Primary sources of health care among LGBTQ+ veterans: Findings from the Behavioral Risk Factor Surveillance System.

OBJECTIVE: This study examined the primary source of health care between veterans with lesbian, gay, bisexual, queer and similar identities (LGBTQ+) and non-LGBTQ+ veterans. DATA SOURCES AND STUDY SETTING: Veterans (N = 20,497) from 17 states who completed the CDC's Behavioral Risk Factor Surveillance System from 2016 to 2020, including the Sexual Orientation and Gender Identity and Health Care Access modules. STUDY DESIGN: We used survey-weighted multiple logistic regression to estimate average marginal effects of the prevalence of utilization of Veteran's Health Administration (VHA)/military health care reported between LGBTQ+ and non-LGBTQ+ veterans. Prevalence estimates were adjusted for age group, sex, race and ethnicity, marital status, educational attainment, employment status, survey year, and US state. DATA COLLECTION METHODS: Study data were gathered via computer-assisted telephone interviews with probability-based samples of adults aged 18 and over. Data are publicly available. PRINCIPAL FINDINGS: Overall, there was not a statistically significant difference in estimated adjusted prevalence of primary use of VHA/military health care between LGBTQ+ and non-LGBTQ+ veterans (20% vs. 23%, respectively, p = 0.13). When examined by age group, LGBTQ+ veterans aged 34 and younger were significantly less likely to report primary use of VHA/military health care compared to non-LGBTQ+ veterans (25% vs. 44%, respectively; p = 0.009). Similarly, in sex-stratified analyses, fewer female LGBTQ+ veterans than female non-LGBTQ+ veterans reported VHA/military health care as their primary source of care (13% vs. 29%, respectively, p = 0.003). Implications and limitations to these findings are discussed. CONCLUSIONS: Female and younger LGBTQ+ veterans appear far less likely to use VHA/military for health care compared to their cisgender, heterosexual peers; however, because of small sample sizes, estimates may be imprecise. Future research should corroborate these findings and identify potential reasons for these disparities.

Evaluation of a collaborative VA network initiative to reduce racial disparities in blood pressure control among veterans with severe hypertension.

BACKGROUND: Compared to White patients in the United States, Black patients have a higher prevalence of hypertension and more severe forms of this condition. OBJECTIVE: To decrease racial disparities in blood pressure (BP) control among Black veterans with severe hypertension within a regional network of Veterans Affairs Medical Centers (VAMCs). METHODS: Health system leaders, clinicians, and health services researchers collaborated on a 12-month quality improvement (QI) project to: (1) examine project implementation and the QI strategies used to improve BP control and (2) assess the effect of the initiative on Black-White differences in BP control among veterans with severe hypertension. RESULTS: Within 9 participating VAMCs, the most frequently used QI strategies involved provider education (n=9), provider audit and feedback (n=8), and health care team change (n=7). Among 141,124 veterans with a diagnosis of hypertension, 9,913 had severe hypertension [2,533 (25.6%) Black and 7380 (74.4%) White]. Over the course of the project, the proportion of Black veterans with severe hypertension decreased from 7.5% to 6.6% (p=.002) and the racial difference in proportions for this condition decreased 0.9 percentage points, from 2.9% to 2.0% (p=.01). CONCLUSIONS: A multicenter, equity-focused QI project in VA reduced the proportion of Black veterans with severe hypertension and ameliorated observed racial disparities for this condition. Embedding health services researchers within a QI team facilitated an evaluation of the processes and effectiveness of our initiative, providing a successful model for QI within a learning health care system.

National Media Coverage of the Veterans Affairs Waitlist Scandal: Effects on Veterans' Distrust of the VA Health Care System.

BACKGROUND: On April 23, 2014, US media outlets broadcast reports of excessive wait times and "secret" waitlists at some Veterans Affairs (VA) hospitals, precipitating legislation to increase Veterans' access to private sector health care. OBJECTIVE: The aims were to assess changes in Veterans' distrust in the VA health care system before and after the media coverage and explore sex and racial/ethnic differences in the temporal patterns. METHODS: Veterans completed semistructured interviews on health care satisfaction from June 2013 to January 2015, including a validated scale of health system distrust (range: 1-5). We used linear splines with knots at 90-day intervals to assess changes in distrust before and after April 23, 2014 ("day 0") in linear mixed models. To explore sex and racial/ethnic differences in temporal patterns, we stratified models by sex and tested for interactions of race/ethnicity with time. RESULTS: For women (n=600), distrust scores (mean=2.09) increased by 0.45 in days 0-90 (P<0.01), then decreased by 0.45 in days 90-180 (P<0.01). Among men (n=575), distrust scores (mean=2.05) increased by 0.18 in days 0-90 (P=0.059). Distrust levels were significantly higher for Black versus White women (time adjusted mean difference=0.21) and for Black and Hispanic versus White men (differences=0.26 and 0.18). However, the temporal patterns did not vary by race/ethnicity for women or men (interaction P=0.85 and 0.21, respectively). CONCLUSIONS: Health system distrust increased in women following media coverage of VA access problems and was higher in Black/Hispanic versus White Veterans at all time periods. Such perceptions could influence Veteran decisions to seek health care in the community rather than VA.

Veteran Satisfaction with Early Experiences of Health Care Through the Veterans Choice Program: a Concurrent Mixed Methods Study.

BACKGROUND: The 2014 Veterans Access, Choice and Accountability Act (i.e., "Choice") allows eligible Veterans to receive covered health care outside the Veterans Affairs (VA) Healthcare System. The initial implementation of Choice was challenging, and use was limited in the first year. OBJECTIVE: To assess satisfaction with Choice, and identify reasons for satisfaction and dissatisfaction during its early implementation. DESIGN AND PARTICIPANTS: Semi-structured telephone interviews from July to September 2015 with Choice-eligible Veterans from 25 VA facilities across the USA. MAIN MEASURES: Satisfaction was assessed with 5-point Likert scales and open-ended questions. We compared ratings of satisfaction with Choice and VA health care, and identified reasons for satisfaction/dissatisfaction with Choice in a thematic analysis of open-ended qualitative data. RESULTS: Of 195 participants, 35 had not attempted to use Choice; 43 attempted but had not received Choice care (i.e., attempted only); and 117 attempted and received Choice care. Among those who attempted only, a smaller percentage were somewhat/very satisfied with Choice than with VA health care (17.9% and 71.8%, p < 0.001); among participants who received Choice, similar percentages were somewhat/very satisfied with Choice and VA health care (66.6% and 71.1%, p = 0.45). When asked what contributed to Choice ratings, participants who attempted but did not receive Choice care reported poor access (50%), scheduling problems (20%), and care coordination issues (10%); participants who received Choice care reported improved access (27%), good quality of care (19%), and good distance to Choice provider (16%). Regardless of receipt of Choice care, most participants expressed interest in using Choice in the future (70-82%). CONCLUSIONS: Access and scheduling barriers contributed to dissatisfaction for Veterans unsuccessfully attempting to use Choice during its initial implementation, whereas improved access and good care contributed to satisfaction for those receiving Choice care. With Veterans' continued interest in using services outside VA facilities, subsequent policy changes should address Veterans' barriers to care.

Racial, Ethnic, and Gender Equity in Veteran Satisfaction with Health Care in the Veterans Affairs Health Care System.

BACKGROUND: Patient satisfaction is an important dimension of health care quality. The Veterans Health Administration (VA) is committed to providing high-quality care to an increasingly diverse patient population. OBJECTIVE: To assess Veteran satisfaction with VA health care by race/ethnicity and gender. DESIGN AND PARTICIPANTS: We conducted semi-structured telephone interviews with gender-specific stratified samples of black, white, and Hispanic Veterans from 25 predominantly minority-serving VA Medical Centers from June 2013 to January 2015. MAIN MEASURES: Satisfaction with health care was assessed in 16 domains using five-point Likert scales. We compared the proportions of Veterans who were very satisfied, somewhat satisfied, and less than satisfied (i.e., neither satisfied nor dissatisfied, somewhat dissatisfied, or very dissatisfied) in each domain, and used random-effects multinomial regression to estimate racial/ethnic differences by gender and gender differences by race/ethnicity. KEY RESULTS: Interviews were completed for 1222 of the 1929 Veterans known to be eligible for the interview (63.3%), including 421 white, 389 black, and 396 Hispanic Veterans, 616 of whom were female. Veterans were less likely to be somewhat satisfied or less than satisfied versus very satisfied with care in each of the 16 domains. The highest satisfaction ratings were reported for costs, outpatient facilities, and pharmacy (74-76% very satisfied); the lowest ratings were reported for access, pain management, and mental health care (21-24% less than satisfied). None of the joint tests of racial/ethnic or gender differences in satisfaction (simultaneously comparing all three satisfaction levels) was statistically significant (p > 0.05). Pairwise comparisons of specific levels of satisfaction revealed racial/ethnic differences by gender in three domains and gender differences by race/ethnicity in five domains, with no consistent directionality across demographic subgroups. CONCLUSIONS: Our multisite interviews of a diverse sample of Veterans at primarily minority-serving sites showed generally high levels of health care satisfaction across 16 domains, with few quantitative differences by race/ethnicity or gender.

How Are Race, Cultural, and Psychosocial Factors Associated With Outcomes in Veterans With Spinal Cord Injury?

OBJECTIVE: To understand the role of cultural and psychosocial factors in the outcomes of veteran wheelchair users with spinal cord injury (SCI) to help clinicians identify unique factors faced by their patients and help researchers identify target variables for interventions to reduce disparities in outcomes. DESIGN: Cross-sectional cohort study. SETTING: Three urban Veterans Affairs medical centers affiliated with academic medical centers. PARTICIPANTS: Of the patients (N=516) who were eligible to participate, 482 completed the interview and 439 had SCI. Because of small numbers in other race groups, analyses were restricted to white and African American participants, resulting in a final sample of 422. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Quality of life (QOL, Veterans RAND 12-Item Health Survey); satisfaction (Client Satisfaction Questionnaire); and participation (Craig Handicap Assessment and Reporting Technique Short Form). RESULTS: African American Veterans reported poorer physical QOL but better mental QOL than did white Veterans. No other significant race differences were found in unadjusted analyses. Multivariable analyses showed that psychosocial factors were predominantly associated with patients' QOL outcomes and satisfaction with service, but demographic and medical factors were predominantly associated with participation outcomes. Interaction analyses showed that there was a stronger negative association between anxiety and mental QOL for African Americans than for whites, and a positive association between higher self-esteem and social integration for whites but not African Americans. CONCLUSIONS: Findings suggest that attempts to improve the outcomes of Veterans with SCI should focus on a tailored approach that emphasizes patients' demographic, medical, and psychosocial assets (eg, building their sense of self-esteem or increasing their feelings of mastery), while providing services targeted to their specific limitations (eg, reducing depression and anxiety).

Quality and Equity in Wheelchairs Used by Veterans.

OBJECTIVES: To assess in Veterans with spinal cord injury (SCI) or amputated limb (AL) the following: (1) patient demographics, medical factors, cultural and psychosocial characteristic by race; (2) wheelchair quality by race; and (3) the independent associations of patient race and the other factors with wheelchair quality. DESIGN: Cross-sectional cohort study. SETTING: Three Department of Veterans Affairs (VA) medical centers affiliated with academic medical centers. PARTICIPANTS: Eligible participants were Veterans with SCI or ALs (N=516); 482 of them completed the interview. Analyses were restricted to white and African American participants. Because there was no variation in wheelchair quality among AL patients (n=42), they were excluded from all but descriptive analyses, leading to a final sample size of 421. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Wheelchair quality as defined by the Medicare Healthcare Common Procedure Coding System. RESULTS: We found race differences in many of our variables, but not in quality for manual (odds ratio [OR]=.67; 95% confidence interval [CI], .33-1.36) or power (OR=.82; 95% CI, .51-1.34) wheelchairs. Several factors including age (OR=.96; 95% CI, .93-.99) and income (OR=3.78; 95% CI, 1.43-9.97) were associated with wheelchair quality. There were no significant associations of cultural or psychosocial factors with wheelchair quality. CONCLUSIONS: Although there were no racial differences in wheelchair quality, we found a significant association of older age and lower income with poorer wheelchair quality among Veterans. Efforts are needed to raise awareness of such disparities among VA wheelchair providers and to take steps to eliminate these disparities in prescription practice across VA sites.

Physical activity counseling in overweight and obese primary care patients: Outcomes of the VA-STRIDE randomized controlled trial.

The purpose of this 2-arm randomized clinical trial was to evaluate the effectiveness of a 12-month, expert system-based, print-delivered physical activity intervention in a primary care Veteran population in Pittsburgh, Pennsylvania. Participants were not excluded for many health conditions that typically are exclusionary criteria in physical activity trials. The primary outcome measures were physical activity reported using the Community Healthy Activities Model Program for Seniors (CHAMPS) questionnaire and an accelerometer-based activity assessment at baseline, 6, and 12 months. Of the 232 Veterans enrolled in the study, 208 (89.7%) were retained at the 6-month follow-up and 203 (87.5%) were retained at 12 months. Compared to the attention control, intervention participants had significantly increased odds of meeting the U.S. recommended guideline of ≥ 150 min/week of at least moderate-intensity physical activity at 12 months for the modified CHAMPS (odds ratio [OR] = 2.86; 95% CI: 1.03-7.96; p = 0.04) but not at 6 months (OR = 1.54; 95% CI: 0.56-4.23; p = 0.40). Based on accelerometer data, intervention participants had significantly increased odds of meeting ≥ 150 min/week of moderate-equivalent physical activity at 6 months (OR = 6.26; 95% CI: 1.26-31.22; p = 0.03) and borderline significantly increased odds at 12 months (OR = 4.73; 95% CI: 0.98-22.76; p = 0.053). An expert system physical activity counseling intervention can increase or sustain the proportion of Veterans in primary care meeting current recommendations for moderate-intensity physical activity. Trial Registration Clinical trials.gov identifier: NCT00731094 URL: http://www.clinicaltrials.gov/ct2/show/NCT00731094.

Veteran, primary care provider, and specialist satisfaction with electronic consultation.

BACKGROUND: Access to specialty care is challenging for veterans in rural locations. To address this challenge, in December 2009, the Veterans Affairs (VA) Pittsburgh Healthcare System (VAPHS) implemented an electronic consultation (e-consult) program to provide primary care providers (PCPs) and patients with enhanced specialty care access. OBJECTIVE: The aim of this quality improvement (QI) project evaluation was to: (1) assess satisfaction with the e-consult process, and (2) identify perceived facilitators and barriers to using the e-consult program. METHODS: We conducted semistructured telephone interviews with veteran patients (N=15), Community Based Outpatient Clinic (CBOC) PCPs (N=15), and VA Pittsburgh specialty physicians (N=4) who used the e-consult program between December 2009 to August 2010. Participants answered questions regarding satisfaction in eight domains and identified factors contributing to their responses. RESULTS: Most participants were white (patients=87%; PCPs=80%; specialists=75%) and male (patients=93%; PCPs=67%; specialists=75%). On average, patients had one e-consult (SD 0), PCPs initiated 6 e-consults (SD 6), and VAPHS specialists performed 17 e-consults (SD 11). Patients, PCPs, and specialty physicians were satisfied with e-consults median (range) of 5.0 (4-5) on 1-5 Likert-scale, 4.0 (3-5), and 3.5 (3-5) respectively. The most common reason why patients and specialists reported increased overall satisfaction with e-consults was improved communication, whereas improved timeliness of care was the most common reason for PCPs. Communication was the most reported perceived barrier and facilitator to e-consult use. CONCLUSIONS: Veterans and VA health care providers were satisfied with the e-consult process. Our findings suggest that while the reasons for satisfaction with e-consult differ somewhat for patients and physicians, e-consult may be a useful tool to improve VA health care system access for rural patients.

Racial Differences in Satisfaction with VA Health Care: A Mixed Methods Pilot Study.

INTRODUCTION: As satisfied patients are more adherent and play a more active role in their own care, a better understanding of factors associated with patient satisfaction is important. PURPOSE: In response to a United States Veterans Administration (VA) Hospital Report Card that revealed lower levels of satisfaction with health care for African Americans compared to Whites, we conducted a mixed methods pilot study to obtain preliminary qualitative and quantitative information about possible underlying reasons for these racial differences. METHODS: We conducted telephone interviews with 30 African American and 31 White veterans with recent inpatient and/or outpatient health care visits at three urban VA Medical Centers. We coded the qualitative interviews in terms of identified themes within defined domains. We summarized racial differences using ordinal logistic regression for Likert scale outcomes and used random effects logistic regression to assess racial differences at the domain level. RESULTS: Compared to Whites, African Americans were younger (p < 0.001) and better educated (p = 0.04). Qualitatively, African Americans reported less satisfaction with trust/confidence in their VA providers and healthcare system and less satisfaction with patient-provider communication. Quantitatively, African Americans reported less satisfaction with outpatient care (odds ratio = 0.28; 95 % confidence interval (CI) 0.10-0.82), but not inpatient care. At the domain level, African Americans were significantly less likely than Whites to express satisfaction themes in the domain of trust/confidence (odds ratio = 0.36; 95 % CI 0.18-0.73). CONCLUSION: The current pilot study demonstrates racial differences in satisfaction with outpatient care and identifies some specific sources of dissatisfaction. Future research will include a large national cohort, including Hispanic veterans, in order to gain further insight into the sources of racial and ethnic differences in satisfaction with VA care and inform future interventions.

Examining implicit bias of physicians who care for individuals with spinal cord injury: A pilot study and future directions.

CONTEXT: Despite evidence that healthcare providers have implicit biases that can impact clinical interactions and decisions, implicit bias among physicians caring for individuals with spinal cord injury (SCI) has not been examined. OBJECTIVE: Conduct a pilot study to examine implicit racial bias of SCI physicians and its association with functioning and wellbeing for individuals with SCI. DESIGN: Combined data from cross-sectional surveys of individuals with SCI and their SCI physicians. SETTING: Four national SCI Model Systems sites. PARTICIPANTS: Individuals with SCI (N = 162) and their SCI physicians (N = 14). OUTCOME MEASURES: SCI physicians completed online surveys measuring implicit racial (pro-white/anti-black) bias. Individuals with SCI completed questionnaires assessing mobility, physical independence, occupational functioning, social integration, self-reported health, depression, and life satisfaction. We used multilevel regression analyses to examine the associations of physician bias and outcomes of individuals with SCI. RESULTS: Physicians had a mean bias score of 0.62 (SD = 0.35), indicating a strong pro-white/anti-black bias. Greater physician bias was associated with disability among individuals with SCI in the domain of social integration (odds ratio = 4.80, 95% confidence interval (CI) = 1.44, 16.04), as well as higher depression (B = 3.24, 95% CI = 1.06, 5.41) and lower life satisfaction (B = -4.54, 95% CI= -8.79, -0.28). CONCLUSION: This pilot study indicates that SCI providers are susceptible to implicit racial bias and provides preliminary evidence that greater implicit racial bias of physicians is associated with poorer psychosocial health outcomes for individuals with SCI. It demonstrates the feasibility of studying implicit bias among SCI providers and provides guidance for future research on physician bias and patient outcomes.

Recruitment of veterans from primary care into a physical activity randomized controlled trial: the experience of the VA-STRIDE study.

BACKGROUND: Much of the existing literature on physical activity (PA) interventions involves physically inactive individuals recruited from community settings rather than clinical practice settings. Recruitment of patients into interventions in clinical practice settings is difficult due to limited time available in the clinic, identification of appropriate personnel to efficiently conduct the process, and time-consuming methods of recruitment. The purpose of this report is to describe the approach used to identify and recruit veterans from the Veterans Affairs (VA) Pittsburgh Healthcare System Primary Care Clinic into a randomized controlled PA study. METHODS: A sampling frame of veterans was developed using the VA electronic medical record. During regularly scheduled clinic appointments, primary care providers (PCPs) screened identified patients for safety to engage in moderate-intensity PA and willingness to discuss the study with research staff members. Research staff determined eligibility with a subsequent telephone screening call and scheduled a research study appointment, at which time signed informed consent and baseline measurements were obtained. RESULTS: Of the 3,482 veterans in the sampling frame who were scheduled for a primary care appointment during the study period, 1,990 (57.2%) were seen in the clinic and screened by the PCP; moderate-intensity PA was deemed safe for 1,293 (37.1%), 871 (25.0%) agreed to be contacted for further screening, 334 (9.6%) were eligible for the study, and 232 (6.7%) enrolled. CONCLUSIONS: Using a semiautomated screening approach that combined an electronically-derived sampling frame with paper and pencil prescreening by PCPs and research staff, VA-STRIDE was able to recruit 1 in 15 veterans in the sampling frame. Using this approach, a high proportion of potentially eligible veterans were screened by their PCPs. TRIAL REGISTRATION: Clinical trials.gov identifier: NCT00731094.

The associations between organizational culture and knowledge, attitudes, and practices in a multicenter Veterans Affairs quality improvement initiative to prevent methicillin-resistant Staphylococcus aureus.

BACKGROUND: Previous research demonstrates that organizational culture (OC) and knowledge, attitudes, and practices of health care personnel are associated with the overall success of infection control programs; however, little attention has been given to the relationships among these factors in contributing to the success of quality improvement programs. METHODS: Cross-sectional surveys assessing OC and knowledge, attitudes, and practices related to methicillin-resistant Staphylococcus aureus (MRSA) were distributed to 16 medical centers participating in a Veterans Affairs MRSA prevention initiative in 2 time periods. Factor analysis was performed on the OC survey responses, and factor scores were generated. To assess associations between OC and knowledge, attitudes, and practices of health care personnel, regression analyses were performed overall and then stratified by job type. RESULTS: The final analyzable sample included 2,314 surveys (43% completed by nurses, 9% by physicians, and 48% by other health care personnel). Three OC factors emerged accounting for 53% of the total variance: "Staff Engagement," "Overwhelmed/Stress-Chaos," and "Hospital Leadership." Overall, higher Staff Engagement was associated with greater knowledge scores, better hand hygiene practices, fewer reported barriers, and more positive attitudes. Higher Hospital Leadership scores were associated with better hand hygiene practices, fewer reported barriers, and more positive attitudes. Conversely, higher Overwhelmed/Stress-Chaos scores were associated with poorer reported prevention practices, more barriers, and less positive attitudes. When these associations were stratified by job type, there were significant associations between OC factors and knowledge for nurses only, between OC factors and practice items for nurses and other health care personnel, and between OC factors and the barriers and attitudes items for all job types. OC factors were not associated with knowledge and practices among physicians. CONCLUSIONS: Three OC factors-Staff Engagement, Overwhelmed/Stress-Chaos, and Hospital Leadership-were found to be significantly associated with individual health care personnel knowledge, attitudes, and self-reported practices regarding MRSA prevention. When developing a prevention intervention program, health care organizations should not only focus on the link between OC and the knowledge, attitudes, and practices of health care personnel, but also target programs based on health care personnel type to maximize their effectiveness.

The association of race, cultural factors, and health-related quality of life in persons with spinal cord injury.

OBJECTIVE: To examine the association of race and cultural factors with quality-of-life factors (participation, life satisfaction, perceived health status) in people with spinal cord injury (SCI). DESIGN: Cross-sectional multisite study using structured questionnaires. SETTING: Six National SCI Model Systems centers. PARTICIPANTS: People with SCI (N=275; age ≥16y; SCI with discernable neurologic impairments; used power or manual wheelchair for >1y as primary means of mobility; nonambulatory except for exercise purposes). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Participation (Craig Handicap Assessment and Reporting Technique Short Form); satisfaction (Satisfaction With Life Scale); and perceived health status (2 items from 36-Item Short Form Health Survey). RESULTS: African American (n=96) with SCI reported more experiences of discrimination in health care, greater perceived racism, more health care system distrust, and lower health literacy than whites (n=156; P range, <.001-<.05). Participants who reported experiencing more discrimination in health care reported better occupational functioning (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.07-2.09; P<.05). Those who perceived more racism in health care settings reported better occupational functioning (OR, 1.65; 95% CI, 1.12-2.43; P<.05) and greater perceived health (ß=.36; 95% CI, .05-.68; P<.05). Those who reported more distrust in the health care system reported better current health compared with 1 year ago (ß=.38; 95% CI, .06-.69; P<.05). Those who reported better communication with their health care provider reported higher levels of mobility (OR, 1.5; 95% CI, 1.05-2.13; P<.05) and better general health (ß=.27; 95% CI, .01-.53; P<.05). CONCLUSIONS: In this cross-sectional study of people with SCI, higher levels of perceived discrimination and racism and better communication with health care providers were associated with an increase in participation and functioning and improvements in perceptions of well-being. These associations are different from those reported in other study populations and warrant confirmation in future prospective studies.

Beyond beta: lessons learned from implementation of the Department of Veterans Affairs Methicillin-Resistant Staphylococcus aureus Prevention Initiative.

To describe the key strategies and potential pitfalls involved with implementing the Department of Veterans Affairs (VA) Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention Initiative in a qualitative evaluation, we conducted in-depth interviews with MRSA Prevention Coordinators at 17 VA beta sites at 2 time points during program implementation.

Survey of employee knowledge and attitudes before and after a multicenter Veterans' Administration quality improvement initiative to reduce nosocomial methicillin-resistant Staphylococcus aureus infections.

BACKGROUND: Although guidelines currently recommend prevention practices to decrease in-hospital transmission of infections, increasing adherence to the practices remains a challenge. This study assessed the effect of a multicenter methicillin-resistant Staphylococcus aureus (MRSA) prevention initiative on changes in employees' knowledge, attitudes, and practices. METHODS: Two cross-sectional surveys were distributed at baseline (October 2006) and follow-up (July 2007) at 17 medical centers participating in the Veterans' Administration (VA) MRSA initiative. RESULTS: Surveys were completed by 1362 employees at baseline and 952 employees at follow-up (representing 57% and 56% of eligible respondents, respectively). Respondents included physicians (9%), nurses (38%), allied health professionals (30%), and other support staff (24%). Of the 5 knowledge items, the mean proportion answered correctly increased slightly from baseline to follow-up (from 71% to 73%; P = .07). The percentage of respondents who believed that MRSA was a problem on their unit increased over time (from 56% to 65%; P < .001). Respondents also reported increased comfort with reminding other staff about proper hand hygiene (from 61% to 70%; P < .001) and contact precautions (from 63% to 70%; P < .002). The percentage of respondents reporting at least one barrier to proper hand hygiene decreased over time (from 25% to 20%; P = .003). CONCLUSIONS: In this multicenter study of VA employees, implementation of a MRSA quality improvement initiative was associated with temporal improvements in knowledge and perceptions regarding MRSA prevention.

Assessing processes of care to promote timely initiation of antibiotic therapy for emergency department patients hospitalized for pneumonia.

BACKGROUND: A mixed-methods quality improvement (QI) project for patients with pneumonia hospitalized from the emergency department (ED) was undertaken to (1) delineate the basic steps in the flow of patient care from presentation in the ED to time to first antibiotic dose (TFAD), (2) identify perceived barriers to and facilitators of reduced TFAD within these steps, (3) describe QI strategies to improve TFAD rates, and (4) identify perceived strategies for facilities to enhance performance. METHODS: The QI project was conducted at 10 lower- and 10 higher-performing Veterans Affairs hospitals on the basis of the proportion of patients whose TFAD was within four hours of presentation. An ED physician, an ED nurse, a radiologist, a pharmacist, and a quality manager from each site were invited to participate in a survey and focus group. RESULTS: Of the 82 survey participants, 59 (72%) perceived that ordering and performing the chest radiograph was the step most frequently resulting in TFAD delays. Medical provider assessment, chest radiograph interpretation, ordering/obtaining blood cultures, and ordering/administering initial antibiotic therapy also caused TFAD delays. The most commonly perceived barriers were patient and x-ray equipment transportation delays and communication delays between providers. The most frequently used strategies to reduce TFAD were stocking antibiotics in the ED and physician education. Focus groups emphasized the importance of multifaceted QI approaches and a top-down hospital leadership style to improve TFAD performance. DISCUSSION: TFAD relies on a series of complex, stepwise processes of care that involve numerous hospital departments and is often delayed by well-described barriers. Addressing these barriers, as well as involving facility leadership in setting institutional QI goals, could possibly improve performance on this pneumonia quality measure.

Toyota production system quality improvement initiative improves perioperative antibiotic therapy.

OBJECTIVE: To assess the role of a Toyota production system (TPS) quality improvement (QI) intervention on appropriateness of perioperative antibiotic therapy and in length of hospital stay (LOS) among surgical patients. STUDY DESIGN: Pre-post quasi-experimental study using local and national retrospective cohorts. METHODS: We used TPS methods to implement a multifaceted intervention to reduce nosocomial methicillin-resistant Staphylococcus aureus infections on a Veterans Affairs surgical unit, which led to a QI intervention targeting appropriate perioperative antibiotic prophylaxis. Appropriate perioperative antibiotic therapy was defined as selection of the recommended antibiotic agents for a duration not exceeding 24 hours from the time of the operation. The local computerized medical record system was used to identify patients undergoing the 25 most common surgical procedures and to examine changes in appropriate antibiotic therapy and LOS over time. RESULTS: Overall, 2550 surgical admissions were identified from the local computerized medical records. The proportion of surgical admissions receiving appropriate perioperative antibiotics was significantly higher (P <.01) in 2004 after initiation of the TPS intervention (44.0%) compared with the previous 4 years (range, 23.4%-29.8%) primarily because of improvements in compliance with antibiotic therapy duration rather than appropriate antibiotic selection. There was no statistically significant decrease in LOS over time. CONCLUSION: The use of TPS methods resulted in a QI intervention that was associated with an increase in appropriate perioperative antibiotic therapy among surgical patients, without affecting LOS.

A preliminary model of wheelchair service delivery.

OBJECTIVE: To integrate and expand on previously published models of wheelchair service delivery, and provide a preliminary framework for developing more comprehensive, descriptive models of wheelchair service delivery for adults with spinal cord injury within the U.S. health care system. DESIGN: Literature review and a qualitative analysis of in-depth interviews. SETTING: Not applicable. PARTICIPANTS: Ten academic, clinical, regulatory, and industry experts (Department of Veterans Affairs [VA] and non-VA) in wheelchair service delivery. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Interviewees were asked to discuss the full range of variables and stakeholders involved in wheelchair service delivery, and to limit their scope to the provision of primary subsequent or replacement chairs (not backup chairs) to adults within the United States. RESULTS: Most experts we interviewed stressed that clients who require a wheelchair play a central role in the wheelchair service delivery process. Providers (including clinicians, rehabilitation engineers, and rehabilitation counselors) are also critical stakeholders. More so than in other health care settings, suppliers play an integral role in the provision of wheelchairs to clients and may significantly influence the appropriateness of the wheelchair provided. Suppliers often have a direct role in wheelchair service delivery through their interactions with the clinician and/or client. This model also identified a number of system-level factors (including facility administration and standards, policies, and regulations) that influence wheelchair service delivery and ultimately the appropriateness of the wheelchair provided. CONCLUSIONS: We developed a detailed, descriptive model of wheelchair service delivery that integrates the delivery process and device outcomes, and includes the patient-level, provider-level, and system-level factors that may directly influence those processes and outcomes. We believe that this detailed model can help clinicians and researchers describe and consider the complexities of wheelchair service delivery. It can be used to identify factors that may be related to disparities in wheelchair service delivery and in the appropriateness of the wheelchair prescribed. Further, this model can help researchers and clinicians identify factors that may be related to disparities in wheelchair service delivery, and intervene to reduce such disparities.

The transtheoretical model in intimate partner violence victimization: stage changes over time.

The transtheoretical model of behavior change (TTM) has been extended to describe the process of change in victims of intimate partner violence (IPV); however, it has not been validated over time or in a population of women experiencing IPV who are not currently in shelter. This article examines the process of change in IPV victims longitudinally and identifies factors that may relate to staging and stage progression. Fifty-three women were enrolled on presentation to an emergency department for health care treatment and completed follow-up at 3 to 4 months. Measures of TTM staging, use of community resources, ongoing abuse, mental health, and social support were collected. Cluster analyses were conducted, and descriptive summaries of clusters and significant demographic, abuse, and outcome variables related to cluster membership are presented. A five-cluster solution was selected on the basis of parsimony, theory, and overall coherence with the data. Forward progression through the stages over time was related to both the use of community resources and ending the IPV relationship.