Depression complexity prevalence and outcomes among veterans affairs patients in integrated primary care.

INTRODUCTION: The Veterans Health Administration (VA) Primary Care-Mental Health Integration (PC-MHI) initiative targets depression (MDD), anxiety/posttraumatic stress disorder (PTSD) and alcohol misuse (AM) for care improvement. In primary care, case finding often relies on depression screening. Whereas clinical practice guidelines solely inform management of depression, minimal information exists to guide treatment when psychiatric symptom clusters coexist. We provide descriptive clinical information for care planners about VA PC patients with depression alone, depression plus alcohol misuse, and depression with complex psychiatric comorbidities (PTSD and/or probable bipolar disorder). METHOD: We examined data from a VA study that used a visit-based sampling procedure to screen 10,929 VA PC patients for depression; 761 patients with probable major depression completed baseline measures of health and care engagement. Follow-up assessments were completed at 7 months. RESULTS: At baseline, 53% of patients evidenced mental health conditions in addition to depression; 10% had concurrent AM, and 43% had psychiatrically complex depression (either with or without AM). Compared with patients with depression alone or depression with AM, those with psychiatrically complex depression evinced longer standing and more severe mood disturbance, higher likelihood of suicidal ideation, higher unemployment, and higher levels of polypharmacy. Baseline depression complexity predicted worse mental health status and functioning at follow-up. DISCUSSION: A substantial proportion of VA primary care patients with depression presented with high medical multimorbidity and elevated safety concerns. Psychiatrically complex depression predicted lower treatment effectiveness, suggesting that PC-MHI interventions should co-ordinate and individualize care for these patients. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The value of genetic testing: beyond clinical utility.

OBJECTIVE: To assess the value of genetic testing from the perspective of the Department of Veterans Affairs (VA) clinical leadership. METHODS: We administered an Internet-based survey to VA clinical leaders nationwide. Respondents rated the value (on a 5-point scale) of each of six possible reasons for genetic testing. Bivariate and linear regressions identified associations between value ratings and environmental, organizational, provider, patient, and encounter characteristics. RESULTS: Respondents (n = 353; 63% response rate) represented 92% of VA medical centers. Tests that inform clinical management had the highest value rating (58.6%), followed by tests that inform disease prevention (56.4%), reproductive options (50.1%), life planning (43.9%), and a suspected (39.9%) or established (32.3%) diagnosis. Factors positively associated with high value included a culture that fosters adoption of genomics, specialist versus primary care provider, genetic tests available on laboratory menus, availability of genetic testing guidelines, clinicians knowing when to request genetics referrals, and availability of genetics professionals. CONCLUSION: Our results demonstrate the varied value of genetic testing from the perspective of clinical leadership within a health-care system. Engaging organizational leadership in understanding the various reasons for genetic testing and its value beyond clinical utility may increase adoption of genetic tests to support patient-centered care.Genet Med advance online publication 15 December 2016.

Women Veterans with Depression in Veterans Health Administration Primary Care: An Assessment of Needs and Preferences.

OBJECTIVE: Depression is the most prevalent mental health condition in primary care (PC). Yet as the Veterans Health Administration increases resources for PC/mental health integration, including integrated care for women, there is little detailed information about depression care needs, preferences, comorbidity, and access patterns among women veterans with depression followed in PC. METHODS: We sampled patients regularly engaged with Veterans Health Administration PC. We screened 10,929 (10,580 men, 349 women) with the two-item Patient Health Questionnaire. Of the 2,186 patients who screened positive (2,092 men, 94 women), 2,017 men and 93 women completed the full Patient Health Questionnaire-9 depression screening tool. Ultimately, 46 women and 715 men with probable major depression were enrolled and completed a baseline telephone survey. We conducted descriptive statistics to provide information about the depression care experiences of women veterans and to examine potential gender differences at baseline and at seven month follow-up across study variables. RESULTS: Among those patients who agreed to screening, 20% of women (70 of 348) had probable major depression, versus only 12% of men (1,243 of 10,505). Of the women, 48% had concurrent probable posttraumatic stress disorder and 65% reported general anxiety. Women were more likely to receive adequate depression care than men (57% vs. 39%, respectively; p < .05); 46% of women and 39% of men reported depression symptom improvement at the 7-month follow-up. Women veterans were less likely than men to prefer care from a PC physician (p < .01) at baseline and were more likely than men to report mental health specialist care (p < .01) in the 6 months before baseline. CONCLUSION AND IMPLICATIONS FOR PRACTICE: PC/mental health integration planners should consider methods for accommodating women veterans unique care needs and preferences for mental health care delivered by health care professionals other than physicians.

Stigma Predicts Treatment Preferences and Care Engagement Among Veterans Affairs Primary Care Patients with Depression.

BACKGROUND: Whereas stigma regarding mental health concerns exists, the evidence for stigma as a depression treatment barrier among patients in Veterans Affairs (VA) primary care (PC) is mixed. PURPOSE: This study tests whether stigma, defined as depression label avoidance, predicted patients' preferences for depression treatment providers, patients' prospective engagement in depression care, and care quality. METHODS: We conducted cross-sectional and prospective analyses of existing data from 761 VA PC patients with probable major depression. RESULTS: Relative to low-stigma patients, those with high stigma were less likely to prefer treatment from mental health specialists. In prospective controlled analyses, high stigma predicted lower likelihood of the following: taking medications for mood, treatment by mental health specialists, treatment for emotional concerns in PC, and appropriate depression care. CONCLUSIONS: High stigma is associated with lower preferences for care from mental health specialists and confers risk for minimal depression treatment engagement.

Who is responsible for what tasks within primary care: Perceived task allocation among primary care providers and interdisciplinary team members.

BACKGROUND: Unclear roles in interdisciplinary primary care teams can impede optimal team-based care. We assessed perceived task allocation among primary care providers (PCPs) and staff during implementation of a new patient-centered care model in Veterans Affairs (VA) primary care practices. METHODS: We performed a cross-sectional survey of PCPs and primary care staff (registered nurses (RNs), licensed practical/vocational nurses (LPNs), and medical assistants/clerks (MAs)) in 23 primary care practices within one VA region. We asked subjects whether PCPs performed each of 14 common primary care tasks alone, or relied upon staff for help. Tasks included gathering preventive service history, disease screening, evaluating patients and making treatment decisions, intervening on lifestyle factors, educating patients about self-care activities and medications, refilling prescriptions, receiving and resolving patient messages, completing forms, tracking diagnostic data, referral tracking, and arranging home health care. We then performed multivariable regression to determine predictors of perceived PCP reliance on staff for each task. RESULTS: 162 PCPs and 257 staff members responded, a 60% response rate. For 12/14 tasks, fewer than 50% of PCPs reported relying on staff for help. For all 14 tasks, over 85% of RNs reported they were relied upon. For 12/14 tasks, over 50% of LPNs reported they were relied on, while for 5/14 tasks a majority of MAs reported being relied upon. Nurse practitioners and physician assistants (NP/PAs) reported relying on staff less than physicians. CONCLUSIONS: Early in the implementation of a team-based primary care model, most PCPs perceived they were solely responsible for most clinical tasks. RNs, and LPNs felt they were relied upon for most of the same tasks, while medical assistants/clerks reported being relied on for fewer tasks. Better understanding of optimal inter-professional team task allocation in primary care is needed.

Veterans with depression in primary care: provider preferences, matching, and care satisfaction.

Primary care is often the first point of care for individuals with depression. Depressed patients often have comorbid alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD). Understanding variations in treatment preferences and care satisfaction in this population can improve care planning and outcomes. The design involved a cross-sectional comparison of veterans screening positive for depression. Veterans receiving primary care during the previous year were contacted (n = 10, 929) and were screened for depression using the PHQ-2/PHQ-9. Those with probable depression (n = 761) underwent a comprehensive assessment including screens for AUD and PTSD, treatment provider preferences, treatments received, and satisfaction with care. Treatment provider preferences differed based on specific mental health comorbidities, and satisfaction with care was associated with receipt of preferred care. Depressed veterans with comorbid PTSD were more likely to prefer care from more than one provider type (e.g., a psychiatrist and a primary care provider) and were more likely to receive treatment that matched their preferences than veterans without comorbid PTSD. Veterans receiving full or partial treatment matches affirmed satisfaction with care at higher rates, and veterans with comorbid PTSD were least satisfied when care did not match their preferences. Patient satisfaction with care is an increasingly important focus for health care systems. This study found significant variations in depressed patients' satisfaction with care in terms of treatment matching, particularly among those with comorbid PTSD. Delivery of care that matches patient treatment preferences is likely to improve depressed patient's satisfaction with the care provided. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Predictors of primary care management of depression in the Veterans Affairs healthcare system.

BACKGROUND: Primary care providers (PCPs) vary in skills to effectively treat depression. Key features of evidence-based collaborative care models (CCMs) include the availability of depression care managers (DCMs) and mental health specialists (MHSs) in primary care. Little is known, however, about the relationships between PCP characteristics, CCM features, and PCP depression care. OBJECTIVE: To assess relationships between various CCM features, PCP characteristics, and PCP depression management. DESIGN: Cross-sectional analysis of a provider survey. PARTICIPANTS: 180 PCPs in eight VA sites nationwide. MAIN MEASURES: Independent variables included scales measuring comfort and difficulty with depression care; collaboration with a MHS; self-reported depression caseload; availability of a collocated MHS, and co-management with a DCM or MHS. Covariates included provider type and gender. For outcomes, we assessed PCP self-reported performance of key depression management behaviors in primary care in the past 6 months. KEY RESULTS: Response rate was 52 % overall, with 47 % attending physicians, 34 % residents, and 19 % nurse practitioners and physician assistants. Half (52 %) reported greater than eight veterans with depression in their panels and a MHS collocated in primary care (50 %). Seven of the eight clinics had a DCM. In multivariable analysis, significant predictors for PCP depression management included comfort, difficulty, co-management with MHSs and numbers of veterans with depression in their panels. CONCLUSIONS: PCPs who felt greater ease and comfort in managing depression, co-managed with MHSs, and reported higher depression caseloads, were more likely to report performing depression management behaviors. Neither a collocated MHS, collaborating with a MHS, nor co-managing with a DCM independently predicted PCP depression management. Because the success of collaborative care for depression depends on the ability and willingness of PCPs to engage in managing depression themselves, along with other providers, more research is necessary to understand how to engage PCPs in depression management.

Delivery of clinical genetic consultative services in the Veterans Health Administration.

OBJECTIVE: To characterize the delivery of genetic consultative services for adults, we examined the prevalence and organizational determinants of genetic consult availability and the organization of these services in the Veterans Health Administration. METHODS: We conducted a Web-based survey of Veterans Health Administration clinical leaders. We summarized facility characteristics using descriptive statistics. Multivariate logistic regression assessed associations between organizational characteristics and consult availability. RESULTS: We received 353 survey responses from key informants representing 141 Veterans Affairs Medical Centers. Clinicians could obtain genetic consults at 110 (78%) Veterans Affairs Medical Centers. Cancer genetic and neurogenetic consults were most common. Academic affiliation (odds ratio = 3.0; 95% confidence interval: 1.1-8.6) and provider education about genetics (odds ratio = 2.9; 95% confidence interval: 1.1-7.8) were significantly associated with consult availability. The traditional model of multidisciplinary specialty clinics or coordinated services between geneticists and other providers was most prevalent, although variability in the organization of these services was described, with consults available on-site, at another Veterans Affairs Medical Center, via telegenetics, or at non-Veterans Health Administration facilities. The emerging model of nongeneticists integrating genetics into their practices was also reported, with considerable variability by specialty. CONCLUSION: Both traditional and emerging models for genetic consultation are available in the Veterans Health Administration; however, there is variability in service organization that could influence quality of care.

Prevalence and correlates of smoking status among veterans affairs primary care patients with probable major depressive disorder.

In an attempt to guide planning and optimize outcomes for population-specific smoking cessation efforts, the present study examined smoking prevalence and the demographic, clinical and psychosocial characteristics associated with smoking among a sample of Veterans Affairs primary care patients with probable major depression. Survey data were collected between 2003 and 2004 from 761 patients with probable major depression who attended one of 10 geographically dispersed VA primary care clinics. Current smoking prevalence was 39.8%. Relative to nonsmokers with probable major depression, bivariate comparisons revealed that current smokers had higher depression severity, drank more heavily, and were more likely to have comorbid PTSD. Smokers with probable major depression were also more likely than nonsmokers with probable major depression to have missed a health care appointment and to have missed medication doses in the previous 5months. Smokers were more amenable than non-smokers to depression treatment and diagnosis, and they reported more frequent visits to a mental health specialist and less social support. Alcohol abuse and low levels of social support were significant concurrent predictors of smoking status in controlled multivariable logistic regression. In conclusion, smoking prevalence was high among primary care patients with probable major depression, and these smokers reported a range of psychiatric and psychosocial characteristics with potential to complicate systems-level smoking cessation interventions.

Alcohol problems as a risk factor for postdisaster depressed mood among U.S. veterans.

Alcohol problems may impede adaptive, proactive responses to disaster-related injury and loss, thus prolonging the adverse impact of disasters on mental health. Previous work suggests that veterans of the U.S. armed forces have a relatively high prevalence of alcohol misuse and other psychiatric disorders. This is the first study to estimate the impact of predisaster alcohol problems on postdisaster depressed mood among veterans, using data that were collected before and after the 1994 Northridge, CA, earthquake. The authors assessed the impact of alcohol problems on postdisaster depressed mood in an existing clinical cohort of veterans who experienced the 6.7-magnitude earthquake that struck Northridge in January 1994. One to 3 months after the disaster, interviewers contacted participants by telephone to administer a follow-up questionnaire based on a survey that had been done preearthquake. Postearthquake data were obtained on 1,144 male veterans for whom there were preearthquake data. We tested a predictive path model of the relationships between latent variables for predisaster alcohol problems, functional limitations, and depressed mood on latent variables representing postdisaster "quake impact" and depressive mood. Results showed that veterans who had more alcohol problems before the earthquake experienced more earthquake-related harms and severely depressed mood after the earthquake, compared with those who had fewer alcohol problems. Programs serving veterans with a high prevalence of alcohol problems should consider designing disaster response protocols to locate and assist these patients in the aftermath of disasters.

Relationships between mood and employment over time among depressed VA primary care patients.

OBJECTIVE: Associations between depression, productivity and work loss have been reported, yet few studies have examined relationships between longitudinal depression status and employment continuity. We assessed these relationships among Veterans of conventional working ages. METHODS: We used longitudinal survey data from Veterans receiving primary care in 1 of 10 Veterans Health Administration primary care practices in five states. Our sample included 516 participants with nine-item Patient Health Questionnaire (PHQ-9) scores indicating probable major depression (PHQ-9≥10) at baseline and who completed either the 7-month follow-up survey or follow-up surveys at both 7 and 18 months postbaseline. We examined relationships between depression persistence and employment status using multinomial logistic regression models. RESULTS: Although general employment rates remained stable (21%-23%), improved depression status was associated with an increased likelihood of becoming employed over 7 months among those who were both depressed and nonemployed at baseline. Improvements in depression status starting at 7 months and continuing through 18 months were associated with remaining employed over the 18-month period, relative to those who were depressed throughout the same time frame. CONCLUSIONS: Given the pressing need to prevent socioeconomic deterioration in the increasing population of conventional working-aged Operation Enduring Freedom and Operation Iraqi Freedom Veterans, further attention to the depression/employment relationship is urgently needed.

Yield of practice-based depression screening in VA primary care settings.

BACKGROUND: Many patients who should be treated for depression are missed without effective routine screening in primary care (PC) settings. Yearly depression screening by PC staff is mandated in the VA, yet little is known about the expected yield from such screening when administered on a practice-wide basis. OBJECTIVE: We characterized the yield of practice-based screening in diverse PC settings, as well as the care needs of those assessed as having depression. DESIGN: Baseline enrollees in a group randomized trial of implementation of collaborative care for depression. PARTICIPANTS: Randomly sampled patients with a scheduled PC appointment in ten VA primary care clinics spanning five states. MEASUREMENTS: PHQ-2 screening followed by the full PHQ-9 for screen positives, with standardized sociodemographic and health status questions. RESULTS: Practice-based screening of 10,929 patients yielded 20.1% positive screens, 60% of whom were assessed as having probable major depression based on the PHQ-9 (11.8% of all screens) (n = 1,313). In total, 761 patients with probable major depression completed the baseline assessment. Comorbid mental illnesses (e.g., anxiety, PTSD) were highly prevalent. Medical comorbidities were substantial, including chronic lung disease, pneumonia, diabetes, heart attack, heart failure, cancer and stroke. Nearly one-third of the depressed PC patients reported recent suicidal ideation (based on the PHQ-9). Sexual dysfunction was also common (73.3%), being both longstanding (95.1% with onset >6 months) and frequently undiscussed and untreated (46.7% discussed with any health care provider in past 6 months). CONCLUSIONS: Practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. The substantial level of comorbid physical and mental illness among PC patients precludes solo management by either PC or mental health (MH) specialists. PC practice- and provider-level guideline adherence is problematic without systems-level solutions supporting adequate MH assessment, PC treatment and, when needed, appropriate MH referral.

Impact of the Northridge earthquake on the mental health of veterans: results from a panel study.

OBJECTIVE: The 1994 earthquake that struck Northridge, California, led to the closure of the Veterans Health Administration Medical Center at Sepulveda. This article examines the earthquake's impact on the mental health of an existing cohort of veterans who had previously used the Sepulveda Veterans Health Administration Medical Center. METHODS: From 1 to 3 months after the disaster, trained interviewers made repeated attempts to contact participants by telephone to administer a repeated measures follow-up design survey based on a survey that had been done preearthquake. Postearthquake data were obtained on 1144 of 1800 (64%) male veterans for whom there were previous data. We tested a predictive latent variable path model of the relations between sociodemographic characteristics, predisaster physical and emotional health measures, and postdisaster emotional health and perceived earthquake impact. RESULTS: Perceived earthquake impact was predicted by predisaster emotional distress, functional limitations, and number of health conditions. Postdisaster emotional distress was predicted by preexisting emotional distress and earthquake impact. The regression coefficient from earthquake impact to postearthquake emotional distress was larger than that of the stability coefficient from preearthquake emotional distress. Postearthquake emotional distress also was affected indirectly by preearthquake emotional distress, health conditions, younger age, and lower socioeconomic status. CONCLUSIONS: The postdisaster emotional health of veterans who experienced greater earthquake impact would have likely benefited from postdisaster intervention, regardless of their predisaster emotional health. Younger veterans and veterans with generally poor physical and emotional health were more vulnerable to greater postearthquake emotional distress. Veterans of lower socioeconomic status were disproportionately likely to experience more effects of the disaster because they had more predisaster emotional distress, more functional limitations, and a greater number of health conditions. Because many veterans use non-Department of Veterans Affairs (VA) health care providers for at least some of their health needs, future disaster planning for both VA and non-VA providers should incorporate interventions targeted at these groups.

Potential safety gaps in order entry and automated drug alerts: a nationwide survey of VA physician self-reported practices with computerized order entry.

OBJECTIVE: Understanding provider perceptions of and experiences with order entry and order checks (drug alerts) in an electronic prescribing system may help improve medication safety technology. DESIGN: Cross-sectional, national survey of Veterans Administration physicians practicing in various specialties. MEASUREMENT: Thirty-five question instrument was divided into 4 content domains. Response options included dichotomous, numeric, multiple choices, and Likert-like scales. Statistical methods included logistic regression. RESULTS: The adjusted response rate was 1543 of 3588 (43%). Almost all providers (90%) felt that the VA electronic prescribing system, including its order checks, improved prescribing safety to some degree. Most respondents (72%) reported that they always or almost always document outside medications in a clinic note, although only 44% always or almost always entered outside medications in the non-VA medication data field. Most physicians (88%) who encountered serious allergic or adverse drug reactions reported either notifying a pharmacist or entering the information in the allergies/adverse reactions field. Generalists and physicians with higher numbers of prescriptions were more likely to enter relevant data into the electronic medical record (or notify a pharmacist, in the case of adverse reactions). In addition, 48% of providers described critical drug-drug interaction alerts as very useful; medical specialists found these less useful, whereas surgical specialists found these more useful when compared with generalists. LIMITATIONS: Survey was conducted within a single healthcare system. CONCLUSION: Computerized provider order entry and related order checks are perceived to improve prescribing safety; however, provider entry of some relevant information into the appropriate electronic fields may not be optimal.

Targeting primary care referrals to smoking cessation clinics does not improve quit rates: implementing evidence-based interventions into practice.

OBJECTIVE: To evaluate the impact of a locally adapted evidence-based quality improvement (EBQI) approach to implementation of smoking cessation guidelines into routine practice. DATA SOURCES/STUDY SETTING: We used patient questionnaires, practice surveys, and administrative data in Veterans Health Administration (VA) primary care practices across five southwestern states. STUDY DESIGN: In a group-randomized trial of 18 VA facilities, matched on size and academic affiliation, we evaluated intervention practices' abilities to implement evidence-based smoking cessation care following structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback, and monitoring. Control practices received mailed guidelines and VA audit-feedback reports as usual care. DATA COLLECTION: To represent the population of primary care-based smokers, we randomly sampled and screened 36,445 patients to identify and enroll eligible smokers at baseline (n=1,941) and follow-up at 12 months (n=1,080). We used computer-assisted telephone interviewing to collect smoking behavior, nicotine dependence, readiness to change, health status, and patient sociodemographics. We used practice surveys to measure structure and process changes, and administrative data to assess population utilization patterns. PRINCIPAL FINDINGS: Intervention practices adopted multifaceted EBQI plans, but had difficulty implementing them, ultimately focusing on smoking cessation clinic referral strategies. While attendance rates increased (p<.0001), we found no intervention effect on smoking cessation. CONCLUSIONS: EBQI stimulated practices to increase smoking cessation clinic referrals and try other less evidence-based interventions that did not translate into improved quit rates at a population level.

The evolution of changes in primary care delivery underlying the Veterans Health Administration's quality transformation.

OBJECTIVES: Suffering from waning demand, poor quality, and reform efforts enabling veterans to "vote with their feet" and leave, the Veterans Health Administration (VA) health care system transformed itself through a series of substantive changes. We examined the evolution of primary care changes underlying VA's transformation. METHODS: We used 3 national organizational surveys from 1993, 1996, and 1999 that measured primary care organization, staffing, management, and resource sufficiency to evaluate changes in VA primary care delivery. RESULTS: Only rudimentary primary care was in place in 1993. Primary care enrollment grew from 38% in 1993 to 45% in 1996, and to 95% in 1999 as VA adopted team structures and increased the assignment of patients to individual providers. Specialists initially staffed primary care until generalist physicians and nonphysican providers increased. Primary care-based quality improvement and authority expanded, and resource sufficiency (e.g., computers, space) grew. Provider notification of admissions and emergency department, urgent-care visit, and sub-specialty-consult results increased nearly 5 times. CONCLUSIONS: Although VA's quality transformation had many underlying causes, investment in primary care development may have served as an essential substrate for many VA quality gains.

The utility of adding retrospective medication profiling to computerized provider order entry in an ambulatory care population.

BACKGROUND: We assessed whether medication safety improved when a medication profiling program was added to a computerized provider order entry system. DESIGN: Between June 2001 and January 2002 we profiled outpatients with potential prescribing errors using computerized retrospective drug utilization software. We focused primarily on drug interactions. Patients were randomly assigned either to Provider Feedback or to Usual Care. Subsequent adverse drug event (ADE) incidence and other outcomes, including ADE preventability and severity, occurring up to 1 year following the last profiling date were evaluated retrospectively by a pharmacist blinded to patient assignment. MEASUREMENTS: Data were abstracted using a study-designed instrument. An ADE was defined by an Adverse Drug Reaction Probability scale score of 1 or more. Statistical analyses included negative binomial regression for comparing ADE incidence. RESULTS: Of 913 patients in the analytic sample, 371 patients (41%) had one or more ADEs. Incidence, by individual, was not significantly different between Usual Care and Provider Feedback groups (37% vs. 45%; p = 0.06; Coefficient, 0.19; 95% CI: -0.008, 0.390). ADE severity was also similar. For example, 51% of ADEs in the Usual Care and 58% in the Provider Feedback groups involved symptoms that were not serious (95% CI for the difference, -15%, 2%). Finally, ADE preventability did not differ. For example, 16% in the Usual Care group and 17% in the Provider Feedback group had an associated warning (95% CI for the difference, -7 to 5%; p = 0.79). CONCLUSION: Medications safety did not improve with the addition of a medication profiling program to an electronic prescribing system.

Exposure to automated drug alerts over time: effects on clinicians' knowledge and perceptions.

OBJECTIVE: We tested whether interval exposure to an automated drug alert system that included approximately 2000 drug-drug interaction alerts increased recognition of selected interacting drug pairs. We also examined other perceptions about computerized order entry. RESEARCH DESIGN: We administered cross-sectional surveys in 2000 and 2002 that included more than 260 eligible clinicians in each time period. SUBJECTS: We studied clinicians practicing in ambulatory settings within a Southern California Veterans Affairs Healthcare System and who responded to both surveys (97 respondents). MEASURES: We sought to measure (1) recognition of selected drug-drug and drug-condition interactions and (2) other benefits and barriers to using automated drug alerts. RESULTS: Clinicians correctly categorized similar percentages of the 7 interacting drug-drug pairs at baseline and follow-up (53% vs. 54%, P = 0.51) but improved their overall recognition of the 3 contraindicated drug-drug pairs (51% vs. 60%, P = 0.01). No significant changes from baseline to follow-up were found for the 8 interacting drug-condition pairs (60% vs. 62%, P = 0.43) or the 4 contraindicated drug-condition pairs (52% vs. 56%, P = 0.24). More providers preferred using order entry at follow-up than baseline (63% vs. 45%, P < 0.001). Signal-to-noise ratio remained the biggest reported problem at follow-up and baseline (54 vs. 57%, P = 0.75). In 2002, clinicians reported seeing a median of 5 drug alerts per week (representing approximately 12.5% of prescriptions entered), with a median 5% reportedly leading to an action. CONCLUSIONS: Interval exposure to automated drug alerts had little to no effect on recognition of selected drug-drug interactions. The primary perceived barrier to effective utilization of drug alerts remained the same over time.

Gender differences in smoking cessation services received among veterans.

INTRODUCTION: Smoking is the leading preventable cause of death among women in the United States. It is a particular problem for women using the Veterans Health Administration (VA), where the prevalence of smoking among women is 30%. We compared the baseline characteristics of male and female smokers and then assessed the smoking cessation services they received to determine whether there are important gender differences in care. METHODS: As part of a study of implementing national guidelines for smoking cessation taking place at 18/23 VA centers in the southwestern and western United States, we conducted a baseline survey of a random sample of 1,941 smokers in primary care (129 women, 1,812 men) to assess the smoking cessation services received by female and male veterans. Subjects were followed 1 year later (73 women, 1007 men). Results for men and women were compared using chi-square tests and analysis of variance. Logistic regression analyses were conducted to determine factors that were independently associated with receipt of smoking cessation services. RESULTS: Female smokers were younger, more educated, and less likely to be married than male smokers. Women were equally likely to report being advised to quit smoking or referred to a smoking cessation program but were much less likely to report receiving a prescription for nicotine patches (OR .5, 95% CI .3-.9). One year later, female smokers were less likely to have successfully quit smoking. CONCLUSION: Women were less likely to report receiving nicotine patches for smoking cessation. Future interventions to increase use of smoking cessation medications for female smokers will also hopefully increase their quit rate.

Primary care practice and facility quality orientation: influence on breast and cervical cancer screening rates.

BACKGROUND: Despite the importance of early cancer detection, variation in screening rates among physicians is high. Insights into factors influencing variation can guide efforts to decrease variation and increase screening rates. OBJECTIVES: To explore the association of primary care practice features and a facility's quality orientation with breast and cervical cancer screening rates. STUDY DESIGN: Cross-sectional study of screening rates among 144 Department of Veterans Affairs (VA) medical centers and for a national sample of women. METHODS: We linked practice structure and quality improvement characteristics of individual VA medical centers from 2 national surveys (1 to primary care directors and 1 to a stratified random sample of employees) to breast and cervical cancer screening rates determined from a review of random medical records. We conducted bivariate analyses and multivariate logistic regression of primary care practice and facility features on cancer screening rates, above and below the median. RESULTS: While the national screening rates were high for breast (87%) and cervical cancer (90%), higher screening rates were more likely when primary care providers were consistently notified of specialty visits and when staff perceived a greater organizational commitment to quality and anticipated rewards and recognition for better performance. CONCLUSIONS: Organization and quality orientation of the primary care practice and its facility can enhance breast and cervical cancer screening rates. Internal recognition of quality performance and an overall commitment to quality improvement may foster improved prevention performance, with impact varying by clinical service.