Evidence-based practice and patient-centered care: Doing both well.

BACKGROUND: Health care organizations increasingly strive to deliver care that is both evidence based and patient centered. Although often complementary, fundamental contradictions may exist between these goals, and the organizational culture and infrastructure necessary to be successful in one domain may inherently diminish performance in the other. PURPOSE: We assessed the relationship between evidence-based practice (EBP) and patient-centered care (PCC) by seeking to identify specific behavioral and process mechanisms, along with organizational characteristics that distinguish medical centers that are able to provide inpatient care that is both evidence based and patient centered from those where performance is either mixed or low in both domains. METHODOLOGY/APPROACH: We analyzed interview data from 142 employees at 12 Veterans Affairs Medical Centers selected based on EBP and PCC performance (high, low, or mixed) using a priori constructs consistent with organizational literature, as well as emergent themes. RESULTS: We confirmed that tensions may arise when attempting to deliver both EBP and PCC and found unique characteristics of organizations that do both well. High-performing sites exhibited organizational cultures of empowerment where both EBP and PCC expectations were emphasized; provided formal and informal institutional supports and structures with regard to PCC and EBP; and fostered multidisciplinary, multidirectional approaches to care and communication that facilitated delivery of both EBP and PCC. CONCLUSIONS AND PRACTICE IMPLICATIONS: Organizations that excel in providing both EBP and PCC exhibit unique characteristics and processes. Recognizing that some characteristics such as culture are difficult to change, these findings nonetheless highlight areas that could be enhanced by medical centers striving to deliver care that is both evidence based and patient centered.

Organizational Coordination and Patient Experiences of Specialty Care Integration.

BACKGROUND: Delivering care to patients with complex healthcare needs benefits from coordination among healthcare providers. Greater levels of care coordination have been associated with more favorable patient experiences, cost management, and lower utilization of services. Organizational approaches consider how systems, practices, and relationships influence coordination and associated outcomes. OBJECTIVE: Examine measures of organizational coordination and their association with patient experiences of care coordination involving specialists. DESIGN: Cross-sectional surveys of patients and primary care providers (PCPs). PARTICIPANTS: Final sample included 3183 patients matched to 233 PCPs from the Veterans Health Administration. All patients had a diagnosis of type 2 diabetes mellitus and one of four other conditions: hypertension; congestive heart failure; depression/anxiety; or severe mental illness/posttraumatic stress disorder. MAIN MEASURES: Patients completed a survey assessing perceptions of coordinated care. We examined ratings on three domains: specialist knowledge management; knowledge integration across settings and time; and knowledge fragmentation across settings and time. We created care coordination measures involving the PCP and three specialty provider types. PCPs provided ratings on relational coordination for specialists, feedback coordination, and team coordination. We aligned patient's specialty services used with corresponding PCP ratings of that specialty. KEY RESULTS: Patient ratings were significantly lower on specialist knowledge management and knowledge integration when either PCPs did not use feedback coordination (b = - .20; b = - .17, respectively) or rated feedback coordination lower (b = - .08 for both). Teamwork was significantly related to specialist knowledge management (b = .06), knowledge integration (b = .04); and knowledge fragmentation (b = - .04). Relational coordination was related to coordination between the primary care provider and (i) diabetes specialist (b = .09) and (ii) mental health provider (b = .12). CONCLUSIONS: Practices to improve provider coordination within and across primary care and specialty care services may improve patient experiences of care coordination. Improvements in these areas may improve care efficiency and effectiveness.

Survey of Patient-Centered Coordination of Care for Diabetes with Cardiovascular and Mental Health Comorbidities in the Department of Veterans Affairs.

BACKGROUND: Multiple comorbidities thought to be associated with poor coordination due to the need for shared treatment plans and active involvement of patients, among other factors. Cardiovascular and mental health comorbidities present potential coordination challenges relative to diabetes. OBJECTIVE: To determine how cardiovascular and mental health comorbidities relate to patient-centered coordinated care in the Department of Veterans Affairs. DESIGN: This observational study used a 2 × 2 factorial design to determine how cardiovascular and mental health comorbidities are associated with patient perceptions of coordinated care among patients with type 2 diabetes mellitus as a focal condition. PARTICIPANTS: Five thousand eight hundred six patients attributed to 262 primary care providers, from a national sample of 29 medical centers, who had completed an online survey of patient-centered coordinated care in the Department of Veterans Affairs (VA). MAIN MEASURES: Eight dimensions from the Patient Perceptions of Integrated Care (PPIC) survey, a state-of-the-art measure of patients' perspective on coordinated and patient-centered care. KEY RESULTS: Mental health conditions were associated with significantly lower patient experiences of coordinated care. Hypotheses for disease severity were not supported, with associations in the hypothesized direction for only one dimension. CONCLUSIONS: Results suggest that VA may be adequately addressing coordination needs related to cardiovascular conditions, but more attention could be placed on coordination for mental health conditions. While specialized programs for more severe conditions (e.g., heart failure and serious mental illness) are important, coordination is also needed for more common, less severe conditions (e.g., hypertension, depression, anxiety). Strengthening coordination for common, less severe conditions is particularly important as VA develops alternative models (e.g., community care) that may negatively impact the degree to which care is coordinated.

Patient-Centered Care in Primary Care Scale: Pilot Development and Psychometric Assessment.

BACKGROUND: Nurse contributions to patient-centered care in primary care clinics are all but ignored in standard patient experience surveys. PURPOSE: The purpose was to conduct a pilot study to develop and psychometrically assess a scale measuring nurses' and other providers' patient-centered care in Veteran Affairs primary care clinics. METHOD: We developed a patient experience survey composed of original items and previous studies' items and scales. The survey was field tested online with patients who had a recent clinic appointment. The nonrandom analytic sample comprised 221 patients. RESULTS: Exploratory factor analyses yielded a 36-item, 4-factor solution explaining 76% of the variance. The factors were: (1) Provider Knowing the Person/Individualizing Care (18 items; α = 0.98); (2) Nurse Knowing the Person (8; 0.95); (3) Nurse Individualizing Care (7; 0.94); and (4) Continuity of Care (3; not calculated). A short form with 23 items was created using stepwise regression. It had the same 4 factors as the long form with 76% of the variance explained. CONCLUSIONS: Patients reported distinctive nurse contributions that have not been routinely measured.

Survey Response Rate and Quality in a Mental Health Clinic Population: Results from a Randomized Survey Comparison.

Given the limited ability of informatics-based assessment technologies to reach individuals with serious mental health conditions, this study evaluated the feasibility and data quality of mail-out healthcare surveys in this population to assist in measure selection for a multi-site controlled implementation trial. Veterans were randomly selected from those who had received services at a mental health clinic in the Department of Veterans Affairs, and were randomly assigned to one of three questionnaire lengths. Survey length (48-127 items) was not associated with differences in response rate, percent of items missing, or data quality. However, internal consistency reliability was variable among scales and survey lengths. Additional analyses indicate the above measures of survey data quality may differ among respondents who are non-white and younger and have psychotic disorders. These results can inform survey protocols to ensure maximal representation of this vulnerable population in health planning and policy assessment.

Implementation of a clinical innovation: the case of advanced clinic access in the Department of Veterans Affairs.

Healthcare organizations seeking to improve clinical practices often have disappointing results because the planned innovations are not successfully implemented. To increase the understanding of implementation, we analyzed the national spread of an ambulatory innovation in the Department of Veterans Affairs. This study provides support for a conceptual model that posits that the extent to which a clinical innovation is implemented will be affected by factors in 3 domains: (1) intentional activities to introduce, spread, and support the innovation; (2) the attitudes and capabilities of clinic staff responsible for implementing the innovation; and (3) the context of the facility in which the innovation is being introduced. Among the strongest predictors of successful implementation, management support for the innovation and clinic team knowledge and skills to make changes successfully were significant across both primary care and specialty clinics.

Psychiatrists' self-reported adherence to evidence-based prescribing practices in the treatment of schizophrenia.

OBJECTIVE: This study sought to identify relationships between psychiatrists' characteristics and their self-reported adherence to evidence-based recommendations regarding antipsychotic use in the treatment of schizophrenia. METHODS: Surveys were sent to 1,757 psychiatrists affiliated with the Veterans Health Administration. Respondents (N=696) reported their own adherence to two recommended prescribing practices for using antipsychotics. RESULTS: Several psychiatrists' characteristics were associated with greater adherence, including midcareer status, male sex, a caseload with a larger proportion of patients with schizophrenia, and use of current information from scientific literature or from drug company detailing. CONCLUSIONS: This study identified several characteristics of psychiatrists that may affect their adherence to evidence-based prescribing practices for patients with schizophrenia.

Partnering with health system operations leadership to develop a controlled implementation trial.

BACKGROUND: Outcome for mental health conditions is suboptimal, and care is fragmented. Evidence from controlled trials indicates that collaborative chronic care models (CCMs) can improve outcomes in a broad array of mental health conditions. US Department of Veterans Affairs leadership launched a nationwide initiative to establish multidisciplinary teams in general mental health clinics in all medical centers. As part of this effort, leadership partnered with implementation researchers to develop a program evaluation protocol to provide rigorous scientific data to address two implementation questions: (1) Can evidence-based CCMs be successfully implemented using existing staff in general mental health clinics supported by internal and external implementation facilitation? (2) What is the impact of CCM implementation efforts on patient health status and perceptions of care? METHODS/DESIGN: Health system operation leaders and researchers partnered in an iterative process to design a protocol that balances operational priorities, scientific rigor, and feasibility. Joint design decisions addressed identification of study sites, patient population of interest, intervention design, and outcome assessment and analysis. Nine sites have been enrolled in the intervention-implementation hybrid type III stepped-wedge design. Using balanced randomization, sites have been assigned to receive implementation support in one of three waves beginning at 4-month intervals, with support lasting 12 months. Implementation support consists of US Center for Disease Control's Replicating Effective Programs strategy supplemented by external and internal implementation facilitation support and is compared to dissemination of materials plus technical assistance conference calls. Formative evaluation focuses on the recipients, context, innovation, and facilitation process. Summative evaluation combines quantitative and qualitative outcomes. Quantitative CCM fidelity measures (at the site level) plus health outcome measures (at the patient level; n = 765) are collected in a repeated measures design and analyzed with general linear modeling. Qualitative data from provider interviews at baseline and 1 year elaborate CCM fidelity data and provide insights into barriers and facilitators of implementation. DISCUSSION: Conducting a jointly designed, highly controlled protocol in the context of health system operational priorities increases the likelihood that time-sensitive questions of operational importance will be answered rigorously and that the outcomes will result in sustainable change in the health-care system. TRIAL REGISTRATION: NCT02543840 ( https://www.clinicaltrials.gov/ct2/show/NCT02543840).

Heterogeneity in aripiprazole diffusion for bipolar disorder treatment in the Veterans Health Administration.

OBJECTIVES: The objectives of this study were to ascertain the relative importance of scientific "approval" versus U.S. Food and Drug Administration (FDA) regulatory approval regarding changes in aripiprazole prescribing rates for treating bipolar disorder and to identify system-level covariates associated with faster regional uptake of aripiprazole. METHODS: Medication use data for 2002­2009 were obtained from the Veterans Health Administration (VHA) National Psychosis Registry for 106,547 patients with diagnoses of bipolar disorder, aggregated at the level of the Veterans Integrated Service Network (VISN). VISN-level independent variables were obtained from several VHA organizational databases. Interrupted time-series analysis was used to examine changes in rates of prescribing aripiprazole, and logistic regression was used to model above- versus below-median growth in aripiprazole prescribing across VISNs. RESULTS: Three inflections were observed, corresponding to the publication of two positive studies and FDA approval of aripiprazole for the treatment of bipolar mania. No significant VISN-level policy, administrative, or staffing predictors of the growth rate in aripiprazole prescribing were identified. Exploratory analyses showed that access to care may play a role in uptake, whereas competing demands, such as substance abuse treatment needs, may retard adoption. CONCLUSIONS: Early published evidence may have a strong impact on practice for low-barrier innovations, such as newly marketed medications or changes in indication for approved medications. Regional targeting of prescriber behavior interventions may maximize efficiency in efforts to change prescribing; further delineation of factors associated with regional heterogeneity in prescribing would support such efforts.