Interprofessional Curriculum Delivery: Experience of a Primary Care Education Program.

Few post-graduate training programs offer a comprehensive curriculum that includes structured clinical experiences to teach interprofessional care. To address this need, the United States Department of Veterans Affairs, Office of Academic Affiliations funded the Centers of Excellence in Primary Care Education (CoEPCE) from 2011-2019 to provide interprofessional curricula for health profession trainees (HPTs), including physician residents, nurse practitioner residents, pharmacy residents, and psychology residents. We examined changes over time in curricular domains, system impacts, and program practices based on HPT survey data and the qualitative evaluation of narrative feedback. An annual survey was administered to participants. Indirect standardized ratios were calculated for interprofessional professional education (IPE) program domains, system impacts, and program practices. Qualitative responses were coded based on curricular domains and key program components. The study cohort included 369 HPTs. Site and profession standardized indirect ratios across all professions indicated improvements in curricular domains, system impacts, and program practices, with significant differences observed for associated health HPTs as compared to other HPTs for performance improvement. Qualitative data indicated that profession was associated with differences in perceptions of the curriculum. Although improvements occurred over time, our findings support the need for the thoughtful consideration of profession-specific identity characteristics when designing interprofessional curricula.

Interprofessional transformation of clinical education: The first six years of the Veterans Affairs Centers of Excellence in Primary Care Education.

This paper describes the Centers of Excellence in Primary Care Education (CoEPCE), a seven-site collaborative project funded by the Office of Academic Affiliations (OAA) within the Veterans Health Administration of the United States Department of Veterans Affairs (VA). The CoEPCE was established to fulfill OAA's vision of large-scale transformation of the clinical learning environment within VA primary care settings. This was accomplished by funding new Centers within VA facilities to develop models of interprofessional education (IPE) to teach health professions trainees to deliver high quality interprofessional team-based primary care to Veterans. Using reports and data collected and maintained by the National Coordinating Center over the first six years of the project, we describe program inputs, the multicomponent intervention, activities undertaken to develop the intervention, and short-term outcomes. The findings have implications for lessons learned that can be considered by others seeking large-scale transformation of education within the clinical workplace and the development of interprofessional clinical learning environments. Within the VA, the CoEPCE has laid the foundation for IPE and collaborative practice, but much work remains to disseminate this work throughout the national VA system.

Health Systems Education Leadership: Learning From the VA Designated Education Officer Role.

Background: The US Department of Veterans Affairs designated education officer (DEO) is a unique facility-based leadership role responsible for training of > 40 health professions in cooperation with affiliated academic institutions. Methods: We conducted mixed methods analyses of data from a DEO needs assessment. Quantitative analysis identified differences between DEOs who are physicians and DEOs who are other professions on role characteristics and self-perceived task effectiveness. Qualitative analysis using rapid analysis procedures was applied to open-ended responses on facilitators and barriers. Results: Responses were received from 127 DEOs (96% response rate). About 80% were physicians. There were no statistically significant differences between physician and other professional DEOs self-ratings for general tasks. For profession-specific tasks, physician DEOs were significantly less confident than other professional DEOs in working with associated health (P < .001-.01) and nurse training programs (P < .001-.03). DEOs identified multiple facilitators that assist their individual effectiveness (eg, training, mentorship, communication) and common barriers (eg, not enough staff). Conclusions: Our findings are supportive of individuals from various health disciplines serving in the DEO role with responsibilities that span multiple health profession training programs. Future quantitative and qualitative work should include additional measures of individual and organizational characteristics, and actual measures of educational effectiveness.

Improving the Assessment of Resident Competency: Physical Medicine and Rehabilitation Milestones 2.0.

ABSTRACT: In 2015, the Accreditation Council for Graduate Medical Education published the Physical Medicine and Rehabilitation Milestones 1.0 as part of the Next Accreditation System. This was the culmination of more than 20 yrs of work on the part of the Accreditation Council for Graduate Medical Education to improve graduate medical education competency assessments. The six core competencies were patient care, medical knowledge, systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills. While providing a good foundation for resident assessment, the Physical Medicine and Rehabilitation Milestones 1.0 was not without faults. With input from program directors, national organizations, and the public, the Physical Medicine and Rehabilitation Milestones 2.0 strives to further advance resident assessment, providing improvements through the integration of the harmonized Milestones and the addition of a supplemental guide.

Association of a Multisite Interprofessional Education Initiative With Quality of Primary Care.

Importance: Studies have shown that interprofessional education (IPE) improves learner proficiencies, but few have measured the association of IPE with patient outcomes, such as clinical quality. Objective: To estimate the association of a multisite IPE initiative with quality of care. Design, Setting, and Participants: This study used difference-in-differences analysis of US Department of Veterans Affairs (VA) electronic health record data from July 1, 2008, to June 30, 2015. Patients cared for by resident clinicians in 5 VA academic primary care clinics that participated in the Centers of Excellence in Primary Care Education (CoEPCE), an initiative designed to promote IPE among physician, nurse practitioner, pharmacist, and psychologist trainees, were compared with patients cared for by resident clinicians in 5 regionally matched non-CoEPCE clinics using data for the 3 academic years (ie, July 1 to June 30) before and 4 academic years after the CoEPCE launch. Analysis was conducted from January 18, 2018, to January 17, 2019. Main Outcomes and Measures: Among patients with diabetes, outcomes included annual hemoglobin A1c, poor hemoglobin A1c control (ie, <9% or unmeasured), and annual renal test; among patients 65 years and older, outcomes included prescription of high-risk medications; among patients with hypertension, outcomes included hypertension control (ie, blood pressure, <140/90 mm Hg); and among all patients, outcomes included timely mental health referrals, primary care mental health integrated visits, and hospitalizations for ambulatory care-sensitive conditions. Results: A total of 44 527 patients contributed 107 686 patient-years; 49 279 (45.8%) were CoEPCE resident patient-years (mean [SD] patient age, 59.3 [15.2] years; 26 206 [53.2%] white; 8073 [16.4%] women; mean [SD] patient Elixhauser comorbidity score, 12.9 [15.1]), and 58 407 (54.2%) were non-CoEPCE resident patient-years (mean [SD] patient age, 61.8 [15.3] years; 43 912 [75.2%] white; 4915 [8.4%] women; mean [SD] patient Elixhauser comorbidity score, 13.8 [15.7]). Compared with resident clinicians who did not participate in the CoEPCE initiative, CoEPCE training was associated with improvements in the proportion of patients with diabetes with poor hemoglobin A1c control (-4.6 percentage points; 95% CI, -7.5 to -1.8 percentage points; P < .001), annual renal testing among patients with diabetes (3.2 percentage points; 95% CI, 0.6 to 5.7 percentage points; P = .02), prescription of high-risk medications among patients 65 years and older (-2.3 percentage points; 95% CI, -4.0 to -0.6 percentage points; P = .01), and timely mental health referrals (1.6 percentage points; 95% CI, 0.6 to 2.6 percentage points; P = .002). Fewer patients cared for by CoEPCE resident clinicians had a hospitalization for an ambulatory care-sensitive condition compared with patients cared for by non-CoEPCE resident clinicians in non-CoEPCE clinics (-0.4 percentage points; 95% CI, -0.9 to 0.0 percentage points; P = .01). Sensitivity analyses with alternative comparison groups yielded similar results. Conclusions and Relevance: In this study, the CoEPCE initiative was associated with modest improvements in quality of care. Implementation of IPE was associated with improvements in patient outcomes and may potentiate delivery system reform efforts.

Developing Interprofessional Primary Care Teams: Alumni Evaluation of the Department of Veterans Affairs Centers of Excellence in Primary Care Education Program.

PURPOSE: The Centers of Excellence in Primary Care Education (CoEPCE) is an interprofessional graduate training program within the Department of Veterans Affairs (VA). In this project, we describe career paths of CoEPCE graduates, their perceptions of CoEPCE program value, their overall satisfaction with the training, and suggestions for program improvement to enhance interprofessional education and workforce development. METHODS: The Graduate Participant Survey was developed and administered in 2018 to CoEPCE graduates from 2012 to 2017. Quantitative data from closed-ended questions were analyzed through descriptive and non-parametric statistics to test for significant differences by profession. Qualitative data from the single open-ended question were analyzed using content analysis with inductive and deductive approaches. RESULTS: The survey was completed by 180 graduates. Greater proportions of pharmacists and psychologists than nurse practitioners and physicians were employed in VA, and greater proportions of nurse practitioners and pharmacists than physicians and psychologists were employed in primary care. Although smaller proportions of physicians were currently employed in primary care (P < .0001), a greater proportion completed advanced training programs (P < .0001). Overall, graduates perceived that their CoEPCE training was highly valued by advanced training programs and employers and improved their chances of finding a job. They reported high levels of satisfaction (mean = 4.3 ± 0.9 out of 5 total) with the training program, continued to use skills they learned during training, and believe their CoEPCE experiences made them better health care providers. CONCLUSIONS: Ninety-four percent of the CoEPCE graduates were employed at the VA and/or primary care at the completion of their training, although there were significant differences by profession. Graduates continued to practice interprofessional skills learned during their training and were highly satisfied with the program. Taken together, the findings indicate that continued enhancements to the interprofessional clinical learning environment are warranted.

Nurse Practitioner residents' perceptions of competency development during a year-long immersion in Veterans Affairs primary care.

BACKGROUND: Nurse Practitioner (NP) Postgraduate Residency programs are rapidly expanding. Currently, little is known about trainees' self-perceptions during these experiences. PURPOSE: Describe NP residents' perceptions of their strengths, areas for improvement, and goals while participating in the Veterans Affairs Centers of Excellence in Primary Care Education NP Residency program. METHODS: NP residents responded to open-ended questions at three time points across their training year. Responses were analyzed using inductive and deductive approaches. FINDINGS: NP residents self-reported strengths in patient-centered care and interprofessional teamwork. They identified clinical skill acquisition as the major area for improvement. Their short- and long-term goals focused on personal and professional growth. DISCUSSION: These results suggest NPs prioritize clinical skill acquisition during a primary care residency. In contrast, leadership and performance improvement skills did not capture their attention. When aggregated at the programmatic level, assessments identified opportunities to improve the NP Residency program curriculum.

Evaluation of Veterans Affairs primary care nurse practitioner residency: Achievement of competencies.

BACKGROUND: The Institute of Medicine has recommended the establishment of residency programs for advanced practice nursing graduates. Currently, the evidence about program effectiveness is limited. PURPOSE: To describe the nurse practitioner (NP) resident outcomes on seven competency domains established by the VA Centers of Excellence in Primary Care Education (VA CoEPCE). METHODS: We evaluated mean NP resident competency self-ratings and mean mentor ratings over the 12-month program across NP residency programs at five sites. Highest and lowest rated items and differences between NP resident self-ratings and mentor ratings were analyzed. RESULTS: Mean NP resident self-ratings and mean mentor ratings demonstrated statistically significant improvement in all domains (p < .0001). At 12 months, NP residents were rated by their mentors as able to practice without supervision in all competency domains. At 1 and 12 months, clinical, leadership and quality improvement/population management competencies were the lowest scored domains while patient-centered care, interprofessional team collaboration, shared decision-making and sustained relationships competencies were highest. CONCLUSIONS: These results provide initial evidence for the effectiveness of VA CoEPCE NP residency programs and also highlight areas of needed improvement.

Effects of contralateral versus ipsilateral cane use on gait in people with knee osteoarthritis.

OBJECTIVE: To compare the immediate effects of contralateral versus ipsilateral cane use on spatiotemporal gait parameters and peak vertical ground force in overweight or obese adults with symptomatic knee osteoarthritis (OA). DESIGN: Prospective observational study. SETTING: An academic tertiary Veterans Affairs Healthcare Center. PARTICIPANTS: Thirty-eight overweight or obese subjects with symptomatic knee OA who had not used a cane for the past 30 days. METHODS: Spatiotemporal gait data were obtained with an optical motion capture system while subjects walked without a cane, with a cane contralateral to the more painful lower limb, or with a cane ipsilateral to the more painful lower limb at self-selected speeds. An in-shoe dynamic pressure distribution system was used to measure the vertical ground reaction force. MAIN OUTCOME MEASUREMENTS: Spatiotemporal measures of gait and peak vertical ground reaction force on both lower limbs were recorded for each walking condition: no cane, contralateral cane, and ipsilateral cane. RESULTS: Walking with a cane either contralateral or ipsilateral to the more symptomatic limb led to significant reductions in gait velocity (14%-16%), cadence (12%-14%), and peak vertical ground reaction force (normalized for body weight; 11%-12%) on the more painful lower limb compared with walking unaided (P < .05). There were no significant differences in the peak vertical ground reaction force on either lower limbs when comparing walking with a cane contralateral to the more painful limb or walking with a cane ipsilateral to the more painful limb. Subjects also experienced a significant decrease in gait velocity with contralateral or ipsilateral cane use compared with walking without a cane; the lower walking speed was due to a decrease in cadence. CONCLUSIONS: These results support the prescription of a single-point cane to offload a lower limb with painful knee OA by holding the cane either ipsilateral or contralateral to the more painful lower limb.

Evaluation of two cane instruments in older adults with knee osteoarthritis.

The objectives of this study were to describe the psychometric properties of the Cane Cognitive Mediator Scale (CCMS) and the Psychosocial Impact of Assistive Devices Scale (PIADS) in adults with knee osteoarthritis (OA) and to determine the feasibility of applying these instruments as screening tools to identify patients with the propensity to use a cane. Data from a randomized crossover trial were analyzed for 53 older adults with knee OA. Perceptions on using a cane were measured at baseline using the CCMS and PIADS. The CCMS was repeated 1 wk later. At 6 mo, subjects rated their intention to use a cane. The findings indicated that 1 wk test-retest reliability was acceptable for the CCMS Attitudes and Subjective Norms subscales (r = 0.48 to 0.93) and low for the CCMS Perceived Behavioral Control subscale (r = 0.15). Internal consistency reliability was good for each CCMS and PIADS subscale. The CCMS Subjective Norms subscale demonstrated acceptable predictive validity across all subgroups (r = 0.53 to 0.88). The PIADS Adaptability subscale demonstrated acceptable predictive validity for the 45 to 64 yr-old age group (r = 0.54). The findings indicate that the CCMS Subjective Norms subscale exhibits good psychometric properties and has potential application as a screening tool.

Association of calcified carotid atheromas visualized on panoramic images and aortic arch calcifications seen on chest radiographs of postmenopausal women.

BACKGROUND: Occult atherosclerotic disease is the leading cause of death among older women. The authors hypothesized that women with calcified carotid artery plaque (CCAP) visualized on panoramic images were more likely to have aortic arch calcifications (AAC) that were visible on chest radiographs (CRs), a risk indicator of experiencing cardiovascular events, than would matched cohorts who did not have atheromas. METHODS: The authors obtained the CRs of 36 female veterans (≥ 50 years) who had CCAP and atherogenically risk-matched them to those of 36 women without CCAP. A radiologist evaluated the CRs for AAC. Other study variables included age, ethnicity, body mass index and presence or absence of hypertension, diabetes and dyslipidemia. The authors computed descriptive and bivariate statistics. RESULTS: Women 60 years or older who had evidence of CCAP on their panoramic radiographs were significantly (P = .022; 95 percent confidence interval, 1.298-26.223) more likely to have evidence of AAC on their CRs than were similarly aged women who did not have evidence of CCAP. This association was not evident in women younger than 60 years. Among women who were both younger and older than 60 years, there was no evident association between the presence of CCAP and the severity (on a four point scale [0-3]) of AAC calcification. CONCLUSION: Prevalence of carotid plaque on panoramic images of women 60 years or older is significantly associated with presence of aortic arch calcifications on CRs. PRACTICAL IMPLICATIONS: Panoramic images of women 60 years or older must be evaluated for CCAP, given their association with AAC. Patients with atheromas should be referred to their physicians for further evaluation given the systemic implications.

Do carotid atheromas on panoramic images prognosticate arterial calcifications on mammograms: acknowledged markers of future adverse cardiovascular events?

OBJECTIVE: The aim of this study was to evaluate the relationship between calcified carotid artery plaque (CCAP) on panoramic images and breast arterial calcifications (BAC) on mammograms, a validated independent risk indicator of fatal myocardial infarctions and strokes. MATERIALS AND METHODS: Women ≥55 years old having CCAP diagnosed by their dentists had their mammograms evaluated for BAC by a physician. Other study variables were age, ethnicity, body mass index, and medications for hypertension, diabetes, and dyslipidemia. Descriptive and bivariate statistics and logistic regression were computed. RESULTS: Researchers identified 40 women (mean age 62.2 ± 6.2 years old) with CCAP, of whom 9 (prevalence rate 22.5%) also had BAC. The women with BAC tended to be older (65.1 vs 61.3 years old), more frequently hypertensive (100% vs 80.6%), and more frequently black than those without BAC, although these differences were not statistically significant (P > 0.10). CONCLUSIONS: CCAP on panoramic images of women is unrelated to the presence of BAC on mammograms.

Prevalence of calcified carotid artery atheromas on the panoramic images of patients with syndrome Z, coexisting obstructive sleep apnea, and metabolic syndrome.

OBJECTIVES: The objective of this study was to compare the prevalence of calcified carotid artery atheromas (CCAAs) on panoramic images of individuals (n = 31) with obstructive sleep apnea (OSA) with individuals (n = 117) with syndrome Z (SZ: OSA with concomitant metabolic syndrome [MetS]). STUDY DESIGN: Images of patients with OSA or SZ referred from the Sleep Service to Dentistry were evaluated. Descriptive statistics and t tests (Bonferroni correction) were conducted to determine significant differences between atheroma prevalence and proatherogenic factors (age, apnea-hypopnea index, body mass index, lipid profile, blood pressure, glucose) between OSA and SZ groups. RESULTS: Individuals with OSA had an atheroma prevalence of 35% and those with SZ 42% (P = .52). Individuals with SZ also had significantly more severe atherogenic profiles (obesity, dyslipidemia, hyperglycemia) than OSA patients (P ≤ .05). Greatest CCAA prevalence (63%) was evidenced by SZ patients with severe OSA and moderate MetS. CONCLUSION: Individuals with SZ have significantly greater atherogenic burden and slightly higher prevalence of CCAAs when compared with individuals with OSA.

Prevalence of comorbid obstructive sleep apnea and metabolic syndrome: syndrome Z and maxillofacial surgery implications.

PURPOSE: To determine the prevalence of the recently identified syndrome Z (SZ), which is the co-occurrence of obstructive sleep apnea (OSA; hypoxia, systemic and pulmonary hypertension, nocturnal arrhythmias) and metabolic syndrome (MetS; increased abdominal girth, hypertriglyceridemia, decreased high-density lipoprotein, hypertension, increased fasting glucose), which places the surgical patient at heightened risk of perioperative complications (myocardial infarction, stroke, pneumonia, wound infection). MATERIALS AND METHODS: Electronic medical records of 296 male veterans were assessed for the presence of SZ using the American Academy of Sleep Medicine definition of OSA and a modified Adult Treatment Panel III definition of MetS, where obesity was defined by a body mass index of at least 30 kg/m(2) rather than by waist circumference. RESULTS: SZ was diagnosed in 59% of patients. These individuals commonly exhibited severe OSA and least commonly mild OSA. The more severe the OSA, the more likely (60%) that patients manifested moderate (4 risk markers) or severe (5 risk markers) MetS. Furthermore, with increasing apnea-hypopnea index values, the more severe were the MetS elements. CONCLUSIONS: The results of this study demonstrate the high prevalence rate of MetS in patients with OSA seeking treatment. Given the risk of perioperative complications, it is suggested that all patients scheduled for maxillofacial surgical procedures to treat OSA be evaluated for SZ.

Clinical and spatiotemporal gait effects of canes in hip osteoarthritis.

OBJECTIVE: To investigate the effects of cane use on spatiotemporal gait parameters, pain, and function in adults with hip osteoarthritis (OA). DESIGN: Prospective observational study. SETTING: An academic tertiary Veterans Affairs Healthcare Center. PARTICIPANTS: Thirteen adults with symptomatic hip OA and 13 healthy adults. METHODS: We undertook gait analysis in all subjects with an optoelectronic camera system. Pain, stiffness, and physical function in subjects with hip OA were assessed with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). MAIN OUTCOME MEASUREMENTS: Baseline spatiotemporal measures of unaided gait were obtained for healthy subjects. Baseline and 4-week spatiotemporal gait parameters were assessed for hip OA subjects while they walked with and without a cane. Participants with hip OA completed the WOMAC at baseline and after 4 weeks of cane use. RESULTS: At baseline when walking unaided, the subjects with hip OA (age range 60-75 years) had a significantly slower gait velocity, shorter affected limb stride length, and longer double-stance time compared with healthy control subjects. When walking with a cane, they had a reduction in gait velocity (P < .05) caused by a decrease in cadence (P < .05) compared with walking unaided. After 4 weeks of cane use, the participants with hip OA demonstrated significant improvements in gait velocity (P < .05) and double-stance time (P < .05) when walking with a cane in comparison with baseline data. There was no improvement in pain and function after 4 weeks of cane use, a period in which only approximately 60% of the hip OA subjects used the cane 6 or more times per week. CONCLUSIONS: Initial use of a cane led to decreased gait velocity and cadence in people with hip OA compared with walking unaided. This difference in gait velocity diminished after they practiced walking with the cane. Inconsistent use of the cane may have contributed to the lack of improvement in the subjects' hip OA pain and function.

Defining core issues in utilizing information technology to improve access: evaluation and research agenda.

The Department of Veterans Affairs (VA) has been at the vanguard of information technology (IT) and use of comprehensive electronic health records. Despite the widespread use of health IT in the VA, there are still a variety of key questions that need to be answered in order to maximize the utility of IT to improve patient access to quality services. This paper summarizes the potential of IT to enhance healthcare access, key gaps in current evidence linking IT and access, and methodologic challenges for related research. We also highlight four key issues to be addressed when implementing and evaluating the impact of IT interventions on improving access to quality care: 1) Understanding broader needs/perceptions of the Veteran population and their caregivers regarding use of IT to access healthcare services and related information. 2) Understanding individual provider/clinician needs/perceptions regarding use of IT for patient access to healthcare. 3) System/Organizational issues within the VA and other organizations related to the use of IT to improve access. 4) IT integration and information flow with non-VA entities. While the VA is used as an example, the issues are salient for healthcare systems that are beginning to take advantage of IT solutions.

Health and ambulatory care use among Native American veterans.

In 1995, the Veterans Health Administration reorganized its health services structure to emphasize ambulatory care. Successful health care planning and improving access to ambulatory care services now depends upon a better understanding of health care needs and outpatient services. Because the veteran population is heterogeneous, it is important to understand the health, access issues, and utilization of ambulatory care services in order to develop effective strategies and interventions to ensure access to and utilization of ambulatory care. Drawing on a focus group methodology with 86 Native American veterans, representing 34 tribes, this study is a qualitative examination of the health, access, use of the Department of Veterans Affairs Health Care services, barriers to health care, and satisfaction with care experienced by Native American veterans. Results reveal problems in accessing care, receiving appropriate care, and coordinating care within the VA health care system. Policy and program recommendations include increasing outreach and education efforts regarding the availability of benefits and services, improving coordination of services between the Indian Health Service and the VA, and reemphasizing the importance of patient-centered care.

Feasibility study of home telerehabilitation for physically inactive veterans.

The aim of this study was to develop a system for and determine the feasibility of monitoring home exercise for physically inactive older adults using a Health Buddy (HB) text messaging device (Robert Bosch Healthcare; Palo Alto, California). Questions and messages related to exercise adherence are displayed on the HB screen and participants choose a response by pressing the corresponding button on the device. Responses are transmitted through a landline connection and high-risk responses are highlighted by the system for follow-up. We developed the questions and messages based on input from patient and clinician focus groups. We evaluated feasibility by administering the intervention to inpatient and outpatient adults aged 60 or older. We gave participants a choice of exercise monitoring by HB (n = 20) or telephone (n = 18). The results showed that home exercise monitoring by HB and telephone is safe, as evidenced by low adverse event rates. We saw a decline in exercise adherence rates to both the HB and telephone after 8 weeks, although adherence was better for HB than telephone. Taken together, the results demonstrate the feasibility of using text messaging to monitor home exercise adherence in physically inactive older adults.