Independent Associations of Aortic Calcification with Cirrhosis and Liver Related Mortality in Veterans with Chronic Liver Disease.

INTRODUCTION: Abdominal aortic calcifications (AAC) are incidentally found on medical imaging and useful cardiovascular burden approximations. The Morphomic Aortic Calcification Score (MAC) leverages automated deep learning methods to quantify and score AACs. While associations of AAC and non-alcoholic fatty liver disease (NAFLD) have been described, relationships of AAC with other liver diseases and clinical outcome are sparse. This study's purpose was to evaluate AAC and liver-related death in a cohort of Veterans with chronic liver disease (CLD). METHODS: We utilized the VISN 10 CLD cohort, a regional cohort of Veterans with the three forms of CLD: NAFLD, hepatitis C (HCV), alcohol-associated (ETOH), seen between 2008 and 2014, with abdominal CT scans (n = 3604). Associations between MAC and cirrhosis development, liver decompensation, liver-related death, and overall death were evaluated with Cox proportional hazard models. RESULTS: The full cohort demonstrated strong associations of MAC and cirrhosis after adjustment: HR 2.13 (95% CI 1.63, 2.78), decompensation HR 2.19 (95% CI 1.60, 3.02), liver-related death HR 2.13 (95% CI 1.46, 3.11), and overall death HR 1.47 (95% CI 1.27, 1.71). These associations seemed to be driven by the non-NAFLD groups for decompensation and liver-related death [HR 2.80 (95% CI 1.52, 5.17; HR 2.34 (95% CI 1.14, 4.83), respectively]. DISCUSSION: MAC was strongly and independently associated with cirrhosis, liver decompensation, liver-related death, and overall death. Surprisingly, stratification results demonstrated comparable or stronger associations among those with non-NAFLD etiology. These findings suggest abdominal aortic calcification may predict liver disease severity and clinical outcomes in patients with CLD.

Evaluating feedback reports to support documentation of veterans' care preferences in home based primary care.

BACKGROUND: To evaluate the effectiveness of delivering feedback reports to increase completion of LST notes among VA Home Based Primary Care (HBPC) teams. The Life Sustaining Treatment Decisions Initiative (LSTDI) was implemented throughout the Veterans Health Administration (VHA) in the United States in 2017 to ensure that seriously ill Veterans have care goals and LST decisions elicited and documented. METHODS: We distributed monthly feedback reports summarizing LST template completion rates to 13 HBPC intervention sites between October 2018 and February 2020 as the sole implementation strategy. We used principal component analyses to match intervention to 26 comparison sites and used interrupted time series/segmented regression analyses to evaluate the differences in LST template completion rates between intervention and comparison sites. Data were extracted from national databases for VA HBPC in addition to interviews and surveys in a mixed methods process evaluation. RESULTS: LST template completion rose from 6.3 to 41.9% across both intervention and comparison HBPC teams between March 1, 2018, and February 26, 2020. There were no statistically significant differences for intervention sites that received feedback reports. CONCLUSIONS: Feedback reports did not increase documentation of LST preferences for Veterans at intervention compared with comparison sites. Observed increases in completion rates across intervention and comparison sites can likely be attributed to implementation strategies used nationally as part of the national roll-out of the LSTDI. Our results suggest that feedback reports alone were not an effective implementation strategy to augment national implementation strategies in HBPC teams.

Envisioning clinical trials as complex interventions.

Clinical trials are critical components of modern health care and infrastructure. Trials benefit society through scientific advancement and individual patients through trial participation. In fact, billions of dollars are spent annually in support of these benefits. Despite the massive investments, clinical trials often fail to accomplish their primary aims and trial enrollment rates remain low. Prior efforts to improve trial conduct and enrollment have had limited success, perhaps due to oversimplification of the complex, multilevel nature of trials. For these reasons, the authors propose applying implementation science to the clinical trials context. In this commentary, the authors posit clinical trials as complex, multilevel evidence-based interventions with significant societal and individual benefits yet with persistent gaps in implementation. An application of implementation science concepts to the clinical trials context as means to build common vocabulary and establish a platform for applying implementation science and practice to improve clinical trial conduct is introduced. Applying implementation science to the clinical trials context can augment improvement efforts and build capacity for better and more efficient evidence-based care for all patients and trial stakeholders throughout the clinical trials enterprise.

Focus group study of factors relevant to treatment decisions and experiences among patients with symptomatic peripheral artery disease.

BACKGROUND: Clinical guidelines recommend shared decision-making for treatment of peripheral artery disease (PAD), which requires understanding of patient perspectives and preferences. We conducted a focus group study of patients with symptomatic PAD to identify factors important and relevant to treatment choices, and to characterize aspects of the health care process that contribute to positive vs negative experiences apart from the specific treatment(s) received. METHODS: Participants were recruited from an academic medical center over 2 years using a purposeful sampling approach based on a clinical diagnosis of symptomatic PAD (either claudication or chronic limb-threatening ischemia [CLTI]) confirmed by the abnormal ankle or toe brachial index. Focus groups were led by a nonphysician moderator, consisted of 5 to 12 participants, and were conducted separately for patients with CLTI and claudication. Audio recordings converted to verbatim transcripts were used for qualitative analysis. RESULTS: A total of 51 patients (26 with CLTI and 25 with claudication) were enrolled and participated in focus groups. Major themes identified related to treatment preferences and decisions included specific interventions under consideration, the chance of technical success versus failure, anticipated degree of symptom improvement, outcome durability, and risk. Major themes related to the process of care included decision-making input, provider communication and trust, the timeline from diagnosis to definitive treatment, and compartmentalized care (including different venues of care). CONCLUSIONS: The results provide insights into patient preferences, perspectives, and experiences related to PAD treatment. These observations can be used to inform patient-centered approaches to shared decision-making, communication, and assessment of PAD treatment outcomes.

Improving the delivery of team-based survivorship care after primary breast cancer treatment through a multi-level intervention: a pilot randomized controlled trial.

PURPOSE: We developed and tested a multi-level intervention, ConnectedCancerCare (CCC), which includes a tailored website and appointment reminder system for women with early-stage breast cancer and a provider summary letter sent to their medical oncologist and primary care provider to improve the delivery of team-based survivorship care. METHODS: We conducted a pilot randomized controlled trial to establish the feasibility and acceptability of CCC. Women diagnosed with stages 0-II breast cancer within one year of completing primary treatment were randomized to CCC (intervention) or a static online survivorship care plan (control). Participants completed baseline and 3-month follow-up surveys online. Post-trial interviews with 5 PCPs, 6 oncology providers, and 8 intervention patients were conducted. RESULTS: Of the 160 eligible women invited to participate, 66 completed the baseline survey and were randomized (41%) and 54 completed a follow-up survey (83%). Participants in the intervention arm found the CCC content to be acceptable, with 82% reporting it was easy to use and 86% reporting they would recommend it to other patients. Women randomized to CCC (vs. control) more often reported scheduling a PCP follow-up visit (64% vs. 42%), communicating with their PCP about provider roles (67% vs. 18%), and higher mean team-based cancer care knowledge scores (3.7 vs. 3.4). CONCLUSION: Deploying CCC in medical oncology practices was feasible, and the intervention content was acceptable. CCC shows promise for improving patient knowledge and patient-provider communication about provider roles in team-based cancer care and encouraging patients to engage with their PCP early in the survivorship period.

Using Health Systems Engineering Approaches to Prepare for Tailoring of Implementation Interventions.

BACKGROUND: Implementation of evidence-based practices often requires tailoring implementation strategies to local contextual factors, including available resources, expertise, and cultural norms. Using an exemplar case, we describe how health systems engineering methods can be used to understand system-level variation that must be accounted for prior to broad implementation. METHODS: Within the context of a single-center quality improvement activity, a multi-disciplinary stakeholder team used health systems engineering methods to describe how pre-endoscopy antithrombotic management was executed, and implemented a redesigned process to improve clinical care. The research team then conducted multiple stakeholder focus groups at four different health-care systems to describe and compare current processes for pre-endoscopy antithrombotic medication management. Detailed work flow maps for each health-care system were developed, analyzed, and integrated to develop an overarching current work flow map, identify key process steps, and describe areas of process variation. RESULTS: Five key process steps were identified across the four health systems: (1) place an endoscopy order, (2) screen for antithrombotic use, (3) coordinate medication management, (4) instruct the patient, and (5) confirm appropriate medication management before procedure. Across health systems, we found a high degree of variation in each step (e.g., who performed, use of technology, systematic vs. ad hoc process). This variation was influenced by two key system-level contextual factors: (1) degree of health system integration and (2) role and training level of available staff. These key steps, areas of variation, and contextual factors were integrated into an assessment tool designed to facilitate tailoring of a future implementation and dissemination strategy. CONCLUSIONS: Tools from health systems engineering can be used to identify key work flow process steps, variations in how those steps are executed, and influential contextual factors. This process and the associated assessment tool may facilitate broader implementation tailoring.

Implementation Strategies for Web-Based Apps for Screening: Scoping Review.

BACKGROUND: Screening is an effective primary prevention strategy in health care, as it enables the early detection of diseases. However, the uptake of such screening remains low. Different delivery methods for screening have been developed and found to be effective in increasing the uptake of screening, including the use of web-based apps. Studies have shown that web-based apps for screening are effective in increasing the uptake of health screening among the general population. However, not much is known about the effective implementation of such web-based apps in the real-world setting. Implementation strategies are theory-based methods or techniques used to enhance the adoption, implementation, and sustainability of evidence-based interventions. Implementation strategies are important, as they allow us to understand how to implement an evidence-based intervention. Therefore, a scoping review to identify the various implementation strategies for web-based apps for screening is warranted. OBJECTIVE: This scoping review aims to identify (1) strategies used to implement web-based apps for health screening, (2) frameworks used for implementing web-based apps for health screening, (3) outcome measures of implementation strategies, and (4) effective implementation strategies. METHODS: This scoping review was conducted based on Arksey and O'Malley's framework. After identifying the review question, two researchers independently screened and selected relevant literature from PubMed, Embase, Cochrane, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, International Standard Randomised Controlled Trial Number Registry, OpenGrey, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and Web of Science. This was followed by charting the data using a standardized form. Finally, we collated, summarized, and reported the results quantitatively and qualitatively based on the review objectives. RESULTS: A total of 16,476 studies were retrieved, of which 5669 were duplicates. From a total of 10,807 studies, 10,784 studies were excluded based on their titles and abstracts. There were 23 full-text articles reviewed, and 4 articles were included in the final analysis. Many studies were excluded because they focused on the effectiveness and not on the implementation of web-based apps. Facilitation was the most cited implementation strategy used, followed by reminders, clinical champions, and educational meetings and materials. Only 2 studies used implementation frameworks to guide the evaluation of their studies. Common outcome measures for implementation strategies were feasibility, fidelity, and penetration. Implementation strategies reported to be effective were quality improvement meetings, facilitation, educational meetings, and clinical champions. CONCLUSIONS: There is a dearth of literature on the implementation of web-based apps for health screening. Implementation strategies were developed without any reported use of implementation theories or frameworks in most studies. More research on the development and evaluation of web-based screening app implementations is needed.

Comparable, but distinct: Perceptions of primary care provided by physicians and nurse practitioners in full and restricted practice authority states.

AIMS: To understand patients' and providers' perceptions of primary care delivered by nurse practitioners (NPs) in the Veterans Affairs Healthcare System. DESIGN: Qualitative exploratory study (in convergent mixed-methods design). METHODS: Semi-structured interviews in 2016 with primary care providers and patients from facilities in states with full and restricted practice authority for NPs. Patient sample based on reassignment to: (a) a NP; or (b) a different physician following an established physician relationship. Data were analysed using content analysis. RESULTS: We interviewed 28 patients, 17 physicians and 14 NPs. We found: (a) NPs provided more holistic care than physicians; (b) patients were satisfied with NPs; and (c) providers' professional experience outweighed provider type. CONCLUSIONS: Patients' preferences for NPs (compared with prior physicians) contributed to perceptions of patient centredness. Similarities in providers' perceptions suggest NPs and physicians are both viable providers for primary care. IMPACT: Nurse Practitioners (NPs): practice authority Veterans Affairs Health care: nurse practitioners will continue to be a viable resource for primary care delivery United States Health care: challenges notions patients may not be satisfied with care provided by NPs and supports expanding their use to provide much-needed access to primary care services; expanding Full Practice Authority would allow states to provide acceptable primary care without diminishing patient or provider experiences.

The "secret sauce" for a mentored training program: qualitative perspectives of trainees in implementation research for cancer control.

BACKGROUND: Mentored training approaches help build capacity for research through mentoring networks and skill building activities. Capacity for dissemination and implementation (D&I) research in cancer is needed and mentored training programs have been developed. Evaluation of mentored training programs through quantitative approaches often provides us with information on "what" improved for participants. Qualitative approaches provide a deeper understanding of "how" programs work best. METHODS: Qualitative interviews were conducted with 21 fellows of the National Cancer Institute-funded Mentored Training for Dissemination and Implementation in Cancer to gain understanding of their experiences with mentoring received during the program. Fellows were selected from all 55 trained participants based upon their gain in D&I research skills (highest and lowest) and number of collaborative connections in the program network (highest and lowest) reported in previous quantitative surveys. Phone interviews were recorded with permission, transcribed verbatim, and de-identified for analysis. Codes were developed a priori to reflect interview guide concepts followed by further development and iterative coding of three common themes that emerged: 1) program and mentoring structure, 2) importance of mentor attributes, and 3) enhanced capacity: credentials, confidence, credibility and connections. RESULTS: Interviews provided valuable information about program components that worked best and impacts attributed to participation in the program. Fellows reported that regular monthly check-in calls with mentors helped to keep their research moving forward and that group mentoring structures aided in their learning of basic D&I research concepts and their application. Accessible, responsive, and knowledgeable mentors were commonly mentioned by fellows as a key to their success in the program. Fellows mentioned various forms of impact that they attributed to their participation in the program including gaining credibility in the field, a network of peers and experts, and career developments (e.g., collaborative publications and grant funding). CONCLUSIONS: These findings suggest that mentored training works best when mentoring is structured and coupled with applied learning and when respected and dedicated mentors are on board. Increased scientific collaborations and credibility within a recognized network are important trainee experiences that should be considered when designing, implementing, and sustaining mentored training programs.

Use of an audit with feedback implementation strategy to promote medication error reporting by nurses.

AIMS AND OBJECTIVES: To outline the development and effect of an audit with feedback implementation strategy that intended to increase the rate of voluntary medication error reporting by nurses. BACKGROUND: Medication errors are a serious global health issue. Audit with feedback is a widely used implementation strategy that has potential to modify nurses' reporting behaviour and improve medication error reporting rates. DESIGN: Quasi-experimental implementation study (fulfilling the TIDieR checklist) with two pairs of matched wards at a private hospital in Australia was conducted from March 2015-September 2016. One ward from each pair was randomised to either the intervention or control group. METHOD: Nurses within intervention wards received audit with feedback on a quarterly basis over a 12-month implementation period. Control wards underwent quarterly audits only (without feedback). Feedback consisted of a one-page infographic poster, with content based on medication error data obtained from audits and the hospitals' risk management system (RiskMan). The primary outcome-rate of medication errors reported per month-was determined in both groups at pre-implementation, implementation and postimplementation phases. Differences between groups were compared using generalised linear mixed models with Poisson distribution and log link. RESULTS: A nonsignificant intervention effect was found for rate of medication errors reported per month. Interestingly, when combining data from both groups, a significant increasing time trend was observed for medication errors reported per month across pre-implementation and implementation phases (80% increase). CONCLUSIONS: The audit with feedback strategy developed in the present study did not effectively influence the voluntary reporting of medication errors by nurses. RELEVANCE TO CLINICAL PRACTICE: Despite the lack of intervention effects, the use of a published checklist to optimise the reporting quality of this study will contribute to the field by furthering the understanding of how to enhance audit with feedback implementation strategies for nurses.

Virtual Consultations Through the Veterans Administration SCAN-ECHO Project Improves Survival for Veterans With Liver Disease.

Access to specialty care has been associated with improved survival in patients with liver disease but universal access is not always feasible. Methods of care delivery using virtual modalities including the SCAN-ECHO (Specialty Access Network-Extension of Community Healthcare Outcome) program were implemented by the Veterans Health Administration (VHA) to address this need but limited data are available on patient outcomes. We sought to evaluate the efficacy of a SCAN-ECHO visit within the context of a regional cohort of patients with liver disease in the VHA (n = 62,237) following implementation in the Ann Arbor SCAN-ECHO Liver Clinic from June 1, 2011, to March 31, 2015. The effect of a SCAN-ECHO visit on all-cause mortality was compared with patients with no liver clinic visit. To adjust for the differences among patients who had a SCAN-ECHO visit versus those with no visit, propensity score matching was performed on condition factors that affect the likelihood of a SCAN-ECHO visit: demographics, geographic location, liver disease diagnosis, severity, and comorbidities. During the study period, 513 patients who had a liver SCAN-ECHO visit were found within the cohort. Patients who had completed a virtual SCAN-ECHO visit were more likely younger, rural, with more significant liver disease, and evidence for cirrhosis. Propensity-adjusted mortality rates using the Cox Proportional Hazard Model showed that a SCAN-ECHO visit was associated with a hazard ratio of 0.54 (95% confidence interval 0.36-0.81, P = 0.003) compared with no visit. Conclusion: Improved survival in patients using SCAN-ECHO suggests that this approach may be an effective method to improve access for selected patients with liver disease, particularly in rural and underserved populations where access to specialty care is limited.

Scope, Themes, and Medical Accuracy of eHealth Peripheral Artery Disease Community Forums.

BACKGROUND: The availability of electronic health (eHealth) information and disease-related community forums has grown over the last decade. Although patients and families frequently use these resources, their content has not been characterized in terms users, content, or reliability of information. eHealth communities therefore represent a potentially valuable but uncharted source of information about key patient issues, communication terminology, and unmet needs. We hypothesized that eHealth forums would contain terminology, themes, and advice inconsistent with resources from medical providers and references. To test this hypothesis, we performed a qualitative analysis of posts and responses from an open-access peripheral artery disease (PAD) eHealth community forum to characterize the discussion, participants, and the information being exchanged. METHODS: Posts were collected from an online PAD Medical Support Community forum (MedHelp), which is open access, does not require participants to identify themselves, and is based in the United States. Posts were selected from threads in which the main topic was PAD, including diagnosis, symptoms, and treatment. Original posts and related responses were analyzed for thematic content, common vernacular, and self-reported characteristics of the participants using a qualitative analysis software program. Disease-specific comments and advice were evaluated for congruence with contemporary PAD treatment guidelines. RESULTS: A total of 103 posts were collected and analyzed, including 40 original posts and 63 responses. Forty-five percent of the original posts and 19% of the responses were authored by participants who self-identified as patients with PAD. The remaining posts were authored by people with undeclared relationships to patients with PAD, followed by children, spouses, and other relatives. The most common themes among original posts included PAD diagnosis (and differential) (25%), treatment (23%), epidemiology and pathophysiology (21%), disease symptoms and impacts on activities of daily living (15%), and health-care provider recommendations (13%). Themes of responses included medical advice (40.5%), personal experiences with PAD (32.8%), and social support (12.6%). Negative attitudes were identified in 10 of 18 (55.6%) posts related to experiences with health-care providers. Of all medical advice, 15.1% was inconsistent with clinical treatment guidelines. CONCLUSION: eHealth communities are a rich source of information related to the experiences of patients with PAD, their treatment preferences, questions they consider important, and terminology that they use. This information can be used to understand unmet patient needs, develop educational resources, and improve communication.

Understanding determinants of acute stroke thrombolysis using the tailored implementation for chronic diseases framework: a qualitative study.

BACKGROUND: The Tailored Implementation in Chronic Disease (TICD) framework is a comprehensive framework describing the determinants of implementation success that has been used extensively in primary care settings. We explored the utility of the TICD to identify determinants of practice in an acute setting, namely guideline concordant acute stroke thrombolysis in a low-resourced, predominately minority serving, large, Emergency Department (ED). METHODS: Through workshops and expert review, we developed an interview guide informed by the TICD framework. We then conducted semi-structured interviews with data collected through written transcripts, audio transcripts or interviewer notes based on participant availability. Three independent coders then performed a content analysis using template analysis, but open to new determinants that arose from the data, into the TICD framework. RESULTS: We performed a total of 15 semi-structured interviews with ED acute stroke providers including medical technicians, nurses, and physicians. We found that guideline factors, individual health professional factors, and patient factors domains were barriers to guideline concordant acute stroke thrombolysis. The domain professional interactions was a facilitator to treatment. We identified three determinants, healthcare professional burnout, health care professional turnover and surrogate decision making, that are not part of the TICD framework. CONCLUSIONS: Most determinants of acute stroke thrombolysis are included within the TICD framework. Inclusion of healthcare professional burnout, healthcare professional turnover and surrogate decision making may assist in expanding the TICD to time-sensitive ED conditions. Further work is needed to confirm this finding and to establish whether the TICD is applicable for use in non-time sensitive ED conditions. Interventions that address guideline, individual health professional and patient factors may improve guideline concordant acute stroke thrombolysis.

Partnership to Enhance Resident Outcomes for Community Living Center Residents With Dementia: Description of the Protocol and Preliminary Findings.

The goal of this quality improvement project is to improve care planning around preferences for life-sustaining treatments (LST) and daily care to promote quality of life, autonomy, and safety for U.S. Department of Veterans Affairs (VA) Community Living Center (CLC) (i.e., nursing home) residents with dementia. The care planning process occurs through partnerships between staff and family surrogate decision makers. This process is separate from but supports implementation of the LST Decision Initiative-developed by the VA National Center for Ethics in Health Care-which seeks to increase the number, quality, and documentation of goals of care conversations (GOCC) with Veterans who have life-limiting illnesses. The current authors will engage four to six VA CLCs in the Mid-Atlantic states, provide teams with audit and feedback reports, and establish learning collaboratives to address implementation concerns and support action planning. The expected outcomes are an increase in CLC residents with dementia who have documented GOCC and LST plans. [Journal of Gerontological Nursing, 45(3), 21-30.].

The implications of baseline bone-health assessment at initiation of androgen-deprivation therapy for prostate cancer.

OBJECTIVES: To assess bone-density testing (BDT) use amongst prostate cancer survivors receiving androgen-deprivation therapy (ADT), and downstream implications for osteoporosis and fracture diagnoses, as well as pharmacological osteoporosis treatment in a national integrated delivery system. PATIENTS AND METHODS: We identified 17 017 men with prostate cancer who received any ADT between 2005 and 2014 using the Veterans Health Administration cancer registry and administrative data. We identified claims for BDT within a 3-year period of ADT initiation. We then used multivariable regression to examine the association between BDT use and incident osteoporosis, fracture, and use of pharmacological treatment. RESULTS: We found that a minority of patients received BDT (n = 2 502, 15%); however, the rate of testing increased to >20% by the end of the study period. Men receiving BDT were older at diagnosis and had higher-risk prostate cancer (both P < 0.001). Osteoporosis and fracture diagnoses, use of vitamin D ± calcium, and bisphosphonates were all more common in men who received BDT. After adjustment, BDT, and to a lesser degree ≥2 years of ADT, were both independently associated with incident osteoporosis, fracture, and osteoporosis treatment. CONCLUSIONS: BDT is rare amongst patients with prostate cancer treated with ADT in this integrated delivery system. However, BDT was associated with substantially increased treatment of osteoporosis indicating an underappreciated burden of osteoporosis amongst prostate cancer survivors initiating ADT. Optimising BDT use and osteoporosis management in this at-risk population appears warranted.

Assessing Responsiveness of Health Systems to Drug Safety Warnings.

OBJECTIVE: In 2011-2012 the U.S. Food and Drug Administration (FDA) issued safety announcements cautioning providers against prescribing high doses of citalopram given concerns for QT prolongation. The authors evaluated Veterans Affairs (VA) national trends in citalopram use and dose compared with alternative antidepressants after the FDA warnings. METHODS: Time series analyses estimated the effect of the FDA warnings on citalopram and other antidepressant across three periods: before the first FDA warning in August 2011, after the 2011 FDA warning until the second warning in March 2012, and after the 2012 FDA warning. In a National VA health system, adult VA outpatients prescribed citalopram or alternative antidepressants from February 2010 to September 2013 were studied. Outpatient use of high-dose citalopram (>40 or >20 mg daily in adults aged > 60 years) including the proportion of patients prescribed citalopram and difference between study periods. RESULTS: Between the first and second FDA warnings, among patients aged 18-60, high-dose citalopram use decreased by 2.0% per month (p < 0.001) and by 1.9% per month (p < 0.001) for older adults. After the second FDA warning in 2012, 30.7% of older patients remained on doses higher than the newly recommended dose of 20 mg. Reductions in overall use of citalopram were accompanied by significant increases in prescriptions of alternative antidepressants, with sertraline most widely prescribed. CONCLUSION: Although trends in high-dose citalopram use declined after the 2011-2012 FDA warnings, roughly one-third of older adults still remained on higher than recommended doses. Concomitant increases in sertraline and other antidepressant prescriptions suggest potential substitution of these medications for citalopram.

Accelerating Research Impact in a Learning Health Care System: VA's Quality Enhancement Research Initiative in the Choice Act Era.

BACKGROUND: Since 1998, the Veterans Health Administration (VHA) Quality Enhancement Research Initiative (QUERI) has supported more rapid implementation of research into clinical practice. OBJECTIVES: With the passage of the Veterans Access, Choice and Accountability Act of 2014 (Choice Act), QUERI further evolved to support VHA's transformation into a Learning Health Care System by aligning science with clinical priority goals based on a strategic planning process and alignment of funding priorities with updated VHA priority goals in response to the Choice Act. DESIGN: QUERI updated its strategic goals in response to independent assessments mandated by the Choice Act that recommended VHA reduce variation in care by providing a clear path to implement best practices. Specifically, QUERI updated its application process to ensure its centers (Programs) focus on cross-cutting VHA priorities and specify roadmaps for implementation of research-informed practices across different settings. QUERI also increased funding for scientific evaluations of the Choice Act and other policies in response to Commission on Care recommendations. RESULTS: QUERI's national network of Programs deploys effective practices using implementation strategies across different settings. QUERI Choice Act evaluations informed the law's further implementation, setting the stage for additional rigorous national evaluations of other VHA programs and policies including community provider networks. CONCLUSIONS: Grounded in implementation science and evidence-based policy, QUERI serves as an example of how to operationalize core components of a Learning Health Care System, notably through rigorous evaluation and scientific testing of implementation strategies to ultimately reduce variation in quality and improve overall population health.

Detecting the presence of an indwelling urinary catheter and urinary symptoms in hospitalized patients using natural language processing.

OBJECTIVE: To develop a natural language processing pipeline to extract positively asserted concepts related to the presence of an indwelling urinary catheter in hospitalized patients from the free text of the electronic medical note. The goal is to assist infection preventionists and other healthcare professionals in determining whether a patient has an indwelling urinary catheter when a catheter-associated urinary tract infection is suspected. Currently, data on indwelling urinary catheters is not consistently captured in the electronic medical record in structured format and thus cannot be reliably extracted for clinical and research purposes. MATERIALS AND METHODS: We developed a lexicon of terms related to indwelling urinary catheters and urinary symptoms based on domain knowledge, prior experience in the field, and review of medical notes. A reference standard of 1595 randomly selected documents from inpatient admissions was annotated by human reviewers to identify all positively and negatively asserted concepts related to indwelling urinary catheters. We trained a natural language processing pipeline based on the V3NLP framework using 1050 documents and tested on 545 documents to determine agreement with the human reference standard. Metrics reported are positive predictive value and recall. RESULTS: The lexicon contained 590 terms related to the presence of an indwelling urinary catheter in various categories including insertion, care, change, and removal of urinary catheters and 67 terms for urinary symptoms. Nursing notes were the most frequent inpatient note titles in the reference standard document corpus; these also yielded the highest number of positively asserted concepts with respect to urinary catheters. Comparing the performance of the natural language processing pipeline against the human reference standard, the overall recall was 75% and positive predictive value was 99% on the training set; on the testing set, the recall was 72% and positive predictive value was 98%. The performance on extracting urinary symptoms (including fever) was high with recall and precision greater than 90%. CONCLUSIONS: We have shown that it is possible to identify the presence of an indwelling urinary catheter and urinary symptoms from the free text of electronic medical notes from inpatients using natural language processing. These are two key steps in developing automated protocols to assist humans in large-scale review of patient charts for catheter-associated urinary tract infection. The challenges associated with extracting indwelling urinary catheter-related concepts also inform the design of electronic medical record templates to reliably and consistently capture data on indwelling urinary catheters.

Specialty Care Access Network-Extension of Community Healthcare Outcomes Model Program for Liver Disease Improves Specialty Care Access.

BACKGROUND AND AIMS: To improve subspecialty access, VA Ann Arbor Healthcare System (VAAAHS) implemented the first Specialty Care Access Network (SCAN)-Extension of Community Healthcare Outcomes (ECHO) in chronic liver disease. SCAN-ECHO Liver links primary care providers (PCPs) to hepatologists via secure video-teleconferencing. We aim to describe characteristics of participants (PCPs) and patients (clinical question and diagnosis) in SCAN-ECHO Liver. METHODS: This is a prospective study of the VAAAHS SCAN-ECHO Liver (June 10, 2011-March 31, 2015). This evaluation was carried out as a non-research activity under the guidance furnished by VHA Handbook 1058.05. It was approved through the Medicine Service at VAAAHS as noted in the attestation document which serves as documentation of approved non-research, quality improvement activities in VHA. RESULTS: In total, 106 PCPs from 23 sites participated. A total of 155 SCAN-ECHO sessions discussed 519 new and 49 return patients. 29.4% of Liver Clinic requests were completed in SCAN-ECHO Liver. SCAN-ECHO Liver consults were completed an average of 10 days sooner than in conventional clinic. Potential travel saving was 250 miles round-trip (median 255 (IQR 142-316) per patient. CONCLUSION: SCAN-ECHO Liver provided specialty care with increased efficiency and convenience for chronic liver disease patients. One of three of Liver Clinic consults was diverted to SCAN-ECHO Liver, reducing consult completion time by 20%.