Publication Briefs

Publication Briefs
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Study Suggests Racial Inequalities in VA Pancreatic Cancer Care This study examined whether there were significant racial disparities in the continuum of pancreatic cancer care in the VA system, hypothesizing that there would be no racial disparities in the receipt of pancreatic cancer care among Black and White Veterans. Findings showed that even in a healthcare system with equal access to care, racial inequalities exist in the timing of pancreatic cancer diagnosis and receipt of treatment. Black Veterans were 19% more likely to have late-stage disease and 25% less likely to undergo surgical resection. After adjusting for sociodemographic characteristics and medical comorbidities, Black Veterans had 13% higher mortality risk compared to White Veterans. However, this was no longer statistically significant after additionally adjusting for cancer stage and receipt of potentially curative treatment. Date: November 13, 2023 Substantial Health Risks Remain for Veterans Two Years after Hospitalization for COVID-19 Investigators in this study conducted a comprehensive assessment of the risks and burdens of post-acute sequelae of COVID-19 among Veterans across care settings two years post-infection. Findings showed that while the risks of many sequelae became non-statistically significant at two years, substantial risk remained that impacted several major organ systems. The risk horizon for those hospitalized during the acute phase was even longer, with persistently increased risk of most sequelae at two years. The risk of death was non-significant at six months after infection among non- hospitalized Veterans but remained significantly elevated through the two years in hospitalized Veterans. Within the 80 pre-specified sequelae, 69% and 35% of them became non-significant at two years after infection among non-hospitalized and hospitalized individuals, respectively. Findings highlight the importance of reducing the risk of hospitalization among Veterans with COVID-19 infection (and reinfection), in order to reduce the risk of long-term health loss. Date: August 21, 2023 Deployment of Medical Scribes Improves Provider Productivity and Wait Times in Cardiology and Orthopedics This study evaluated the impact of medical scribes on VHA provider productivity, wait times, and patient satisfaction in cardiology and orthopedics, as mandated by the MISSION Act. Findings showed that randomization into the scribes pilot was associated with increased productivity in cardiology and orthopedics, decreased wait times in orthopedics, and no changes in patient satisfaction. Randomization was also associated with a decrease of 8.5 days in request to appointment day wait times in orthopedics. No change in wait times for cardiology was observed. Date: July 1, 2023 Intervention for Patient-Family Dyads Improves Outcomes for Veterans with Diabetes Researchers designed the Caring Others Increasing Engagement in Patient Aligned Care Teams (CO-IMPACT) intervention to provide training and tools to adult patient-supporter dyads. This randomized clinical trial evaluated the CO-IMPACT intervention compared with standard care among Veterans with diabetes and HbA1c>8% or systolic blood pressure (SBP)>150mmHg, each with an adult supporter (239 dyads). Findings showed that CO-IMPACT successfully engaged patient-supporter dyads and led to improved patient activation, diabetes self-efficacy, and healthy eating. Most (97% Veterans, 93% supporters) said they would “definitely” or “probably” recommend CO-IMPACT to others like them, and 83% of supporters felt they and the patient improved how they worked together to manage diabetes. Diabetes-specific cardiac risk and glycemic control improved similarly in both groups. Date: November 14, 2022 Difficulty of Diagnosing and Treating Veterans Suspected of Having Long COVID Using data from VA’s electronic health record (EHR), investigators identified a random, nation-wide sample of 200 VA patients who were assigned a new ICD-10 diagnostic code for long COVID between October 1, 2021, and March 1, 2022. Investigators then conducted a text word search and qualitative analysis of Veterans’ EHRs to identify dominant themes pertaining to the diagnosis and management of long COVID. Findings showed that there was substantial clinical uncertainty around the diagnosis and management of long COVID; most Veterans had one or more comorbid conditions with symptoms that might overlap those of long COVID. Some patients had prolonged or repeated hospital admissions or nursing home stays, blurring the boundaries between outcomes associated with acute infection, prolonged hospitalization, and long COVID. Patients’ own reports of how they had been impacted by COVID often referenced an exacerbation of pre-existing symptoms rather than an entirely new set of symptoms. Uncertainty about the etiology of patients’ symptoms led to ongoing monitoring, diagnostic testing, and specialist referral. Long COVID-specific care processes were often siloed and poorly coordinated with the care patients were already receiving for other health conditions and could lead to care that was burdensome and even unwanted, particularly among those with complex medical conditions and functional limitations. Date: November 3, 2022 Timeliness of VA Purchased Community Primary Care Did Not Improve Following Early Expansion Under MISSION Act This study examined whether early Community Care Network (CCN) implementation impacted community primary care (PC) appointment wait times. Findings showed that expanded contracting with community providers and new provider network adequacy standards implemented through CCNs did not, in early stages, improve the timeliness of community primary care for Veterans. Wait times increased sharply for both CCN and comparison appointments after CCN implementation, ranging from approximately 30 to 40 days, which is beyond VA’s new urban and rural network adequacy wait-time standard for community care. Date: October 28, 2022 VA Treatment of Opioid Use Disorder was Maintained During the COVID Pandemic Through Rapid Shift to Telehealth At the beginning of the COVID pandemic, key federal policy changes were implemented to decrease barriers to telehealth-delivery of buprenorphine, a life-saving medication treatment for patients with opioid use disorder (OUD). This study examined the impact of these COVID-19 policies on buprenorphine treatment across different modalities (telephone, video, and in-person visits). Findings showed that buprenorphine treatment for OUD was maintained during the COVID-19 pandemic – across the VA healthcare system – through a rapid shift to telehealth, at a time when other healthcare delivery decreased. The number of Veterans receiving buprenorphine increased from 13,415 in March 2019 to 15,339 in February 2021. By February 2021, phone visits were used by the most patients (50%), followed by video (32%) and in-person (17%). Among Veterans receiving a buprenorphine treatment visit each month, the proportion of telehealth visits (phone and video) increased dramatically from 12% in March 2019 to 83% in February 2021. The proportion of Veterans reaching 90-day retention on buprenorphine treatment decreased significantly from the pre- to post-pandemic periods (50% to 48%), but days on buprenorphine increased significantly from 204 to 209. Policy changes that were rapidly implemented to reduce barriers to telehealth allowed continued delivery of buprenorphine treatment. Future changes to these policies (e.g., reversing support for telehealth prescribing of buprenorphine) could have major implications for patient care. Date: July 28, 2022 Despite Guidelines, Women Veterans More Likely to Receive Unrecommended Psychiatric Medications for PTSD than Men The primary objectives of this work were to examine PTSD prescribing practices over the last decade (2010–2019) for women and men receiving VA care – and to determine the impact of comorbid diagnoses and demographic characteristics on these practices. Findings showed that across medication classes and years, women were more likely to receive all psychiatric medications of interest. Gender differences were notably larger for medications recommended against using for PTSD, including benzodiazepines and anticonvulsants, after adjustment for psychiatric comorbidity. Benzodiazepine prescriptions decreased in both women and men across the study decade, but the difference between prescribing for women and men persisted. Antidepressants recommended against use for PTSD treatment decreased across time for both men and women, however the adjusted gender gap increased from being slightly lower for women in 2010 to being 27% higher in 2019. Generally, for both women and men, the likelihood of receiving a recommended psychiatric medication was higher when comorbid depressive and anxious disorders were present. To inform tailored intervention strategies, future work is needed to fully understand why women receive more medications that experts recommended against using for the treatment of PTSD. Date: July 7, 2022 PTSD-Multimorbidity in Recently Discharged Veterans Predicts Poor Social Functioning, Increasing Risk for Suicidal Ideation A growing body of literature suggests that problems experienced by Veterans during their transition from military to civilian life confer significant risk for suicidal ideation (SI). One of these problems is PTSD, which, along with chronic pain and sleep disturbance, can increase risk for SI. Findings from this study showed that at approximately 15 months post-separation, almost 91% of Veterans with probable PTSD also reported sleep disturbance and/or chronic pain. Relative to Veterans with PTSD alone, sleep disturbance and chronic pain did not confer greater risk for SI. Relative to Veterans without probable PTSD, Veterans with all three conditions (PTSD-multimorbidity: PTSD, chronic pain, and sleep disturbance) experienced the poorest social functioning and had greater risk for suicidal ideation. The impact of PTSD-multimorbidity on risk for SI was partially explained by its negative effect on social functioning. Given the additional risk for suicidal ideation associated with poor social functioning, clinicians should be mindful to not only support Veterans’ efforts to seek social support, but also to monitor the quality of support received and integrate social functioning aims into treatment planning. Date: June 2, 2022 Predictive Tool Associated with 22% Lower Odds of All-Cause Mortality among High-Risk Veterans Taking Opioids In 2018, VA mandated a case review intervention that targeted patients who had been prescribed opioid analgesics and who were at high risk of adverse outcomes. The Stratification Tool for Opioid Risk Mitigation (STORM), a provider-facing dashboard that uses predictive analytics to stratify patients prescribed opioids based on their risk for overdose/suicide, was developed to identify these patients and assist providers in determining whether a patient needed a revised treatment plan or augmented care. Investigators then evaluated the impact of the case review mandate on serious adverse events (SAEs) and all-cause mortality among Veterans designated as high-risk between 2018-2020. Findings showed that identifying high-risk patients and mandating they receive an interdisciplinary case review was associated with 22% lower odds of all-cause mortality relative to control patients. This kind of impact is on par with interventions such as common medications for heart disease. Mandated review patients were five times more likely to receive a case review than non-mandated patients with similar risk – and they received more risk mitigation strategies. Date: May 2, 2022 VA’s National Performance Measurement System Reveals Gaps in Timely Communication of Test Results to Veterans Investigators in this study analyzed the first full year of timeliness of test results communication measures in a sample including all 141 VA facilities. Findings showed that External Peer Review Program measures showed timely communication for 71% of abnormal; 80% of normal; and 82% of all test results within 30 days. Performance varied by facility: timely communication ranged between 46-94% for abnormal, 53-97% for normal, and 59-95% for all tests. Performance also varied by test; for example, for abnormal tests, results were communicated to Veterans least often in a timely way for DEXA scans (62%) and most often for chest x-rays (85%). Survey of Healthcare Experiences of Patients data showed that 8% of Veterans reported test results were “never” communicated; 6% said “sometimes;” 16% said “usually;” and 70% said test results were “always” communicated. This also varied by facility; for example, Veterans reporting results were “never” communicated ranged from 3-24%, while Veterans reporting results were “always” communicated ranged from 51-84%. Communication gaps in this study varied by facility, emphasizing the need for local quality improvement efforts to address contextual factors that may impact follow-up (e.g., local workflows or team support for test result management). Using these measures for accountability rather than just for quality improvement may be an important consideration. Date: April 22, 2022 Specialized Primary Care Homes Effective in Treatment of Patients with Serious Mental Illness This project studied the implementation and effectiveness of a primary care medical home specifically designed to improve the healthcare of Veterans with serious mental illness. SMI PACTs (Patient Aligned Care Teams) include a specialized, integrated team that can provide both primary and psychiatric care. Findings showed that a primary care medical home for Veterans with SMI can be safe and more effective than usual care, as well as feasible to implement. Compared with Veterans who received usual care, those who received the SMI PACT intervention had greater improvement in screenings, treatment quality, chronic illness care (e.g., goal setting, counseling), care experience (e.g., doctor-patient interaction, care coordination, access), psychotic symptoms, and mental health-related quality of life at 12 months. Investigators saw no signs of worsening of mental health status under the SMI PACT model of care. This care model can be effective and should be considered among the interventions for improving medical care in patient populations with serious mental illness. Date: April 5, 2022 Impact of COVID-19 Pandemic on Healthcare Workers and First Responders This study examined the relationships between COVID-19 related occupational stressors, psychiatric symptoms, and occupational outcomes (likelihood of leaving current field and occupational functioning). Findings showed high levels of psychiatric symptoms and distress in healthcare workers during the COVID-19 pandemic. Half of the healthcare workers in this study – and 59% of all nurses – indicated a decreased likelihood of staying in their current occupation due to the pandemic. Nurses and emergency medical service workers reported the greatest burdens: more than 40% had PTSD symptoms and more than 80% had depression symptoms. Among all respondents, more than one-third (38%) had PTSD symptoms, and nearly three-quarters had depression (74%) and anxiety (75%) symptoms. More than 15% of participants reported thoughts of suicide or self-harm in the preceding two weeks. More than 18% of respondents reported trouble completing work-related tasks. The volume of critically ill patients, risk of COVID-19 exposure, and factors promoting demoralization were associated with psychiatric distress. Distress was associated with increased odds of planning to leave the profession. Demoralizing factors (e.g., feeling unsupported by one’s workplace, being asked to take unnecessary risks) were most strongly associated with distress. Healthcare staffing shortages are in and of themselves a COVID-19 stressor, so turnover could exponentially worsen HCW’s wellbeing and professional retention. Date: December 16, 2021 Examining the Investment in Caring for High-Needs Patients Since 2013, VA has invested more than $22 million in fostering and testing interventions within patient-centered medical homes at five demonstration sites to improve care for Veterans at highest risk for hospitalizations or death. In this commentary, VA authors involved in this project, known as the VA PACT Intensive Management program, reflect on lessons learned about improving care for this population, including: using a combination of population management and clinician judgment is valuable for identifying patients best suited for intensive management; the top reasons for preventable emergency department visits and hospitalizations include treatment nonadherence and lack of patient engagement, rather than uncoordinated care; and intensive management efforts should focus on assessment for – and treatment of – modifiable risk factors among moderately high-risk patients, such as social needs and caregiver issues. As intensive management programs did not decrease costs any more than patient-centered medical homes, VA’s Office of Primary Care plans to incorporate those intensive management practices that are feasible into existing patient-centered medical homes. Date: September 10, 2021 Intervention May Decrease Workplace Staff Injury Rates Due to Assaults in VA Community Living Centers An interdisciplinary, person-centered, behavioral intervention for managing distress behaviors in dementia, called STAR-VA, has been implemented in VA Community Living Centers (CLCs). This study sought to describe the incidence of workplace disruptive behavior incidents and staff injury rates occurring in 120 CLCs (62 of which had completed STAR-VA training) from FY12-FY17 and to assess the association between STAR-VA implementation and workplace incidents. Findings showed that the implementation of STAR-VA was significantly associated with lower staff injury rates due to assault, particularly following the first year of training, but was not associated with other reported workplace disruptive behavior incident rates. Verbal incident rates increased over time. STAR-VA lowered agitation and target distress behavior frequency and severity among CLC residents with dementia. Date: August 30, 2021 Brief Training Increases Discussions between VA Providers and Veterans on Firearm Safety to Reduce Suicide This study evaluated the impact of a one-hour educational seminar for VA clinicians on lethal means safety, “A Public Health Approach to Talking About Firearms and Death by Suicide.” Findings showed that the webinar was effective in providing clinicians with the skills to talk with Veterans about firearm safety, and it continued to impact their practice four months after training. After the training, participants reported that they felt that it was very important to speak to all Veterans about firearm safety and believed that harm reduction was important in reducing death by suicide. Importantly, they felt more confident in their ability to have the discussion after the webinar. In the four-month evaluation, participants responded that they had been successful with speaking with Veterans about firearm safety, with 71% percent of respondents reporting being moderately to very successful. On average, clinicians asked more than half of Veterans they had treated about firearm safety. Clinicians also felt it was important to let others know that Veterans were open to talking about firearm safety. Date: July 1, 2021 Primary Care Intensive Management for High-Risk VA Patients Did Not Improve Long-term (12-24 Month) Outcomes or Costs This randomized trial tested whether primary care intensive management (PIM) teams could decrease acute care use, such as emergency department visits and hospitalizations, among high-risk Veterans during the second year of PIM implementation. Findings showed that offering an intensive case management program in addition to routine primary care services for high-risk patients increased outpatient use (e.g., primary care, mental health, home visits, case management, telehealth) during the 2nd year of implementation. But it did not significantly decrease inpatient use or healthcare costs, even when taking VA-covered community care costs into account. There were also no significant differences in VA healthcare use or costs for Veterans older than 65 years old or Veterans who were more frail and functionally impaired. Findings suggest approaches targeting VA patients based solely on high risk of hospitalization are unlikely to reduce acute care use or total costs beyond that provided by a well-functioning patient-centered medical home with additional support services. Date: June 18, 2021 Healthcare Supplement Features HSR&D Articles on the Importance of Embedded Research This supplemental issue of the journal Healthcare: The Journal of Delivery Science and Innovation considers the impact of embedded research on solving the disconnect between healthcare organizations and health services researchers. In November 2019, a national meeting was organized by a trio of Federal funders – VA, the Agency for Healthcare Research and Quality (AHRQ), and the Patient-Centered Outcomes Research Institute (PCORI) – in collaboration with AcademyHealth and Kaiser Permanente to address the following themes: Organizational arrangements, including governance, staffing, and funding; Research support for management decisions; Data resources and use; Strengthening the embedded research community; and Accelerating implementation of embedded research output. Articles in this Supplement reflect the work that began during this national meeting. Date: June 1, 2021 Gender Differences in Relationship between Civility and Burnout among VA Primary Care Providers This study analyzed gender differences in civility, burnout, and the relationship between civility and burnout among male and female primary care providers (PCPs). Findings showed that greater workplace civility was significantly associated with lower odds of burnout for women, reflecting that in workplaces with higher civility, women were less impacted by burnout. However, workplace civility was not significantly related to burnout among men. Almost half of the sample reported burnout (48%), but this difference was not significant between the genders. Across occupational groups, female nurse practitioners reported lower burnout compared to female physicians. Female supervisors also reported lower burnout rates. Black male and Asian female providers reported lower burnout compared to white male and female providers, respectively. Overall, burnout was lowest among employees with less than or equal to one year of tenure. Interventions tailored to gender- and primary care-specific needs should be employed to increase civility and reduce burnout among primary care providers. Date: April 26, 2021 Two Studies Show Positive Impact of COVID-19 Vaccinations on VA and Community Nursing Home Residents U.S. nursing homes incurred more than one-third of COVID-19 fatalities in the United States and began vaccine clinics in mid-December. The first study describes the proportion of COVID-19 positive tests among 130 VA Community Living Centers (CLCs) before and after COVID-19 vaccination. Findings showed that the number of COVID-19 positive tests dropped among all CLC residents in the fourth week after vaccination, with an approximately 75% drop in the proportion of COVID-19 positive tests. The second study compared incident COVID-19 infection and 30-day hospitalization or death among residents with COVID-19 between non-VA nursing homes with earlier versus later vaccine clinics. Findings showed that one week after their initial vaccine clinics, nursing homes with earlier vaccination had 2.5 fewer new COVID-19 infections per 100 at-risk residents than expected relative to facilities with later vaccination. Cumulatively over 7 weeks, earlier vaccination facilities had 5.2 fewer infections per 100 at-risk residents and 5 fewer hospitalizations and/or deaths per 100 infected residents. These results suggest that COVID-19 vaccines accelerated the rate of decline of incident infections, morbidity, and mortality. Date: April 16, 2021 Need for Systemic, Multi-Level Interventions for Patient-Perpetrated Sexual Harassment in VA Healthcare Settings This study sought to identify challenges and stakeholder recommendations for addressing patient-perpetrated sexual harassment of women staff and patients at VA facilities. Findings highlight the complexity of addressing patient-perpetrated harassment and underscore the need for systemic, multi-level interventions. Perceived organizational-level challenges included a climate of tolerance for harassment, lack of formal policies, and insufficient leadership support. Perceived staff-level challenges included ambiguity around defining harassment, fear of negatively impacting patient-staff dynamics, and competing priorities. Study participants emphasized the need for greater education and training around harassment. Participants explained that some patients lack awareness and do not realize that their behaviors may be construed as harassing. Findings indicate an urgent need for clear, well-disseminated, action-oriented policies addressing how to report and/or intervene around patient-perpetrated harassment. Date: February 25, 2021 Referral Coordination Team Improves Timeliness of VA Specialty Care Delivery and Patient Experience In 2018, the Office of Veterans Access to Care (OVAC) partnered with local providers at the VA Puget Sound Medical Center to pilot a referral coordination team to manage new referrals in sleep medicine. Investigators then compared the referral coordination team and the traditional specialist-led referral method in terms of timeliness and community care referrals. Findings showed that the referral coordination team was linked to improved timeliness of specialist appointments, reduced reliance on community care services, and greater patient satisfaction, with favorable impacts on cost. Patients whose consults had been completed by the referral coordination team were much more likely to have appointment dates within 28 days after referral than matched peers in the traditional system (33% vs. 12%) and to have these appointments scheduled within 7 days (35% vs. 7%). Each year, VA Puget Sound receives approximately 6,000 sleep medicine consults. Investigators estimate that the referral coordination team could allow VA Puget Sound to accommodate 4,800 additional visits, valued at $420,368. Although referrals to community care were low among patients in both groups, patients whose consults had been managed by the referral coordination team were slightly less likely to be referred outside of VA to community care, consistent with more timely service delivery. Informed by these results, national VA partners, including OVAC and the Office of Specialty Care, are working to disseminate referral coordination to other specialties nationwide. Date: February 1, 2021 VA Mental Health Use During Pregnancy/Postpartum Periods Remained Strong among Women with Prepregnancy Depression, PTSD, and Anxiety Diagnoses This study examined how prepregnancy psychiatric diagnoses could impact mental health treatment use during pregnancy and postpartum, given there is increased risk of symptom recurrence and/or medication discontinuation during pregnancy. Findings showed that there was a strong correlation between a prepregnancy diagnosis of major depressive disorder (MDD), PTSD, or anxiety and use of mental healthcare during pregnancy and the postpartum period. For women with these pre-pregnancy diagnoses, there was an increase in the use of psychotherapy during pregnancy and postpartum, while the percentage of women using antidepressants only or antidepressants plus therapy decreased during the same time periods; 42% of women reported stopping their antidepressants at the onset of the pregnancy. Date: November 18, 2020 Project Identifies and Validates Recommendations to Stop or Scale Back Unnecessary Routine Services in Primary Care Investigators in this study conducted a focused review of existing guidelines and recommendations – concentrating primarily on those published between 2011 and 2016 – to identify potential deintensification recommendations related to routine primary care. Investigators reconfigured about 50 high-priority recommendations by explicitly defining and specifying the deintensification action and appropriate target population. Starting from a set of 86 guidelines, Choosing Wisely recommendations, and National Quality Forum measures, investigators identified 409 recommendations – corresponding to 178 unique indications – that represented opportunities to stop or scale back routine services in primary care. After prioritization, specification, and expert panel revisions, the panel rated 37 of 44 deintensification recommendations as valid – and 32 of 44 as both valid and an important improvement opportunity (i.e., likely to affect many patients or substantially impact a smaller number of patients). This study builds on previous guidelines and lists of recommendations by making explicit when and for whom ongoing medical services should be stopped or scaled back. The approach used in this study in the first to systematically identify, specify, and validate actionable and measurable recommendations for deintensification in routine primary care. Date: September 14, 2020 Primary Care Intensive Management Teams Impact Medication Management for Diabetes and Hyperlipidemia This study examined the impact of primary care intensive management (PIM) on adherence to medications and medication adjustments including changes in number of drugs filled, switches between drug classes, added or discontinued prescriptions, and dose changes. Findings showed that PIM teams appear to have contributed to medication management for diabetes and hyperlipidemia. Medication adherence improved for DPP-4 inhibitors (class of drugs used to control high blood sugar in adults with type 2 diabetes), and more hyperlipidemia drugs were prescribed for PIM patients. There was a 12% increase (79% to 91%) in predicted mean adherence to DPP-4 inhibitors for diabetes in PIM patients between pre- and post-randomization, while usual care PACT patients had a 4% decrease (71% to 67%) in predicted mean adherence. PIM patients had a significantly higher mean number of hyperlipidemia drugs at study end due to more hyperlipidemia prescriptions. Date: August 7, 2020 Contextualized Care Planning Results in Improved Veteran Outcomes and Significant Cost Savings Contextualizing care is the process of adapting research evidence to patient context. For example, recognizing that a patient is not managing their diabetes because they cannot afford the medication and switching them to a less costly alternative is a contextualized care plan. This study evaluated the effectiveness of a quality improvement program in which providers receive ongoing feedback on their attention to patient contextual factors based on audio recordings of their clinical encounters. Findings showed that contextualized care planning was associated with a significantly greater likelihood of improved outcomes – and resulted in significant cost savings from avoided hospitalizations. At baseline, providers addressed 413 of out 618 contextual factors in their care plans (67%). Following either standard or enhanced feedback, they addressed 1,707 out of 2,367 contextual factors (72%), a significant improvement. In a budget impact analysis, estimated savings from avoided hospitalizations were $25.2 million at a cost of $337,000 for the intervention. Giving clinicians ongoing feedback on their attention to the life challenges that their patients face may be an effective strategy for heightening their awareness and attention to social determinants of health, which may significantly improve healthcare outcomes and reduce costs. QI programs may be well advised to consider routine incorporation of training in contextualizing care through audit and feedback. Date: July 31, 2020 VA Patients Have Fewer Potentially Avoidable Hospitalizations Post-Chemotherapy than Medicare Patients The Centers for Medicare and Medicaid Services (CMS) released a new quality measure to reduce potentially avoidable hospital admissions among patients receiving outpatient chemotherapy. In this study, investigators used this CMS measure to compare the quality of care received by chemotherapy patients treated through traditional Fee-for-Service Medicare versus VA, using a cohort of dually-enrolled Veterans. Findings showed that Veterans with cancer receiving chemotherapy through VA have higher-quality care with respect to avoidable hospitalizations than Veterans receiving chemotherapy through Medicare. Roughly 7% of Veterans treated through Medicare had potentially avoidable hospitalizations in the 30 days following chemotherapy compared with approximately 5% of Veterans treated by VA. In the entire cohort, the top reasons for an avoidable hospitalization were pneumonia (41%), sepsis (24%), anemia (21%), and pain (11%), though the order of frequency changed when evaluating Medicare versus VA treatment. This study was driven by recent legislation (Choice Act of 2014, MISSION Act of 2018) allowing Veterans to seek care in the private sector if VA care is difficult to access. As these policy changes are implemented, it is critical to understand whether this shift in system of care will impact care quality, especially for conditions as serious as cancer. Date: July 15, 2020 Both PTSD Symptoms and Moral Injury are Associated with Adverse Perinatal Outcomes among Women Veterans This longitudinal study is the first to examine the impact of PTSD symptoms and moral injury on adverse perinatal outcomes among women who became pregnant in the first three years after separating from military service. Findings showed that after adjusting for age, racial/ethnic minority status, socioeconomic status, and lifetime trauma, both PTSD symptoms and moral injury were associated with adverse perinatal outcomes. Only women with greater PTSD symptoms were more likely to report having postpartum depression/anxiety, and to describe their pregnancy as being more difficult. The new VA/DoD clinical practice guidelines on pregnancy management published in March 2018 incorporate the importance of screening for mental health conditions regularly during pregnancy, as well as the coordination of care between medical and mental health providers to prevent adverse perinatal outcomes. These findings specifically support increased screening for PTSD and moral injury, in order to increase access to treatment for these problems as warranted. Date: June 1, 2020 Common Drugs for Hypertension and Diabetes Not Associated with Severe COVID-19 Illness or Testing Positive for COVID-19 Originally requested by the World Health Organization (WHO), this systematic review examined the relationship between angiotensin-converting enzyme inhibitors (ACEI) or angiotensin-receptor blockers (ARB) use and COVID-19 illness. Findings showed that high-certainty evidence suggests that ACEI or ARB use is not associated with more severe COVID-19 illness, and moderate-certainty evidence suggests no association between the use of these medications and positive SARS-CoV-2 test results among symptomatic patients. Findings from this rapidly expanding literature show no indication to prophylactically stop ACEI or ARB treatment because of concerns about COVID-19. Moreover, withdrawal of long-term ACEIs or ARBs may be harmful, especially in patients with heart failure, because observational studies and trials have suggested that discontinuation of ACEI or ARB therapy is associated with worse outcomes. Date: May 15, 2020 Possible Impact of Measures to Curb COVID-19 Spread on Suicide Prevention Efforts Social distancing and other public health actions intended to curb the spread of COVID-19 have the potential for adverse outcomes on suicide risk. However, concerns about negative secondary outcomes of COVID-19 prevention efforts should not imply that that these public health actions should not be taken. Implementation should include a comprehensive approach that considers the public health priority of suicide prevention as well. Date: April 10, 2020 Embedding Social Workers in VA Primary Care Teams Reduces Emergency Department Visits In 2016, VA’s National Social Work Program initiated the Social Work Patient Aligned Care Team (PACT) Staffing Program, which provided funding from the Office of Rural Health for PACT social workers to serve Veterans living in rural areas. This study evaluated the impact of this program on Veterans who had at least one primary care visit between October 2016 and June 2019 at one of 93 VA outpatient sites. Findings showed that addressing Veterans’ social determinants of health is an integral component of delivering effective primary care. For example, the percentage of ED visits for Veterans in the study cohort decreased after a PACT social worker was assigned to the primary care clinic. Among high-risk patients there was a 3% decrease in Veterans who had ED visits and a 4% decrease in the number of Veterans who had acute hospital admissions. This translates to an expected decrease of about 8,000 fewer VA-paid ED visits per year after the deployment of additional social workers, and as many as 9,000 fewer hospital days. The program increased social work visits by 33% in the full cohort, and by 29% in the high-risk group. Date: April 1, 2020 Veterans Reveal Positive Aspects of Routine VA Pain Screening Using data from a study that evaluated a strategy to improve the use of the “5th Vital Sign” of pain in primary care, investigators identified 36 Veterans from five primary care clinics and three VA healthcare systems who were interviewed about pain screening. Generally, Veterans believed that routine pain screening is positive. Findings revealed five themes that summarize Veterans’ experience and preferences of being screened for pain: 1) Pain screening can determine the tone and guide the focus of the visit; 2) Screening can initiate communication about pain, which is important because some Veterans feel that discussing pain indicates weakness; 3) Screening can facilitate patient recall and reflection, allowing the patient to bring up symptoms that may have been overlooked in the past or would have gone unmentioned; 4) Screening can help identify under-reported psychological pain, mental distress, and suicidality that might not come up without provider probing; and 5) Screening allows patients to offer recommendations to improve screening for pain; e.g., Veterans emphasized that screening language and specific word choices matter. Results indicate that Veterans perceive meaningful, positive impacts of routine pain screening, specifically, routine screening for pain may help capture mental health concerns that may otherwise not emerge Date: March 6, 2020 Integrated Pain Team Programs Improve Outcomes for Chronic Pain and May Reduce Reliance on High-Risk Opioid Therapy This study examined changes in self-reported chronic pain-, opioid-, and treatment-related outcomes among Veterans with chronic pain following the implementation of a primary care-based biopsychosocial Integrated Pain Team (IPT) model within the San Francisco VA Health Care System. Findings showed that Veterans with chronic pain who engaged in the IPT program reported improvement in several outcomes related to pain-related distress and disability, and opioid misuse. While patients did not report a significant change in pain severity from baseline to follow-up, they did report significantly reduced pain interference in daily functioning. Pain catastrophizing also showed significant reduction, driven by decreases in pain-related magnification and helplessness. Regarding patients prescribed opioids at both baseline and follow-up, opioid misuse decreased significantly. For example, there was a significant reduction in the frequency of opioid misuse behaviors. At follow-up versus baseline, patients reported increased use of integrative (e.g., acupuncture) and active pain management strategies (e.g., exercise), and were less likely to use only pharmacological pain management strategies. Findings suggest that primary care-based IPT programs may improve patient-centered outcomes for individuals with chronic pain and reduce reliance on potentially high-risk opioid therapy. Date: February 25, 2020 Increases in Opioid Dosing of 20% or Greater were Not Associated with Improvements in Pain among Veterans This study examined the influence of opioid dose escalation on pain scores recorded in the VA electronic medical record among patients on chronic opioid therapy for chronic non-cancer pain. Findings showed that increases in opioid dose of 20% or greater were not associated with improvements in pain scores. In the follow-up period, dose escalators had higher average morphine milligram equivalents (MME) when compared to dose maintainers and were more likely to use long-acting opioids in combination with a short-acting opioid (18% vs. 8%, respectively). Clinicians should carefully evaluate increasing opioid doses, regardless of the current dose. When determining whether to escalate the dose, considerations should focus less on the potential benefit to improve pain intensity and more on the balance of other potential benefits and harms. Date: January 7, 2020 Mental Health Integration in VA Primary Care Settings Increased Access to Care – and Costs This study examined the effect of the Primary Care-Mental Health Integration Program (PC-MHI) on healthcare use and cost patterns among 5.4 million primary care patients in 396 VA clinics (FY2014-FY2016), while also accounting for the implementation of VA’s Patient Aligned Care Team (PACT) model of care. Investigators assessed VA outpatient and inpatient care and total cost of VA care as a function of attending a clinic with a high vs. low PC-MHI penetration rate. Findings showed that Veterans treated in clinics with higher proportions of primary care patients seen by PC-MHI providers received more outpatient care than those treated in clinics with lower PC-MHI penetration, but at a higher total cost. Each percentage-point increase in the proportion of clinic patients seen by PC-MHI providers was associated with 11% more mental health and 40% more primary care visits, but also 9% higher average total costs per patient per year. Among patients with serious mental illness, increasing PC-MHI penetration was associated with greater use of specialty-based mental health and all other healthcare visits. Among patients seen in hospital-based clinics, increasing PC-MHI penetration was associated with fewer emergency visits per person per year. Date: August 1, 2019 VA Nurse Practitioners and Physician Assistants Lower Cost of Care for Complex Primary Care Patients with Diabetes This study compared health services use and costs depending on whether a Veteran’s primary care provider was a physician, NP, or PA. Findings showed that Veterans in this study were medically complex, averaging almost seven chronic conditions each and 3.5 times the complexity of the typical Medicare patient. Investigators found greater rates of hospitalizations and ED visits and higher healthcare expenditures among primary care patients of physicians compared to those of NPs or PAs. Mean per patient inpatient costs were $1,328 and $914 less for NPs and PAs, respectively, and pharmacy costs were about $300 less, compared to physicians. In sum, NP and PA patients had about $2,000 lower annual total care costs than patients of physicians. This study addressed a long-standing concern that NPs and PAs might practice in ways that increase total costs of care and found no evidence to support this concern. Findings suggest that NPs and PAs can effectively manage primary care for medically complex patients with diabetes without increasing total care costs. Findings also provide further evidence that NPs and PAs may be appropriately used as primary care providers for complex patients, as opposed to being limited to supplementing the care of physicians within primary care settings. Date: June 1, 2019 Effect of Intensive Primary Care on Patient Experience Outcomes To address the gap in evidence about patient experiences with intensive primary care, study investigators conducted a survey of Veterans in a five-site randomized trial of intensive primary care in the VA healthcare system. Findings showed that augmenting VA’s patient-centered medical home with intensive primary care had a modestly positive influence on high-risk patients’ experiences with care coordination and provider relationships – but did not have a significant impact on most patient-reported access and satisfaction measures. Veterans randomized to PIM (PACT-Intensive Management) were more likely than those in PACT to report that they were asked about their health goals (73% vs. 68%) and about barriers to taking care of their health (60% vs. 55%). Veterans randomized to PIM also were more likely than those in PACT to strongly agree that they could trust their VA healthcare provider (61% vs. 53%) and were more likely to report 10 out of 10 on satisfaction with primary care (37% vs. 32%). Findings suggest that augmenting a medical home with an intensive management program may help fulfill the promise of primary care, with the potential for long-term consequences such as changes in health behaviors and clinical outcomes. Date: May 1, 2019 Benefits of Medical Home Model Tailored for Homeless Veterans Versus Standard Primary Care This study examined whether a homeless-tailored medical home model (H-PACT) offers a better patient experience than standard VA primary care. Findings showed that Veterans empaneled in H-PACT were more likely than those receiving standard primary care in the same facilities to report positive experiences with access, communication, office staff, provider ratings, and comprehensiveness. Veterans receiving standard care in facilities with H-PACT among their services were more likely than Veterans from facilities without H-PACT to report positive experiences with communication and self-management support. Patient-centered medical homes that are designed to address the social determinants of health offer a better care experience for homeless Veterans than standard primary care approaches. Date: April 1, 2019 Positive Effect of Collaborative Chronic Care Model on Mental Health Clinical Teams This is one of the first studies to evaluate Collaborative Chronic Care Model (CCM) implementation for individuals treated in mental health clinics, and the first CCM trial to assess implementation impact in a multi-diagnosis mental health population. Findings showed that implementation efforts at the clinician level enhance evidence-based care organization, which may result in improvements in outcomes for more complex individuals and those at risk for hospitalization. Mental health hospitalizations decreased significantly for Veterans treated on facilitated teams compared to Veterans treated in other mental health clinics in those facilities. Although no improvement in population-level Veteran self-ratings of health status was seen, mental health status improved in Veterans with >3 treated mental health diagnoses versus others. This implementation initiative used existing clinical staff, with external facilitation the only added research-supported effort, totaling less than 3 hours per week per facility, and still decreased hospitalization rates and, for complex individuals, improved mental health status. Date: March 1, 2019 Women Veterans Who Report Stranger Harassment on VA Grounds More Likely to Delay or Miss Healthcare This study examined the prevalence of self-reported harassment among women Veterans who use VA healthcare. Findings showed that one in four women Veterans reported inappropriate and/or unwanted comments or behavior by male Veterans on VA grounds. Eight percent said that this usually or always took place at VA. Negative interactions included sexual/derogatory comments and questions about the women’s Veteran identity and right to VA care. Those who reported harassment were less likely to report feeling welcome at VA, and more likely to report feeling unsafe and delaying/missing care. Younger women were more likely to report harassment, as were women Veterans with self-reported fair or poor health status, those with MST and/or other trauma exposures, and those with anxiety. VA Women’s Health Services has responded by establishing a national workgroup, gauging effective harassment reduction programs outside VA, convening an expert panel, piloting interventions, and launching a national culture campaign. Date: January 24, 2019 Women’s Health VA Stakeholders Discuss “Ideal” Care As part of a multisite implementation trial of evidence-based quality improvement for tailoring PACT to women Veterans’ healthcare needs, investigators conducted semi-structured interviews with 86 local leaders. At the conclusion of interviews about women’s primary care, participants were asked to describe their conceptualizations of “ideal care” for women Veterans. Respondents commonly discussed whether women Veterans should have separate primary care services from men; the need for childcare, expanded reproductive health services, resources, and staffing; geographic accessibility; the value of input from women Veterans; physical appearance of facilities; fostering active interest in women’s health across providers and staff; and the relative priority of women’s health at VA. Paths toward ideal care could include projecting and anticipating growth in women’s health programs; building on VA’s pilot program to provide childcare for patients’ children during visits; designing a hiring process to more consistently recruit providers with a strong interest in caring for women; and conducting listening sessions and creating other opportunities that allow senior VA leadership to hear women Veterans’ perspectives and preferences directly. Date: January 1, 2019 Web-Based Program Helps Empower Veterans Who Read their Mental Health Notes Online to Actively Participate in Care The VA OpenNotes initiative has expanded patient access to health information and VA now allows patients to access their electronic health record progress notes online. To reduce unintended harms and increase benefits, investigators developed a web-based educational program with the goal of increasing Veterans’ understanding of their mental health notes and providing guidance on communicating with clinicians about notes. This study sought to evaluate whether the program improved patient-clinician communication and increased patient engagement in their care. Findings showed that overall, improvements were observed among Veterans post-training in patient activation, perceived efficacy in healthcare interactions, and trust in their physician. This web-based educational program may help Veterans who read their mental health notes feel more empowered in their healthcare and improve perceptions of their clinician relationships. Date: January 1, 2019 Intervention Utilizing Community Health Workers Improves Quality of Patient Care and Reduces Hospitalizations Individualized Management for Patient-Centered Targets (IMPaCT) is a standardized intervention in which community health workers (CHWs) provide tailored social support, navigation, and advocacy to help low-income patients achieve health goals. This randomized trial assessed the scalability and effectiveness of IMPaCT in three primary care settings that provide treatment to low-income patients: one VA medical center, a federally-qualified health center, and an academic family practice clinic. Findings showed that compared to those in the control group, those in the intervention (CHW) group, including Veterans, had nearly twice the odds of reporting high-quality primary care, were less likely to be re-hospitalized within 30 days of discharge (12% vs. 28%), and spent fewer total days in the hospital at 6 months. Patients in the CHW intervention group also had lower odds of repeat hospitalizations, including 30-day readmissions. Date: December 1, 2018 VA Geriatric Patient Aligned Care Teams Need Additional Mental Health Integration for Older Veterans Geriatric Patient Aligned Care Teams (GeriPACT) provide healthcare for a subset of older Veterans with chronic disease, functional dependency, cognitive decline, and psychosocial challenges. This study examines mental healthcare integration within GeriPACT by describing the role of psychiatrists/psychologists to help inform geriatric mental health policy. Findings showed that mental health integration was less than 50% in the GeriPACT teams in this study: only 43% of GeriPACT teams had a mental health provider – either a psychiatrist (29%) and/or psychologist (24%). Teams with psychiatrist/psychologist providers were more likely to endorse management of psychosocial issues, dementia, and depression, indicating the potential benefit of including mental healthcare providers on teams. Date: September 13, 2018 Increase in Travel Reimbursement Increases Use of VA Outpatient Services The extent to which VA and non-VA care are substitutes or complements for each other will dictate how the demand for VA care will change as Veterans make use of the Choice Program. This study used another VA policy change – one that increased the reimbursement rate that eligible Veterans receive for VA healthcare-related travel – to understand the use of VA and Medicare services among Medicare-enrolled Veterans. This analysis allowed investigators to determine whether the increased VA utilization due to the travel reimbursement rate increase was accompanied by a decrease in non-VA utilization, indicating that the two were substitutes, or if there was also an increase in non-VA utilization, which would indicate that the two were complements. Findings showed that compared to those not eligible to receive travel reimbursement, Veterans who were eligible for reimbursement had significantly more VA outpatient encounters following the reimbursement rate increases. This was true both for Medicare-enrolled Veterans over and under age 65. Veterans living in rural areas in both age groups significantly decreased their use of non-VA outpatient care following the travel reimbursement increase, suggesting that VA outpatient care may be a substitute for Medicare outpatient care for Medicare-enrolled Veterans in both age groups living in rural areas. Date: July 1, 2018 Homeless Veterans Report More Positive Experiences in Facilities with Homeless-Tailored Primary Care Teams In 2012, VA implemented homeless-tailored primary care teams (HPACTs) that could improve the primary care experience for homeless patients. This study compared the primary care experiences of homeless and non-homeless Veterans from 25 VA facilities that had HPACTs available in 2012 and 485 facilities lacking HPACTs. Findings showed that in facilities lacking HPACT programs, homeless Veterans reported more negative experiences with communication and fewer positive experiences with comprehensiveness, compared to non-homeless Veterans in the same facilities. In facilities with HPACTs, homeless Veterans reported more positive and/or fewer negative experiences with office staff, provider ratings, comprehensiveness, and self-management support, compared to non-homeless Veterans in the same facilities. Many of the domains in which homeless Veterans reported more positive experiences than non-homeless Veterans are key targets of the HPACT program. Facilities with HPACT programs offer a better primary care experience for homeless Veterans, reversing the pattern of relatively poor primary care experiences that is often associated with homelessness. Date: July 1, 2018 Systematic Review: Pay-for-Performance and VA Healthcare Investigators sought to identify studies that examined the effects of pay-for-performance (P4P) on the quality of care and health of Veterans, including potential unintended consequences, as well as program design features and implementation factors important to P4P both within VA and in the community. Findings showed that overall, evidence is insufficient to determine whether P4P results in durable improvements in the quality of healthcare in VA settings. Only 1 controlled trial and 2 observational studies examined the effectiveness of P4P on intermediate clinical outcomes (e.g., blood pressure) in Veterans. Interviews with key informants were consistent with studies that identified the potential for overtreatment associated with performance metrics in VA. Key informants’ views on P4P in community settings included the need to: develop relationships with providers and strong-performing health systems; improve coordination by targeting documentation and data sharing processes, and troubleshoot the limited impact of P4P among practices where Veterans make up a small fraction of the patient population. Qualitative studies on P4P in VA found that participants felt performance measures may lead to unintended negative consequences, i.e., reduced focus on patient needs, un-incentivized areas of care, and/or healthier patient populations, and that they may negatively affect team dynamics. Key informants recognized the potential for unintended consequences of P4P, such as overtreatment in VA settings, and suggest that implementation of P4P in the community focus on relationship building – and target areas such as documentation and coordination of care. Date: July 1, 2018 LGBT Women Veterans Report Missing Needed Health Care Due to Concerns about Interacting with Other Veterans This study sought to examine LGBT women Veterans’ experiences within the VA healthcare system, and whether their experiences impact use of VA care. Findings showed that the majority of women Veterans reported feeling welcome at their VA. However, fewer LGBT women reported feeling welcome and safe at VA compared with non-LGBT women Veterans. After controlling for demographics, health status, and positive trauma screens, LGBT identity was predictive of women Veterans experiencing harassment from male Veterans at VA in the past 12 months, as well as feeling unwelcome or unsafe at VA. LGBT women Veterans were about 3 times more likely than non-LGBT women Veterans to attribute missing needed care in the previous 12 months to concerns about interacting with other Veterans. Study participant descriptions of harassment indicated that male Veterans’ comments and actions were distressing and influenced LGBT women Veteran’s healthcare accessing behavior. Despite VA’s ongoing efforts to educate employees and change the culture toward a more inclusive environment, more targeted work addressing the needs of LGBT women Veterans may be needed. Date: July 1, 2018 High-Risk Veterans with Access to Primary Care Intensive Management Receive Increased Outpatient Care without Increased Cost Intensive Management (IM) models aim to proactively reduce complex patients’ deteriorations in health and resultant high-cost hospitalizations through interdisciplinary teams, care coordination, and support for care transitions. This study evaluated the impact of outpatient primary care IM programs on health care utilization and cost at five VA medical centers. Findings showed that Veterans receiving IM care had higher utilization of outpatient care without an increase in total costs (including costs of the IM program) or differences in mortality over a 12-month period. Veterans in IM care had greater use of outpatient services such as mental health/substance abuse care, home care, and palliative/hospice care both in person and by telephone. Increased outpatient costs were attributed to higher use of these services. Veterans in IM care had a statistically significant reduction in nursing home days and non-significant trends toward lower mean inpatient costs, number of inpatient stays, and number of hospital days. IM programs appeared to improve access to necessary outpatient services and improve engagement in care. Date: June 19, 2018 Veterans Eligible for VA Purchased Healthcare Based on Distance from VA Facilities Face Shortage of Non-VA Providers This study examined the potential impacts of reforms to improve access to care for Veterans living in rural areas on these Veterans and healthcare providers. Findings showed that initiatives to purchase care for Veterans living more than 40 miles from VA facilities may not significantly improve their access to care, as these areas are underserved by non-VA providers. For example, about 16% of these Veterans lived in areas where there was a shortage of primary care providers, while 70% lived in areas where there was a shortage of mental healthcare providers; the majority of VA users eligible for purchased care lived in counties with no psychiatrists, cardiologists, pulmonologists, neurologists, PM&R specialists, or community mental health centers; and nearly half of these Veterans (47%) lived in counties with no community health center. Veterans eligible for purchased care based on distance were much more likely than the general population to live in counties with a median household income < $40,000 per year (40% vs. 11%) and very poor population health status (28% vs. 10%). VA should continue to develop telehealth programs and other strategies to deliver care to Veterans in rural areas underserved by both community and VA providers. Such programs are a necessary complement to initiatives to purchase in-person care from community providers. Date: May 29, 2018 Identifying Best Strategies to Implement Patient-Centered Care This paper describes a qualitative study of four early Centers of Innovation (VA medical centers considered early leaders in patient-centered care [PCC]) to inform VA leadership about how best to catalyze and sustain change across the system. Investigators identified seven domains that impacted PCC implementation: 1) leadership, 2) patient and family engagement, 3) staff engagement, 4) focus on PCC innovations, 5) alignment of staff roles and priorities, 6) organizational structures and processes, and 7) environment of care. Within each domain, multi-faceted strategies for implementing change were identified. These included efforts by leadership at all levels of the organization who modeled PCC in their interactions – and who fostered willingness to try novel approaches to care among staff. Capturing patients’ voices, obtaining patient perspectives, and finding out what matters most to Veterans and their families also were essential to selecting, planning, and implementing PCC initiatives. Alignment and integration of patient-centered care within the organization, particularly surrounding roles, priorities, and bureaucratic rules, remained major challenges. Findings from this study were used to create policy-level incentives to change by incorporating the seven domains into VA senior executive performance measures. Date: March 7, 2018 Intervention to Lessen Low-Value Electronic Health Record Notifications Reduces Workload for Primary Care Physicians This study evaluated the impact of a national multi-component quality improvement program to reduce low-value electronic health record notifications. Findings showed that the program potentially saved 1.5 hours per week per primary care physician to enable higher-value work (based on prior estimates of 85 seconds to process each notification). The mean number of daily notifications per PCP decreased significantly from 128 to 116, however, the number of daily notifications remained high, suggesting the need for additional multifaceted interventions and protected clinical time to help manage them. Program impact appeared to be achieved by reducing certain types versus just the sheer number of mandatory notifications, underscoring the complexity of addressing notification burden. Date: March 5, 2018 Homeless Population-tailored Patient-Aligned Care Team Can Reduce Acute Care Services and Healthcare Costs This trial compared healthcare service use and cost outcomes among homeless Veterans enrolled in a traditional (not tailored to a homeless population) PACT with outcomes among Veterans enrolled in a homeless population–tailored H-PACT. Findings showed that annual costs per patient were significantly higher in the PACT group than the H-PACT group ($37,415 vs $28,036), and most cost savings came from fewer VA and non-VA hospitalizations. A significantly greater percentage of Veterans in the PACT arm compared to H-PACT were hospitalized for any cause (35% vs 23%), had a mental health–related ED visit (48% vs 34%), or attended group therapy (54% vs 40%). In addition, there were significant differences in primary care provider–specific visits (H-PACT 5 vs PACT 4 visits), mental healthcare visits (H-PACT 9 vs PACT 13 visits), 30-day prescription drug fills (H-PACT 41 vs PACT 59 fills), and use of group therapy (H-PACT 40% vs PACT 54%). Results indicate that a population-tailored medical home approach for socially disadvantaged populations can both reduce reliance on acute care service use and generate significant cost savings. Date: February 15, 2018 Journal Features VA Research on Combating Multi-drug Resistant Organisms Posing Public Health Threat As an integrated healthcare system with acute care, community living centers, and community-based outpatient clinics, VA provides an ideal setting in which to study multi-drug resistant organism prevention and make a significant impact. Thus, a group of HSR&D infectious disease researchers and operations partners convened in Iowa City, IA, in September 2016. Conference participants included experts in hospital epidemiology, antimicrobial stewardship, medical anthropology, clinical medicine, infection prevention, pharmacy, and sociology. The participants were divided into four subgroups, to work together to identify key knowledge gaps and important targets for future investigation. Articles resulting from this collaboration are highlighted in this journal issue. Date: February 8, 2018 Dual Use of VA and Medicare Associated with Substantial Increase in Risk of Potentially Unsafe Opioid Use among Veterans This study sought to estimate the prevalence and consequences of receiving prescription opioids from both VA and Medicare Part D for all dually-enrolled Veterans who filled a prescription opioid in either system in calendar year 2012. Findings showed that among Veterans dually enrolled in Medicare Part D and VA and receiving prescription opioids in 2012, more than 1 in 8 received opioids from both systems, in many cases concurrently. Compared to VA-only use of opioids, dual use was associated with a 3-fold higher risk of high-dose opioid exposure and more than twice the risk of long-term high-dose opioid exposure. Dual use also was associated with a 60-90% greater risk of these exposures than Part D only use. VA is evolving into a less integrated delivery system with more community care options. As these options increase, the prevalence of poorly coordinated dual-system care (e.g., overlapping opioids and other drug interactions and duplication) also will likely increase. Date: February 1, 2018 More Patient-Aligned Care Team Components Translates to Improved Quality of Care for Veterans with Chronic Disease This study examined whether the extent to which clinics had implemented PACT components was associated with improvements in the quality of care for Veterans with chronic conditions over a four year period. Findings showed that over four years concurrent with PACT implementation, primary care clinics with the most PACT components in place had greater improvements in 5 of 7 chronic disease intermediate clinical outcome and 2 of 8 chronic disease process measures when compared to clinics with the least PACT components in place. Quality measures that improved more among the clinics with highest PACT implementation included LDL< 100 in CAD and DM patients, and BP < 160/100 in DM and HTN patients. Improvements in percentage of clinic patient population meeting clinical outcome quality measures over four years in the high PACT implementation clinics ranged from 1.3% to 5.2%. VA primary care clinics may be able to achieve improved quality of care for patients with common chronic conditions through patient-centered medical home-aligned changes in care delivery across all patients, if those changes are extensively implemented. Date: November 20, 2017 VA Experience with Implementing Intensive Primary Care Programs for Veterans at Highest Risk This case study describes VA’s experience with implementing intensive primary care programs, as well as the program elements that appear to be necessary to meet the complex care needs of these high-risk Veterans. Findings showed that the PACT Intensive Management program (PIM) has been successfully implemented for more than three years at five demonstration sites in the VA healthcare system. The PIM program has evolved over time, eventually converging on implementation of the following elements: an interdisciplinary care team, chronic disease management, comprehensive patient assessment and evaluation, care and case management, transitional care support, preventive home visits, pharmaceutical services, chronic disease self-management, caregiver support services, health coaching, and advanced care planning. PIM teams also found that including social workers and mental health providers on the interdisciplinary teams was critical to effectively address the psychosocial needs of these complex patients. In addition, having a central implementation coordinator facilitated the convergence of these program features across diverse demonstration sites. Date: October 25, 2017 Impact of Intensive BP Therapy on Patient-Reported Outcomes This randomized controlled trial compared two strategies for managing systolic blood pressure (SBP) in older adults with hypertension – an intensive strategy with an SBP target of <120 mmHg versus a standard care strategy targeting <140 mmHg – and whether such intensive therapy affects patient-reported outcomes. Findings showed that intensive therapy resulted in a 14.8 mmHg lower blood pressure compared to standard therapy; however, this had little impact on changes in patient-reported outcomes and adherence. The majority of participants in both groups reported that they were satisfied or very satisfied with their blood pressure care: 89% vs 88% in intensive and standard groups respectively. Overall, 44% of participants reported high adherence with blood pressure medications at 12 months, and no differences were noted between the intensive and standard treatment groups. Results provide reassurance that intensive hypertension therapy not only reduces cardiovascular morbidity and mortality, but will be well-tolerated, even in older patients with multiple comorbidities. Date: August 24, 2017 Effects of Cannabis among Adults with Chronic Pain This systematic review assesses the efficacy of cannabis for treating chronic pain, and provides a broad overview of the short- and long-term physical and mental health effects of cannabis use in chronic pain and general patient populations. Overall, investigators found low-strength evidence that cannabis may improve pain in some patients with neuropathic pain and insufficient evidence to characterize the effects of cannabis on pain in patients with multiple sclerosis. Moderate-strength evidence suggests that light to moderate cannabis smoking does not adversely impact lung function over about 20 years, however, the limited evidence examining the effects of heavy use suggests a possible deleterious effect on lung function over time. There is a consistent association between cannabis use and the development of psychotic symptoms over the short and long term, and cannabis appears to be associated with at least small, short-term deleterious effects on cognition in active users. Date: August 5, 2017 A Positive Psychological Intervention Improves Outcomes for Veterans with Knee or Hip Osteoarthritis This study sought to determine whether patients randomized to a program designed to boost positive affect and develop positive psychological skills (e.g., gratitude and kindness) would report greater improvements over time in osteoarthritis (OA) symptom severity and measures of psychosocial well-being compared with patients randomized to a neutral control program. Findings showed that the 6-week positive psychological intervention produced large reductions in OA symptom severity, decreased negative affect, and increased life satisfaction compared to a robust control program among Veterans with knee or hip osteoarthritis. Retention through both 6-week programs was high, with 79% of participants completing at least 5 of 6 weekly calls and 64% reporting that they completed 80% or more of their weekly activities. Participants rated the activities as highly beneficial, highly enjoyable, and low in difficulty. Results indicate the potential of a non-pharmacological therapy to improve symptom management in this population with moderate to severe pain and suggest that using positive activities as part of an overall treatment program for patients with OA could have a large impact. Date: June 27, 2017 PACT Initiative Did Not Reduce Most Disparities in Improved Hypertension or Diabetes Control among VA Patients This study sought to determine whether PACTs helped mitigate national racial/ethnic disparities in VA clinical outcomes, after adjusting for variable implementation and social determinants of health. Findings showed that improvements in clinical outcomes for hypertension and diabetes control had not been achieved for whites or most racial/ethnic groups four years into VA’s system-wide roll-out of the PACT initiative. Greater PACT implementation was associated with higher percentages of Veterans who achieved hypertension or diabetes control, but most racial/ethnic disparities in achieving control persisted. Authors suggest that to promote health equity, healthcare innovations such as patient-centered medical homes should incorporate tailored strategies that account for determinants of racial/ethnic variations. Date: June 1, 2017 Current Diagnosis of PTSD is Risk Factor for Pregnant Women This analysis evaluated the associations between PTSD and antepartum complications to explore how PTSD’s pathophysiology impacts pregnancy in a large cohort of women Veterans. Findings showed that a current diagnosis of PTSD increases the risk of hypertensive/ischemic placental complications of pregnancy, specifically preeclampsia, and is a risk factor for gestational diabetes. PTSD also was associated with an increased risk of prolonged (>4 day) delivery hospitalization and repeat hospitalization. Authors suggest that pregnancies in women with currently active PTSD should be identified as potentially high-risk, high-need pregnancies. Date: May 1, 2017 Impact of Comprehensive Caregiver Support Program on VA Healthcare Utilization and Cost The Program of Comprehensive Assistance for Family Caregivers (PCAFC) supports caregivers of Veterans from the post-9/11 era who need assistance with activities of daily living (ADLs) or supervision or protection because of the residual effect of injuries sustained during their service. A monthly stipend is provided to caregivers based on Veterans’ care needs. In this study, investigators examined the early impact of PCAFC on VA healthcare utilization and costs. Findings showed that Veterans in PCAFC had similar acute care utilization when compared with those in the control group, but significantly greater primary, specialty, and mental health outpatient care use at least 30 – and up to 36 months post-application. Compared with Veterans in the control group, over time, Veterans in the PCAFC group had about a 10 percentage point higher probability of receiving any VA primary care. In the first six months, Veterans in the PCAFC group had an increased probability of using any VA specialty care (75% vs. 64%). Veterans in the treatment group also had an increased probability of using mental healthcare in the first 6 months (84% vs. 77%) and this increase was sustained through 31-36 months. Estimated total healthcare costs for Veterans in the PCAFC group were $1,500 to $3,400 higher per Veteran per 6-month interval than for Veterans in the control group. Findings suggest that comprehensive supports for family caregivers can increase patient engagement in outpatient care in the short term, which may enhance long-term health outcomes. Date: April 1, 2017 Opioid Use among Afghanistan and Iraq War Veterans This study sought to understand current opioid use in OEF/OIF/OND Veterans who are regular users of VA care and did not have a cancer diagnosis at the time of this study. Findings showed that opioid use among OEF/OIF/OND Veterans is characterized by moderate doses that are used over relatively long periods of time by a minority of Veterans. Approximately 23% of all OEF/OIF/OND Veterans received opioids, with 7-8% receiving them chronically. The prevalence of high-dose opioids, concurrent use of multiple opioids, and use of long-acting opioids was fairly low. Diagnoses of PTSD, major depressive disorder, and tobacco use disorder were strongly associated with chronic opioid use. Back pain also was strongly associated with chronic use. Findings suggest that the use of opioids is less common among OEF/OIF/OND Veterans compared with Veterans as a whole, and provide a strong baseline for evaluating the impact of recently implemented opioid-related policies. Date: March 25, 2017 Gender and Smoking Impact Severity of Musculoskeletal Pain among OEF/OIF Veterans This study sought to examine gender differences in the association between cigarette smoking and moderate to severe musculoskeletal pain in Veterans of the wars in Afghanistan and Iraq. Findings showed that both gender and current smoking status were significantly associated with increased odds of moderate to severe musculoskeletal pain. Male Veteran non-smokers were more likely than female Veteran non-smokers to report moderate to severe pain; however, there were no gender differences in moderate to severe pain among Veteran smokers. Relative to female non-smokers, female Veteran smokers had increased odds of reporting moderate to severe musculoskeletal pain. Date: March 14, 2017 Systematic Review: Effects of Pay-for-Performance on Healthcare This review updates and expands on a prior systematic review in order to summarize current understanding of the effects of pay-for-performance (P4P) programs on process of care and patient outcomes in ambulatory and outpatient settings in and outside the United States. Findings showed that overall, in the ambulatory setting there was low-strength evidence that P4P programs might improve process of care outcomes over the short term (2 to 3 years), but there were limited data on longer-term effects. Many of the studies reporting positive findings were conducted in the United Kingdom (where incentives are much larger than P4P programs in the U.S.), and the largest improvements were seen in areas where baseline performance was poor. There was low-strength evidence that P4P had little to no impact on intermediate health outcomes (e.g., changes in lab measures), though there were inconsistencies among study results. In addition, the evidence examining patient health outcomes was insufficient because few methodologically rigorous studies reported these outcomes. In the hospital setting, there was low strength evidence that P4P had a neutral effect on patient health outcomes and a positive effect on reducing hospital readmissions. Findings complement and add to prior reviews that have also generally found that P4P programs have not been consistently effective in improving patient outcomes. In addition, there is low-strength, contradictory evidence that these programs could improve processes of care. Thus, in the absence of strong evidence of benefit, the authors suggest that it may be particularly important to consider the potential harms and costs associated with P4P. Date: March 7, 2017 VA’s Patient Aligned Care Teams’ Challenges in Providing Care for Women Veterans In this study, investigators conducted interviews with primary care providers and staff in eight VA medical centers to assess provider and staff experiences with PACT, implementation of core medical home features, and facilitators and barriers encountered in providing PACT care to women Veteran patients. Findings showed that providers and staff have generally positive attitudes toward PACT. However, early challenges to the delivery of PACT-principled care persist in both primary care and women’s health clinics. Ongoing barriers to PACT implementation include short staffing, conflicting performance requirements for continuity and same-day access, space constraints, and sharing of support staff across multiple providers. Challenges unique to the care of women Veterans included a higher prevalence of psychosocial needs and the need for specialized training of primary care personnel in gender-specific care. Primary care providers and staff in women’s health clinics are often physically separated from other PACT and medical neighborhood resources or asked to share their support staff with specialists. Primary care providers and staff face unique challenges in the delivery of comprehensive primary care to women Veterans that may require special policy, practice, and management actions if the full benefits of PACT are to be realized for this patient population. Date: March 1, 2017 VA Pharmacy Use in the First Year of Choice Act This study sought to describe pharmaceutical use during the first year of the Veterans Choice Program (VCP) and to understand barriers and facilitators for VA pharmacists to dispensing medications under the VCP. Findings showed that a majority of VCP pharmacy spending in the first year was for hepatitis C virus (HCV) medications, which accounted for only 5% of prescriptions but 90% of costs. However, in 2015, VA experienced greater than expected demand for HCV medications, which exceeded available funding, thus some patients obtained medications through the VCP. The impact of HCV medications on the VCP should be short-lived given broadened availability in VA in 2016. Topical eye drops and opioids represented the most commonly dispensed prescriptions: 16% and 9% of all prescriptions, respectively. Most prescriptions dispensed (93%) were for formulary agents, but substantial efforts were required from VA pharmacists to work with non-VA providers to use formulary drugs. Challenges related to obtaining medications from VA pharmacies through VCP included requiring controlled substance prescriptions to be hand-delivered, a lack of access to lab data required to safely dispense medications, and substantial time required by pharmacists to communicate with non-VA providers. Safe use of opioids, efficient management of non-formulary medications, and unintended new barriers to access created by the VCP must be addressed, in addition to robust ongoing evaluations to identify new cost, quality, and safety concerns. Date: February 17, 2017 Effects of Homeless Veterans’ Use of Peer Mentors This trial tested the use of peer mentors among homeless Veterans at VA primary care clinics. Findings showed that while significant impacts of peer mentors on healthcare patterns or costs were not detected, some patients engaged in frequent contact with peer mentors. Most (87%) of the peer mentor group had at least one peer contact – and spent the most time discussing housing and health issues. Patients also spent time discussing basic needs (i.e., food and clothing), VA benefits, work experience, and social issues. Peer mentor patients had more outpatient encounters, although differences were not significant. There were no other differences in utilization or costs between groups. Costs of the peer mentor intervention were estimated to be $737 per patient. Peer mentors may serve a key role in building trust between patients and providers to foster engagement with the healthcare system. Date: February 1, 2017 VA Opioid Safety Initiative Decreases Potentially Risky Opioid Prescriptions among Veterans This study examined changes associated with Opioid Safety Initiative (OSI) implementation among all adult VA patients who filled outpatient opioid prescriptions from October 2012 through September 2014 in any of 141 VA facilities. Findings showed that during the two-year study period there was a decrease in the number of VA patients receiving risky opioid regimens, with an overall reduction of 16% among Veterans receiving >100 morphine-equivalent milligrams (mEq) daily dosages and 24% among Veterans receiving >200 mEq. There was a 21% reduction in Veterans receiving benzodiazepines concurrently with opioids. Implementation of the OSI dashboard tool was associated with a significant decrease in all three outcomes (>100 mEq, >200 mEq and concurrent opioid/benzodiazepine prescribing). The implementation of the OSI dashboard tool was associated with a significant decrease in risky opioid prescribing across the VA healthcare system, which highlights the possibility of system-wide approaches to address high-risk opioid prescribing. However, a large number of VA patients remained on these regimens at the end of the study period, which emphasizes the challenges of making significant changes in healthcare systems that treat a large population of complex patients. Date: January 4, 2017 Intensive Outpatient Care for High-Need Patients Does Not Reduce Acute Care Use or Costs Compared to Standard VA Care This study evaluated the effectiveness of augmenting VA’s Patient-Aligned Care Teams (PACTs) with an Intensive Management program (ImPACT). In February 2013, the Palo Alto VAMC launched an ImPACT multidisciplinary team that addressed healthcare needs and quality of life through comprehensive patient assessments, intensive outpatient case management, care coordination, and social and recreational services. Findings showed that intensive outpatient care for high-need patients did not reduce acute care utilization or costs compared with standard VA care, although there were positive effects on healthcare experiences among Veterans who participated in ImPACT. During the first 16 months of the intervention period, the average number of primary care visits was 22 for ImPACT patients vs. 7 for PACT patients. However, after accounting for the cost of ImPACT encounters, the average baseline and follow-up person-level monthly costs declined at similar rates among ImPACT patients (21.0%) and PACT patients (20.7%). Implementing intensive outpatient programs in VA may offer high-need Veterans more comprehensive services. However, in settings with high-functioning PACTs, these programs may not prevent hospitalizations or achieve substantial cost savings. Date: December 27, 2016 Importance of VA’s Quality Enhancement Research Initiative in the Choice Act Era The Veterans Access, Choice and Accountability Act of 2014 (Choice Act) allows Veterans enrolled in VA healthcare who have waited longer than 30 days to see a provider – or who live more than 40 miles from a VA clinic – the option of seeking care from non-VA providers. The Choice Act also mandated an independent assessment of VA business and healthcare practices. This article describes how VA’s Quality Enhancement Research Initiative (QUERI) is responding to the Choice Act, particularly through the implementation strategies that facilitate more rapid uptake of effective practices across different settings, and the rigorous evaluation of new VA programs and policies. Date: December 16, 2016 Frailty Screening Initiative Associated with Improved Post-Operative Survival among Veterans The Frailty Screening Initiative (FSI) is aimed at improving post-operative survival. This study assessed the impact of the FSI on mortality and complications by comparing surgical outcomes before and after implementation of the FSI. Findings showed that implementing frailty screening was associated with reduced mortality, suggesting both the feasibility of widespread screening of patients pre-operatively to identify frailty – and the efficacy of system-level initiatives aimed at improving their surgical outcomes. Overall, 30-day mortality dropped from 1.6% to 0.7% after FSI implementation. Improvement was greatest among the frail (12% to 4%). Moreover, the magnitude of improvement among frail patients increased at 180 and 365 days. After controlling for age, frailty, and predicted mortality, models showed that the FSI resulted in a three-fold survival benefit in this study cohort. Frailty screening of preoperative patients is feasible, and may be an effective and scalable tool for improving surgical outcomes for aging and increasingly frail U.S. and Veteran populations. Date: November 30, 2016 “Virtual Hope Box” Smartphone App Helps Veterans Regulate Emotion and Cope with Distress that Can Lead to Suicide Investigators in this study developed a smartphone app, Virtual Hope Box (VHB), to provide a portable and easily accessed suite of tools to enhance coping self-efficacy. They then assessed the impact of VHB on stress coping skills, suicidal ideation, and perceived reasons for living in patients at elevated risk of suicide and self-harm. Findings showed that VHB users reported significantly greater ability to cope with unpleasant emotions and thoughts (i.e., coping, self-efficacy) at 3 and 12 weeks compared with Veterans in the control group. There was no significant advantage of treatment augmented by the VHB for other outcome measures. The most frequently cited reasons for using VHB by Veterans were for distress, when emotions were overwhelming, when they felt like hurting themselves, and for relaxation, distraction, and/or inspiration. Data suggested that clinicians appreciated the VHB's capacity to serve as an additional therapeutic tool – and valued the fact that the VHB served to reinforce patients' existing coping skills and gave them an outlet to practice these skills. Because the Virtual Hope Box smartphone app is easily disseminated across a large population of users, investigators believe it has broad, positive utility in behavioral healthcare. Date: November 15, 2016 Evaluating Patient-Mediated Health Information Exchange In 2013, VA’s Office of Rural Health and the Department of Health and Human Services (Office of the National Coordinator) partnered to promote the use of My HealtheVet’s Blue Button capability to facilitate the transfer of Veterans’ health information to non-VA providers to improve care coordination for Veterans living in rural settings who use both VA and non-VA care (dual users). This partnership resulted in the Veteran-Initiated Electronic Care Coordination pilot study, which sought to: 1) train rural-dwelling dual-use Veterans to use Blue Button capabilities to share their health information with non-VA providers, and 2) evaluate whether or not the availability of VA information during community clinical encounters impacted the care they received. Findings from this study showed that with brief training, Veterans were able to generate their Continuity of Care Document (CCD) in My HealtheVet, share it with non-VA providers, and benefit from improved communication about medications and reduced laboratory duplication. After training, 78% of Veterans reported that the CCD would help them be more involved in their healthcare, and 86% planned to share it regularly with non-VA providers. The majority of non-VA providers (97%) were confident in the accuracy of the information, and 96% wanted to continue to receive the CCD. Moreover, 50% of non-VA providers reported that they did not order a laboratory test or other procedure because of CCD information. Date: October 11, 2016 Application of Triggers on VA “Big Data” may Help Identify Patients Experiencing Delays in Diagnostic Evaluation of Chest Imaging Triggers offer one method to use big electronic health record (EHR) data to prevent and mitigate the impact of delays in care related to missed test results. Triggers consist of computerized algorithms that can scan thousands of patient records to flag those with clues suggestive of patient safety events. This study tested the application of a trigger within VA’s EHR to help identify delays in patient follow-up related to abnormal chest imaging results. Findings showed that the trigger identified delays in patient follow-up with a reasonable accuracy for use in the clinical setting, suggesting that triggers are able to identify almost all delays related to abnormal lung imaging follow-up, and cost-effectively minimize the amount of effort providers spend reviewing false-positive results. Date: September 1, 2016 Disclosure of Clinical Adverse Events between VA Surgeons and their Patients This study assessed surgeons’ reports of disclosing adverse events and aspects of their experiences with the disclosure process. Findings showed that surgeons reporting they were less likely to discuss preventability of the adverse event, or who reported difficult communication experiences were more negatively affected by disclosure than others: 60% indicated that the event had moderately, quite a bit, or extremely affected them. Most surgeons did not report significant impacts of the event on job satisfaction, confidence, professional reputation, or sleep, but 27% reported anxiety about future outcomes or events. Date: July 20, 2016 New Guidelines May Significantly Decrease Cost for Testing Immune Function in Veterans with HIV In 2012, the Department of Health and Human Services recommended CD4 testing in patients with HIV every 3 to 6 months – except in patients with consistently suppressed virus and sustained CD4 cell count, who could be tested every 6 to 12 months. In 2014, updated guidelines recommended that in individuals with viral suppression, CD4 testing be considered either optional or annual, depending on the cell count. This study evaluated how these recommendations might affect Veterans with HIV who receive care from the largest provider of HIV care in the United States – the VA healthcare system. Findings showed that VA providers decreased the frequency of CD4 testing by 11% between 2009 and 2012, reducing the direct cost of testing by $196,000 per year. While VA has made substantial progress in reducing the frequency of optional CD4 testing, it could be reduced a further 29% by full implementation of new treatment guidelines, with an expected annual savings of $600,000. Reduced CD4 monitoring also would likely reduce patient anxiety with little or no impact on quality of care. Date: July 1, 2016 Home-based Geriatric Care Management Decreases Rate of VA Healthcare Utilization for Older Veterans following Hospitalization This practical clinical trial assessed Veterans aged 65 years and older with primary care providers (PCPs) from VAMCs in Indianapolis, IN, who were enrolled in the Geriatric Resources for Assessment and Care of Elders (GRACE) Team Care program following hospital discharge to home compared to Veterans who were not enrolled after hospital discharge. Findings showed that enrollment in GRACE was associated with a 7% reduction in emergency department visits, 15% fewer 30-day readmissions, a 38% reduction in hospital admissions, and 29% decreased total bed days of care. The 179 Veterans enrolled in GRACE avoided 15 hospital admissions and 53 readmissions in the year after program enrollment. This saved VA more than $200,000 in the first year – over and above GRACE program costs. Date: July 1, 2016 Pay-for-Performance Intervention Improves Blood Pressure Control among Black Veterans with Hypertension without Unintended Consequences This study sought to evaluate the effect of a pay-for-performance intervention on the quality of hypertension care provided to black Veterans. Findings showed that VA physicians who received performance incentives for meeting guideline-recommended hypertension quality measures demonstrated better performance than control group physicians on a combined measure of BP control or appropriate clinical response to uncontrolled BP in black Veterans. The proportion of black patients who achieved BP control or received appropriate response to uncontrolled BP was 6% greater for physicians who received an incentive. There was no evidence found for risk selection, i.e., there was no difference between intervention and control groups in the proportion of Veterans who switched providers, and there were no differences in visit frequency or panel turnover, creating reassurance that the incentives did not have negative unintended effects on the care of black patients. Date: June 22, 2016 Impact of Evidence-based Quality Improvement Strategy on VA Patient-Aligned Care Team Implementation This study assessed changes in VA healthcare utilization and costs for Veterans from six practices in three different medical centers using an evidence-based quality improvement (EBQI) approach to implement PACT and 28 comparison practices over a five-year period (FY2009 to FY2013). Findings showed that after PACT implementation, the overall use of primary care, specialty care, and mental health/substance abuse care decreased, while the use of telephone care increased. Decreased outpatient care use occurred more rapidly for VA practices that employed an EBQI approach to PACT implementation, including outpatient visits for primary care, specialty care, and mental health and substance abuse care that appeared to augment the effects of PACT. EBQI practice was significantly associated with a 15% reduction in primary care encounters over the study period. For specialty care, there was a 17% decrease in encounters associated with EBQI overall, but the rate of decrease slowed each year after the implementation of PACT. There was no significant effect of EBQI status on emergency department visits, all-cause hospitalizations, or prescription drugs. Total VA healthcare costs per patient decreased by 5% each year across all practices, but there was no effect of EBQI practice on costs. Date: February 1, 2016 Impact of New Institute of Medicine Report on Patient Safety The authors of this NEJM article discuss why the topic of diagnostic error is timely and suggest next steps to translate the Institute of Medicine recommendations into action. Date: December 24, 2015 Data from Electronic Health Records Can Predict and Possibly Prevent Missed Patient Appointments This study sought to develop a model that identifies patients at high risk for missing scheduled appointments (no-shows and cancellations), and to project the impact of predictive over-booking in a gastrointestinal (GI) endoscopy clinic – a resource-intensive environment with a high no-show rate. Findings showed that information from electronic health records can accurately predict whether patients will no-show. The model used in this study was able to correctly classify 711 out of 888 attended appointments, and 317 out of 538 missed appointments. The strongest predictor of no-show was a patient’s cancellation history – the proportion of all outpatient appointments missed. Veterans with histories of mood or substance use disorder, and those with a greater overall disease burden also were less likely to keep appointments. Predictors of being more likely to keep appointments included: being married, having a history of diverticular disease, attending a colonoscopy education class, and having care partly funded by VA. Urgency of appointment, race, ethnicity, and day of the week of appointment were not significant predictors of appointment no-shows. Compared to a strategy that employs a fixed level of overbooking, predictive over-booking was much less likely to lead to days where the clinic was substantially over- or under-booked. Date: December 1, 2015 Study Compares Data Sources for Provider Financial Incentives This study examined how well data from automated processing of EHRs (AP-EHR) reflect data collected via manual chart review, and assessed the potential impact of data collection methods on incentive earnings for physicians and provider groups participating in a trial evaluating pay-for-performance for hypertension care. Findings showed that the total amount of incentives disbursed to providers would have been lower (by 10%) using the AP-EHR data to reward performance because this method under-reported the number of Veterans receiving appropriate medications – compared to manual review. Regarding how well the AP-EHR reflect data from manual review, results show almost perfect agreement for the BP control measure: manual review indicated 70% of Veterans had controlled BP compared to 67% by AP-EHR review. Moderate agreement was found between the data sources for the use of guideline-recommended anti-hypertensive medication: manual review showed 72% of Veterans were considered to have received guideline-recommended anti-hypertensive medications compared to 65% by AP-EHR. And low agreement was found for the appropriate response to uncontrolled BP: manual review showed that 52% of Veterans received an appropriate response for uncontrolled BP compared to 40% by AP-EHR review. Given the large amount of resources needed for chart review endeavors, investigators feel that a 10% difference in the total amount of incentive earnings disbursed based on AP-EHR data compared to manual review is acceptable. Date: October 1, 2015 Effect of Childhood Physical and Sexual Abuse on Female Veterans’ Health and Healthcare Use This study sought to investigate whether childhood physical abuse and childhood sexual abuse predict health symptoms and healthcare use. Findings showed that childhood physical abuse was an important contributor to both physical and mental health for female Veterans. After adjusting for age, race, military branch, childhood sexual abuse, and MST, childhood physical abuse was predictive of poorer physical health, greater depressive and PTSD symptoms, and more frequent use of medical healthcare. No significant association was found between childhood sexual abuse and poor physical or mental health, and it was not a predictor for healthcare use. Screening for adverse childhood experiences may facilitate access to appropriate physical and mental health treatment, as well as inform mental health assessment and treatment planning, among female Veterans. Date: October 1, 2015 VA Hospital Observation Stays Increasing When acutely ill patients present to the emergency department (ED) and neither inpatient admission nor ED treatment followed by discharge is clearly indicated, physicians are likely to place the patients in the hospital under “observation” status. This study sought to identify trends and variations in observation rates across 21 VISNs and 128 VA hospitals nationwide. Findings showed that of the 4,423,010 hospital admissions in this study, 392,939 (9%) were initiated in medical observation status. From 2005 through 2013, observation rates across VA hospitals more than doubled, with substantial variation across both hospitals and VISNs. There were 451,229 acute admissions in the first year (2005), of which 29,119 (6.5%) initiated in observation status compared to 517,248 acute admissions in the last year (2013), of which 71,124 (13.8%) initiated in observation status. While most hospitals in this study increased their observation rate, some reduced their rate. Overall, changes in the use of observation ranged from a 27 percentage-point decrease to a 43 percentage-point increase, with the average change being an increase of 7.1 percentage points. Findings suggest that trends in the use of observation stays are similar in VA and Medicare patients despite differing payment structures and financial incentives in the two systems. VA policymakers, like their Medicare counterparts, will need to examine the impact of the growing number of observation stays on patient outcomes and costs. Date: October 1, 2015 NEJM Perspective Discusses Withholding of CMS Data Related to Substance Use Disorder and Its Impact on Research In November 2013, the Centers for Medicare and Medicaid Services (CMS) began to withhold from research data sets any Medicare or Medicaid claim with a substance use disorder (SUD) diagnosis or related procedure code. This move — the result of privacy-protection regulations overseen by the Substance Abuse and Mental Health Services Administration — affects about 4.5% of inpatient Medicare claims [recent research suggests this figure is closer to 7%] and about 8% of inpatient Medicaid claims from key research files, impeding a wide range of research evaluating policies and practices intended to improve care for patients with substance use disorders. As a consequence, VA researchers cannot see the full utilization of Veterans who also use Medicare- or Medicaid-financed healthcare. This Perspective summarizes the problem, quantifies it, describes how it arose, and argues that research access to such data should be restored. Date: April 15, 2015 Impact of Medical Home Features on Use of VA Healthcare and Total Costs of Care This study evaluated changes in the adoption of different components of the PACT model in all VA primary care clinics and the relationship to patients’ use of acute and non-acute care, as well as total costs after two years. Findings showed that VA clinics reported large improvements in the adoption of all medical home components from FY09 to FY11. Improvements under the components ‘organization of practice’ and ‘care coordination and transitions in care’ appear to have impacted VA outpatient care (fewer primary care visits and more specialty care/fewer ED visits, respectively), but reductions in acute care were largely absent. Moreover, none of the changes in medical home components was significantly related to telephone visits, ACSC hospitalizations, or total health care costs. During the study period, the mean number of primary care visits decreased by 17%, while ED visits rose by 7%, and telephone visits rose by 85%. Date: March 1, 2015 Veterans Receiving Brief Alcohol Misuse Intervention Rate VA Providers and Care Higher than Veterans without Intervention This study assessed the relationship between receipt of brief alcohol intervention and patient-reported indicators of care quality. Findings showed that among Veterans who screened positive for unhealthy alcohol use, a higher proportion who reported receipt of a brief alcohol intervention, compared to those who did not, rated their provider (87% vs. 82%) and VA healthcare (83% vs. 76%) as high quality. Sixty-one percent of Veterans in this study screened positive for mild unhealthy alcohol use, and 21%, 11%, and 8% screened positive for moderate, severe, and very severe unhealthy alcohol use, respectively. Of drinkers reporting unhealthy alcohol use, 44% of Veterans reported receipt of a brief intervention for unhealthy alcohol use in the previous year. Overall, 84% and 79% of Veterans rated their provider and VA healthcare as high quality, respectively. Thus, although the literature suggests providers may be concerned that discussions of unhealthy alcohol use may negatively impact relationships with their patients, study findings do not support concerns that delivering alcohol-related advice adversely affects patients’ perceptions of care. Date: February 18, 2015 Racial/Ethnic Disparities in Treatment Retention for Veterans with PTSD This study of Veterans recently diagnosed with PTSD sought to determine whether the odds of premature mental health treatment termination varied by patient race/ethnicity and, if so, whether such variation is due to differential access to services or beliefs about mental health treatment, or whether there is a disparity in the provision of treatment. Findings showed that compared to White Veterans, African-American and Latino Veterans were less likely to receive a minimal trial of pharmacotherapy and, overall, African-Americans were less likely to receive a minimal trial of any treatment in the six months after being diagnosed with PTSD. Controlling for beliefs about mental health treatments diminished the lower odds of pharmacotherapy retention among Latino Veterans but not African-American Veterans. As expected, positive beliefs about psychotherapy or pharmacotherapy facilitated treatment retention. Access barriers did not contribute to treatment retention disparities. They significantly impacted psychotherapy participation, but equally across the entire sample. To improve treatment equity, clinicians may need to directly address patients’ treatment beliefs and preferences. Date: November 24, 2014 VA PACT Implementation Increases Primary Care among Veterans with PTSD This study assessed the association between PACT and the use of health services among Veterans with PTSD. Findings showed that the period following PACT implementation was associated with lower rates of hospitalization and specialty care visits and a higher rate of primary care visits for Veterans with PTSD, indicating enhanced access to primary care. Adjusted results show a 9% decrease in hospitalizations, an 8% decrease in specialty care, and an 11% increase in primary care visits in the post-PACT period. No significant effects were found on mental health, ED, or urgent care visits. For Veterans younger than 65 years, findings mirrored the full sample, with significantly lower hospitalizations and specialty care visits and higher primary care visits in the post-PACT period. However, for Veterans older than 65 years, there were significant increases in both primary and specialty care visits, significant decreases in urgent care visits, and no significant decrease in hospitalizations. Date: November 10, 2014 JGIM Supplement Highlights VA’s Partnered Research In this JGIM Supplement, 12 articles describe partnered research at various stages – from conceptualizing partnered research to examples of findings borne from bi-directional collaborations with investigators and leaders from clinical operations. These articles cover a wide range of topics highly relevant to VA policy and practice, including performance measure implementation on provider motivation, opioid management, suicide prevention, homelessness, medical home models, and communication of adverse events. Date: November 1, 2014 Electronic Health Record-based Alerting Systems Can be Source of Turnover for Clinical Practices The use of certain components of electronic health records (EHRs), such as EHR-based alerting systems (EAS), might reduce provider satisfaction – a strong precursor to turnover. This study examined how providers’ perceptions of the use of EAS (known within the VA CPRS as View Alert notifications) may impact their satisfaction, intention to quit, and turnover. Findings showed that providers’ perceptions of the value of EAS predicted both provider satisfaction and facility-level turnover. For example, perceptions of the degree of monitoring and feedback received regarding EAS were significantly associated with intention to quit, with high levels of monitoring and feedback associated with increased intention to quit. Monitoring/feedback on EAS practices, training on the use of EAS, and the extent to which colleagues used/valued EAS had little impact on provider satisfaction. Date: November 1, 2014 Adverse Childhood Experiences More Common among Men with Military Service Those with a history of military service may be a specific subpopulation of interest regarding adverse childhood experiences (ACE), as some may enlist to escape personal problems, potentially elevating the prevalence of ACE among military populations. This study sought to compare the prevalence of ACE among individuals with and without histories of military service based on service during the draft era (enlisted prior to 1973) or during the all-volunteer era (enlisted on/after 1973). Findings showed that men with military service during the all-volunteer era had a higher prevalence of all 11 ACE items than men without military service in this era. Notably, men with military service during this era had more than twice the odds of men without military service history of reporting household drug or alcohol abuse while growing up, suffering physical abuse or witnessing domestic violence, or some form of sexual abuse (being touched or being forced to touch, or to have sex before age 18). During this era, men with military service had more than twice the prevalence of experiencing 4 or more ACE categories (27% vs. 13%) compared to those without military service. Markedly fewer differences in ACE were found among women with and without military service histories across either era. Women with military service histories from both eras had similar patterns of elevated odds for physical abuse, household alcohol abuse, exposure to domestic violence, and emotional abuse compared with women without military service. Identifying the presence of ACE among military service members and Veterans may aid in better understanding the etiology of trauma-related mental and behavioral health conditions as well as the cumulative impact of trauma. Date: September 1, 2014 Affordable Care Act May Impact Continuity of Care for Homeless VA Healthcare Users This study compared Veterans who are likely eligible for the Medicaid expansion (LEME) and those who are not LEME, stratified by homeless status. Findings showed that among all VA healthcare users under the age of 65, homeless Veterans were two times more likely to be LEME than non-homeless Veterans (64% vs. 30%). Regardless of housing status, Veterans who were LEME were physically healthier than those not LEME. However, Veterans who were LEME were more likely to have substance use disorders and PTSD. Among homeless VA healthcare users, those who were LEME were less than half as likely to be married, to be an OEF/OIF/OND Veteran, and had less than one-third the income of Veterans who were not LEME. Among non-homeless VA healthcare users, those who were LEME were younger and more likely to be OEF/OIF/OND Veterans. Cross-sytem use of VA and Medicaid-funded services may be advantageous for Veterans with extensive medical and psychiatric needs, but also risks fragmented care. Information and education for VA clinicians and patients about possible implications of the Affordable Care Act may be important. Date: September 1, 2014 Potential Impact of Affordable Care Act on Massachusetts Veterans’ Enrollment in VA Healthcare This study examined the potential impact of the Affordable Care Act (ACA) on Veterans’ enrollment in VA, private insurance, and Medicaid, using the Massachusetts Health Care Reform Act (MHCRA), implemented in June 2006, as a proxy for ACA. Findings showed that overall, healthcare reform in Massachusetts was associated with significantly greater Medicaid enrollment, but was not significantly associated with VA and private insurance enrollment. Compared to other Veterans living in New England, Veterans living in Massachusetts decreased their enrollment in VA and private insurance by 0.2 and 0.9 percentage points, respectively, following healthcare reform. By contrast, Medicaid enrollment increased by 2.5 percentage points. Veterans increasingly took advantage of the expanded Medicaid options that were part of MHCRA; Veterans who might otherwise have enrolled in VA or private insurance opted for Medicaid. Date: August 1, 2014 Detection of Suicidal Ideation Not Associated with Increased Mental Health Utilization in Year Following SI Assessment This study evaluated the impact of brief suicidal ideation (SI) assessments on mental healthcare use among new-to-care OEF/OIF Veterans. Findings showed that 32% of the Veterans in this study had positive SI assessment results. The detection and presence of suicidal ideation was not associated with subsequent mental healthcare utilization over the following year, when accounting for the severity of depression symptoms. In other words, SI itself was not found to be associated with increased Veteran engagement in specialty mental healthcare over and above depression symptom severity. When a Veteran’s inaugural visit to VA healthcare included a mental health clinician, the Veteran was more likely to attend more subsequent specialty mental health visits – and to receive an antidepressant medication – than Veterans who were seen by a primary care clinician only. Date: July 30, 2014 VA’s “Big Data”: Benefits and Challenges This paper provides an overview of VA’s evolving approach to “big data” and illustrates how advanced analytics support clinical activities, with particular emphasis on the Patient-Aligned Care Team (PACT) model of patient-centered primary care. It also shares some of the challenges, concerns, responses, and future plans that have emerged from these initiatives. Date: July 9, 2014 JGIM Supplement Highlights VA’s Patient-Aligned Care Teams This JGIM Supplement includes 19 articles that share lessons learned by researchers and their clinical and policy partners during the early stages of PACT implementation. Articles focus on its roll-out, as well as its evaluation. Date: July 1, 2014 Veterans’ Use of Blue Button Feature in MyHealtheVet The Blue Button feature in VA’s online combined personal health record and patient portal, My HealtheVet (MHV), allows patients to access electronic health record (EHR) components, such as past and future appointments, lab results, and medications. This study aimed to characterize users of the MHV Blue Button, its perceived impact on Veterans’ health, and its role in sharing healthcare information. Findings showed that among users of the Blue Button, the benefit most highly endorsed by Veterans (73%) was the value of having their health history in one place. In addition, 21% of users with a non-VA provider shared their VA health information, and of those, 87% reported the non-VA provider found the information somewhat or very helpful. Veterans’ self-rated computer ability was the strongest factor contributing to both Blue Button use and to sharing information with non-VA providers. The majority of non-users of the Blue Button stated they were not aware of it. However, non-users who were aware of the Blue Button stated they did not use it because they did not know how (34%), they only use MHV for prescription renewal (26%), they preferred other methods to keep track of health information (11%), or they did not know where the Blue Button was located (10%). Age was not associated with Blue Button use. Date: July 1, 2014 Outcomes Associated with VA Implementation of PACT Investigators in this study created the PACT Implementation Progress Index (Pi2) to measure the extent and variation of PACT implementation, and then conducted an observational study to examine the association between the index and key outcomes (e.g., patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout. Findings showed that the extent of PACT implementation was highly associated with important outcomes for both patients and providers. Significant trends were observed in quality of care in relation to the Pi2 score: 77 sites that achieved the most effective implementation exhibited higher clinical quality outcome measures than less successful sites. The rate of emergency department visits was significantly lower in sites with more effective PACT implementation than in those with less effective implementation, and there were larger projected decreases in rates of ambulatory care sensitive condition admissions after the start of PACT. Patient satisfaction was significantly higher among sites that had effectively implemented PACT than among those that had not, and a similarly favorable pattern was observed for staff burnout. Date: June 23, 2014 Trends in Healthcare Use and Costs after VA’s Implementation of Patient-Aligned Care Teams This study analyzed data for 11 million VA primary care patients treated from FY03 through FY12 to assess how trends in healthcare use and costs changed after the PACT implementation. Findings showed that PACT implementation was associated with modest increases in primary care visits – and with modest decreases in both hospitalizations for conditions like heart failure that might be avoided with better ambulatory care, and outpatient visits with mental health specialists. It is estimated that these changes avoided $596 million in costs compared to the investment in PACT of $774 million, for a potential net loss of $178 million during the study period. The investment in PACT was overwhelmingly attributed to hiring personnel to staff primary care teams. Although PACT has not generated a positive financial return, it is still maturing and trends in costs and use are favorable. Thus, adopting patient-centered care does not appear to have been a major financial risk for VA. Date: June 1, 2014 Implementation of Telemedicine in VA ICUs May Not Reduce Mortality Rates or Length of Hospital Stays This study evaluated the impact of telemedicine (TM) implementation on short-term (ICU and in-hospital) and longer-term (30-day) mortality rates and length of stay (LOS) within a regional network of seven Midwest VA hospitals. Findings showed that the implementation of an ICU telemedicine program did not reduce mortality rates or length of hospital stay. It was not associated with a significant decline in ICU, in-hospital, or 30-day mortality rates or LOS in unadjusted or adjusted analyses. Date: May 12, 2014 Combat Deployments Associated with New-Onset Coronary Heart Disease among Young U.S. Service Members and Veterans This study sought to determine whether specific deployment experiences and PTSD symptoms are associated with newly reported coronary heart disease (CHD) among a young cohort (mean age = 34 years at baseline) of U.S. military personnel (active duty) from all service branches. Findings showed that combat deployments were associated with new-onset CHD among young U.S. service members and Veterans. Service members who reported combat experiences had nearly twice the odds of having a diagnosis code for new-onset CHD than service members without combat exposure. This suggests that experiences of intense stress may increase the risk for CHD over a relatively short period among young adults. Screening positive for PTSD symptoms was associated with self-reported CHD prior to – but not after adjusting for depression and anxiety, and was not associated with a new diagnosis of CHD. Date: March 11, 2014 Hepatitis C Virus Genotype 3 Associated with Increased Risk of Cirrhosis and Hepatocellular Cancer among Veterans Investigators in this study identified 110,484 Veterans with chronic Hepatitis C virus (HCV) infection and an average follow-up of more than five years to examine the differences between HCV genotypes in the risk of progression to cirrhosis and hepatocellular cancer (HCC). Findings showed that HCV genotype 3 (present in 8% of all cases) was associated with a significantly increased risk of developing cirrhosis and HCC compared to HCV genotype 1 (80% of cases). Veterans with HCV genotype 3 were 31% and 80% more likely to develop cirrhosis and HCC, respectively, compared to Veterans with the most common HCV genotype 1 infection. Genotype 3 has traditionally been considered easier to treat than genotype 1 infection. Investigators found that a significantly higher proportion of Veterans with genotype 3 received and subsequently responded to antiviral treatment than those with genotype 1. However, this therapeutic advantage did not counterbalance the negative impact of genotype 3 on cirrhosis and HCC. Given the accelerated progression to advanced liver disease, patients with HCV genotype 3 may serve as a high-risk group that will need to be prioritized in the era of new antiviral treatments. Date: February 24, 2014 Intimate Partner Violence: Current State of Knowledge in Regard to Women Veterans This article provides an overview of the risk and impact of experiencing intimate partner violence (IPV) among women Veterans, who currently make up 10% of the Veteran population, and who appear particularly likely to report IPV (research has shown prevalence ranges from 24% - 29% of past-year IPV). Investigators also discuss evidence-based treatment for IPV and identify future priorities for research and clinical programming. Date: February 7, 2014 Social Network Encouragement Helps Veterans with PTSD Seek VA Mental Healthcare This study sought to determine whether beliefs about mental health treatment and/or social encouragement to seek treatment influence initiation of mental healthcare among Veterans with PTSD. Findings showed that whether Veterans initiate mental healthcare after a PTSD diagnosis depends not only on symptom severity and access to treatment, but also on encouragement by those in their social network, whether the Veteran perceives the need for treatment, how they view treatment for PTSD (e.g., positive beliefs about the efficacy of antidepressants), as well as their ability to follow treatment recommendations. Encouragement to get mental healthcare by individuals in their social network increased the odds of getting treatment, even after controlling for beliefs, particularly if encouragement was given by both family and friends/other Veterans. While not the focus of this study, investigators noted that for all outcomes, older VA healthcare users, Veterans with service connection, and those who were diagnosed in non-mental health clinics were less likely to receive treatment. In addition, Veterans who were seen in PTSD specialty clinics, though less likely to receive medication than those in general mental health clinics, were more likely to receive psychotherapy. Date: February 3, 2014 Changes in Care Processes and Patient Outcomes Related to VA’s Implementation of PACT Model This study examined whether changes in VA healthcare delivery under the PACT transformation led to changes in organizational processes of care and patient outcomes. Findings showed that medical home implementation in the VA healthcare system resulted in large changes in the structure of care, but few changes in patient-level organizational processes or outcomes. There were significant improvements in two-day post-hospital discharge contact, but not primary care visits occurring by telephone or within three days of the requested date. There was no association between medical home implementation and rates of emergency department use by Veterans. Over the study period, the percentage of PCPs who were part of the PACT model more than tripled, and the percentage of PCPs that implemented elements of the PACT model increased significantly. Date: January 30, 2014 Rehabilitation Settings for Veterans Following Hospital Discharge for Hip Fracture This study explored the factors that impact choice of VA rehabilitation setting after acute hip fracture repair procedures. Findings showed that following hospitalization for hip fracture, nearly half (48%) of the Veterans in this study were discharged directly home – without VA-paid rehabilitation. Few Veterans (0.8%) were discharged with home health, with higher proportions discharged to a nursing home (15%), outpatient rehabilitation (19%), or inpatient rehabilitation (17%). Veterans with higher comorbidity scores were less likely to be discharged to inpatient rehabilitation. Veterans were more likely to be discharged to non-home settings if they had total functional dependence, had high American Society of Anesthesiology (ASA) class scores, had one or more surgical complications, or lived in counties with lower nursing home bed occupancy rates. Thus, it appeared that the most vulnerable patients were provided inpatient care. Surgical complications were the most significant predictor of discharge setting, but the availability of community resources also was an important predictor. Date: January 1, 2014 Study Assesses VA/Alzheimer’s Association Care Coordination Program for Informal Caregivers of Veterans with Dementia A new initiative targeting caregivers of Veterans with dementia is “Partners in Dementia Care” (PDC) — a care-coordination program delivered via a partnership between VA and Alzheimer’s Association chapters. This study assessed the effectiveness of the PDC program. Findings showed that the PDC program is a promising model that improves linkages between VA healthcare services and community services for informal caregivers of Veterans with dementia. Compared to comparison caregivers, those who participated in the PDC program had significant improvement in outcomes representing unmet needs, all three types of caregiver strains, depression, and support resources. Most improvements were evident after six months, with more limited improvements from months 6 – 12. However, improvements after the first six months were maintained during the entire study. Some outcomes improved for all caregivers, while others improved for caregivers with more initial difficulties – or those who were caring for Veterans with more severe impairments. Date: August 1, 2013 Veterans with Prostate Cancer Living in Rural Settings have Less Access to Comprehensive Oncology Resources than Urban Veterans, but Receive Similar or Better Quality of Care This study sought to determine the degree to which access barriers impact the quality of prostate cancer care for rural patients in the VA healthcare system. Findings showed that Veterans with prostate cancer living in rural settings traveled nearly 5-fold further for care and were less likely to be treated at facilities with comprehensive cancer resources, compared with Veterans living in urban settings. Despite differences in access to resources, rural patients received similar or better quality of care for 4 of 5 measures (e.g., appropriate number of biopsies, no bone scan for low-risk disease, appropriate chemotherapy for progressive disease, and appropriate hormonal therapy for high-risk patients treated with radiation therapy). Time to prostate cancer treatment was similar for Veterans living in rural compared with urban settings (97 days vs. 106 days). Date: July 30, 2013 Changes in VA Care since PACT Implementation This study evaluated interim changes in PACT-related care processes. Findings showed that VA achieved rapid progress in building a PACT infrastructure in the first 30 months of an extensive four-year implementation plan, and some interim changes in processes of care were observed: in-person PCP visit rates decreased slightly; healthcare via telephone and Internet increased dramatically (e.g., phone encounters increased 10-fold and patients using telehealth increased from 38,747 in 12/09 to 70,486 in 6/12); shared medical appointments increased slightly; appointment access and continuity improved slightly, but started at high levels; and post-hospitalization follow-up improved substantially but remains below goal (e.g., patients evaluated by primary care clinicians within 48 hrs of hospital discharge increased from 6% in 12/09 to 61% in 12/11). Facilities’ average overall score on the ACP Biopsy survey (assessing the presence of 127 PACT components via “yes” or “no” items in 7 categories) increased from 69% “yes” in 10/09 to 80% “yes” in 7/11. Date: July 10, 2013 Incentives to Impact Patient Engagement and Health Behavior This essay discusses a range of efforts in implementing wellness programs and incentives intended to promote healthy behaviors by insurers, employers, and providers, and how they might be made more effective. Date: July 1, 2013 Cancer Genetics Toolkit Improves Quality and Frequency of Family History Documentation among VA Primary Care Patients Investigators in this study developed a cancer genetics toolkit designed to improve familial risk assessment and appropriate referrals for hereditary breast-ovarian cancer (HBOC) and Lynch syndrome. They then evaluated the impact of the toolkit by comparing clinician behaviors relating to documentation of cancer family history and referral for genetic consultation before and after its implementation in women’s primary care clinics. Findings showed that the toolkit increased the frequency and improved the quality of cancer family history documented by primary care clinicians; increased recognition of high-risk Veterans; and increased the numbers of appropriate referrals for genetic consultation. A clinical reminder in the electronic health record was a key component of the toolkit; when used, it was associated with a two-fold increase in cancer family history documentation, and history was more complete. In addition, veterans whose clinicians completed the reminder were twice as likely to be referred for genetic consultation. Date: June 13, 2013 Adoption of PACT Features is Significantly Associated with Lower Risk of Avoidable Hospitalization The primary outcome measured in this study was potentially avoidable hospitalizations for ambulatory care sensitive conditions (ACSC) that included: asthma, angina without procedure, pneumonia, dehydration, COPD, congestive heart failure, complications related to diabetes, hypertension, perforated appendix, and urinary tract infection. In addition, the total number and costs of ACSC hospitalizations were measured for each Veteran during a 12-month follow-up period. Findings showed that greater adoption of medical home features by VA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations. Veterans in clinics with the highest medical home adoption had significantly lower ACSC rates (20 per 1,000) compared to Veterans in clinics with the lowest (25 per 1,000) and medium (26 per 1,000) adoption of medical home features. If clinics were transformed from the mean level of medical home adoption to the maximum level, the reduction in hospitalization costs in an average-sized clinic with 3,500 Veterans could be as much as $83,000 annually. Two PACT features were independently related to lower risk of ACSC hospitalization: access and scheduling, and care coordination/transitions in care. For example, Veterans in clinics with the highest scores on access and scheduling had 17% lower odds of having an ACSC admission compared to the lowest scoring clinics. Date: March 26, 2013 Journal Issue Highlights the State of Health Information Technology in VA Healthcare This Medical Care Supplement focuses on the use and impact of health information technology (HIT) in quality improvement research conducted within VHA. Articles in this Supplement highlight a range of specific HIT approaches, including innovative and interactive uses of VHA’s electronic health record, databases, and information systems, as well as applications of automated systems for intervention, evaluation, and tracking patient care. Date: March 1, 2013 Prolonged Exposure or Cognitive Processing Therapy May Reduce Use of Mental Health Services in Veterans with PTSD This study evaluated the impact of a course of Prolonged Exposure (PE) or Cognitive Processing Therapy (CPT) on VA mental health and medical service utilization and healthcare costs. Findings showed that Veterans who had successfully completed PE or CPT for PTSD experienced a reduction of both PTSD and depression symptomatology; they also reduced their mental health service utilization by 32% in the year following treatment when compared to the year prior to the initiation of PE or CPT. There was a slight, non-significant decline in primary care usage among Veterans who had completed therapy, while emergency department usage remained virtually the same. Per Veteran, there was a 39% reduction in total costs – from an average of $5,173 in the year prior to treatment to $3,133 in the year following treatment. These preliminary findings suggest that the successful completion of PE and CPT for the treatment of PTSD significantly reduces mental health service use and outweighs the cost of treatment. Date: January 1, 2013 Majority of Veterans with Serious Mental Illness Prefer Family Involvement in their Care This article reports on baseline data from the Recovery Oriented Decisions for Relative’s Support (REORDER) intervention, an innovative, manualized protocol that uses a shared decision-making process to facilitate a patient’s consideration of family involvement in care. Findings showed that the majority (78%) of Veterans in this study wanted their family involved in their care. Veterans were concerned about the impact family involvement would have on themselves and their family. Veterans also expressed concerns about the negative effects of involvement, including a loss of personal privacy and decreased time for the involved family member to attend to other responsibilities. The degree to which a Veteran expected benefits from family involvement in care predicted the degree of desired family involvement, whereas anticipating barriers did not. Date: December 15, 2012 Quality of VA’s PTSD Disability Assessment Would Improve by Using Evidence-Based Assessment This trial compared usual disability examiner practices with a standardized assessment that incorporates evidence-based assessments. Findings showed that administering a standardized disability assessment resulted in more complete diagnostic information on functional impairment and PTSD symptoms. Standardized assessments were 85% complete for diagnosis compared to 30% for non-standardized assessments; and for functional impairment, the rates were 76% compared to 3%. Standardized assessment elicited an increase in relevant information and nearly eliminated variation between examiners and medical centers. While the standardized examination was more sensitive than routine examination, it did not result in a significant change in the overall prevalence of diagnosed PTSD. Date: December 1, 2012 Factors Affecting Readiness for Implementation of VA’s Patient-Aligned Care Team Model This study sought to describe the impact of readiness for implementation on the efforts of 32 pilot PACT teams to make changes to improve access to healthcare for Veterans – and to identify successful strategies to overcome barriers to change. Findings showed that key factors related to readiness for implementation (or lack thereof) had an impact on which interventions pilot teams could put into place, as well as viability and sustainability of access gains. Leadership Engagement. Lack of leadership engagement/support posed a barrier to open access, however, strategies to engage/educate administrators led to successful interventions to improve access. Staffing Resources. Lack of personnel to staff PACT teams was a barrier to improving access; at sites where funds were made available to hire new staff or where teams were able to re-configure existing staff, access interventions were more often implemented. Access to Information and Knowledge. Having experienced staff who could generate reports from the electronic medical record was a major facilitator of access interventions. Pilot teams used a number of effective strategies for improving access, i.e., extending time between appointments for some Veterans; reorganizing clinic schedules in order to provide a mix of face-to-face, telephone, and same-day appointments; and contacting Veterans after an ED visit to determine appropriate follow-up care. The authors note that wide variations in interventions to improve access occurred across sites, which has important implications for efforts to measure the impact of enhanced access on patient outcomes, costs, and other systems level indicators of the PACT model’s success. Date: November 29, 2012 Systematic Review Evaluates Patient-Centered Medical Home Model for Primary Care Transformation This systematic review sought to describe how studies conducted to date have implemented patient-centered medical homes (PCMH) – and to evaluate the current evidence of the effect of PCMH interventions on patient, staff, and economic outcomes. Findings showed that there is moderately strong evidence that the patient-centered medical home has a small positive impact on patient experiences and small to moderate positive effects on delivery of preventive care services. Staff experiences are also improved by a small to moderate degree (low strength of evidence [SOE]), but no study reported effects on staff retention. Current evidence is insufficient to determine effects on clinical and most economic outcomes, with the exception of emergency department utilization, which was reduced among older adults (low SOE). Given the relatively small number of studies directly evaluating the PCMH, and the evolving approaches to designing and implementing the medical home model, the authors caution that these findings should be considered preliminary. The PCMH evidence base is expected to double in the next two to three years. Date: November 27, 2012 Perceptions of Coercive Treatment and Satisfaction with Care among Veterans Hospitalized for Severe Mental Illness This study examined associations between perceptions of coercive treatment and satisfaction with care among psychiatric inpatients at one VAMC. Findings show that both involuntary commitment status and perceptions of coercion were independently and negatively associated with patient satisfaction with psychiatric inpatient hospitalization. Among the Veterans who were psychiatric inpatients in this study, 15% were involuntarily admitted, 40% reported prior involuntary admissions, and nearly half endorsed the perception of some coercion during their index admission. In addition, self-reported history of being denied a requested medication during psychiatric hospitalization (a potentially coercive treatment) may influence appraisal of care during the current hospitalization. Self-reported lifetime rates of other coercive treatment experiences ranged from 22% reporting being forced to take medications to 46% reporting ever being transported to the ER or hospital by law enforcement. Date: September 28, 2012 Construction of a Clinical Indicator for the Risk of Over-Treatment among Elderly Patients with Diabetes The publication of three major trials, including the VA Diabetes Trial (VADT), has prompted greater attention to the potential harms of overly tight glycemic control among patients with diabetes, especially in the elderly and those with cardiovascular disease. The high frequency of risk factors for hypoglycemia and its adverse impact, the marginal benefits of tight control in individuals with short life expectancy, and potential for inaccurate measures suggest a need for a quality measure to reduce over-treatment, particularly among elderly patients. This Commentary discusses these issues and explores the construction of a clinical indicator for the risk of over-treatment. Date: September 10, 2012 Effectiveness of Medical Pre-Operative Clinics This study evaluated the impact of the addition of a hospitalist-run pre-operative clinic to standard practice in one VAMC. Findings showed that the addition of an internal medicine-focused pre-operative clinic was associated with improved patient outcomes and reduced hospital length of stay for Veterans undergoing surgery. Inpatient mortality rates were reduced for Veterans seen in the hospitalist-run preoperative clinic in Period B (the first year of the new hospitalist-run system) compared to Veterans seen in Period A, when Anesthesia Department staff supervised the pre-operative clinic (0.36% vs. 1.27%). There also was a trend toward a reduction in same day, medically avoidable surgical cancellations (8.5% vs. 4.9%). There was a significant increase in the number of Veterans on perioperative beta blockers, with 26% in Period A compared to 33% in Period B. Date: September 7, 2012 Veterans with Greater Clinical Complexity Receive Higher Quality of Care for Diabetes This study examined the impact of clinical complexity on three quality indicators for diabetes care: glycemic, blood pressure (BP), and lipid control. Findings showed that of the Veterans in this study,18% were controlled for all three quality indicators at index, and 19% were controlled at 90-day follow-up. Veterans with the greatest levels of clinical complexity received higher quality of care for diabetes based on BP, glycemic, and lipid quality indicators compared to less complex patients, regardless of the definition of complexity. Date: September 1, 2012 Despite Individual Hospital Performance, Pay-for-Performance Program May Result in Small Changes in Medicare Payments Despite differences across hospitals in terms of performance, expected changes in payments from Medicare under the new hospital pay-for-performance program were small, even for hospitals with the best and worst performance scores. Almost two-thirds of hospitals would experience changes of just a fraction of 1%, and only eight hospitals would have a change of greater than 0.75%. Hospital performance varied substantially across states, which translated into regional differences in Medicare payments. For example, in New Hampshire, one of the states with the highest scores, average Medicare payments would increase by $66,948 (0.24%), while in Hawaii, one of the states with the lowest scores, average Medicare payments would decrease by $25,596 (0.20%). Changes in expected hospital payment also varied by most hospital characteristics. For example, the percentage of hospitals that would have an increase in Medicare payment by 0.25% or more varied by teaching status: 10% of hospitals with a major teaching affiliation were in this category compared to 20% of non-teaching hospitals. These results raise questions about whether the new pay-for-performance program will substantially alter the quality of hospital care, and findings highlight the challenges of designing effective quality improvement incentives. Date: September 1, 2012 IRB Process for Multisite, Minimal-Risk VA Trial Complying with IRB requirements for a minimal-risk randomized controlled trial involved 115 submissions, consumed more than 6,700 staff hours, and lasted nearly two years longer than planned. The IRB approval process had a profound financial impact on the project, costing close to $170,000 in staff salaries. Delays in approval affected participant recruitment and retention; for example, seven physician participants had left their primary care settings before all IRB approvals were received. One IRB’s concern about incentivizing a medication recommended by national guidelines prompted a protocol modification (broadening study inclusion criteria beyond uncomplicated hypertension) at all sites in order to preserve the study’s internal validity. Requirements for local site principal investigators and for IRB and R&D committee approvals resulted in the inclusion of more highly-affiliated, urban sites that were treating more complex patients, potentially affecting the external validity (generalizability) of the study findings. Date: May 15, 2012 Factors Associated with Increased VA Preventable Acute Care Use Prior mental health diagnoses and medication use were independent risk factors for ambulatory care sensitive condition- (ACSC) related acute care. These risk factors will require focused attention if the full benefits of new primary care models, such as PACT, are to be achieved. The highest rate of ACSC admissions was among Veterans with drug use disorders (46 admissions per 1,000 patients), followed by those with depression (35 admissions per 1,000 patients), compared to 21 admissions per 1,000 patients for those with no mental health diagnoses. The rate of ED visits for ACSCs was also higher among those with mental health diagnoses (70 visits per 1,000 vs. 44 visits per 1,000 for those without mental health diagnoses). Patients without mental health conditions experienced significantly lower rates of both all-cause and ACSC admissions than patients with mental health conditions. The mean cost and length of stay of ACSC admissions, however, was similar and not statistically different between the two groups. Date: March 20, 2012 Multi-Component Support Program Helps Lessen Burden for Caregivers of Aging Veterans with Disabilities A multi-component support services program that allowed Veterans aging with a disability to remain in the home, while also addressing the unmet needs of caregivers, was implemented and evaluated in one VA facility in 2009. Caregivers experienced meaningful improvements in burden after support services were rendered. Although there were no changes in caregivers’ physical health status, the support services program had a positive impact on mental health that was reflected in significant improvements in caregiver scores on the mental health components of the SF-12 health status scale. Satisfaction with services increased from baseline to follow-up. Date: February 1, 2012 Relationship between Resources and Quality of VA Primary Care This study examined the relationship between resource use and care quality in VA primary care clinics using the concept of organizational slack, which is defined as extra organizational resources (i.e., staff, budget, equipment) available to meet a given level of demand. Findings showed that Veterans seen in VA primary care clinics where staffing was below the recommended level were more likely to experience lower quality of care. Although some level of organizational slack resource for staffing was associated with better quality of care, additional staffing – beyond guideline recommendations – exhibited diminished returns. Thus, the addition of staffing resources in primary care clinics contributed to higher levels of quality, but only to a point, at which more staff appeared to make only minimal contributions to quality. Findings are relevant to understanding the cost and benefits of adding staff to new models of primary care, such as panel management and the Patient-Aligned Care Team (PACT). Also, staff cost and quality trade-off issues may be an increasingly important issue in future policy discussions. Date: December 20, 2011 Low Rates of Screening for Intimate Partner Violence among Veterans with PTSD This study sought to determine how many Veterans’ records showed documentation of screening for intimate partner violence (IPV) perpetration – and to assess the total number of screenings, and whether an initial screening affected future screenings. Findings show a low rate of screening and assessment for IPV perpetration in male, treatment-seeking Veterans with PTSD – a population believed to have high rates of relationship conflict. While most patient records did not show documentation of a screening or assessment for IPV perpetration, many provided rich descriptions of relationships, indicating that Veterans gave VA staff opportunities to ask about IPV. Authors suggest that documenting IPV screening and perpetration can alert other providers, offering an opportunity for further assessment of its impact on the Veteran and his family members. Date: November 1, 2011 JGIM Special Supplement Highlights Access to VA Healthcare The JGIM Supplement includes both the white papers commissioned as background for the September 2010 state-of-the-art (SOTA) conference on “Improving Access to VA Care” and manuscripts submitted in response to a post-SOTA solicitation for original research and reviews pertaining to improving access to VA care. Articles focus on a myriad of topics related to improving access to care for Veterans, including: eHealth technologies (e.g., Care Coordination Home Telehealth program, and My HealtheVet personal electronic health record); measuring the impact of access on healthcare utilization, quality, and outcomes; and redefining access for 21st century healthcare. Date: November 1, 2011 Distance Most Important Barrier for Rural-Residing Veterans Seeking Healthcare This study of rural Veterans, providers, and staff examined the impact of travel distance on the use of VA healthcare services, satisfaction, and impact on care delivery. Findings showed that distance was identified by Veterans, providers, and staff as the most important barrier for rural Veterans seeking healthcare. The average one-way distance that Veterans traveled to a VA primary care clinic was 44.5 miles. The most common types of distance barriers discussed pertained to patient health, functioning, and financial or time resources. Other barriers frequently cited included challenges associated with travel, such as limited transportation and cost/expense. Veterans perceived the same travel distance as more burdensome when seeking care for regular services available locally (e.g. laboratory, podiatry), when compared with specialty care (e.g., cardiology, neurology). Many older Veterans who were able to drive viewed distance more as a ‘way of life’ than a ‘barrier.’ However, given that 44% of Veterans are >65 years old, travel distance is likely to become increasingly salient as a barrier in this aging population. Date: November 1, 2011 Effect of Active versus Passive Monitoring of VA Quality Performance Measures This study compared the nature and rate of change in hospital outpatient clinical performance as a function of VA performance measures’ status (active vs. passive), and examined the mean time to stability of performance after changing status. Findings showed that performance measure monitoring status (active vs. passive) did not significantly impact performance over time. Structural organizational characteristics, including facility size, academic mission, and primary care structure, had no impact on this finding. There was variability in whether or not measures stabilized after a status change, suggesting the possibility that some measures may take more than two years to stabilize. However, performance scores for measures with short stability times were no higher or lower than scores for measures with longer stability times. All measures that stabilized did so immediately after the status change (e.g., time to stability was one quarter). Of the 6 measures that did not stabilize, 5 suggested continued improvement after the change. Date: October 1, 2011 Adherence to National Prevention Measures for Surgical Site Infection Does Not Impact VA Surgical Outcomes This study evaluated whether the Surgical Care Improvement Project (SCIP) improved surgical site infection (SSI) rates at the VA patient or hospital level. Findings showed that none of the 5 SCIP infection prevention measures were significantly associated with lower odds of SSI among Veterans after adjusting for variables known to predict SSI and procedure type. Individual hospital SCIP performance also was not associated with hospital SSI rates. While adherence to SCIP measures improved, risk-adjusted SSI rates remained stable. For Veterans with all measures assessed, the composite rate of adherence was 81%. Although SCIP measures are best practices and should continue, they may not discriminate hospital quality. Mandatory SCIP reporting without improvement in care may lead to health professional skepticism and fatigue with quality improvement measures. Date: September 1, 2011 Veterans with COPD Living in Isolated Rural Areas have Elevated Risk of Mortality This study sought to determine if COPD mortality is higher for Veterans living in isolated rural areas, and, if so, to assess whether or not hospital characteristics mediate such associations. Findings showed that Veterans living in the most isolated rural areas of the United States appear to have an elevated risk of COPD-related 30-day mortality. Overall unadjusted mortality was higher for Veterans from isolated rural areas (5.0%) and rural areas (4.0%) compared to Veterans from urban areas (3.8%). Hospital characteristics were not found to account for this effect. Veterans from isolated rural but not rural areas remained at higher risk for death after adjusting for clinical characteristics, the proportion of COPD admissions in hospitals that came from rural areas, and hospital volume. Date: July 19, 2011 Women’s Health Issues Journal Focuses on Women Veterans This special issue of Women’s Health Issues includes 18 peer-reviewed manuscripts summarizing health services research findings about women Veterans and women in the military, framed in the context of informing evidence-based practice and policy. Highlights include: VA has tailored primary care to women through the use of designated providers or separate women’s clinics. VA’s with these clinics were rated higher on most dimensions of care. These findings are particularly important to VA’s current implementation of patient-aligned care teams (PACTs). More than half of VA facilities now offer one or more mental healthcare services specifically for women Veterans, including services embedded within women’s primary care clinics, designation of women’s healthcare providers within general mental health clinics, and/or separate women’s mental health clinics. Recent data on VA care among men and women Veterans with histories of military sexual trauma (MST) show high satisfaction with care. Authors suggest that VA’s system-wide monitoring of MST-related care may be contributing to these positive results. PTSD among women Veterans is associated with poorer occupational functioning and satisfaction, but not employment status. Symptoms of depression have substantial effects across all components of work-related quality of life, independent of PTSD symptoms. PTSD is the most common psychiatric condition among both women and men with traumatic brain injury (TBI). However, women with TBI are less likely than men to have a PTSD diagnosis, but more likely to have a depression or anxiety disorder diagnosis. Date: July 6, 2011 Medicare-Eligible Veterans’ Reliance on VA Primary and Specialty Care Decreased Significantly from 2001 through 2004 This study assessed longitudinal changes in patterns of cross-system healthcare use in VA and Medicare among Medicare-eligible Veterans who had used VA primary care in FY00. Findings showed that during the study period (FY01-FY04), 39% of all primary and specialty care visits occurred within VA, with almost three times more specialty care visits than primary care visits each year. However, a majority of specialty care and nearly half of all primary care for Medicare-eligible Veterans was provided outside VA over this time period. Reliance on both VA primary and specialty care decreased substantially over the study period but the decrease was greatest in specialty care. By FY04, only 20% of Medicare-eligible Veterans were completely reliant on Medicare for primary care (i.e., had 90% or more of their primary care visits with a Medicare provider) but 47% were completely reliant on Medicare for specialty care. Among Medicare-eligible Veterans, use of Medicare primary care increased among patients who were older, had a greater burden of illness, were served by a VA community-based outpatient clinic, or lived farther from a VA facility. Patient reductions in reliance on VA primary and specialty care suggest increasingly fragmented care and more difficult care coordination. Increasing use of non-VA services may complicate implementation of the PACT model, but also may emphasize new opportunities for care coordination initiatives within PACT. Date: June 16, 2011 Telemedicine-Based Collaborative Care Does Not Increase Total Workload for Primary Care or Mental Health Providers This study examined patterns of healthcare utilization and cost associated with telemedicine-based collaborative care for depression among Veterans who received care in seven VA community-based outpatient clinics (CBOCs). Findings suggest that telemedicine-based collaborative care does not increase total workload for primary care or mental health providers; therefore, there is no disincentive for mental health providers to offer telemedicine-based care ? or for primary care providers to refer Veterans to telemedicine care. There was no significant difference in the total number or cost of primary care encounters between Veterans in the intervention group and those in the usual care group. Between the two groups, there also were no statistically significant differences in total mental health encounters or cost; however, Veterans in the intervention group did have significantly more cost and encounters in specialty physical health clinics. In addition, Veterans in the intervention group had a significantly greater total outpatient cost compared to Veterans in usual care. These differences were likely due to the high levels of physical and mental health comorbidities in this study population. Date: May 26, 2011 Medication Reconciliation Reduces Adverse Drug Events Related to Some Hospital Admission Prescribing Changes This study estimated the effectiveness of inpatient medication reconciliation at the time of hospital admission on adverse drug events (ADEs) caused by admission prescribing changes. Findings showed that medication reconciliation at the time of hospital admission reduced ADEs caused by admission prescribing changes that were classified as errors by 43%, but it did not reduce ADEs caused by all admission prescribing changes. Non-error-related ADEs would not be averted by one-time medication reconciliation on admission, but they might be averted by improved provider awareness and monitoring of admission prescribing changes during the hospital stay. The potential impact of such an intervention is large, as 50% of the ADEs in this study were caused by admission medication changes that were not errors. Date: May 9, 2011 Initial Implementation of VA Primary Care Mental Health Not Associated with Differences in Specialty Mental Health Clinic Use by Veterans This study sought to determine whether the implementation of primary care mental health services is associated with differences in specialty mental health clinic use within the VA healthcare system. Findings show that the initial implementation of primary care mental health within VA is not associated with substantial differences in mental health clinic use – or diagnoses received in specialty mental health clinics by primary care patients. Facilities with primary care mental health – compared to those without – had similar rates of primary care patients initiating specialty mental health treatment (5.6% vs. 5.8%), and their primary care patients averaged similar total specialty mental health clinic visits (7.0 vs. 6.3). After adjusting for facility characteristics and multiple comparisons, there were no statistically significant differences with regard to diagnoses for Veterans who initiated specialty mental health clinic treatment at primary care mental health facilities. The authors note that primary care mental health may impact mental health clinic use over longer periods of time as these programs mature. Date: April 1, 2011 Telemedicine ICU Coverage Lowers ICU Mortality but Not In-Hospital Mortality Because many hospitals lack the patient volume or financial resources to hire dedicated specialists trained to care for critically ill patients (intensivists) – and because of a shortage of these trained specialists – hospitals are increasingly adopting telemedicine ICU (tele-ICU) coverage. This systematic review of the literature examined the impact of tele-ICU coverage on mortality and length of stay in non-VA hospitals. Findings showed that tele-ICU coverage was associated with a significant 20% reduction in ICU mortality, but did not significantly reduce in-hospital mortality for patients admitted to an ICU. Tele-ICU coverage was associated with a 1.26 day mean reduction in ICU length of stay, which translates into a 10%-30% relative reduction in ICU length of stay. Tele-ICU was not associated with a reduction in the patient’s length of stay in the hospital. Date: March 28, 2011 Redefining “Normal” Blood Pressure This study examined the independent effects of diastolic (DBP) and systolic (SBP) blood pressure on mortality – and estimated the number of Americans affected by accounting for these effects in the definition of “normal.” Findings show that systolic blood pressure elevations are more important than diastolic blood pressure elevations in individuals older than age 50. The situation was reversed in individuals younger than age 50, in whom DBP was the more important predictor of mortality. For individuals older than age 50, the lowest and highest blood pressures were associated with the greatest rates of death. Without adjusting for SBP, the rate of death began to increase at a DBP of 90 or higher; however, adjusting for SBP made the relationship disappear. The mortality rate began to significantly increase at SBP >140 – independent of DBP. For individuals younger than age 50, a DBP above 100 was associated with significant increases in mortality, with or without adjustment for SBP. The current definition of normal BP (<120/80) leads an estimated 160 million adult Americans to be labeled abnormal. Redefining normal BP as one that does not confer an increased mortality risk (DBP <100 under age 50, SBP <140 over age 50) would reduce that number to less than 60 million. Date: March 15, 2011 Successful Translation of Behavioral Intervention for Caregivers of Veterans with Dementia This study assessed the translation of the NIA/NINR Resources for Enhancing Alzheimer’s Caregivers Health (REACH II) intervention into REACH VA – a behavioral intervention for caregivers of Veterans with dementia that ran from 9/07 through 8/09. Findings show that the REACH VA intervention provided clinically significant benefits for caregivers of Veterans with progressive dementia. Caregivers reported significantly decreased burden, depression, impact of depression on daily life, frustrations associated with caregiving, and number of troubling dementia-related behaviors. Also, a decrease of two hours per day “on duty” trended toward significance. Of the caregivers who participated in the REACH VA intervention, 96% believed that the program should be provided by VA to caregivers. Date: February 28, 2011 Routine, Oral, Rapid HIV Testing in VA Emergency Departments Financially Equivalent to Usual Care Using a dynamic decision analysis model, this study examined the budget impact of implementing a routine oral HIV rapid-testing program in a VA emergency department (ED) versus the impact of following ‘usual’ care. Findings show that a routine oral HIV screening program using a rapid testing approach is financially equivalent to following a usual care approach within the VA healthcare system. Assuming a 1% prevalence of the disease and an 80% acceptance of testing, the total cost of HIV rapid-testing was $1,418,088 versus $1,320,338 for ‘usual care.’ While the HIV rapid-testing program had substantial screening costs, they were offset by lower inpatient expenses associated with earlier identification of disease. The higher treatment costs for ‘usual care’ patients were largely due to inpatient stays, reflecting more hospitalizations for these patients due to opportunistic infections. Given that early detection of HIV and linkage to treatment is associated with better health outcomes – and non-targeted testing does not result in a greater budget impact than usual care – the authors suggest that this analysis provides support for the implementation of a routine oral rapid testing program within VA. Date: January 27, 2011 Suicide Risk Factors for OIF Veterans This study examined combat and mental health as risk factors for suicidal ideation among OIF Veterans. Findings show that, overall, 2.8% of the OIF Veterans in the study reported suicidal thinking, the desire for self-harm, or both. Post-deployment depression symptoms were associated with suicidal thoughts, while post-deployment PTSD symptoms were associated with current desire for self-harm. Post-deployment depression and PTSD symptoms mediated the association between killing in combat and suicidal thinking, while post-deployment PTSD symptoms mediated the association between killing in combat and the desire for self-harm. These results provide preliminary evidence that suicidal thinking and the desire for self-harm are associated with different mental health predictors, and that the impact of killing on suicidal ideation may be important to consider in the evaluation and care of our newly returning Veterans. Date: January 22, 2011 Electronic Health Information’s Effect on Clinical Workflow This study sought to assess aspects of health information technology (HIT) that impact clinical workflow – and to identify a set of HIT characteristics that support patient care processes. Investigators identified many examples of how HIT affects workflow, but characteristics were strongest within four primary domains: 1) Trustworthy and reliable (e.g., inconsistent incomplete, incorrect information in the electronic health record (EHR); 2) Ubiquitous (e.g., poor accessibility due to lack of computer workstations or lengthy secure login processes, but good information availability ); 3) Effectively displayed (e.g., problems locating scanned documents in the EHR, lack of searchability , information not well-organized or prioritized); and 4) Adaptable to work demands (e.g., EHR is not portable or customizable, difficult to modify information). The findings from this study underscore the value of obtaining input from healthcare employees and may be used to enhance HIT design, clinical practice, and patient safety. Date: December 1, 2010 Education Intervention Decreases Inappropriate Prostate Cancer Screening among Veterans This study tested an e-mail-based intervention called “spaced education” (SE) that was developed to reduce clinicians’ inappropriate screening for prostate cancer. Findings show that during the intervention period (36 weeks), clinicians who received the spaced education intervention ordered significantly fewer inappropriate PSA screening tests than clinicians in the control group. Over the 72-week follow-up period, SE clinicians continued to order fewer inappropriate tests compared to controls, representing a 40% relative reduction in inappropriate screening. The impact of the intervention was unaffected by clincians’ age, gender, or provider type. Date: November 1, 2010 Link between Psychiatric Diagnosis and Higher Risk of Suicide among Veterans As part of VA’s ongoing evaluation of suicide risk among Veterans being treated in VA facilities, this study examined the impact of different psychiatric diagnoses on the risk of suicide. Findings show that a clinical diagnosis of a psychiatric disorder increased the risk of subsequent suicide by 160%. Psychiatric diagnoses were an especially strong risk factor for suicide among women, increasing their risk of suicide more than 5-fold. Bipolar disorder was the least common diagnosis (only 3% of all Veterans studied), but was diagnosed in approximately 9% of all Veterans who died by suicide. A diagnosis of bipolar disorder increased the risk of suicide nearly 3-fold in men and 6-fold in women. Authors suggest this makes bipolar disorder particularly appropriate for targeted interventions (e.g., improving medication adherence). Overall, suicides were more than three times as common in men than in women and were 37% to 77% more common in Veterans ages 30 and older than among those ages 18 to 29. Date: November 1, 2010 Model Used for Cholesterol Guidelines May Lead to Misclassification of Risk for Heart Attack and Coronary Death National cholesterol guidelines use the “Framingham model” to calculate a person’s 10-year risk of myocardial infarction or coronary death. Based on this risk, patients are categorized into different risk groups, which are used to guide treatment decisions. Both original and point-based versions of the model are in use and endorsed by national guidelines. Given that approximately 36 million persons in the U.S. are eligible for lipid-lowering therapy, differences in risk classification depending on which model is used could result in millions receiving different lipid-lowering therapy. This study compared differences in predicted risk between the original and point-based Framingham calculations. Findings show that compared with the original Framingham model, the point-based version of the tool misclassifies millions of Americans into different risk groups, with 25-46% of affected individuals experiencing potential impacts on drug treatment recommendations for cholesterol control. Date: November 1, 2010 Threshold for Glycemic Control among Veterans with Diabetes In 2009, the National Committee for Quality Assurance (NCQA) – Healthcare Employer Information Data Set (HEDIS) measure for good (<7% A1c) glycemic control for individuals with diabetes was revised to apply only to persons younger than 65 years without cardiovascular disease, end-stage diabetes complications, or dementia. However, multiple guidelines recommend that glycemic control targets be individualized, especially in the presence of comorbid medical and mental health conditions. This retrospective study used the NCQA <7% measure to compare overall VA facility rankings with a subset of Veterans receiving complex glycemic treatment regimens (CGR). Findings show that the assessment of the quality of good glycemic control among VA facilities differs using the NCQA-HEDIS measure for the overall study population compared to a subset of patients receiving CGR. For example, the overall top 10% performing facilities achieved a rate of 57% at the <7% A1c threshold compared to 34% for Veterans on CGR using the same measure. Therefore, the authors suggest that reliance upon a <7% A1c threshold measure as the “quality standard” for public reporting or pay-for-performance could have the unintended consequence of adversely impacting patient safety. Moreover, they propose that rather than assessing “good glycemic control” by an all-or-none threshold, developers of measures should provide credit for an A1c result within an acceptable range (e.g. incremental credit for improvement between 7.9% and <7%) in order to balance the trade-offs of benefits, harms, and patient preferences. Date: October 1, 2010 PTSD Associated with Poorer Couple Adjustment and Increased Parenting Challenges among Male OIF National Guard Troops This study examined associations among combat-related PTSD symptoms, parenting behaviors, and couple adjustment among male National Guard troops who had served in Iraq (OIF). Findings show that increases in PTSD symptoms were associated with poorer couple adjustment and greater perceived parenting challenges one year post-deployment. Further, PTSD symptoms predicted parenting challenges independently of their impact on couple adjustment. PTSD was associated with higher levels of alcohol use, but alcohol use was not significantly associated with couple adjustment or parenting. Deployment injury also was independently associated with increased PTSD symptoms. Findings suggest that symptoms of PTSD may exert their influence at multiple levels within the family, making transitions from combat to home life even more complicated. This highlights the importance of investigating and intervening to support parenting and couple-adjustment among combat-affected National Guard families, who often lack the support available to active duty families via the military base community. Date: October 1, 2010 VA Increases Prescriptions for Smoking Cessation Medications among Veterans Since 2002, VA has implemented a range of policies and programs to increase evidence-based treatment for smoking. This study examined the change in rates of dispensing cessation-related medications to Veterans in the VA healthcare system to assess the impact of these policy changes. Findings show that VA policy initiatives instituted since 2002 have greatly increased prescriptions for smoking cessation medications among Veterans, while decreasing costs. The number of Veterans filling a prescription for nicotine replacement therapy (NRT) increased 63% from FY04 through FY08. Thirty-day-equivalent NRT prescriptions rose nearly 50% over the same period. Bupropion prescribing also rose sharply; the four-year growth rate among Veterans also prescribed a NRT was 61% greater than the 35% growth rate among all Veterans receiving bupropion prescriptions. While prescriptions for NRT and bupropion rose, spending per treated patient fell by 39% for bupropion and by 24% across all NRT formats (e.g., patch, gum). Date: September 24, 2010 Using One Classification System for Estimates of Urban/Rural Impact on AMI Outcomes among Veterans May Not Be Adequate This study examined whether: 1) two different rural classification systems identify differential rates of Veterans admitted for AMI; 2) rural-urban disparities exist for risk-adjusted AMI outcomes (measured by mortality and receipt of coronary revascularization); and 3) whether hospital transfer rates differ for patients admitted with AMI. Findings showed no observed differences between rural-dwelling and urban-dwelling Veterans in risk-adjusted 30-day mortality, regardless of the urban-rural classification system used. However, rural-dwelling Veterans were less likely to receive revascularization compared to urban-dwelling Veterans, but risk estimations were dependent upon the urban-rural classification system used. Regardless of classification system, Veterans residing in rural settings were transferred more often and were more likely to be admitted to VA hospitals without revascularization facilities. This study demonstrates that using a single rural classification system for estimating the effects of living in a rural setting on AMI outcomes among Veterans may not be adequate. Date: September 1, 2010 Prostate Screening Does Not Reduce Prostate Cancer or All-Cause Mortality In a 2006 review of the evidence, authors identified insufficient evidence to either support or refute the use of routine screening for prostate cancer. This article presents findings from their updated study, in which investigators sought to determine whether population-based screening reduces prostate cancer-specific mortality and/or all-cause mortality. They also examined its impact on quality of life, including adverse events (e.g., harms of screening from false-positive or false-negative results). Findings show that prostate cancer screening did not result in a statistically significant reduction in prostate cancer-specific or all-cause mortality. One of the studies in this review showed a marginally significant benefit for prostate cancer screening among a subgroup of men aged 55 to 69. Among this group, it was reported that 1,410 men would need to be screened, with 48 men needing prostate cancer treatment, to prevent one additional death from prostate cancer during a 9-year period. Any benefits from prosate cancer screening may take up to 10 years to accrue; therefore, the authors suggest that men with a life expectancy of less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial. None of the studies reviewed provided detailed assessment of the effect of screening on quality of life or costs associated with screening. Date: September 1, 2010 Study Examines the State of Colorectal Cancer and Finds Cause for Optimism, Particularly within the VA Healthcare System In contrast to the health disparities that are evident in the community, when colorectal cancer (CRC) outcomes were studied within an equal-access, integrated healthcare system, such as VA, racial disparities were markedly decreased or absent. The type of screening test used in the US has varied over the last decade, but colonoscopy is becoming the dominant modality. However, VA relies primarily on fecal occult blood tests (FOBT). From 1998 to 2003, the proportion of screened Veterans undergoing FOBT within VA increased from 82% to 90% compared to that of Veterans receiving screening colonoscopies, which decreased from 6% to 5%. From the perspective of population-based screening, VA is actually more successful than the general population at screening, and has CRC screening rates well above the national average. Date: June 1, 2010 Characteristics and Needs of Veteran Cancer Survivors Findings show that 11% of the Veterans treated within the VA healthcare system in FY07 were cancer survivors. The most common cancer types were prostate, skin (non-melanoma), and colorectal. Compared to the general population, Veteran cancer survivors are older (84% are older than 60) and predominantly male (97%). Cancer site prevalence statistics vary between the VA and general U.S. cancer patient populations due to differences in age, gender, and risk factors. Overall, the four common symptom concerns reported by cancer survivors are sexual dysfunction, fatigue, anxiety, and depression. The authors suggest that Veteran-specific research is needed on topics such as cancer survival among older Veterans, and the role of military exposures (physical, emotional, and psychological) in causing cancer and impacting recovery. The authors also suggest that four models of care may be relevant to improving care for Veterans who have survived cancer: 1) cancer survivorship clinics, 2) cancer care transition plans, 3) rehabilitation, and 4) chronic disease management. These models of care may help integrate the physical and mental health needs of cancer survivors. Date: March 1, 2010 Taking a Life in War Associated with Higher Rates of PTSD and Behavioral/Adjustment Problems in OIF Soldiers This study examined the relationship between killing and mental health among 2,797 soldiers returning from Operation Iraqi Freedom (OIF). Overall, 40% of the soldiers in this study reported direct killing or being responsible for killing during their deployment. Taking another life in war was an independent predictor of multiple mental health symptoms. Even after controlling for combat exposure, killing was a significant predictor of PTSD symptoms, alcohol abuse, anger, and relationship problems. In addition, 22% of soldiers met threshold screening criteria for PTSD, 32% for depression, and 25% for alcohol abuse. The authors suggest a comprehensive evaluation of Veterans returning from combat should include an assessment of direct and indirect killing and reactions to killing. This information could be part of a treatment plan, including specific interventions targeted at the impact of taking a life. Date: February 1, 2010 Comparing Two Weight Loss Therapies in Overweight/Obese Veterans This study compared a low-carbohydrate, ketogenic diet (LCKD) to orlistat combined with a low-fat, reduced-calorie diet (O+LFD). Findings show that a low-carbohydrate diet led to similar improvements as O+LFD for weight, serum lipid, and glycemic parameters – and was more effective for lowering blood pressure. While weight loss was significant and similar for both diet interventions, and decrease in waist circumference also was similar, the LCKD had a more beneficial impact than the O+LFD on systolic (-5.9 vs. 1.5 mm Hg) and diastolic (-4.5vs. 0.4 mm Hg) blood pressure. Study results also show that participants who attended 80% or more of the group counseling sessions lost considerably more weight, regardless of treatment assignment. The authors suggest that efforts be made to incorporate similarly intensive weight loss programs into medical practice. Date: January 25, 2010 Increase in VA Drug Co-Payment Resulted in Decrease in Veterans’ Adherence to Some Medications This study examined the impact of the VA medication co-payment increase on adherence to diabetes, hypertension, and hyperlipidemic medications by Veterans with diabetes or hypertension at 4 VAMCs during a 35-month period (2/01--12/03). Findings showed that a medication co-payment increase from $2 to $7 adversely impacted adherence to statins and anti-hypertensives by Veterans subject to the co-payment, but the impact was greatest among Veterans taking oral hypoglycemic medication. Adherence to all medications increased in the short term for all Veterans (12 months after co-payment increase), but then declined in the longer term (subsequent 11-month period). The impact of the co-payment increase was particularly adverse for Veterans with diabetes who were responsible for co-payments. Their adherence to oral hypoglycemic medication in the period 13-23 months after the co-payment increase was 10.3% lower than their pre-period adherence – and 9% lower than comparable Veterans who were exempt from co-payments. Date: January 1, 2010 Intensive Surveillance following Colorectal Cancer Increases Survival This article reviews the clinical trials and evidence that inform the current approach to surveillance among colorectal cancer (CRC) survivors, as well as clinical guidelines developed by various organizations. Overall, findings suggest that intensive surveillance, particularly in the first 2-3 years of follow-up, appears to be associated with the early detection of recurrences, and thus has a beneficial impact on all-cause survival at five years. Imaging tests of the chest and abdomen have also increasingly been recommended by professional organizations to detect resectable recurrences. Date: December 1, 2009 Older Elderly Patients Experience Poorer Outcomes Following Collaborative Depression Care This study examined the differences between young-old (age 60 to 74) and old-old (age 75 and older) patients who received collaborative depression care as part of the IMPACT (Improving Mood: Promoting Access to Collaborative Treatment) study, which include both VA and non-VA patients. Findings show that young-old and old-old patients who receive collaborative depression care have a similar initial clinical response, but old-old patients may have a lower rate of long-term treatment response and complete remission. For example, young-old and old-old patients randomized to the IMPACT intervention responded similarly to initial treatment at 3 months, but the old-old were less likely to respond to treatment at later follow-up intervals. Treatment response and remission rates peaked for both age groups at 6 months, although treatment response rates for the young-old were significantly higher than those for the old-old group (51% vs. 44%). Study findings also show that the process of care did not differ between young-old and old-old patients who received the IMPACT intervention. Date: December 1, 2009 Veterans with Psychosis More Likely to Die from Heart Disease This study assessed whether Veterans with mental disorders receiving care in the VA healthcare system were more likely to die from heart disease than Veterans without these disorders, and whether modifiable factors may explain mortality risks. Findings show that compared to Veterans without a mental health diagnosis, Veterans with psychosis (schizophrenia or other psychotic disorder diagnoses) were more likely to die from heart disease. Smoking and physical inactivity were the behavioral factors most strongly associated with mortality related to heart disease. Veterans with schizophrenia were the most likely to be current smokers, and those with bipolar disorder were the least likely to report adequate physical activity. Controlling for behavioral factors (e.g., smoking and physical inactivity) diminished but did not eliminate the impact of psychosis on mortality. The authors suggest that to reduce mortality related to heart disease, early interventions that promote smoking cessation and physical activity among Veterans with psychotic disorders are warranted. Date: November 1, 2009 Veterans’ Age and Disability Status Associated with Choice of Medicare Plans Medicare-eligible Veterans may choose between care in VA or Medicare (or both), and they also have to choose between obtaining Medicare services in the fee-for-service (FFS) sector or in a Medicare Advantage (MA) plan. This study sought to assess factors associated with enrollment in an MA vs. FFS plan in 2000-2004 among this population. Findings show that age and disability status were both significantly associated with choice of MA vs. FFS plan. For example, age-eligible Veterans were more likely to be enrolled in an MA plan if aged 75 or older, female, able to receive free VA care, or not enrolled in Medicaid, while disability-eligible Veterans were more likely to be enrolled if they were married or elderly. Minority Veterans and Veterans with lower disease risk scores (better average health) were more likely to be enrolled in an MA plan than white Veterans or Veterans with higher risk scores. Overall, Veterans living in zip codes with greater population density and higher per capita income were also more likely to enroll in an MA plan. The authors suggest that future studies examine the Medicare health plan choice of disabled Veterans, particularly OEF/OIF Veterans who begin to qualify for Medicare, to better understand the possible impact of MA enrollment on continuity, duplication, cost, and quality of care. Date: November 1, 2009 Team-Based Care Led by Pharmacists or Nurses Improves Blood Pressure Control Investigators in this study conducted a systematic review of the literature to evaluate the effectiveness of team-based BP care involving pharmacists and nurses. Findings indicate that team-based interventions involving nurses or pharmacists were associated with significantly improved blood pressure control, with community pharmacists having the greatest impact. In addition, counseling on lifestyle modification and providing free BP medications had a significant impact on lowering systolic BP. Results also show that intervention strategies that provided medication education were the most effective, but this strategy cannot be evaluated on its own merit because it was usually provided with additional strategies. Date: October 26, 2009 Long-Term Impact of Home Telehealth on Preventable Hospitalizations for Veterans with Diabetes This study assessed the longitudinal effect of a VA Care Coordination Home Telehealth (CCHT) program on preventable hospitalizations for Veterans with diabetes. Findings showed a statistically significant reduction in preventable hospitalizations for Veterans enrolled in the CCHT program during the initial 18 months of follow-up compared to Veterans in the control group, even after adjusting for potential socio-demographic and clinical risk factors. However, the program did not demonstrate a significant impact after the initial 18 months, which may largely be due to the fact that the control group had more deaths than the CCHT group during those 18 months, likely resulting in the control group’s decreased use of preventable hospitalizations during the remainder of the study period. Over the entire four-year study period, the CCHT group had a lower death rate and longer survival time than the control group, while the control group had much higher frequency in all diabetes-related ambulatory care sensitive conditions such as lower-extremity amputations, uncontrolled diabetes, and bacterial pneumonia. Date: October 1, 2009 Demands on VHA for Post-Deployment Healthcare Needs of OEF/OIF Veterans will be Overshadowed by the Needs of Older Veterans This article discusses the implications for the Veterans healthcare system of the demand for healthcare services from OEF/OIF Veterans. Findings show that although the pressing needs of newly discharged Veterans require immediate attention, especially in the areas of TBI, PTSD, and physical disability services, the demand for immediate post-deployment VA healthcare services by OEF/OIF Veterans will be overshadowed by the demands of aging Korean and Vietnam War Veterans (and, eventually, aging OEF/OIF Veterans), in terms of the number of patients and the average cost of their care. Thus, the major demand on VA healthcare services will be from aging Veterans whose usage and needs for services will be relatively stable and predictable; however, it is the extra cost for OEF/OIF Veterans that is difficult to quantify because of the unknowns (e.g., nature, severity, and number of PTSD and TBI cases). Date: September 1, 2009 Electronic Reminder Increases Follow-Up Rates for Positive Fecal Occult Blood Tests Screening with fecal occult blood tests (FOBT) reduces colorectal cancer mortality by 15-33% and decreases the incidence of the disease by 20%; however, as many as 46-66% of patients with an abnormal FOBT do not receive proper diagnostic testing (e.g., follow-up colonoscopy). This study sought to determine the impact of an electronic reminder on the timeliness and proportion of Veterans referred to gastroenterology (GI) for evaluation after a positive FOBT. Findings show that the electronic reminder was associated with a significant improvement in the proportion and timeliness of follow-up for Veterans with a positive FOBT. The intervention was associated with a 20.3% increase in GI consultations within 14 days, and the median time to colonoscopy decreased by 38 days (105 vs. 143 days). Date: September 1, 2009 Focus Groups Recommend Strategies to Decrease Missed Test Results This paper reports on the efforts of two focus groups that formed as part of the Diagnostic Error in Medicine – A National Conference, which was held by the American Medical Informatics Association in 2008. Clinicians who were part of the focus groups were asked to develop interventions that might decrease the risk of diagnostic delay due to missed test results in the future. The focus groups concluded that while the electronic medical record helps to improve access to test results, eliminating all missed test results would be difficult to achieve. However, they did recommend several strategies that might decrease the rates of missed test results, including: improving standardization of the steps involved in the flow of test result information, greater involvement of patients to insure the follow-up of test results, and systems re-engineering to improve the management and presentation of data. They also suggest that healthcare organizations focus initial quality improvement efforts on specific tests that have been identified as high-risk for adverse impact on patient outcomes, such as tests associated with a possible malignancy or acute coronary syndrome. Date: September 1, 2009 Study Questions Validity of HEDIS Quality Measures for Substance Use Disorder Specialty Care Healthplan Employer Data and Information Set (HEDIS) is the most widely used set of quality measures, thus many healthcare systems now track HEDIS measures of Initiation and Engagement in Alcohol and Other Drug Dependence Treatment. Using VA data, this study identified 320,238 Veterans who received at least one of the HEDIS-specified substance use disorder (SUD) diagnoses during FY06. Investigators then developed a model to determine their progression through Initiation and Engagement, with a focus on clinical setting and care specialty. Findings show that Veterans who have contact with SUD specialty treatment have higher rates of advancing from diagnosis to Initiation – and from Initiation to Engagement – compared to Veterans who are diagnosed with substance use disorders in psychiatric or other medical locations. For example, outpatients who were diagnosed in SUD specialty treatment settings were much more likely to “initiate” than those who were diagnosed in psychiatric and other specialty settings. Results also showed that 85% of the Veterans who received an SUD diagnosis in FY06 did so first in an outpatient setting, and that more than 40% of “engagement” occurred outside of SUD specialty care. Therefore, the usual combining of inpatient and outpatient performance on these measures into overall facility scores may affect measurement and interpretation. The authors suggest that these particular quality measures be considered measures of facility performance rather than measures of the quality of SUD specialty care. Date: August 1, 2009 Resident Duty Hour Reform has No Systematic Impact on Patient Safety in Teaching Hospitals This observational study focused on patients admitted to VA and Medicare acute-care hospitals, examining changes in patient safety events in more vs. less teaching-intensive hospitals before (2000-2003) and after (2003-2005) duty hour reform. Findings show that the implementation of duty hour regulations did not have an overall systematic impact on potential safety-related events in either VA or non-VA (Medicare) hospitals of different teaching intensity. In the few cases where there were statistically significant increases in the relative odds of developing a patient safety event, the increases were too small to be clinically meaningful. Date: July 1, 2009 Lower Mortality for African American Veterans with COPD Exacerbation not Explained by More Aggressive Care This study sought to determine the potential impact of racial differences in ICU admission and the use of ventilator support on mortality among African American and white Veterans admitted to VA hospitals with COPD (chronic obstructive pulmonary disease) exacerbation. Findings show that mortality was lower in African American Veterans compared to white Veterans, even after adjusting for differences in ICU admission rates and ventilator support. However, mortality was similar for African Americans and whites receiving mechanical ventilation (28.8% vs. 31.4%), thus the lower risk-adjusted mortality among African Americans was not explained by more aggressive care. Date: July 1, 2009 Veterans with Hypertension and Comorbidities Receive Better Care than Veterans with Hypertension Alone This study sought to determine the impact of different types of co-existing chronic diseases on quality of care for hypertension, as well as patient perceptions of quality. Findings show that Veterans with hypertension and comorbid conditions had greater odds of receiving good quality of care. Moreover, as the number of chronic conditions increased, so did the odds of receiving appropriate overall care for hypertension. No relationship was found between the provision of guideline-recommended care for hypertension and Veterans’ perception of quality of care, nor did Veterans’ assessment of quality of care vary by the presence of co-existing conditions. Date: June 16, 2009 Improving Adherence to Cardiovascular Medications This article focuses on cardiovascular medication adherence and discusses studies that address: 1) different methods of measuring adherence, 2) prevalence of non-adherence, 3) association between non-adherence and outcomes, 4) reasons for non-adherence, and 5) interventions to improve medication adherence. Findings show that while there are many different methods for assessing medication adherence, non-adherence to cardiovascular medications is common and associated with adverse outcomes. The authors also found that non-adherence is not solely a patient problem but is impacted by both providers and the healthcare system. To date, interventions targeting medication adherence have produced only modest success. Multi-modal interventions have shown the most promise in improving adherence, but require the clinical personnel to manage and coordinate multiple intervention components. Date: June 16, 2009 Review Suggests PTSD Negatively Impacts Physical Health but More Research Needed In this systematic review, investigators searched case reports, comparative studies, meta-analyses, and review articles that examined the relationship between PTSD and specific physical-health diagnoses. Findings suggest that PTSD can have negative effects on physical health, but evidence regarding its association with specific physical disorders is lacking. Evidence suggests a significant association between PTSD and musculoskeletal disorders, especially participant report of arthritis, in the general population – but not in Veterans. There also was an association between PTSD and digestive disorders, particularly ulcers, among non-Veterans. The rest of the associations were either found in single studies or are conflicting, particularly in regard to diabetes, congestive heart failure, and stroke. Authors suggest that large, prospective epidemiological trials are needed to examine the relationship between PTSD and physical illness. Date: June 1, 2009 Veterans with HIV Treated at Clinics with Integrated Specialty Services More Likely to Achieve Better Outcomes The most common way HIV clinics address patients with comorbidities is by integrating non-infectious disease providers (e.g., psychiatrists and social workers) into HIV primary care. This retrospective cohort study evaluated the association between Integrated HIV Care and patient outcomes among 1018 Veterans with HIV who received care at five VA facilities from 2000-2006. Findings show that Veterans who visited HIV clinics with more integrated specialty services were more likely to achieve viral suppression. In particular, Veterans visiting clinics that offered hepatitis, psychiatric, psychological, and social services in addition to primary care and HIV specialty services were three times more likely to achieve viral suppression than Veterans visiting clinics that offered only primary care and HIV specialty services. Results also showed that 93% of Veterans in this study had one or more comorbid conditions, with a mean of 3.2 comorbidities. Authors suggest that resources should be allocated to integrate sub-specialty services into HIV primary care clinics, and that providers should direct patients toward these clinics and retain them in care. Date: May 1, 2009 Study Assesses Knowledge Gains for SGIM Meeting Attendees This pilot study assessed the feasibility of surveys to measure the impact of continuing medical education provided at the 2006 Society of General Internal Medicine (SGIM) Annual Meeting on both short- and long-term educational outcomes. Investigators assessed responses to a brief questionnaire administered to SGIM meeting participants who attended one research pre-course, one research methods workshop, and/or one clinical workshop. Findings show that all three sessions showed initial gains in knowledge: the research pre-course gain was large; the clinical workshop gain was moderate; and the research methods workshop gain was modest. Two of the three sessions showed a decrease in knowledge over the subsequent 9 months: the research pre-course decrease was moderate; the clinical workshop’s decrease was small; while the research workshop had a large gain in knowledge levels over the subsequent 9 months. Date: May 1, 2009 Many Healthy Older Veterans Not Being Screened for Colorectal Cancer Many healthy older Veterans with substantial life expectancies are not being screened, while some with severe comorbidity are being screened. For example, only 47% of Veterans aged >70 without comorbidity were screened despite having a high probability of living >5 years. Number of outpatient visits was a strong predictor of screening, independent of comorbidity. Veterans without comorbidity who did not attend a VA primary care, gastroenterology, or general surgery clinic had a lower incidence of screening than patients with severe comorbidity who visited these clinics. Date: April 7, 2009 Quality Enhancement Research Initiative Advances Implementation Science This Editorial offers a perspective from implementation researchers outside the U.S. about VA/HSR&D’s Quality Enhancement Research Initiative (QUERI) and its impact on and contributions to implementation science. Date: March 6, 2009 Spinal Cord Injury and Alcohol Use are Risk Factors for Osteoporosis Hospitalization Spinal cord injury (SCI) is associated with severe osteoporosis, increasing the risk of low-impact fractures that occur in the absence of trauma. Findings from this study show that hospitalization for low-impact fractures was more common in motor complete SCI (no motor function below the neurological level of injury) and was associated with greater alcohol use after injury. Osteoporosis diagnosis, prevention, and management were not included in the treatment plans for any of the Veterans hospitalized with fractures. These findings suggest that future studies should address prevention and treatment of bone loss among Veterans with motor complete SCI. Date: March 1, 2009 Improving Audit and Feedback Strategies Audit and feedback (A&F) furnishes providers with summaries of clinical performance over a specified period of time, offering providers current information and motivation to improve. This study found that A&F has a modest but significant positive effect on quality outcomes. A&F reports containing specific suggestions for performance improvements – delivered in writing, rather than verbally or graphically, and delivered frequently – can noticeably improve the effectiveness of audit and feedback. Also, providing combined group- and individual-level feedback appeared to positively impact feedback effectiveness; however, definitive conclusions could not be made. Date: March 1, 2009 Increase in VA Prescription Co-Pay Leads to Decrease in Adherence to Statins for Veterans at Risk of Heart Disease VA’s increase in drug co-payments from $2 to $7 adversely affected lipid-lowering medication adherence among Veterans, including those at high risk of coronary heart disease. After the increase in medication co-payments, the percent of Veterans who were adherent to lipid-lowering therapy declined significantly, even for Veterans with no co-pay. The co-payment increase was also accompanied by a significant increase in the likelihood of having continuous gaps in lipid-lowering medication use. Date: January 27, 2009 Healthcare Providers Should Adopt Principles of Both Patient Centeredness and Cultural Competence to Meet the Needs of All Patients Authors suggest that healthcare organizations and providers should adopt principles of both patient centeredness and cultural competence so that services are aligned to meet the needs of all patients. Moreover, health services researchers should develop measures of cultural competence and patient centeredness and explore the impact of their unique and overlapping components on patient outcomes. Date: November 1, 2008 Pain among Veterans with Spinal Cord Injury Veterans reported higher rates of pain-related catastrophizing (exaggerated negative interpretations of pain, e.g., “my pain is unbearable and will never get better”). Authors suggest that in clinical settings it may be important to assess and manage catastrophizing as a factor important to the experience of pain and especially the impact of pain on functioning. Date: October 1, 2008
What is included in Publication Briefs? HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations. ^ top

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