- 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
- Brief Training Increases Discussions between VA Providers and Veterans on Firearm Safety to Reduce Suicide
This study evaluated the im
pact 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 im
pact 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 im
pact 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 im
pacted 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 Im
pact 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 im
pacting 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 im
pacts 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 im
pact 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 im
pact 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 Im
pact Medication Management for Diabetes and Hyperlipidemia
This study examined the im
pact 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 im
pact 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 im
pact 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 im
pact 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
- Possible Im
pact 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 im
pact 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 im
pacts of routine pain screening, specifically, routine screening for pain may help capture mental health concerns that may otherwise not emerge
Date: March 6, 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
- 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 im
pact 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 im
pact 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’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
- Intervention Utilizing Community Health Workers Improves Quality of Patient Care and Reduces Hospitalizations
Individualized Management for Patient-Centered Targets (IM
PaCT) 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 IM
PaCT 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 (Geri
PACT) 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 Geri
PACT 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 Geri
PACT teams in this study: only 43% of Geri
PACT 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
- 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 im
pact 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
- Homeless Veterans Report More Positive Experiences in Facilities with Homeless-Tailored Primary Care Teams
In 2012, VA implemented homeless-tailored primary care teams (H
PACTs) 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 H
PACTs available in 2012 and 485 facilities lacking H
PACTs. Findings showed that in facilities lacking H
PACT 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 H
PACTs, 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 H
PACT program. Facilities with H
PACT 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 im
pact 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
- 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 im
pact 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 im
pacts 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 im
pacted 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 im
pact 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 im
pact 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 im
pact. 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
- 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
pact 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 im
pact 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 im
pact 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 im
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 im
pacts 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
pact 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 im
pact 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 im
pact of recently implemented opioid-related policies.
Date: March 25, 2017
- Gender and Smoking Im
pact 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 im
pact 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 im
pact 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 im
pacts 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
- 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 (Im
PACT). In February 2013, the Palo Alto VAMC launched an Im
PACT 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 Im
PACT. During the first 16 months of the intervention period, the average number of primary care visits was 22 for Im
PACT patients vs. 7 for
PACT patients. However, after accounting for the cost of Im
PACT encounters, the average baseline and follow-up person-level monthly costs declined at similar rates among Im
PACT 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
- 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 im
pact 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 im
pact 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 im
pacted 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 im
pact 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 im
pacts 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 im
pact on quality of care.
Date: July 1, 2016
pact 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
pact 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 im
pact 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 im
pact 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
- 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 im
pact 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 Im
pact 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
pact 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 im
pacted 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 im
pact 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 im
pacted 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
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 im
pact 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 im
pact 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 im
pact of trauma.
Date: September 1, 2014
- Affordable Care Act May Im
pact 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 Im
pact of Affordable Care Act on Massachusetts Veterans’ Enrollment in VA Healthcare
This study examined the potential im
pact 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 im
pact 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
- 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 im
pact 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
- 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
- Outcomes Associated with VA Implementation of
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 im
pact 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
- 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 im
pact 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 im
pact 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
- Changes in Care Processes and Patient Outcomes Related to VA’s Implementation of
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 im
pact 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
- 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 im
pact 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
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 Im
pact 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 im
pact 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 im
pact 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 im
pact 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 im
pact 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
- Factors Affecting Readiness for Implementation of VA’s Patient-Aligned Care Team Model
This study sought to describe the im
pact 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 im
pact 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 im
pact 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 im
pact 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
- 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 im
pact, 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 im
pact 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 im
pact 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
- 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 im
pact 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 im
pact 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
- 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 im
pact 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 im
pact of travel distance on the use of VA healthcare services, satisfaction, and im
pact 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
- 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 im
pact on the Veteran and his family members.
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 im
pact performance over time. Structural organizational characteristics, including facility size, academic mission, and primary care structure, had no im
pact 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 Im
pact 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
- 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
Date: June 16, 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 im
pact 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 im
pact 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 im
pact 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
- 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, im
pact 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 im
pact of implementing a routine oral HIV rapid-testing program in a VA emergency department (ED) versus the im
pact 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 im
pact 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 im
pact 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 im
pact 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 im
pact 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 im
pact 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 im
pacts on drug treatment recommendations for cholesterol control.
Date: November 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 im
pact 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
- 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 im
pacting 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
- 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 im
pact 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 Im
pact 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 im
pact 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
- 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 im
pacting 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 im
pact 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 im
pact 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 im
pact 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 im
pacted adherence to statins and anti-hypertensives by Veterans subject to the co-payment, but the im
pact 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 im
pact 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 im
pact 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 IM
PACT (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 IM
PACT 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 IM
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 im
pact 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 im
pact 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 im
pact. In addition, counseling on lifestyle modification and providing free BP medications had a significant im
pact 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 Im
pact 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 im
pact 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
- 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 im
pact 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 im
pact on patient outcomes, such as tests associated with a possible malignancy or acute coronary syndrome.
Date: September 1, 2009
- Resident Duty Hour Reform has No Systematic Im
pact 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 im
pact 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 im
pact 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 im
pact 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 im
pacted 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 Im
pacts 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
- Study Assesses Knowledge Gains for SGIM Meeting Attendees
This pilot study assessed the feasibility of surveys to measure the im
pact 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
- 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 im
pact 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-im
pact fractures that occur in the absence of trauma. Findings from this study show that hospitalization for low-im
pact 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 im
pact feedback effectiveness; however, definitive conclusions could not be made.
Date: March 1, 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 im
pact 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 im
pact of pain on functioning.
Date: October 1, 2008