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Imperiale TF, Myers LJ, Barker BC, Stump TE, Daggy JK. Colon Age: A Metric for Whether and How to Screen Male Veterans for Early-Onset Colorectal Cancer. Cancer Prev Res (Phila) 2024:745416. [PMID: 38758606 DOI: 10.1158/1940-6207.capr-23-0544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/27/2024] [Accepted: 05/15/2024] [Indexed: 05/19/2024]
Abstract
We aimed to develop a metric for estimating risk for early-onset colorectal cancer (EOCRC) to help decide whether and how to screen persons < age 50. We used risk prediction models derived and validated on male Veterans to calculate the relative risks (RRs) for 6 scenarios: one low-risk scenario (no risk factors present), four intermediate risk scenarios (some factors present), and one high-risk scenario (all factors present) for three age groups (35-39, 40-44, and 45-49 years). For each scenario, we estimated absolute CRC risk using SEER CRC incidence rates and each scenario's RR. We identified the current SEER 5-year age group to which the revised estimate was closest and refer to the midpoint of this group as the "colon age". When the revised estimate was ≥ that for 50-54-year-olds and for 70-74-year-olds, respective recommendations were made for (any) CRC screening and screening with colonoscopy. Among the scenarios, there was inconsistency between the two models for the 35-39 and 40-44 age groups, with only the 15-variable model recommending screening for the higher-risk 35-to-39-year-olds. Both models recommended screening for some intermediate risk and high-risk 40-44-year-olds. The models were well-aligned on whether and how to screen most 45-49-year-olds. Using risk factors for EOCRC with CRC incidence rates, "colon age" may be useful for shared decision making about whether and how to screen male Veterans < 50 years. For 45-49-year-olds, the 7-variable model may be preferred by patients, providers, and health systems.
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Affiliation(s)
- Thomas F Imperiale
- Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Laura J Myers
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, United States
| | - Barry C Barker
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, United States
| | - Timothy E Stump
- Indiana University-Indianapolis, Indianapolis, IN, United States
| | - Joanne K Daggy
- Indiana University - Purdue University Indianapolis, Indianapolis, IN, United States
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Seigel CR, Martin H, Bastin G, Myers LJ, Taylor S, Pike F, Wilkinson J, Williams LS. Patient acceptance of teleneurology across neurologic conditions. J Neurol 2024; 271:2850-2858. [PMID: 38388928 PMCID: PMC11055742 DOI: 10.1007/s00415-024-12200-y] [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] [Received: 10/09/2023] [Revised: 01/08/2024] [Accepted: 01/16/2024] [Indexed: 02/24/2024]
Abstract
INTRODUCTION Patient acceptability with outpatient teleneurology has been reported within specific conditions, but less is known about acceptability across neurologic conditions. The study objective was to compare the acceptability of teleneurology between patients with various neurological conditions and determine what other factors influence acceptability. METHODS This was a prospective study of Veterans who completed new outpatient teleneurology visits with the Department of Veterans Affairs National Teleneurology Program. Visits were conducted via video to home or video to the outpatient clinic. Patient acceptability was assessed via telephone interview two weeks post-visit. Acceptability was a summed score (3-21) of three 7-point Likert questions (higher = more acceptable). Clinical diagnosis categories were based on the neurologists' ICD10 diagnosis code. Acceptability score was modeled using a censored Tobit model controlling for demographics, type of tele-visit, medical comorbidity, and ICD10 category. RESULTS In FY 2021, 277 of 637 (43.5%) patients completed an interview with analyzable acceptability data. Of these 277, 70 (25.3%) had codes indicating headache, 46 (16.6%) movement disorder, 45 (16.2%) general symptoms, and 116 (41.9%) for all other categories. Mean patient acceptability was 18.3 (SD 3.2). There was no significant difference in scores between these groups. The only factor independently related to acceptability was medical comorbidity, with higher comorbidity associated with higher acceptability scores. DISCUSSION Patients find their outpatient teleneurology experience highly acceptable independent of neurologic condition. Those with more comorbidity report higher acceptability. Use of teleneurology may be useful and acceptable across many outpatient neurologic conditions including for more medically complex patients.
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Affiliation(s)
| | - Holly Martin
- Richard L. Roudebush VAMC HSR&D EXTEND QUERI, Indianapolis, IN, USA
- Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Grace Bastin
- Richard L. Roudebush VAMC HSR&D EXTEND QUERI, Indianapolis, IN, USA
| | - Laura J Myers
- Indiana University School of Medicine, Indianapolis, IN, USA
- Richard L. Roudebush VAMC HSR&D EXTEND QUERI, Indianapolis, IN, USA
- Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Stan Taylor
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Francis Pike
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jayne Wilkinson
- Corporal Michael J Crescenz VAMC, Philadelphia, PA, USA
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Linda S Williams
- Richard L. Roudebush VAMC HSR&D EXTEND QUERI, Indianapolis, IN, USA
- Regenstrief Institute, Inc., Indianapolis, IN, USA
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
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Schubert CC, Penney LS, Schwartzkopf AL, Damush TM, Preddie A, Flemming S, Myers J, Myers LJ, Perkins AJ, Zhang Y, Bravata DM. Expanding Access to Comprehensive Geriatric Evaluation via Telehealth: Development of Hybrid-Virtual Home Visits. J Gen Intern Med 2024; 39:36-43. [PMID: 38227169 PMCID: PMC10937878 DOI: 10.1007/s11606-023-08460-5] [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: 04/18/2023] [Accepted: 10/06/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND In response to the aging population, the Department of Veterans Affairs (VA) seeks to expand access to evidence-based practices which support community-dwelling older persons such as the Geriatric Resources for Assessment and Care of Elders (GRACE) program. GRACE is a multidisciplinary care model which provides home-based geriatric evaluation and management for older Veterans residing within a 20-mile drive radius from the hospital. We sought to expand the geographic reach of VA-GRACE by developing a hybrid-virtual home visit (TeleGRACE). OBJECTIVES The objectives were to: (1) describe challenges encountered and solutions implemented during the iterative, pre-implementation program development process; and (2) illustrate potential successes of the program with two case examples. DESIGN Quality improvement project with longitudinal qualitative data collection. PROGRAM DESCRIPTION The hybrid-virtual home visit involved a telehealth technician travelling to patients' homes and connecting virtually to VA-GRACE team members who participated remotely. APPROACH & PARTICIPANTS We collected multiple data streams throughout program development: TeleGRACE staff periodic reflections, fieldnotes, and team meeting notes; and VA-GRACE team member interviews. KEY RESULTS The five program domains that required attention and problem-solving were: telehealth connectivity and equipment, virtual physical examination, protocols and procedures, staff training, and team integration. For each domain, we describe several challenges and solutions. An example from the virtual physical examination domain: several iterations were required to identify the combination of telehealth stethoscope with dedicated headphones that allowed remote nurse practitioners to hear heart and lung sounds. The two cases illustrate how this hybrid-virtual home visit model provided care for patients who would not otherwise have received timely healthcare services. CONCLUSIONS These results provide a blueprint to translate an in-person home-based geriatrics program into a hybrid-virtual model and support the feasibility of using hybrid-virtual home visits to expand access to comprehensive geriatric evaluation and ongoing care for high-risk, community-dwelling older persons who reside geographically distant from the primary VA facility.
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Affiliation(s)
- Cathy C Schubert
- Geriatrics and Community Service, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lauren S Penney
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Ashley L Schwartzkopf
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Teresa M Damush
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - Alaina Preddie
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Soyna Flemming
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Jennifer Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Laura J Myers
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Anthony J Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ying Zhang
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dawn M Bravata
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA.
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.
- Regenstrief Institute, Indianapolis, IN, USA.
- Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis, IN, USA.
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Matthias MS, Daggy JK, Perkins AJ, Adams J, Bair MJ, Burgess DJ, Eliacin J, Flores P, Myers LJ, Menen T, Procento P, Rand KL, Salyers MP, Shanahan ML, Hirsh AT. Communication and activation in pain to enhance relationships and treat pain with equity (COOPERATE): a randomized clinical trial. Pain 2024; 165:365-375. [PMID: 37733487 DOI: 10.1097/j.pain.0000000000003021] [Citation(s) in RCA: 1] [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] [Received: 03/24/2023] [Accepted: 05/23/2023] [Indexed: 09/23/2023]
Abstract
ABSTRACT Racialized disparities in chronic pain care are well-documented and persist despite national priorities focused on health equity. Similar disparities have been observed in patient activation (ie, having the knowledge, confidence, and skills to manage one's health). As such, interventions targeting patient activation represent a novel approach to addressing and reducing disparities in pain care. Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity is a randomized controlled trial of a 6-session telephone-delivered intervention to increase patient activation for Black patients with chronic pain. Two hundred fifty Black patients from a Midwestern Veterans Affairs medical center were randomized to the intervention or attention control. The primary outcome was patient activation; secondary outcomes included communication self-efficacy, pain, and psychological functioning. Outcomes were assessed at baseline and at 3 (primary endpoint), 6, and 9 months (sustained effects). Analyses used an intent-to-treat approach. Compared with baseline, patient activation increased 4.6 points at 3 months (versus +0.13 in control group, 95% CI: 0.48, 7.34; P = 0.03). These improvements in the intervention group were sustained, with +7 from baseline at 6 months and +5.77 at 9 months, and remained statistically significant from the control group. Communication self-efficacy increased significantly relative to the control group from baseline to 3 months. Pain intensity and interference improved at 3 months, but differences were not significant after adjusting for multiple comparisons. Most other secondary outcomes improved, but group differences were not statistically significant after controlling for multiple comparisons. Results suggest that increasing patient activation is a potentially fruitful path toward improving pain management and achieving health equity.
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Affiliation(s)
- Marianne S Matthias
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
- Regenstrief Institute, Indianapolis, IN, United States
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Joanne K Daggy
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Anthony J Perkins
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Jasma Adams
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
| | - Matthew J Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
- Regenstrief Institute, Indianapolis, IN, United States
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Diana J Burgess
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Center for Care Delivery and Outcomes Research, Veterans Affairs Medical Center, Minneapolis, MN, United States
| | - Johanne Eliacin
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
- Regenstrief Institute, Indianapolis, IN, United States
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, United States
| | - Perla Flores
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
| | - Laura J Myers
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
- Regenstrief Institute, Indianapolis, IN, United States
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Tetla Menen
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
| | - Philip Procento
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States
| | - Kevin L Rand
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States
| | - Michelle P Salyers
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States
| | - Mackenzie L Shanahan
- VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States
| | - Adam T Hirsh
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States
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Preddie AK, Donnelly CE, Miech EJ, Myers LJ, Williams LS, Damush TM. Coming back for more: factors linked to higher participation among Veterans with chronic pain in an innovative VA-YMCA wellness clinic. BMJ Open Qual 2024; 13:e002523. [PMID: 38286565 PMCID: PMC10826581 DOI: 10.1136/bmjoq-2023-002523] [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] [Received: 07/29/2023] [Accepted: 01/02/2024] [Indexed: 01/31/2024] Open
Abstract
In 2019, the Indianapolis VA developed a Wellness Clinic in partnership with the Young Men's Christian Associations (YMCA) to comprehensively address Veterans' chronic pain. Our specific aims were twofold: (1) to evaluate the implementation of the Veterans Health Indiana (VHI) Wellness Clinic on patient utilisation and (2) to evaluate patient functioning.We conducted a mixed-methods evaluation, which included the extraction of VA administrative data to identify a patient cohort; the conduct of chart review to extract clinic utilisation, clinical outcomes collected during pain-related healthcare services and comorbidities; and semistructured interviews with Veteran patients who used the VHI Wellness Clinic in different patterns to identify challenges and facilitators to clinic utilisation. We applied configurational analysis to a Veteran sample who had their first visit to the VHI Wellness Clinic in March/April 2019 to pinpoint difference-making factors linked to Veterans' successful participation.The cohort included 312 Veterans (83% male), mean age of 55.4 years. The configurational model included six factors: participation in physical therapy, pain psychology or pain education sessions (22%); presence of any 'no-shows' (57% had 0); history of depression (39%) and clinic referral source (51% self-referred from primary care). The model consisted of four different pathways to successful participation, explaining 60% of cases in the higher-participation group with 86% consistency. Patient outcomes after clinic utilisation demonstrated a significant reduction in self-reported pain and pain catastrophising across time. Moreover, patients reported distance to clinic as both a facilitator and challenge.This mixed-methods analysis identified specific biopsychosocial factors and clinical services directly linked to higher Veteran participation in a new VA-YMCA Wellness Clinic. The VHI Wellness Clinic embedded within a YMCA facility is a feasible and efficacious healthcare delivery model for primary care patients experiencing chronic pain. Additional marketing to clinical providers for referrals and to patients to extend its reach is needed.
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Affiliation(s)
- Alaina K Preddie
- VA Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- Center for Health Information and Communication (CHIC), Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Indianapolis, Indiana, USA
| | - Claire E Donnelly
- VA Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- Health Services Research, Regenstrief Institute Inc, Indianapolis, Indiana, USA
| | - Edward J Miech
- VA Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- Center for Health Information and Communication (CHIC), Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Indianapolis, Indiana, USA
- Health Services Research, Regenstrief Institute Inc, Indianapolis, Indiana, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Laura J Myers
- VA Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- Center for Health Information and Communication (CHIC), Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Indianapolis, Indiana, USA
- Health Services Research, Regenstrief Institute Inc, Indianapolis, Indiana, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Linda S Williams
- VA Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- Center for Health Information and Communication (CHIC), Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Indianapolis, Indiana, USA
- Health Services Research, Regenstrief Institute Inc, Indianapolis, Indiana, USA
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Teresa M Damush
- VA Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- Center for Health Information and Communication (CHIC), Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Indianapolis, Indiana, USA
- Health Services Research, Regenstrief Institute Inc, Indianapolis, Indiana, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Sico JJ, Hu X, Myers LJ, Levine D, Bravata DM, Arling GW. Real-world analysis of two ischaemic stroke and TIA systolic blood pressure goals on 12-month mortality and recurrent vascular events. Stroke Vasc Neurol 2024:svn-2023-002759. [PMID: 38191185 DOI: 10.1136/svn-2023-002759] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 12/12/2023] [Indexed: 01/10/2024] Open
Abstract
INTRODUCTION Whether obtaining the more intensive goal systolic blood pressure (SBP) of <130 mm Hg, rather than a less intensive SBP goal of <140 mm Hg poststroke/transient ischaemic attack (TIA) is associated with incremental mortality and recurrent vascular event benefit is largely unexplored using real-world data. Lowering SBP excessively may result in poorer outcomes. METHODS This is a retrospective cohort study of 26 368 Veterans presenting to a Veterans Administration Medical Center (VAMC) with a stroke/TIA between October 2015 and July 2018. Patients were excluded from the study if they had missing or extreme BP values, receiving dialysis or palliative care, left against medical advice had a cancer diagnosis, were cared for in a VAMC enrolled in a stroke/TIA quality improvement initiative, died or had a cerebrovascular or cardiovascular event within 90 days after their index stroke/TIA. The analytical sample included 12 337 patients. Average SBP during 90 days after discharge was assessed in categories (≤105 mm Hg, 106-115 mm Hg, 116-130 mm Hg, 131-140 mm Hg and >140 mm Hg). Separate multivariable Cox proportional hazard regressions were used to examine the relationship between average SBP groups and time to: (1) mortality and (2) any recurrent vascular event, from 90 days to up to 365 days after discharge from the index emergency department visit or inpatient admission. RESULTS Compared with those with SBP>140 mm Hg, patients with SBP between 116 and 130 mm Hg had a significantly lower risk of recurrent stroke/TIA (HR 0.77, 95% CI 0.60 to 0.99) but not cardiovascular events. Patients with SBP lower than 105 mm Hg, compared with those with >140 mm Hg demonstrated a statistically significant higher risk of death (HR 2.07, 95% CI 1.43 to 3.00), but no statistical differences were found in other SBP groups. DISCUSSION Data support a more intensive SBP goal to prevent recurrent cerebrovascular events among stroke/TIA patients by 90 days poststroke/TIA compared with less intensive goal. Very low SBPs were associated with increased mortality risk.
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Affiliation(s)
- Jason J Sico
- Internal Medicine and Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Neurology, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Xin Hu
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Laura J Myers
- VA Health Services Research and Development (HSR&D) Center for Healthcare Informatics and Communication and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Deborah Levine
- Departments of Medicine and Neurology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Dawn M Bravata
- Health Services Research and Development (HSR&D) Center for Healthcare Informatics and Communication and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI); Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Greg W Arling
- Department of Veterans Affairs (VA), Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- Department of Nursing, Purdue University, West Lafayette, Indiana, USA
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Matthias MS, Myers LJ, Coffing JM, Carter JL, Daggy JK, Slaven JE, Bair MJ, Bravata DM, McGuire AB. Patterns of Opioid Prescriptions in the Veterans Health Administration for Patients With Chronic Low-Back Pain After the Onset of the COVID-19 Pandemic: A Retrospective Cohort Analysis. J Pain 2023:104445. [PMID: 38072219 DOI: 10.1016/j.jpain.2023.12.002] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/14/2023] [Accepted: 12/05/2023] [Indexed: 12/25/2023]
Abstract
The COVID-19 pandemic led to severe disruptions in health care and a relaxation of rules surrounding opioid prescribing-changes which led to concerns about increased reliance on opioids for chronic pain and a resurgence of opioid-related harms. Although some studies found that opioid prescriptions increased in the first 6 months of the pandemic, we know little about the longer-term effects of the pandemic on opioid prescriptions. Further, despite the prevalence of pain in veterans, we know little about patterns of opioid prescriptions in the Veterans Health Administration (VA) associated with the pandemic. Using a retrospective cohort of VA patients with chronic low-back pain, we examined the proportion of patients with an opioid prescription and mean morphine milligram equivalents over a 3-year period-1 year prior to and 2 years after the pandemic's onset. Analyses revealed that both measures fell during the entire observation period. The largest decrease in the odds of filling an opioid prescription occurred in the first quarter of the pandemic, but this downward trend continued throughout the observation period, albeit at a slower pace. Clinically meaningful differences in opioid prescriptions and dose over time did not emerge based on patient race or rurality; however, differences emerged between female and male veterans, with decreases in opioid prescriptions slowing more markedly for women after the pandemic onset. These findings suggest that the pandemic was not associated with short- or long-term increases in opioid prescriptions or doses in the VA. PERSPECTIVE: This article examines opioid prescribing over a 3-year period-1 year prior to and 2 years after the onset of the COVID-19 pandemic-for VA patients with chronic low-back pain. Results indicate that, despite disruptions to health care, opioid prescriptions and doses decreased over the entire observation period.
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Affiliation(s)
- Marianne S Matthias
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana; Regenstrief Institute, Indianapolis, Indiana; Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Laura J Myers
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
| | - Jessica M Coffing
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
| | - Jessica L Carter
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
| | - Joanne K Daggy
- Department of Biostatistics & Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
| | - James E Slaven
- Department of Biostatistics & Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
| | - Matthew J Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana; Regenstrief Institute, Indianapolis, Indiana; Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Dawn M Bravata
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana; Regenstrief Institute, Indianapolis, Indiana; Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Alan B McGuire
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana; Department of Psychology, Indiana University Purdue University, Indianapolis, Indiana
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Waddell KJ, Myers LJ, Perkins AJ, Sico JJ, Sexson A, Burrone L, Taylor S, Koo B, Daggy JK, Bravata DM. Development and validation of a model predicting mild stroke severity on admission using electronic health record data. J Stroke Cerebrovasc Dis 2023; 32:107255. [PMID: 37473533 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107255] [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: 12/20/2022] [Revised: 07/10/2023] [Accepted: 07/13/2023] [Indexed: 07/22/2023] Open
Abstract
OBJECTIVE Initial stroke severity is a potent modifier of stroke outcomes but this information is difficult to obtain from electronic health record (EHR) data. This limits the ability to risk-adjust for evaluations of stroke care and outcomes at a population level. The purpose of this analysis was to develop and validate a predictive model of initial stroke severity using EHR data elements. METHODS This observational cohort included individuals admitted to a US Department of Veterans Affairs hospital with an ischemic stroke. We extracted 65 independent predictors from the EHR. The primary analysis modeled mild (NIHSS score 0-3) versus moderate/severe stroke (NIHSS score ≥4) using multiple logistic regression. Model validation included: (1) splitting the cohort into derivation (65%) and validation (35%) samples and (2) evaluating how the predicted stroke severity performed in regard to 30-day mortality risk stratification. RESULTS The sample comprised 15,346 individuals with ischemic stroke (n = 10,000 derivation; n = 5,346 validation). The final model included 15 variables and correctly classified 70.4% derivation sample patients and 69.4% validation sample patients. The areas under the curve (AUC) were 0.76 (derivation) and 0.76 (validation). In the validation sample, the model performed similarly to the observed NIHSS in terms of the association with 30-day mortality (AUC: 0.72 observed NIHSS, 0.70 predicted NIHSS). CONCLUSIONS EHR data can be used to construct a surrogate measure of initial stroke severity. Further research is needed to better differentiate moderate and severe strokes, enhance stroke severity classification, and how to incorporate these measures in evaluations of stroke care and outcomes.
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Affiliation(s)
- Kimberly J Waddell
- VA Center for Health Equity Research and Promotion (CHERP), Crescenz VA Medical Center; Philadelphia, PA, USA; Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania; Philadelphia, PA, USA; Leonard Davis Institute for Health Economics, University of Pennsylvania; Philadelphia, PA, USA.
| | - Laura J Myers
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center; Indianapolis, IN, USA; Department of Medicine, Indiana University School of Medicine; Indianapolis, IN, USA; Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA; Regenstrief Institute; Indianapolis, IN, USA
| | - Anthony J Perkins
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center; Indianapolis, IN, USA; Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA; Department of Biostatistics and Health Data Science, Indiana University School of Medicine & Fairbanks School of Public Health, Indianapolis, IN, USA
| | - Jason J Sico
- Neurology Service, VA Connecticut Healthcare System; West Haven, CT, USA; Departments of Neurology and Internal Medicine, Yale School of Medicine; New Haven, CT, USA; Pain Research, Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System; West Haven, CT, USA
| | - Ali Sexson
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center; Indianapolis, IN, USA
| | - Laura Burrone
- Pain Research, Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System; West Haven, CT, USA
| | - Stanley Taylor
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center; Indianapolis, IN, USA; Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
| | - Brian Koo
- Neurology Service, VA Connecticut Healthcare System; West Haven, CT, USA; Departments of Neurology and Internal Medicine, Yale School of Medicine; New Haven, CT, USA; Pain Research, Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System; West Haven, CT, USA
| | - Joanne K Daggy
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center; Indianapolis, IN, USA; Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA; Department of Biostatistics and Health Data Science, Indiana University School of Medicine & Fairbanks School of Public Health, Indianapolis, IN, USA
| | - Dawn M Bravata
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center; Indianapolis, IN, USA; Department of Medicine, Indiana University School of Medicine; Indianapolis, IN, USA; Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA; Department of Neurology, Indiana University School of Medicine; Indianapolis, IN, USA; Regenstrief Institute; Indianapolis, IN, USA
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Imperiale TF, Myers LJ, Barker BC, Larson J, Stump TE, Daggy JK. Risk Factors for Early-onset Sporadic Colorectal Cancer in Male Veterans. Cancer Prev Res (Phila) 2023; 16:513-522. [PMID: 37079701 DOI: 10.1158/1940-6207.capr-22-0506] [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] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/14/2023] [Accepted: 04/19/2023] [Indexed: 04/22/2023]
Abstract
Identifying risk factors for early-onset colorectal cancer (EOCRC) could help reverse its rising incidence through risk factor reduction and/or early screening. We sought to identify EOCRC risk factors that could be used for decisions about early screening. Using electronic databases and medical record review, we compared male veterans ages 35 to 49 years diagnosed with sporadic EOCRC (2008-2015) matched 1:4 to clinic and colonoscopy controls without colorectal cancer, excluding those with established inflammatory bowel disease, high-risk polyposis, and nonpolyposis syndromes, prior bowel resection, and high-risk family history. We ascertained sociodemographic and lifestyle factors, family and personal medical history, physical measures, vital signs, medications, and laboratory values 6 to 18 months prior to case diagnosis. In the derivation cohort (75% of the total sample), univariate and multivariate logistic regression models were used to derive a full model and a more parsimonious model. Both models were tested using a validation cohort. Among 600 cases of sporadic EOCRC [mean (SD) age 45.2 (3.5) years; 66% White], 1,200 primary care clinic controls [43.4 (4.2) years; 68% White], and 1,200 colonoscopy controls [44.7 (3.8) years; 63% White], independent risk factors included age, cohabitation and employment status, body mass index (BMI), comorbidity, colorectal cancer, or other visceral cancer in a first- or second-degree relative (FDR or SDR), alcohol use, exercise, hyperlipidemia, use of statins, NSAIDs, and multivitamins. Validation c-statistics were 0.75-0.76 for the full model and 0.74-0.75 for the parsimonious model, respectively. These independent risk factors for EOCRC may identify veterans for whom colorectal cancer screening prior to age 45 or 50 years should be considered. PREVENTION RELEVANCE Screening 45- to 49-year-olds for colorectal cancer is relatively new with uncertain uptake thus far. Furthermore, half of EOCRC occurs in persons < 45 years old. Using risk factors may help 45- to 49-year-olds accept screening and may identify younger persons for whom earlier screening should be considered. See related Spotlight, p. 479.
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Affiliation(s)
- Thomas F Imperiale
- Center of Innovation, Health Services Research and Development, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Laura J Myers
- Center of Innovation, Health Services Research and Development, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
- Division of General Internal Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Barry C Barker
- Center of Innovation, Health Services Research and Development, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Jason Larson
- Center of Innovation, Health Services Research and Development, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Timothy E Stump
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
| | - Joanne K Daggy
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
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Damush TM, Wilkinson JR, Martin H, Miech EJ, Tang Q, Taylor S, Daggy JK, Bastin G, Islam R, Myers LJ, Penney LS, Narechania A, Schreiber SS, Williams LS. The VA National TeleNeurology Program implementation: a mixed-methods evaluation guided by RE-AIM framework. Front Health Serv 2023; 3:1210197. [PMID: 37693238 PMCID: PMC10484508 DOI: 10.3389/frhs.2023.1210197] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/01/2023] [Indexed: 09/12/2023]
Abstract
Introduction The Veteran Affairs (VA) Office of Rural Health (ORH) funded the Veterans Health Administration (VHA) National TeleNeurology Program (NTNP) as an Enterprise-Wide Initiative (EWI). NTNP is an innovative healthcare delivery model designed to fill the patient access gap for outpatient neurological care especially for Veterans residing in rural communities. The specific aim was to apply the RE-AIM framework in a pragmatic evaluation of NTNP services. Materials and methods We conducted a prospective implementation evaluation. Guided by the pragmatic application of the RE-AIM framework, we conceptualized a mixed-methods evaluation for key metrics: (1) reach into the Veteran patient population assessed as total NTNP new patient consult volume and total NTNP clinical encounters (new and return); (2) effectiveness through configurational analysis of conditions leading to high Veteran satisfaction and referring providers perceived effectiveness; (3) adoption and implementation by VA sites through site staff and NTNP interviews; (4) implementation success through perceived management, implementation barriers, facilitators, and adaptations and through rapid qualitative analysis of multiple stakeholders' assessments; and (5) maintenance of NTNP through monitoring quarterly TeleNeurology consultation volume. Results NTNP was successfully implemented in 13 VA Medical Centers over 2 years. The total NTNP new patient consult volume in fiscal year 2021 (FY21) was 836 (58% rurally residing); this increased to 1,706 in fiscal year 2022 (FY22) (55% rurally residing). Total (new and follow-up) NTNP clinical encounters were 1,306 in FY21 and 3,730 in FY22. Overall, the sites reported positive experiences with program implementation and perceived that the program was serving Veterans with little access to neurological care. Veterans also reported high satisfaction with the NTNP program. We identified the patient level of perceived excellent teleneurologist-patient communications, reduced need to drive to get care, and that NTNP provided care that the Veteran otherwise could not access as key factors related to high Veteran satisfaction. Conclusions The VA NTNP demonstrated substantial reach, adoption, effectiveness, implementation success, and maintenance over the first 2 years of the program. The NTNP was highly acceptable to both the clinical providers making the referrals and the Veterans receiving the referred video care. The pragmatic application of the RE-AIM framework to guide implementation evaluations is appropriate, comprehensive, and recommended for future applications.
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Affiliation(s)
- Teresa M. Damush
- Richard L. Roudebush VAMC HSR&D EXTEND QUERI, Indianapolis, IN, United States
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
- Regenstrief Institute, Inc., Indianapolis, IN, United States
| | - Jayne R. Wilkinson
- Corporal Michael J Crescenz VAMC, Philadelphia, PA, United States
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Holly Martin
- Regenstrief Institute, Inc., Indianapolis, IN, United States
| | - Edward J. Miech
- Richard L. Roudebush VAMC HSR&D EXTEND QUERI, Indianapolis, IN, United States
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
- Regenstrief Institute, Inc., Indianapolis, IN, United States
| | - Qing Tang
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Stanley Taylor
- Richard L. Roudebush VAMC HSR&D EXTEND QUERI, Indianapolis, IN, United States
| | - Joanne K. Daggy
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Grace Bastin
- Richard L. Roudebush VAMC HSR&D EXTEND QUERI, Indianapolis, IN, United States
| | - Robin Islam
- Corporal Michael J Crescenz VAMC, Philadelphia, PA, United States
| | - Laura J. Myers
- Richard L. Roudebush VAMC HSR&D EXTEND QUERI, Indianapolis, IN, United States
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
- Regenstrief Institute, Inc., Indianapolis, IN, United States
| | - Lauren S. Penney
- South Texas Veterans Health Care System, San Antonio, TX, United States
| | - Aditi Narechania
- Jesse Brown VAMC, Chicago, IL, United States
- University of Illinois Chicago, Chicago, IL, United States
- Northwestern University, Chicago, IL, United States
| | - Steve S. Schreiber
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Linda S. Williams
- Richard L. Roudebush VAMC HSR&D EXTEND QUERI, Indianapolis, IN, United States
- Regenstrief Institute, Inc., Indianapolis, IN, United States
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, United States
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Wasmuth S, Rattray NA, Cheng P, Crow S, Myers J, Burns DS, Myers LJ, Hook B, Lustig A, Perkins AJ, Cheatham AJ, Bravata DM. A developmental formative evaluation of a pilot participatory music program for veterans with housing insecurity. BMC Public Health 2023; 23:1583. [PMID: 37596545 PMCID: PMC10439562 DOI: 10.1186/s12889-023-16427-8] [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] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 07/31/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Interventions are needed to improve well-being and promote community reintegration among Veterans with housing insecurity. The objective was to conduct a developmental formative evaluation of a participatory music program. METHODS This single-site, pilot study implemented a participatory music program at a U.S. Department of Veterans Affairs (VA) Homeless Domiciliary that included one-hour sessions (group music instruction and ensemble playing), 3 times per week for 3 months. Intervention development was guided by the Model of Human Occupation (MOHO). Evaluation was guided by the MOHO and the Consolidated Framework for Implementation Evaluation (CFIR). Qualitative data were collected via semi-structured interviews from participants and non-participants, and were analyzed using an interdisciplinary, constant comparison qualitative analysis technique. RESULTS Sixteen program participants and 8 non-participants were enrolled, age range 26-59 (mean 41; standard deviation, 11) years; 75% were White. The sample for this study (N = 12) included five participants and seven non-participants. Semi-structured interview responses produced three salient themes illuminating Veterans' perspectives: (1) key characteristics of the intervention (the relative advantage of the participatory program over other problem-focused programs; the importance of a supportive, encouraging teaching; the group setting; the role of music); (2) the therapeutic power of the program (based on it being enjoyable; and serving as an escape from preoccupations); and (3) the context and culture (which included Veterans supporting each other and the Domiciliary setting). CONCLUSIONS Veterans described the benefits of a participatory music intervention compared to problem-based groups, which included enjoyment, skill acquisition facilitating pride, escape, reconnecting with their identity prior to current problems, and experiencing positive aspects of Veteran culture such as mutual support and discipline. These data support ongoing research about participatory music programs to support Veterans with housing insecurity.
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Affiliation(s)
- Sally Wasmuth
- Department of Occupational Therapy, Indiana University-Purdue University, Indianapolis, IN, USA
| | - Nicholas A Rattray
- Department of Veteran Affairs, Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), United States, Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, IN, 46202, Indianapolis, USA
- HSR&D Center for Health Information and Communication (CHIC), United States Department of Veteran Affairs, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Anthropology, Indiana University-Purdue University, Indianapolis, IN, USA
| | - Phillip Cheng
- School of Medicine, Indiana University, IN, Indianapolis, USA
| | - Shannon Crow
- Department of Veteran Affairs, Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), United States, Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, IN, 46202, Indianapolis, USA
| | - Jennifer Myers
- Department of Veteran Affairs, Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), United States, Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, IN, 46202, Indianapolis, USA
- HSR&D Center for Health Information and Communication (CHIC), United States Department of Veteran Affairs, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Debra S Burns
- Department of Music and Arts Technology, Indiana University-Purdue University, Indianapolis, IN, USA
| | - Laura J Myers
- Department of Veteran Affairs, Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), United States, Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, IN, 46202, Indianapolis, USA
- HSR&D Center for Health Information and Communication (CHIC), United States Department of Veteran Affairs, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Brittany Hook
- United States Department of Veteran Affairs, Domiciliary Care for Homeless Veterans Program (DCHV), IN, Indianapolis, USA
| | - Anne Lustig
- United States Department of Veteran Affairs, Domiciliary Care for Homeless Veterans Program (DCHV), IN, Indianapolis, USA
| | - Anthony J Perkins
- Department of Veteran Affairs, Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), United States, Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, IN, 46202, Indianapolis, USA
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ariel J Cheatham
- Department of Veteran Affairs, Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), United States, Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, IN, 46202, Indianapolis, USA
- HSR&D Center for Health Information and Communication (CHIC), United States Department of Veteran Affairs, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Dawn M Bravata
- Department of Veteran Affairs, Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), United States, Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, IN, 46202, Indianapolis, USA.
- HSR&D Center for Health Information and Communication (CHIC), United States Department of Veteran Affairs, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA.
- Regenstrief Institute, Indianapolis, IN, USA.
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Arling G, Miech EJ, Myers LJ, Sexson A, Bravata DM. The impact of the COVID-19 pandemic on blood pressure control after a stroke or transient ischemic attack among patients at VA medical centers. J Stroke Cerebrovasc Dis 2023; 32:107140. [PMID: 37084497 PMCID: PMC10103761 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107140] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 04/23/2023] Open
Abstract
OBJECTIVE To study factors associated with systolic blood pressure(SBP) control for patients post-discharge from an ischemic stroke or transient ischemic attack(TIA) during the early months of the COVID-19 pandemic compared to pre-pandemic periods within the Veterans Health Administration(VHA). MATERIALS AND METHODS We analyzed retrospective data from patients discharged from Emergency Departments or inpatient admissions after an ischemic stroke or TIA. Cohorts consisted of 2,816 patients during March-September 2020 and 11,900 during the same months in 2017-2019. Outcomes included primary care or neurology clinic visits, recorded blood pressure readings and average blood pressure control in the 90-days post-discharge. Random effect logit models were used to compare clinical characteristics of the cohorts and relationships between patient characteristics and outcomes. RESULTS The majority (73%) of patients with recorded readings during the COVID-19 period had a mean post-discharge SBP within goal (<140 mmHg); this was slightly lower than the pre-COVID-19 period (78%; p=0.001). Only 38% of the COVID-19 cohort had a recorded SBP in the 90-days post-discharge compared with 83% of patients during the pre-pandemic period (p=0.001). During the pandemic period, 29% did not have follow-up primary care or neurologist visits, and 33% had a phone or video visit without a recorded SBP reading. CONCLUSIONS Patients with an acute cerebrovascular event during the initial COVID-19 period were less likely to have outpatient visits or blood pressure measurements than during the pre-pandemic period; patients with uncontrolled SBP should be targeted for follow-up hypertension management.
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Affiliation(s)
- Greg Arling
- Purdue University School of Nursing, West Lafayette, IN, USA.
| | - Edward J Miech
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA; Regenstrief Institute, Indianapolis, IN, USA; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Laura J Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA; VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical Center; Indianapolis, IN, USA; Regenstrief Institute, Indianapolis, IN, USA; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ali Sexson
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA; VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical Center; Indianapolis, IN, USA
| | - Dawn M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA; VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical Center; Indianapolis, IN, USA; Regenstrief Institute, Indianapolis, IN, USA; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA; Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
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Kahi CJ, Myers LJ, Monahan PO, Barker BC, Stump TE, Imperiale TF. Mortality After Postcolonoscopy Colorectal Cancer in the Veterans Affairs Health Care System. JAMA Netw Open 2023; 6:e236693. [PMID: 37022683 PMCID: PMC10080371 DOI: 10.1001/jamanetworkopen.2023.6693] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
Importance Postcolonoscopy colorectal cancer (PCCRC) refers to colorectal cancer (CRC) diagnosed after a colonoscopy in which no cancer was found and is reflective of colonoscopy quality at the individual and system levels. Colonoscopy is widely performed in the Veterans Affairs (VA) health care system, but the prevalence of PCCRC and its associated mortality are unknown. Objective To examine PCCRC prevalence and its all-cause mortality (ACM) and CRC-specific mortality (CSM) within the VA health care system. Design, Setting, and Participants This retrospective cohort study used VA-Medicare administrative data to identify 29 877 veterans aged 50 to 85 years with newly diagnosed CRC between January 1, 2003, and December 31, 2013. Patients whose colonoscopy occurred less than 6 months before CRC diagnosis with no other colonoscopy within the previous 36 months were categorized as having detected CRC (DCRC). Those who had a colonoscopy that did not detect CRC between 6 and 36 months before CRC diagnosis were categorized as having postcolonoscopy CRC (PCCRC-3y). A third group included patients with CRC and no colonoscopy within the prior 36 months. The final analysis of the data was performed in September 2022. Exposures Prior receipt of colonoscopy. Main Outcomes and Measures Cox proportional hazards regression (with censoring, last follow-up December 31, 2018) analyses were conducted to compare PCCRC-3y and DCRC for 5-year ACM and CSM after CRC diagnosis. Results Of 29 877 patients with CRC (median [IQR] age, 67 [60-75] years; 29 353 [98%] male; 5284 [18%] Black, 23 971 [80%] White, and 622 [2%] other), 1785 (6%) were classified as having PCCRC-3y and 21 811 (73%) as having DCRC. The 5-year ACM rates were 46% vs 42% for patients with PCCRC-3y vs patients with DCRC. The 5-year CSM rates were 26% vs 25% for patients with PCCRC-3y vs patients with DCRC. In multivariable Cox proportional hazards regression analysis, there was no significant difference in ACM and CSM between patients with PCCRC-3y (adjusted hazard ratio [aHR], 1.04; 95% CI, 0.98-1.11; P = .18) and patients with DCRC (aHR, 1.04; 95% CI, 0.95-1.13; P = .42). However, compared with patients with DCRC, patients with no prior colonoscopy had significantly higher ACM (aHR, 1.76; 95% CI, 1.70-1.82; P < .001) and CSM (aHR, 2.22; 95% CI, 2.12-2.32; P < .001). Compared with patients with DCRC, patients with PCCRC-3y had significantly lower odds of having undergone colonoscopy performed by a gastroenterologist (odds ratio, 0.48; 95% CI, 0.43-0.53; P < .001). Conclusions and Relevance This study found that PCCRC-3y constituted 6% of CRCs in the VA system, which is similar to other settings. Compared with patients with CRC detected by colonoscopy, those with PCCRC-3y have comparable ACM and CSM.
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Affiliation(s)
- Charles J Kahi
- Department of Medicine, Richard L. Roudebush Veterans Affairs (VA) Medical Center, Indianapolis, Indiana
- Department of Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Indiana University School of Medicine, Indianapolis
| | - Laura J Myers
- Department of Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Indiana University School of Medicine, Indianapolis
- The Regenstrief Institute, Indianapolis, Indiana
| | - Patrick O Monahan
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
| | | | - Timothy E Stump
- Indiana University School of Medicine, Indianapolis
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
| | - Thomas F Imperiale
- Department of Medicine, Richard L. Roudebush Veterans Affairs (VA) Medical Center, Indianapolis, Indiana
- Department of Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Indiana University School of Medicine, Indianapolis
- The Regenstrief Institute, Indianapolis, Indiana
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Sico JJ, Koo BB, Perkins AJ, Burrone L, Sexson A, Myers LJ, Taylor S, Yarbrough WC, Daggy JK, Miech EJ, Bravata DM. Impact of the coronavirus disease-2019 pandemic on Veterans Health Administration Sleep Services. SAGE Open Med 2023; 11:20503121231169388. [PMID: 37152838 PMCID: PMC10158800 DOI: 10.1177/20503121231169388] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 03/27/2023] [Indexed: 05/09/2023] Open
Abstract
Objectives To understand the impact of the coronavirus disease-2019 pandemic on sleep services within the United States Department of Veterans Affairs using separate surveys from "pre-COVID" and pandemic periods. Methods Data from a pre-pandemic survey (September to November 2019) were combined with data from a pandemic-period survey (August to November 2020) to Veterans Affairs sleep medicine providers about their local sleep services within 140 Veterans Affairs facilities). Results A total of 67 (47.9%) facilities responded to the pandemic online survey. In-lab diagnostic and titration sleep studies were stopped at 91.1% of facilities during the pandemic; 76.5% of facilities resumed diagnostic studies and 60.8% resumed titration studies by the time of the second survey. Half of the facilities suspended home sleep testing; all facilities resumed these services. In-person positive airway pressure clinics were stopped at 76.3% of facilities; 46.7% resumed these clinics. Video telehealth was either available or in development at 86.6% of facilities and was considered a lasting addition to sleep services. Coronavirus disease-2019 transmission precautions occurred at high rates. Sleep personnel experienced high levels of stress, anxiety, fear, and burnout because of the pandemic and in response to unexpected changes in sleep medicine care delivery. Conclusions Sleep medicine services within the Veterans Affairs evolved during the pandemic with many key services being interrupted, including in-lab studies and in-person positive airway pressure clinics. Expansion and initiation of telehealth sleep services occurred commonly. The pandemic adversely affected sleep medicine personnel as they sought to maintain access to care.
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Affiliation(s)
- Jason J Sico
- Neurology Service, VA Connecticut Healthcare System, West Haven, CT, USA
- Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Jason J Sico, VA Connecticut Healthcare System, Mailing Code 689GF, VA Annex, 200 Edison Road, Orange, CT, 06477, USA.
| | - Brian B Koo
- Neurology Service, VA Connecticut Healthcare System, West Haven, CT, USA
- Center for NeuroEpidemiological and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Anthony J Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Laura Burrone
- Pain Research, Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Ali Sexson
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Laura J Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Stanley Taylor
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - W Claibe Yarbrough
- Medicine Service, VA North Texas Healthcare System, Dallas, TX, USA
- Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Joanne K Daggy
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine & Fairbanks School of Public Health, Indianapolis, IN, USA
| | - Edward J Miech
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - Dawn M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
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McGuire AB, Flanagan ME, Myers LJ, Kukla M, Rollins AL, Garabrant J, Henry N, Eliacin J, Hunt MG, Iwamasa GY, Carter JL, Salyers MP. Recovery-oriented inpatient mental health care and readmission. Psychiatr Rehabil J 2022; 45:331-335. [PMID: 36201808 DOI: 10.1037/prj0000533] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE This article examines the relationship between inpatient mental health units' adherence to recovery-oriented care and 30-day patient readmission. METHOD The sample included patients admitted to one of 34 Veterans Health Administration inpatient mental health units. Recovery-oriented care was assessed using interviews and site visits. Patient characteristics and readmission data were derived from administrative data. FINDINGS Overall recovery orientation was not associated with readmission. Exploratory analyses found higher scores on a subsample of items pertaining to inpatient therapeutic programming were associated with lower patient readmissions. Additionally, patients with more prior service use and substance abuse or personality disorders were more likely to be readmitted. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE A growing body of literature supports the association between psychotherapeutic services in inpatient units and better patient outcomes. However, further research is needed to examine this association. More work is needed to develop appropriate psychotherapy services for the inpatient setting and support their implementation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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16
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Schubert CC, Perkins AJ, Myers LJ, Damush TM, Penney LS, Zhang Y, Schwartzkopf AL, Preddie AK, Riley S, Menen T, Bravata DM. Effectiveness of the VA-Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program: An observational cohort study. J Am Geriatr Soc 2022; 70:3598-3609. [PMID: 36054760 PMCID: PMC10087268 DOI: 10.1111/jgs.18013] [Citation(s) in RCA: 1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/01/2022] [Accepted: 07/29/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND As the Department of Veterans Affairs (VA) healthcare system seeks to expand access to comprehensive geriatric assessments, evidence-based models of care are needed to support community-dwelling older persons. We evaluated the VA Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program's effect on mortality and readmissions, as well as patient, caregiver, and staff satisfaction. METHODS This retrospective cohort included patients admitted to the Richard L. Roudebush VA hospital (2010-2019) who received VA-GRACE services post-discharge and usual care controls who were potentially eligible for VA-GRACE but did not receive services. The VA-GRACE program provided home-based comprehensive, multi-disciplinary geriatrics assessment, and ongoing care. Primary outcomes included 90-day and 1-year all-cause readmissions and mortality, and patient, caregiver, and staff satisfaction. We used propensity score modeling with overlapping weighting to adjust for differences in characteristics between groups. RESULTS VA-GRACE patients (N = 683) were older than controls (N = 4313) (mean age 78.3 ± 8.2 standard deviation vs. 72.2 ± 6.9 years; p < 0.001) and had greater comorbidity (median Charlson Comorbidity Index 3 vs. 0; p < 0.001). VA-GRACE patients had higher 90-day readmissions (adjusted odds ratio [aOR] 1.55 [95%CI 1.01-2.38]) and higher 1-year readmissions (aOR 1.74 [95%CI 1.22-2.48]). However, VA-GRACE patients had lower 90-day mortality (aOR 0.31 [95%CI 0.11-0.92]), but no statistically significant difference in 1-year mortality was observed (aOR 0.88 [95%CI 0.55-1.41]). Patients and caregivers reported that VA-GRACE home visits reduced travel burden and the program linked Veterans and caregivers to needed resources. Primary care providers reported that the VA-GRACE team helped to reduce their workload, improved medication management for their patients, and provided a view into patients' daily living situation. CONCLUSIONS The VA-GRACE program provides comprehensive geriatric assessments and care to high-risk, community-dwelling older persons with high rates of satisfaction from patients, caregivers, and providers. Widespread deployment of programs like VA-GRACE will be required to support Veterans aging in place.
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Affiliation(s)
- Cathy C. Schubert
- Medicine ServiceRichard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
- Department of Internal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Anthony J. Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- Department of BiostatisticsIndiana University School of Medicine, IUPUIIndianapolisIndianaUSA
| | - Laura J. Myers
- Department of Internal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
| | - Teresa M. Damush
- Department of Internal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
- Regenstrief InstituteIndianapolisIndianaUSA
| | - Lauren S. Penney
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care SystemSan AntonioTexasUSA
- Department of MedicineUniversity of Texas Health San AntonioSan AntonioTexasUSA
| | - Ying Zhang
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- Department of BiostatisticsCollege of Public Health, University of Nebraska Medical CenterOmahaNebraskaUSA
| | - Ashley L. Schwartzkopf
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
| | - Alaina K. Preddie
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
| | - Sam Riley
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
| | - Tetla Menen
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
| | - Dawn M. Bravata
- Medicine ServiceRichard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
- Department of Internal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
- Regenstrief InstituteIndianapolisIndianaUSA
- Department of NeurologyIndiana University School of MedicineIndianapolisIndianaUSA
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Redd DF, Shao Y, Zeng-Treitler Q, Myers LJ, Barker BC, Nelson SJ, Imperiale TF. Identification of colorectal cancer using structured and free text clinical data. Health Informatics J 2022; 28:14604582221134406. [DOI: 10.1177/14604582221134406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Colorectal cancer incidence has continually fallen among those 50 years old and over. However, the incidence has increased in those under 50. Even with the recent screening guidelines recommending that screening begins at age 45, nearly half of all early-onset colorectal cancer will be missed. Methods are needed to identify high-risk individuals in this age group for targeted screening. Colorectal cancer studies, as with other clinical studies, have required labor intensive chart review for the identification of those affected and risk factors. Natural language processing and machine learning can be used to automate the process and enable the screening of large numbers of patients. This study developed and compared four machine learning and statistical models: logistic regression, support vector machine, random forest, and deep neural network, in their performance in classifying colorectal cancer patients. Excellent classification performance is achieved with AUCs over 97%.
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Affiliation(s)
- Douglas F Redd
- Washington DC VA Medical Center, Washington, DC, USA Biomedical Informatics Center, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Yijun Shao
- Washington DC VA Medical Center, Washington, DC, USA Biomedical Informatics Center, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Qing Zeng-Treitler
- Washington DC VA Medical Center, Washington, DC, USA Biomedical Informatics Center, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Laura J Myers
- Richard L Roudebush VA Medical Center, Indianapolis, IN, USAIndiana University School of Medicine, Indianapolis, IN, USA Regenstrief Institute Inc, Indianapolis, IN, USA
| | - Barry C Barker
- Richard L Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Stuart J Nelson
- Biomedical Informatics Center, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Thomas F Imperiale
- Richard L Roudebush VA Medical Center, Indianapolis, IN, USA Indiana University School of Medicine, Indianapolis, IN, USA Regenstrief Institute Inc, Indianapolis, IN, USA
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18
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Matthias MS, Adams J, Burgess D, Daggy J, Eliacin J, Flores P, Hirsh AT, Myers LJ, Perkins AJ, Menen T, Philip Procento, Rand KL, Salyers MP, Shanahan ML, Bair MJ. Corrigendum to: Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE): Rationale, study design, methods, and sample characteristics (Contemporary Clinical Trials, volume 118, article number 106790). Contemp Clin Trials 2022; 120:106883. [PMID: 35999166 DOI: 10.1016/j.cct.2022.106883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Marianne S Matthias
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America; Regenstrief Institute, Indianapolis, IN, United States of America; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America.
| | - Jasma Adams
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America
| | - Diana Burgess
- Center for Care Delivery and Outcomes Research, Veterans Affairs Medical Center, Minneapolis, MN, United States of America; Department of Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Joanne Daggy
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Johanne Eliacin
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America; Regenstrief Institute, Indianapolis, IN, United States of America; Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Perla Flores
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America
| | - Adam T Hirsh
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States of America
| | - Laura J Myers
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America; Regenstrief Institute, Indianapolis, IN, United States of America; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Anthony J Perkins
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Tetla Menen
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America
| | - Philip Procento
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States of America
| | - Kevin L Rand
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States of America
| | - Michelle P Salyers
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States of America
| | - Mackenzie L Shanahan
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States of America
| | - Matthew J Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America; Regenstrief Institute, Indianapolis, IN, United States of America; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
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19
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Myers LJ, Perkins AJ, Zhang Y, Bravata DM. Identifying transient ischemic attack (TIA) patients at high-risk of adverse outcomes: development and validation of an approach using electronic health record data. BMC Neurol 2022; 22:256. [PMID: 35820867 PMCID: PMC9275263 DOI: 10.1186/s12883-022-02776-1] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 06/20/2022] [Indexed: 11/24/2022] Open
Abstract
Background Risk-stratification tools that have been developed to identify transient ischemic attack (TIA) patients at risk of recurrent vascular events typically include factors which are not readily available in electronic health record systems. Our objective was to evaluate two TIA risk stratification approaches using electronic health record data. Methods Patients with TIA who were cared for in Department of Veterans Affairs hospitals (October 2015—September 2018) were included. The six outcomes were mortality, recurrent ischemic stroke, and the combined endpoint of stroke or death at 90-days and 1-year post-index TIA event. The cohort was split into development and validation samples. We examined the risk stratification of two scores constructed using electronic health record data. The Clinical Assessment Needs (CAN) score is a validated measure of risk of hospitalization or death. The PREVENT score was developed specifically for TIA risk stratification. Results A total of N = 5250 TIA patients were included in the derivation sample and N = 4248 in the validation sample. The PREVENT score had higher c-statistics than the CAN score across all outcomes in both samples. Within the validation sample the c-statistics for the PREVENT score were: 0.847 for 90-day mortality, 0.814 for 1-year mortality, 0.665 for 90-day stroke, and 0.653 for 1-year stroke, 0.699 for 90-day stroke or death, and 0.744 for 1-year stroke or death. The PREVENT score classified patients into categories with extreme nadir and zenith outcome rates. The observed 1-year mortality rate among validation patients was 7.1%; the PREVENT score lowest decile of patients had 0% mortality and the highest decile group had 30.4% mortality. Conclusions The PREVENT score had strong c-statistics for the mortality outcomes and classified patients into distinct risk categories. Learning healthcare systems could implement TIA risk stratification tools within electronic health records to support ongoing quality improvement. Registration ClinicalTrials.gov Identifier: NCT02769338.
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Affiliation(s)
- Laura J Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA. .,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA. .,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA. .,Regenstrief Institute, Indianapolis, IN, USA.
| | - Anthony J Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA.,Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ying Zhang
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA.,Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dawn M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Indianapolis, IN, USA.,Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
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20
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Bravata DM, Miech EJ, Myers LJ, Perkins AJ, Zhang Y, Rattray NA, Baird SA, Penney LS, Austin C, Damush TM. The Perils of a "My Work Here is Done" perspective: a mixed methods evaluation of sustainment of an evidence-based intervention for transient ischemic attack. BMC Health Serv Res 2022; 22:857. [PMID: 35787273 PMCID: PMC9254423 DOI: 10.1186/s12913-022-08207-8] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/16/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To evaluate quality improvement sustainment for Transient Ischemic Attack (TIA) and identify factors influencing sustainment, which is a challenge for Learning Healthcare Systems. METHODS Mixed methods were used to assess changes in care quality across periods (baseline, implementation, sustainment) and identify factors promoting or hindering sustainment of care quality. PREVENT was a stepped-wedge trial at six US Department of Veterans Affairs implementation sites and 36 control sites (August 2015-September 2019). Quality of care was measured by the without-fail rate: proportion of TIA patients who received all of the care for which they were eligible among brain imaging, carotid artery imaging, neurology consultation, hypertension control, anticoagulation for atrial fibrillation, antithrombotics, and high/moderate potency statins. Key informant interviews were used to identify factors associated with sustainment. RESULTS The without-fail rate at PREVENT sites improved from 36.7% (baseline, 58/158) to 54.0% (implementation, 95/176) and settled at 48.3% (sustainment, 56/116). At control sites, the without-fail rate improved from 38.6% (baseline, 345/893) to 41.8% (implementation, 363/869) and remained at 43.0% (sustainment, 293/681). After adjustment, no statistically significant difference in sustainment quality between intervention and control sites was identified. Among PREVENT facilities, the without-fail rate improved ≥2% at 3 sites, declined ≥2% at two sites, and remained unchanged at one site during sustainment. Factors promoting sustainment were planning, motivation to sustain, integration of processes into routine practice, leadership engagement, and establishing systems for reflecting and evaluating on performance data. The only factor that was sufficient for improving quality of care during sustainment was the presence of a champion with plans for sustainment. Challenges during sustainment included competing demands, low volume, and potential problems with medical coding impairing use of performance data. Four factors were sufficient for declining quality of care during sustainment: low motivation, champion inactivity, no reflecting and evaluating on performance data, and absence of leadership engagement. CONCLUSIONS Although the intervention improved care quality during implementation; performance during sustainment was heterogeneous across intervention sites and not different from control sites. Learning Healthcare Systems seeking to sustain evidence-based practices should embed processes within routine care and establish systems for reviewing and reflecting upon performance. TRIAL REGISTRATION Clinicaltrials.gov ( NCT02769338 ).
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Affiliation(s)
- Dawn M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA.
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA.
- Regenstrief Institute, Indianapolis, IN, USA.
| | - Edward J Miech
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - Laura J Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - Anthony J Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- Department of Biostatistics, Indiana University School of Medicine, IN, Indianapolis, USA
| | - Ying Zhang
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Nicholas A Rattray
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - Sean A Baird
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - Lauren S Penney
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Curt Austin
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - Teresa M Damush
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
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Matthias MS, Adams J, Burgess DJ, Daggy J, Eliacin J, Flores P, Hirsh AT, Myers LJ, Perkins AJ, Menen T, Procento P, Rand KL, Salyers MP, Shanahan ML, Bair MJ. Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE): Rationale, study design, methods, and sample characteristics. Contemp Clin Trials 2022; 118:106790. [PMID: 35568376 DOI: 10.1016/j.cct.2022.106790] [Citation(s) in RCA: 1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 05/06/2022] [Accepted: 05/06/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Chronic pain is associated with profound negative effects, and racial disparities are well-documented in chronic pain treatment. In addition, Black patients report poorer communication with providers and exhibit lower levels of patient activation (self-management self-efficacy) than White patients. Although the causes of healthcare disparities are complex and require intervention at multiple levels, empowering patients is one critical path to achieving health equity. The current study is a coaching intervention focused on increasing patient activation and building communication skills for Black patients with chronic pain. METHODS In this randomized controlled trial, 250 Black patients with chronic pain were randomized to either the coaching intervention or an attention control arm. Intervention patients attended 6 telephone-delivered individual coaching sessions over 12 weeks. Coaching focused on clarifying and prioritizing goals and on communication skills, such as agenda setting. The primary outcome is patient activation. Secondary outcomes include communication self-efficacy, pain intensity and interference, and psychological functioning. DISCUSSION Having the knowledge and confidence to participate in one's pain care, coupled with the skills needed to effectively communicate with providers, is essential to optimize chronic pain care. This is particularly important for Black patients who often experience lower quality pain care. Interventions such as COOPERATE hold promise for helping patients to acquire the requisite tools to take greater control of their chronic pain care. TRIAL REGISTRATION clinicaltrials.gov, # NCT03562793.
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Affiliation(s)
- Marianne S Matthias
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America; Regenstrief Institute, Indianapolis, IN, United States of America; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America.
| | - Jasma Adams
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America
| | - Diana J Burgess
- Center for Care Delivery and Outcomes Research, Veterans Affairs Medical Center, Minneapolis, MN, United States of America; Department of Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Joanne Daggy
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Johanne Eliacin
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America; Regenstrief Institute, Indianapolis, IN, United States of America; Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Perla Flores
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America
| | - Adam T Hirsh
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States of America
| | - Laura J Myers
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America; Regenstrief Institute, Indianapolis, IN, United States of America; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Anthony J Perkins
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Tetla Menen
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America
| | - Philip Procento
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States of America
| | - Kevin L Rand
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States of America
| | - Michelle P Salyers
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States of America
| | - Mackenzie L Shanahan
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States of America
| | - Matthew J Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States of America; Regenstrief Institute, Indianapolis, IN, United States of America; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
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22
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Arling G, Perkins A, Myers LJ, Sico JJ, Bravata DM. Blood Pressure Trajectories and Outcomes for Veterans Presenting at VA Medical Centers with a Stroke or Transient Ischemic Attack. Am J Med 2022; 135:889-896.e1. [PMID: 35292287 DOI: 10.1016/j.amjmed.2022.02.012] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/31/2022] [Accepted: 02/10/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Blood pressure control has been shown to reduce risk of vascular events and mortality after an ischemic stroke or transient ischemic attack (TIA). Yet, questions remain about effectiveness, timing, and targeted blood pressure reduction. METHODS We analyzed data from a retrospective cohort of 18,837 veterans cared for 12 months prior and up to 12 months after an emergency department visit or inpatient admission for stroke or TIA. Latent class growth analysis was used to classify patients into systolic blood pressure trajectories. With Cox proportional hazard models, we examined relationships between blood pressure trajectories, intensification of antihypertensive medication, and stroke (fatal or non-fatal) and all-cause mortality in 12 months following the index event. RESULTS The cohort was classified into 4 systolic blood pressure trajectories: 19% with a low systolic blood pressure trajectory (mean systolic blood pressure = 116 mm Hg); 65% with a medium systolic blood pressure trajectory (mean systolic blood pressure = 136 mm Hg); 15% with a high systolic blood pressure trajectory (mean systolic blood pressure = 158 mm Hg), and 1% with a very high trajectory (mean systolic blood pressure = 183 mm Hg). After the stroke or TIA, individuals in the high and very high systolic blood pressure trajectories experienced a substantial decrease in systolic blood pressure that coincided with intensification of antihypertensive medication. Patients with very low and very high systolic blood pressure trajectories had a significantly greater (P < .05) hazard of mortality, while medication intensification was related significantly (P < .05) to lower hazard of mortality. CONCLUSIONS These findings point to the importance of monitoring blood pressure over multiple time points and of instituting enhanced hypertension management after stroke or TIA, particularly for individuals with high or very high blood pressure trajectories.
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Affiliation(s)
- Greg Arling
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Washington, DC; School of Nursing, Purdue University, West Lafayette, Indianapolis, IN.
| | - Anthony Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Washington, DC; Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Laura J Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Washington, DC; VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN; Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN; Health Services Research, Regenstrief Institute, Indianapolis, IN
| | - Jason J Sico
- Neurology Service, VA Connecticut Healthcare System, West Haven, Conn; Department of Neurology, Yale School of Medicine, New Haven, Conn
| | - Dawn M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Washington, DC; VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN; Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN; Health Services Research, Regenstrief Institute, Indianapolis, IN; Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, IN
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Miech EJ, Perkins AJ, Zhang Y, Myers LJ, Sico JJ, Daggy J, Bravata DM. Pairing regression and configurational analysis in health services research: modelling outcomes in an observational cohort using a split-sample design. BMJ Open 2022; 12:e061469. [PMID: 35672067 PMCID: PMC9174826 DOI: 10.1136/bmjopen-2022-061469] [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] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Configurational methods are increasingly being used in health services research. OBJECTIVES To use configurational analysis and logistic regression within a single data set to compare results from the two methods. DESIGN Secondary analysis of an observational cohort; a split-sample design involved randomly dividing patients into training and validation samples. PARTICIPANTS AND SETTING Patients who had a transient ischaemic attack (TIA) in US Department of Veterans Affairs hospitals. MEASURES The patient outcome was the combined endpoint of all-cause mortality or recurrent ischaemic stroke within 1 year post-TIA. The quality-of-care outcome was the without-fail rate (proportion of patients who received all processes for which they were eligible, among seven processes). RESULTS For the recurrent stroke or death outcome, configurational analysis yielded a three-pathway model identifying a set of (validation sample) patients where the prevalence was 15.0% (83/552), substantially higher than the overall sample prevalence of 11.0% (relative difference, 36%). The configurational model had a sensitivity (coverage) of 84.7% and specificity of 40.6%. The logistic regression model identified six factors associated with the combined endpoint (c-statistic, 0.632; sensitivity, 63.3%; specificity, 63.1%). None of these factors were elements of the configurational model. For the quality outcome, configurational analysis yielded a single-pathway model identifying a set of (validation sample) patients where the without-fail rate was 64.3% (231/359), nearly twice the overall sample prevalence (33.7%). The configurational model had a sensitivity (coverage) of 77.3% and specificity of 78.2%. The logistic regression model identified seven factors associated with the without-fail rate (c-statistic, 0.822; sensitivity, 80.3%; specificity, 84.2%). Two of these factors were also identified in the configurational analysis. CONCLUSIONS Configurational analysis and logistic regression represent different methods that can enhance our understanding of a data set when paired together. Configurational models optimise sensitivity with relatively few conditions. Logistic regression models discriminate cases from controls and provided inferential relationships between outcomes and independent variables.
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Affiliation(s)
- Edward J Miech
- Quality Enhancement Research Initiative (QUERI) and Health Services Research and Development (HSR&D), Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute Inc, Indianapolis, Indiana, USA
| | - Anthony J Perkins
- Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ying Zhang
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Laura J Myers
- Quality Enhancement Research Initiative (QUERI) and Health Services Research and Development (HSR&D), Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute Inc, Indianapolis, Indiana, USA
| | - Jason J Sico
- Neurology Service, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joanne Daggy
- Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dawn M Bravata
- Quality Enhancement Research Initiative (QUERI) and Health Services Research and Development (HSR&D), Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute Inc, Indianapolis, Indiana, USA
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Kahi CJ, Myers LJ, Stump TE, Imler TD, Sherer EA, Larson J, Imperiale TF. Tailoring Surveillance Colonoscopy in Patients With Advanced Adenomas. Clin Gastroenterol Hepatol 2022; 20:847-854.e1. [PMID: 33775897 DOI: 10.1016/j.cgh.2021.03.027] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/06/2021] [Accepted: 03/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with advanced colorectal adenomas (AAs) are directed to undergo intensive surveillance. However, the benefit derived from surveillance may be outweighed by the risk of death from non-colorectal cancer (CRC) causes, leading to uncertainty on how best to individualize follow-up. The aim of this study was to derive a risk prediction model and risk index that estimate and stratify the risk for non-CRC cancer mortality (NCM) subsequent to diagnosis and removal of AA. METHODS We conducted a retrospective cohort study of veterans ≥40 years old who had colonoscopy for diagnostic or screening indications at 13 Veterans Affairs Medical Centers between 2002 and 2009 and had 1 or more AAs. The primary outcome was NCM using a fixed follow-up time period of 5 years. Logistic regression using the lasso technique was used to identify factors independently associated with NCM, and an index based on points from regression coefficients was constructed to estimate risk of 5-year NCM. RESULTS We identified 2943 veterans with AA (mean age [standard deviation] 63 [8.6] years, 98% male, 74% white), with an overall 5-year mortality of 16.7%, which was nearly all due to NCM (16.6%). Age, comorbidity burden, specific comorbid conditions, and hospitalization within the preceding year were independently associated with NCM. The risk prediction model had a goodness of fit (calibration) P value of .41 and c-statistic (discrimination) of 0.74 (95% confidence interval, 0.71-0.76). On the basis of comparable 5-year risks of NCM, the scores comprised 3 risk categories: low (score of 0-1), intermediate (score of 2-4), and high (score of ≥5), in which NCM occurred in 6.5%, 14.1%, and 33.2%, respectively. CONCLUSIONS We derived a risk prediction model that identifies veterans with advanced adenomas who are at high risk of NCM within 5 years, and who are thus unlikely to benefit from further surveillance.
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Affiliation(s)
- Charles J Kahi
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University, Indianapolis; Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis; Indiana University School of Medicine, Indianapolis.
| | - Laura J Myers
- Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis; Indiana University School of Medicine, Indianapolis
| | - Timothy E Stump
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | | | - Eric A Sherer
- Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis
| | - Jason Larson
- Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis
| | - Thomas F Imperiale
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University, Indianapolis; Health Services Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis; Indiana University School of Medicine, Indianapolis; The Regenstrief Institute, Indianapolis, Indiana
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25
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McGuire AB, Kukla M, Rollins AL, Garabrant J, Henry N, Eliacin J, Myers LJ, Flanagan ME, Hunt MG, Iwamasa GY, Bauer SM, Carter JL, Salyers MP. Recovery-oriented acute inpatient mental health care: Operationalization and measurement. Psychiatr Rehabil J 2021; 44:318-326. [PMID: 34323532 PMCID: PMC8664980 DOI: 10.1037/prj0000494] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The current article describes efforts to develop and test a measure of recovery-oriented inpatient care. METHOD The Recovery-oriented Acute INpatient (RAIN) scale was based on prior literature and current Veterans Health Administration (VHA) policy and resources and further revised based on data collection from 34 VHA acute inpatient units. RESULTS A final scale of 23, behaviorally anchored items demonstrated a four-factor structure including the following factors: inpatient treatment planning, outpatient treatment planning, group programming, and milieu. While several items require additional revision to address psychometric concerns, the scale demonstrated adequate model fit and was consistent with prior literature on recovery-oriented inpatient care. Conclusions and Implementations for Practice: The RAIN scale represents an important tool for future implementation and empirical study of recovery-oriented inpatient care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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McGuire AB, Flanagan ME, Kukla M, Rollins AL, Myers LJ, Bass E, Garabrant JM, Salyers MP. Inpatient Mental Healthcare before and during the COVID-19 Pandemic. Healthcare (Basel) 2021; 9:healthcare9121613. [PMID: 34946338 PMCID: PMC8701042 DOI: 10.3390/healthcare9121613] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/03/2021] [Accepted: 11/08/2021] [Indexed: 11/30/2022] Open
Abstract
Prior studies have demonstrated disruption to outpatient mental health services after the onset of the COVID-19 pandemic. Inpatient mental health services have received less attention. The current study utilized an existing cohort of 33 Veterans Health Affairs (VHA) acute inpatient mental health units to examine disruptions to inpatient services. It further explored the association between patient demographic, clinical, and services variables on relapse rates. Inpatient admissions and therapeutic services (group and individual therapy and peer support) were lower amongst the COVID-19 sample than prior to the onset of COVID-19 while lengths of stay were longer. Relapse rates did not differ between cohorts. Patients with prior emergent services use as well as substance abuse or personality disorder diagnoses were at higher risk for relapse. Receiving group therapy while admitted was associated with lower risk of relapse. Inpatient mental health services saw substantial disruptions across the cohort. Inpatient mental health services, including group therapy, may be an important tool to prevent subsequent relapse.
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Affiliation(s)
- Alan B. McGuire
- Health Services Research & Development, Richard L. Roudebush VAMC, Indianapolis, IN 46202, USA; (M.E.F.); (M.K.); (A.L.R.); (L.J.M.); (E.B.); (J.M.G.)
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN 46202, USA;
- Correspondence:
| | - Mindy E. Flanagan
- Health Services Research & Development, Richard L. Roudebush VAMC, Indianapolis, IN 46202, USA; (M.E.F.); (M.K.); (A.L.R.); (L.J.M.); (E.B.); (J.M.G.)
| | - Marina Kukla
- Health Services Research & Development, Richard L. Roudebush VAMC, Indianapolis, IN 46202, USA; (M.E.F.); (M.K.); (A.L.R.); (L.J.M.); (E.B.); (J.M.G.)
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN 46202, USA;
| | - Angela L. Rollins
- Health Services Research & Development, Richard L. Roudebush VAMC, Indianapolis, IN 46202, USA; (M.E.F.); (M.K.); (A.L.R.); (L.J.M.); (E.B.); (J.M.G.)
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN 46202, USA;
- Health Services Research, Regenstrief Institute, Indianapolis, IN 46202, USA
| | - Laura J. Myers
- Health Services Research & Development, Richard L. Roudebush VAMC, Indianapolis, IN 46202, USA; (M.E.F.); (M.K.); (A.L.R.); (L.J.M.); (E.B.); (J.M.G.)
- Health Services Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Emily Bass
- Health Services Research & Development, Richard L. Roudebush VAMC, Indianapolis, IN 46202, USA; (M.E.F.); (M.K.); (A.L.R.); (L.J.M.); (E.B.); (J.M.G.)
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN 46202, USA;
| | - Jennifer M. Garabrant
- Health Services Research & Development, Richard L. Roudebush VAMC, Indianapolis, IN 46202, USA; (M.E.F.); (M.K.); (A.L.R.); (L.J.M.); (E.B.); (J.M.G.)
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN 46202, USA;
| | - Michelle P. Salyers
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN 46202, USA;
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Penney LS, Damush TM, Rattray NA, Miech EJ, Baird SA, Homoya BJ, Myers LJ, Bravata DM. Multi-tiered external facilitation: the role of feedback loops and tailored interventions in supporting change in a stepped-wedge implementation trial. Implement Sci Commun 2021; 2:82. [PMID: 34315540 PMCID: PMC8317410 DOI: 10.1186/s43058-021-00180-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 06/29/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Facilitation is a complex, relational implementation strategy that guides change processes. Facilitators engage in multiple activities and tailor efforts to local contexts. How this work is coordinated and shared among multiple, external actors and the contextual factors that prompt and moderate facilitators to tailor activities have not been well-described. METHODS We conducted a mixed methods evaluation of a trial to improve the quality of transient ischemic attack care. Six sites in the Veterans Health Administration received external facilitation (EF) before and during a 1-year active implementation period. We examined how EF was employed and activated. Data analysis included prospective logs of facilitator correspondence with sites (160 site-directed episodes), stakeholder interviews (a total of 78 interviews, involving 42 unique individuals), and collaborative call debriefs (n=22) spanning implementation stages. Logs were descriptively analyzed across facilitators, sites, time periods, and activity types. Interview transcripts were coded for content related to EF and themes were identified. Debriefs were reviewed to identify instances of and utilization of EF during site critical junctures. RESULTS Multi-tiered EF was supported by two groups (site-facing quality improvement [QI] facilitators and the implementation support team) that were connected by feedback loops. Each site received an average of 24 episodes of site-directed EF; most of the EF was delivered by the QI nurse. For each site, site-directed EF frequently involved networking (45%), preparation and planning (44%), process monitoring (44%), and/or education (36%). EF less commonly involved audit and feedback (20%), brainstorming solutions (16%), and/or stakeholder engagement (5%). However, site-directed EF varied widely across sites and time periods in terms of these facilitation types. Site participants recognized the responsiveness of the QI nurse and valued her problem-solving, feedback, and accountability support. External facilitators used monitoring and dialogue to intervene by facilitating redirection during challenging periods of uncertainty about project direction and feasibility for sites. External facilitators, in collaboration with the implementation support team, successfully used strategies tailored to diverse local contexts, including networking, providing data, and brainstorming solutions. CONCLUSIONS Multi-tiered facilitation capitalizing on emergent feedback loops allowed for tailored, site-directed facilitation. Critical juncture cases illustrate the complexity of EF and the need to often try multiple strategies in combination to facilitate implementation progress. TRIAL REGISTRATION The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) is a registered trial ( NCT02769338 ), May 11, 2016-prospectively registered.
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Affiliation(s)
- Lauren S. Penney
- grid.280682.60000 0004 0420 5695VA HSR&D Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, San Antonio, TX USA ,grid.267309.90000 0001 0629 5880School of Medicine, University of Texas Health at San Antonio, San Antonio, TX USA
| | - Teresa M. Damush
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA ,grid.448342.d0000 0001 2287 2027Regenstrief Institute, Inc., Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN USA
| | - Nicholas A. Rattray
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA ,grid.448342.d0000 0001 2287 2027Regenstrief Institute, Inc., Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Anthropology, Indiana University-Purdue University, Indianapolis, IN USA
| | - Edward J. Miech
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA ,grid.448342.d0000 0001 2287 2027Regenstrief Institute, Inc., Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN USA
| | - Sean A. Baird
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA
| | - Barbara J. Homoya
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA
| | - Laura J. Myers
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA
| | - Dawn M. Bravata
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA ,grid.448342.d0000 0001 2287 2027Regenstrief Institute, Inc., Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Neurology, Indiana University School of Medicine, Indianapolis, IN USA
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Kelly JD, Bravata DM, Bent S, Wray CM, Leonard SJ, Boscardin WJ, Myers LJ, Keyhani S. Association of Social and Behavioral Risk Factors With Mortality Among US Veterans With COVID-19. JAMA Netw Open 2021; 4:e2113031. [PMID: 34106264 PMCID: PMC8190626 DOI: 10.1001/jamanetworkopen.2021.13031] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 12/21/2022] Open
Abstract
IMPORTANCE The US Department of Veterans Affairs (VA) offers programs that reduce barriers to care for veterans and those with housing instability, poverty, and substance use disorder. In this setting, however, the role that social and behavioral risk factors play in COVID-19 outcomes is unclear. OBJECTIVE To examine whether social and behavioral risk factors were associated with mortality among US veterans with COVID-19 and whether this association might be modified by race/ethnicity. DESIGN, SETTING, AND PARTICIPANTS This cohort study obtained data from the VA Corporate Data Warehouse to form a cohort of veterans who received a positive COVID-19 test result between March 2 and September 30, 2020, in a VA health care facility. All veterans who met the inclusion criteria were eligible to participate in the study, and participants were followed up for 30 days after the first SARS-CoV-2 or COVID-19 diagnosis. The final follow-up date was October 31, 2020. EXPOSURES Social risk factors included housing problems and financial hardship. Behavioral risk factors included current tobacco use, alcohol use, and substance use. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality in the 30-day period after the SARS-CoV-2 or COVID-19 diagnosis date. Multivariable logistic regression was used to estimate odds ratios, clustering for health care facilities and adjusting for age, sex, race, ethnicity, marital status, clinical factors, and month of COVID-19 diagnosis. RESULTS Among 27 640 veterans with COVID-19 who were included in the analysis, 24 496 were men (88.6%) and the mean (SD) age was 57.2 (16.6) years. A total of 3090 veterans (11.2%) had housing problems, 4450 (16.1%) had financial hardship, 5358 (19.4%) used alcohol, and 3569 (12.9%) reported substance use. Hospitalization occurred in 7663 veterans (27.7%), and 1230 veterans (4.5%) died. Housing problems (adjusted odds ratio [AOR], 0.96; 95% CI, 0.77-1.19; P = .70), financial hardship (AOR, 1.13; 95% CI, 0.97-1.31; P = .11), alcohol use (AOR, 0.82; 95% CI, 0.68-1.01; P = .06), current tobacco use (AOR, 0.85; 95% CI, 0.68-1.06; P = .14), and substance use (AOR, 0.90; 95% CI, 0.71-1.15; P = .41) were not associated with higher mortality. Interaction analyses by race/ethnicity did not find associations between mortality and social and behavioral risk factors. CONCLUSIONS AND RELEVANCE Results of this study showed that, in an integrated health system such as the VA, social and behavioral risk factors were not associated with mortality from COVID-19. Further research is needed to substantiate the potential of an integrated health system to be a model of support services for households with COVID-19 and populations who are at risk for the disease.
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Affiliation(s)
- J. Daniel Kelly
- San Francisco VA Medical Center, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco
| | - Dawn M. Bravata
- US Department of Veterans Affairs, Health Services and Development, Center for Health Information and Communication, Indianapolis, Indiana
- Department of Medicine, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Veterans Affairs Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Stephen Bent
- San Francisco VA Medical Center, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
- Department of Medicine, University of California, San Francisco, San Francisco
| | - Charlie M. Wray
- San Francisco VA Medical Center, San Francisco, California
- Department of Medicine, University of California, San Francisco, San Francisco
| | - Samuel J. Leonard
- Department of Medicine, University of California, San Francisco, San Francisco
| | - W. John Boscardin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
- Department of Medicine, University of California, San Francisco, San Francisco
| | - Laura J. Myers
- US Department of Veterans Affairs, Health Services and Development, Center for Health Information and Communication, Indianapolis, Indiana
| | - Salomeh Keyhani
- San Francisco VA Medical Center, San Francisco, California
- Department of Medicine, University of California, San Francisco, San Francisco
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Levine DA, Perkins AJ, Sico JJ, Myers LJ, Phipps MS, Zhang Y, Bravata DM. Hospital Factors, Performance on Process Measures After Transient Ischemic Attack, and 90-Day Ischemic Stroke Incidence. Stroke 2021; 52:2371-2378. [PMID: 34039034 DOI: 10.1161/strokeaha.120.031721] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Deborah A Levine
- University of Michigan Departments of Internal Medicine and Neurology, and Cognitive Health Services Research Program, Ann Arbor (D.A.L.)
| | - Anthony J Perkins
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis (A.J.P., D.M.B.).,Department of Veterans Affairs Health Services Research and Development Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Indianapolis, IN (A.J.P., L.J.M., D.M.B.)
| | - Jason J Sico
- Department of Neurology, VA Connecticut Healthcare System, West Haven, CT (J.J.S.).,Yale School of Medicine Departments of Neurology and Internal Medicine, New Haven, CT (J.J.S.)
| | - Laura J Myers
- Department of Veterans Affairs Health Services Research and Development Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Indianapolis, IN (A.J.P., L.J.M., D.M.B.).,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN (L.J.M., M.S.P., D.M.B.)
| | - Michael S Phipps
- VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN (L.J.M., M.S.P., D.M.B.)
| | - Ying Zhang
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha (Y.Z.)
| | - Dawn M Bravata
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis (A.J.P., D.M.B.).,Department of Veterans Affairs Health Services Research and Development Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Indianapolis, IN (A.J.P., L.J.M., D.M.B.).,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN (L.J.M., M.S.P., D.M.B.)
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Dearborn-Tomazos JL, Hu X, Bravata DM, Phadke MA, Baye FM, Myers LJ, Concato J, Zillich AJ, Reeves MJ, Sico JJ. Deintensification or No Statin Treatment Is Associated With Higher Mortality in Patients With Ischemic Stroke or Transient Ischemic Attack. Stroke 2021; 52:2521-2529. [PMID: 34015937 DOI: 10.1161/strokeaha.120.030089] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Jennifer L Dearborn-Tomazos
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.L.D.-T.)
| | - Xin Hu
- Yale Center for Analytical Sciences, New Haven, CT (X.H., M.A.P.)
| | - Dawn M Bravata
- Department of Veterans Affairs Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., F.M.B., L.J.M.).,Indiana University School of Medicine, Indianapolis (D.M.B., F.M.B., L.J.M.).,Regenstrief Institute, Indianapolis, IN (D.M.B.)
| | - Manali A Phadke
- Yale Center for Analytical Sciences, New Haven, CT (X.H., M.A.P.)
| | - Fitsum M Baye
- Department of Veterans Affairs Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., F.M.B., L.J.M.).,Indiana University School of Medicine, Indianapolis (D.M.B., F.M.B., L.J.M.)
| | - Laura J Myers
- Department of Veterans Affairs Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., F.M.B., L.J.M.).,Indiana University School of Medicine, Indianapolis (D.M.B., F.M.B., L.J.M.)
| | - John Concato
- Department of Medicine (J.C.), Yale University School of Medicine, New Haven, CT.,Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD (J.C.)
| | - Alan J Zillich
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN (A.J.Z.)
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Jason J Sico
- Department of Neurology and Department of Internal Medicine (J.J.S.), Yale University School of Medicine, New Haven, CT.,VA Connecticut Healthcare System, West Haven (J.J.S.)
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Rawl SM, Christy SM, Perkins SM, Tong Y, Krier C, Wang HL, Huang AM, Laury E, Rhyant B, Lloyd F, Willis DR, Imperiale TF, Myers LJ, Springston J, Skinner CS, Champion VL. Computer-tailored intervention increases colorectal cancer screening among low-income African Americans in primary care: Results of a randomized trial. Prev Med 2021; 145:106449. [PMID: 33549682 PMCID: PMC8091507 DOI: 10.1016/j.ypmed.2021.106449] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 01/18/2021] [Accepted: 02/02/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Although African Americans have the highest colorectal cancer (CRC) incidence and mortality rates of any racial group, their screening rates remain low. STUDY DESIGN/PURPOSE This randomized controlled trial compared efficacy of two clinic-based interventions for increasing CRC screening among African American primary care patients. METHODS African American patients from 11 clinics who were not current with CRC screening were randomized to receive a computer-tailored intervention (n = 335) or a non-tailored brochure (n = 358) designed to promote adherence to CRC screening. Interventions were delivered in clinic immediately prior to a provider visit. Univariate and multivariable logistic regression models analyzed predictors of screening test completion. Moderators and mediators were determined using multivariable linear and logistic regression analyses. RESULTS Significant effects of the computer-tailored intervention were observed for completion of a stool blood test (SBT) and completion of any CRC screening test (SBT or colonoscopy). The colonoscopy screening rate was higher among those receiving the computer-tailored intervention group compared to the nontailored brochure but the difference was not significant. Predictors of SBT completion were: receipt of the computer-tailored intervention; being seen at a Veterans Affairs Medical Center clinic; baseline stage of adoption; and reason for visit. Mediators of intervention effects were changes in perceived SBT barriers, changes in perceived colonoscopy benefits, changes in CRC knowledge, and patient-provider discussion. Moderators of intervention effects were age, employment, and family/friend recommendation of screening. CONCLUSION This one-time computer-tailored intervention significantly improved CRC screening rates among low-income African American patients. This finding was largely driven by increasing SBT but the impact of the intervention on colonoscopy screening was strong. Implementation of a CRC screening quality improvement program in the VA site that included provision of stool blood test kits and follow-up likely contributed to the strong intervention effect observed at that site. The trial is registered at ClinicalTrials.gov as NCT00672828.
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Affiliation(s)
- Susan M Rawl
- Indiana University School of Nursing, Indianapolis, IN, United States of America; Indiana University Simon Comprehensive Cancer Center, Indianapolis, IN, United States of America.
| | - Shannon M Christy
- Division of Population Science, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, United States of America; Morsani College of Medicine, University of South Florida, Tampa, FL, United States of America
| | - Susan M Perkins
- Indiana University Simon Comprehensive Cancer Center, Indianapolis, IN, United States of America; Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Yan Tong
- Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Connie Krier
- Indiana University School of Nursing, Indianapolis, IN, United States of America
| | - Hsiao-Lan Wang
- College of Nursing, University of South Florida, Tampa, FL, United States of America
| | - Amelia M Huang
- Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Esther Laury
- Villanova University M. Louise Fitzpatrick College of Nursing, Villanova, PA, United States of America
| | - Broderick Rhyant
- Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Frank Lloyd
- Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Deanna R Willis
- Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Thomas F Imperiale
- Indiana University School of Medicine, Indianapolis, IN, United States of America; Roudebush Veterans Affairs Medical Center, Indianapolis, IN, United States of America
| | - Laura J Myers
- Indiana University School of Medicine, Indianapolis, IN, United States of America; Roudebush Veterans Affairs Medical Center, Indianapolis, IN, United States of America
| | - Jeffrey Springston
- Grady College of Journalism and Mass Communication, University of Georgia, Athens, Georgia
| | - Celette Sugg Skinner
- University of Texas Southwestern Medical Center & Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, United States of America
| | - Victoria L Champion
- Indiana University School of Nursing, Indianapolis, IN, United States of America; Indiana University Simon Comprehensive Cancer Center, Indianapolis, IN, United States of America
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Bravata DM, Myers LJ, Perkins AJ, Keyhani S, Zhang Y, Zillich AJ, Dysangco A, Lindsey R, Sharmitha D, Myers J, Austin C, Sexson A, Arling G. Heterogeneity in COVID-19 patient volume, characteristics and outcomes across US Department of Veterans Affairs facilities: an observational cohort study. BMJ Open 2021; 11:e044646. [PMID: 34006034 PMCID: PMC7941674 DOI: 10.1136/bmjopen-2020-044646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Studies describe COVID-19 patient characteristics and outcomes across populations, but reports of variation across healthcare facilities are lacking. The objectives were to examine differences in COVID-19 patient volume and mortality across facilities, and understand whether facility variation in mortality was due primarily to differences in patient versus facility characteristics. DESIGN Observational cohort study with multilevel mixed effects logistic regression modelling. SETTING The Veterans Health Administration (VA) is the largest healthcare system in the USA. PARTICIPANTS Patients with COVID-19. MAIN OUTCOME All-cause mortality within 45 days after COVID-19 testing (March-May, follow-up through 16 July 2020). RESULTS Among 13 510 patients with COVID-19, 3942 (29.2%) were admitted (2266/3942 (57.5%) ward; 1676/3942 (42.5%) intensive care unit (ICU)) and 679/3942 (17.2%) received mechanical ventilation. Marked heterogeneity was observed across facilities in median age (range: 34.3-83.9 years; facility mean: 64.7, SD 7.2 years); patient volume (range: 1-737 at 160 facilities; facility median: 48.5, IQR 14-105.5); hospital admissions (range: 1-286 at 133 facilities; facility median: 11, IQR 1-26.5); ICU caseload (range: 1-85 at 115 facilities; facility median: 4, IQR 0-12); and mechanical ventilation (range: 1-53 at 90 facilities; facility median: 1, IQR 0-5). Heterogeneity was also observed in facility mortality for all patients with COVID-19 (range: 0%-29.7%; facility median: 8.9%, IQR 2.4%-13.7%); inpatients (range: 0%-100%; facility median: 18.0%, IQR 5.6%-28.6%); ICU patients (range: 0%-100%; facility median: 28.6%, IQR 14.3%-50.0%); and mechanical ventilator patients (range: 0%-100%; facility median: 52.7%, IQR 33.3%-80.6%). The majority of variation in facility mortality was attributable to differences in patient characteristics (eg, age). CONCLUSIONS Marked heterogeneity in COVID-19 patient volume, characteristics and mortality were observed across VA facilities nationwide. Differences in patient characteristics accounted for the majority of explained variation in mortality across sites. Variation in unadjusted COVID-19 mortality across facilities or nations should be considered with caution.
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Affiliation(s)
- Dawn M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Health Services Research, Regentrief Institute, Indianapolis, Indiana, USA
| | - Laura J Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Health Services Research, Regentrief Institute, Indianapolis, Indiana, USA
| | - Anthony J Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Salomeh Keyhani
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- Department of General Internal Medicine, San Francisco VA Medical Center, San Francisco, California, USA
- San Francisco VA Medical Center, Department of Veterans Affairs, San Francisco, California, USA
| | - Ying Zhang
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Alan J Zillich
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana, USA
| | - Andrew Dysangco
- Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Reese Lindsey
- Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dev Sharmitha
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Health Services Research, Regentrief Institute, Indianapolis, Indiana, USA
- Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jennifer Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Charles Austin
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Ali Sexson
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Greg Arling
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- School of Nursing, Purdue University System, West Lafayette, Indiana, USA
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Penney LS, Homoya BJ, Damush TM, Rattray NA, Miech EJ, Myers LJ, Baird S, Cheatham A, Bravata DM. Seeding Structures for a Community of Practice Focused on Transient Ischemic Attack (TIA): Implementing Across Disciplines and Waves. J Gen Intern Med 2021; 36:313-321. [PMID: 32875499 PMCID: PMC7878647 DOI: 10.1007/s11606-020-06135-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 08/30/2019] [Accepted: 08/11/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND The Community of Practice (CoP) model represents one approach to address knowledge management to support effective implementation of best practices. OBJECTIVE We sought to identify CoP developmental strategies within the context of a national quality improvement project focused on improving the quality for patients receiving acute transient ischemic attack (TIA) care. DESIGN Stepped wedge trial. PARTICIPANTS Multidisciplinary staff at six Veterans Affairs medical facilities. INTERVENTIONS To encourage site implementation of a multi-component quality improvement intervention, the trial included strategies to improve the development of a CoP: site kickoff meetings, CoP conference calls, and an interactive website (the "Hub"). APPROACH Mixed-methods evaluation included data collected through a CoP attendance log; semi-structured interviews with site participants at 6 months (n = 32) and 12 months (n = 30), and CoP call facilitators (n = 2); and 22 CoP call debriefings. KEY RESULTS The critical seeding structures that supported the cultivation of the CoP were the kickoffs which fostered relationships (key to the community element of CoPs) and provided the evidence base relevant to TIA care (key to the domain element of CoPs). The Hub provided the forum for sharing quality improvement plans and other tools which were further highlighted during the CoP calls (key to the practice element of CoPs). CoP calls were curated to create a positive context around participants' work by recognizing team successes. In addition to improving care at their local facilities, the community created a shared set of tools which built on their collective knowledge and could be shared within and outside the group. CONCLUSIONS The PREVENT CoP advanced the mission of the learning healthcare system by successfully providing a forum for shared learning. The CoP was grown through seeding structures that included kickoffs, CoP calls, and the Hub. A CoP expands upon the learning collaborative implementation strategy as an effective implementation practice.
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Affiliation(s)
- Lauren S Penney
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.
- VA HSR&D Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, San Antonio, TX, USA.
- School of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA.
| | - Barbara J Homoya
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Teresa M Damush
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
- Regenstrief Institute, Inc., Indianapolis, IN, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas A Rattray
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
- Regenstrief Institute, Inc., Indianapolis, IN, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Anthropology, Indiana University-Purdue University, Indianapolis, IN, USA
| | - Edward J Miech
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
- Regenstrief Institute, Inc., Indianapolis, IN, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Laura J Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Sean Baird
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Ariel Cheatham
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Dawn M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
- Regenstrief Institute, Inc., Indianapolis, IN, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
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Bravata DM, Perkins AJ, Myers LJ, Arling G, Zhang Y, Zillich AJ, Reese L, Dysangco A, Agarwal R, Myers J, Austin C, Sexson A, Leonard SJ, Dev S, Keyhani S. Association of Intensive Care Unit Patient Load and Demand With Mortality Rates in US Department of Veterans Affairs Hospitals During the COVID-19 Pandemic. JAMA Netw Open 2021; 4:e2034266. [PMID: 33464319 PMCID: PMC7816100 DOI: 10.1001/jamanetworkopen.2020.34266] [Citation(s) in RCA: 167] [Impact Index Per Article: 55.7] [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: 12/15/2022] Open
Abstract
IMPORTANCE Although strain on hospital capacity has been associated with increased mortality in nonpandemic settings, studies are needed to examine the association between coronavirus disease 2019 (COVID-19) critical care capacity and mortality. OBJECTIVE To examine whether COVID-19 mortality was associated with COVID-19 intensive care unit (ICU) strain. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted among veterans with COVID-19, as confirmed by polymerase chain reaction or antigen testing in the laboratory from March through August 2020, cared for at any Department of Veterans Affairs (VA) hospital with 10 or more patients with COVID-19 in the ICU. The follow-up period was through November 2020. Data were analyzed from March to November 2020. EXPOSURES Receiving treatment for COVID-19 in the ICU during a period of increased COVID-19 ICU load, with load defined as mean number of patients with COVID-19 in the ICU during the patient's hospital stay divided by the number of ICU beds at that facility, or increased COVID-19 ICU demand, with demand defined as mean number of patients with COVID-19 in the ICU during the patient's stay divided by the maximum number of patients with COVID-19 in the ICU. MAIN OUTCOMES AND MEASURES All-cause mortality was recorded through 30 days after discharge from the hospital. RESULTS Among 8516 patients with COVID-19 admitted to 88 VA hospitals, 8014 (94.1%) were men and mean (SD) age was 67.9 (14.2) years. Mortality varied over time, with 218 of 954 patients (22.9%) dying in March, 399 of 1594 patients (25.0%) dying in April, 143 of 920 patients (15.5%) dying in May, 179 of 1314 patients (13.6%) dying in June, 297 of 2373 patients (12.5%) dying in July, and 174 of 1361 (12.8%) patients dying in August (P < .001). Patients with COVID-19 who were treated in the ICU during periods of increased COVID-19 ICU demand had increased risk of mortality compared with patients treated during periods of low COVID-19 ICU demand (ie, demand of ≤25%); the adjusted hazard ratio for all-cause mortality was 0.99 (95% CI, 0.81-1.22; P = .93) for patients treated when COVID-19 ICU demand was more than 25% to 50%, 1.19 (95% CI, 0.95-1.48; P = .13) when COVID-19 ICU demand was more than 50% to 75%, and 1.94 (95% CI, 1.46-2.59; P < .001) when COVID-19 ICU demand was more than 75% to 100%. No association between COVID-19 ICU demand and mortality was observed for patients with COVID-19 not in the ICU. The association between COVID-19 ICU load and mortality was not consistent over time (ie, early vs late in the pandemic). CONCLUSIONS AND RELEVANCE This cohort study found that although facilities augmented ICU capacity during the pandemic, strains on critical care capacity were associated with increased COVID-19 ICU mortality. Tracking COVID-19 ICU demand may be useful to hospital administrators and health officials as they coordinate COVID-19 admissions across hospitals to optimize outcomes for patients with this illness.
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Affiliation(s)
- Dawn M Bravata
- Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Health Services Research and Development, Department of Veterans Affairs, Indianapolis, Indiana
- Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, Indiana
- Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Department of Neurology, Indiana University School of Medicine, Indianapolis
- William M. Tierney Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana
| | - Anthony J Perkins
- Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Health Services Research and Development, Department of Veterans Affairs, Indianapolis, Indiana
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Laura J Myers
- Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Health Services Research and Development, Department of Veterans Affairs, Indianapolis, Indiana
- Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- William M. Tierney Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana
| | - Greg Arling
- Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Health Services Research and Development, Department of Veterans Affairs, Indianapolis, Indiana
- School of Nursing, Purdue University, West Lafayette, Indiana
| | - Ying Zhang
- Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Health Services Research and Development, Department of Veterans Affairs, Indianapolis, Indiana
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha
| | - Alan J Zillich
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, Indiana
| | - Lindsey Reese
- Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Andrew Dysangco
- Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Rajiv Agarwal
- Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Jennifer Myers
- Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Health Services Research and Development, Department of Veterans Affairs, Indianapolis, Indiana
- Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, Indiana
| | - Charles Austin
- Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Health Services Research and Development, Department of Veterans Affairs, Indianapolis, Indiana
- Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, Indiana
| | - Ali Sexson
- Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Health Services Research and Development, Department of Veterans Affairs, Indianapolis, Indiana
- Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, Indiana
| | - Samuel J Leonard
- Northern California Institute for Research and Education, San Francisco
| | - Sharmistha Dev
- Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, Indiana
- Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- William M. Tierney Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana
| | - Salomeh Keyhani
- Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Health Services Research and Development, Department of Veterans Affairs, Indianapolis, Indiana
- San Francisco VA Medical Center, San Francisco, California
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco
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Rattray NA, Damush TM, Miech EJ, Homoya B, Myers LJ, Penney LS, Ferguson J, Giacherio B, Kumar M, Bravata DM. Empowering Implementation Teams with a Learning Health System Approach: Leveraging Data to Improve Quality of Care for Transient Ischemic Attack. J Gen Intern Med 2020; 35:823-831. [PMID: 32875510 PMCID: PMC7652965 DOI: 10.1007/s11606-020-06160-y] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 08/14/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Questions persist about how learning healthcare systems should integrate audit and feedback (A&F) into quality improvement (QI) projects to support clinical teams' use of performance data to improve care quality. OBJECTIVE To identify how a virtual "Hub" dashboard that provided performance data for patients with transient ischemic attack (TIA), a resource library, and a forum for sharing QI plans and tools supported QI activities among newly formed multidisciplinary clinical teams at six Department of Veterans Affairs (VA) medical centers. DESIGN An observational, qualitative evaluation of how team members used a web-based Hub. PARTICIPANTS External facilitators and multidisciplinary team members at VA facilities engaged in QI to improve the quality of TIA care. APPROACH Qualitative implementation process and summative evaluation of observational Hub data (interviews with Hub users, structured field notes) to identify emergent, contextual themes and patterns of Hub usage. KEY RESULTS The Hub supported newly formed multidisciplinary teams in implementing QI plans in three main ways: as an information interface for integrated monitoring of TIA performance; as a repository used by local teams and facility champions; and as a tool for team activation. The Hub enabled access to data that were previously inaccessible and unavailable and integrated that data with benchmark and scientific evidence to serve as a common data infrastructure. Led by champions, each implementation team used the Hub differently: local adoption of the staff and patient education materials; benchmarking facility performance against national rates and peer facilities; and positive reinforcement for QI plan development and monitoring. External facilitators used the Hub to help teams leverage data to target areas of improvement and disseminate local adaptations to promote resource sharing across teams. CONCLUSIONS As a dynamic platform for A&F operating within learning health systems, hubs represent a promising strategy to support local implementation of QI programs by newly formed, multidisciplinary teams.
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Affiliation(s)
- Nicholas A Rattray
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.,Department of Anthropology, Indiana University-Purdue University, Indianapolis, IN, USA.,Regenstrief Institute, Inc., Indianapolis, IN, USA.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Teresa M Damush
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA. .,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA. .,Regenstrief Institute, Inc., Indianapolis, IN, USA. .,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Edward J Miech
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.,Regenstrief Institute, Inc., Indianapolis, IN, USA.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Barbara Homoya
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Laura J Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.,Regenstrief Institute, Inc., Indianapolis, IN, USA.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lauren S Penney
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,Veterans Evidence-Based Research Dissemination and Implementation Center (VERDICT), South Texas Veterans Health Care System, San Antonio, TX, USA.,University of Texas Health San Antonio, San Antonio, TX, USA
| | - Jared Ferguson
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Brenna Giacherio
- Office of Healthcare Transformation (OHT), Veterans Health Administration (VHA), Washington, DC, USA
| | - Meetesh Kumar
- Office of Healthcare Transformation (OHT), Veterans Health Administration (VHA), Washington, DC, USA
| | - Dawn M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.,Regenstrief Institute, Inc., Indianapolis, IN, USA.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
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McGrath M, Smith J, Rattray NA, Lillie A, Crow S, Myers LJ, Myers J, Perkins AJ, Wasmuth S, Burns DS, Cheatham AJ, Patel H, Bravata DM. Teaching pursed-lip breathing through music: MELodica Orchestra for DYspnea (MELODY) trial rationale and protocol. Arts Health 2020; 14:49-65. [PMID: 33064621 DOI: 10.1080/17533015.2020.1827277] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) commonly experience dyspnea, which may limit activities of daily living. Pursed-lip breathing improves dyspnea for COPD patients; however, access to pursed-lip breathing training is limited. METHODS The proposed MELodica Orchestra for DYspnea (MELODY) study will be a single-site pilot study to assess the safety, feasibility, and efficacy of a music-based approach to teach pursed-lip breathing. Patients with COPD and moderate-severe dyspnea are randomized to intervention, education-control, or usual care control groups. Intervention patients meet twice weekly for eight weeks for melodica instruction, group music-making, and COPD education. Safety, feasibility, and efficacy is assessed qualitatively and quantitatively. RESULTS This manuscript describes the rationale and methods of the MELODY pilot project. CONCLUSIONS If pilot data demonstrate efficacy, then a multi-site randomized control trial will be conducted to evaluate program effectiveness and implementation.
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Affiliation(s)
| | - Joseph Smith
- Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Medicine Division of Pulmonary, Critical Care, Sleep & Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Nicholas A Rattray
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.,Center for Health Services Research, Regenstrief Institute, Indianapolis, IN, USA.,Department of Anthropology, IUPUI, Indianapolis, IN, USA
| | - Aimee Lillie
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Shannon Crow
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
| | - Laura J Myers
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Jennifer Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Anthony J Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis, IN, USA
| | - Sally Wasmuth
- School of Occupational Therapy, Indiana University School of Health & Human Sciences, Indianapolis, IN, USA
| | - Debra S Burns
- Department of Music and Arts Technology, Indiana University-Purdue University Indianapolis (IUPUI), Indianapolis, IN, USA
| | - Ariel J Cheatham
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Himalaya Patel
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Dawn M Bravata
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.,Center for Health Services Research, Regenstrief Institute, Indianapolis, IN, USA.,Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, 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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Bravata DM, Myers LJ, Perkins AJ, Zhang Y, Homoya BJ, Miech EJ, Rattray NA, Giacherio B, Kumar M, Penney LS, Cheng E, Levine D, Sico JJ, Myers J, Austin C, Baird S, Damush T. Abstract WP347: The Effectiveness and Implementation of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) Quality Improvement Program: An Exampleofa Learning Healthcare System in Action. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wp347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives:
Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) trial evaluated the implementation of a quality improvement (QI) program aligned with Learning Healthcare System principles to improve TIA care.
Methods:
A facility-based, stepped-wedge trial was conducted at six diverse sites. The intervention included five components: clinical programs, data feedback, professional education, electronic health record tools, and QI support. Implementation strategies included: team activation via audit and feedback, goal setting, reflecting and evaluating, and planning; external facilitation; and building a community of practice. The primary effectiveness outcome was the Without Fail rate (WFR); proportion of TIA patients who received all processes of care for which they were eligible among: brain imaging, carotid artery imaging, neurology consultation, hypertension control, anticoagulation for atrial fibrillation, antithrombotics, high/moderate potency statins. The primary implementation outcomes were the number of improvement activities completed and the Group Organization (GO) scores for providing and improving care (scale of 1-10).
Results:
The 6 PREVENT facilities cared for N=162 control period TIA patients and N=191 intervention period TIA patients. The mean facility WFR increased from 36.7% (baseline) to 53.9% (active implementation); p=0.002 (adjusted for temporal trend, hospital admission). The mean number of improvement activities completed during the 1-year implementation period was 26 (range 11-39). The mean facility GO scores increased: providing care, 1.2 to 6.5; improving care, 1.0 to 6.7.
Conclusions:
PREVENT advances three aspects of a learning healthcare system:
Learning from Data
(teams interacted with their facility’s performance data to explore hypotheses, plan QI activities, and evaluate change over time);
Learning from Each Other
(teams participated in monthly virtual collaborative conferences), and
Sharing Best Practices
(teams shared tools and protocols).
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Affiliation(s)
| | | | | | - Ying Zhang
- Biostatistics, Univ of Nebraska Med Cntr, Omaha, NE
| | | | | | | | | | | | - Lauren S Penney
- Medicine, South Texas Veterans Health Care System, San Antonio, TX
| | - Eric Cheng
- Neurology, Univ of California, Los Angeles, Los Angeles, CA
| | - Deb Levine
- Medicine, Univ of Michigan, Ann Arbor, MI
| | - Jason J Sico
- NEUROLOGY, VA Connecticut Healthcare System, West Haven, CT
| | | | | | - Sean Baird
- Richard L Roudebush VAMC, Indianapolis, IN
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Bravata DM, Myers LJ, Homoya B, Miech EJ, Rattray NA, Perkins AJ, Zhang Y, Ferguson J, Myers J, Cheatham AJ, Murphy L, Giacherio B, Kumar M, Cheng E, Levine DA, Sico JJ, Ward MJ, Damush TM. The protocol-guided rapid evaluation of veterans experiencing new transient neurological symptoms (PREVENT) quality improvement program: rationale and methods. BMC Neurol 2019; 19:294. [PMID: 31747879 PMCID: PMC6865042 DOI: 10.1186/s12883-019-1517-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 06/14/2019] [Accepted: 10/28/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) developed, implemented, and evaluated a TIA quality improvement (QI) intervention aligned with Learning Healthcare System principles. METHODS This stepped-wedge trial developed, implemented and evaluated a provider-facing, multi-component intervention to improve TIA care at six facilities. The unit of analysis was the medical center. The intervention was developed based on benchmarking data, staff interviews, literature, and electronic quality measures and included: performance data, clinical protocols, professional education, electronic health record tools, and QI support. The effectiveness outcome was the without-fail rate: the proportion of patients who receive all processes of care for which they are eligible among seven processes. The implementation outcomes were the number of implementation activities completed and final team organization level. The intervention effects on the without-fail rate were analyzed using generalized mixed-effects models with multilevel hierarchical random effects. Mixed methods were used to assess implementation, user satisfaction, and sustainability. DISCUSSION PREVENT advanced three aspects of a Learning Healthcare System. Learning from Data: teams examined and interacted with their performance data to explore hypotheses, plan QI activities, and evaluate change over time. Learning from Each Other: Teams participated in monthly virtual collaborative calls. Sharing Best Practices: Teams shared tools and best practices. The approach used to design and implement PREVENT may be generalizable to other clinical conditions where time-sensitive care spans clinical settings and medical disciplines. TRIAL REGISTRATION clinicaltrials.gov: NCT02769338 [May 11, 2016].
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Affiliation(s)
- D M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA.
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA.
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA.
- Regenstrief Institute, Indianapolis, IN, USA.
| | - L J Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - B Homoya
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - E J Miech
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - N A Rattray
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - A J Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Y Zhang
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | - J Ferguson
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - J Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - A J Cheatham
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - L Murphy
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - B Giacherio
- Office of Healthcare Transformation (OHT), Veterans Health Administration (VHA), Washington, DC, USA
| | - M Kumar
- Office of Healthcare Transformation (OHT), Veterans Health Administration (VHA), Washington, DC, USA
| | - E Cheng
- Department of Neurology, VA Greater Los Angeles Healthcare System, California, Los Angeles, USA
- Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles, California, Los Angeles, USA
| | - D A Levine
- Department of Internal Medicine and Neurology and Institute for Health Policy and Innovation, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - J J Sico
- Clinical Epidemiology Research Center and Neurology Service, VA Connecticut Healthcare System, West Haven, CT, USA
- Departments of Internal Medicine and Neurology and Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA
| | - M J Ward
- VA Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - T M Damush
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
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Koo BB, Sico JJ, Myers LJ, Perkins AJ, Levine D, Miech EJ, Damush TM, Rattray N, Homoya B, Ferguson J, Myers J, Zhang Y, Bravata DM. Polysomnography Utilization in Veterans Presenting Acutely with Ischemic Stroke or Transient Ischemic Attack. Cerebrovasc Dis 2019; 48:179-183. [PMID: 31722335 DOI: 10.1159/000504406] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 10/28/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is an independent cerebrovascular risk factor and highly prevalent in patients with ischemic stroke and transient ischemic attack (TIA). Timely diagnosis and treatment of OSA is important as clinical data suggest that treatment of OSA in the setting of acute ischemic stroke improves functional outcomes. We aimed to assess polysomnography (PSG) utilization in US. Veterans with acute stroke or TIA over a 2-year period. METHODS Veterans with acute ischemic stroke or TIA presenting to a Veterans Administration Medical Center (VAMC) between October 1, 2015, and June 30, 2017, were included. Demographic, clinical data, and PSG within 12 months of hospital discharge were obtained from the VA Corporate Data Warehouse to determine the rate of PSG testing among those with acute ischemic stroke or TIA. Fisher's exact test and two-sample t tests were used to compare demographic and clinical characteristics for those receiving and not receiving PSG. Mixed effect logistic regression was used to model the association of clinical and demographic characteristics with PSG receipt. RESULTS In fiscal years (FYs) 2016 and 2017, 9,200 Veterans were admitted to a VAMC with ischemic stroke (6,011) or TIA (3,089). Veterans were elderly (70.5 ± 11.1 years), predominantly male (95.7%), and largely Caucasian (68.0% Caucasian, 26.3% African-American). Just 6.0% of Veterans underwent PSG within 1 year of acute ischemic stroke or TIA in FY 2016, compared to 6.2% in FY 2017 (p = 0.72). Compared to Veterans ≥80 years, those <60 had adjusted OR of 6.73 (4.10-11.05), those 60-69 had OR 4.29 (2.73-6.74), and those 70-79 had OR 2.63 (1.66-4.18) of having PSG. Veterans with diabetes or heart failure had significantly higher odds, whereas those with dementia had significantly lower odds of receiving PSG. CONCLUSION PSG utilization among US Veterans is low and stable over time, despite recent guidelines recommending PSG among those having stroke or TIA. Older Veterans and those with dementia were unlikely to get PSG, representing especially vulnerable populations.
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Affiliation(s)
- Brian B Koo
- Department of Neurology, VA Connecticut, West Haven, Connecticut, USA, .,Department of Neurology, Yale University, West Haven, Connecticut, USA,
| | - Jason J Sico
- Department of Neurology, VA Connecticut, West Haven, Connecticut, USA.,Department of Neurology, Yale University, West Haven, Connecticut, USA
| | - Laura J Myers
- VA Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA.,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VAMC, Indianapolis, Indiana, USA.,Department of Internal Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Anthony J Perkins
- VA Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA.,Department of Biostatistics, Indiana University, Indianapolis, Indiana, USA
| | - Deborah Levine
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Edward J Miech
- VA Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA.,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VAMC, Indianapolis, Indiana, USA.,Department of Internal Medicine, Indiana University, Indianapolis, Indiana, USA.,Regenstrief Institute, Indianapolis, Indiana, USA.,Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Teresa M Damush
- VA Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA.,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VAMC, Indianapolis, Indiana, USA.,Department of Internal Medicine, Indiana University, Indianapolis, Indiana, USA.,Regenstrief Institute, Indianapolis, Indiana, USA
| | - Nicholas Rattray
- VA Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA.,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VAMC, Indianapolis, Indiana, USA.,Regenstrief Institute, Indianapolis, Indiana, USA
| | - Barbara Homoya
- VA Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA.,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VAMC, Indianapolis, Indiana, USA
| | - Jared Ferguson
- VA Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA.,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VAMC, Indianapolis, Indiana, USA
| | - Jennifer Myers
- VA Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA.,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VAMC, Indianapolis, Indiana, USA
| | - Ying Zhang
- VA Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA.,Department of Biostatistics, Indiana University, Indianapolis, Indiana, USA
| | - Dawn M Bravata
- VA Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA.,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VAMC, Indianapolis, Indiana, USA.,Department of Internal Medicine, Indiana University, Indianapolis, Indiana, USA.,Regenstrief Institute, Indianapolis, Indiana, USA.,Department of Neurology, Indiana University, Indianapolis, Indiana, USA
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Bravata DM, Myers LJ, Arling G, Miech EJ, Damush T, Sico JJ, Phipps MS, Zillich AJ, Yu Z, Reeves M, Williams LS, Johanning J, Chaturvedi S, Baye F, Ofner S, Austin C, Ferguson J, Graham GD, Rhude R, Kessler CS, Higgins DS, Cheng E. Quality of Care for Veterans With Transient Ischemic Attack and Minor Stroke. JAMA Neurol 2019; 75:419-427. [PMID: 29404578 DOI: 10.1001/jamaneurol.2017.4648] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Importance The timely delivery of guideline-concordant care may reduce the risk of recurrent vascular events for patients with transient ischemic attack (TIA) and minor stroke. Although many health care organizations measure stroke care quality, few evaluate performance for patients with TIA or minor stroke, and most include only a limited subset of guideline-recommended processes. Objective To assess the quality of guideline-recommended TIA and minor stroke care across the Veterans Health Administration (VHA) system nationwide. Design, Setting, and Participants This cohort study included 8201 patients with TIA or minor stroke cared for in any VHA emergency department (ED) or inpatient setting during federal fiscal year 2014 (October 1, 2013, through September 31, 2014). Patients with length of stay longer than 6 days, ventilator use, feeding tube use, coma, intensive care unit stay, inpatient rehabilitation stay before discharge, or receipt of thrombolysis were excluded. Outlier facilities for each process of care were identified by constructing 95% CIs around the facility pass rate and national pass rate sites when the 95% CIs did not overlap. Data analysis occurred from January 16, 2016, through June 30, 2017. Main Outcomes and Measures Ten elements of care were assessed using validated electronic quality measures. Results In the 8201 patients included in the study (mean [SD] age, 68.8 [11.4] years; 7877 [96.0%] male; 4856 [59.2%] white), performance varied across elements of care: brain imaging by day 2 (6720/7563 [88.9%]; 95% CI, 88.2%-89.6%), antithrombotic use by day 2 (6265/7477 [83.8%]; 95% CI, 83.0%-84.6%), hemoglobin A1c measurement by discharge or within the preceding 120 days (2859/3464 [82.5%]; 95% CI, 81.2%-83.8%), anticoagulation for atrial fibrillation by day 7 after discharge (1003/1222 [82.1%]; 95% CI, 80.0%-84.2%), deep vein thrombosis prophylaxis by day 2 (3253/4346 [74.9%]; 95% CI, 73.6%-76.2%), hypertension control by day 90 after discharge (4292/5979 [71.8%]; 95% CI, 70.7%-72.9%), neurology consultation by day 1 (5521/7823 [70.6%]; 95% CI, 69.6%-71.6%), electrocardiography by day 2 or within 1 day prior (5073/7570 [67.0%]; 95% CI, 65.9%-68.1%), carotid artery imaging by day 2 or within 6 months prior (4923/7685 [64.1%]; 95% CI, 63.0%-65.2%), and moderate- to high-potency statin prescription by day 7 after discharge (3329/7054 [47.2%]; 95% CI, 46.0%-48.4%). Performance varied substantially across facilities (eg, neurology consultation had a facility outlier rate of 53.0%). Performance was higher for admitted patients than for patients cared for only in EDs with the greatest disparity for carotid artery imaging (4478/5927 [75.6%] vs 445/1758 [25.3%]; P < .001). Conclusions and Relevance This national study of VHA system quality of care for patients with TIA or minor stroke identified opportunities to improve care quality, particularly for patients who were discharged from the ED. Health care systems should engage in ongoing TIA care performance assessment to complement existing stroke performance measurement.
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Affiliation(s)
- Dawn M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,VA HSR&D 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
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
| | - Greg Arling
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,Purdue University School of Nursing, West Lafayette, Indiana
| | - Edward J Miech
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.,Regenstrief Institute, Indianapolis, Indiana.,Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Teresa Damush
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,VA HSR&D 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
| | - Jason J Sico
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.,Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Michael S Phipps
- Department of Neurology, University of Maryland School of Medicine, Baltimore
| | - Alan J Zillich
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana
| | - Zhangsheng Yu
- Department of Biostatistics, Indiana University School of Medicine, Indiana University-Purdue University, Indianapolis
| | - Mathew Reeves
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,Department of Epidemiology, Michigan State University, East Lansing
| | - Linda S Williams
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.,Department of Neurology, Indiana University School of Medicine, Indianapolis.,Regenstrief Institute, Indianapolis, Indiana
| | - Jason Johanning
- VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha.,Department of Surgery, University of Nebraska, Omaha
| | - Seemant Chaturvedi
- Department of Neurology, Miami VA Medical Center, Miami, Florida.,Department of Neurology, University of Miami School of Medicine, Miami, Florida
| | - Fitsum Baye
- Department of Biostatistics, Indiana University School of Medicine, Indiana University-Purdue University, Indianapolis
| | - Susan Ofner
- Department of Biostatistics, Indiana University School of Medicine, Indiana University-Purdue University, Indianapolis
| | - Curt Austin
- VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
| | - Jared Ferguson
- VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.,Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Glenn D Graham
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,Specialty Care Services, Department of Veterans Affairs, Washington, DC.,Department of Neurology, University of California, San Francisco (UCSF) School of Medicine, San Francisco
| | - Rachel Rhude
- VA Inpatient Evaluation Center, Cincinnati, Ohio
| | - Chad S Kessler
- Specialty Care Services, VA Central Office, Washington, DC.,Department of Emergency Medicine, Durham VA Medical Center, Durham, North Carolina
| | - Donald S Higgins
- Specialty Care Services, Department of Veterans Affairs, Washington, DC.,Department of Neurology, Stratton VA Medical Center, Albany, New York
| | - Eric Cheng
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Neurology, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
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Homoya BJ, Damush TM, Sico JJ, Miech EJ, Arling GW, Myers LJ, Ferguson JB, Phipps MS, Cheng EM, Bravata DM. Uncertainty as a Key Influence in the Decision To Admit Patients with Transient Ischemic Attack. J Gen Intern Med 2019; 34:1715-1723. [PMID: 30484102 PMCID: PMC6712185 DOI: 10.1007/s11606-018-4735-9] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 09/11/2018] [Accepted: 10/26/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with transient ischemic attacks (TIA) are at high risk of subsequent vascular events. Hospitalization improves quality of care, yet admission rates for TIA patients vary considerably. OBJECTIVES We sought to identify factors associated with the decision to admit patents with TIA. DESIGN We conducted a secondary analysis of a prior study's data including semi-structured interviews, administrative data, and chart review. PARTICIPANTS We interviewed multidisciplinary clinical staff involved with TIA care. Administrative data included information for TIA patients in emergency departments or inpatient settings at VA medical centers (VAMCs) for fiscal years (FY) 2011 and 2014. Chart reviews were conducted on a subset of patients from 12 VAMCs in FY 2011. APPROACH For the qualitative data, we focused on interviewees' responses to the prompt: "Tell me what influences you in the decision to or not to admit TIA patients." We used administrative data to identify admission rates and chart review data to identify ABCD2 scores (a tool to classify stroke risk after TIA). KEY RESULTS Providers' decisions to admit TIA patients were related to uncertainty in several domains: lack of a facility TIA-specific policy, inconsistent use of ABCD2 score, and concerns about facilities' ability to complete a timely workup. There was a disconnect between staff perceptions about TIA admission and facility admission rates. According to chart review data, staff at facilities with higher admission rates in FY 2011 reported consistent reliance on ABCD2 scores and related guidelines in admission decision-making. CONCLUSIONS Many factors contributed to decisions regarding admitting a patient with TIA; however, clinicians' uncertainty appeared to be a key driver. Further quality improvement interventions for TIA care should focus on facility adoption of TIA protocols to address uncertainty in TIA admission decision-making and to standardize timely evaluation of TIA patients and delivery of secondary prevention strategies.
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Affiliation(s)
- Barbara J Homoya
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA. .,VA HSR&D Center for Health Information and Communication (CHIC), Veteran Health Indiana, Indianapolis, IN, USA.
| | - Teresa M Damush
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Veteran Health Indiana, Indianapolis, IN, USA.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Indianapolis, IN, USA
| | - Jason J Sico
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT, USA.,Departments of Internal Medicine and Neurology and Center for NeuroEpidemiological and Clinical Research, Yale School of Medicine, New Haven, CT, USA
| | - Edward J Miech
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Veteran Health Indiana, Indianapolis, IN, USA.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Indianapolis, IN, USA.,Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gregory W Arling
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,Regenstrief Institute, Indianapolis, IN, USA.,Purdue University School of Nursing, West Lafayette, IN, USA
| | - Laura J Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Veteran Health Indiana, Indianapolis, IN, USA.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jared B Ferguson
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Veteran Health Indiana, Indianapolis, IN, USA
| | - Michael S Phipps
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eric M Cheng
- Department of Neurology, Los Angeles School of Medicine, University of California, Los Angeles, CA, USA
| | - Dawn M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Veteran Health Indiana, Indianapolis, IN, USA.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Indianapolis, IN, USA.,Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
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Li J, Zhang Y, Myers LJ, Bravata DM. Power calculation in stepped-wedge cluster randomized trial with reduced intervention sustainability effect. J Biopharm Stat 2019; 29:663-674. [PMID: 31317805 DOI: 10.1080/10543406.2019.1633658] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The stepped-wedge design for pragmatic clinical trials has received increased attention in health service-related research seeking to evaluate the effect of interventions. Compared with the parallel design, the stepped-wedge design is preferred when there is prior knowledge supporting the effectiveness and harmlessness of the intervention, and/or when practical or financial constraints exist such that the intervention can only be implemented sequentially on a fraction of clusters. In some health service studies, the study period may consist of two parts: an active implementation followed by a sustainability phase, where the intervention effect is possibly reduced. There is a gap in current literature of the stepped-wedge design for cluster randomization trials for dealing with this specific scenario. We aim to provide an analytical formula for power analysis under this situation to aid the stepped-wedge design of an ongoing PREVENT trial.
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Affiliation(s)
- Jing Li
- a Department of Biostatistics, Richard M. Fairbanks School of Public Health, Indiana University , Indianapolis , IN , USA
| | - Ying Zhang
- b Department of Biostatistics, College of Public Health, University of Nebraska Medical Center , Omaha , NE , USA
| | - Laura J Myers
- c Health Services Research Service, Richard L. Roudebush VA Medical Center , Indianapolis , IN , USA.,d Department of Internal Medicine, Indiana University School of Medicine , Indianapolis , IN , USA
| | - Dawn M Bravata
- c Health Services Research Service, Richard L. Roudebush VA Medical Center , Indianapolis , IN , USA.,d Department of Internal Medicine, Indiana University School of Medicine , Indianapolis , IN , USA.,e Center for Health Services Research, Regenstrief Institute , Indianapolis , IN , USA
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Bravata DM, Myers LJ, Reeves M, Cheng EM, Baye F, Ofner S, Miech EJ, Damush T, Sico JJ, Zillich A, Phipps M, Williams LS, Chaturvedi S, Johanning J, Yu Z, Perkins AJ, Zhang Y, Arling G. Processes of Care Associated With Risk of Mortality and Recurrent Stroke Among Patients With Transient Ischemic Attack and Nonsevere Ischemic Stroke. JAMA Netw Open 2019; 2:e196716. [PMID: 31268543 PMCID: PMC6613337 DOI: 10.1001/jamanetworkopen.2019.6716] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 12/12/2022] Open
Abstract
IMPORTANCE Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes. OBJECTIVE To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This cohort study included all patients with TIA or nonsevere ischemic stroke at Department of Veterans Affairs emergency department or inpatient settings from October 2010 to September 2011. Multivariable logistic regression was used to model associations of processes of care and without-fail care, defined as receiving all guideline-concordant processes of care for which patients are eligible, with risk of death and recurrent stroke. Data were analyzed from March 2018 to April 2019. MAIN OUTCOMES AND MEASURES Risk of all-cause mortality and recurrent ischemic stroke at 90 days and 1 year was calculated. Overall, 28 processes of care were examined. Without-fail care was assessed for 6 processes: brain imaging, carotid artery imaging, hypertension medication intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation. RESULTS Among 8076 patients, the mean (SD) age was 67.8 (11.6) years, 7752 patients (96.0%) were men, 5929 (73.4%) were white, 474 (6.1%) had a recurrent ischemic stroke within 90 days, 793 (10.7%) had a recurrent ischemic stroke within 1 year, 320 (4.0%) died within 90 days, and 814 (10.1%) died within 1 year. Overall, 9 processes were independently associated with lower odds of both 90-day and 1-year mortality after adjustment for multiple comparisons: carotid artery imaging (90-day adjusted odds ratio [aOR], 0.49; 95% CI, 0.38-0.63; 1-year aOR, 0.61; 95% CI, 0.52-0.72), antihypertensive medication class (90-day aOR, 0.58; 95% CI, 0.45-0.74; 1-year aOR, 0.70; 95% CI, 0.60-0.83), lipid measurement (90-day aOR, 0.68; 95% CI, 0.51-0.90; 1-year aOR, 0.64; 95% CI, 0.53-0.78), lipid management (90-day aOR, 0.46; 95% CI, 0.33-0.65; 1-year aOR, 0.67; 95% CI, 0.53-0.85), discharged receiving statin medication (90-day aOR, 0.51; 95% CI, 0.36-0.73; 1-year aOR, 0.70; 95% CI, 0.55-0.88), cholesterol-lowering medication intensification (90-day aOR, 0.47; 95% CI, 0.26-0.83; 1-year aOR, 0.56; 95% CI, 0.41-0.77), antithrombotics by day 2 (90-day aOR, 0.56; 95% CI, 0.40-0.79; 1-year aOR, 0.69; 95% CI, 0.55-0.87) or at discharge (90-day aOR, 0.59; 95% CI, 0.41-0.86; 1-year aOR, 0.69; 95% CI, 0.54-0.88), and neurology consultation (90-day aOR, 0.67; 95% CI, 0.52-0.87; 1-year aOR, 0.74; 95% CI, 0.63-0.87). Anticoagulation for atrial fibrillation was associated with lower odds of 1-year mortality only (aOR, 0.59; 95% CI, 0.40-0.85). No processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons. The rate of without-fail care was 15.3%; 1216 patients received all guideline-concordant processes of care for which they were eligible. Without-fail care was associated with a 31.2% lower odds of 1-year mortality (aOR, 0.69; 95% CI, 0.55-0.87) but was not independently associated with stroke risk. CONCLUSIONS AND RELEVANCE Patients who received 6 readily available processes of care had lower adjusted mortality 1 year after TIA or nonsevere ischemic stroke. Clinicians caring for patients with TIA and nonsevere ischemic stroke should seek to ensure that patients receive all guideline-concordant processes of care for which they are eligible.
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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
- 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
| | - Mathew Reeves
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Department of Epidemiology, Michigan State University, East Lansing
| | - 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
| | - Fitsum Baye
- 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
| | - Susan Ofner
- 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
| | - 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
| | - Teresa 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
| | - Jason J. Sico
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven
| | - Alan Zillich
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana
| | - Michael Phipps
- Department of Neurology, University of Maryland School of Medicine, Baltimore
| | - Linda S. Williams
- 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
- Department of Neurology, Indiana University School of Medicine, Indianapolis
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland School of Medicine, Baltimore
| | - Jason Johanning
- Omaha Division, VA Nebraska-Western Iowa Health Care System, Omaha
- Department of Surgery, University of Nebraska, Lincoln
| | - Zhangsheng Yu
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven
| | - 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
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven
| | - Ying Zhang
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven
| | - Greg Arling
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Purdue University School of Nursing, Lafayette, Indiana
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Bravata DM, Coffing JM, Kansagara D, Myers J, Murphy L, Homoya BJ, Perkins AJ, Snow K, Quin JA, Zhang Y, Myers LJ. Association Between Antithrombotic Medication Use After Bioprosthetic Aortic Valve Replacement and Outcomes in the Veterans Health Administration System. JAMA Surg 2019; 154:e184679. [PMID: 30586138 DOI: 10.1001/jamasurg.2018.4679] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The recommendations about antithrombotic medication use after bioprosthetic aortic valve replacement (bAVR) vary. Objectives To describe the post-bAVR antithrombotic medication practice across the Veterans Health Administration (VHA) and to assess the association between antithrombotic strategies and post-bAVR outcomes. Design, Setting, and Participants Retrospective cohort study. Multivariable modeling with propensity scores was conducted to adjust for differences in patient characteristics across the 3 most common antithrombotic medication strategies (aspirin plus warfarin sodium, aspirin only, and dual antiplatelets). Text mining of notes was used to identify the patients with bAVR (fiscal years 2005-2015). Main Outcomes and Measures This study used VHA and non-VHA outpatient pharmacy data and text notes to classify the following antithrombotic medications prescribed within 1 week after discharge from the bAVR hospitalization: aspirin plus warfarin, aspirin only, dual antiplatelets, no antithrombotics, other only, and warfarin only. The 90-day outcomes included all-cause mortality, thromboembolism risk, and bleeding events. Outcomes were identified using primary diagnosis codes from emergency department visits or hospital admissions. Results The cohort included 9060 veterans with bAVR at 47 facilities (mean [SD] age, 69.3 [8.8] years; 98.6% male). The number of bAVR procedures per year increased from 610 in fiscal year 2005 to 1072 in fiscal year 2015. The most commonly prescribed antithrombotic strategy was aspirin only (4240 [46.8%]), followed by aspirin plus warfarin (1638 [18.1%]), no antithrombotics (1451 [16.0%]), dual antiplatelets (1010 [11.1%]), warfarin only (439 [4.8%]), and other only (282 [3.1%]). Facility variation in antithrombotic prescription patterns was observed. During the 90-day post-bAVR period, adverse events were uncommon, including all-cause mortality in 127 (1.4%), thromboembolism risk in 142 (1.6%), and bleeding events in 149 (1.6%). No differences in 90-day mortality or thromboembolism were identified across the 3 antithrombotic medication groups in either the unadjusted or adjusted models. Patients receiving the combination of aspirin plus warfarin had higher odds of bleeding than patients receiving aspirin only in the unadjusted analysis (odds ratio, 2.58; 95% CI, 1.71-3.89) and after full risk adjustment (adjusted odds ratio, 1.92; 95% CI, 1.17-3.14). Conclusions and Relevance These data demonstrate that bAVR procedures are increasingly being performed in VHA facilities and that aspirin only was the most commonly used antithrombotic medication strategy after bAVR. The risk-adjusted results suggest that the combination of aspirin plus warfarin does not improve either all-cause mortality or thromboembolism risk but increases the risk of bleeding events compared with aspirin only.
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Affiliation(s)
- Dawn M Bravata
- Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, Indiana.,Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, 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
| | - Jessica M Coffing
- Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, Indiana
| | - Devan Kansagara
- VA Evidence-Based Synthesis Program, Portland, Oregon.,Department of Internal Medicine, Portland VA Medical Center, Portland, Oregon.,Department of Internal Medicine, Oregon Health & Science University, Portland.,Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Jennifer Myers
- Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, Indiana.,Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
| | - Lauren Murphy
- Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, Indiana.,Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana.,Regenstrief Institute, Indianapolis, Indiana
| | - Barbara J Homoya
- Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, Indiana.,Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
| | - Anthony J Perkins
- 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
| | - Kathryn Snow
- Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, Indiana
| | - Jacquelyn A Quin
- Department of Surgery, VA Boston Healthcare System, West Roxbury, Massachusetts
| | - Ying Zhang
- 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
| | - Laura J Myers
- Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, Indiana.,Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
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Kahi CJ, Pohl H, Myers LJ, Robertson DJ, Imperiale TF. Colonoscopy and Colorectal Cancer Mortality. Ann Intern Med 2018; 169:424-425. [PMID: 30242410 DOI: 10.7326/l18-0297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Charles J Kahi
- Richard L. Roudebush VA Medical Center and Indiana University School of Medicine, Indianapolis, Indiana (C.J.K., L.J.M.)
| | - Heiko Pohl
- VA White River Junction, White River Junction, Vermont (H.P.)
| | - Laura J Myers
- Richard L. Roudebush VA Medical Center and Indiana University School of Medicine, Indianapolis, Indiana (C.J.K., L.J.M.)
| | | | - Thomas F Imperiale
- Richard L. Roudebush VA Medical Center, Indiana University School of Medicine, and Regenstrief Institute, Indianapolis, Indiana (T.F.I.)
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Bravata DM, Myers LJ, Cheng E, Reeves M, Baye F, Yu Z, Damush T, Miech EJ, Sico J, Phipps M, Zillich A, Johanning J, Chaturvedi S, Austin C, Ferguson J, Maryfield B, Snow K, Ofner S, Graham G, Rhude R, Williams LS, Arling G. Development and Validation of Electronic Quality Measures to Assess Care for Patients With Transient Ischemic Attack and Minor Ischemic Stroke. Circ Cardiovasc Qual Outcomes 2018; 10:CIRCOUTCOMES.116.003157. [PMID: 28912200 DOI: 10.1161/circoutcomes.116.003157] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 07/12/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite interest in using electronic health record (EHR) data to assess quality of care, the accuracy of such data is largely unknown. We sought to develop and validate transient ischemic attack and minor ischemic stroke electronic quality measures (eQMs) using EHR data. METHODS AND RESULTS A random sample of patients with transient ischemic attack or minor ischemic stroke, cared for in Veterans Health Administration facilities (fiscal year 2011), was identified. We constructed 31 eQMs based on existing quality measures. Chart review was the criterion standard for validating the eQMs. To evaluate eQMs in terms of eligibility, we calculated the proportion of patients who were genuinely not eligible to receive a process (based on chart review) and who were correctly identified as not eligible by the EHR data (specificity). To assess eQMs about classification of whether patients received a process, we calculated the proportion of patients who actually received the process (based on chart review) and who were classified correctly by the EHR data as passing (sensitivity). Seven hundred sixty-three patients were included. About eligibility, specificity varied from 25% (brain imaging; carotid imaging) to 99% (anticoagulation quality). About pass rates, sensitivity varied from 30% (antihypertensive class) to 100% (coronary risk assessment; international normalized ratio measured). The 16 eQMs with ≥70% specificity in eligibility and ≥70% sensitivity in pass rates included coronary risk assessment, international normalized ratio measured, HbA1c measurement, speech language pathology consultation, anticoagulation for atrial fibrillation, discharge on statin, lipid management, neurology consultation, Holter, deep vein thrombosis prophylaxis, oral hypoglycemic intensification, cholesterol medication intensification, antihypertensive intensification, antihypertensive class, carotid stenosis intervention, and substance abuse referral for alcohol. CONCLUSIONS It is feasible to construct valid eQMs for processes of transient ischemic attack and minor ischemic stroke care. Healthcare systems with EHRs should consider using electronic data to evaluate care for their patients with transient ischemic attack and to complement and expand quality measurement programs currently focused on patients with stroke.
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Affiliation(s)
- Dawn M Bravata
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.).
| | - Laura J Myers
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Eric Cheng
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Mathew Reeves
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Fitsum Baye
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Zhangsheng Yu
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Teresa Damush
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Edward J Miech
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Jason Sico
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Michael Phipps
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Alan Zillich
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Jason Johanning
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Seemant Chaturvedi
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Curt Austin
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Jared Ferguson
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Bailey Maryfield
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Kathy Snow
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Susan Ofner
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Glenn Graham
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Rachel Rhude
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Linda S Williams
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
| | - Greg Arling
- From the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Washington, DC (D.M.B., L.J.M., E.C., M.R., T.D., E.J.M., B.M., G.G., L.S.W., G.A.); VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B., L.J.M., T.D., E.J.M., C.A., J.F., B.M., K.S., L.S.W.); Department of Internal Medicine (D.M.B., L.J.M., T.D., E.J.M., C.A.) and Department of Neurology (D.M.B., L.S.W.), and Department of Emergency Medicine (E.J.M.), Indiana University School of Medicine, Indianapolis; Regenstrief Institute, Indianapolis, IN (D.M.B., T.D., E.J.M., L.S.W.); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha, NE (J.J.); Department of Surgery, University of Nebraska, Lincoln (J.J.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (J.S.); Departments of Internal Medicine and Neurology, Yale University School of Medicine, New Haven, CT (J.S., J.F.); School of Nursing, Purdue University, West Lafayette, IN (G.A.); Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis (F.B., Z.Y., S.O.); Department of Neurology, University of Maryland School of Medicine, Baltimore (M.P.); Miami VA Medical Center (S.C.); Department of Neurology, School of Medicine, University of Miami, FL (S.C.); Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN (A.Z.); Department of Epidemiology, Michigan State University, East Lansing (M.R.); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, CA (E.C.); Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles (E.C.); and Department of Veterans Affairs, Office of Analytics and Business Intelligence, In-Patient Evaluation Center (IPEC), Cincinnati, OH (R.R.)
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Outcalt SD, Nicolaidis C, Bair MJ, Myers LJ, Miech EJ, Matthias MS. A Qualitative Examination of Pain Centrality Among Veterans of Iraq and Afghanistan Conflicts. Pain Med 2018; 18:211-219. [PMID: 28204704 DOI: 10.1093/pm/pnw137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Centrality of pain refers to the degree to which a patient views chronic pain as integral to his or her life or identity. The purpose of this study was to gain a richer understanding of pain centrality from the perspective of patients who live with chronic pain. Methods Face-to-face interviews were conducted with 26 Veterans with chronic and disabling musculoskeletal pain after completing a stepped care intervention within a randomized controlled trial. Qualitative data were analyzed using an immersion/crystallization approach. We evaluated the role centrality plays in Veterans’ lives and examined whether and how their narratives differ when centrality either significantly decreases or increases after participation in a stepped care intervention for chronic pain. Results Our data identified three emergent themes that characterized pain centrality: 1) control, 2) acceptance, and 3) preoccupation. We identified five characteristics that distinguished patients’ changes in centrality from baseline: 1) biopsychosocial viewpoint, 2) activity level, 3) pain communication, 4) participation in managing own pain, and 5) social support. Conclusions This study highlights centrality of pain as an important construct to consider within the overall patient experience of chronic pain.
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Affiliation(s)
- Samantha D Outcalt
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN, Indianapolis, Indiana, USA.,Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute Inc, Indianapolis, IN, USA
| | - Christina Nicolaidis
- Regional Research Institute, School of Social Work, Portland State University, Portland, Oregon.,Departments of Medicine and Public Health & Preventive Medicine, Oregon Health & Science University, Portland, Oregon
| | - Matthew J Bair
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN, Indianapolis, Indiana, USA.,Regenstrief Institute Inc, Indianapolis, IN, USA
| | - Laura J Myers
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN, Indianapolis, Indiana, USA
| | - Edward J Miech
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN, Indianapolis, Indiana, USA.,Regenstrief Institute Inc, Indianapolis, IN, USA.,Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marianne S Matthias
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN, Indianapolis, Indiana, USA.,Regenstrief Institute Inc, Indianapolis, IN, USA.,Department of Communication Studies, IUPUI, Indianapolis, Indiana USA
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49
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Sico JJ, Baye F, Myers LJ, Concato J, Ferguson J, Cheng EM, Jadbabaie F, Yu Z, Arling G, Zillich AJ, Reeves MJ, Williams LS, Bravata DM. Receipt of cardiac screening does not influence 1-year post-cerebrovascular event mortality. Neurol Clin Pract 2018; 8:192-200. [PMID: 30105158 PMCID: PMC6075977 DOI: 10.1212/cpj.0000000000000465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 03/16/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND American Heart Association/American Stroke Association expert consensus guidelines recommend consideration of cardiac stress testing to screen for occult coronary heart disease (CHD) among patients with ischemic stroke/TIA who have a high-risk Framingham Cardiac Risk Score (FCRS). Whether this guideline is being implemented in routine clinical practice, and the association of its implementation with mortality, is less clear. METHODS Study participants were Veterans with stroke/TIA (n = 11,306) during fiscal year 2011 who presented to a VA Emergency Department or who were admitted. Patients were excluded (n = 6,915) based on prior CHD/angina/chest pain history, receipt of cardiac stress testing within 18 months prior to cerebrovascular event, death within 90 days of discharge, discharge to hospice, transfer to a non-VA acute care facility, or missing/unknown race. FCRS ≥20% was classified as high risk for CHD. ICD-9 and Common Procedural Terminology codes were used to identify receipt of any cardiac stress testing. RESULTS Among 4,391 eligible patients, 62.8% (n = 2,759) had FCRS ≥20%. Cardiac stress testing was performed infrequently and in similar proportion among high-risk (4.5% [123/2,759]) vs low/intermediate-risk (4.4% [72/1,632]) patients (adjusted odds ratio [aOR] 0.77, 95% confidence interval [CI] 0.54-1.10). Receipt of stress testing was not associated with reduced 1-year mortality (aOR 0.59, CI 0.26-1.30). CONCLUSIONS In this observational cohort study of patients with cerebrovascular disease, cardiac screening was relatively uncommon and was not associated with 1-year mortality. Additional work is needed to understand the utility of CHD screening among high-risk patients with cerebrovascular disease.
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Affiliation(s)
- Jason J Sico
- Neurology Service (JJS), Clinical Epidemiology Research Center (CERC) (JJS, JC), and Medical Service (JC, FJ), VA Connecticut Healthcare System, West Haven; Department of Neurology (JJS), Center for Neuroepidemiological and Clinical Research (JJS), and Department of Internal Medicine (JJS, JC, JF, FJ), Yale School of Medicine, New Haven, CT; VA Health Services Research and Development (HSR&D) Center for Health Information and Communication (CHIC) (FB, LJM, JF, LSW, DMB) and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI) (FB, LJM, JF, LSW, DMB), Richard L. Roudebush VA Medical Center, Indianapolis; Departments of Biostatistics (FB, ZY), Internal Medicine (LJM, DMB), and Neurology (LSW, DMB), Indiana University School of Medicine, Indianapolis; Department of Neurology (EMC), VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California, Los Angeles; College of Health and Human Services (GA), Purdue University School of Nursing; Department of Pharmacy Practice (AJZ), Purdue University College of Pharmacy, West Lafayette, IN; Department of Epidemiology and Biostatistics (MJR), Michigan State University, East Lansing; and Regenstrief Institute (LSW, DMB), Indianapolis, IN
| | - Fitsum Baye
- Neurology Service (JJS), Clinical Epidemiology Research Center (CERC) (JJS, JC), and Medical Service (JC, FJ), VA Connecticut Healthcare System, West Haven; Department of Neurology (JJS), Center for Neuroepidemiological and Clinical Research (JJS), and Department of Internal Medicine (JJS, JC, JF, FJ), Yale School of Medicine, New Haven, CT; VA Health Services Research and Development (HSR&D) Center for Health Information and Communication (CHIC) (FB, LJM, JF, LSW, DMB) and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI) (FB, LJM, JF, LSW, DMB), Richard L. Roudebush VA Medical Center, Indianapolis; Departments of Biostatistics (FB, ZY), Internal Medicine (LJM, DMB), and Neurology (LSW, DMB), Indiana University School of Medicine, Indianapolis; Department of Neurology (EMC), VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California, Los Angeles; College of Health and Human Services (GA), Purdue University School of Nursing; Department of Pharmacy Practice (AJZ), Purdue University College of Pharmacy, West Lafayette, IN; Department of Epidemiology and Biostatistics (MJR), Michigan State University, East Lansing; and Regenstrief Institute (LSW, DMB), Indianapolis, IN
| | - Laura J Myers
- Neurology Service (JJS), Clinical Epidemiology Research Center (CERC) (JJS, JC), and Medical Service (JC, FJ), VA Connecticut Healthcare System, West Haven; Department of Neurology (JJS), Center for Neuroepidemiological and Clinical Research (JJS), and Department of Internal Medicine (JJS, JC, JF, FJ), Yale School of Medicine, New Haven, CT; VA Health Services Research and Development (HSR&D) Center for Health Information and Communication (CHIC) (FB, LJM, JF, LSW, DMB) and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI) (FB, LJM, JF, LSW, DMB), Richard L. Roudebush VA Medical Center, Indianapolis; Departments of Biostatistics (FB, ZY), Internal Medicine (LJM, DMB), and Neurology (LSW, DMB), Indiana University School of Medicine, Indianapolis; Department of Neurology (EMC), VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California, Los Angeles; College of Health and Human Services (GA), Purdue University School of Nursing; Department of Pharmacy Practice (AJZ), Purdue University College of Pharmacy, West Lafayette, IN; Department of Epidemiology and Biostatistics (MJR), Michigan State University, East Lansing; and Regenstrief Institute (LSW, DMB), Indianapolis, IN
| | - John Concato
- Neurology Service (JJS), Clinical Epidemiology Research Center (CERC) (JJS, JC), and Medical Service (JC, FJ), VA Connecticut Healthcare System, West Haven; Department of Neurology (JJS), Center for Neuroepidemiological and Clinical Research (JJS), and Department of Internal Medicine (JJS, JC, JF, FJ), Yale School of Medicine, New Haven, CT; VA Health Services Research and Development (HSR&D) Center for Health Information and Communication (CHIC) (FB, LJM, JF, LSW, DMB) and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI) (FB, LJM, JF, LSW, DMB), Richard L. Roudebush VA Medical Center, Indianapolis; Departments of Biostatistics (FB, ZY), Internal Medicine (LJM, DMB), and Neurology (LSW, DMB), Indiana University School of Medicine, Indianapolis; Department of Neurology (EMC), VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California, Los Angeles; College of Health and Human Services (GA), Purdue University School of Nursing; Department of Pharmacy Practice (AJZ), Purdue University College of Pharmacy, West Lafayette, IN; Department of Epidemiology and Biostatistics (MJR), Michigan State University, East Lansing; and Regenstrief Institute (LSW, DMB), Indianapolis, IN
| | - Jared Ferguson
- Neurology Service (JJS), Clinical Epidemiology Research Center (CERC) (JJS, JC), and Medical Service (JC, FJ), VA Connecticut Healthcare System, West Haven; Department of Neurology (JJS), Center for Neuroepidemiological and Clinical Research (JJS), and Department of Internal Medicine (JJS, JC, JF, FJ), Yale School of Medicine, New Haven, CT; VA Health Services Research and Development (HSR&D) Center for Health Information and Communication (CHIC) (FB, LJM, JF, LSW, DMB) and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI) (FB, LJM, JF, LSW, DMB), Richard L. Roudebush VA Medical Center, Indianapolis; Departments of Biostatistics (FB, ZY), Internal Medicine (LJM, DMB), and Neurology (LSW, DMB), Indiana University School of Medicine, Indianapolis; Department of Neurology (EMC), VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California, Los Angeles; College of Health and Human Services (GA), Purdue University School of Nursing; Department of Pharmacy Practice (AJZ), Purdue University College of Pharmacy, West Lafayette, IN; Department of Epidemiology and Biostatistics (MJR), Michigan State University, East Lansing; and Regenstrief Institute (LSW, DMB), Indianapolis, IN
| | - Eric M Cheng
- Neurology Service (JJS), Clinical Epidemiology Research Center (CERC) (JJS, JC), and Medical Service (JC, FJ), VA Connecticut Healthcare System, West Haven; Department of Neurology (JJS), Center for Neuroepidemiological and Clinical Research (JJS), and Department of Internal Medicine (JJS, JC, JF, FJ), Yale School of Medicine, New Haven, CT; VA Health Services Research and Development (HSR&D) Center for Health Information and Communication (CHIC) (FB, LJM, JF, LSW, DMB) and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI) (FB, LJM, JF, LSW, DMB), Richard L. Roudebush VA Medical Center, Indianapolis; Departments of Biostatistics (FB, ZY), Internal Medicine (LJM, DMB), and Neurology (LSW, DMB), Indiana University School of Medicine, Indianapolis; Department of Neurology (EMC), VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California, Los Angeles; College of Health and Human Services (GA), Purdue University School of Nursing; Department of Pharmacy Practice (AJZ), Purdue University College of Pharmacy, West Lafayette, IN; Department of Epidemiology and Biostatistics (MJR), Michigan State University, East Lansing; and Regenstrief Institute (LSW, DMB), Indianapolis, IN
| | - Farid Jadbabaie
- Neurology Service (JJS), Clinical Epidemiology Research Center (CERC) (JJS, JC), and Medical Service (JC, FJ), VA Connecticut Healthcare System, West Haven; Department of Neurology (JJS), Center for Neuroepidemiological and Clinical Research (JJS), and Department of Internal Medicine (JJS, JC, JF, FJ), Yale School of Medicine, New Haven, CT; VA Health Services Research and Development (HSR&D) Center for Health Information and Communication (CHIC) (FB, LJM, JF, LSW, DMB) and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI) (FB, LJM, JF, LSW, DMB), Richard L. Roudebush VA Medical Center, Indianapolis; Departments of Biostatistics (FB, ZY), Internal Medicine (LJM, DMB), and Neurology (LSW, DMB), Indiana University School of Medicine, Indianapolis; Department of Neurology (EMC), VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California, Los Angeles; College of Health and Human Services (GA), Purdue University School of Nursing; Department of Pharmacy Practice (AJZ), Purdue University College of Pharmacy, West Lafayette, IN; Department of Epidemiology and Biostatistics (MJR), Michigan State University, East Lansing; and Regenstrief Institute (LSW, DMB), Indianapolis, IN
| | - Zhangsheng Yu
- Neurology Service (JJS), Clinical Epidemiology Research Center (CERC) (JJS, JC), and Medical Service (JC, FJ), VA Connecticut Healthcare System, West Haven; Department of Neurology (JJS), Center for Neuroepidemiological and Clinical Research (JJS), and Department of Internal Medicine (JJS, JC, JF, FJ), Yale School of Medicine, New Haven, CT; VA Health Services Research and Development (HSR&D) Center for Health Information and Communication (CHIC) (FB, LJM, JF, LSW, DMB) and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI) (FB, LJM, JF, LSW, DMB), Richard L. Roudebush VA Medical Center, Indianapolis; Departments of Biostatistics (FB, ZY), Internal Medicine (LJM, DMB), and Neurology (LSW, DMB), Indiana University School of Medicine, Indianapolis; Department of Neurology (EMC), VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California, Los Angeles; College of Health and Human Services (GA), Purdue University School of Nursing; Department of Pharmacy Practice (AJZ), Purdue University College of Pharmacy, West Lafayette, IN; Department of Epidemiology and Biostatistics (MJR), Michigan State University, East Lansing; and Regenstrief Institute (LSW, DMB), Indianapolis, IN
| | - Gregory Arling
- Neurology Service (JJS), Clinical Epidemiology Research Center (CERC) (JJS, JC), and Medical Service (JC, FJ), VA Connecticut Healthcare System, West Haven; Department of Neurology (JJS), Center for Neuroepidemiological and Clinical Research (JJS), and Department of Internal Medicine (JJS, JC, JF, FJ), Yale School of Medicine, New Haven, CT; VA Health Services Research and Development (HSR&D) Center for Health Information and Communication (CHIC) (FB, LJM, JF, LSW, DMB) and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI) (FB, LJM, JF, LSW, DMB), Richard L. Roudebush VA Medical Center, Indianapolis; Departments of Biostatistics (FB, ZY), Internal Medicine (LJM, DMB), and Neurology (LSW, DMB), Indiana University School of Medicine, Indianapolis; Department of Neurology (EMC), VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California, Los Angeles; College of Health and Human Services (GA), Purdue University School of Nursing; Department of Pharmacy Practice (AJZ), Purdue University College of Pharmacy, West Lafayette, IN; Department of Epidemiology and Biostatistics (MJR), Michigan State University, East Lansing; and Regenstrief Institute (LSW, DMB), Indianapolis, IN
| | - Alan J Zillich
- Neurology Service (JJS), Clinical Epidemiology Research Center (CERC) (JJS, JC), and Medical Service (JC, FJ), VA Connecticut Healthcare System, West Haven; Department of Neurology (JJS), Center for Neuroepidemiological and Clinical Research (JJS), and Department of Internal Medicine (JJS, JC, JF, FJ), Yale School of Medicine, New Haven, CT; VA Health Services Research and Development (HSR&D) Center for Health Information and Communication (CHIC) (FB, LJM, JF, LSW, DMB) and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI) (FB, LJM, JF, LSW, DMB), Richard L. Roudebush VA Medical Center, Indianapolis; Departments of Biostatistics (FB, ZY), Internal Medicine (LJM, DMB), and Neurology (LSW, DMB), Indiana University School of Medicine, Indianapolis; Department of Neurology (EMC), VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California, Los Angeles; College of Health and Human Services (GA), Purdue University School of Nursing; Department of Pharmacy Practice (AJZ), Purdue University College of Pharmacy, West Lafayette, IN; Department of Epidemiology and Biostatistics (MJR), Michigan State University, East Lansing; and Regenstrief Institute (LSW, DMB), Indianapolis, IN
| | - Mathew J Reeves
- Neurology Service (JJS), Clinical Epidemiology Research Center (CERC) (JJS, JC), and Medical Service (JC, FJ), VA Connecticut Healthcare System, West Haven; Department of Neurology (JJS), Center for Neuroepidemiological and Clinical Research (JJS), and Department of Internal Medicine (JJS, JC, JF, FJ), Yale School of Medicine, New Haven, CT; VA Health Services Research and Development (HSR&D) Center for Health Information and Communication (CHIC) (FB, LJM, JF, LSW, DMB) and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI) (FB, LJM, JF, LSW, DMB), Richard L. Roudebush VA Medical Center, Indianapolis; Departments of Biostatistics (FB, ZY), Internal Medicine (LJM, DMB), and Neurology (LSW, DMB), Indiana University School of Medicine, Indianapolis; Department of Neurology (EMC), VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California, Los Angeles; College of Health and Human Services (GA), Purdue University School of Nursing; Department of Pharmacy Practice (AJZ), Purdue University College of Pharmacy, West Lafayette, IN; Department of Epidemiology and Biostatistics (MJR), Michigan State University, East Lansing; and Regenstrief Institute (LSW, DMB), Indianapolis, IN
| | - Linda S Williams
- Neurology Service (JJS), Clinical Epidemiology Research Center (CERC) (JJS, JC), and Medical Service (JC, FJ), VA Connecticut Healthcare System, West Haven; Department of Neurology (JJS), Center for Neuroepidemiological and Clinical Research (JJS), and Department of Internal Medicine (JJS, JC, JF, FJ), Yale School of Medicine, New Haven, CT; VA Health Services Research and Development (HSR&D) Center for Health Information and Communication (CHIC) (FB, LJM, JF, LSW, DMB) and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI) (FB, LJM, JF, LSW, DMB), Richard L. Roudebush VA Medical Center, Indianapolis; Departments of Biostatistics (FB, ZY), Internal Medicine (LJM, DMB), and Neurology (LSW, DMB), Indiana University School of Medicine, Indianapolis; Department of Neurology (EMC), VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California, Los Angeles; College of Health and Human Services (GA), Purdue University School of Nursing; Department of Pharmacy Practice (AJZ), Purdue University College of Pharmacy, West Lafayette, IN; Department of Epidemiology and Biostatistics (MJR), Michigan State University, East Lansing; and Regenstrief Institute (LSW, DMB), Indianapolis, IN
| | - Dawn M Bravata
- Neurology Service (JJS), Clinical Epidemiology Research Center (CERC) (JJS, JC), and Medical Service (JC, FJ), VA Connecticut Healthcare System, West Haven; Department of Neurology (JJS), Center for Neuroepidemiological and Clinical Research (JJS), and Department of Internal Medicine (JJS, JC, JF, FJ), Yale School of Medicine, New Haven, CT; VA Health Services Research and Development (HSR&D) Center for Health Information and Communication (CHIC) (FB, LJM, JF, LSW, DMB) and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI) (FB, LJM, JF, LSW, DMB), Richard L. Roudebush VA Medical Center, Indianapolis; Departments of Biostatistics (FB, ZY), Internal Medicine (LJM, DMB), and Neurology (LSW, DMB), Indiana University School of Medicine, Indianapolis; Department of Neurology (EMC), VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California, Los Angeles; College of Health and Human Services (GA), Purdue University School of Nursing; Department of Pharmacy Practice (AJZ), Purdue University College of Pharmacy, West Lafayette, IN; Department of Epidemiology and Biostatistics (MJR), Michigan State University, East Lansing; and Regenstrief Institute (LSW, DMB), Indianapolis, IN
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Sico JJ, Myers LJ, Fenton BJ, Concato J, Williams LS, Bravata DM. Association between admission haematocrit and mortality among men with acute ischaemic stroke. Stroke Vasc Neurol 2018; 3:160-168. [PMID: 30294472 PMCID: PMC6169611 DOI: 10.1136/svn-2018-000149] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 02/20/2018] [Indexed: 12/04/2022] Open
Abstract
Objective Anaemia is associated with higher mortality among patients with non-stroke cardiovascular conditions; less is known regarding the relationship between anaemia and mortality among patients with acute ischaemic stroke. Methods Medical records were abstracted for n=3965 veterans from 131 Veterans Health Administration facilities who were admitted with ischaemic stroke in fiscal year 2007. Haematocrit values within 24 hours of admission were classified as ≤27%, 28%–32%, 33%–37%, 38%–42%, 43%–47% or ≥48%. Multivariate logistic regression was used to examine the relationship between anaemia and in-hospital, 30-day, 6-month and 1-year mortality, adjusting for age, medical comorbidities, modified Acute Physiology and Chronic Health Evaluation-III and stroke severity. Impact factors were calculated to standardise comparisons between haematocrit tier and other covariates. Results Among n=3750 patients included in the analysis, the haematocrit values were ≤27% in 2.1% (n=78), 28%–32% in 6.2% (n=234), 33%–37% in 17.9% (n=670), 38%–42% in 36.4% (n=1366), 43%–47% in 28.2% (n=1059) and ≥48% in 9.1% (n=343). Patients with haematocrit ≤27%, compared with patients in the 38%–42% range, were more likely to have died across all follow-up intervals, with statistically significant adjusted ORs (aORs) ranging from 2.5 to 3.5. Patients with polycythaemia (ie, haematocrit ≥48%) were at increased risk of in-hospital mortality (aOR=2.9; 95% CI 1.4 to 6.0), compared with patients with mid-range admission haematocrits. Pronounced differences between patients receiving and not receiving blood transfusion limited our ability to perform a propensity analysis. Impact factors in the 1-year mortality model were 0.46 (severe anaemia), 0.06 (cancer) and 0.018 (heart disease). Conclusions Anaemia is independently associated with an increased risk of death throughout the first year post stroke; high haematocrit is associated with early poststroke mortality. Severe anaemia is associated with 1-year mortality to a greater degree than cancer or heart disease. These data cannot address the question of whether interventions targeting anaemia might improve patient outcomes.
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Affiliation(s)
- Jason J Sico
- Neurology Service, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Neurology, Center for NeuroEpidemiological and Clinical Neurological Research, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Laura J Myers
- Communication and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,VA Health Services Research and Development (HSR&D), Center for Healthcare Informatics, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Brenda J Fenton
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Division of Chronic Disease Epidemiology, Yale School of Public Health, West Haven, Connecticut, USA
| | - John Concato
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Medical Service, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Linda S Williams
- Communication and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,VA Health Services Research and Development (HSR&D), Center for Healthcare Informatics, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Regenstrief Institute, Indianapolis, Indiana, USA.,Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dawn M Bravata
- Communication and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI), Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,VA Health Services Research and Development (HSR&D), Center for Healthcare Informatics, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA.,Regenstrief Institute, Indianapolis, Indiana, USA.,Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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