Publication Briefs

Publication Briefs
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VA Surgical Care Comparable or Better than Non-VA Surgical Care Investigators conducted a systematic review to compare VA and non-VA care for surgical conditions across domains of quality and safety, access, patient experience, and comparative cost/efficiency using studies published between 2015 and 2021 – following implementation of the Choice and MISSION Acts. Findings showed that in all but two studies, VA care had comparable or better quality and safety outcomes than non-VA care. For access to care, neither VA nor non-VA care was found to be consistently better. Studies of patient experience were too limited to draw conclusions, and the few studies of cost and efficiency outcomes favored non-VA care. Findings suggest that expanding eligibility for Veterans to receive care in the community may not provide benefits in terms of increasing access to surgical procedures or result in better quality, but may reduce inpatient length of stay and cost. Date: May 8, 2023 Rural-Urban Telemedicine Disparity among Veterans Worsens Following Onset of COVID-19 Pandemic This study examined changes over time in rural-urban differences in telemedicine use for primary care and mental health integration services among nearly 64 million primary care and 4 million mental health integration visits. Findings showed that the pandemic exacerbated the rural-urban telemedicine divide across VA, possibly because underlying causes of digital inequity were not addressed as initiatives to expand telemedicine use across VA were instituted. Prior to the pandemic, telemedicine use for primary care services was higher at rural VA healthcare systems than urban ones (34% vs. 29%). Following the onset of the pandemic, usage rates switched (55% vs. 60%). The rural-urban telemedicine gap was even larger post pandemic for mental health integration than for primary care services, with unadjusted analyses showing 76% rural vs. 84% urban telemedicine use. Future telemedicine research, implementation efforts, and policy must address rural-urban structural disparities (e.g., internet bandwidth) and possibly tailor technology to encourage telemedicine adoption among rural users at the patient, provider, and healthcare system level. Date: March 7, 2023 Timeliness of VA Purchased Community Primary Care Did Not Improve Following Early Expansion Under MISSION Act This study examined whether early Community Care Network (CCN) implementation impacted community primary care (PC) appointment wait times. Findings showed that expanded contracting with community providers and new provider network adequacy standards implemented through CCNs did not, in early stages, improve the timeliness of community primary care for Veterans. Wait times increased sharply for both CCN and comparison appointments after CCN implementation, ranging from approximately 30 to 40 days, which is beyond VA’s new urban and rural network adequacy wait-time standard for community care. Date: October 28, 2022 VA-GRACE Program Effectively Supports Aging Veterans and Caregivers But Does Not Reduce Readmissions The Geriatric Resources for Assessment and Care of Elders (GRACE) program is a collaborative, multidisciplinary care model that provides home-based geriatric care management. This study evaluated VA-GRACE from its implementation (2010) to 2020 in terms of its effect on mortality and readmissions – and examined patient, caregiver, primary care provider, and VA-GRACE staff satisfaction. Findings showed that Veterans receiving VA-GRACE services had a much greater comorbidity burden than Veterans in usual care, indicating that the program is serving its target population: highest-risk, community-dwelling older Veterans. Veterans participating in VA-GRACE had higher 90-day and one-year hospital readmissions, but lower 90-day mortality rates than Veterans in usual care. Veterans, caregivers, and primary care providers reported very high satisfaction with the program. More specifically, Veterans and caregivers reported that VA-GRACE home visits reduced travel burden, and that the program linked them to needed resources. Primary care providers reported that the VA-GRACE team helped reduce their workload, improved medication management for their patients, and provided a view into patients’ daily living situation. Date: August 29, 2022 HSR Special Issue on the Importance of Research Translation This special issue of Health Services Research features innovative, cutting-edge research that addresses the intersection of evidence-based policy evaluation, implementation science, and community engagement. Featuring several VA HSR&D and QUERI investigators, the ultimate goal is to highlight emerging scientific work that helps bridge the gap between generating evidence and making policy changes. Date: May 16, 2022 Specialized Primary Care Homes Effective in Treatment of Patients with Serious Mental Illness This project studied the implementation and effectiveness of a primary care medical home specifically designed to improve the healthcare of Veterans with serious mental illness. SMI PACTs (Patient Aligned Care Teams) include a specialized, integrated team that can provide both primary and psychiatric care. Findings showed that a primary care medical home for Veterans with SMI can be safe and more effective than usual care, as well as feasible to implement. Compared with Veterans who received usual care, those who received the SMI PACT intervention had greater improvement in screenings, treatment quality, chronic illness care (e.g., goal setting, counseling), care experience (e.g., doctor-patient interaction, care coordination, access), psychotic symptoms, and mental health-related quality of life at 12 months. Investigators saw no signs of worsening of mental health status under the SMI PACT model of care. This care model can be effective and should be considered among the interventions for improving medical care in patient populations with serious mental illness. Date: April 5, 2022 Rapid Response to Executive Order by HSR&D Investigators Leads to Widespread Adoption of Suicide Prevention Strategies As part of the response to Presidential Executive Order #13861, this study analyzed a large body of text responses collected as a federal Request for Information (RFI) to uncover gaps in policy and practice across the U.S. in order to more effectively address and prevent suicide among Veterans. Findings identified unique barriers to care, in addition to ways in which data and research could be better aligned to improve outcomes. For example, Veterans need a greater connection to the community when they transition from military service and they want healthcare professionals who understand and/or have experience with military culture. Metrics for evidence-based risk prevention and treatment methods need to incorporate Veterans’ perspectives to ensure suicide prevention efforts address their needs and concerns. VA used the findings and policy opportunities identified from this RFI analysis to contribute to the development of The PREVENTS Roadmap with recommendations and implementation steps for suicide prevention. Thus far, the governors of 42 states and territories have submitted state proclamations to support the PREVENTS campaign and follow strategies outlined within the report. The HSR&D “QUICk: A Qualitative Interdisciplinary Collaboration” method developed for this study has been submitted for VA invention disclosure and could be useful for other researchers to address similar public requests for information or to help analyze other types of qualitative data to fulfill research mandates. Date: March 3, 2022 Intervention May Decrease Workplace Staff Injury Rates Due to Assaults in VA Community Living Centers An interdisciplinary, person-centered, behavioral intervention for managing distress behaviors in dementia, called STAR-VA, has been implemented in VA Community Living Centers (CLCs). This study sought to describe the incidence of workplace disruptive behavior incidents and staff injury rates occurring in 120 CLCs (62 of which had completed STAR-VA training) from FY12-FY17 and to assess the association between STAR-VA implementation and workplace incidents. Findings showed that the implementation of STAR-VA was significantly associated with lower staff injury rates due to assault, particularly following the first year of training, but was not associated with other reported workplace disruptive behavior incident rates. Verbal incident rates increased over time. STAR-VA lowered agitation and target distress behavior frequency and severity among CLC residents with dementia. Date: August 30, 2021 Primary Care Intensive Management for High-Risk VA Patients Did Not Improve Long-term (12-24 Month) Outcomes or Costs This randomized trial tested whether primary care intensive management (PIM) teams could decrease acute care use, such as emergency department visits and hospitalizations, among high-risk Veterans during the second year of PIM implementation. Findings showed that offering an intensive case management program in addition to routine primary care services for high-risk patients increased outpatient use (e.g., primary care, mental health, home visits, case management, telehealth) during the 2nd year of implementation. But it did not significantly decrease inpatient use or healthcare costs, even when taking VA-covered community care costs into account. There were also no significant differences in VA healthcare use or costs for Veterans older than 65 years old or Veterans who were more frail and functionally impaired. Findings suggest approaches targeting VA patients based solely on high risk of hospitalization are unlikely to reduce acute care use or total costs beyond that provided by a well-functioning patient-centered medical home with additional support services. Date: June 18, 2021 Healthcare Supplement Features HSR&D Articles on the Importance of Embedded Research This supplemental issue of the journal Healthcare: The Journal of Delivery Science and Innovation considers the impact of embedded research on solving the disconnect between healthcare organizations and health services researchers. In November 2019, a national meeting was organized by a trio of Federal funders – VA, the Agency for Healthcare Research and Quality (AHRQ), and the Patient-Centered Outcomes Research Institute (PCORI) – in collaboration with AcademyHealth and Kaiser Permanente to address the following themes: Organizational arrangements, including governance, staffing, and funding; Research support for management decisions; Data resources and use; Strengthening the embedded research community; and Accelerating implementation of embedded research output. Articles in this Supplement reflect the work that began during this national meeting. Date: June 1, 2021 Medical Care Supplement Highlights VA Efforts to Increase Healthcare Options for Veterans through Community Care In this Medical Care Supplement, 12 articles highlight research focusing on Veterans’ use of community care and how VA facilities interact with community care providers. The Supplement offers a broad examination of VA’s expanded Community Care program, from the Choice Act through the first two years of MISSION Act implementation, and highlights areas where additional research is needed to understand Veterans’ perceptions, satisfaction, and use of VA Community Care. Date: May 13, 2021 Research Suggests Battlefield Acupuncture is Immediate but Short-Term Pain Management Tool This commentary summarizes work conducted to examine battlefield acupuncture’s (BFA’s) implementation and effectiveness within the VA healthcare system. Findings show that there is some evidence that BFA is a potentially effective, immediate, but short-term pain management tool that can be used in adjunct with other pain therapies. BFA produced a minimal clinically important improvement in pain for over half of Veterans receiving it, including patients who recently filled opioid prescriptions or had significant psychological and physical comorbidities. Both individual and group BFA sessions were effective. BFA providers perceived BFA as having many benefits; they also reported that it was low risk and easy to deliver. Given its effectiveness in providing immediate, short-term pain relief, from the perspective of both providers and patients, BFA is one potentially important tool to address pain. BFA also may provide a “window” to allow some patients to engage in more long-term self-management approaches (i.e., yoga and Tai Chi) to address their chronic pain. Date: March 26, 2021 Important IT Issues Impede Implementation of VA Mobile Teledermatology Application To improve access to teledermatology for Veterans, VA created the web-based VA Telederm application (app), which interfaces with the EHR (electronic health record). This study evaluated the initial implementation process for the VA Telederm app – and assessed organizational readiness for change (ORC). Findings showed that at all sites, technical issues including sub-optimal information technology infrastructure negatively affected adoption, leading to the inoperability of the app at two sites. There also were technical inefficiencies related to users’ unfamiliarity with new devices and inconsistent Internet access. Each site had a high level of organizational commitment for change, including support from leadership and clinical champions, but this was insufficient to surmount the technological barriers. Communication and early-user involvement encouraged individual and system-wide adoption. Thus, information obtained from users at an early stage of implementation provided an understanding of needed communication strategies. Leadership support, commitment to change, staff perceptions about the value of a change and their ability to implement it, and a clinical champion were important for implementation effectiveness, but were not enough to overcome technological barriers. Date: March 1, 2021 Accelerating Implementation of VA Virtual Care In December 2019, HSR&D investigators hosted a four-hour Think Tank, Accelerating Implementation of Virtual Care in VHA Practice, to: a) examine current virtual care research and practice; b) consider challenges to virtual care research across VA; c) discuss novel approaches to using and evaluating virtual care; and d) assess perspectives of virtual care from a variety of stakeholders. Think Tank attendees identified an initial list of 15 potential priorities and narrowed these down to four: 1) scaling evidence-based practices, 2) centralizing virtual care, 3) creating high-value care within VHA with virtual care, and 4) identifying appropriate patients for virtual care. The Think Tank took an important step in setting a partnered research agenda to optimize the use of virtual care within VHA. In doing so, investigators learned that clarifying who “owns” virtual care is essential to its success, and creating a faster pipeline of inception to implementation can help to align aims and timelines for research and operations. Date: January 26, 2021 JGIM Supplement Features HSR&D/QUERI Research on the Importance of Implementation Science to Quality Improvement Sponsored by the Agency for Healthcare Research and Quality (AHRQ), Kaiser Permanente, and VA, this supplemental issue of the Journal of General Internal Medicine (JGIM) on implementation science (IS) and quality improvement (QI) marks the formal addition of IS/QI as an area of emphasis for JGIM. The supplement features innovative research that applied evidence across diverse delivery systems and settings, as well as a high-level overview of important contributions for implementation science with selected stories amplifying successes in the field. Editors discuss how the IS/QI research featured in this supplement can advance internal medicine care delivery and ensure that the foundational knowledge generated by internal medicine research finds its way into practice. Date: November 10, 2020 Use of Community Outpatient Providers During the Choice Program was Associated with Less Attrition from VA Care This study examined the characteristics of patients and practices that used Choice outpatient care in the first year of implementation – and whether using Choice outpatient care was associated with attrition from VA primary care over a two-year period. Findings showed that overall, the attrition rate from VA primary care was low (4.4%), and Veterans who used Choice outpatient care were less likely to leave VA primary care than VA-only users. Compared to Veterans who used only VA outpatient care, those using Choice care were more likely to be female, white, or Hispanic, to live in the Continental or Pacific region, to have a higher service-connected disability rating, to have longer driving distances to all VA care, to not have a mental health condition, and to have greater primary care and total healthcare costs at baseline. Practices that sent more patients out for Choice care had lower mean scores for patient-centered medical home implementation, especially regarding access, and longer mean waiting times for appointments. Findings suggest that the use of community care more often supplements rather than replaces VA primary care, especially for practices that experience more difficulty in providing timely patient-centered primary care. Date: September 10, 2020 Quality Improvement Intervention Improves Outcomes for Veterans with New Ischemic Stroke Symptoms The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) intervention was developed to improve the quality of VA care for Veterans experiencing transient ischemic attack (TIA). This trial evaluated the PREVENT intervention at six diverse VA medical centers and assessed temporal trends in care quality among 36 matched control sites (six control sites matched to each intervention site on TIA patient volume, facility complexity, and quality of care). Findings showed that over the course of a one-year implementation period, the mean without-fail rate (Veterans with TIA at a specific facility who received all of the processes of care for which they were eligible) improved substantially at the six VA sites utilizing PREVENT (37% to 54%; +17%) and improved only modestly at the 36 matched control sites (39% to 42%; +3%). Investigators observed a net improvement of 14% at PREVENT intervention sites compared with matched controls. At PREVENT sites, the observed 90-day all-cause mortality rate decreased from 2.5% to 1.6%; at matched control sites this rate declined similarly from 2.3% to 1.7%. Decreases in the 90-day stroke rate, combined 90-day stroke or death rate, and the recurrent event rate were modestly higher for PREVENT sites than for the matched control sites, but differences were not statistically significant. Based on observed improvements in quality of care, PREVENT was deployed nationwide across the VA healthcare system in 2019. Date: September 8, 2020 VA/HSR&D Research on Complementary and Integrative Health Therapies within VA Funded by HSR&D, this special issue of Medical Care highlights how research on complementary and integrative health (CIH) therapies in the VA healthcare system has progressed along the QUERI (Quality Enhancement Research Initiative) Implementation Roadmap – from pre- implementation to implementation to sustainment. CIH approaches are becoming more available throughout VA, due to: 1) increased implementation of the Whole Health System of Care, which integrates allopathic and CIH care; and 2) development of the infrastructure for CIH implementation, which includes new standards for hiring CIH providers, the involvement of volunteers who teach CIH, and development of policy and guidance for providing CIH at VAMCs, via telehealth, and/or in the community. Conducting pre- implementation, implementation, and sustainment phases of research on CIH approaches in VA is yet another way to boost the scale-up and spread of these therapies to reach as many Veterans as possible. Date: September 1, 2020 Wait Times Longer for Specialty Community Care vs VA Specialty Care Since Implementation of Veterans Choice Program This study sought to: 1) Determine whether VA wait times declined after Veterans Choice Program (VCP) implementation, 2) Compare appointment wait times for specialty care in VA versus community medical centers, and 3) Identify the proportions of community care wait times that were attributable to VA administrative processes. Findings showed that within VA, orthopedics experienced the largest decline in mean wait times – from 53 days to 30 days. Lesser declines were observed for urology (42 days to 34 days) and gastroenterology (58 days to 51 days). Wait times for cardiology did not differ over time. Mean wait times for specialty care were lower at most VA medical centers compared with community care alternatives, even after accounting for administrative delays. Mean wait times at VA vs community facilities were 33 vs 38 days for cardiology; 54 vs 60 days for gastroenterology; 36 vs 44 days for orthopedics, 36 vs 51 days for urology and 41 vs 49 days overall. Date: August 26, 2020 Better Patient Experience for Outpatient Care Delivered by VA vs Community Care on Every Measure but Access This study examined trends in Veterans’ experiences with outpatient community care (CC) compared with those in VA during the second and third years after Choice Act implementation. Findings showed that patient experiences were better for VA than community care in all respects except access. For specialty care, access scores were better in the community; and for primary and mental healthcare, access scores were similar in the two settings. There were significant differences in sociodemographic characteristics between VA and CC respondents across all types of outpatient care. Overall, VA respondents were older; had better perceived physical health status and mental health; had different distributions by race and ethnicity (i.e., higher portion of African American respondents); had lower education levels; lived in more urban areas; and were more likely to be insured. As purchased care further expands under the MISSION Act, the monitoring of meaningful differences between healthcare settings should continue, with the results used to inform both VA purchasing decisions and patients’ care choices. Date: August 1, 2020 Proactive Outreach Helps Veterans with PTSD Overcome Barriers to Getting Treatment to Help Quit Smoking Investigators identified participants with and without PTSD and evaluated a proactive outreach intervention for increasing treatment utilization and smoking abstinence among these Veterans. Findings showed that compared to usual care, proactive outreach increased combined counseling and nicotine replacement therapy use among Veterans with PTSD (19% vs 1%) and without PTSD (15% vs 2%). For the primary abstinence outcome, Veterans randomized to proactive outreach reported higher rates of 7-day point prevalence abstinence at 12 months in both the PTSD (21% vs 9%) and non-PTSD groups (19% vs 15%). Findings suggest that proactive outreach may help overcome barriers to treatment utilization and smoking cessation among Veterans with PTSD. Further, given the documented cost-effectiveness of proactive outreach, future work should focus on the development of strategies to enable more widespread implementation of these interventions. Date: July 2, 2020 Possible Impact of Measures to Curb COVID-19 Spread on Suicide Prevention Efforts Social distancing and other public health actions intended to curb the spread of COVID-19 have the potential for adverse outcomes on suicide risk. However, concerns about negative secondary outcomes of COVID-19 prevention efforts should not imply that that these public health actions should not be taken. Implementation should include a comprehensive approach that considers the public health priority of suicide prevention as well. Date: April 10, 2020 Computer-Based Cognitive Behavioral Therapy with Peer Support Provides Greater Improvement of Depression Symptoms This trial sought to determine whether computer-based cognitive behavioral therapy (cCBT) combined with peer support improved outcomes relative to enhanced usual care (EUC) for 330 primary care patients with depression who were treated at three Midwestern VA medical centers and two of their associated outpatient clinics. Findings showed that peer-supported cCBT as an add-on to usual primary care treatment for depression was associated with greater improvements in depression symptoms, quality of life, and mental health recovery at three months compared to enhanced usual care alone. Improvements in mental health recovery, although not the other outcomes, were sustained up to six months. Remission rates were 14% for Veterans in the peer-supported cCBT group and 6% for Veterans in the EUC group at three months, and 22% and 11%, respectively, at six months. The more modest benefits found with peer-supported cCBT should be considered in the context that more than 50% of Veterans also received antidepressant medication with high levels of adherence and over 30% received some in-person psychotherapy. Computerized CBT with peer support should be considered for implementation and evaluation in primary care, and adaptations to the computer CBT and peer support components should be considered to further improve effectiveness. Date: March 1, 2020 Integrated Pain Team Programs Improve Outcomes for Chronic Pain and May Reduce Reliance on High-Risk Opioid Therapy This study examined changes in self-reported chronic pain-, opioid-, and treatment-related outcomes among Veterans with chronic pain following the implementation of a primary care-based biopsychosocial Integrated Pain Team (IPT) model within the San Francisco VA Health Care System. Findings showed that Veterans with chronic pain who engaged in the IPT program reported improvement in several outcomes related to pain-related distress and disability, and opioid misuse. While patients did not report a significant change in pain severity from baseline to follow-up, they did report significantly reduced pain interference in daily functioning. Pain catastrophizing also showed significant reduction, driven by decreases in pain-related magnification and helplessness. Regarding patients prescribed opioids at both baseline and follow-up, opioid misuse decreased significantly. For example, there was a significant reduction in the frequency of opioid misuse behaviors. At follow-up versus baseline, patients reported increased use of integrative (e.g., acupuncture) and active pain management strategies (e.g., exercise), and were less likely to use only pharmacological pain management strategies. Findings suggest that primary care-based IPT programs may improve patient-centered outcomes for individuals with chronic pain and reduce reliance on potentially high-risk opioid therapy. Date: February 25, 2020 Mental Health Integration in VA Primary Care Settings Increased Access to Care – and Costs This study examined the effect of the Primary Care-Mental Health Integration Program (PC-MHI) on healthcare use and cost patterns among 5.4 million primary care patients in 396 VA clinics (FY2014-FY2016), while also accounting for the implementation of VA’s Patient Aligned Care Team (PACT) model of care. Investigators assessed VA outpatient and inpatient care and total cost of VA care as a function of attending a clinic with a high vs. low PC-MHI penetration rate. Findings showed that Veterans treated in clinics with higher proportions of primary care patients seen by PC-MHI providers received more outpatient care than those treated in clinics with lower PC-MHI penetration, but at a higher total cost. Each percentage-point increase in the proportion of clinic patients seen by PC-MHI providers was associated with 11% more mental health and 40% more primary care visits, but also 9% higher average total costs per patient per year. Among patients with serious mental illness, increasing PC-MHI penetration was associated with greater use of specialty-based mental health and all other healthcare visits. Among patients seen in hospital-based clinics, increasing PC-MHI penetration was associated with fewer emergency visits per person per year. Date: August 1, 2019 VA Opioid Treatment Outcomes Vary Significantly among Homeless and Unstably Housed Veterans To better address the opioid epidemic in Veterans who are unstably housed or homeless, it is necessary to determine where gaps in opioid-related care exist. This study examined a national sample of 59,954 Veterans who accessed VA homeless programs and represented a range of homeless experiences; 6% of this cohort (3,624 Veterans) entered a homeless program with a history of opioid use disorder (OUD). Findings showed that among the subgroup of homeless Veterans with an OUD history, opioid dose prescribing practices and rates of medication for addiction treatment (MAT) and naloxone receipt varied significantly. Less than one-quarter (23%) of Veterans received a prescription for naloxone, with homeless program-level rates of receipt ranging from 19% to 32%. Thirty-eight percent of Veterans received MAT in the year following entry into a VA homeless program, with program-specific rates ranging from 31% to 50%. Rates of high-dose opioid prescribing and concomitant opioid-benzodiazepine prescribing were highest, and rates of MAT and naloxone prescribing were lowest, among those ages 55+. Current treatment gaps indicate the need for universal policy goals to address OUD among Veterans at risk of being homeless – or who are currently or formerly homeless. Implementation strategies are needed to tailor opioid treatment access and dissemination to homeless and similar vulnerable Veteran groups. Date: August 1, 2019 Opioid Prescribing Safety Initiative Effective in Decreasing Rates of Opioid Prescribing for Older Veterans with Osteoarthritis Investigators in this study examined national trends in opioid and non-opioid analgesic prescribing before and after implementation of VA’s Opioid Safety Initiative (OSI). Findings showed that before OSI implementation, total analgesic prescriptions showed a steady rise, which abruptly decreased to a flat trajectory after the OSI was implemented. This trend was primarily due to a decrease in opioid prescribing after OSI, as well as a significant modest rise in acetaminophen prescriptions post-OSI. Among Veterans reporting pain, the intensity of pain remained unchanged over the study period. Thus, changes in analgesic prescribing trends were not accompanied by changes in reported pain intensity for older Veterans with osteoarthritis. No changes in non-steroidal anti-inflammatory drug prescribing were observed. Thus, over the period 2012-2016, VA’s successful efforts to reduce opioid prescribing did not result in worsening pain among patients with osteoarthritis. Date: June 1, 2019 Intervention Helps Identify Specialty Mental Health Patients Ready for Transition to Primary Care This pilot project tested the implementation of electronic medical record (EMR)-based criteria to identify Veterans currently receiving treatment in the specialty mental health (MH) setting who might be considered for transition to primary care. The intervention, called FLOW (not an acronym), espouses a process of shared decision-making in which MH providers, patients, and, ideally, primary care (PC) providers collaboratively determine whether primary care is the most appropriate setting for ongoing treatment once a patient has recovered or stabilized from his/her MH treatment. Findings showed that FLOW combined with sound clinical practices can be used to identify mental health patients who are candidates for primary care and foster their effective transition. During the 12-month pilot study, 424 Veterans with mental illness transitioned from MH to PC; of those patients only 9 (2%) returned to MH care after the transition. VA’s Office of Mental Health is supporting development of a national version of the online MH-FLOW report and the FLOW development team is developing a national implementation plan based on knowledge gained from this pilot. Date: March 14, 2019 Positive Effect of Collaborative Chronic Care Model on Mental Health Clinical Teams This is one of the first studies to evaluate Collaborative Chronic Care Model (CCM) implementation for individuals treated in mental health clinics, and the first CCM trial to assess implementation impact in a multi-diagnosis mental health population. Findings showed that implementation efforts at the clinician level enhance evidence-based care organization, which may result in improvements in outcomes for more complex individuals and those at risk for hospitalization. Mental health hospitalizations decreased significantly for Veterans treated on facilitated teams compared to Veterans treated in other mental health clinics in those facilities. Although no improvement in population-level Veteran self-ratings of health status was seen, mental health status improved in Veterans with >3 treated mental health diagnoses versus others. This implementation initiative used existing clinical staff, with external facilitation the only added research-supported effort, totaling less than 3 hours per week per facility, and still decreased hospitalization rates and, for complex individuals, improved mental health status. Date: March 1, 2019 Women’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 Pharmacotherapy for Opioid Use Disorder Highly Variable across VA Residential Substance Abuse Treatment Programs Pharmacotherapy, including methadone, buprenorphine, and naltrexone, is both efficacious and cost-effective for treating opioid use disorder (OUD), however it is infrequently prescribed in VA. Investigators in this study sought to describe barriers to and facilitators of pharmacotherapy provided to a national cohort of VA patients with OUD in VA residential substance use disorder (SUD) treatment programs in FY2012. Findings showed that implementation of pharmacotherapy for OUD is highly variable across VA residential SUD treatment programs. Across all 97 treatment programs, the average rate of receipt of pharmacotherapy for OUD in FY2012 was 21% and ranged from 0% to 67%. There were 11 programs where 0% of patients received pharmacotherapy for OUD. Barriers included program or provider philosophy against pharmacotherapy and a lack of care coordination with non-residential treatment settings. Facilitators included education for staff and patients and having a prescriber on staff. Intensive educational programs, such as academic detailing, and policy changes such as mandating buprenorphine waiver training for VA providers, may help improve receipt of pharmacotherapy for OUD. Date: November 1, 2018 Systematic Review: Pay-for-Performance and VA Healthcare Investigators sought to identify studies that examined the effects of pay-for-performance (P4P) on the quality of care and health of Veterans, including potential unintended consequences, as well as program design features and implementation factors important to P4P both within VA and in the community. Findings showed that overall, evidence is insufficient to determine whether P4P results in durable improvements in the quality of healthcare in VA settings. Only 1 controlled trial and 2 observational studies examined the effectiveness of P4P on intermediate clinical outcomes (e.g., blood pressure) in Veterans. Interviews with key informants were consistent with studies that identified the potential for overtreatment associated with performance metrics in VA. Key informants’ views on P4P in community settings included the need to: develop relationships with providers and strong-performing health systems; improve coordination by targeting documentation and data sharing processes, and troubleshoot the limited impact of P4P among practices where Veterans make up a small fraction of the patient population. Qualitative studies on P4P in VA found that participants felt performance measures may lead to unintended negative consequences, i.e., reduced focus on patient needs, un-incentivized areas of care, and/or healthier patient populations, and that they may negatively affect team dynamics. Key informants recognized the potential for unintended consequences of P4P, such as overtreatment in VA settings, and suggest that implementation of P4P in the community focus on relationship building – and target areas such as documentation and coordination of care. Date: July 1, 2018 Evaluating Care Coordination Program for Pregnant Veterans The VA Maternity Care Coordinator Telephone Care Program (MCC-TCP) was created to support MCCs and includes outlines to guide up to eight calls with Veterans on topics such as VA maternity care benefits, chronic health problems, substance use cessation, and depression and suicide screening. Investigators evaluated the program and assessed its feasibility, as well as facilitators and barriers to its implementation in 11 VA facilities. Findings showed that the VA Maternity Care Coordinator Telephone Care Program was successfully implemented and was perceived by the maternity care coordinators as valuable in meeting the care coordination needs of pregnant Veterans. MCC-TCP implementation barriers included limited information and communication technology tools to support the program – and lack of coordinator time for delivering telephone care. Consistent with prior research, pregnant women Veterans using VA maternity care had a high need for care coordination services due to their substantial burden of physical and mental health problems: 41% had pre-pregnancy chronic physical problem(s); 34% had mental health problem(s), particularly depression (28%) and PTSD/anxiety (21%); and 18% actively or recently smoked. Given the substantial and growing maternity care coordination needs among pregnant Veterans, especially those with chronic medical and mental illness, further investments in programs such as the Maternity Care Coordinator Telephone Care Program should be prioritized. Date: May 23, 2018 Online Toolkit to Improve Primary Care Coordination within VA and with Community Providers The Coordination Toolkit and Coaching (CTAC) project aims to improve patients’ experience of care coordination, while also developing better methods for bringing research evidence on care coordination into routine care. In this article, investigators describe CTAC’s first phase, which involved selecting tools for an online care coordination toolkit and developing a VA Intranet site to support the tools. The final Care Coordination Toolkit, available on the VA Intranet at https://vaww.visn10.portal.va.gov/sites/Toolkits/toolkit/Pages/Home.aspx, provides access to 18 tools that remained after the selection process noted above, as well as detailed information about tools’ expected benefits, and the resources required for tool implementation. The 18 tools cover 5 topics: 1) managing referrals to specialty care, 2) medication management, 3) patient after-visit summary, 4) patient activation materials, and 5) provider contact information for patients. The CTAC project is expected to improve care coordination in VA primary care clinics and provide readily-applicable methods for spreading improvements throughout VA. In addition, the project will inform VA policymakers regarding what other implementation strategies, including the use of distance coaching, might influence the use of toolkits within healthcare delivery systems. Date: May 23, 2018 Identifying Best Strategies to Implement Patient-Centered Care This paper describes a qualitative study of four early Centers of Innovation (VA medical centers considered early leaders in patient-centered care [PCC]) to inform VA leadership about how best to catalyze and sustain change across the system. Investigators identified seven domains that impacted PCC implementation: 1) leadership, 2) patient and family engagement, 3) staff engagement, 4) focus on PCC innovations, 5) alignment of staff roles and priorities, 6) organizational structures and processes, and 7) environment of care. Within each domain, multi-faceted strategies for implementing change were identified. These included efforts by leadership at all levels of the organization who modeled PCC in their interactions – and who fostered willingness to try novel approaches to care among staff. Capturing patients’ voices, obtaining patient perspectives, and finding out what matters most to Veterans and their families also were essential to selecting, planning, and implementing PCC initiatives. Alignment and integration of patient-centered care within the organization, particularly surrounding roles, priorities, and bureaucratic rules, remained major challenges. Findings from this study were used to create policy-level incentives to change by incorporating the seven domains into VA senior executive performance measures. Date: March 7, 2018 Veterans with Heart Disease More Likely to Participate in Cardiac Rehabilitation (CR) When Home-Based CR Program is Available This study examined whether the implementation of new home-based cardiac rehabilitation (HBCR) programs is associated with improved cardiac rehabilitation (CR) participation among Veterans. Findings showed that Veterans hospitalized with ischemic heart disease were more likely to participate in CR when a home-based program was available. Implementation of HBCR increased participation from 6% to 25%, and was associated with four-fold greater odds of participation. Overall, participation in at least one CR session increased from 8% to 13%. Veterans offered HBCR were less likely to drop out after the first session than were those for whom HBCR was not available. Home-based cardiac rehabilitation may be an effective tool for increasing CR participation among Veterans who would otherwise decline participation, thereby improving patient outcomes. Date: January 22, 2018 Medical Record Alert Associated with Reduced Opioid and Benzodiazepine Co-prescribing This implementation project evaluated the effectiveness of an advanced medication alert designed to reduce opioid and benzodiazepine co-prescribing among Veterans with high-risk conditions (substance use disorder, sleep apnea, suicide risk, and age =65) at one VA healthcare system (VA Puget Sound). Findings showed that the proportions of patients with concurrent prescriptions decreased significantly post-alert launch among Veterans with substance use (25%), sleep apnea (39%), and suicide risk (62%), with greater decreases at the alert site relative to the comparison site in sleep apnea and suicide-risk cohorts. Significant decreases in benzodiazepine prescribing were observed at the alert site only. Date: December 28, 2017 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 Medical Care Supplement Features Articles by VA Researchers on Improving the Quality and Equity of Health and Healthcare In 2016, HSR&D’s Center for Health Equity Research and Promotion (CHERP) and the Health Equity and Rural Outreach Innovation Center (HEROIC) hosted a state-of-the-science conference. This field-based meeting to “Engage Diverse Stakeholders and Operational Partners in Advancing Health Equity in the VA Healthcare System” brought together health equity investigators, representatives of vulnerable Veteran populations, and operational leaders to identify strategies to advance the implementation of evidence-based interventions to improve the quality and equity of health and healthcare. The conference focused on three specific vulnerable Veteran populations: racial and ethnic minorities, homeless Veterans, and Veterans from the LGBT community. This supplement features several articles that emanated from this meeting. Date: September 1, 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 Initiative Decreases Inappropriate Prescribing to Older Veterans Discharged from VA Emergency Department Care This study evaluated the effectiveness and sustainability of the Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED) program to reduce the use of potentially inappropriate medications (PIMs). Findings showed that EQUiPPED was associated with a sustained reduction in inappropriate medication prescribing at all four VAMCs in the study. Post-intervention, the proportion of PIMs at site one decreased from 12% to 5%; at site two it decreased from 8% to 5%, at site three from 9% to 6%, and at site four from 7% to 6%. The implementation timeline for the initiative ranged from 6 to 14 months depending on the site. While the implementation timelines varied across sites, all VAMCs achieved a monthly PIM proportion between 5% and 6%. The EQUiPPED intervention led to safer prescribing and was sustainable across multiple VA sites. Implementation is currently underway at six additional VA emergency department sites, as well as three non-VA ED sites to evaluate broader dissemination. Date: April 7, 2017 Patient and Provider Experiences with Comprehensive Lung Cancer Screening Program This article describes the organizational- and patient-level experiences with the VA Lung Cancer Screening Demonstration Project (LCSDP), and estimates the number of VA patients who may be screening candidates. Findings showed that participants in the LCSDP found implementing a comprehensive lung cancer screening program to be challenging and complex, requiring new tools (e.g., electronic tools to capture necessary clinical data in real time) and patient care processes for staff, in addition to dedicated patient coordination. There was wide variation in processes and patient experience among the study sites. For example, across the eight sites, 58% of patients who were offered screening agreed to be screened, ranging from 34% to 66% across the sites. Overall, 60% of the Veterans screened for lung cancer had a positive result, including having nodules that needing tracking, needing a workup for possible lung cancer, and being diagnosed with lung cancer. It is estimated that nearly 900,000 VA patients may be candidates for lung cancer screening. Implementation of lung cancer screening in the VA healthcare system will likely lead to large numbers of screen-eligible patients – and will require substantial clinical effort for both patients and staff. Date: March 1, 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 Substantial Portion of Elderly Veterans Receive Medications from Medicare Part D-Reimbursed Pharmacies – Either Alone or in Conjunction with VA Pharmacies This study examined patterns of medication acquisition from VA and Medicare Part D-reimbursed pharmacies following the implementation of Part D. Findings showed that nearly one-third of VA healthcare users received medications from Part D-reimbursed pharmacies, either alone or in combination with VA pharmacies. Veterans who lived in rural areas, were not black, had VA medication copayments, or were dual or Medicare-only outpatient users were more likely to be dual (i.e., both VA and Part D) pharmacy users or Part D-reimbursed only pharmacy users compared to other Veterans. Among dual pharmacy users, more than half of the Veterans received medications from the same drug class from both VA and Part D-reimbursed pharmacies that overlapped by more than seven days. Results highlight the clinical importance of assessing medications from VA and non-VA sources. At particular risk for suboptimal medication reconciliation are those Veterans who receive care within VA only or from both VA and Medicare outpatient clinics, but who solely obtain their medications from non-VA pharmacies. Date: February 1, 2017 VA Opioid Safety Initiative Decreases Potentially Risky Opioid Prescriptions among Veterans This study examined changes associated with Opioid Safety Initiative (OSI) implementation among all adult VA patients who filled outpatient opioid prescriptions from October 2012 through September 2014 in any of 141 VA facilities. Findings showed that during the two-year study period there was a decrease in the number of VA patients receiving risky opioid regimens, with an overall reduction of 16% among Veterans receiving >100 morphine-equivalent milligrams (mEq) daily dosages and 24% among Veterans receiving >200 mEq. There was a 21% reduction in Veterans receiving benzodiazepines concurrently with opioids. Implementation of the OSI dashboard tool was associated with a significant decrease in all three outcomes (>100 mEq, >200 mEq and concurrent opioid/benzodiazepine prescribing). The implementation of the OSI dashboard tool was associated with a significant decrease in risky opioid prescribing across the VA healthcare system, which highlights the possibility of system-wide approaches to address high-risk opioid prescribing. However, a large number of VA patients remained on these regimens at the end of the study period, which emphasizes the challenges of making significant changes in healthcare systems that treat a large population of complex patients. Date: January 4, 2017 Importance of VA’s Quality Enhancement Research Initiative in the Choice Act Era The Veterans Access, Choice and Accountability Act of 2014 (Choice Act) allows Veterans enrolled in VA healthcare who have waited longer than 30 days to see a provider – or who live more than 40 miles from a VA clinic – the option of seeking care from non-VA providers. The Choice Act also mandated an independent assessment of VA business and healthcare practices. This article describes how VA’s Quality Enhancement Research Initiative (QUERI) is responding to the Choice Act, particularly through the implementation strategies that facilitate more rapid uptake of effective practices across different settings, and the rigorous evaluation of new VA programs and policies. Date: December 16, 2016 Frailty Screening Initiative Associated with Improved Post-Operative Survival among Veterans The Frailty Screening Initiative (FSI) is aimed at improving post-operative survival. This study assessed the impact of the FSI on mortality and complications by comparing surgical outcomes before and after implementation of the FSI. Findings showed that implementing frailty screening was associated with reduced mortality, suggesting both the feasibility of widespread screening of patients pre-operatively to identify frailty – and the efficacy of system-level initiatives aimed at improving their surgical outcomes. Overall, 30-day mortality dropped from 1.6% to 0.7% after FSI implementation. Improvement was greatest among the frail (12% to 4%). Moreover, the magnitude of improvement among frail patients increased at 180 and 365 days. After controlling for age, frailty, and predicted mortality, models showed that the FSI resulted in a three-fold survival benefit in this study cohort. Frailty screening of preoperative patients is feasible, and may be an effective and scalable tool for improving surgical outcomes for aging and increasingly frail U.S. and Veteran populations. Date: November 30, 2016 Racial Disparities in HIV Quality of Care that May Extend to Common Comorbid Conditions To more fully understand patterns of racial disparities in the quality of care for persons with HIV infection, this study examined a national cohort of Veterans in care for HIV in the VA healthcare system during 2013. Findings showed that racial disparities were identified in quality of care specific to HIV infection – and in the care of common comorbid conditions. Blacks were less likely than whites to receive combination antiretroviral therapy (90% vs. 93%) or to experience viral control (85% vs. 91%), hypertension control (62% vs. 68%), diabetes control (86% vs. 90%), or lipid monitoring (82% vs. 85%). Although performance on quality measures was generally high, racial disparities in HIV care for Veterans remain problematic and extend to comorbid conditions. Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities. Date: September 22, 2016 New Guidelines May Significantly Decrease Cost for Testing Immune Function in Veterans with HIV In 2012, the Department of Health and Human Services recommended CD4 testing in patients with HIV every 3 to 6 months – except in patients with consistently suppressed virus and sustained CD4 cell count, who could be tested every 6 to 12 months. In 2014, updated guidelines recommended that in individuals with viral suppression, CD4 testing be considered either optional or annual, depending on the cell count. This study evaluated how these recommendations might affect Veterans with HIV who receive care from the largest provider of HIV care in the United States – the VA healthcare system. Findings showed that VA providers decreased the frequency of CD4 testing by 11% between 2009 and 2012, reducing the direct cost of testing by $196,000 per year. While VA has made substantial progress in reducing the frequency of optional CD4 testing, it could be reduced a further 29% by full implementation of new treatment guidelines, with an expected annual savings of $600,000. Reduced CD4 monitoring also would likely reduce patient anxiety with little or no impact on quality of care. Date: July 1, 2016 National Program to Prevent Catheter-Associated Urinary Tract Infection is Successful in Non-ICU Settings The National Implementation of Comprehensive Unit-based Program (CUSP) to reduce catheter-associated urinary tract infection (CAUTI) focused on both the technical and socio-adaptive aspects of implementation of prevention guidelines. This study examined CAUTI and catheter utilization outcomes in 926 units (non-VA) within 603 hospitals in 30 states. Findings showed that participation in the program led to reduced CAUTI rates. Reductions occurred mainly in non-ICU settings, where CAUTI rates showed a 32% reduction. Rates did not significantly change in ICU settings. Catheter utilization also decreased significantly in adjusted analysis in non-ICUs (20% to 19%), but did not significantly change in ICUs (63% to 62%). The reason ICUs have had less success in CAUTI prevention is unclear. Authors suggest that it could be related to the belief that if a patient is ill enough to require ICU admission, they are unstable enough to need a urinary catheter for close urine output monitoring. The frequent occurrence of fever in critically ill patients, coupled with routine urine culturing to determine possible infectious sources could also lead to higher CAUTI rates in ICUs compared to non-ICUs. Date: June 2, 2016 JGIM Supplement Features Ten Articles by VA Researchers on Next Generation Clinical Performance Measures Papers discuss empirical research on the effects of performance measurement on improvements in clinical care, as well as on unintended outcomes (e.g., inappropriate treatment or over-treatment). Papers also describe new methods and methodological challenges in the selection and creation of performance measures that incorporate measures of benefit and harm, value, or patient preferences, and also present research on the implementation of performance measures that address human factors, incentives and facilitators, barriers, and expected and unintended consequences. Date: April 1, 2016 Impact of Evidence-based Quality Improvement Strategy on VA Patient-Aligned Care Team Implementation This study assessed changes in VA healthcare utilization and costs for Veterans from six practices in three different medical centers using an evidence-based quality improvement (EBQI) approach to implement PACT and 28 comparison practices over a five-year period (FY2009 to FY2013). Findings showed that after PACT implementation, the overall use of primary care, specialty care, and mental health/substance abuse care decreased, while the use of telephone care increased. Decreased outpatient care use occurred more rapidly for VA practices that employed an EBQI approach to PACT implementation, including outpatient visits for primary care, specialty care, and mental health and substance abuse care that appeared to augment the effects of PACT. EBQI practice was significantly associated with a 15% reduction in primary care encounters over the study period. For specialty care, there was a 17% decrease in encounters associated with EBQI overall, but the rate of decrease slowed each year after the implementation of PACT. There was no significant effect of EBQI status on emergency department visits, all-cause hospitalizations, or prescription drugs. Total VA healthcare costs per patient decreased by 5% each year across all practices, but there was no effect of EBQI practice on costs. Date: February 1, 2016 Potential Problems and Suggested Solutions for VA as Veterans Take Advantage of Dual Use Care via the “Choice Act” This Commentary describes the problems of dual use and care fragmentation, the complexity of the Choice Program, and offers suggestions for ensuring its safe and effective implementation. Date: August 20, 2015 Bundled Intervention Associated with Lower Rates of Surgical Site Infections following Cardiac or Orthopedic Operations This study evaluated whether the implementation of an evidence-based bundle is associated with a lower risk of S. aureus surgical site infections (SSIs) in patients undergoing cardiac operations or hip or knee arthroplasties. Findings showed that implementation of an SSI prevention bundle was associated with reduced S. aureus SSI rates. During the pre-intervention period, there were 101 complex S. aureus SSIs compared with 29 during the intervention period. Also, the number of months without any complex S. aureus SSIs increased from 2 of 39 (5%) to 8 of 22 (36%). After a 3-month phase-in period, bundle adherence was 83%. The complex S. aureus SSI rates decreased significantly among patients in the fully adherent group compared with the pre-intervention period, but rates did not decrease significantly in the partially adherent or non-adherent group. Date: June 2, 2015 Electronic Health Record-Based Interventions for Reducing Inappropriate Imaging in the Clinical Setting Given that adoption of electronic health records (EHRs) is expanding, investigators conducted a systematic review and meta-analysis of EHR-based interventions to improve the appropriateness of diagnostic imaging. Findings showed that Computerized clinical decision support that is integrated into the physician order entry system of an electronic health record can help improve the appropriate ordering of diagnostic imaging studies. Of the 23 studies in this review, 21 studies provided moderate-quality evidence that EHR-based interventions can change appropriate test ordering by a moderate amount – and can reduce overall use by a small amount. Interventions that include a “hard stop” to prevent clinicians from ordering imaging tests classified as inappropriate, and implementation in an integrated care delivery setting may improve effectiveness. Potential harms of computerized clinical decision-support interventions have been rarely studied. Date: April 21, 2015 VA Healthcare for Women Veterans: Medical Care Supplement The goal of this Supplement is to disseminate new research findings related to the planning, organization, financing, provision, evaluation, and improvement of health services and/or outcomes for women Veterans and women actively serving in the military. In addition to 21 articles, the Supplement features several editorials that describe emerging areas of women’s health research, particularly following the 2014 Veterans Choice Act, as well as a partnered-research initiative that aims to accelerate the implementation of comprehensive care for women Veterans. Date: April 1, 2015 Use of Electronic Health Information Exchange may Reduce Emergency Department Utilization Investigators in this study conducted a systematic review of the health information exchange (HIE) literature, specifically examining the evidence of effect on health outcomes, healthcare use and efficiency, evidence of clinicians’ use of HIE, and the financial sustainability of HIE organizations. Investigators also evaluated evidence about patient and provider attitudes toward HIE, as well as barriers and facilitators to its use. Findings showed that using HIE may reduce emergency department (ED) usage and costs. The effects of HIE on other healthcare outcomes are uncertain. The use of HIE is low relative to the estimated potential need, with most studies reporting use in 2% to 10% of healthcare encounters. However, some sites reported much greater HIE use, and specifics of the context and implementation may be responsible for these differences. All stakeholders claim to value HIE, but many barriers to acceptance and sustainability exist, including workflow and interface issues, privacy and security of patient health information, and the lack of a compelling business case for sustainability. Date: December 2, 2014 Study Highlights Mental Health Services Important to Women Veterans Investigators in this study identified a subset of women Veteran primary care users who were potential stakeholders for mental health services, and then quantified their priorities for these services. Treatment for depression, pain management, coping with chronic conditions, sleep problems, weight management, and PTSD emerged as the top six mental healthcare priorities for women. The majority of women Veterans in this study (98%) selected at least one of these services as important, and 80% selected at least three of these six services as important. The majority of women who prioritized each of these six services reported that they had either used this type of service in the past year or were quite a bit or extremely likely to use the service within the next six months, ranging from 62% for weight management to 96% for chronic conditions. Findings suggest that women’s primary care clinics, which are available at many VA healthcare facilities, are a strategic setting to enhance the implementation of women’s health services through primary care-mental health integration. Date: November 17, 2014 VA PACT Implementation Increases Primary Care among Veterans with PTSD This study assessed the association between PACT and the use of health services among Veterans with PTSD. Findings showed that the period following PACT implementation was associated with lower rates of hospitalization and specialty care visits and a higher rate of primary care visits for Veterans with PTSD, indicating enhanced access to primary care. Adjusted results show a 9% decrease in hospitalizations, an 8% decrease in specialty care, and an 11% increase in primary care visits in the post-PACT period. No significant effects were found on mental health, ED, or urgent care visits. For Veterans younger than 65 years, findings mirrored the full sample, with significantly lower hospitalizations and specialty care visits and higher primary care visits in the post-PACT period. However, for Veterans older than 65 years, there were significant increases in both primary and specialty care visits, significant decreases in urgent care visits, and no significant decrease in hospitalizations. Date: November 10, 2014 JGIM Supplement Highlights VA’s Partnered Research In this JGIM Supplement, 12 articles describe partnered research at various stages – from conceptualizing partnered research to examples of findings borne from bi-directional collaborations with investigators and leaders from clinical operations. These articles cover a wide range of topics highly relevant to VA policy and practice, including performance measure implementation on provider motivation, opioid management, suicide prevention, homelessness, medical home models, and communication of adverse events. Date: November 1, 2014 Systematic Frailty Screening may Lead to Reduced Post-Operative Mortality in Frail Veterans Investigators in this study implemented a quality improvement initiative to screen Veterans scheduled for elective surgery for frailty in order to identify those at high risk for post-operative mortality and morbidity. This systematic frailty-screening program effectively identified at-risk surgical patients and was associated with a significant reduction in mortality in Veterans undergoing palliative care consultation. Implementation of the screening program was associated with a 33% reduction in 180-day mortality even after controlling for age, frailty, and whether the patients had surgery. Further, given the high risk of dying in this frail cohort, study models suggest that for every four patients screened, one death was prevented or delayed at 180 days. After implementation of the frailty-screening program, palliative care consultations were more frequently ordered by surgeons, and they were more likely to take place before the index operation. Moreover, pre-operative palliative care consultations ordered by a surgeon were associated with the greatest reduction in mortality. Date: September 10, 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 PACT Investigators in this study created the PACT Implementation Progress Index (Pi2) to measure the extent and variation of PACT implementation, and then conducted an observational study to examine the association between the index and key outcomes (e.g., patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout. Findings showed that the extent of PACT implementation was highly associated with important outcomes for both patients and providers. Significant trends were observed in quality of care in relation to the Pi2 score: 77 sites that achieved the most effective implementation exhibited higher clinical quality outcome measures than less successful sites. The rate of emergency department visits was significantly lower in sites with more effective PACT implementation than in those with less effective implementation, and there were larger projected decreases in rates of ambulatory care sensitive condition admissions after the start of PACT. Patient satisfaction was significantly higher among sites that had effectively implemented PACT than among those that had not, and a similarly favorable pattern was observed for staff burnout. Date: June 23, 2014 Trends in Healthcare Use and Costs after VA’s Implementation of Patient-Aligned Care Teams This study analyzed data for 11 million VA primary care patients treated from FY03 through FY12 to assess how trends in healthcare use and costs changed after the PACT implementation. Findings showed that PACT implementation was associated with modest increases in primary care visits – and with modest decreases in both hospitalizations for conditions like heart failure that might be avoided with better ambulatory care, and outpatient visits with mental health specialists. It is estimated that these changes avoided $596 million in costs compared to the investment in PACT of $774 million, for a potential net loss of $178 million during the study period. The investment in PACT was overwhelmingly attributed to hiring personnel to staff primary care teams. Although PACT has not generated a positive financial return, it is still maturing and trends in costs and use are favorable. Thus, adopting patient-centered care does not appear to have been a major financial risk for VA. Date: June 1, 2014 Implementation of Telemedicine in VA ICUs May Not Reduce Mortality Rates or Length of Hospital Stays This study evaluated the impact of telemedicine (TM) implementation on short-term (ICU and in-hospital) and longer-term (30-day) mortality rates and length of stay (LOS) within a regional network of seven Midwest VA hospitals. Findings showed that the implementation of an ICU telemedicine program did not reduce mortality rates or length of hospital stay. It was not associated with a significant decline in ICU, in-hospital, or 30-day mortality rates or LOS in unadjusted or adjusted analyses. Date: May 12, 2014 Changes in Care Processes and Patient Outcomes Related to VA’s Implementation of PACT Model This study examined whether changes in VA healthcare delivery under the PACT transformation led to changes in organizational processes of care and patient outcomes. Findings showed that medical home implementation in the VA healthcare system resulted in large changes in the structure of care, but few changes in patient-level organizational processes or outcomes. There were significant improvements in two-day post-hospital discharge contact, but not primary care visits occurring by telephone or within three days of the requested date. There was no association between medical home implementation and rates of emergency department use by Veterans. Over the study period, the percentage of PCPs who were part of the PACT model more than tripled, and the percentage of PCPs that implemented elements of the PACT model increased significantly. Date: January 30, 2014 VA’s “Housing First” Approach to Helping Homeless Veterans Presents Several Challenges Over the past three years VA has shifted toward a Housing First (HF) approach to its HUD-VASH program, pivoting away from the traditional approach (often termed “Treatment First”), which emphasized housing readiness prior to awarding rental vouchers. This study examined the experiences of eight VA facilities that were at varying stages of HF adoption in 2012. Findings showed that front-line staff faced challenges in rapidly housing homeless Veterans due to difficult rental markets, the need to coordinate with local public housing authorities, and a lack of available funds for move-in costs. Finding interim sheltering options for Veterans waiting for housing (i.e., with no expectations of sobriety or treatment participation) also presented a significant challenge to the implementation of HF. Staff struggled to balance the time spent on housing search activities with intensive case management of highly vulnerable Veterans; this tension is acute immediately after the release of vouchers, when facilities are closely monitored on the speed with which the vouchers are used. Facility leadership supported HF implementation through resource allocation, performance monitoring, and reliance on mid-level managers to meet the challenges of implementation. The authors suggest that HF cannot successfully proceed unless VA is able to secure housing in discrete geographies and markets. Moreover, securing housing while simultaneously advancing the recovery agenda for each Veteran remains an ambitious undertaking. Date: January 15, 2014 Health Information Technology This review sought to examine recent evidence that relates health IT functionalities prescribed in meaningful use regulations to key aspects of healthcare, such as quality, safety, and efficiency. Findings showed that most published IT evaluation studies report positive effects on quality, safety, and efficiency. Strong evidence supports the use of clinical decision support (CDS) and computerized provider order entry (CPOE). Fifty-seven percent of the studies in this review evaluated CDS and CPOE, and most reported positive results. Insufficient reporting of implementation and context of use makes it impossible to determine why some health IT implementations are successful and others are not. Therefore, the most important improvement that can be made in health IT evaluations is increased reporting of the effects of implementation and context. Authors note that with the increasing adoption of electronic health records and other forms of health IT, it is no longer sufficient to ask whether health IT creates value, but rather the most useful studies will help us understand how to realize value from health IT. Date: January 7, 2014 VA’s Online Quality Improvement Toolkits In 2009, VA/HSR&D’s Quality Enhancement Research Initiative (QUERI) was tasked by VHA leadership to develop online toolkits that would facilitate the spread of locally developed innovations to improve quality of care for Veterans. The QI Toolkit Series was designed as a two-year pilot project that would offer VHA staff access to innovations to help improve performance on specific performance measures across a variety of high-priority care conditions. The Toolkit Series is now an enhanced Intranet website, accessible by all staff using the VHA network. This article describes the general approach to creating such toolkits, aspects of implementation, and a brief evaluation. Date: December 1, 2013 Electronic Patient Portals and their Effect on Health Outcomes Investigators conducted a systematic review of the relevant literature evaluating peer-reviewed articles on patient portals tied to existing electronic medical record systems, specifically looking at whether or not these systems improve health outcomes, patient satisfaction, healthcare utilization and efficiency, and adherence. Findings showed that the evidence is insufficient as to the effects of patient portals on health outcomes. A limited number of studies and variations in study design, portal functionalities, and implementation processes make it difficult to draw strong conclusions or generalizations about this relatively new technology. Examples were identified in which portal use was associated with improved outcomes for patients with chronic diseases (i.e., diabetes, hypertension, depression), but these were generally studies that used the portal in conjunction with case management. Evidence was mixed about the effect of portals on healthcare utilization and efficiency. Some findings included more acceptance of portals by patients who were younger and had more computer literacy or trust in the Internet, and more enthusiasm for portals among patients than physicians. Administrative and human factors in the interface were cited as barriers to use. Thus, the jury is still out on whether patient portals such as MyHealtheVet improve health outcomes or increase healthcare efficiency, although patients seem to value the ability to access their own medical records. While patients’ attitudes on portals are generally positive, more widespread use may require efforts to overcome racial, ethnic, and literacy barriers. Date: November 19, 2013 Changes in VA Care since PACT Implementation This study evaluated interim changes in PACT-related care processes. Findings showed that VA achieved rapid progress in building a PACT infrastructure in the first 30 months of an extensive four-year implementation plan, and some interim changes in processes of care were observed: in-person PCP visit rates decreased slightly; healthcare via telephone and Internet increased dramatically (e.g., phone encounters increased 10-fold and patients using telehealth increased from 38,747 in 12/09 to 70,486 in 6/12); shared medical appointments increased slightly; appointment access and continuity improved slightly, but started at high levels; and post-hospitalization follow-up improved substantially but remains below goal (e.g., patients evaluated by primary care clinicians within 48 hrs of hospital discharge increased from 6% in 12/09 to 61% in 12/11). Facilities’ average overall score on the ACP Biopsy survey (assessing the presence of 127 PACT components via “yes” or “no” items in 7 categories) increased from 69% “yes” in 10/09 to 80% “yes” in 7/11. Date: July 10, 2013 Suicidal Ideation is Common among OEF/OIF Veterans who Receive VA Healthcare This study sought to determine the prevalence and correlates of suicidal ideation among OEF/OIF Veterans who screened positive for depression following implementation of required brief assessments. Findings showed that suicidal ideation is common among OEF/OIF Veterans who receive VA healthcare: one in three Veterans who screened positive for depression acknowledged possible suicidal ideation. High PHQ-2 scores (> 5) nearly doubled the odds of suicidal ideation, even when controlling for diagnoses of depression. Depression and bipolar or schizophrenia diagnoses significantly increased the odds of suicidal ideation. In addition, having a single diagnosed psychiatric disorder did not significantly increase the odds of suicidal ideation, but two disorders were associated with a 60% increase, and three or more disorders more than doubled the odds. In contrast to previous reports, this study found no increase in suicidal ideation for Veterans with PTSD, substance use disorders, anxiety disorders, or traumatic brain injury. However, the authors note that a recently published evidence-based synthesis concluded that despite mixed results, PTSD should be considered a risk factor for suicide attempts and completion among Veterans. Date: July 1, 2013 Cancer Genetics Toolkit Improves Quality and Frequency of Family History Documentation among VA Primary Care Patients Investigators in this study developed a cancer genetics toolkit designed to improve familial risk assessment and appropriate referrals for hereditary breast-ovarian cancer (HBOC) and Lynch syndrome. They then evaluated the impact of the toolkit by comparing clinician behaviors relating to documentation of cancer family history and referral for genetic consultation before and after its implementation in women’s primary care clinics. Findings showed that the toolkit increased the frequency and improved the quality of cancer family history documented by primary care clinicians; increased recognition of high-risk Veterans; and increased the numbers of appropriate referrals for genetic consultation. A clinical reminder in the electronic health record was a key component of the toolkit; when used, it was associated with a two-fold increase in cancer family history documentation, and history was more complete. In addition, veterans whose clinicians completed the reminder were twice as likely to be referred for genetic consultation. Date: June 13, 2013 Multimodal Intervention Increases HIV Testing in VA Primary Care Investigators with VA/HSR&D’s HIV/Hepatitis Quality Enhancement Research Initiative (QUERI) previously developed, implemented, and evaluated a multimodal program to promote HIV testing, which more than doubled testing among at-risk Veterans. These results prompted the current study that scaled up this intervention in a large number of diverse VA facilities. Investigators examined the effectiveness of promoting routine as well as risk-based HIV testing, and the effect of providing different levels of organizational support at study sites. Findings showed that the use of clinical reminders, provider feedback, education, and social marketing in this HIV-testing intervention significantly increased the frequency with which HIV testing was offered and performed within the VA healthcare system. Implementation of this intervention increased the rate of risk-based HIV testing two- to three-fold, and increased routine testing three- to four-fold. Risk-based and routine HIV testing increased in all facility-, provider-, and patient-level groups. Date: April 19, 2013 Significant Financial Burden for Caregivers of Veterans with Polytrauma and Traumatic Brain Injury This study (conducted prior to the implementation of stipends from the Caregivers and Veterans Omnibus Health Services Act) evaluated the prevalence of financial strain as measured by asset depletion and/or debt accumulation, and labor force exit among caregivers of Veterans with polytrauma and traumatic brain injury (TBI). Findings showed that financial strain is common for caregivers: 62% reported depleted assets and/or accumulated debt, and 41% reported leaving the labor force. The latter finding stands in sharp contrast to studies in other populations internationally, where between 2% to 27% of caregivers left the labor force. If a severely injured Veteran needed intensive help with activities of daily living, the primary caregiver faced 4.6 higher odds of leaving the labor force, and used $27,576 more assets and/or debt to help care for the Veteran compared to caregivers of Veterans needing little or no help. Male caregivers, those providing care since the time of injury, and those providing care to Veterans with high-intensity needs and with the lowest overall functioning at time of discharge experienced significantly higher amounts of asset depletion and/or debt accumulation compared to female caregivers, caregivers relatively new to their role, and those providing care to higher functioning Veterans with low-intensity care needs. Spouses did not face higher financial strain compared to parents; financial strain was no higher for caregivers of those injured in Iraq, Afghanistan or the Middle East compared to those injured in the U.S., and the timing of injury was not associated with greater financial strain. Date: February 1, 2013 Protected Sleep Periods for Medical Interns Increase Overnight Sleep and Improve Morning Alertness This study evaluated the feasibility and consequences of protected sleep periods among medical interns during extended duty. Findings showed that the implementation of a protected sleep period resulted in approximately a 50% increase in overnight sleep duration, a 200% reduction in nights without any sleep, a reduction of about 50% in disturbed sleep, and improved alertness the next morning. Interns with protected sleep, compared to those without protected sleep, were significantly less likely to have on-call nights with no sleep: 6% vs. 19% at the VAMC, and 6% vs. 14% at the University hospital. Interns with protected sleep also felt less sleepy after on-call nights. The proportion of interns who reported having disturbed sleep at the VAMC was 50% among interns with protected sleep periods compared to 85% among those without protected sleep periods. Date: December 5, 2012 Design and Implementation of a VA Hospital-Based Usability Laboratory for Health Information Technology This article describes the HSR&D Human-Computer Interaction & Simulation Laboratory, housed within one VAMC, which was intended to provide research-level findings about health information technology (HIT) design and was developed to investigate the usability of HIT toward transforming VA’s health information system. Investigators provide insight about the Laboratory’s design and implementation, and the use of a usability laboratory in the healthcare setting. Date: December 1, 2012 Factors Affecting Readiness for Implementation of VA’s Patient-Aligned Care Team Model This study sought to describe the impact of readiness for implementation on the efforts of 32 pilot PACT teams to make changes to improve access to healthcare for Veterans – and to identify successful strategies to overcome barriers to change. Findings showed that key factors related to readiness for implementation (or lack thereof) had an impact on which interventions pilot teams could put into place, as well as viability and sustainability of access gains. Leadership Engagement. Lack of leadership engagement/support posed a barrier to open access, however, strategies to engage/educate administrators led to successful interventions to improve access. Staffing Resources. Lack of personnel to staff PACT teams was a barrier to improving access; at sites where funds were made available to hire new staff or where teams were able to re-configure existing staff, access interventions were more often implemented. Access to Information and Knowledge. Having experienced staff who could generate reports from the electronic medical record was a major facilitator of access interventions. Pilot teams used a number of effective strategies for improving access, i.e., extending time between appointments for some Veterans; reorganizing clinic schedules in order to provide a mix of face-to-face, telephone, and same-day appointments; and contacting Veterans after an ED visit to determine appropriate follow-up care. The authors note that wide variations in interventions to improve access occurred across sites, which has important implications for efforts to measure the impact of enhanced access on patient outcomes, costs, and other systems level indicators of the PACT model’s success. Date: November 29, 2012 Determinants of Implementing Depression Care Improvement Models in VA Primary Care Practices This study examined three VA-endorsed depression care models and tested the relationships between measures of organizational readiness and implementation of the models in VA primary care clinics. The three models include: 1) collocation of mental health specialists in primary care settings, 2) the Translating Initiatives in Depression (TIDES) model, and 3) the Behavioral Health Laboratory (BHL) model. Findings show that pre-existing demographic and readiness characteristics of primary care practices are associated with whether the practice chooses to implement a depression care improvement model – and with what type of model the practice chooses. Of the three approaches, primary care practices appear most ready to implement collocation, which had been present the longest (average 6 years) in practices adopting it. Moreover, the majority of practices that had not adopted it planned to do so. By 2007, 48% of clinics had implemented collocation, 17% had implemented TIDES, and 8% had implemented BHL. Having established quality improvement processes or a depression clinician champion was associated with collocation. Being located in a VA regional network that endorsed TIDES was associated with TIDES implementation. The presence of psychologists or psychiatrists on primary care staff, greater financial sufficiency, or greater space sufficiency was associated with BHL implementation. Date: October 5, 2012 Mental and Physical Health – and Substance Use in Veterans One Year after Deployment to Iraq or Afghanistan Within one year of returning from deployment, OEF/OIF Veterans in this study reported significantly worse mental health functioning than the general population. In addition, 39% screened positive for “probable alcohol abuse,” which is considerably higher than numbers reported based on mandated screening of VA outpatients. OIF (Iraq) Veterans reported more depression/functioning problems, as well as alcohol and drug use than OEF (Afghanistan) Veterans. Marine and Army Veterans reported worse mental and physical health than Air Force or Navy Veterans. Men reported more alcohol and drug use than women, but there were no gender differences in PTSD or other mental health domains. The authors suggest that continued identification of Veterans at risk for mental health and substance use problems is important for the development and implementation of evidence-based interventions intended to increase resilience and enhance treatment. Date: January 1, 2012 Chronic Disease Management Initiative Reduces Hospitalizations for Ambulatory Care Sensitive Conditions among Veterans A chronic disease management (CDM) initiative in VISN 23 was associated with a significant reduction in hospitalizations for ambulatory care sensitive conditions (ACSCs) compared with other VA healthcare systems. The estimated annual effect of the CDM initiative is 2.9 fewer hospital admissions per 1,000 Veterans who have an ACSC. This is nearly 10% of the average of 30.8 ACSC admissions per 1,000 Veterans in the other networks in 2010. ACSC hospitalization ratios were nearly identical in 2006 (before CDM implementation) between VISN 23 and the other VISNs. Date: January 1, 2012 Intervention to Increase HIV Testing Can Be Successfully Implemented by Non-Research Staff This study reports on the one-year results of implementing a program that doubled HIV testing rates in at-risk Veterans receiving care at two VAMCs in two other VA facilities where the research team played a much smaller part in the intervention implementation. Findings showed that the annual rate of HIV testing among at-risk Veterans increased by 6% and 16% after the end of the first year for the two sites to which the project was newly exported, and where non-research staff were responsible for implementation. In contrast, for the original two implementation sites where research staff played a major role, testing rates increased by 9% and 12%. There was no change in the rate of testing at the one control site that did not participate in the project. Authors note that even with differences between the original and “export” sites (e.g., strength of academic affiliations, emphasis on specialized services), the successful implementation and similar increases in HIV testing rates across patient and sub-facility levels provides further support for the generalizability of the intervention. Date: December 1, 2011 Unintended Consequences of Local Implementation of VA Performance Measures This study explored the possible relationships between a centralized primary care clinical performance measurement (PM) system, facility-level practices to implement the PM system into daily care, and unintended negative consequences for Veterans. Findings showed that primary care staff described several ways in which PMs may lead to inappropriate care (e.g., over-prescribing of medication), decrease focus on Veterans’ concerns and patient service (e.g., inconveniencing patients for little benefit), and may make it more difficult for Veterans to make informed, value-consistent decisions (e.g., performance system doesn’t acknowledge when a patient makes an informed refusal of a recommended intervention). Staff also described unintended consequences on primary care team dynamics, e.g., requiring nurses to check on providers to be sure they completed and documented PMs, and providing performance bonuses based on PMs to physicians, but not to nurses. In many instances, problems originated from local implementation strategies developed in response to national PM definitions and policies. Some noted benefits of PMs included feedback from the system helping some clinic staff feel more confident that their care was thorough, and performance scores as a source of pride and positive competition. VA is currently making changes to the national PM system based on this and other research, e.g., developing new PMs that reward clinically appropriate action, even if the patient has not achieved specific targets, and developing clinical reminders that facilitate patient-centered decisions. Date: October 13, 2011 Women’s Health Issues Journal Focuses on Women Veterans This special issue of Women’s Health Issues includes 18 peer-reviewed manuscripts summarizing health services research findings about women Veterans and women in the military, framed in the context of informing evidence-based practice and policy. Highlights include: VA has tailored primary care to women through the use of designated providers or separate women’s clinics. VA’s with these clinics were rated higher on most dimensions of care. These findings are particularly important to VA’s current implementation of patient-aligned care teams (PACTs). More than half of VA facilities now offer one or more mental healthcare services specifically for women Veterans, including services embedded within women’s primary care clinics, designation of women’s healthcare providers within general mental health clinics, and/or separate women’s mental health clinics. Recent data on VA care among men and women Veterans with histories of military sexual trauma (MST) show high satisfaction with care. Authors suggest that VA’s system-wide monitoring of MST-related care may be contributing to these positive results. PTSD among women Veterans is associated with poorer occupational functioning and satisfaction, but not employment status. Symptoms of depression have substantial effects across all components of work-related quality of life, independent of PTSD symptoms. PTSD is the most common psychiatric condition among both women and men with traumatic brain injury (TBI). However, women with TBI are less likely than men to have a PTSD diagnosis, but more likely to have a depression or anxiety disorder diagnosis. Date: July 6, 2011 Medicare-Eligible Veterans’ Reliance on VA Primary and Specialty Care Decreased Significantly from 2001 through 2004 This study assessed longitudinal changes in patterns of cross-system healthcare use in VA and Medicare among Medicare-eligible Veterans who had used VA primary care in FY00. Findings showed that during the study period (FY01-FY04), 39% of all primary and specialty care visits occurred within VA, with almost three times more specialty care visits than primary care visits each year. However, a majority of specialty care and nearly half of all primary care for Medicare-eligible Veterans was provided outside VA over this time period. Reliance on both VA primary and specialty care decreased substantially over the study period but the decrease was greatest in specialty care. By FY04, only 20% of Medicare-eligible Veterans were completely reliant on Medicare for primary care (i.e., had 90% or more of their primary care visits with a Medicare provider) but 47% were completely reliant on Medicare for specialty care. Among Medicare-eligible Veterans, use of Medicare primary care increased among patients who were older, had a greater burden of illness, were served by a VA community-based outpatient clinic, or lived farther from a VA facility. Patient reductions in reliance on VA primary and specialty care suggest increasingly fragmented care and more difficult care coordination. Increasing use of non-VA services may complicate implementation of the PACT model, but also may emphasize new opportunities for care coordination initiatives within PACT. Date: June 16, 2011 Journal Section Focuses on Implementing Evidence-Based Interventions for Substance Use Disorders This article introduces a special section of Psychology of Addictive Behaviors, which provides an overview of conceptual frameworks for and research on the implementation of evidence-based practices and treatments for substance use disorders (SUDs). The types of treatments that are examined range from brief interventions to psychological treatments and continuing care to pharmacological treatment. The settings in which treatments are implemented range from primary care to specialty SUD care settings. Date: June 1, 2011 Initial Implementation of VA Primary Care Mental Health Not Associated with Differences in Specialty Mental Health Clinic Use by Veterans This study sought to determine whether the implementation of primary care mental health services is associated with differences in specialty mental health clinic use within the VA healthcare system. Findings show that the initial implementation of primary care mental health within VA is not associated with substantial differences in mental health clinic use – or diagnoses received in specialty mental health clinics by primary care patients. Facilities with primary care mental health – compared to those without – had similar rates of primary care patients initiating specialty mental health treatment (5.6% vs. 5.8%), and their primary care patients averaged similar total specialty mental health clinic visits (7.0 vs. 6.3). After adjusting for facility characteristics and multiple comparisons, there were no statistically significant differences with regard to diagnoses for Veterans who initiated specialty mental health clinic treatment at primary care mental health facilities. The authors note that primary care mental health may impact mental health clinic use over longer periods of time as these programs mature. Date: April 1, 2011 Low Follow-Up Rates for Positive TBI Screens This retrospective study evaluated VA’s TBI screening program in terms of predictors of screening and positive-screen follow-up. Findings show that almost 90% of Iraq and Afghanistan war Veterans in this study were offered TBI screening, and 17% screened positive; 52% of those screening positive had subsequent appointments in a TBI/polytrauma specialty clinic during the 18-month study period. Of 1,185 patients evaluated in a TBI/polytrauma clinic following a positive screen, 55% were given a TBI diagnosis, and of 92 patients not evaluated in a TBI/polytrauma clinic following a positive screen, 8.5% were given a TBI diagnosis. Screening likelihood increased with time since implementation of the TBI screening program and was greater at the first clinic encounter. There was considerable variation by facility; for example, Veterans seen in a VAMC were more likely to be screened than those seen in a CBOC. Screening was particularly likely to occur during TBI/polytrauma and primary care clinic appointments. Younger, male, Army Veterans without psychiatric diagnoses were more likely to be screened compared with women Veterans, Iraq/Afghanistan Veterans from other branches of the military, and those who were at least 40 years old. Date: February 11, 2011 Routine, Oral, Rapid HIV Testing in VA Emergency Departments Financially Equivalent to Usual Care Using a dynamic decision analysis model, this study examined the budget impact of implementing a routine oral HIV rapid-testing program in a VA emergency department (ED) versus the impact of following ‘usual’ care. Findings show that a routine oral HIV screening program using a rapid testing approach is financially equivalent to following a usual care approach within the VA healthcare system. Assuming a 1% prevalence of the disease and an 80% acceptance of testing, the total cost of HIV rapid-testing was $1,418,088 versus $1,320,338 for ‘usual care.’ While the HIV rapid-testing program had substantial screening costs, they were offset by lower inpatient expenses associated with earlier identification of disease. The higher treatment costs for ‘usual care’ patients were largely due to inpatient stays, reflecting more hospitalizations for these patients due to opportunistic infections. Given that early detection of HIV and linkage to treatment is associated with better health outcomes – and non-targeted testing does not result in a greater budget impact than usual care – the authors suggest that this analysis provides support for the implementation of a routine oral rapid testing program within VA. Date: January 27, 2011 VA’s Brief Alcohol Intervention Strategy Successful This study evaluated the prevalence of documented brief interventions among VA outpatients with alcohol misuse before, during, and after implementation of a national performance measure linked to incentives and dissemination of an electronic clinical reminder for brief interventions. Findings show that VA’s strategy of implementing brief alcohol interventions with a performance measure supported by a clinical reminder meaningfully increased documentation of brief interventions over a one-year period. Among Veteran outpatients with alcohol misuse, the prevalence for brief interventions increased significantly over successive phases of implementation – from 5.5% at baseline – to 7.6% after announcement of the brief intervention performance measure – to 19.1% following implementation of the measure – to 29% following dissemination of the clinical reminder. Brief interventions increased among patients without prior alcohol use disorders or addictions treatment, as well as those with recognized drinking problems, with proportionately greater increases among the former group after clinical reminder dissemination. Date: September 28, 2010 Pain Screening Implementation for Veterans Falls Short This study included surveys of Veteran outpatients and nursing staff who screened for pain during normal vital sign intake. Investigators compared pain levels documented by the nursing staff with those reported by Veterans during the study survey. Findings show that despite a longstanding mandate, pain screening implementation falls short, and informal screening is common. Although pain was evaluated in all patient encounters, less than half of the Veterans reported that the nursing staff formally rated their pain. However, the majority of the time the nursing staff’s pain documentation matched the Veteran’s subsequent report within one point on the rating scale. When differences did occur, the nursing staff under-estimated pain in 25% of the cases, and overestimated pain in 7% of the cases. Veterans with PTSD or another anxiety disorder were almost twice as likely to report higher pain levels than those documented by the nursing staff. Additionally, nursing staff were less likely to underestimate pain when the patient self-reported excellent, very good, or good health status (relative to fair or poor health status). Date: August 6, 2010 Implementation of a VA Quality Improvement Initiative Improves Knowledge and Perceptions Regarding MRSA Prevention Implementation of the initiative at 17 VAMCs was associated with temporal improvements in knowledge and perceptions regarding MRSA prevention. Between baseline and follow-up, there were increases in the number of respondents who: correctly identified that alcohol-based hand rub is more effective at inactivating MRSA than soap and water, reported cleaning their hands when entering and exiting a patient room in the past 30 days, reported using alcohol-based hand rub over soap and water when cleaning their hands, and felt comfortable reminding others about proper hand hygiene. Date: February 3, 2010 Checklist Successfully Identifies VA Environmental Hazards for Inpatient Suicide This is the first study to examine the implementation and effectiveness of the Mental Health Environment of Care Checklist to improve patient safety. Findings show that between 2007 and 2008, 7,642 environmental suicide hazards had been identified and 5,834 (76.3%) had been abated. Approximately 2% of these suicide hazards were identified as critical, and another 27% were rated as serious. The most common hazard was anchor points for hanging (44%); anchor points also presented the greatest risk level, followed by suffocation and poison. High-risk locations included bedrooms and bathrooms. Date: February 1, 2010 Implementing a Successful Fall Prevention Program for Elderly Veterans This article discusses the implementation of a Telecare fall prevention program at the VA Greater Los Angeles Healthcare System (VAGLAHS) that was designed to be sustainable. Findings show that leadership and workgroup meetings led to the development of a functional program. The Telecare fall prevention program screened its first Veteran in October 2008 and is ongoing. The program uses an existing telephone nurse advice line to: 1) place outgoing calls to Veterans at high risk of falling, 2) assess the Veterans’ risk factors, and 3) triage Veterans to the appropriate services. Because Telecare operates via the telephone, it can accept referrals from anywhere in VAGLAHS, thus reaching Veterans in geographically remote areas. The authors suggest that another potential advantage of the Telecare fall prevention program is the opportunity to unburden primary care providers of additional responsibilities by helping assess patients’ needs and arranging the appropriate services. Date: November 16, 2009 Improving Provider-Patient Communication about Routine HIV Testing in VA This study sought to understand patient and provider perspectives on the adoption of routine HIV testing within the VA healthcare system. Findings show that Veterans and providers agreed that the implementation of routine HIV testing, treating HIV like other chronic diseases, and removing requirements for written informed consent and pre-test counseling would benefit both Veterans and public health. Veterans wished to have HIV testing routinely offered by providers so that they could decide whether or not to be tested; they also believed that routine testing would help de-stigmatize HIV. Six steps for providers to use in communicating about routine testing also were identified, such as raising the topic of HIV testing, reassuring the Veteran that he/she is not showing clinical signs of the disease, and responding to Veteran questions about HIV. Date: October 1, 2009 Improving Acute Care for Elders at Risk for Poor Hospital Outcomes For patients older than age 65, traditional hospital care frequently results in adverse outcomes that increase their risk of mortality, functional dependency, and institutionalization. There are several alternative models to traditional hospital care that have been shown to address these problems and improve outcomes for older patients. One such model is VA’s Geriatric Evaluation and Management (GEM) program, which was launched in 1976 to provide interdisciplinary, multi-dimensional evaluations for elderly Veterans in need of geriatric treatment, rehabilitation, health promotion, and social service interventions. However, alternative models are not widely disseminated. This Editorial challenges healthcare providers to think outside the traditional hospital box. They suggest broadening the implementation and availability of programs such as GEM and Hospital at Home (non-VA program providing hospital-level care of elders in their own homes) for those patients who would benefit from acute care outside a hospital setting. Date: September 28, 2009 Federal Investment in Electronic Medical Records The American Recovery and Reinvestment Act (ARRA) includes $19 billion in incentives for the adoption of electronic medical records (EMRs) and $50 billion to promote health information technology. Medicare physicians adopting and making “meaningful use” of EMRs in 2011 and 2012 will be eligible for an initial payment of up to $18,000, with reduced payments in 2013 and 2014. However, current EMR systems’ inability to learn from aggregated health data has led to implementations and hospital information technology departments that can actually obstruct quality improvement. For example, much of the information contained in EMRs is formatted as unstructured free text – useful for essential individual communication but unsuitable for detecting quantifiable trends. This commentary suggests that the Department of Health and Human Services capitalize on the opportunity to mandate EMRs that have the potential to learn from data in the EMR system. Date: September 9, 2009 Resident Duty Hour Reform has No Systematic Impact on Patient Safety in Teaching Hospitals This observational study focused on patients admitted to VA and Medicare acute-care hospitals, examining changes in patient safety events in more vs. less teaching-intensive hospitals before (2000-2003) and after (2003-2005) duty hour reform. Findings show that the implementation of duty hour regulations did not have an overall systematic impact on potential safety-related events in either VA or non-VA (Medicare) hospitals of different teaching intensity. In the few cases where there were statistically significant increases in the relative odds of developing a patient safety event, the increases were too small to be clinically meaningful. Date: July 1, 2009 Comparative Effectiveness Research Initiatives Fall Short without Commitment to Implementation President Obama recently signed into law an initiative providing $1.1 billion to support research on the comparative effectiveness of drugs, medical devices, surgical procedures, and other treatments for various conditions. Although comparative effectiveness research (CER) funding has increased, the translation of this investment into practice is very slow, and little attention has been paid to a critical question: Will CER results significantly improve the quality and safety of the healthcare received by the average patient? This Editorial focuses on the issue of translating evidence into practice, as well as existing programs that can serve as models for achieving important implementation research objectives. Authors note that Federal (CER) initiatives will fall short unless they include a commitment to implementation research to help translate findings into high-quality health care. An implementation research and development program could fulfill three important objectives: 1) accelerate the translation of evidence into everyday care; 2) enhance opportunities for healthcare providers and patients to define value (balancing expected benefits with costs); and 3) provide the means for providers and patients to communicate with researchers and policymakers about clinically important issues earlier in the research process. Three programs already exist as models for achieving the aforementioned objectives: 1) VA’s Quality Enhancement Research Initiative (QUERI), 2) VA’s Center for Implementation Practice and Research Support, and 3) the Agency for Healthcare Research and Quality’s (AHRQ) John M. Eisenberg Clinical Decisions and Communications Science Center. Date: May 7, 2009 Multi-faceted Quality Improvement Intervention Improves Follow-up Colonoscopy for Veterans with Positive Colorectal Cancer Screening Test Inadequate follow-up of abnormal fecal occult blood test (FOBT) screening for colorectal cancer (CRC) may be related to patient, provider, or system-level factors. Thus, in calendar years 2004 and 2005 the Houston VAMC implemented multi-faceted quality improvement (QI) activities to improve follow-up of positive FOBT results. This study examined the effects of these activities on timeliness and appropriateness of positive-FOBT follow-up for 800 Veterans, and also identified factors that affect colonoscopy performance. Findings show that in cases where a colonoscopy was indicated, the proportion of Veterans who received timely referral and performance was significantly higher after the implementation of the QI activities. In addition, there was a significant decrease in median times to colonoscopy referral and performance. However, colonoscopy was not indicated in more than one-third of Veterans with positive FOBTs, raising concerns about current screening practices and the appropriate performance measures related to CRC screening. Date: April 1, 2009 Taking Stock: Quality Enhancement Research Initiative and Implementation Science The Quality Enhancement Research Initiative (QUERI) program and implementation research emerged at the same time – about 10 years ago. This Editorial takes stock of how much both QUERI and implementation science have grown in the intervening decade, and reflects on the opportunities and challenges ahead. Date: March 6, 2009 Quality Enhancement Research Initiative Advances Implementation Science This Editorial offers a perspective from implementation researchers outside the U.S. about VA/HSR&D’s Quality Enhancement Research Initiative (QUERI) and its impact on and contributions to implementation science. Date: March 6, 2009 Costs and Benefits of Health Information Technology The use of health information technology (HIT) has been promoted as having tremendous promise in improving the efficiency, cost-effectiveness, quality, and safety of medical care delivery. Findings from this literature review show a proliferation of patient-focused HIT applications, many of which are designed for use by patients without significant oversight by healthcare providers. Investigators believe that accelerating the adoption of HIT will require greater public-private partnerships, new policies to address the misalignment of financial incentives, and a more robust evidence base regarding HIT implementation. Date: March 1, 2009 Costs Associated with Providing Depression Care in the Primary Care Setting This study reports on organizational costs associated with depression care quality improvement, specifically introducing an evidence-based depression model – Translating Initiatives in Depression into Effective Solutions (TIDES) Project – into VA primary care settings. Findings show that organizational costs for the TIDES project (in the locations studied) were significant, and should be accounted for in planning the implementation of evidence-based depression care. Date: February 1, 2009 Hybrid Quality Improvement Approach May Be Best There is a growing consensus that a hybrid of two common approaches to quality improvement (QI) – local participatory QI and central expert QI – might be the best method for achieving quality care across a variety of conditions. This study examined preferences of frontline staff and managers participating in HSR&D’s Translating Initiatives for Depression into Effective Solutions (TIDES) project regarding how to engage in QI dialogue and provide practical suggestions for implementation. Many study participants believed that a hybrid of participatory and expert QI models might provide the best formula for improving the quality of care. Date: February 1, 2009 Successful Strategy that Engages Veterans and Families in Psychoeducation to Improve Treatment for Mental Illness Recently, VA funded 19 initiatives to implement family psychoeducation, an evidence-based practice in the treatment of psychotic disorders that results in reduced risk of relapse, remission of residual psychotic symptoms, and enhanced social and family functioning, but the implementation of such programs requires engaging mental health clinicians, consumers, and families. This paper discusses the engagement strategies used in the Reaching out to Educate and Assist Caring, Healthy Families (REACH) program, a 9-month family psychoeducation program for Veterans with serious mental illness or post-traumatic stress disorder (PTSD). Findings show that REACH has had notable success in engaging Veterans and their families, with participation rates that are comparable to those for programs requiring a much shorter commitment than 9 months, and suggest that the REACH engagement strategy may be a promising tool in recruiting Veterans and their families into family psychoeducation. Date: February 1, 2009 Quality Improvement Collaborative Improves ICU Care for Veterans This study focused on two “bundles” (ventilator bundle and central line insertion bundle) – tools designed to facilitate the application of best practices and evidence-based care at the bedside. Using these bundles, the goals were to increase adherence with specific evidence-based ICU practices, and to determine whether this would promote additional and sustained quality improvement across VISN 23. Adherence with all five elements of the ventilator bundle improved to 82% in the final three months of the intervention. The use of a central line insertion checklist to monitor adherence with the central line bundle increased to 74% in the final three months of the intervention. In addition, the implementation of the ventilator and central line bundles was associated with a reduction in rates of ventilator-associated pneumonias and catheter-related blood stream infections, respectively. Date: November 1, 2008 Program Improves Access to Mental Health Care for Veterans This article discusses the implementation and outcomes for the first four years of the “Primary Mental Health Care Clinic” (PMHC) program, an innovative program developed at one VA medical center that shifted specialized staffing into an existing mental health clinic in primary care and added advanced clinical access in primary care. Waiting time for new appointments was shortened from a mean of 33 days to 19 minutes. Clinician productivity and evaluations of new referrals more than doubled. In addition, the program has reduced the number of veterans referred into the specialized mental health clinic, thus conserving resources. Date: November 1, 2008

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