Factors associated with primary care physician turnover in the VA.

Objectives: To quantify the association between primary care team workload satisfaction and primary care physician (PCP) turnover and examine potential mediation of workplace climate factors using survey and administrative data. Study Design: Longitudinal observational study using data from 2008 to 2016. Methods: The outcome variable was PCP turnover. The main explanatory variable was satisfaction with amount of workload. We included 7 additional workplace climate measures (eg, satisfaction with direct supervision) as mediators. We included characteristics of PCPs (eg, PCP years of experience, gender), salary, and clinic factors (eg, urban vs rural geography, community vs hospital based) as covariates. Results: US Department of Veterans Affairs (VA) PCPs working at 787 VA primary care clinics nationally were recruited for this study. Over the 9-year study period, 8362 unique PCPs were employed in the VA. The unadjusted mean quarterly turnover rate was 1.83%, and the mean (SD) workload satisfaction score was 3.58 ( 0.24) on a 5-point Likert scale over the study period. In adjusted analysis, a 1-point increase in workload satisfaction was associated with a decrease of 0.73 (95% CI, 0.36-1.10) percentage points in the probability of turnover in a calendar quarter. In the mediation analysis, we found that workload satisfaction impacted turnover through only 1 of the 7 workplace climate measures: satisfaction with direction by senior managers. Conclusions: Our study findings highlight the key role that achieving primary care workload satisfaction can play in reducing PCP turnover. Identification of direction by senior managers as an underlying mechanism is an important finding for strategic planning to mitigate PCP turnover.

Characteristics of Veterans With Depression Who Use the Veterans Choice Program of the Veterans Health Administration.

OBJECTIVE: The Veterans Choice Program (VCP) of the Veterans Health Administration (VHA) allowed eligible veterans to use their benefits with participating providers outside the VHA. The authors aimed to identify characteristics of veterans with depression who used or did not use mental health care through the VCP. METHODS: In this cross-sectional study, the authors analyzed secondary data from the national VHA Corporate Data Warehouse. VHA administrative data were linked with VCP claims to examine characteristics of VCP-eligible veterans with depression. The study sample included 595,943 unique veterans who were enrolled in the VHA before 2013, were eligible for the VCP in 2016, were alive in 2018, and had an assessed Patient Health Questionnaire-9 (PHQ-9) score or depressive disorder diagnosis documented in the VHA between 2016 and 2018. RESULTS: Veterans who used the VCP had lower medical comorbidity scores and lived in less socioeconomically disadvantaged counties, compared with veterans who received only VHA care. VCP veterans were also more likely to have a PHQ-9 score assessment and to have higher mean depression scores. Mean counts of annual mental health visits per 1,000 veterans were markedly higher for direct VHA care than for care provided via the VCP. As a percentage of the total counts of visits per 1,000 veterans across the VCP and VHA, residential programs and outpatient procedures were the services that were most frequently delivered through the VCP. CONCLUSIONS: Between 2016 and 2018, the VCP was used primarily to augment mental health care provided by the VHA, rather than to fill a gap in care.

Identifying Individual and Clinic Characteristics Associated With Primary Care Provider Turnover During Implementation of the Veterans Health Administration Patient-Centered Medical Home.

Understanding which factors predict primary care provider (PCP) turnover can help organizations prepare for PCP shortages. We conducted a retrospective cohort study of Veteran Health Administration PCPs between 2012 and 2016. We analyzed whether 7 domains of the patient centered medical home (PCMH) implementation-including access, care coordination, comprehensiveness, self-management support, communication, shared decision-making, and team-based care-were associated with PCP turnover. We found that 2 domains of PCMH (access and self-management) were associated with lower turnover, which may reflect that practice cultures that support these characteristics may lower PCP turnover.

A Novel Gap Staffing Metric for Primary Care in the Veterans Health Administration and Implications for Rural and Urban Clinics.

Primary care providers (PCPs), including physicians and advanced practice providers, are the front line of medical care. Patient access must balance PCP availability and patient needs. This work develops a new PCP staffing metric using panel size and full-time equivalent data to determine whether a clinic is adequately staffed and describes variation by clinic rurality. Data were from the Veterans Health Administration, 2017-2021. Results describe the gap staffing metric, provide summary graphics, and compare the gap staffing between rural and urban clinics. This novel gap staffing metric can inform strategic clinic staffing in health care systems.

How Did Veterans' Reliance on Veterans Health Administration Outpatient Care Change After Expansion of the Veterans Community Care Program?

BACKGROUND: The Veterans Community Care Program (VCCP) aims to address access constraints in the Veterans Health Administration (VA) by reimbursing care from non-VA community providers. Little existing research explores how veterans' choice of VA versus VCCP providers has evolved as a significant VCCP expansion in 2014 as part of the Veterans Access, Choice, and Accountability Act. OBJECTIVES: We examined changes in reliance on VA for primary care (PC), mental health (MH), and specialty care (SC) among VCCP-eligible veterans. RESEARCH DESIGN: We linked VA administrative data with VCCP claims to retrospectively examine utilization during calendar years 2016-2018. SUBJECTS: 1.78 million veterans enrolled in VA before 2013 and VCCP-eligible in 2016 due to limited VA capacity or travel hardship. MEASURES: We measured reliance as the proportion of total annual outpatient (VA+VCCP) visits occurring in VA for PC, MH, and SC. RESULTS: Of the 26.1 million total outpatient visits identified, 45.6% were for MH, 29.9% for PC, and 24.4% for SC. Over the 3 years, 83.2% of veterans used any VA services, 23.8% used any VCCP services, and 20.0% were dual VA-VCCP users. Modest but statistically significant declines in reliance were observed from 2016-2018 for PC (94.5%-92.2%), and MH (97.8%-96.9%), and a more significant decline was observed for SC (88.5%-79.8%). CONCLUSIONS: Veterans who have the option of selecting between VA or VCCP providers continued using VA for most of their outpatient care in the initial years after the 2014 VCCP expansion.

Perspectives on Training and Working in the VHA: Implications for Primary Care Physician Recruitment and Retention.

PURPOSE: The primary care physician shortage in the United States presents significant challenges for health systems seeking to maintain a sufficient primary care workforce. Perspectives on training or working in primary care in the Veterans Health Administration (VHA) may yield insights into strategic recruitment to make the VHA and other health systems more attractive to primary care physicians. The authors sought to understand the experiences of resident and staff physicians with limited tenure within VHA primary care to identify factors to guide health systems in improving recruitment and retention. METHOD: This qualitative exploratory study was conducted from June 2018 to October 2019 with 24 internal medicine residents and 30 staff physicians in VHA primary care. Heterogeneity was ensured by sampling for geographical region, rurality, and gender within each cohort. The authors conducted semistructured interviews to ascertain perspectives on training and employment preferences at VHA and non-VHA sites. Combined content analysis was used to generate findings. RESULTS: The authors identified 4 key themes, centered around shared values and the VHA's mission-driven culture: the VHA "community" was perceived as unique and a major contributor to job satisfaction; facility-level leadership support was important to perceptions of workplace culture around harassment; the VHA primary care delivery model allowed residents and staff physicians to get patients needed care but did not always live up to its potential; and VHA employment was better than expected, but the process of getting hired was a challenge. CONCLUSIONS: Mission and workplace culture may serve important roles in the desirability of health systems for prospective physicians and the job satisfaction of physicians who work in these systems. Physician recruitment efforts based on these attributes may yield the most success in maintaining a sufficient physician workforce.

Identifying and Prioritizing Workplace Climate Predictors of Burnout Among VHA Primary Care Physicians.

OBJECTIVE: Burnout, or job-related stress, affects more than half of all US physicians, with primary care physicians (PCPs) experiencing some of the highest rates in medicine. Our study analyzes national survey data to identify and prioritize workplace climate predictors of burnout among PCPs within a large integrated health system. DESIGN: Observational study of annual survey data from the Veterans Health Administration (VHA) All Employee Survey (AES) for 2013-2017. AES response rate ranged from 56 to 60% during the study period. Independent and dependent variables were measured from separate random samples. In total, 8,456 individual-level responses among PCPs at 110 VHA practice sites were aggregated at the facility level by reporting year. We used the semi-automated LASSO procedure to identify workplace climate measures that were more influential in predicting burnout and assessed relative importance using the Shapely value decomposition. PARTICIPANTS: VHA employees that self-identify as PCPs. MAIN MEASURES: Dependent variables included two dichotomous measures of burnout: emotional exhaustion and depersonalization. Independent measures included 30 survey measures related to dimensions of workplace climate (e.g., workload, leadership, satisfaction). RESULTS: We identified seven influential workplace climate predictors of emotional exhaustion and nine predictors of depersonalization. With few exceptions, higher agreement/satisfaction scores for predictors were associated with a lower likelihood of burnout. The majority of explained variation in emotional exhaustion was attributable to perceptions of workload (32.6%), organization satisfaction (28.2%), and organization support (19.4%). The majority of explained variation in depersonalization was attributable to workload (25.3%), organization satisfaction (22.9%), and connection to VHA mission (20.7%). CONCLUSION: Identifying the relative importance of workplace climate is important for the allocation of health organization resources to mitigate and prevent burnout within the PCP workplace. In a context of limited resources, efforts to reduce perceived workload and improve organization satisfaction may represent the biggest leverage points for health organizations to address physician burnout.

Prescription opioid overdose and adverse effect hospitalisations among injured workers in eight states (2010-2014).

OBJECTIVE: High-risk opioid prescribing practices in workers' compensation (WC) settings are associated with excess opioid-related morbidity, longer work disability and higher costs. This study characterises the burden of prescription opioid-related hospitalisations among injured workers. METHODS: Hospital discharge data for eight states (Arizona, Colorado, Michigan, New Jersey, New York, South Carolina, Utah and Washington) were obtained from the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. We calculated 5-year (2010-2014) average annual rates of prescription opioid overdose/adverse effect (AE) hospitalisations. Injured workers were identified using payer (WC) and external cause codes. RESULTS: State-level average annual prescription opioid overdose/AE hospitalisation rates ranged from 0.3 to 1.2 per 100 000 employed workers. Rates for workers aged ≥65 years old were two to six times the overall rates. Among those hospitalised with prescription opioid overdose/AEs, injured workers were more likely than other inpatients to have a low back disorder diagnosis, and less likely to have an opioid dependence/abuse or cancer diagnosis, or a fatal outcome. Averaged across states, WC was the primary expected payer for <1% of prescription opioid overdose/AE hospitalisations vs 6% of injury hospitalisations. CONCLUSIONS: Population-based estimates of prescription opioid morbidity are almost nonexistent for injured workers; this study begins to fill that gap. Rates for injured workers increased markedly with age but were low relative to inpatients overall. Research is needed to assess whether WC as payer adequately identifies work-related opioid morbidity for surveillance purposes, and to further quantify the burden of prescription opioid-related morbidity.

Opioid-Prescribing Metrics in Washington State: Trends and Challenges.

CONTEXT: Analyses of prescribing trends using prescription drug monitoring programs (PDMP) are impacted by changes in reporting requirements and in the scheduling of medications by the Drug Enforcement Administration. In 2014, the Drug Enforcement Administration changed the status of tramadol from an unscheduled to a scheduled medication. The addition of tramadol to the PDMP may affect the prevalence of opioid-prescribing metrics and the interpretation of prescribing trends. OBJECTIVE: The objectives were to (1) examine trends in opioid prescribing in Washington State between 2012 and 2017, (2) assess the potential impact of adding tramadol to PDMP on these trends, and (3) describe challenges in defining and implementing opioid-prescribing metrics. DESIGN: Analysis of quarterly summary statistics of opioid prescribing. SETTING: Washington State. PARTICIPANTS: Washington State residents. MAIN OUTCOME MEASURES: The metrics include measures of opioid prescribing overall and by age group, chronic opioid prescribing, high-dose prescribing among those on chronic opioid therapy, prescribing of concurrent opioids and sedatives, days' supply of new opioid prescriptions, and transition from short-term to long-term use of opioids. RESULTS: In Washington, the prevalence of any opioid prescribing, chronic opioid prescribing, high-dose opioid prescribing, and prescribing of concurrent opioids and sedatives declined between 2012 and 2017. The prevalence of opioid prescribing was higher in older than in younger age groups. The addition of tramadol to the Washington PDMP in 2014 affected the observed prevalence of all opioid metrics and of all opioid-prescribing trends. Conclusions about trends in opioid prescribing differ substantially depending on whether tramadol is included or not, particularly in 2014 and 2015. CONCLUSIONS: The development of opioid-prescribing metrics is relatively new. There is likely much benefit of standard definitions of opioid metrics at the state and national levels to track important trends and compare progress from state to state.

Physical Activity Support Predicts Safety-Net Patients' Digital Health-Care Engagement: Implications for Patient Care Delivery.

PURPOSE: Assess relationship among health services received and patients' digital health-care engagement. DESIGN: Quantitative cross-sectional survey study. SETTING: Community health centers in Washington state and DC. SAMPLE: N = 164 adult safety-net patients. INTERVENTION: Not applicable. MEASURES: Outcomes were knowledge and use of health apps. Predictors were health service access (access to specialists and health information); health service delivery (healthy eating and physical activity counsel); health service satisfaction; and perceived service value. ANALYSIS: Descriptive and multivariate regression analyses. Odds ratios (OR) reported for 95% confidence interval (CI). RESULTS: Response rate was 35%. Of all, 71% were knowledgeable of smartphone use for wellness and 48% used health apps. Physical activity (PA) counseling predicted knowledge and health apps use. Respondents receiving PA counseling were 2.61 times more likely to be knowledgeable about using smartphones for health promotion (OR = 2.61; P = .047; 95% CI: 1.01-6.73). Respondents receiving PA counseling were 2.89 times more likely to use health apps (OR = 2.89; P = .022; 95% CI: 1.17-7.17). Health information access predicted health apps use; respondents with easy access to general health information were 0.29 times as likely to use health apps (OR = 0.29; P = .043; 95% CI: 0.09-0.96). CONCLUSION: Targeted preventive care support encourages digital health-care engagement. mHealth may supplement health-care needs outside clinics.

On-Demand Telemedicine as a Disruptive Health Technology: Qualitative Study Exploring Emerging Business Models and Strategies Among Early Adopter Organizations in the United States.

BACKGROUND: On-demand telemedicine is increasingly adopted by health organizations to meet patient demand for convenient, accessible, and affordable services. Little guidance is currently available to new entrant organizations as they consider viable business models and strategies to harness the disruptive potential of on-demand telemedicine services (in particular, virtual urgent care clinics [VCCs] as a predominant and catalyst form of on-demand telemedicine). OBJECTIVE: We recognized on-demand telemedicine as a disruptive technology to explore the experiences of early adopter organizations as they launch on-demand telemedicine services and deploy business models and strategies. Focusing on VCC service lines, this study addressed the following research questions: (1) what is the emerging business model being deployed for on-demand telemedicine?; (2) what are the core components of the emerging business model for on-demand telemedicine?; and (3) what are the disruptive business strategies employed by early adopter organizations as they launch on-demand telemedicine services? METHODS: This qualitative study gathered data from 32 semistructured phone interviews with key informants from 19 VCC early adopter organizations across the United States. Interview protocols were developed based on noted dissemination and implementation science frameworks. We used the constant comparison method to transform study data into stable dimensions that revealed emerging business models, core business model components (value proposition, key resources, key processes, and profit formula), and accompanying business strategies. RESULTS: Early adopters are deploying business models that most closely align with a value-adding process model archetype. By and large, we found that this general model appropriately matches resources, processes, and profit formulas to support the disruptive potential of on-demand telemedicine. In total, 4 business strategy areas were discovered to particularly contribute to business model success for on-demand disruption among early adopters: fundamental disruptions to the model of care delivery; outsourcing support for on-demand services; disruptive market strategies to target potential users; and new and unexpected organizational partnerships to increase return on investment. CONCLUSIONS: On-demand telemedicine is a potentially disruptive innovation currently in the early adopter stage of technology adoption and diffusion. On-demand telemedicine must cross into the early majority stage to truly be a positive disruption that will increase accessibility and affordability for health care consumers. Our findings provide guidance for adopter organizations as they seek to deploy viable business models and successful strategies to smooth the transition to early majority status. We present important insights for both early adopters and potential early majority organizations to better harness the disruptive potential of on-demand telemedicine.

Viewing Telehealth Through the Lens of a Community Benefit Mission.

INTRODUCTION: This article reviews the intersection of common objectives between telehealth initiatives launched by health systems and community health (specifically community benefit). Telehealth initiatives can benefit communities and play a potential role in improving population health. There is great opportunity to better integrate telehealth activities into community health strategies and community benefit reporting (for nonprofit hospitals) while building the case for telehealth service expansion. METHODS: Through descriptive, hypothetical cases, we demonstrate the intersection of the triple aim, specifically improving population-level health, and three common objectives between telehealth and community benefit: (1) improving access to care, (2) enhancing community health, and (3) advancing medical or healthcare knowledge. CONCLUSIONS: This article is intended to spur inspiration for possible telehealth and community health/community benefit connections.

Health Literacy INDEX: development, reliability, and validity of a new tool for evaluating the health literacy demands of health information materials.

There is no consensus on how best to assess the health literacy demands of health information materials. Comprehensive, reliable, and valid assessment tools are needed. The authors report on the development, refinement, and testing of Health Literacy INDEX, a new tool reflecting empirical evidence and best practices. INDEX is comprised of 63 indicators organized into 10 criteria: plain language, clear purpose, supporting graphics, user involvement, skill-based learning, audience appropriateness, user instruction, development details, evaluation methods, and strength of evidence. In a sample of 100 materials, intercoder agreement was high: 90% or better for 52% of indicators, and above 80% for nearly all others. Overall scores generated by INDEX were highly correlated with average ratings from 12 health literacy experts (r = 0.89, p < .0001). Additional research is warranted to examine the association between evaluation ratings generated by INDEX and individual understanding, behaviors, and improved health. Health Literacy INDEX is a comprehensive tool with evidence for reliability and validity that can be used to evaluate the health literacy demands of health information materials. Although improvement in health information materials is just one aspect of mitigating the effects of limited health literacy on health outcomes, it is an essential step toward a more health literate public.