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.

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.

The Diabetes Telemonitoring Study Extension: an exploratory randomized comparison of alternative interventions to maintain glycemic control after withdrawal of diabetes home telemonitoring.

BACKGROUND: Telemonitoring interventions featuring transmission of home glucose records to healthcare providers have resulted in improved glycemic control in patients with diabetes. No research has addressed the intensity or duration of telemonitoring required to sustain such improvements. PURPOSE: The DiaTel study (10 January 2005 to 1 November 2007) compared active care management (ACM) with home telemonitoring (n=73) to monthly care coordination (CC) telephone calls (n=77) among veterans with diabetes and suboptimal glycemic control. The purpose of the DiaTel Extension was to assess whether initial improvements could be sustained with interventions of the same or lower intensity among participants who re-enrolled in a 6-month extension of DiaTel. METHODS: DiaTel participants receiving ACM were re-assigned randomly to monthly CC calls with continued telemonitoring but no active medication management (ACM-to-CCHT, n=23) or monthly CC telephone calls (ACM-to-CC, n=21). DiaTel participants receiving CC were re-assigned randomly to continued CC (CC-to-CC, n=28) or usual care (UC, ie, CC-to-UC, n=29). Hemaglobin A1c (HbA1c) was assessed at 3 and 6 months following re-randomization. RESULTS: Marked HbA1c improvements observed in DiaTel ACM participants were sustained 6 months after re-randomization in both ACM-to-CCHT and ACM-to-CC groups. Lesser HbA1c improvements observed in DiaTel CC participants were sustained in both CC-to-CC and CC-to-UC groups. No benefit was apparent for continued transmission of glucose data among DiaTel ACM participants or continued monthly telephone calls among DiaTel CC participants 6 months after re-randomization. CONCLUSION: Significant improvements in HbA1c achieved using home telemonitoring and active medication management for 6 months were sustained 6 months later with interventions of decreased intensity in VA Health System-qualified veterans. CLINICAL TRIAL REG. NO: NCT00245882, http://www.clinicaltrials.gov.

Active care management supported by home telemonitoring in veterans with type 2 diabetes: the DiaTel randomized controlled trial.

OBJECTIVE We compared the short-term efficacy of home telemonitoring coupled with active medication management by a nurse practitioner with a monthly care coordination telephone call on glycemic control in veterans with type 2 diabetes and entry A1C > or =7.5%. RESEARCH DESIGN AND METHODS Veterans who received primary care at the VA Pittsburgh Healthcare System from June 2004 to December 2005, who were taking oral hypoglycemic agents and/or insulin for > or =1 year, and who had A1C > or =7.5% at enrollment were randomly assigned to either active care management with home telemonitoring (ACM+HT group, n = 73) or a monthly care coordination telephone call (CC group, n = 77). Both groups received monthly calls for diabetes education and self-management review. ACM+HT group participants transmitted blood glucose, blood pressure, and weight to a nurse practitioner using the Viterion 100 TeleHealth Monitor; the nurse practitioner adjusted medications for glucose, blood pressure, and lipid control based on established American Diabetes Association targets. Measures were obtained at baseline, 3-month, and 6-month visits. RESULTS Baseline characteristics were similar in both groups, with mean A1C of 9.4% (CC group) and 9.6% (ACM+HT group). Compared with the CC group, the ACM+HT group demonstrated significantly larger decreases in A1C at 3 months (1.7 vs. 0.7%) and 6 months (1.7 vs. 0.8%; P < 0.001 for each), with most improvement occurring by 3 months. CONCLUSIONS Compared with the CC group, the ACM+HT group demonstrated significantly greater reductions in A1C by 3 and 6 months. However, both interventions improved glycemic control in primary care patients with previously inadequate control.

Diabetes preventive care and non-traumatic lower extremity amputation rates.

Clinical performance monitoring data on processes of care from a 3-year period were used to assess whether preventive foot care was associated with improved health outcomes in diabetes mellitus patients. Preventive foot care as well as sensory and pedal-pulse examinations were associated with reduced rates of Lower extremity amputation. It is believed that an administrative focus, resource direction, and improvement in process monitoring will lead to better patient outcomes. External review measures can be used by administrators and cLinicians to determine trends in quality of care and patient outcomes andto provide feedback on prevention efforts.

Relevance of carotid stenosis progression as a predictor of ischemic neurological outcomes.

BACKGROUND: The progression of carotid stenosis may be a better predictor of adverse neurological outcomes than a single measurement of stenosis in asymptomatic patients. METHODS: Retrospective review of prospectively collected data from a noninvasive vascular surgery laboratory between 1988 and 1997 at a Veterans Affairs Medical Center. A total of 1701 carotid arteries from 1004 asymptomatic patients were prospectively followed by duplex ultrasonographic scanning. Carotid arteries treated with endarterectomy were excluded. The main outcome measures were ipsilateral transient ischemic attack (TIA) and cerebrovascular accident (CVA). RESULTS: The baseline degree of carotid stenosis was less than 50% of artery diameter in 75% of patients. The annual rates of ipsilateral TIA and CVA were each 3.3%. When categorized with respect to carotid artery, the annual rates of ipsilateral TIAs and CVAs were 2.0% and 2.1%, respectively. Univariable Cox proportional hazards modeling showed that both baseline carotid stenosis and progression of stenosis were significant predictors of the composite outcome TIA and CVA, as well as the outcome CVA alone. In multivariable modeling, the progression of carotid stenosis was a highly significant predictor of the composite outcome TIA and CVA (risk ratio [RR], 1.68; P<.001) and of CVA alone (RR, 1.78; P<.001). However, baseline stenosis was found to be a significant predictor of time to the combined outcome (RR, 1.29; P =.01) but not of CVA alone. Clinical risk factors did not add any additional predictive information. CONCLUSION: The progression of carotid stenosis assessed by serial duplex scanning is a better predictor of ischemic neurological events than a single measurement of stenosis.

Promotion criteria for clinician-educators.

OBJECTIVE: Department of medicine chairs have a critical role in the promotion of clinician-educators. Our primary objective was to determine how chairs viewed: 1) the importance of specific areas of clinician-educator performance in promotion decisions; and 2) the importance and quality of information on available measures of performance. A secondary objective was to compare the views of department chairs with those of promotion and tenure committee chairs. METHODS: In October 1997, a questionnaire was mailed to all department chairs in the United States and Canada asking them to rate the importance of 11 areas of clinician-educators' performance in evaluating them for promotion. We also asked them to rate 36 measures of performance. We compared their responses to a similar 1996 survey administered to promotion committee chairs. RESULTS: One hundred fourteen of 139 department chairs (82%) responded to the survey. When considering a clinician-educator for promotion, department chairs view teaching skills and clinical skills as the most important areas of performance, as did the promotion committee chairs. Of the measures used to evaluate teaching performance, teaching awards were considered most important and rated as a high-quality measure. When evaluating a clinician-educator's clinical skills, peer and trainee evaluation were considered as the most important measures of performance, but these were rated low in quality. Patient satisfaction and objective outcome measures also were viewed as important measures that needed improvement. Promotion committee chairs placed more emphasis on productivity in publications and external grant support when compared to department chairs. CONCLUSION: It is reassuring that both department chairs and promotion committee chairs value teaching skills and clinical skills as the most important areas of a clinician-educator's performance when evaluating for promotion. However, differences in opinion regarding the importance of several performance measures and the need for improved quality measures may represent barriers to the timely promotion of clinician-educators.

Guideline chaos: conflicting recommendations for preoperative cardiac assessment.

The American College of Cardiology/American Heart Association (ACC/AHA) and the American College of Physicians (ACP) have disseminated guidelines to assess preoperative cardiac risks before noncardiac surgery. The objectives of this study were to determine if these guidelines differ in preoperative recommendations for a group of patients, and whether these recommendations differ from actual provider recommendations. In this retrospective cohort study, patient characteristics and physician recommendations were abstracted from electronic medical records of consecutive patients attending a Veteran Affairs medical preoperative evaluation clinic from January 1 to April 1, 1998. Patient characteristics were used to determine what preoperative cardiac testing should have been ordered if each guideline was followed. Possible recommendations included operation without testing (OWT), noninvasive stress testing (NST), cardiac catheterization (CC), or cancel or delay surgery (OTHER). Recommendations were compared using statistical tests for agreement. Of the 138 patients identified, most underwent moderate-risk surgeries. Recommendations for preoperative testing were discordant between guidelines for 17% of patients (kappa = 0.38). Guidelines never agreed on the need for NST. Extreme differences in recommendations (i.e., one recommends OWT, the other CC) occurred in 9 patients (7%). Physicians ordered NST more often (n = 27) than either guideline. In this subgroup of patients where providers ordered a NST, the 2 guidelines significantly differed (kappa = 0.26). When applied to real patients being evaluated for surgery, ACC/AHA and ACP guidelines significantly differed in recommendations for preoperative cardiac testing. Results have implications for implementation, management, and practitioner adherence to published guidelines.

The case against routine preoperative laboratory testing.

In this article, we have shown that almost all "routine" laboratory tests before surgery have limited clinical value. Clinicians should order only a small number of routine tests based on age as noted in Table 13. Selective use of other preoperative tests should be based on history and physical examination findings that identify subgroups of patients who are more likely to have abnormal results. In general, clinicians should order tests only if the outcome of an abnormal test will influence management. When an abnormal test results from such testing, it is critical that physicians document their thinking about the result. Most routine preoperative tests are neither expensive nor risky. For this reason, clinicians can have a low threshold for ordering these tests in patients for whom the frequency of abnormalities is increased compared with a healthy population. We believe that physicians should not be criticized for selective test ordering before surgery. Physicians and institutions recommending routine preoperative testing for all patients provide no clinical value to their patients at considerable cost.

Black-white differences in severity of coronary artery disease among individuals with acute coronary syndromes.

OBJECTIVE: To determine whether the extent of coronary obstructive disease is similar among black and white patients with acute coronary syndromes. DESIGN: Retrospective chart review. PATIENTS: We used administrative discharge data to identify white and black male patients, 30 years of age or older, who were discharged between October 1, 1989 and September 30, 1995 from 1 of 6 Department of Veterans Affairs (VA) hospitals with a primary diagnosis of acute myocardial infarction (AMI) or unstable angina (UnA) and who underwent coronary angiography during the admission. We excluded patients if they did not meet standard clinical criteria for AMI or UnA or if they had had prior percutaneous transluminal coronary angioplasty or coronary artery bypass grafting. MEASUREMENTS AND MAIN RESULTS: Physician reviewers classified the degree of coronary obstruction from blinded coronary angiography reports. Obstruction was considered significant if there was at least 50% obstruction of the left main coronary artery, or if there was 70% obstruction in 1 of the 3 major epicardial vessels or their main branches. Of the 628 eligible patients, 300 (48%) had AMI. Among patients with AMI, blacks were more likely than whites to have no significant coronary obstructions (28/145, or 19%, vs 10/155 or 7%, P =.001). Similarly, among patients with UnA, 33% (56/168) of blacks but just 17% (27/160) of whites had no significant stenoses (P =.012). There were no racial differences in severity of coronary disease among veterans with at least 1 significant obstruction. Racial differences in coronary obstructions remained after correcting for coronary disease risk factors and characteristics of the AMI. CONCLUSIONS: Black veterans who present with acute coronary insufficiency are less likely than whites to have significant coronary obstruction. Current understanding of coronary disease does not provide an explanation for these differences.