Chobanian and Avedisian School of MedicineBostonMassachusettsUSA
| | - Alicia J. Cohen
- Center of Innovation in Long Term Services and Supports (LTSS‐COIN)VA Providence Healthcare SystemProvidenceRhode IslandUSA
- Department of Family MedicineWarren Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Maria K. Mor
- Center for Health Equity Research and PromotionVeterans Affairs (VA) Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
- Graduate School of Public HealthUniversity of PittsburghPittsburghPennsylvaniaUSA
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Kimpel CC, Myer EA, Cupples A, Roman Jones J, Seidler KJ, Rick CK, Brown R, Rawlins C, Hadler R, Tsivitse E, Lawlor MAC, Ratcliff A, Holt NR, Callaway-Lane C, Godwin K, Ecker AH. Identifying Barriers and Facilitators to Veterans Affairs Whole Health Integration Using the Updated Consolidated Framework for Implementation Research. J Healthc Qual 2024; 46:137-149. [PMID: 38147581 PMCID: PMC11065588 DOI: 10.1097/jhq.0000000000000419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
BACKGROUND Veterans Affairs (VA) implemented the Veteran-centered Whole Health System initiative across VA sites with approaches to implementation varying by site. PURPOSE Using the Consolidated Framework for Implementation Research (CFIR), we aimed to synthesize systemic barriers and facilitators to Veteran use with the initiative. Relevance to healthcare quality, systematic comparison of implementation procedures across a national healthcare system provides a comprehensive portrait of strengths and opportunities for improvement. METHODS Advanced fellows from 11 VA Quality Scholars sites performed the initial data collection, and the final report includes CFIR-organized results from six sites. RESULTS Key innovation findings included cost, complexity, offerings, and accessibility. Inner setting barriers and facilitators included relational connections and communication, compatibility, structure and resources, learning centeredness, and information and knowledge access. Finally, results regarding individuals included innovation deliverers, implementation leaders and team, and individual capability, opportunity, and motivation to implement and deliver whole health care. DISCUSSION AND IMPLICATIONS Examination of barriers and facilitators suggest that Whole Health coaches are key components of implementation and help to facilitate communication, relationship building, and knowledge access for Veterans and VA employees. Continuous evaluation and improvement of implementation procedures at each site is also recommended.
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Wallace MM, Hackstadt AJ, Zhao Z, Patrinely JR, Zic J, Ellis D, Paul L, Sultan M, Danford B, Hanlon AM. The Teledermatology Experience: Cost Savings and Image Quality Control. Telemed J E Health 2024; 30:1411-1417. [PMID: 38150704 DOI: 10.1089/tmj.2022.0528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Introduction: Teledermatology adoption continues to increase, in part, spurred by the COVID-19 pandemic. This study analyzes the utility and cost savings of a store-and-forward teledermatology consultative system within the Veterans Health Administration (VA). Methods: Retrospective cohort of 4,493 patients across 14 remote sites in Tennessee and Kentucky from May 2017 through August 2019. The study measured the agreement between the teledermatology diagnoses and follow-up face-to-face clinic evaluations as well as the cost effectiveness of the teledermatology program over the study period. Results: Fifty-four percent of patients were recommended for face-to-face appointment for biopsy or further evaluation. Most patients, 80.5% received their face-to-face care by a VA dermatologist. There was a high level of concordance between teledermatologist and clinic dermatologist for pre-malignant and malignant cutaneous conditions. Veterans were seen faster at a VA clinic compared with a community dermatology site. Image quality improved as photographers incorporated teledermatologist feedback. From a cost perspective, teledermatology saved the VA system $1,076,000 in community care costs. Discussion: Teledermatology is a useful diagnostic tool within the VA system providing Veteran care at a cost savings.
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Affiliation(s)
- Matthew M Wallace
- Department of Medicine, Tennessee Valley Healthcare System, Nashville Veterans Administration Medical Center, Nashville, Tennessee, USA
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amber J Hackstadt
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Zijun Zhao
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - John Zic
- Department of Medicine, Tennessee Valley Healthcare System, Nashville Veterans Administration Medical Center, Nashville, Tennessee, USA
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Darrel Ellis
- Department of Medicine, Tennessee Valley Healthcare System, Nashville Veterans Administration Medical Center, Nashville, Tennessee, USA
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lynn Paul
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Miliyard Sultan
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Brandon Danford
- Department of Medicine, Tennessee Valley Healthcare System, Nashville Veterans Administration Medical Center, Nashville, Tennessee, USA
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Allison M Hanlon
- Department of Medicine, Tennessee Valley Healthcare System, Nashville Veterans Administration Medical Center, Nashville, Tennessee, USA
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Arredondo K, Renfro DR, Naungayan A, Renfro D, Burgos S, Yarlagadda S, Horstman MJ, Naik AD, Godwin KM. Improving the Discharge Process at the VA Palo Alto Through Change Management and Implementation of Project Re-Engineered Discharge. Rehabil Nurs 2024; 49:95-100. [PMID: 38696435 DOI: 10.1097/rnj.0000000000000461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
ABSTRACT This quality improvement project demonstrates that nursing leadership with Project Re-Engineered Discharge can effect change in the discharge process and improve patient outcomes.
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Affiliation(s)
| | - David R Renfro
- Veterans Affairs Medical Center Palo Alto, Palo Alto, CA, USA
| | | | - Denise Renfro
- Veterans Affairs Medical Center Palo Alto, Palo Alto, CA, USA
| | - Sharlene Burgos
- Veterans Affairs Medical Center Palo Alto, Palo Alto, CA, USA
| | - Sudha Yarlagadda
- Medicine-Hematology and Oncology, University of Chicago, Chicago, IL, USA
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Griesemer I, Palmer JA, MacLaren RZ, Harvey KLL, Li M, Garikipati A, Linsky AM, Mohr DC, Gurewich D. Rural Veterans' Experiences with Social Risk Factors: Impacts, Challenges, and Care System Recommendations. J Gen Intern Med 2024; 39:782-789. [PMID: 38010459 PMCID: PMC11043235 DOI: 10.1007/s11606-023-08530-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Social risk factors, such as food insecurity and financial needs, are associated with increased risk of cardiovascular diseases, health conditions that are highly prevalent in rural populations. A better understanding of rural Veterans' experiences with social risk factors can inform expansion of Veterans Health Administration (VHA) efforts to address social needs. OBJECTIVE To examine social risk and need from rural Veterans' lived experiences and develop recommendations for VHA to address social needs. DESIGN We conducted semi-structured interviews with participants purposively sampled for racial diversity. The interview guide was informed by Andersen's Behavioral Model of Health Services Use and the Outcomes from Addressing Social Determinants of Health in Systems framework. PARTICIPANTS Rural Veterans with or at risk of cardiovascular disease who participated in a parent survey and agreed to be recontacted. APPROACH Interviews were recorded and transcribed. We analyzed transcripts using directed qualitative content analysis to identify themes. KEY RESULTS Interviews (n = 29) took place from March to June 2022. We identified four themes: (1) Social needs can impact access to healthcare, (2) Structural factors can make it difficult to get help for social needs, (3) Some Veterans are reluctant to seek help, and (4) Veterans recommended enhancing resource dissemination and navigation support. CONCLUSIONS VHA interventions should include active dissemination of information on social needs resources and navigation support to help Veterans access resources. Community-based organizations (e.g., Veteran Service Organizations) could be key partners in the design and implementation of future social need interventions.
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Affiliation(s)
- Ida Griesemer
- Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA.
| | - Jennifer A Palmer
- Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Risette Z MacLaren
- Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA
| | - Kimberly L L Harvey
- Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA
| | - Mingfei Li
- Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA
- Department of Mathematical Sciences, Bentley University, Waltham, MA, USA
| | | | - Amy M Linsky
- Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - David C Mohr
- Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA
- Department of Health Law, Policy & Management, School of Public Health, Boston University, Boston, MA, USA
| | - Deborah Gurewich
- Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
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Holliday R, Desai A, Edwards ER, Borges LM. Personality Disorder Diagnosis Among Justice-Involved Veterans: An Investigation of VA Using Veterans. J Nerv Ment Dis 2023; 211:402-406. [PMID: 37040142 DOI: 10.1097/nmd.0000000000001627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
ABSTRACT Justice-involved veterans are more likely to experience myriad mental health sequelae. Nonetheless, examination of personality psychopathology among justice-involved veterans remains limited, with studies focused on males within correctional settings. We examined Department of Veterans Affairs (VA) electronic medical records for 1,534,108 (12.28% justice-involved) male and 127,230 (8.79% justice-involved) female veterans. Male and female veterans accessing VA justice-related services were both approximately three times more likely to have a personality disorder diagnosis relative to those with no history of using justice-related services. This effect persisted after accounting for VA use (both overall and mental health), age, race, and ethnicity. Augmenting and tailoring VA justice-related services to facilitate access to evidence-based psychotherapy for personality psychopathology may promote optimal recovery and rehabilitation among these veterans.
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Affiliation(s)
| | - Alisha Desai
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention
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Gray CP, Azevedo KJ, Urech TH, Lerner B, Charns MP, Vashi AA. Engaging Patients in the Veterans Health Administration's Lean Enterprise Transformation: A Qualitative Study. Qual Manag Health Care 2023; 32:75-80. [PMID: 35793546 DOI: 10.1097/qmh.0000000000000371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND OBJECTIVES Lean management is a strategy for improving health care experiences of patients. While best practices for engaging patients in quality improvement have solidified in recent years, few reports specifically address patient engagement in Lean activities. This study examines the benefits and challenges of incorporating patient engagement strategies into the Veterans Health Administration's (VA) Lean transformation. METHODS We conducted a multisite, mixed-methods evaluation of Lean deployment at 10 VA medical facilities, including 227 semistructured interviews with stakeholders, including patients. RESULTS Interviewees noted that a patient-engaged Lean approach is mutually beneficial to patients and health care employees. Benefits included understanding the veteran's point of view, uncovering inefficient aspects of care processes, improved employee participation in Lean events, increased transparency, and improved reputation for the organization. Challenges included a need for focused time and resources to optimize veteran participation, difficulty recruiting a diverse group of veteran stakeholders, and a lack of specific instructions to encourage meaningful participation of veterans. CONCLUSIONS/IMPLICATIONS As the first study to focus on patient engagement in Lean transformation efforts at the VA, this study highlights ways to effectively partner with patients in Lean-based improvement efforts. Lessons learned may also help optimize patient input into quality improvement more generally.
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Affiliation(s)
- Caroline P Gray
- Center for Innovation to Implementation (Ci2i) (Drs Gray, Azevedo, and Vashi and Ms Urech) and National Center for PTSD (NCPTSD) (Dr Azevedo), VA Palo Alto Health Care System, Palo Alto, California; Center for Healthcare Organization and Implementation Research, VA Boston Health Care System, Boston, Massachusetts (Drs Lerner and Charns); and Boston University School of Public Health, Boston, Massachusetts (Dr Charns)
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Graham LA, Schoemaker L, Rose L, Morris AM, Aouad M, Wagner TH. Expansion of the Veterans Health Administration Network and Surgical Outcomes. JAMA Surg 2022; 157:1115-1123. [PMID: 36223115 PMCID: PMC9558067 DOI: 10.1001/jamasurg.2022.4978] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/16/2022] [Indexed: 01/11/2023]
Abstract
Importance The US Department of Veterans Affairs (VA) Veterans Choice Program (VCP) expanded health care access to community settings outside the VA for eligible patients. Little is known about the effect of VCP on access to surgery and postoperative outcomes. Since its initiation, care coordination issues, which are often associated with adverse postoperative outcomes, have been reported. Research findings on the association of VCP and postoperative outcomes are limited to only a few select procedures and have been mixed, potentially due to bias from unmeasured confounding. Objective To investigate the association of the VCP with access to surgery and postoperative outcomes using a nonrandomized controlled regression discontinuity design (RDD) to reduce the impact of unmeasured confounders. Design, Setting, and Participants This was a nonrandomized RDD study of the Veterans Health Administration (VHA). Participants included veterans enrolled in the VHA who required surgery between October 1, 2014, and June 1, 2019. Interventions The VCP, which expanded access to VA-paid community care for eligible veterans living 40 miles or more from their closest VA hospital. Main Outcomes and Measures Postoperative emergency department visits, inpatient readmissions, and mortality at 30 and 90 days. Results A total of 615 473 unique surgical procedures among 498 427 patients (mean [SD] age, 63.0 [12.9] years; 450 366 male [90.4%]) were identified. Overall, 94 783 procedures (15.4%) were paid by the VHA, and the proportion of VHA-paid procedures varied by procedure type. Patients who underwent VA-paid procedures were more likely to be women (9209 [12.7%] vs men, 38 771 [9.1%]), White race (VA paid, 54 544 [74.4%] vs VA provided, 310 077 [73.0%]), and younger than 65 years (VA paid, 36 054 [49.1%] vs 229 411 [46.0%] VA provided), with a significantly lower comorbidity burden (mean [SD], 1.8 [2.2] vs 2.6 [2.7]). The nonrandomized RDD revealed that VCP was associated with a slight increase of 0.03 in the proportion of VA-paid surgical procedures among eligible veterans (95% CI, 0.01-0.05; P = .01). However, there was no difference in postoperative mortality, readmissions, or emergency department visits. Conclusions and Relevance Expanded access to health care in the VHA was associated with a shift in the performance of surgical procedures in the private sector but had no measurable association with surgical outcomes. These findings may assuage concerns of worsened patient outcomes resulting from care coordination issues when care is expanded outside of a single health care system, although it remains unclear whether these additional procedures were appropriate or improved patient outcomes.
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Affiliation(s)
- Laura A. Graham
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Stanford, California
| | - Lena Schoemaker
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
| | - Liam Rose
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Stanford, California
| | - Arden M. Morris
- Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Stanford, California
| | - Marion Aouad
- Department of Economics, University of California, Irvine
| | - Todd H. Wagner
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Stanford, California
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Hysong SJ, SoRelle R, Hughes AM. Prevalence of Effective Audit-and-Feedback Practices in Primary Care Settings: A Qualitative Examination Within Veterans Health Administration. Hum Factors 2022; 64:99-108. [PMID: 33830786 DOI: 10.1177/00187208211005620] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The purpose of this study is to uncover and catalog the various practices for delivering and disseminating clinical performance in various Veterans Affairs (VA) locations and to evaluate their quality against evidence-based models of effective feedback as reported in the literature. BACKGROUND Feedback can enhance clinical performance in subsequent performance episodes. However, evidence is clear that the way in which feedback is delivered determines whether performance is harmed or improved. METHOD We purposively sampled 16 geographically dispersed VA hospitals based on high, low, consistently moderate, and moderately average highly variable performance on a set of 17 outpatient clinical performance measures. We excluded four sites due to insufficient interview data. We interviewed four key personnel from each location (n = 48) to uncover effective and ineffective audit and feedback strategies. Interviews were transcribed and analyzed qualitatively using a framework-based content analysis approach to identify emergent themes. RESULTS We identified 102 unique strategies used to deliver feedback. Of these strategies, 64 (62.74%) have been found to be ineffective according to the audit-and-feedback research literature. Comparing features common to effective (e.g., individually tailored, computerized feedback reports) versus ineffective (e.g., large staff meetings) strategies, most ineffective strategies delivered feedback in meetings, whereas strategies receiving the highest effectiveness scores delivered feedback via visually understood reports that did not occur in a group setting. CONCLUSIONS Findings show that current practices are leveraging largely ineffective feedback strategies. Future research should seek to identify the longitudinal impact of current feedback and audit practices on clinical performance. APPLICATION Feedback in primary care has little standardization and does not follow available evidence for effective feedback design. Future research in this area is warranted.
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Affiliation(s)
- Sylvia J Hysong
- Michael E. DeBakey VA Medical Center, Texas, USA
- 3989 Baylor College of Medicine, Texas, USA
| | | | - Ashley M Hughes
- 5228 University of Illinois at Chicago, Champaign, USA
- 20116 Edward Hines JR VA Medical Center, Illinois, USA
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11
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Silva GC, Jiang L, Gutman R, Wu WC, Mor V, Fine MJ, Kressin NR, Trivedi AN. Racial/Ethnic Differences in 30-Day Mortality for Heart Failure and Pneumonia in the Veterans Health Administration Using Claims-based, Clinical, and Social Risk-adjustment Variables. Med Care 2021; 59:1082-1089. [PMID: 34779794 PMCID: PMC8652730 DOI: 10.1097/mlr.0000000000001650] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Prior studies have identified lower mortality in Black Veterans compared with White Veterans after hospitalization for common medical conditions, but these studies adjusted for comorbid conditions identified in administrative claims. OBJECTIVES The objectives of this study were to compare mortality for non-Hispanic White (hereafter, "White"), non-Hispanic Black (hereafter, "Black"), and Hispanic Veterans hospitalized for heart failure (HF) and pneumonia and determine whether observed mortality differences varied according to whether claims-based comorbid conditions and/or clinical variables were included in risk-adjustment models. RESEARCH DESIGN This was an observational study. SUBJECTS The study cohort included 143,520 admissions for HF and 127,782 admissions for pneumonia for Veterans hospitalized in 132 Veterans Health Administration (VA) Medical Centers between January 2009 and September 2015. MEASURES The primary independent variable was racial/ethnic group (ie, Black, Hispanic, and non-Hispanic White), and the outcome was all-cause mortality 30 days following admission. To compare mortality by race/ethnicity, we used logistic regression models that included different combinations of claims-based, clinical, and sociodemographic variables. For each model, we estimated the average marginal effect (AME) for Black and Hispanic Veterans relative to White Veterans. RESULTS Among the 143,520 (127,782) hospitalizations for HF (pneumonia), the average patient age was 71.6 (70.9) years and 98.4% (97.1%) were male. The unadjusted 30-day mortality rates for HF (pneumonia) were 7.2% (11.0%) for White, 4.1% (10.4%) for Black and 8.4% (16.9%) for Hispanic Veterans. Relative to White Veterans, when only claims-based variables were used for risk adjustment, the AME (95% confidence interval) for the HF [pneumonia] cohort was -2.17 (-2.45, -1.89) [0.08 (-0.41, 0.58)] for Black Veterans and 1.32 (0.49, 2.15) [4.51 (3.65, 5.38)] for Hispanic Veterans. When clinical variables were incorporated in addition to claims-based ones, the AME, relative to White Veterans, for the HF [pneumonia] cohort was -1.57 (-1.88, -1.27) [-0.83 (-1.31, -0.36)] for Black Veterans and 1.50 (0.71, 2.30) [3.30 (2.49, 4.11)] for Hispanic Veterans. CONCLUSIONS Compared with White Veterans, Black Veterans had lower mortality, and Hispanic Veterans had higher mortality for HF and pneumonia. The inclusion of clinical variables into risk-adjustment models impacted the magnitude of racial/ethnic differences in mortality following hospitalization. Future studies examining racial/ethnic disparities should consider including clinical variables for risk adjustment.
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Affiliation(s)
| | - Lan Jiang
- Providence VA Medical Center, Brown University School of Public Health, Providence, RI
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health
| | - Wen-Chih Wu
- Providence VA Medical Center, Brown University School of Public Health, Providence, RI
| | - Vincent Mor
- Providence VA Medical Center, Brown University School of Public Health, Providence, RI
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
| | - Michael J. Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
- Division of General Internal Medicine, School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nancy R. Kressin
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System
- School of Medicine, Boston University, Boston, MA
| | - Amal N. Trivedi
- Providence VA Medical Center, Brown University School of Public Health, Providence, RI
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
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Anderson TS, Lee AK, Jing B, Lee S, Herzig SJ, Boscardin WJ, Fung K, Rizzo A, Steinman MA. Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System. JAMA Netw Open 2021; 4:e2128998. [PMID: 34673963 PMCID: PMC8531994 DOI: 10.1001/jamanetworkopen.2021.28998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
IMPORTANCE Transient elevations of blood glucose levels are common in hospitalized older adults with diabetes and may lead clinicians to discharge patients with more intensive diabetes medications than they were using before hospitalization. OBJECTIVE To investigate outcomes associated with intensification of outpatient diabetes medications at discharge. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study assessed patients 65 years and older with diabetes not taking insulin who were hospitalized in the Veterans Health Administration Health System between January 1, 2011, and September 28, 2016, for common medical conditions. Data analysis was performed from January 1, 2020, to March 31, 2021. EXPOSURE Discharge with intensified diabetes medications, defined as filling a prescription at hospital discharge for a new or higher-dose medication than was being used before hospitalization. Propensity scores were used to construct a matched cohort of patients who did and did not receive diabetes medication intensifications. MAIN OUTCOMES AND MEASURES Coprimary outcomes of severe hypoglycemia and severe hyperglycemia were assessed at 30 and 365 days using competing risk regressions. Secondary outcomes included all-cause readmissions, mortality, change in hemoglobin A1c (HbA1c) level, and persistent use of intensified medications at 1 year after discharge. RESULTS The propensity-matched cohort included 5296 older adults with diabetes (mean [SD] age, 73.7 [7.7] years; 5212 [98.4%] male; and 867 [16.4%] Black, 47 [0.9%] Hispanic, 4138 [78.1%] White), equally split between those who did and did not receive diabetes medication intensifications at hospital discharge. Within 30 days, patients who received medication intensifications had a higher risk of severe hypoglycemia (hazard ratio [HR], 2.17; 95% CI, 1.10-4.28), no difference in risk of severe hyperglycemia (HR, 1.00; 95% CI, 0.33-3.08), and a lower risk of death (HR, 0.55; 95% CI, 0.33-0.92). At 1 year, no differences were found in the risk of severe hypoglycemia events, severe hyperglycemia events, or death and no difference in change in HbA1c level was found among those who did vs did not receive intensifications (mean postdischarge HbA1c, 7.72% vs 7.70%; difference-in-differences, 0.02%; 95% CI, -0.12% to 0.16%). At 1 year, 48.0% (591 of 1231) of new oral diabetes medications and 38.5% (548 of 1423) of new insulin prescriptions filled at discharge were no longer being filled. CONCLUSIONS AND RELEVANCE In this national cohort study, among older adults hospitalized for common medical conditions, discharge with intensified diabetes medications was associated with an increased short-term risk of severe hypoglycemia events but was not associated with reduced severe hyperglycemia events or improve HbA1c control. These findings indicate that short-term hospitalization may not be an effective time to intervene in long-term diabetes management.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Alexandra K. Lee
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Bocheng Jing
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Sei Lee
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Shoshana J. Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - W. John Boscardin
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Kathy Fung
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Anael Rizzo
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Michael A. Steinman
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
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13
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McCarthy JF, Cooper SA, Dent KR, Eagan AE, Matarazzo BB, Hannemann CM, Reger MA, Landes SJ, Trafton JA, Schoenbaum M, Katz IR. Evaluation of the Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment Suicide Risk Modeling Clinical Program in the Veterans Health Administration. JAMA Netw Open 2021; 4:e2129900. [PMID: 34661661 PMCID: PMC8524305 DOI: 10.1001/jamanetworkopen.2021.29900] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE The Veterans Health Administration (VHA) implemented a national clinical program using a suicide risk prediction algorithm, Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET), in which clinicians facilitate care enhancements for individuals identified in local top 0.1% suicide risk tiers. Evaluation studies are needed. OBJECTIVE To determine associations with treatment engagement, health care utilization, suicide attempts, safety plan documentation, and 6-month mortality. DESIGN, SETTING, AND PARTICIPANTS This cohort study used triple differences analyses comparing 6-month changes in outcomes after vs before program entry for individuals entering the REACH VET program (March 2017-December 2018) vs a similarly identified top 0.1% suicide risk tier cohort from prior to program initiation (March 2014-December 2015), adjusting for trends across subthreshold cohorts. Subcohort analyses (including individuals from March 2017-June 2018) evaluated difference-in-differences for cause-specific mortality using death certificate data. The subthreshold cohorts included individuals in the top 0.3% to 0.1% suicide risk tier, below the threshold for REACH VET eligibility, from the concurrent REACH VET period and from the pre-REACH VET period. Data were analyzed from December 2019 through September 2021. EXPOSURES REACH VET-designated clinicians treatment reevaluation and outreach for care enhancements, including safety planning, increased monitoring, and interventions to enhance coping. MAIN OUTCOMES AND MEASURES Process outcomes included VHA scheduled, completed, and missed appointments; mental health visits; and safety plan documentation and documentation within 6 months for individuals without plans within the prior 2 years. Clinical outcomes included mental health admissions, emergency department visits, nonfatal suicide attempts, and all-cause, suicide, and nonsuicide external-cause mortality. RESULTS A total of 173 313 individuals (mean [SD] age, 51.0 [14.7] years; 161 264 [93.1%] men and 12 049 [7.0%] women) were included in analyses, including 40 816 individuals eligible for REACH VET care and 36 604 individuals from the pre-REACH VET period in the top 0.1% of suicide risk. The REACH VET intervention was associated with significant increases in completed outpatient appointments (adjusted triple difference [ATD], 0.31; 95% CI, 0.06 to 0.55) and proportion of individuals with new safety plans (ATD, 0.08; 95% CI, 0.06 to 0.10) and reductions in mental health admissions (ATD, -0.08; 95% CI, -0.10 to -0.05), emergency department visits (ADT, -0.03; 95% CI, -0.06 to -0.01), and suicide attempts (ADT, -0.05; 95% CI, -0.06 to -0.03). Subcohort analyses did not identify differences in suicide or all-cause mortality (eg, age-and-sex-adjusted difference-in-difference for suicide mortality, 0.0007; 95% CI, -0.0006 to 0.0019). CONCLUSIONS AND RELEVANCE These findings suggest that REACH VET implementation was associated with greater treatment engagement and new safety plan documentation and fewer mental health admissions, emergency department visits, and suicide attempts. Clinical programs using risk modeling may be effective tools to support care enhancements and risk reduction.
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Affiliation(s)
- John F. McCarthy
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Washington, District of Columbia
| | - Samantha A. Cooper
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Washington, District of Columbia
| | - Kallisse R. Dent
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Washington, District of Columbia
| | - Aaron E. Eagan
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Washington, District of Columbia
| | - Bridget B. Matarazzo
- Rocky Mountain Mental Illness Research, Education and Clinical Center, Department of Veterans Affairs, Aurora, Colorado
| | - Claire M. Hannemann
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Washington, District of Columbia
| | - Mark A. Reger
- VA Puget Sound Healthcare System, Seattle, Washington
| | - Sara J. Landes
- South Central Mental Illness Research Education Clinical Center, Department of Veterans Affairs, Little Rock, Arkansas
| | - Jodie A. Trafton
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Washington, District of Columbia
| | | | - Ira R. Katz
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Washington, District of Columbia
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Spinola S, Fenton BT, Meshberg-Cohen S, Black AC, Rosen MI. Comparison of attitudes towards the service connection claims process among veterans filing for PTSD and veterans filing for musculoskeletal disorders. Medicine (Baltimore) 2021; 100:e27068. [PMID: 34477140 PMCID: PMC8415949 DOI: 10.1097/md.0000000000027068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 03/15/2021] [Accepted: 08/05/2021] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT Many veterans have negative views about the service connection claims process for posttraumatic stress disorder (PTSD), which likely impacts willingness to file service connection claims, re-file claims, and use Veterans Healthcare Administration care. Nevertheless, veterans have reported that PTSD claims are important to them for the financial benefits, validation of prior experience and harm, and self-other issues such as pleasing a significant other. It is unknown if reported attitudes are specific to PTSD claimants or if they would be similar to those submitting claims for other disorders, such as musculoskeletal disorders. Therefore, the purpose of this study was to compare attitudes and beliefs about service connection processes between veterans submitting service connection claims for PTSD and musculoskeletal disorders.Participants were Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans filing service connection claims for PTSD (n = 218) or musculoskeletal disorder (n = 257) who completed a modified Disability Application Appraisal Inventory. This secondary data analysis using multiple regression models tested the effect of demographics, clinical characteristics, and claim type on 5 Disability Application Appraisal Inventory subscales: Knowledge about service connection claims, Negative Expectations about the process, and importance of Financial Benefits, importance of Validation of veteran's experience/condition, and importance of Self-Other attitudes.The PTSD group assigned significantly less importance to financial benefits than the musculoskeletal disorder group. In addition, the subset of the PTSD group without depression had significantly more Negative Expectations than musculoskeletal disorder claimants without depression. Negative Expectations did not differ between the PTSD and musculoskeletal disorder groups with depression. Depression was significantly positively associated with Negative Expectations, importance of Financial Benefits, and importance of Validation.Most perceptions around seeking service connection are not specific to PTSD claimants. Depression is associated with having negative expectations about service connection claims and motivations to file claims. Addressing depression and negative expectations during the compensation and pension process might help veterans at this important point of contact with Veterans Healthcare Administration services.
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Affiliation(s)
- Suzanne Spinola
- VA Connecticut Healthcare System, West Haven, CT
- Yale University School of Medicine, Department of Psychiatry, CT
| | - Brenda T. Fenton
- VA Connecticut Healthcare System, West Haven, CT
- Yale University School of Medicine, Department of Neurology, CT
| | - Sarah Meshberg-Cohen
- VA Connecticut Healthcare System, West Haven, CT
- Yale University School of Medicine, Department of Psychiatry, CT
| | - Anne C. Black
- VA Connecticut Healthcare System, West Haven, CT
- Yale University School of Medicine, Department of Internal Medicine, CT
| | - Marc I. Rosen
- VA Connecticut Healthcare System, West Haven, CT
- Yale University School of Medicine, Department of Psychiatry, CT
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Hussain SF, Raza Z, Cash ATG, Zampieri T, Mazzoli RA, Kardon RH, Gomes RSM. Traumatic brain injury and sight loss in military and veteran populations- a review. Mil Med Res 2021; 8:42. [PMID: 34315537 PMCID: PMC8317328 DOI: 10.1186/s40779-021-00334-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/23/2021] [Indexed: 01/14/2023] Open
Abstract
War and combat exposure pose great risks to the vision system. More recently, vision related deficiencies and impairments have become common with the increased use of powerful explosive devices and the subsequent rise in incidence of traumatic brain injury (TBI). Studies have looked at the effects of injury severity, aetiology of injury and the stage at which visual problems become apparent. There was little discrepancy found between the frequencies or types of visual dysfunctions across blast and non-blast related groups, however complete sight loss appeared to occur only in those who had a blast-related injury. Generally, the more severe the injury, the greater the likelihood of specific visual disturbances occurring, and a study found total sight loss to only occur in cases with greater severity. Diagnosis of mild TBI (mTBI) is challenging. Being able to identify a potential TBI via visual symptoms may offer a new avenue for diagnosis.
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Affiliation(s)
- Syeda F. Hussain
- Research & Innovation, Blind Veterans UK, 12-14 Harcourt Street, London, W1H 4HD UK
- Bravo Victor, Research, 12-14 Harcourt Street, London, W1H 4HD UK
| | - Zara Raza
- Research & Innovation, Blind Veterans UK, 12-14 Harcourt Street, London, W1H 4HD UK
- Bravo Victor, Research, 12-14 Harcourt Street, London, W1H 4HD UK
| | - Andrew T. G. Cash
- Research & Innovation, Blind Veterans UK, 12-14 Harcourt Street, London, W1H 4HD UK
- Bravo Victor, Research, 12-14 Harcourt Street, London, W1H 4HD UK
| | - Thomas Zampieri
- Blinded Veterans Association, 1101 King Street, Suite 300, Alexandria, Virginia 22314 USA
| | - Robert A. Mazzoli
- Department of Ophthalmology, Madigan Army Medical Center, 9040 Jackson Avenue, Tacoma, Washington, 98431 USA
| | - Randy H. Kardon
- Iowa City VA Health Care System and Iowa City VA Center for the Prevention and Treatment of Visual Loss, Iowa City, Iowa 52246 USA
- Department of Ophthalmology and Visual Sciences, The University of Iowa, Iowa City, Iowa 52242 USA
| | - Renata S. M. Gomes
- Research & Innovation, Blind Veterans UK, 12-14 Harcourt Street, London, W1H 4HD UK
- Bravo Victor, Research, 12-14 Harcourt Street, London, W1H 4HD UK
- Northern Hub for Veterans and Military Families Research, Department of Nursing, Midwifery and Health, Faculty of Health and Life Sciences, Northumbria University, Newcastle, NE7 7XA UK
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16
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Núñez ER, Caverly TJ, Zhang S, Glickman ME, Qian SX, Boudreau JH, Slatore CG, Miller DR, Wiener RS. Adherence to Follow-up Testing Recommendations in US Veterans Screened for Lung Cancer, 2015-2019. JAMA Netw Open 2021; 4:e2116233. [PMID: 34236409 PMCID: PMC8267608 DOI: 10.1001/jamanetworkopen.2021.16233] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Lung cancer screening (LCS) can reduce lung cancer mortality with close follow-up and adherence to management recommendations. Little is known about factors associated with adherence to LCS in real-world practice, with data limited to case series from selected LCS programs. OBJECTIVE To analyze adherence to follow-up based on standardized follow-up recommendations in a national cohort and to identify factors associated with delayed or absent follow-up. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted in Veterans Health Administration (VHA) facilities across the US. Veterans were screened for lung cancer between 2015 to 2019 with sufficient follow-up time to receive recommended evaluation. Patient- and facility-level logistic regression analyses were performed. Data were analyzed from November 26, 2019, to December 16, 2020. MAIN OUTCOMES AND MEASURES Receipt of the recommended next step after initial LCS according to Lung CT Screening Reporting & Data System (Lung-RADS) category, as captured in VHA or Medicare claims. RESULTS Of 28 294 veterans (26 835 [94.8%] men; 21 969 individuals [77.6%] were White; mean [SD] age, 65.2 [5.5] years) who had an initial LCS examination, 17 863 veterans (63.1%) underwent recommended follow-up within the expected timeframe, whereas 3696 veterans (13.1%) underwent late evaluation, and 4439 veterans (15.7%) had no apparent evaluation. Facility-level differences were associated with 9.2% of the observed variation in rates of late or absent evaluation. In multivariable-adjusted models, Black veterans (odds ratio [OR], 1.19 [95% CI, 1.10-1.29]), veterans with posttraumatic stress disorder (OR, 1.13 [95% CI, 1.03-1.23]), veterans with substance use disorders (OR, 1.11 [95% CI, 1.01-1.22]), veterans with lower income (OR, 0.88 [95% CI, 0.79-0.98]), and those living at a greater distance from a VHA facility (OR, 1.06 [95% CI, 1.02-1.10]) were more likely to experience delayed or no follow-up; veterans with higher risk findings (Lung-RADS category 4 vs Lung-RADS category 1: OR, 0.35 [95% CI, 0.28-0.43]) and those screened in high LCS volume facilities (OR, 0.38 [95% CI, 0.21-0.67]) or academic facilities (OR, 0.86 [95% CI, 0.80-0.92]) were less likely to experience delayed or no follow-up. In sensitivity analyses, varying how stringently adherence was defined, expected evaluation ranged from 14 486 veterans (49.7%) under stringent definitions to 20 578 veterans (78.8%) under liberal definitions. CONCLUSIONS AND RELEVANCE In this cohort study that captured follow-up care from the integrated VHA health care system and Medicare, less than two-thirds of patients received timely recommended follow-up after initial LCS, with higher risk of delayed or absent follow-up among marginalized populations, such as Black individuals, individuals with mental health disorders, and individuals with low income, that have long experienced disparities in lung cancer outcomes. Future work should focus on identifying facilities that promote high adherence and disseminating successful strategies to promote equity in LCS among marginalized populations.
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Affiliation(s)
- Eduardo R. Núñez
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Tanner J. Caverly
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- University of Michigan School of Medicine, Ann Arbor
| | - Sanqian Zhang
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
- Department of Statistics, Harvard University, Cambridge, Massachusetts
| | - Mark E. Glickman
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
- Department of Statistics, Harvard University, Cambridge, Massachusetts
| | - Shirley X. Qian
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Jacqueline H. Boudreau
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Christopher G. Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland
| | - Donald R. Miller
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, Bedford VA Healthcare System, Bedford, Massachusetts
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
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17
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Essien UR, Kim N, Hausmann LRM, Mor MK, Good CB, Magnani JW, Litam TMA, Gellad WF, Fine MJ. Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System. JAMA Netw Open 2021; 4:e2114234. [PMID: 34319358 PMCID: PMC8319757 DOI: 10.1001/jamanetworkopen.2021.14234] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Atrial fibrillation is a common cardiac rhythm disturbance causing substantial morbidity and mortality that disproportionately affects racial/ethnic minority groups. Anticoagulation reduces stroke risk in atrial fibrillation, yet studies show it is underprescribed in racial/ethnic minority patients. OBJECTIVE To compare initiation of anticoagulant therapy by race/ethnicity for patients in the Veterans Health Administration (VA) system with atrial fibrillation. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included 111 666 patients within the VA system with incident atrial fibrillation between January 1, 2014, and December 31, 2018. Data were analyzed between December 1, 2019, and March 31, 2020. EXPOSURES Any anticoagulation was defined as receipt of warfarin or direct-acting oral anticoagulants, apixaban, dabigatran, edoxaban, or rivaroxaban. MAIN OUTCOMES AND MEASURES Initiation of any anticoagulation (or direct-acting oral anticoagulant therapy in those who initiated any anticoagulation) was examined within 90 days of an index atrial fibrillation diagnosis. RESULTS Our final cohort comprised 111 666 patients (109 386 men [98.0%] and 95 493 White patients [85.5%]; mean [SD] age, 72.9 [10.4] years). A total of 69 590 patients (62.3%) initiated any anticoagulant therapy, varying 10.5 percentage points by race/ethnicity (P < .001); initiation was lowest in Asian (52.2% [n = 676]) and Black (60.3% [n = 6177]) patients and highest in White patients (62.7% [n = 59 881]). Among anticoagulant initiators, 45 381 (65.2%) used direct-acting oral anticoagulants, varying 7.2 percentage points by race/ethnicity (P < .001); initiation was lowest in Hispanic (58.3% [n = 1470]), American Indian/Alaska Native (59.8% [n = 201]), and Black (60.9% [n = 3763]) patients and highest in White patients (66.0% [n = 39 502). Compared with White patients, the odds of initiating any anticoagulant therapy were significantly lower for Asian (adjusted odds ratio [aOR], 0.82; 95% CI, 0.72-0.94) and Black (aOR, 0.90; 95% CI 0.85-0.95) patients. Among initiators, the adjusted odds of direct-acting oral anticoagulant initiation were significantly lower for Hispanic (aOR, 0.79; 95% CI, 0.70-0.89), American Indian/Alaska Native (aOR, 0.75; 95% CI, 0.57-0.99), and Black (aOR, 0.74; 95% CI 0.69-0.80) patients. CONCLUSIONS AND RELEVANCE This cohort study found that in patients with incident atrial fibrillation managed in the VA system, race/ethnicity was independently associated with initiating any anticoagulant therapy and direct-acting oral anticoagulant use among anticoagulant initiators. Understanding the reasons for these treatment disparities is essential to improving equitable atrial fibrillation management and outcomes among racial/ethnic minority patients treated in the VA system.
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Affiliation(s)
- Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, UPMC Health Plan, Pittsburgh, Pennsylvania
| | - Jared W Magnani
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Terrence M A Litam
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Cattle CJ, McSteen B, Cheng MKW. Courage in Accommodation: Connecting With Older Adults During the COVID-19 Pandemic. Acad Med 2021; 96:783. [PMID: 33635838 PMCID: PMC8140643 DOI: 10.1097/acm.0000000000004019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Chloe J Cattle
- Medical student, University of California, San Francisco, San Francisco, California;
| | - Brian McSteen
- Medical student, University of California, San Francisco, San Francisco, California
| | - Mike K W Cheng
- Clinician educator fellow, Department of Medicine, University of California, San Francisco, San Francisco, California; ORCID: https://orcid.org/0000-0001-5004-080X
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Kertesz SG, deRussy AJ, Kim YI, Hoge AE, Austin EL, Gordon AJ, Gelberg L, Gabrielian SE, Riggs KR, Blosnich JR, Montgomery AE, Holmes SK, Varley AL, Pollio DE, Gundlapalli AV, Jones AL. Comparison of Patient Experience Between Primary Care Settings Tailored for Homeless Clientele and Mainstream Care Settings. Med Care 2021; 59:495-503. [PMID: 33827104 PMCID: PMC8567819 DOI: 10.1097/mlr.0000000000001548] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND More than 1 million Americans receive primary care from federal homeless health care programs yearly. Vulnerabilities that can make care challenging include pain, addiction, psychological distress, and a lack of shelter. Research on the effectiveness of tailoring services for this population is limited. OBJECTIVE The aim was to examine whether homeless-tailored primary care programs offer a superior patient experience compared with nontailored ("mainstream") programs overall, and for highly vulnerable patients. RESEARCH DESIGN National patient survey comparing 26 US Department of Veterans Affairs (VA) Medical Centers' homeless-tailored primary care ("H-PACT"s) to mainstream primary care ("mainstream PACT"s) at the same locations. PARTICIPANTS A total of 5766 homeless-experienced veterans. MEASURES Primary care experience on 4 scales: Patient-Clinician Relationship, Cooperation, Accessibility/Coordination, and Homeless-Specific Needs. Mean scores (range: 1-4) were calculated and dichotomized as unfavorable versus not. We counted key vulnerabilities (chronic pain, unsheltered homelessness, severe psychological distress, and history of overdose, 0-4), and categorized homeless-experienced veterans as having fewer (≤1) and more (≥2) vulnerabilities. RESULTS H-PACTs outscored mainstream PACTs on all scales (all P<0.001). Unfavorable care experiences were more common in mainstream PACTs compared with H-PACTs, with adjusted risk differences of 11.9% (95% CI=6.3-17.4), 12.6% (6.2-19.1), 11.7% (6.0-17.3), and 12.6% (6.2-19.1) for Relationship, Cooperation, Access/Coordination, and Homeless-Specific Needs, respectively. For the Relationship and Cooperation scales, H-PACTs were associated with a greater reduction in unfavorable experience for patients with ≥2 vulnerabilities versus ≤1 (interaction P<0.0001). CONCLUSIONS Organizations that offer primary care for persons experiencing homelessness can improve the primary care experience by tailoring the design and delivery of services.
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Affiliation(s)
- Stefan G. Kertesz
- Birmingham Veterans Affairs Medical Center, 700 19th Street S., Birmingham, AL 35233
- University of Alabama at Birmingham School of Medicine, 1670 University Blvd, Birmingham, AL 35233
- University of Alabama at Birmingham School of Public Health, 1665 University Blvd, Birmingham, AL 35233
| | - Aerin J. deRussy
- Birmingham Veterans Affairs Medical Center, 700 19th Street S., Birmingham, AL 35233
| | - Young-il Kim
- Birmingham Veterans Affairs Medical Center, 700 19th Street S., Birmingham, AL 35233
- University of Alabama at Birmingham School of Medicine, 1670 University Blvd, Birmingham, AL 35233
| | - April E. Hoge
- Birmingham Veterans Affairs Medical Center, 700 19th Street S., Birmingham, AL 35233
| | - Erika L. Austin
- Birmingham Veterans Affairs Medical Center, 700 19th Street S., Birmingham, AL 35233
- University of Alabama at Birmingham School of Public Health, 1665 University Blvd, Birmingham, AL 35233
| | - Adam J. Gordon
- VA Salt Lake City Health Care System, 500 Foothill Dr, Salt Lake City, UT 84148
- University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132
| | - Lillian Gelberg
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA 90073
- University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095
| | - Sonya E. Gabrielian
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA 90073
- University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095
| | - Kevin R. Riggs
- Birmingham Veterans Affairs Medical Center, 700 19th Street S., Birmingham, AL 35233
- University of Alabama at Birmingham School of Medicine, 1670 University Blvd, Birmingham, AL 35233
| | - John R. Blosnich
- University of Southern California, Los Angeles CA 90089
- VA Pittsburgh Healthcare System, 4100 Allequippa St, Pittsburgh, PA 15219
| | - Ann Elizabeth Montgomery
- Birmingham Veterans Affairs Medical Center, 700 19th Street S., Birmingham, AL 35233
- University of Alabama at Birmingham School of Public Health, 1665 University Blvd, Birmingham, AL 35233
| | - Sally K. Holmes
- Birmingham Veterans Affairs Medical Center, 700 19th Street S., Birmingham, AL 35233
| | - Allyson L. Varley
- Birmingham Veterans Affairs Medical Center, 700 19th Street S., Birmingham, AL 35233
- University of Alabama at Birmingham School of Medicine, 1670 University Blvd, Birmingham, AL 35233
| | - David E. Pollio
- Birmingham Veterans Affairs Medical Center, 700 19th Street S., Birmingham, AL 35233
- University of Alabama at Birmingham College of Arts and Sciences, 1720 2 Ave. S., Birmingham AL 35294
| | - Adi V. Gundlapalli
- University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132
| | - Audrey L. Jones
- University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA 90073
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20
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Jones AL, Gordon AJ, Gabrielian SE, Montgomery AE, Blosnich JR, Varley AL, deRussy AJ, Austin EL, Hoge AE, Kim YI, Gelberg L, Kertesz SG. Perceptions of Care Coordination Among Homeless Veterans Receiving Medical Care in the Veterans Health Administration and Community Care Settings: Results From a National Survey. Med Care 2021; 59:504-512. [PMID: 33827108 PMCID: PMC8119353 DOI: 10.1097/mlr.0000000000001547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Initiatives to expand Veterans' access to purchased health care outside Veterans Health Administration (VHA) facilities ("community care") present care coordination challenges for Veterans experiencing homelessness. OBJECTIVE Among Veterans with homeless experiences, to evaluate community care use and satisfaction, and compare perceptions of care coordination among Veterans using VHA services and community care to those using VHA services without community care. RESEARCH DESIGN Cross-sectional analysis of responses to a 2018 mailed survey. SUBJECTS VHA outpatients with homeless experiences. MEASURES Self-reported use of community care, Likert-style ratings of satisfaction with that care, and Access/Coordination experiences from the Primary Care Quality-Homeless (PCQ-H) survey. RESULTS Of 4777 respondents, 1325 (26.7%) reported using community care; most of this subsample affirmed satisfaction with the community care they received (83%) and its timeliness (75%). After covariate adjustment, Veteran characteristics associated with greater community care use included female sex, being of retirement age and nonmarried, and having higher education, more financial hardship, ≥3 chronic conditions, psychological distress, depression, and posttraumatic stress disorder. Satisfaction with community care was lower among patients with travel barriers, psychological distress, and less social support. Compared with those using the VHA without community care, Veterans using VHA services and community care were more likely to report unfavorable access/coordination experiences [odds ratio (OR)=1.34, confidence interval (CI)=1.15-1.57]. This included hassles following referral (OR=1.37, CI=1.14-1.65) and perceived delays in receiving health care (OR=1.38, CI=1.19-1.61). CONCLUSIONS Veterans with homeless experiences value community care options. Potential access benefits are balanced with risks of unfavorable coordination experiences for vulnerable Veterans with limited resources.
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Affiliation(s)
- Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Veterans Affairs Salt Lake City Health Care System
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Veterans Affairs Salt Lake City Health Care System
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Sonya E Gabrielian
- VA Greater Los Angeles Health Care System
- David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA
| | - Ann Elizabeth Montgomery
- Birmingham VA Medical Center
- University of Alabama at Birmingham School of Public Health, Birmingham, AL
| | - John R Blosnich
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA
| | | | | | - Erika L Austin
- Birmingham VA Medical Center
- University of Alabama at Birmingham School of Public Health, Birmingham, AL
| | | | - Young-Il Kim
- Birmingham VA Medical Center
- University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Lillian Gelberg
- VA Greater Los Angeles Health Care System
- David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA
| | - Stefan G Kertesz
- Birmingham VA Medical Center
- University of Alabama at Birmingham School of Public Health, Birmingham, AL
- University of Alabama at Birmingham School of Medicine, Birmingham, AL
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21
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Mattocks KM, Elwy AR, Yano EM, Giovannelli J, Adelberg M, Mengeling MA, Cunningham KJ, Matthews KL. Developing network adequacy standards for VA Community Care. Health Serv Res 2021; 56:400-408. [PMID: 33782979 PMCID: PMC8143680 DOI: 10.1111/1475-6773.13651] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To inform how the VA should develop and implement network adequacy standards, we convened an expert panel to discuss Community Care Network (CCN) adequacy and how VA might implement network adequacy standards for community care. DATA SOURCES/STUDY SETTING Data were generated from expert panel ratings and from an audio-recorded expert panel meeting conducted in Arlington, Virginia, in October 2017. STUDY DESIGN We used a modified Delphi panel process involving one round of expert panel ratings provided by nine experts in network adequacy standards. Expert panel members received a list of network adequacy standard measures used in commercial and government market and were provided a rating form listing a total of 11 measures and characteristics to rate. DATA COLLECTION METHODS Items on the rating form were individually discussed during an expert panel meeting between the nine expert panel members and VA Office of Community Care leaders. Attendees addressed discordant views and generated revised or new standards accordingly. Recorded audio data were transcribed to facilitate thematic analysis regarding opportunities and challenges with implementing network adequacy standards in VA Community Care. PRINCIPAL FINDINGS The five highest ranked standards were network directories for Veterans, regular reporting of network adequacy data to VA, maximum wait time/distance standards, minimum ratio of providers to enrolled population, and qualitative assessments of network adequacy. During the expert panel discussion with VA Community Care leaders, opportunities and challenges implementing network adequacy standards were highlighted. CONCLUSIONS Our expert panel shed light on priorities for network adequacy to be implemented under CCN contracts, such as developing comprehensive provider directories for Veterans to use when selecting community providers. Remaining questions focus on whether the VA could reasonably develop and implement network adequacy standards given current Congressional restraints on VA reimbursement to community providers.
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Affiliation(s)
- Kristin M. Mattocks
- VA Central Western Massachusetts Healthcare SystemLeedsMassachusettsUSA
- University of Massachusetts Medical SchoolWorcesterMassachusettsUSA
| | - A. Rani Elwy
- Center for Healthcare Organization and Implementation ResearchEdith Nourse Rogers Memorial Veterans HospitalBedfordMassachusettsUSA
- Department of Psychiatry and Human BehaviorAlpert Medical SchoolBrown UniversityProvidenceRhode IslandUSA
| | - Elizabeth M. Yano
- VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation and PolicyVA Greater Los Angeles Healthcare SystemSepulvedaCaliforniaUSA
- Department of Health Policy and ManagementUCLA Fielding School of Public HealthLos AngelesCaliforniaUSA
| | - Justin Giovannelli
- Georgetown University Health Policy InstituteWashingtonDistrict of ColumbiaUSA
| | | | - Michelle A. Mengeling
- Center for Access & Delivery Research and Evaluation (CADRE) and VA Office of Rural Health (ORH)Veterans Rural Health Resource Center‐Iowa City (VRHRC‐IC)Iowa City VA Health Care SystemIowa CityIowaUSA
- Department of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
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22
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Cornell PY, Celardo C, Chmelka G, Giles AJ, Halladay CW, Halaszynski J, Montano AR, Rudolph JL, Silva JW. Social work and telehealth: How Patient Aligned Care Team (PACT) social workers in the Veterans Health Administration responded to COVID-19. Soc Work Health Care 2021; 60:131-145. [PMID: 33826466 DOI: 10.1080/00981389.2021.1904320] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/20/2021] [Accepted: 03/12/2021] [Indexed: 06/12/2023]
Abstract
In March 2020, the Veterans Health Administration (VA) responded to pandemic shutdowns with a rapid pivot toward providing services via telehealth. Using data on Veterans who received interventions from social workers between 2019 and 2020 at sites that participated in a national program to increase social work staffing in primary care, we examined changes in frequency and modality of social work encounters that occurred with the onset of the COVID-19 pandemic. We found that primary care social workers maintained a consistent level of engagement, with increases in telephone and video telehealth encounters as in-person visits decreased. Through front-line perspectives, we discuss the practical innovations and policies that enabled those changes in care from VA primary care social workers.
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Affiliation(s)
- Portia Y Cornell
- Providence Veterans Administration (VA) Medical Center, Providence, Rhode Island, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Caitlin Celardo
- National Social Work Program Office, Care Management and Social Work, Patient Care Services, Department of Veterans Affairs, Washington, District of Columbia, USA
- Northport VA Medical Center, Northport, New York, USA
| | - GinaR Chmelka
- National Social Work Program Office, Care Management and Social Work, Patient Care Services, Department of Veterans Affairs, Washington, District of Columbia, USA
- Tomah VA Medical Center, Tomah, Wisconsin, USA
| | - Angela J Giles
- National Social Work Program Office, Care Management and Social Work, Patient Care Services, Department of Veterans Affairs, Washington, District of Columbia, USA
- Hampton VA Medical Center, Hampton, Virginia, USA
| | | | - Jaime Halaszynski
- Butler VA Health Care System, Social Work Service, Butler, Pennsylvania, USA
| | - Anna-Rae Montano
- Providence Veterans Administration (VA) Medical Center, Providence, Rhode Island, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - James L Rudolph
- Providence Veterans Administration (VA) Medical Center, Providence, Rhode Island, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jennifer W Silva
- National Social Work Program Office, Care Management and Social Work, Patient Care Services, Department of Veterans Affairs, Washington, District of Columbia, USA
- VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
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23
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Dellefield ME, Madrigal CB, Verkaaik C, Close J. Nursing surveillance and immediate jeopardy in Veteran Health Administration community living centers unannounced survey program 2018 to 2019. Nurs Outlook 2021; 69:182-192. [PMID: 33541725 DOI: 10.1016/j.outlook.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/15/2020] [Accepted: 11/03/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND The VA Community Living Center (CLC) Unannounced Survey Program aims to assess standards of care set by the government to protect residents. PURPOSE To describe patterns of practice failures in nursing surveillance causing or having potential to cause immediate jeopardy, as defined by the Centers for Medicare and Medicaid Services. METHODS Using CLC survey data consisting of 200 statements of deficiency (SODs) for 2018 to 2019, we collected a SOD sample (n = 20) of immediate jeopardy events. They were described using descriptive statistics and discourse content analysis. FINDINGS We identified clinical events, their duration, work shift, and nursing skill mix for each SOD. Most to least common themes about failures in nursing surveillance were acquisition/transfer of information; decision-making; and early recognition of problems. DISCUSSION Our analysis of nursing surveillance failures in CLC immediate jeopardy SODs provides insight into opportunities for registered nurses and the nursing skill mix to reduce avoidable harms.
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Affiliation(s)
- Mary Ellen Dellefield
- Department of Nursing and Patient Care Services, VA San Diego Healthcare System, San Diego, CA.
| | - Caroline B Madrigal
- Center of Innovation in Long-term Services and Supports, Providence VA Medical Center, Providence, RI
| | - Catherine Verkaaik
- Department of Nursing and Patient Care Services, VA San Diego Healthcare System, San Diego, CA
| | - Jackie Close
- Department of Nursing and Patient Care Services, VA San Diego Healthcare System, San Diego, CA
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Kaul B, Hynes DM, Hickok A, Smith C, Niederhausen M, Totten AM, Whooley MA, Sarmiento K. Does Community Outsourcing Improve Timeliness of Care for Veterans With Obstructive Sleep Apnea? Med Care 2021; 59:111-117. [PMID: 33290324 PMCID: PMC7899214 DOI: 10.1097/mlr.0000000000001472] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Providing timely access to care has been a long-standing priority for the Veterans Affairs Healthcare System. Recent strategies to reduce long wait times have focused on purchasing community care by a fee-for-service model. Whether outsourcing Veterans Affairs (VA) specialty care to the community improves access is unclear. OBJECTIVES We compared time from referral to treatment among Veterans whose care was provided by VA versus community care purchased by the VA, using obstructive sleep apnea as an example condition. METHODS This was a retrospective cohort study of Northern California Veterans seeking sleep apnea care through the San Francisco VA Healthcare System between 2012 and 2018. We used multivariable linear regression with propensity score matching to investigate the relationship between time to care delivery and care setting (VA provided vs. VA-purchased community care). A total of 1347 Northern California Veterans who completed sleep apnea testing within the VA and 88 Veterans who completed sleep apnea testing in the community had complete data for analysis. RESULTS Among Northern California Veterans with obstructive sleep apnea, outsourcing of care to the community was associated with longer time from referral to therapy (mean±SD, 129.6±82.8 d with VA care vs. 252.0±158.8 d with community care, P<0.001) and greater loss to follow-up. CONCLUSIONS These findings suggest that purchasing community care may lead to care fragmentation and not improve wait times nor improve access to subspecialty care for Veterans.
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Affiliation(s)
- Bhavika Kaul
- San Francisco Veterans Affairs Healthcare System
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland
- Health Management and Policy, College of Public Health and Human Services, and Center for Genome Research and Biocomputing, Oregon State University, Corvallis, OR
| | - Alex Hickok
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland
| | - Connor Smith
- Department of Clinical Epidemiology and Medical Informatics
| | - Meike Niederhausen
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR
| | - Annette M. Totten
- Department of Clinical Epidemiology and Medical Informatics
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR
| | - Mary A. Whooley
- San Francisco Veterans Affairs Healthcare System
- Department of Medicine, University of California San Francisco, San Francisco, CA
- Quality Enhancement Research Initiative, Veterans Health Administration, Washington, DC
| | - Kathleen Sarmiento
- San Francisco Veterans Affairs Healthcare System
- Department of Medicine, University of California San Francisco, San Francisco, CA
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25
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Mattocks KM, Kroll-Desrosiers A, Kinney R, Bastian LA, Bean-Mayberry B, Goldstein KM, Shivakumar G, Copeland L. Racial Differences in the Cesarean Section Rates Among Women Veterans Using Department of Veterans Affairs Community Care. Med Care 2021; 59:131-138. [PMID: 33201084 DOI: 10.1097/mlr.0000000000001461] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Racial disparities in maternal morbidity and mortality remain a pressing public health problem. Variations in cesarean section (C-section) rates among racial and ethnic groups have been well documented, though reasons for these variations remain unknown. In the Department of Veterans Affairs (VA), nearly half of all women Veterans are of reproductive age and >40% of these women are racial and ethnic minorities. Because the VA does not provide obstetrical services, all obstetrical care is provided by community obstetrical providers under the auspices of the VA Community Care Network. However, little is known regarding the rates and correlates of C-sections among women Veterans receiving community obstetrical care. OBJECTIVE To examine predictors of C-section deliveries among a cohort of racially diverse pregnant Veterans enrolled in VA care at 15 VA medical facilities nationwide. RESEARCH DESIGN Cross-sectional analysis of a longitudinal, prospective, multisite, observational cohort study of pregnant, and postpartum Veterans receiving community-based obstetrical care. RESULTS Overall, 659 Veterans delivered babies during the study period, and 35% of the deliveries were C-sections. Predictors of C-section receipt included being a woman of color [adjusted odds ratio (AOR), 1.76; 95% confidence interval (CI), 1.19-2.60], having an Edinburgh Postnatal Depression Scale score ≥10 (AOR, 1.71; 95% CI, 1.11-2.65), having a higher body mass indexes (AOR, 1.07; 95% CI, 1.04-1.11), and women who were older (AOR, 1.08; 95% CI, 1.03-1.13). There was a substantial racial variation in C-section rates across our 15 study sites, with C-section rates meeting or exceeding 50% for WOC in 8 study sites. CONCLUSIONS There is substantial racial and geographic variation in C-section rates among pregnant Veterans receiving obstetrical care through VA community care providers. Future research should carefully examine variations in C-sections by the hospital, and which providers and hospitals are included in VA contracts. There should also be an increased focus on the types of providers women Veterans have access to for obstetrical care paid for by the VA and the quality of care delivered by those providers.
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Affiliation(s)
- Kristin M Mattocks
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
- VA Central Western Massachusetts Healthcare System, Leeds, MA
| | - Aimee Kroll-Desrosiers
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
- VA Central Western Massachusetts Healthcare System, Leeds, MA
| | - Rebecca Kinney
- VA Central Western Massachusetts Healthcare System, Leeds, MA
| | - Lori A Bastian
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Bevanne Bean-Mayberry
- VA Greater Los Angeles Healthcare System, VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP)
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Karen M Goldstein
- Durham VA Health Care System-Center for Health Services Research in Primary Care
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC
| | - Geetha Shivakumar
- Mental Health, VA North Texas Health Care System
- Department of Psychiatry, UT Southwestern Medical Center, Dallas, TX
| | - Laurel Copeland
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
- VA Central Western Massachusetts Healthcare System, Leeds, MA
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26
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Yank V, Gale RC, Nevedal A, Okwara L, Koenig CJ, Trivedi RB, Dupke NJ, Kabat M, Asch SM. Improving Uptake of a National Web-Based Psychoeducational Workshop for Informal Caregivers of Veterans: Mixed Methods Implementation Evaluation. J Med Internet Res 2021; 23:e16495. [PMID: 33410759 PMCID: PMC7819783 DOI: 10.2196/16495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 07/13/2020] [Accepted: 11/18/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Although web-based psychoeducational programs may be an efficient, accessible, and scalable option for improving participant well-being, they seldom are sustained beyond trial publication. Implementation evaluations may help optimize program uptake, but few are performed. When the US Department of Veterans Affairs (VA) launched the web-based psychoeducational workshop Building Better Caregivers (BBC) for informal caregivers of veterans nationwide in 2013, the workshop did not enroll as many caregivers as anticipated. OBJECTIVE This study aims to identify the strengths and weaknesses of initial implementation, strategies likely to improve workshop uptake, whether the VA adopted these strategies, and whether workshop enrollment changed. METHODS We used mixed methods and the Promoting Action on Research Implementation in Health Services (PARIHS) implementation evaluation framework. In stage 1, we conducted semistructured interviews with caregivers, local staff, and regional and national VA leaders and surveys with caregivers and staff. We collected and analyzed survey and interview data concurrently and integrated the results to identify implementation strengths and weaknesses, and strategies likely to improve workshop uptake. In stage 2, we reinterviewed national leaders to determine whether the VA adopted recommended strategies and used national data to determine whether workshop enrollment changed over time. RESULTS A total of 54 caregivers (n=32, 59%), staff (n=13, 24%), and regional (n=5, 9%) and national (n=4, 7%) leaders were interviewed. We received survey responses from 72% (23/32) of caregivers and 77% (10/13) of local staff. In stage 1, survey and interview results were consistent across multiple PARIHS constructs. Although participants from low-enrollment centers reported fewer implementation strengths and more weaknesses, qualitative themes were consistent across high- and low-enrollment centers, and across caregiver, staff, and leadership respondent groups. Identified strengths included belief in a positive workshop impact and the use of some successful outreach approaches. Implementation weaknesses included missed opportunities to improve outreach and to better support local staff. From these, we identified and recommended new and enhanced implementation strategies-increased investment in outreach and marketing capabilities; tailoring outreach strategies to multiple stakeholder groups; use of campaigns that are personal, repeated, and detailed, and have diverse delivery options; recurrent training and mentoring for new staff; and comprehensive data management and reporting capabilities. In stage 2, we determined that the VA had adopted several of these strategies in 2016. In the 3 years before and after adoption, cumulative BBC enrollment increased from 2139 (2013-2015) to 4030 (2016-2018) caregivers. CONCLUSIONS This study expands the limited implementation science literature on best practices to use when implementing web-based psychoeducational programs. We found that robust outreach and marketing strategies and support for local staff were critical to the implementation success of the BBC workshop. Other health systems may want to deploy these strategies when implementing their web-based programs.
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Affiliation(s)
- Veronica Yank
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Randall C Gale
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States
| | - Andrea Nevedal
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States
| | - Leonore Okwara
- Department of Behavioral and Community Health, University of Maryland, Baltimore, MD, United States
| | - Christopher J Koenig
- Department of Communication Studies, San Francisco State University, San Francisco, CA, United States
| | - Ranak B Trivedi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, United States
| | - Nancy J Dupke
- VA Caregivers Support Program, Department of Veterans Affairs, Washington, DC, United States
| | - Margaret Kabat
- VA Caregivers Support Program, Department of Veterans Affairs, Washington, DC, United States
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States
- Division of Primary Care and Population Health, Stanford University, Palo Alto, CA, United States
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Gawron AJ, Kaltenbach T, Dominitz JA. The Impact of the Coronavirus Disease-19 Pandemic on Access to Endoscopy Procedures in the VA Healthcare System. Gastroenterology 2020; 159:1216-1220.e1. [PMID: 32710908 PMCID: PMC7375295 DOI: 10.1053/j.gastro.2020.07.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 12/26/2022]
Affiliation(s)
- Andrew J Gawron
- VA Salt Lake City Health Care System and, University of Utah School of Medicine, Division of Gastroenterology, Salt Lake City, Utah
| | - Tonya Kaltenbach
- San Francisco VA Health Care System and, University of California San Francisco, San Francisco, California
| | - Jason A Dominitz
- VA Puget Sound Health Care System and, University of Washington School of Medicine, Division of Gastroenterology, Seattle, Washington
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Zulman DM, Maciejewski ML, Grubber JM, Weidenbacher HJ, Blalock DV, Zullig LL, Greene L, Whitson HE, Hastings SN, Smith VA. Patient-Reported Social and Behavioral Determinants of Health and Estimated Risk of Hospitalization in High-Risk Veterans Affairs Patients. JAMA Netw Open 2020; 3:e2021457. [PMID: 33079198 PMCID: PMC7576406 DOI: 10.1001/jamanetworkopen.2020.21457] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
IMPORTANCE Despite recognition of the association between individual social and behavioral determinants of health (SDH) and patient outcomes, little is known regarding the value of SDH in explaining variation in outcomes for high-risk patients. OBJECTIVE To describe SDH factors among veterans who are at high risk for hospitalization, and to determine whether adding patient-reported SDH measures to electronic health record (EHR) measures improves estimation of 90-day and 180-day all-cause hospital admission. DESIGN, SETTING, AND PARTICIPANTS A survey was mailed between April 16 and June 29, 2018, to a nationally representative sample of 10 000 Veterans Affairs (VA) patients whose 1-year risk of hospitalization or death was in the 75th percentile or higher based on a VA EHR-derived risk score. The survey included multiple SDH measures, such as resilience, social support, health literacy, smoking status, transportation barriers, and recent life stressors. MAIN OUTCOMES AND MEASURES The EHR-based characteristics of survey respondents and nonrespondents were compared using standardized differences. Estimation of 90-day and 180-day hospital admission risk was assessed for 3 logistic regression models: (1) a base model of all prespecified EHR-based covariates, (2) a restricted model of EHR-based covariates chosen via forward selection based on minimizing Akaike information criterion (AIC), and (3) a model of EHR- and survey-based covariates chosen via forward selection based on AIC minimization. RESULTS In total, 4685 individuals (response rate 46.9%) responded to the survey. Respondents were comparable to nonrespondents in most characteristics, but survey respondents were older (eg, >80 years old, 881 [18.8%] vs 800 [15.1%]), comprised a higher percentage of men (4391 [93.7%] vs 4794 [90.2%]), and were composed of more White non-Hispanic individuals (3366 [71.8%] vs 3259 [61.3%]). Based on AIC, the regression model with survey-based covariates and EHR-based covariates better estimated hospital admission at 90 days (AIC, 1947.7) and 180 days (AIC, 2951.9) than restricted models with only EHR-based covariates (AIC, 1980.2 at 90 days; AIC, 2981.9 at 180 days). This result was due to inclusion of self-reported measures such as marital or partner status, health-related locus of control, resilience, smoking status, health literacy, and medication insecurity. CONCLUSIONS AND RELEVANCE Augmenting EHR data with patient-reported social information improved estimation of 90-day and 180-day hospitalization risk, highlighting specific SDH factors that might identify individuals who are at high risk for hospitalization.
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Affiliation(s)
- Donna M. Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Matthew L. Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Janet M. Grubber
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Hollis J. Weidenbacher
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Dan V. Blalock
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Leah L. Zullig
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Heather E. Whitson
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Center for the Study of Human Aging and Development, Duke University, Durham, North Carolina
| | - Susan N. Hastings
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Center for the Study of Human Aging and Development, Duke University, Durham, North Carolina
| | - Valerie A. Smith
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
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Bahraini N, Brenner LA, Barry C, Hostetter T, Keusch J, Post EP, Kessler C, Smith C, Matarazzo BB. Assessment of Rates of Suicide Risk Screening and Prevalence of Positive Screening Results Among US Veterans After Implementation of the Veterans Affairs Suicide Risk Identification Strategy. JAMA Netw Open 2020; 3:e2022531. [PMID: 33084900 PMCID: PMC7578771 DOI: 10.1001/jamanetworkopen.2020.22531] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
IMPORTANCE In 2018, the Veterans Health Administration (VHA) implemented the Veterans Affairs (VA) Suicide Risk Identification Strategy to improve the identification and management of suicide risk among veterans receiving VHA care. OBJECTIVES To examine the prevalence of positive suicide screening results among veterans in ambulatory care and emergency departments (EDs) or urgent care clinics (UCCs) and to compare acuity of suicide risk among patients screened in these settings. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from the VA's Corporate Data Warehouse (CDW) to assess veterans with at least 1 ambulatory care visit (n = 4 101 685) or ED or UCC visit (n = 1 044 056) at 140 VHA medical centers from October 1, 2018, through September 30, 2019. EXPOSURES Standardized suicide risk screening and evaluation tools. MAIN OUTCOMES AND MEASURES One-year rate of suicide risk screening and evaluation, prevalence of positive primary and secondary suicide risk screening results, and levels of acute and chronic risk based on the VHA's Comprehensive Suicide Risk Evaluation. RESULTS A total of 4 101 685 veterans in ambulatory care settings (mean [SD] age, 62.3 [16.4] years; 3 771 379 [91.9%] male; 2 996 974 [73.1%] White) and 1 044 056 veterans in ED or UCC settings (mean [SD] age, 59.2 [16.2] years; 932 319 [89.3%] male; 688 559 [66.0%] White) received the primary suicide screening. The prevalence of positive suicide screening results was 3.5% for primary screening and 0.4% for secondary screening in ambulatory care and 3.6% for primary screening and 2.1% in secondary screening for ED and UCC settings. Compared with veterans screened in ambulatory care, those screened in the ED or UCC were more likely to endorse suicidal ideation with intent (odds ratio [OR], 4.55; 95% CI, 4.37-4.74; P < .001), specific plan (OR, 3.16; 95% CI, 3.04-3.29; P < .001), and recent suicidal behavior (OR, 1.95; 95% CI, 1.87-2.03; P < .001) during secondary screening. Among the patients who received a Comprehensive Suicide Risk Evaluation, those in ED or UCC settings were more likely than those in ambulatory care settings to be at high acute risk (34.1% vs 8.5%; P < .001). CONCLUSIONS AND RELEVANCE In this cross-sectional study, population-based suicide risk screening and evaluation in VHA ambulatory care and ED or UCC settings may help identify risk among patients who may not be receiving mental health treatment. Higher acuity of risk among veterans in ED or UCC settings compared with those in ambulatory care settings highlights the importance of scaling up implementation of brief evidence-based interventions in the ED or UCC to reduce suicidal behavior.
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Affiliation(s)
- Nazanin Bahraini
- Rocky Mountain Mental Illness Research, Education and Clinical Center, Rocky Mountain Regional Veterans Affairs (VA) Medical Center, Aurora, Colorado
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz School of Medicine, Aurora
| | - Lisa A. Brenner
- Rocky Mountain Mental Illness Research, Education and Clinical Center, Rocky Mountain Regional Veterans Affairs (VA) Medical Center, Aurora, Colorado
- Department of Neurology, University of Colorado Anschutz School of Medicine, Aurora
| | - Catherine Barry
- Veterans Health Administration (VHA) Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, Palo Alto, California
| | - Trisha Hostetter
- Rocky Mountain Mental Illness Research, Education and Clinical Center, Rocky Mountain Regional Veterans Affairs (VA) Medical Center, Aurora, Colorado
| | - Janelle Keusch
- VHA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Edward P. Post
- Ann Arbor VA Health Care System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Chad Kessler
- Durham VA Health Care System, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Cliff Smith
- VHA Office of Mental Health and Suicide Prevention, Washington DC
| | - Bridget B. Matarazzo
- Rocky Mountain Mental Illness Research, Education and Clinical Center, Rocky Mountain Regional Veterans Affairs (VA) Medical Center, Aurora, Colorado
- Department of Psychiatry, University of Colorado Anschutz School of Medicine, Aurora
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Horvat Davey C, Dolansky MA, Singh MK, Aron DC. The interprofessional VA quality scholars program: Promoting predoctoral nursing scientists and their career trajectories. Nurs Outlook 2020; 69:221-227. [PMID: 32981670 DOI: 10.1016/j.outlook.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/27/2020] [Accepted: 08/17/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The VA Quality Scholars (VAQS) program is an interprofessional fellowship that provides a unique opportunity for predoctoral nurse scientists to embed their work in quality improvement learning "laboratories" to inform their scholarship, science, and research. PURPOSE To describe the VAQS program in relation to promoting nursing science and predoctoral nurse scientist (PhD) career trajectories, and to propose policy implications. METHOD Data were collected on all predoctoral (PhD, DNP) nurses who entered and completed the VAQS program nationally. FINDINGS A total of 17 predoctoral nurses (11 PhD and 6 DNP) have completed the VAQS program. Ten predoctoral PhD nurses (91%) completed their degree while in the program. Nine predoctoral PhD nurses (82%) entered a postdoctoral fellowship, and many obtained positions as faculty at research-intensive universities postfellowship. DISCUSSION The knowledge, skills, and experiences gained by predoctoral nurse scientists from the VAQS's program contribute to their nursing research and professional career growth.
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Affiliation(s)
- Christine Horvat Davey
- VA Quality Scholar, Cleveland, OH; Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH.
| | - Mary A Dolansky
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH; Senior Faculty Scholar, VA Quality Scholars Program, Cleveland, OH
| | - Mamta K Singh
- Senior Faculty Scholar, VA Quality Scholars Program, Cleveland, OH; School of Medicine, Case Western Reserve University, Cleveland, OH
| | - David C Aron
- Senior Faculty Scholar, VA Quality Scholars Program, Cleveland, OH; School of Medicine, Case Western Reserve University, Cleveland, OH
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Purcell N, Becker WC, Zamora KA, McGrath SL, Hagedorn HJ, Fabian ER, McCamish N, Seal KH. Tailored to Fit: How an Implementation Framework Can Support Pragmatic Pain Care Trial Adaptation for Diverse Veterans Affairs Clinical Settings. Med Care 2020; 58 Suppl 2 9S:S80-S87. [PMID: 32826776 PMCID: PMC7444583 DOI: 10.1097/mlr.0000000000001376] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Veterans Affairs (VA) has rolled out a holistic, multicomponent Whole Health care model nationwide, yet no pragmatic trials have been conducted in real-world clinical settings to compare its effectiveness against other evidence-based approaches for chronic pain management in veterans. OBJECTIVES We describe the adaptation of the first large pragmatic randomized controlled trial of the Whole Health model for chronic pain care for diverse VA clinical settings. RESEARCH DESIGN Informed by the Promoting Action on Research Implementation in Health Systems implementation framework, we conducted qualitative semistructured interviews to obtain feedback on trial design from VA leadership, frontline clinicians, and veterans with chronic pain at 5 VA enrollment sites. Next, we convened in-person evidence-based quality improvement (EBQI) meetings with study stakeholders (including frontline clinicians and administrators) at each site to discuss study design; review interview themes; and identify site-specific barriers, facilitators, and approaches to implementation. Ethnographic observations from EBQI meetings provided additional insight into implementation strategies. SUBJECTS Seventy-four veteran and VA staff stakeholders were interviewed; 71 stakeholders participated in EBQI meetings. RESULTS At each site, unique clinical contexts and varying resources for Whole Health and pain care delivery affected plans for trial implementation. We present examples of local adaptations that emerged through the formative evaluation process to facilitate implementation and yield a more pragmatic trial design. CONCLUSIONS A systematic formative evaluation can facilitate engagement and buy-in of study stakeholders. Locally tailored pragmatic implementation strategies may improve the likelihood of successful trial execution as well as future implementation of evidence-based pain care approaches in real-world clinical settings.
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Affiliation(s)
- Natalie Purcell
- San Francisco VA Health Care System (San Francisco, CA)
- University of California, San Francisco (San Francisco, CA)
| | - William C. Becker
- VA Connecticut Healthcare System (West Haven, CT)
- Yale School of Medicine (New Haven, CT)
| | - Kara A. Zamora
- San Francisco VA Health Care System (San Francisco, CA)
- University of California, San Francisco (San Francisco, CA)
| | | | - Hildi J. Hagedorn
- Minneapolis VA Health Care System (Minneapolis, MN)
- University of Minneapolis (Minneapolis, MN)
| | - Eva R. Fabian
- San Francisco VA Health Care System (San Francisco, CA)
| | | | - Karen H. Seal
- San Francisco VA Health Care System (San Francisco, CA)
- University of California, San Francisco (San Francisco, CA)
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Adler JL. A Time of Scandal: Charles R. Forbes, Warren G. Harding, and the Making of the Veterans Bureau, by Rosemary Stevens. Nurs Hist Rev 2020; 28:209-211. [PMID: 31537734 DOI: 10.1891/1062-8061.28.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jessica L Adler
- Assistant Professor of History and Health Policy & Management, Florida International University
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Zeliadt SB, Thomas ER, Olson J, Coggeshall S, Giannitrapani K, Ackland PE, Reddy KP, Federman DG, Drake DF, Kligler B, Taylor SL. Patient Feedback on the Effectiveness of Auricular Acupuncture on Pain in Routine Clinical Care: The Experience of 11,406 Veterans. Med Care 2020; 58 Suppl 2 9S:S101-S107. [PMID: 32826779 PMCID: PMC7497594 DOI: 10.1097/mlr.0000000000001368] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Veterans Health Administration (VHA) launched a national initiative to train providers in a specific, protocolized auricular acupuncture treatment (also called Battlefield Acupuncture or BFA) as a nonpharmacological approach to pain management. This evaluation assessed the real-world effectiveness of BFA on immediate pain relief and identified subgroups of patients for whom BFA is most effective. RESEARCH DESIGN In a cross-sectional cohort study, electronic medical record data for 11,406 Veterans treated with BFA at 57 VHA medical centers between October 2016 and September 2018 was analyzed. The multivariate analysis incorporated data on pain history, change in pain level on an 11-point scale, complications, and demographic information. METHODS A total of 11,406 Veterans were treated with BFA at 57 VHA medical centers between October 2016 and September 2018 and had effectiveness data recorded in their electronic medical record. RESULTS More than 3 quarters experienced immediate decreases in pain following administration of BFA, with nearly 60% reported experiencing a minimal clinically important difference in pain intensity. The average decrease in pain intensity was -2.5 points (SD=2.2) at the initial BFA treatment, and -2.2 points (SD=2.0) at subsequent treatments. BFA was effective across a wide range of Veterans with many having preexisting chronic pain, or physical, or psychological comorbid conditions. Veterans with opioid use in the year before BFA experienced less improvement, with pain intensity scores improving more among Veterans who had not recently used opioids. CONCLUSION VHA's rapid expansion of training providers to offer BFA as a nonpharmacological approach to pain management has benefited many Veterans.
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Affiliation(s)
- Steven B. Zeliadt
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA
| | - Eva R. Thomas
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
| | - Juli Olson
- VA Central Iowa Health Care System, Des Moines, IA
| | - Scott Coggeshall
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
| | - Karleen Giannitrapani
- Center for Innovation to Implementation, Palo Alto VA Health Care System, Palo Alto, CA
| | - Princess E. Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Kavitha P. Reddy
- John Cochran Veterans Hospital, VA St. Louis Health Care System
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO
| | - Daniel G. Federman
- VA Connecticut Health Care System
- Yale University School of Medicine, New Haven, CT
| | - David F. Drake
- Department of Physical Medicine and Rehabilitation, Hunter Holmes McGuire VA Medical Center, Richmond, VA
- Integrative Health Coordinating Center, Veterans Health Administration, Washington, DC
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA
| | - Benjamin Kligler
- Integrative Health Coordinating Center, Veterans Health Administration, Washington, DC
- Office of Patient-Centered Care and Cultural Transformation, Veterans Health Administration, Washington, DC
| | - Stephanie L. Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, Greater Los Angeles VA Health Care System
- Department of Health Policy and Management, UCLA School of Public Health, Los Angeles, CA
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Wyse JJ, Ono SS, Kabat M, True G. Supporting family caregivers of Veterans: Participant perceptions of a federally-mandated caregiver support program. Healthc (Amst) 2020; 8:100441. [PMID: 32919580 PMCID: PMC8054832 DOI: 10.1016/j.hjdsi.2020.100441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/23/2020] [Accepted: 05/26/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To understand patients' and caregivers' experiences with and perceptions of a federally-mandated program within the Department of Veterans Affairs (VA) that provides educational and monetary support to family caregivers of post-9/11 Veterans. METHODS Twenty-six Veterans and their family caregivers were recruited to participate in individual and dyadic interviews. Interviews lasted between 60 and 90 min and took place between August 2016 and July 2018 in Oregon and Louisiana. Interviews were recorded, transcribed and coded by multiple team members. Recurrent themes and categories were identified through close examination of coded text and comparison within and across transcripts. RESULTS Three main themes emerged in the data: 1) appreciation of the caregiver program for validating and compensating family caregiver work; 2) perception that some caregiving activities are less visible, and thus go unrecognized and uncompensated; 3) concern about loss of benefits. CONCLUSIONS Implications and policy recommendations for programs to support family caregivers, both within the VA and in the context of the broader national movement to support family caregivers, are discussed.
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Affiliation(s)
- Jessica J Wyse
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, USA; Oregon Health & Science University-Portland State University School of Public Health, USA.
| | - Sarah S Ono
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, USA; Department of Family Medicine, Oregon Health & Science University, USA
| | - Margaret Kabat
- Atlas Research, Former National Director, Caregiver Support Program, US Department of Veterans Affairs, USA
| | - Gala True
- South Central Mental Illness Research, Education, and Clinical Center, Southeast Louisiana Veterans Health Care System, USA; Section of Population and Community Medicine, LSU School of Medicine, USA
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Bravata DM, Myers LJ, Perkins AJ, Zhang Y, Miech EJ, Rattray NA, Penney LS, Levine D, Sico JJ, Cheng EM, Damush TM. Assessment of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) Program for Improving Quality of Care for Transient Ischemic Attack: A Nonrandomized Cluster Trial. JAMA Netw Open 2020; 3:e2015920. [PMID: 32897372 PMCID: PMC7489850 DOI: 10.1001/jamanetworkopen.2020.15920] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Patients with transient ischemic attack (TIA) are at high risk of recurrent vascular events. Timely management can reduce that risk by 70%; however, gaps in TIA quality of care exist. OBJECTIVE To assess the performance of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) intervention to improve TIA quality of care. DESIGN, SETTING, AND PARTICIPANTS This nonrandomized cluster trial with matched controls evaluated a multicomponent intervention to improve TIA quality of care at 6 diverse medical centers in 6 geographically diverse states in the US and assessed change over time in quality of care among 36 matched control sites (6 control sites matched to each PREVENT site on TIA patient volume, facility complexity, and quality of care). The study period (defined as the data period) started on August 21, 2015, and extended to May 12, 2019, including 1-year baseline and active implementation periods for each site. The intervention targeted clinical teams caring for patients with TIA. INTERVENTION The quality improvement (QI) intervention included the following 5 components: clinical programs, data feedback, professional education, electronic health record tools, and QI support. MAIN OUTCOMES AND MEASURES The primary outcome was the without-fail rate, which was calculated as the proportion of veterans with TIA at a specific facility who received all 7 guideline-recommended processes of care for which they were eligible (ie, anticoagulation for atrial fibrillation, antithrombotic use, brain imaging, carotid artery imaging, high- or moderate-potency statin therapy, hypertension control, and neurological consultation). Generalized mixed-effects models with multilevel hierarchical random effects were constructed to evaluate the intervention associations with the change in the mean without-fail rate from the 1-year baseline period to the 1-year intervention period. RESULTS Six facilities implemented the PREVENT QI intervention, and 36 facilities were identified as matched control sites. The mean (SD) age of patients at baseline was 69.85 (11.19) years at PREVENT sites and 71.66 (11.29) years at matched control sites. Most patients were male (95.1% [154 of 162] at PREVENT sites and 94.6% [920 of 973] at matched control sites at baseline). Among the PREVENT sites, the mean without-fail rate improved substantially from 36.7% (58 of 158 patients) at baseline to 54.0% (95 of 176 patients) during a 1-year implementation period (adjusted odds ratio, 2.10; 95% CI, 1.27-3.48; P = .004). Comparing the change in quality at the PREVENT sites with the matched control sites, the improvement in the mean without-fail rate was greater at the PREVENT sites than at the matched control sites (36.7% [58 of 158 patients] to 54.0% [95 of 176 patients] [17.3% absolute improvement] vs 38.6% [345 of 893 patients] to 41.8% [363 of 869 patients] [3.2% absolute improvement], respectively; absolute difference, 14%; P = .008). CONCLUSIONS AND RELEVANCE The implementation of this multifaceted program was associated with improved TIA quality of care across the participating sites. The PREVENT QI program is an example of a health care system using QI strategies to improve performance, and may serve as a model for other health systems seeking to provide better care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02769338.
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Affiliation(s)
- Dawn M. Bravata
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
- Department of Neurology, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Laura J. Myers
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Anthony J. Perkins
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Ying Zhang
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- now with Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha
| | - Edward J. Miech
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Nicholas A. Rattray
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Lauren S. Penney
- South Texas Veterans Health Care System, San Antonio
- Department of Medicine, University of Texas Health, San Antonio
| | - Deborah Levine
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor
| | - Jason J. Sico
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven
- VA Neurology Service, VA Connecticut Healthcare System, West Haven
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Neurology and Center for Neuroepidemiology and Clinical Neurological Research, Yale University School of Medicine, New Haven, Connecticut
| | - Eric M. Cheng
- Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles
| | - Teresa M. Damush
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
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Bhalla IP, Stefanovics EA, Rosenheck RA. Social determinants of mental health care systems: intensive community based Care in the Veterans Health Administration. BMC Public Health 2020; 20:1311. [PMID: 32859202 PMCID: PMC7456068 DOI: 10.1186/s12889-020-09402-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/18/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Since deinstitutionalization in the 1950s-1970s, public mental health care has changed its focus from asylums to general hospitals, outpatient clinics and specialized community-based programs addressing both clinical and social determinants of mental health. Analysis of the place of community-based programs within a comprehensive health system such as the Veterans Health Administration (VHA) may illuminate the role of social forces in shaping contemporary public mental health systems. METHODS National VHA administrative data were used to compare veterans who exclusively received outpatient clinic care to those receiving four types of specialized community-based services, addressing: 1) functional disabilities from severe mental illness (SMI), 2) justice system involvement, 3) homelessness, and 4) vocational rehabilitation. Bivariate comparisons and multinomial logistic regression analyses compared groups on demographics, diagnoses, service use, and psychiatric prescription fills. RESULTS An hierarchical classification of 1,386,487 Veterans who received specialty mental health services from VHA in Fiscal Year 2012, showed 1,134,977 (81.8%) were seen exclusively in outpatient clinics; 27,931 (2.0%) received intensive SMI-related services; 42,985 (3.1%) criminal justice services; 160,273 (11.6%) specialized homelessness services; and 20,921 (1.5%) vocational services. Compared to those seen only in clinics, veterans in the four community treatment groups were more likely to be black, diagnosed with HIV and hepatitis, had more numerous substance use diagnoses and made far more extensive use of mental health outpatient and inpatient care. CONCLUSIONS Almost one-fifth of VHA mental health patients receive community-based services prominently addressing major social determinants of health and multimorbid substance use disorders.
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Affiliation(s)
- Ish P Bhalla
- Yale University Department of Psychiatry, 950 Campbell Ave, Building 35, West Haven, CT, 06516, USA.
- University of California, Los Angeles National Clinician Scholars Program, 1100 Glendon Ave, Suite 900, Los Angeles, CA, 90024, USA.
| | - Elina A Stefanovics
- Yale University Department of Psychiatry, 950 Campbell Ave, Building 35, West Haven, CT, 06516, USA
- Veterans Affairs New England Mental Illness Research Education, and Clinical Center, West Haven, USA
| | - Robert A Rosenheck
- Yale University Department of Psychiatry, 950 Campbell Ave, Building 35, West Haven, CT, 06516, USA
- Veterans Affairs New England Mental Illness Research Education, and Clinical Center, West Haven, USA
- Yale University School of Public Health, 950 Campbell Ave, Building 35, West Haven, CT, 06516, USA
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Smigelsky MA, Nieuwsma JA, Meador K, Vega RJ, Henderson B, Jackson GL. Dynamic Diffusion Network: Advancing moral injury care and suicide prevention using an innovative model. Healthc (Amst) 2020; 8:100440. [PMID: 32919579 PMCID: PMC7405892 DOI: 10.1016/j.hjdsi.2020.100440] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/24/2020] [Accepted: 05/23/2020] [Indexed: 11/19/2022]
Abstract
Healthcare providers across a wide variety of settings face a common challenge: the need to provide real time care for complex problems that are not adequately addressed by existing protocols. In response to these intervention gaps, frontline providers may utilize existing evidence to develop new approaches that are tailored to specific problems. It is imperative that such approaches undergo some form of evaluation, ensuring quality control while permitting ongoing adaptation and refinement. “Dynamic diffusion” is an innovative approach to intervention improvement and dissemination whereby care practices are delivered and continuously evaluated under real-world conditions as part of a structured network experience. This “dynamic diffusion network” (DDN) promotes cross-pollination of ideas and shared learning to generate relatively rapid improvements in care. The pilot Mental Health and Chaplaincy DDN was developed to advance suicide prevention efforts and moral injury care practices being conducted by 13 chaplain-mental health professional teams across the Veterans Health Administration. Lessons learned from the pilot DDN include the importance of the following: geographic and cultural diversity among innovation collaborators to ensure the broadest possible relevance of solutions; leadership support to facilitate engagement of frontline providers in quality improvement efforts; and participation in a community of practice to motivate providers and offer opportunities for direct collaboration and cross-pollination of ideas.
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Affiliation(s)
- Melissa A Smigelsky
- Mental Health and Chaplaincy, Department of Veterans Affairs, Durham, NC, USA; Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA.
| | - Jason A Nieuwsma
- Mental Health and Chaplaincy, Department of Veterans Affairs, Durham, NC, USA; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Keith Meador
- Mental Health and Chaplaincy, Department of Veterans Affairs, Durham, NC, USA; Departments of Psychiatry and Health Policy, Center for Biomedical Ethics and Society, Vanderbilt Divinity School, Vanderbilt University, Nashville, TN, USA
| | - Ryan J Vega
- VHA Innovation Ecosystem/Diffusion of Excellence, Department of Veterans Affairs, Washington, DC, USA
| | - Blake Henderson
- VHA Innovation Ecosystem/Diffusion of Excellence, Department of Veterans Affairs, Washington, DC, USA
| | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA; Department of Population Health Sciences and Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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Rogal SS, Chinman M, Gellad WF, Mor MK, Zhang H, McCarthy SA, Mauro GT, Hale JA, Lewis ET, Oliva EM, Trafton JA, Yakovchenko V, Gordon AJ, Hausmann LRM. Tracking implementation strategies in the randomized rollout of a Veterans Affairs national opioid risk management initiative. Implement Sci 2020; 15:48. [PMID: 32576214 PMCID: PMC7313133 DOI: 10.1186/s13012-020-01005-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/29/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In 2018, the Department of Veterans Affairs (VA) issued Notice 2018-08 requiring facilities to complete "case reviews" for Veterans identified in the Stratification Tool for Opioid Risk Mitigation (STORM) dashboard as high risk for adverse outcomes among patients prescribed opioids. Half of the facilities were randomly assigned to a Notice version including additional oversight. We evaluated implementation strategies used, whether strategies differed by randomization arm, and which strategies were associated with case review completion rates. METHODS Facility points of contact completed a survey assessing their facility's use of 68 implementation strategies based on the Expert Recommendations for Implementing Change taxonomy. We collected respondent demographic information, facility-level characteristics, and case review completion rates (percentage of high-risk patients who received a case review). We used Kruskal-Wallis tests and negative binomial regression to assess strategy use and factors associated with case reviews. RESULTS Contacts at 89 of 140 facilities completed the survey (64%) and reported using a median of 23 (IQR 16-31) strategies. The median case review completion rate was 71% (IQR 48-95%). Neither the number or types of strategies nor completion rates differed by randomization arm. The most common strategies were using the STORM dashboard (97%), working with local opinion leaders (80%), and recruiting local partners (80%). Characteristics associated with case review completion rates included respondents being ≤ 35 years old (incidence rate ratio, IRR 1.35, 95% CI 1.09-1.67) and having < 5 years in their primary role (IRR 1.23; 95% CI 1.01-1.51), and facilities having more prior academic detailing around pain and opioid safety (IRR 1.40, 95% CI 1.12-1.75). Controlling for these characteristics, implementation strategies associated with higher completion rates included (1) monitoring and adjusting practices (adjusted IRR (AIRR) 1.40, 95% CI 1.11-1.77), (2) identifying adaptations while maintaining core components (AIRR 1.28, 95% CI 1.03-1.60), (3) conducting initial training (AIRR 1.16, 95% CI 1.02-1.50), and (4) regularly sharing lessons learned (AIRR 1.32, 95% CI 1.09-1.59). CONCLUSIONS In this national evaluation of strategies used to implement case reviews of patients at high risk of opioid-related adverse events, point of contact age and tenure in the current role, prior pain-related academic detailing at the facility, and four specific implementation strategies were associated with case review completion rates, while randomization to additional centralized oversight was not. TRIAL REGISTRATION This project is registered at the ISRCTN Registry with number ISRCTN16012111. The trial was first registered on May 3, 2017.
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Affiliation(s)
- Shari S Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Matthew Chinman
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Veterans Integrated Service Network 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- RAND Corporation, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Hongwei Zhang
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Sharon A McCarthy
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Veterans Integrated Service Network 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Genna T Mauro
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jennifer A Hale
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Eleanor T Lewis
- VA Office of Mental Health and Suicide Prevention, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- VA Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Elizabeth M Oliva
- VA Office of Mental Health and Suicide Prevention, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- VA Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Jodie A Trafton
- VA Office of Mental Health and Suicide Prevention, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- VA Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Vera Yakovchenko
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy, University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Finley EP, Schneegans S, Curtis ME, Bebarta VS, Maddry JK, Penney L, McGeary D, Potter JS. Confronting challenges to opioid risk mitigation in the U.S. health system: Recommendations from a panel of national experts. PLoS One 2020; 15:e0234425. [PMID: 32542028 PMCID: PMC7295233 DOI: 10.1371/journal.pone.0234425] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 05/26/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Amid the ongoing U.S. opioid crisis, achieving safe and effective chronic pain management while reducing opioid-related morbidity and mortality is likely to require multi-level efforts across health systems, including the Military Health System (MHS), Department of Veterans Affairs (VA), and civilian sectors. OBJECTIVE We conducted a series of qualitative panel discussions with national experts to identify core challenges and elicit recommendations toward improving the safety of opioid prescribing in the U.S. DESIGN We invited national experts to participate in qualitative panel discussions regarding challenges in opioid risk mitigation and how best to support providers in delivery of safe and effective opioid prescribing across MHS, VA, and civilian health systems. PARTICIPANTS Eighteen experts representing primary care, emergency medicine, psychology, pharmacy, and public health/policy participated. APPROACH Six qualitative panel discussions were conducted via teleconference with experts. Transcripts were coded using team-based qualitative content analysis to identify key challenges and recommendations in opioid risk mitigation. KEY RESULTS Panelists provided insight into challenges across multiple levels of the U.S. health system, including the technical complexity of treating chronic pain, the fraught national climate around opioids, the need to integrate surveillance data across a fragmented U.S. health system, a lack of access to non-pharmacological options for chronic pain care, and difficulties in provider and patient communication. Participating experts identified recommendations for multi-level change efforts spanning policy, research, education, and the organization of healthcare delivery. CONCLUSIONS Reducing opioid risk while ensuring safe and effective pain management, according to participating experts, is likely to require multi-level efforts spanning military, veteran, and civilian health systems. Efforts to implement risk mitigation strategies at the patient level should be accompanied by efforts to increase education for patients and providers, increase access to non-pharmacological pain care, and support use of existing clinical decision support, including state-level prescription drug monitoring programs.
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Affiliation(s)
- Erin P. Finley
- UT Health San Antonio, San Antonio, Texas, United States of America
- South Texas Veterans Health Care System, San Antonio, Texas, United States of America
| | - Suyen Schneegans
- UT Health San Antonio, San Antonio, Texas, United States of America
| | - Megan E. Curtis
- UT Health San Antonio, San Antonio, Texas, United States of America
| | - Vikhyat S. Bebarta
- University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Joseph K. Maddry
- Emergency Department, Brooke Army Medical Center, San Antonio, Texas, United States of America
- 59th Medical Wing Science and Technology Cell, San Antonio, Texas, United States of America
- San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas, United States of America
| | - Lauren Penney
- UT Health San Antonio, San Antonio, Texas, United States of America
- South Texas Veterans Health Care System, San Antonio, Texas, United States of America
| | - Don McGeary
- UT Health San Antonio, San Antonio, Texas, United States of America
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Molling D, Vincent BM, Wiitala WL, Escobar GJ, Hofer TP, Liu VX, Rosen AK, Ryan AM, Seelye S, Prescott HC. Developing a template matching algorithm for benchmarking hospital performance in a diverse, integrated healthcare system. Medicine (Baltimore) 2020; 99:e20385. [PMID: 32541458 PMCID: PMC7302661 DOI: 10.1097/md.0000000000020385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Template matching is a proposed approach for hospital benchmarking, which measures performance based on matching a subset of comparable patient hospitalizations from each hospital. We assessed the ability to create the required matched samples and thus the feasibility of template matching to benchmark hospital performance in a diverse healthcare system.Nationwide Veterans Affairs (VA) hospitals, 2017.Observational cohort study.We used administrative and clinical data from 668,592 hospitalizations at 134 VA hospitals in 2017. A standardized template of 300 hospitalizations was selected, and then 300 hospitalizations were matched to the template from each hospital.There was substantial case-mix variation across VA hospitals, which persisted after excluding small hospitals, hospitals with primarily psychiatric admissions, and hospitalizations for rare diagnoses. Median age ranged from 57 to 75 years across hospitals; percent surgical admissions ranged from 0.0% to 21.0%; percent of admissions through the emergency department, 0.1% to 98.7%; and percent Hispanic patients, 0.2% to 93.3%. Characteristics for which there was substantial variation across hospitals could not be balanced with any matching algorithm tested. Although most other variables could be balanced, we were unable to identify a matching algorithm that balanced more than ∼20 variables simultaneously.We were unable to identify a template matching approach that could balance hospitals on all measured characteristics potentially important to benchmarking. Given the magnitude of case-mix variation across VA hospitals, a single template is likely not feasible for general hospital benchmarking.
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Affiliation(s)
- Daniel Molling
- VA Center for Clinical Management Research, Ann Arbor, MI
| | | | | | - Gabriel J. Escobar
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Timothy P. Hofer
- VA Center for Clinical Management Research, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Amy K. Rosen
- VA Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
| | - Andrew M. Ryan
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Sarah Seelye
- VA Center for Clinical Management Research, Ann Arbor, MI
| | - Hallie C. Prescott
- VA Center for Clinical Management Research, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan
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Waljee AK, Ryan KA, Krenz CD, Ioannou GN, Beste LA, Tincopa MA, Saini SD, Su GL, Arasim ME, Roman PT, Nallamothu BK, De Vries R. Eliciting patient views on the allocation of limited healthcare resources: a deliberation on hepatitis C treatment in the Veterans Health Administration. BMC Health Serv Res 2020; 20:369. [PMID: 32357873 PMCID: PMC7193376 DOI: 10.1186/s12913-020-05211-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 04/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In response to the development of highly effective but expensive new medications, policymakers, payors, and health systems are considering novel and pragmatic ways to provide these medications to patients. One approach is to target these treatments to those most likely to benefit. However, to maximize the fairness of these policies, and the acceptance of their implementation, the values and beliefs of patients should be considered. The provision of treatments for chronic hepatitis C (CHC) in the resource-constrained context of the Veterans Health Administration (VHA) offered a real-world example of this situation, providing the opportunity to test the value of using Democratic Deliberation (DD) methods to solicit the informed opinions of laypeople on this complex issue. METHODS We recruited Veterans (n = 30) from the VHA to attend a DD session. Following educational presentations from content experts, participants engaged in facilitated small group discussions to: 1) identify strategies to overcome CHC treatment barriers and 2) evaluate, vote on, and modify/improve two CHC treatment policies - "first come, first served" (FCFS) and "sickest first" (SF). We used transcripts and facilitators' notes to identify key themes from the small group discussions. Additionally, participants completed pre- and post-DD surveys. RESULTS Most participants endorsed the SF policy over the FCFS policy, emphasizing the ethical and medical appropriateness of treating the sickest first. Concerns about SF centered on the difficulty of implementation (e.g., how is "sickest" determined?) and unfairness to other Veterans. Proposed modifications focused on: 1) the need to consider additional health factors, 2) taking behavior and lifestyle into account, 3) offering education and support, 4) improving access, and 5) facilitating better decision-making. CONCLUSIONS DD offered a robust and useful method for addressing the allocation of the scarce resource of CHC treatment. Participants were able to develop a modified version of the SF policy and offered diverse recommendations to promote fairness and improve quality of care for Veterans. DD is an effective approach for incorporating patient preferences and gaining valuable insights for critical healthcare policy decisions in resource-limited environments.
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Affiliation(s)
- Akbar K. Waljee
- VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI 48105 USA
- Michigan Medicine, Department of Internal Medicine, Division of Gastroenterology and Hepatology, 3912 Taubman Center, 1500 East Medical Center Drive, SPC 5362, Ann Arbor, MI 48109-5362 USA
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), 2800 Plymouth Road, North Campus Research Complex (NCRC), Building 16, Ann Arbor, MI 48109-2800 USA
| | - Kerry A. Ryan
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Bldg. 14, G016, Ann Arbor, MI 48109-2800 USA
| | - Chris D. Krenz
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Bldg. 14, G016, Ann Arbor, MI 48109-2800 USA
| | - George N. Ioannou
- Veterans Affairs Puget Sound Healthcare System, 1660 South Columbian Way, Seattle, WA 98108 USA
- Division of Gastroenterology, Department of Medicine, University of Washington, 1959 NE Pacific St., Box 356424, Seattle, WA 98195-6424 USA
| | - Lauren A. Beste
- Division of Gastroenterology, Department of Medicine, University of Washington, 1959 NE Pacific St., Box 356424, Seattle, WA 98195-6424 USA
- Division of General Internal Medicine, University of Washington, Harborview Medical Center, 325 Ninth Ave, Box 359780, Seattle, WA 98104 USA
| | - Monica A. Tincopa
- Michigan Medicine, Department of Internal Medicine, Division of Gastroenterology and Hepatology, 3912 Taubman Center, 1500 East Medical Center Drive, SPC 5362, Ann Arbor, MI 48109-5362 USA
| | - Sameer D. Saini
- VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI 48105 USA
- Michigan Medicine, Department of Internal Medicine, Division of Gastroenterology and Hepatology, 3912 Taubman Center, 1500 East Medical Center Drive, SPC 5362, Ann Arbor, MI 48109-5362 USA
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), 2800 Plymouth Road, North Campus Research Complex (NCRC), Building 16, Ann Arbor, MI 48109-2800 USA
| | - Grace L. Su
- VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI 48105 USA
- Michigan Medicine, Department of Internal Medicine, Division of Gastroenterology and Hepatology, 3912 Taubman Center, 1500 East Medical Center Drive, SPC 5362, Ann Arbor, MI 48109-5362 USA
| | - Maria E. Arasim
- VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI 48105 USA
| | - Patti T. Roman
- VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI 48105 USA
| | - Brahmajee K. Nallamothu
- VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI 48105 USA
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), 2800 Plymouth Road, North Campus Research Complex (NCRC), Building 16, Ann Arbor, MI 48109-2800 USA
- Michigan Medicine, Department of Internal Medicine, Division of Cardiovascular Medicine, 1500 East Medical Center Drive, SPC 5856, Ann Arbor, MI 48109-5362 USA
| | - Raymond De Vries
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Bldg. 14, G016, Ann Arbor, MI 48109-2800 USA
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Dayoub EJ, Medvedeva EL, Khatana SAM, Nathan AS, Epstein AJ, Groeneveld PW. Federal Payments for Coronary Revascularization Procedures Among Dual Enrollees in Medicare Advantage and the Veterans Affairs Health Care System. JAMA Netw Open 2020; 3:e201451. [PMID: 32250432 PMCID: PMC7136831 DOI: 10.1001/jamanetworkopen.2020.1451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE More than 1 million US veterans are dually enrolled in a Medicare Advantage (MA) plan and in the Veterans Affairs (VA) health care system. The federal government prepays private MA plans to cover veterans; if a dually enrolled veteran receives an MA-covered service at the VA, the government is making 2 payments for the same service. It is not clear what proportion of veterans dually enrolled in VA and MA are undergoing coronary revascularization at VA vs non-VA hospitals. OBJECTIVE To describe where veterans who are enrolled in both VA and MA undergo coronary revascularization and the associated costs. DESIGN, SETTINGS, AND PARTICIPANTS This is a cohort study consisting of US veterans dually enrolled in VA and MA from January 1, 2010, to December 31, 2013, who had at least 1 VA encounter and underwent coronary revascularization during the study period. Data were analyzed from April 2019 to September 2019. MAIN OUTCOMES AND MEASURES Number of coronary artery bypass graft (CABG) operations and percutaneous coronary interventions (PCIs) performed through the VA and through MA during years 2010 to 2013, and the associated VA costs of coronary revascularization. In addition, multivariable logistic regression was performed to assess patient factors associated with receiving care through the VA. RESULTS A total of 18 874 VA users with concurrent MA enrollment who underwent coronary revascularization during 2010 to 2013 were identified (mean [SD] age, 75.3 [8.8] years; 18 739 men [99.0%]). Enrollees were predominantly white (17 457 patients [92.0%]). Among patients, 4115 (22.0%) underwent either CABG or PCI through the VA only, 14 281 (75.0%) did so through MA only, and 478 (2.5%) underwent coronary revascularization procedures through both payers. From 2010 to 2013, these veterans underwent 4764 coronary revascularization procedures (721 CABGs and 3043 PCIs) that cost the VA $214.7 million ($115.8 million for CABGs and $99.0 million for PCIs). In multivariable analysis, nonwhite patients were more likely than white patients to undergo coronary revascularization through the VA (odds ratio, 1.73; 95% CI, 1.52-1.96; P < .001), and for each year of age, veterans were less likely to undergo coronary revascularization through the VA (odds ratio, 0.95; 95% CI, 0.94-0.95; P < .001). There was no statistically significant association between undergoing coronary vascularization through the VA and distance in miles to the nearest VA hospital (odds ratio, 1.00; 95% CI, 0.99-1.00; P = .30). CONCLUSIONS AND RELEVANCE A substantial share of VA users concurrently enrolled in an MA plan underwent coronary revascularization procedures through the VA, incurring significant duplicative federal health care spending. Given the financial pressures facing both Medicare and the VA, government officials should consider policy solutions to mitigate redundant spending.
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Affiliation(s)
- Elias J. Dayoub
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Elena L. Medvedeva
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Sameed Ahmed M. Khatana
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Ashwin S. Nathan
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Andrew J. Epstein
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Peter W. Groeneveld
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Brunner J, Rose DE, Chuang E, Canelo I, Yano EM. The role of healthcare system hassles in delaying or forgoing care. Healthc (Amst) 2020; 8:100411. [PMID: 32127306 DOI: 10.1016/j.hjdsi.2020.100411] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 12/04/2019] [Accepted: 02/04/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Several factors besides appointment availability can influence access to care. Among these factors are the diverse challenges that patients may experience in navigating the healthcare system. However, the relationship between these challenges or "hassles" and delaying or forgoing care has not been assessed. METHODS We examined the relationship between healthcare system hassles and delaying or forgoing needed care. We used data from a 2016 Veterans Affairs (VA) survey of women veterans (N = 821) who were active users of primary care (3+ primary care visits in the past year) at any of 12 VA medical centers. The main independent variable was a measure of 16 healthcare system hassles, encompassing a wide range of clinically-relevant aspects of patient experience, such as uncertainty about when/how to take a medication or difficulty getting questions answered between appointments. The outcome was a self-reported measure of delaying or forgoing needed care. We used logistic regression to estimate this outcome as a function of hassles, adjusting for age, comorbidities, and health care utilization. Survey weights accounted for within-site clustering, nonproportional sampling, and nonresponse. RESULTS Overall, 26% of participants reported 0 hassles, and 39% reported 4 or more. Reporting 4 or more hassles (vs. 0) was associated with a roughly 5-fold increase in the predicted probability of delaying or forgoing care. CONCLUSION Addressing healthcare system hassles could yield unexpected benefits to realized access.
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Affiliation(s)
- Julian Brunner
- HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Health Care System, 16111 Plummer St, Sepulveda, CA, 91343, Building 25, USA.
| | - Danielle E Rose
- HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Health Care System, 16111 Plummer St, Sepulveda, CA, 91343, Building 25, USA.
| | - Emmeline Chuang
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, 650 Charles Young Dr. S, 31-269 CHS Box 951772, Los Angeles, CA, 90095, USA.
| | - Ismelda Canelo
- HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Health Care System, 16111 Plummer St, Sepulveda, CA, 91343, Building 25, USA.
| | - Elizabeth M Yano
- HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Health Care System, 16111 Plummer St, Sepulveda, CA, 91343, Building 25, USA; Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, 650 Charles Young Dr. S, 31-269 CHS Box 951772, Los Angeles, CA, 90095, USA.
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Wyte-Lake T, Claver M, Johnson-Koenke R, Davis D, Dobalian A. Hurricanes Harvey, Irma, and Maria: Exploring the Role of Home-Based Care Programs. Disaster Med Public Health Prep 2020; 14:119-124. [PMID: 32014082 PMCID: PMC7064407 DOI: 10.1017/dmp.2019.158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The aim of this study is to determine the response of home-based primary care programs to the fall 2017 Atlantic hurricane season. METHODS This study examines the experiences of 9 Veterans Health Administration (VHA) Home-Based Primary Care (HBPC) programs in their responses to Hurricanes Harvey, Irma, and Maria. Thirty-four phone interviews with HBPC leadership and staff were conducted from April to July 2018. RESULTS The total census of impacted HBPC programs was 3118. No program reported loss of life due to these hurricanes. Early preparedness was key to an effective program response. Response included prompt tracking of the patients. In the most affected areas, respondents noted limited resources to support basic patient needs. CONCLUSIONS Medically complex patients served by programs such as the VHA's HBPC program represent a subset of the population, yet they have an outsized impact on health care resources that could be exacerbated by inadequate disaster preparedness. HBPC programs serve a unique role in supporting the "older old." They are tasked with supporting disaster preparedness activities of patients. Understanding what is involved in actualizing their requirements shows communities how to effectively engage with these programs.
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Affiliation(s)
- Tamar Wyte-Lake
- Veterans Emergency Management Evaluation Center (VEMEC), U.S. Department of Veterans Affairs, North Hills, CA
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Maria Claver
- Gerontology Program, California State University, Long Beach, CA
| | - Rachel Johnson-Koenke
- Denver-Seattle Center of Innovation, Rocky Mountain Regional VA Medical Center, U.S. Department of Veterans Affairs
| | - Darlene Davis
- Geriatrics and Extended Care, Home and Community Based Care, U.S. Department of Veterans Affairs (VA)
| | - Aram Dobalian
- Veterans Emergency Management Evaluation Center (VEMEC), U.S. Department of Veterans Affairs, North Hills, CA
- Division of Health Systems Management and Policy, University of Memphis School of Public Health, Memphis, TN
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Abstract
BACKGROUND Although breastfeeding is a major public health priority and provides numerous benefits, women veterans encounter many barriers to initiating and sustaining breastfeeding. Women veterans are a growing population with unique health care needs related to exposures and injuries experienced during military service. These military experiences are linked to health diagnoses known to impact postpartum health behaviors, such as breastfeeding. RESEARCH AIM The aim of this study was to identify factors associated with breastfeeding at 4 weeks postpartum among women veterans. METHODS We used 2016-to-2018 survey data from women veterans (N = 420), interviewed before and after delivery, who were enrolled in maternity care coordination at a national sample of Veterans Health Administration facilities. Using the social ecological model, logistic regression was employed to explore the relationship between breastfeeding at least 4 weeks and postpartum and maternal/infant characteristics, interpersonal dynamics, community influences, and system factors. RESULTS The rate of breastfeeding at 4 weeks postpartum was 78.6% among this sample of veterans. Self-employed participants were 2.8 times more likely to breastfeed than those who were employed outside the home. Participants who had been deployed at any point in their military career were twice as likely to breastfeed compared with those who never deployed. In this study sample, race independently predicted lower rates of breastfeeding, with African American participants being 48% less likely to breastfeed as compared with white participants. CONCLUSION Our analysis suggests significant racial disparities in breastfeeding within veteran populations utilizing Veterans Health Administration, despite access to multiple sources of support from both the Veterans Health Administration and the community.
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Affiliation(s)
- Shimrit Keddem
- University of Pennsylvania, Philadelphia, PA, USA
- Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | | | | | - Marilyn M Schapira
- University of Pennsylvania, Philadelphia, PA, USA
- Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Kristin M Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
- University of Massachusetts, Worcester, MA, USA
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Abraham TH, Deen TL, Hamilton M, True G, O'Neil MT, Blanchard J, Uddo M. Analyzing free-text survey responses: An accessible strategy for developing patient-centered programs and program evaluation. Eval Program Plann 2020; 78:101733. [PMID: 31675509 DOI: 10.1016/j.evalprogplan.2019.101733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/11/2019] [Accepted: 10/17/2019] [Indexed: 06/10/2023]
Abstract
Despite widespread availability of yoga in the Veterans Health Administration (VA), it remains unclear how to best evaluate yoga programs. This is particularly problematic for programs aimed at veterans with mental health concerns, as evaluation typically focuses narrowly upon mental health symptom severity, even though program participants may have other health-related priorities. We analyzed responses to free-text questions on 237 surveys completed by veterans with mental health concerns enrolled in a yoga program at six VA clinics in Louisiana to characterize veteran participants' experiences with yoga. Qualitative analysis resulted in 15 domains reflecting veterans' individual health-related values and priorities. We use results to illustrate the potential for analysis of free-text responses to reveal valuable insights into patient experiences, demonstrating how these data can inform patient-centered program evaluation. The approach we present is more accessible to those responsible for decision-making about local programs than conventional methods of analyzing qualitive evaluation data.
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Affiliation(s)
- Traci H Abraham
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, 2200 Fort Roots Drive, Building 58, North Little Rock, AR 72114-1706, United States; Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, United States; VA South Central Mental Illness Research, Education and Clinical Center, 2200 Fort Roots Drive, Building 58, North Little Rock, AR 72114-1706, United States.
| | - Tisha L Deen
- Central Arkansas Veterans Healthcare System, Eugene J. Towbin Healthcare Center, 2200 Fort Roots Drive, North Little Rock, AR 72114-1706, United States
| | - Michelle Hamilton
- Southeast Louisiana Veterans Health Care System, 2400 Canal Street, New Orleans, LA 70119, United States
| | - Gala True
- South Central Mental Illness Research, Education and Clinical Center, Southeast Louisiana Veterans Health Care System, 2400 Canal Street, New Orleans, LA 70119, United States; Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, United States
| | | | | | - Madeline Uddo
- South Central Mental Illness Research, Education and Clinical Center, Southeast Louisiana Veterans Health Care System, 2400 Canal Street, New Orleans, LA 70119, United States
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Gundlapalli AV, Redd AM, Suo Y, Pettey WBP, Brignone E, Chin DL, Walker LE, Poltavskiy EA, Janak JC, Howard JT, Sosnov JA, Stewart IJ. Predicting and Planning for Musculoskeletal Service-Connected Disabilities in VA Using Disability for Active Duty OEF/OIF Military Service Members. Mil Med 2020; 185:413-419. [PMID: 32074349 PMCID: PMC10416188 DOI: 10.1093/milmed/usz223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Musculoskeletal (MSK) conditions are commonly seen among military service members (SM) and Veterans. We explored correlates of award of MSK-related service-connected disability benefits (SCDB) among SM seeking care in Veterans Affairs (VA) hospitals. MATERIALS AND METHODS Department of Defense data on SM who separated from October 1, 2001 to May 2017 were linked to VA administrative data. Using adjusted logistic regression models, we determined the odds of receiving MSK SCDB. RESULTS A total of 1,558,449 (79% of separating SM) had at least one encounter in VA during the study period (7.8% disability separations). Overall, 51% of this cohort had at least one MSK SCDB (88% among disability separations, 48% among normal). Those with disability separations (as compared to normal separations) were significantly more likely to receive MSK SCDB (odds ratio 2.37) as were females (compared to males, odds ratio 1.15). CONCLUSIONS Although active duty SM with disability separations were more likely to receive MSK-related service-connected disability ratings in the VA, those with normal separations also received such awards. Identifying those at highest risk for MSK-related disability could lead to improved surveillance and prevention strategies in the Department of Defense and VA health care systems to prevent further damage and disability.
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Affiliation(s)
- Adi V Gundlapalli
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS 2.0) Center, VA Salt Lake City Health Care System, 500 Foothill Dr, Salt Lake City, UT 84148
- Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132
| | - Andrew M Redd
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS 2.0) Center, VA Salt Lake City Health Care System, 500 Foothill Dr, Salt Lake City, UT 84148
- Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132
| | - Ying Suo
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS 2.0) Center, VA Salt Lake City Health Care System, 500 Foothill Dr, Salt Lake City, UT 84148
- Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132
| | - Warren B P Pettey
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS 2.0) Center, VA Salt Lake City Health Care System, 500 Foothill Dr, Salt Lake City, UT 84148
- Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132
| | - Emily Brignone
- VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA 15240
| | - David L Chin
- Department of Health Promotion and Policy, School of Public Health, University of Massachusetts Amherst, 715 N Pleasant St., Amherst, MA 01003
| | - Lauren E Walker
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis AFB, CA 94535
| | - Eduard A Poltavskiy
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis AFB, CA 94535
| | - Jud C Janak
- Department of Defense Joint Trauma System, Defense Health Agency, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX 78234
| | - Jeffrey T Howard
- Department of Kinesiology, Health and Nutrition, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249
| | - Jonathan A Sosnov
- 375th Medical Group, 375 MDG, Scott AFB, IL 62225
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814
| | - Ian J Stewart
- Clinical Investigation Facility, David Grant USAF Medical Center, 101 Bodin Circle, Travis AFB, CA 94535
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814
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Abstract
The Veterans Health Administration (VHA) led implementation of the Clinical Nurse Leader (CNL) role nationally with the goal to meet system needs for strong clinical leadership across all settings. After a decade of CNL role implementation, the VHA supported this evaluation to determine the current state, the successes, the challenges, and the fidelity to the original intent of the role. The team used mixed methods to evaluate the state of the CNL initiative. Ten evaluation activities were undertaken including a facility survey directed toward chief nurse executives at all VHA facilities, and a second survey directed at registered nurses who completed a CNL graduate program, were certified as a CNL, or were currently enrolled in a CNL graduate program. The evaluation results suggest the CNL initiative had not yet accomplished the stated goals to improve cost and financial outcomes, increase patient satisfaction, increase staff satisfaction and retention, improve quality and internal processes, and facilitate practice model transformation including evidence-based practice and collaborative, interdisciplinary practice across the system. Observed CNL practices within the VHA could serve as exemplars for developing a care delivery model that could achieve these goals and offer potential paths to move this role forward.
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Affiliation(s)
- Rebecca S Miltner
- University of Alabama at Birmingham School of Nursing, Birmingham (Drs Miltner and Patrician); WJB Dorn VA Medical Center, Columbia, South Carolina (Dr Haddock); and Central Texas Veterans Health Care System, Temple (Dr Williams)
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Hebert CA, Trudeau SA, Sprinkle W, Moo LR, McConnell ES. Directed content analysis of Veterans Affairs policy documents: A strategy to guide implementation of a dementia home safety toolkit for Veterans to promote ageing in place. Health Soc Care Community 2020; 28:182-194. [PMID: 31523881 DOI: 10.1111/hsc.12852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 08/17/2019] [Accepted: 08/22/2019] [Indexed: 06/10/2023]
Abstract
Older adults' preference to age in place, coupled with an increasing prevalence of dementia, creates an imperative to address home safety risks that occur due to cognitive impairment. Providing caregivers with home safety items and education can facilitate ageing in place for older adults living with dementia. In 2015-2017, we examined barriers and facilitators within 17 policy documents and dementia guidelines of the United States (US) Veterans Health Administration pertinent to implementation of a home safety toolkit (HST) for Veterans living with dementia. The documents were issued from 2000 to 2015. Directed qualitative content analysis of these documents guided by themes from stakeholder interviews revealed two key implementation barriers: a focus on physical rather than cognitive risks when determining medical necessity for home equipment, and a focus on rehabilitation and treatment rather than prevention. Mandates for person-centred care planning, including comprehensive assessment, interdisciplinary collaboration, staff education and a focus on population health in primary care facilitate HST implementation. Content analysis can identify policy-level barriers that slow innovation and facilitators that can increase access to care that support ageing in place.
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Affiliation(s)
| | - Scott A Trudeau
- American Occupational Therapy Association, Inc., Bethesda, Maryland
- NE Geriatric Research Education and Clinical Center, Bedford, Massachusetts
- Department of Occupational Therapy, Tufts University, Medford, Massachusetts
| | | | - Lauren R Moo
- New England GRECC, ENRM VAMC, Bedford, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Eleanor S McConnell
- Durham VA Geriatric Research, Education and Clinical Center (GRECC), Durham, North Carolina
- Duke University School of Nursing, Durham, North Carolina
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Dunn SH, Rogal SS, Maier MM, Chartier M, Morgan TR, Beste LA. Access to Comprehensive Services for Advanced Liver Disease in the Veterans Health Administration. Dig Dis Sci 2019; 64:3471-3479. [PMID: 31432344 DOI: 10.1007/s10620-019-05785-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 08/07/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND The Veterans Health Administration (VHA) provides care to the one of the largest cohorts of patients with advanced liver disease (ALD) in the USA. AIMS We performed a national survey to assess system-wide strengths and barriers to care for Veterans with ALD in this national integrated healthcare setting. METHODS A 52-item survey was developed to assess access and barriers to care in Veterans with ALD. The survey was distributed to all VHA medical centers in 2015. Results were analyzed using descriptive statistics. RESULTS One hundred and fifty-three sites responded to this survey. Multidisciplinary services were available on-site at > 80% of sites. Ninety-five percent of sites had mental health and addictions treatment available, with 14% co-locating these services within the liver clinic. Few sites (< 25%) provided pharmacologic treatment for alcohol use disorder in primary care or hepatology settings. Seventy-two percent of sites reported at least one barrier to liver-related care. Of the sites reporting at least one barrier, 53% reported barriers to liver transplant referral, citing complex processes and lack of staff/resources to coordinate referrals. Palliative care was widely available, but 61% of sites reported referring < 25% of their patients with ALD for palliative services. CONCLUSION Multidisciplinary services for Veterans with ALD are widely available at VHA sites, though barriers to optimal care remain. Opportunities for improvement include the expansion of providers with hepatology expertise, integrating pharmacotherapy for alcohol use disorder into hepatology and primary care, streamlining the transplant referral process, and expanding palliative care referrals for patients with ALD.
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Affiliation(s)
- S Hunter Dunn
- Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA.
| | - Shari S Rogal
- Departments of Surgery and Medicine, VA Pittsburgh Healthcare System, 1 University Drive, Pittsburgh, PA, 15240, USA
| | - Marissa M Maier
- Division of Infectious Diseases, VA Portland Health Care System, 3710 SW US Veterans Hospital Road, Portland, OR, 97239, USA
| | - Maggie Chartier
- HIV, Hepatitis, and Related Conditions Programs Office of Specialty Care Services, U.S. Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC, 20571, USA
| | - Timothy R Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, 5901 E. Seventh Street, Long Beach, CA, 90822, USA
| | - Lauren A Beste
- General Medicine Service, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA, 98108, USA
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