Lead/Presenter: Elizabeth Yano,
COIN - Los Angeles
All Authors: Yano EM (Center for the Study of Healthcare Innovation, Implementation & Policy), Than C (Center for the Study of Healthcare Innovation, Implementation & Policy), Canelo I (Center for the Study of Healthcare Innovation, Implementation & Policy) Hamilton AB (Center for the Study of Healthcare Innovation, Implementation & Policy)
Women Veterans' numerical minority, high rates of military sexual trauma, and gender-specific healthcare needs have complicated implementation of comprehensive primary care under PACT. We deployed evidence-based quality improvement (EBQI) to gender-tailor PACT and determine its effects on provider and patient experience and utilization.
We evaluated EBQI effectiveness in a cluster randomized trial with unbalanced random allocation to EBQI (n = 8) vs. naturalistic PACT implementation VAMCs (n = 4). Primary care (PC) and women's health (WH) providers and staff completed surveys, as did women Veterans with 3+ PC and/or WH clinic visits in the prior year. Using VA administrative data, we explored PACT-related utilization outcomes. Over 24-months, EBQI included multilevel, multidisciplinary stakeholder engagement and priority-setting to generate VISN-level QI roadmaps, followed by training and technical support of EBQI teams who developed local projects based on VISN-level QI roadmaps. The research team provided formative feedback of data and external practice facilitation of local teams, and convened across-EBQI site collaboration calls. For patient and provider/staff outcomes, we adjusted for relevant covariates, baseline information, and non-response for difference-in-differences analyses.
EBQI improved PACT team function by 0.43 points (95% CI: -0.01, 0.87) and provider gender-sensitivity by 0.33 points (95% CI: 0.10, 0.57). EBQI was also associated with lower provider burnout (AOR: 0.79; 95% CI: 0.30, 2,07). Over a 24-month period, patients in EBQI sites maintained the average number of PC and WH visits, while visits decreased among patients in control sites (1.2 adjusted mean difference for PC [95% CI: 0.1, 2.4]; 1.7 adjusted mean difference for WH [95% CI: 0.9, 2.5]). Patient-level experiences of PACT constructs of access, continuity and coordination did not differ significantly between EBQI and control sites, nor did other experiential measures (e.g., patient-rated provider communication).
EBQI was effective in improving team- and provider-level behaviors and attitudes but not patient-level experience by 24-months. More time with EBQI may be necessary for provider- and staff-level changes to affect what patients experience.
Improvements in EBQI sites resulted in VA adoption of EBQI for use in VAs where implementation of comprehensive women's health care was low compared to other VAs.