Institutional Incentives for Mentoring at the U.S. Department of Veterans Affairs and Universities: Associations With Mentors' Perceptions and Time Spent Mentoring.

PURPOSE: Limited empirical attention to date has focused on best practices in advanced research mentoring in the health services research domain. The authors investigated whether institutional incentives for mentoring (e.g., consideration of mentoring in promotion criteria) were associated with mentors' perceptions of mentoring benefits and costs and with time spent mentoring. METHOD: The authors conducted an online survey in 2014 of a national sample of mentors of U.S. Department of Veterans Affairs (VA) Health Services Research and Development Service (HSR&D) mentored career development award recipients who received an award during 2000-2012. Regression analyses were used to examine institutional incentives as predictors of perceptions of benefits and costs of mentoring and time spent mentoring. RESULTS: Of the 145 mentors invited, 119 (82%) responded and 110 (76%) provided complete data for the study items. Overall, mentors who reported more institutional incentives also reported greater perceived benefits of mentoring (P = .03); however, more incentives were not significantly associated with perceived costs of mentoring. Mentors who reported more institutional incentives also reported spending a greater percentage of time mentoring (P = .02). University incentives were associated with perceived benefits of mentoring (P = .02), whereas VA incentives were associated with time spent mentoring (P = .003). CONCLUSIONS: Institutional policies that promote and support mentorship of junior investigators, specifically by recognizing and rewarding the efforts of mentors, are integral to fostering mentorship programs that contribute to the development of early-career health services researchers into independent investigators.

Patient Perception of Enough Time Spent With Provider Is a Mechanism for Improving Women Veterans' Experiences With VA Outpatient Health Care.

We postulated that associations between two specific provider characteristics, class (nurse practitioner relative to physician) and primary care providers who are proficient and interested in women's health (designated women's provider relative to nondesignated) and overall satisfaction with provider, were mediated through women veterans' perception of enough time spent with the provider. A national patient experience survey was administered to 7,620 women veterans. Multivariable models of overall patient satisfaction with provider were compared with and without the proposed mediator. A structural equation model (SEM) of the mediation of the two provider characteristics was also evaluated. Without the mediator, associations of provider class and designation with overall patient satisfaction were significant. With the proposed mediator, these associations became nonsignificant. An SEM showed that the majority (>80%) of the positive associations between provider class and designation and the outcome were exerted through patient perception of enough time spent with provider. Higher ratings of overall satisfaction with provider exhibited by nurse practitioners and designated women's health providers were exerted through patient perception of enough time spent with provider. Future research should examine what elements of provider training can be developed to improve provider-patient communication and patient satisfaction with their health care.

Evaluating the Productivity of VA, NIH, and AHRQ Health Services Research Career Development Awardees.

PURPOSE: To evaluate the academic advancement and productivity of Department of Veterans Affairs Health Services Research and Development (HSR&D) Career Development Award (CDA) program recipients, National Institutes of Health (NIH) K awardees in health services research (HSR), and Agency for Healthcare Research and Quality (AHRQ) K awardees. METHOD: In all, 219 HSR&D CDA recipients from fiscal year (FY) 1991 through FY2010; 154 NIH K01, K08, and K23 awardees FY1991-FY2010; and 69 AHRQ K01 and K08 awardees FY2000-FY2010 were included. Most data were obtained from curricula vitae. Academic advancement, publications, grants, recognition, and mentoring were compared after adjusting for years since award, and personal characteristics, training, and productivity prior to the award. RESULTS: No significant differences emerged in covariate-adjusted tenure-track academic rank, number of grants as primary investigator (PI), major journal articles as first/sole author, Hirsch h-index scores, likelihood of a journal editorship position or membership in a major granting review panel, or mentoring postgraduate researchers between the HSR&D CDA and NIH K awardees from FY1991-FY2010, or among the three groups of awardees from FY2000 or later. Among those who reported grant funding levels, HSR&D CDAs from FY1991-2010 had been PI on more grants of $100,000 than NIH K awardees. HSR&D CDAs had a higher mean number of major journal articles than NIH K awardees from FY1991-2010. CONCLUSIONS: Findings show that all three HSR career development programs are successfully selecting and mentoring awardees, ensuring additional HSR capacity to improve the quality and delivery of high-value care.

Ten-Year Publication Trajectories of Health Services Research Career Development Award Recipients: Collaboration, Awardee Characteristics, and Productivity Correlates.

This study's purpose was to identify distinct publishing trajectories among 442 participants in three prominent mentored health services research career development programs (Veterans Affairs, National Institutes of Health, and Agency for Healthcare Research & Quality) in the 10 years after award receipt and to examine awardee characteristics associated with different trajectories. Curricula vitae (CVs) of researchers receiving awards between 1991 and 2010 were coded for publications, grants, and awardee characteristics. We found that awardees published at constant or increasing rates despite flat or decreasing rates of first-author publications. Senior-author publications rose concurrently with rates of overall publications. Higher overall publication trajectories were associated with receiving more grants, more citations as measured by the h-index, and more authors per article. Lower trajectory groups were older and had a greater proportion of female awardees. Career development awards supported researchers who generally published successfully, but trajectories varied across individual researchers. Researchers' collaborative efforts produced an increasing number of articles, whereas first author articles were written at a more consistent rate. Career development awards in health services research supported the careers of researchers who published at a high rate; future research should further examine reasons for variation in publishing among early career researchers.

The Changing Faces of Mentorship: Application of a Developmental Network Framework in a Health Services Research Career Development Program.

Historically, mentorship has been conceived of as a dyadic relationship between a senior mentor and an early-career investigator. Models involving multiple mentors have gained favor in recent years, but empirical research on multiple-mentor models has been lacking. The current work aims to fill this gap by describing a long-standing health services research mentoring program at the U.S. Department of Veterans Affairs which has adopted a network-based approach to mentoring. As part of a broader project, we surveyed VA HSR&D Career Development Awardees who received an award between 2000 and 2012. In total, 133 awardees participated (84%). Awardees reported on the structure of mentoring relationships with their two most influential mentors. Awardees were mentored by teams consisting of one to five mentors (M = 2.7 mentors). Most often, one mentor served as primary mentor while one or more mentors played a supporting role. In most cases, an awardee's primary mentor was co-located with the awardee, with fewer secondary mentors co-located. More recently funded CDAs had more mentors and were less likely to be co-located with secondary mentors. The VA HSR&D CDA program incorporates current thinking about Developmental Network models of mentorship into a comprehensive program providing a rich mentorship experience for its awardees.

Travel time and attrition from VHA care among women veterans: how far is too far?

BACKGROUND: Travel time, an access barrier, may contribute to attrition of women veterans from Veterans Health Administration (VHA) care. OBJECTIVE: We examined whether travel time influences attrition: (a) among women veterans overall, (b) among new versus established patients, and (c) among rural versus urban patients. RESEARCH DESIGN: This retrospective cohort study used logistic regression to estimate the association between drive time and attrition, overall and for new/established and rural/urban patients. SUBJECTS: In total, 266,301 women veteran VHA outpatients in the Fiscal year 2009. MEASURES: An "attriter" did not return for VHA care during the second through third years after her first 2009 visit (T0). Drive time (log minutes) was between the patient's residence and her regular source of VHA care. "New" patients had no VHA visits within 3 years before T0. Models included age, service-connected disability, health status, and utilization as covariates. RESULTS: Overall, longer drive times were associated with higher odds of attrition: drive time adjusted odds ratio=1.11 (99% confidence interval, 1.09-1.14). The relationship between drive time and attrition was stronger among new patients but was not modified by rurality. CONCLUSIONS: Attrition among women veterans is sensitive to longer drive time. Linking new patients to VHA services designed to reduce distance barriers (telemedicine, community-based clinics, mobile clinics) may reduce attrition among women new to VHA.

Readying the workforce: evaluation of VHA's comprehensive women's health primary care provider initiative.

BACKGROUND: Veterans Health Administration (VHA) primary care providers (PCPs) often see few women, making it challenging to maintain proficiency in women's health (WH). Therefore, VHA in 2010 established Designated WH Providers, who would maintain proficiency in comprehensive WH care and be preferentially assigned women patients. OBJECTIVE: To evaluate early implementation of this national policy. METHODS: At each VHA health care system (N=140), the Women Veterans Program Manager completed a Fiscal Year 2012 workforce capacity assessment (response rate, 100%), representing the first time the national Designated WH Provider workforce had been identified. Assessment data were linked to administrative data. RESULTS: Of all VHA PCPs, 23% were Designated WH Providers; 100% of health care systems and 83% of community clinics had at least 1 Designated WH Provider. On average, women veterans comprised 19% (SD=27%) of the patients Designated WH Providers saw in primary care, versus 5% (SD=7%) for Other PCPs (P<0.001). For women veterans using primary care (N=313,033), new patients were less likely to see a Designated WH Provider than established women veteran patients (52% vs. 64%; P<0.001). CONCLUSIONS: VHA has achieved its goal of a Designated WH Provider in every health care system, and is approaching its goal of a Designated WH Provider at every hospital/community clinic. Designated WH Providers see more women than do Other PCPs. However, as the volume of women patients remains low for many providers, attention to alternative approaches to maintaining proficiency may prove necessary, and barriers to assigning new women patients to Designated WH Providers merit attention.

Associations between provider designation and female-specific cancer screening in women Veterans.

BACKGROUND: In 2010, the Department of Veterans Affairs Healthcare System (VA) implemented policy to provide Comprehensive Primary Care (for acute, chronic, and female-specific care) from designated Women's Health providers (DWHPs) at all VA sites. However, since that time no comparisons of quality measures have been available to assess the level of care for women Veterans assigned to these providers. OBJECTIVES: To evaluate the associations between cervical and breast cancer screening rates among age-appropriate women Veterans and designation of primary-care provider (DWHP vs. non-DWHP). RESEARCH DESIGN: Cross-sectional analyses using the fiscal year 2012 data on VA women's health providers, administrative files, and patient-specific quality measures. SUBJECTS: The sample included 37,128 women Veterans aged 21 through 69 years. MEASURES: Variables included patient demographic and clinical factors (ie, age, race, ethnicity, mental health diagnoses, obesity, and site), and provider factors (ie, DWHP status, sex, and panel size). Screening measures were defined by age-appropriate subgroups using VA national guidelines. RESULTS: Female-specific cancer screening rates were higher among patients assigned to DWHPs (cervical cytology 94.4% vs. 91.9%, P<0.0001; mammography 86.3% vs. 83.3%, P<0.0001). In multivariable models with adjustment for patient and provider characteristics, patients assigned to DWHPs had higher odds of cervical cancer screening (odds ratio, 1.26; 95% confidence interval, 1.07-1.47; P<0.0001) and breast cancer screening (odds ratio, 1.24; 95% CI, 1.10-1.39; P<0.0001). CONCLUSIONS: As the proportion of women Veterans increases, assignment to DWHPs may raise rate of female-specific cancer screening within VA. Separate evaluation of sex neutral measures is needed to determine whether other measures accrue benefits for patients with DWHPs.

Prevalence of mental health disorders among justice-involved veterans.

Justice-involved veterans are a special population with unique mental health needs compared with other veterans or justice-involved adults. Prevalence estimates of mental health concerns of justice-involved veterans across 18 samples of these veterans (1987-2013), including both incarcerated and community samples, were identified through a systematic literature search of published studies supplemented by Department of Veterans Affairs Veterans Justice Programs data. Despite heterogeneity across samples and measures used, the review highlights several prominent mental health concerns among veterans. Many justice-involved veterans have likely experienced at least one traumatic event, and many have post-traumatic stress disorder (prevalence from 4% to 39% across samples). At least half of justice-involved veterans have an alcohol and/or drug use disorder (estimates as high as 71% and 65%, respectively), and other psychiatric disorders, such as depression (14%-51%) and psychotic disorders (4%-14%), are common. Justice-involved veterans with comorbid substance use and psychiatric disorders are at increased risk of negative outcomes, including homelessness and violent behavior. Overall, comparisons of justice-involved veterans with other justice-involved adults found a slightly higher rate of mental health concerns among justice-involved veterans, with some indication that intravenous drug use is more prevalent. Compared with other veterans, justice-involved veterans have consistently higher rates of mental health concerns, particularly substance use disorders.

Association between women veterans' experiences with VA outpatient health care and designation as a women's health provider in primary care clinics.

BACKGROUND: Women veterans comprise a small percentage of Department of Veterans Affairs (VA) health care users. Prior research on women veterans' experiences with primary care has focused on VA site differences and not individual provider characteristics. In 2010, the VA established policy requiring the provision of comprehensive women's health care by designated women's health providers (DWHPs). Little is known about the quality of health care delivered by DWHPs and women veterans' experience with care from these providers. METHODS: Secondary data were obtained from the VA Survey of Healthcare Experience of Patients (SHEP) using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient-centered medical home (PCMH) survey from March 2012 through February 2013, a survey designed to measure patient experience with care and the DWHPs Assessment of Workforce Capacity that discerns between DWHPs versus non-DWHPs. FINDINGS: Of the 28,994 surveys mailed to women veterans, 24,789 were seen by primary care providers and 8,151 women responded to the survey (response rate, 32%). A total of 3,147 providers were evaluated by the SHEP-CAHPS-PCMH survey (40%; n = 1,267 were DWHPs). In a multivariable model, patients seen by DWHPs (relative risk, 1.02; 95% CI, 1.01-1.04) reported higher overall experiences with care compared with patients seen by non-DWHPs. CONCLUSIONS: The main finding is that women veterans' overall experiences with outpatient health care are slightly better for those receiving care from DWHPs compared with those receiving care from non-DWHPs. Our findings have important policy implications for how to continue to improve women veterans' experiences. Our work provides support to increase access to DWHPs at VA primary care clinics.

A meta-analysis of topiramate's effects for individuals with alcohol use disorders.

BACKGROUND: Influenced by several trials and reviews highlighting positive outcomes, topiramate is increasingly prescribed as a treatment for alcohol use disorders (AUDs). The only previously published meta-analysis of topiramate for AUDs was limited by a sample of only 3 randomized, placebo-controlled trials (RCTs). METHODS: A systematic search identified 7 RCTs (including a total of 1,125 participants) that compared topiramate to placebo for the treatment for AUDs. This meta-analysis estimated the overall effects of topiramate on abstinence, heavy drinking, craving, and γ-glutamyltranspeptidase (GGT) outcomes and included several sensitivity analyses to account for the small sample of studies. RESULTS: Overall, the small to moderate effects favored topiramate, although the effect on craving was not quite significantly different from 0. The largest effect was found on abstinence (g = 0.468, p < 0.01), followed by heavy drinking (g = 0.406, p < 0.01), GGT (g = 0.324, p = 0.02), and craving (g = 0.312, p = 0.07) outcomes. Sensitivity analyses did not change the magnitude or direction of the results, and tests did not indicate significant publication bias. The small sample size did not allow for examination of specific moderators of the effects of topiramate. CONCLUSIONS: Topiramate can be a useful tool in the treatment of AUDs. Its efficacy, based on the current sample of studies, seems to be of somewhat greater magnitude than that of the most commonly prescribed medications for AUDs (naltrexone and acamprosate). Further research will help to identify the contexts in which topiramate is most beneficial (e.g., dose, concurrent psychotherapy, patient characteristics).

How effective is continuing care for substance use disorders? A meta-analytic review.

Given the often chronic nature of substance use disorders, patients sometimes receive less intensive continuing care following an initial period of more intensive treatment. This meta-analysis estimated the effect of continuing care and formally tested several proposed moderators (intervention duration, intensity, modality, and setting) of that effect. A systematic search identified 33 controlled trials of continuing care; 19 included a no/minimal treatment condition and were analyzed to assess the overall effect of continuing care versus control. Continuing care had a small, but significant, positive effect size, both at the end of the continuing care interventions (g=0.187, p<0.001) and at follow-up (g=0.271, p<0.01). Limited by a small number of studies, analyses did not identify any significant moderators of overall effects. These results show that continuing care can provide at least modest benefit after initial treatment. We discuss study characteristics that may have reduced the magnitude of the overall continuing care effect estimate.

Intention-to-treat analyses and missing data approaches in pharmacotherapy trials for alcohol use disorders.

OBJECTIVES: Intention to treat (ITT) is an analytic strategy for reducing potential bias in treatment effects arising from missing data in randomised controlled trials (RCTs). Currently, no universally accepted definition of ITT exists, although many researchers consider it to require either no attrition or a strategy to handle missing data. Using the reports of a large pool of RCTs, we examined discrepancies between the types of analyses that alcohol pharmacotherapy researchers stated they used versus those they actually used. We also examined the linkage between analytic strategy (ie, ITT or not) and how missing data on outcomes were handled (if at all), and whether data analytic and missing data strategies have changed over time. DESIGN: Descriptive statistics were generated for reported and actual data analytic strategy and for missing data strategy. In addition, generalised linear models determined changes over time in the use of ITT analyses and missing data strategies. PARTICIPANTS: 165 RCTs of pharmacotherapy for alcohol use disorders. RESULTS: Of the 165 studies, 74 reported using an ITT strategy. However, less than 40% of the studies actually conducted ITT according to the rigorous definition above. Whereas no change in the use of ITT analyses over time was found, censored (last follow-up completed) and imputed missing data strategies have increased over time, while analyses of data only for the sample actually followed have decreased. CONCLUSIONS: Discrepancies in reporting versus actually conducting ITT analyses were found in this body of RCTs. Lack of clarity regarding the missing data strategy used was common. Consensus on a definition of ITT is important for an adequate understanding of research findings. Clearer reporting standards for analyses and the handling of missing data in pharmacotherapy trials and other intervention studies are needed.

Representativeness of patients enrolled in influential clinical trials: a comparison of substance dependence with other medical disorders.

OBJECTIVE: The purpose of this study was to determine whether randomized trials of treatments for substance dependence differ from those for other medical disorders on quality of enrollment information reporting and sample representativeness. METHOD: Twenty highly cited clinical trials (publication date 2002-2010) of treatments for each of 14 prevalent disorders were identified by structured literature search. The disorders were alcohol dependence, drug dependence, nicotine dependence, Alzheimer's disease, breast cancer, colorectal cancer, chronic obstructive pulmonary disease, depression, diabetes, HIV/AIDS, hypertension, ischemic heart disease, lung cancer, and schizophrenia. The 280 clinical trials were coded for number of individuals screened for eligibility, number of screened individuals meeting eligibility criteria, and number of eligible individuals refusing to participate. RESULTS: Substance-dependence treatment trials were significantly more likely to track and report enrollment information (75% vs. 45% of clinical trials for other disorders, p < .001). Substance-dependence trials did not differ from trials focused on other disorders on mean rate of non-enrollment. Across disorders, the primary driver of non-enrollment appeared to be clinical trial exclusion criteria rather than eligible patients refusing to enroll. CONCLUSIONS: Relative to other disorders, trials in the substance-dependence field do a better (although imperfect) job of tracking and reporting enrollment information. Low enrollment rates and unrepresentative samples are not challenges unique to treatment outcome studies in the substance-dependence field. Across a range of disorders, clinical trials that use eligibility criteria judiciously are more likely to produce findings that generalize to front-line clinical practice than are trials that restrict enrollment to a small and unrepresentative subset of patients.

Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful?

AIMS: Although debates over the efficacy of oral naltrexone and acamprosate in treating alcohol use disorders tend to focus on their global efficacy relative to placebo or their efficacy relative to each other, the underlying reality may be more nuanced. This meta-analysis examined when naltrexone and acamprosate are most helpful by testing: (i) the relative efficacy of each medication given its presumed mechanism of action (reducing heavy drinking versus fostering abstinence) and (ii) whether different ways of implementing each medication (required abstinence before treatment, detoxification before treatment, goal of treatment, length of treatment, dosage) moderate its effects. METHODS: A systematic literature search identified 64 randomized, placebo-controlled, English-language clinical trials completed between 1970 and 2009 focused on acamprosate or naltrexone. RESULTS: Acamprosate had a significantly larger effect size than naltrexone on the maintenance of abstinence, and naltrexone had a larger effect size than acamprosate on the reduction of heavy drinking and craving. For naltrexone, requiring abstinence before the trial was associated with larger effect sizes for abstinence maintenance and reduced heavy drinking compared with placebo. For acamprosate, detoxification before medication administration was associated with better abstinence outcomes compared with placebo. CONCLUSIONS: In treatment for alcohol use disorders, acamprosate has been found to be slightly more efficacious in promoting abstinence and naltrexone slightly more efficacious in reducing heavy drinking and craving. Detoxification before treatment or a longer period of required abstinence before treatment is associated with larger medication effects for acamprosate and naltrexone respectively.

Safely testing the alarm: close others' responses to personal positive events.

Previous research has shown that receiving social support in the face of negative events (i.e., enacted support) is sometimes correlated with positive outcomes, sometimes unrelated to outcomes, and sometimes associated with negative outcomes. However, people's perception that they have high-quality support available to them when they have a stressor (i.e., perceived support) is consistently and strongly associated with better health, well-being, and relationship functioning. However, both enacted and perceived support available in response to positive event disclosures are consistently associated with positive outcomes. In 2 studies, we examined why enacted support for negative events has such a spotty record and compared it with enacted support for positive events; a third study examined how support for positive events may be a major contributor to perceived availability of effective support for negative events. The results showed that providing responsive support to negative events is particularly difficult; received support for negative events disclosures (but not positive event disclosures) involves substantial drawbacks and risks, especially when that support is not responsive to the recipient's needs; and that enacted support for positive events was a better predictor of later perceptions of the quality of available support for stressors than enacted support for negative events. Findings are discussed in terms of implications for the social support literature and how positive relationship processes influence health and well-being, not only directly but also indirectly by providing critical information regarding the availability of others if a problem occurs.

Socioeconomic status moderates associations among stressful events, mental health, and relationship satisfaction.

Although stressful events and poor mental health predict worse intimate relationships in all segments of society, they may be especially detrimental for poorer couples who lack the financial resources that facilitate successful coping. To examine this hypothesis, associations among stress, mental health, and relationship satisfaction were examined in the Florida Family Formation study, a stratified random sample of more than 2000 Florida residents that included oversamples of low-income participants. As predicted, stressful life events and mental health problems accounted for more variance in relationship satisfaction among poorer than among more affluent individuals. These results suggest that models of relationship satisfaction addressing low-income populations may need to emphasize contextual and individual variables more than models developed in more affluent populations.

Barriers to use of pharmacotherapy for addiction disorders and how to overcome them.

Substance use disorders are highly prevalent, debilitating conditions for which effective pharmacotherapies exist with a broad evidence base, yet pharmacotherapy for the treatment of addiction disorders is underutilized. The goals of this review are to describe the barriers that may contribute to poor adoption and utilization of pharmacotherapy for alcohol and opioid dependence at the system, provider, and patient level and to discuss ways to overcome those barriers. Multifaceted efforts directed at all three levels may be needed to speed pharmacotherapy adoption. More research is needed to help us better understand barriers from patients' perspectives. Strategies to promote adoption of pharmacotherapy for addiction disorders should be modified to fit the needs of the practice, system, and individual patients. Pharmacotherapy is a valuable tool in the clinical armamentarium of addiction treatment; thus, overcoming barriers to implementation may improve clinical and social outcomes.

The attractive female body weight and female body dissatisfaction in 26 countries across 10 world regions: results of the international body project I.

This study reports results from the first International Body Project (IBP-I), which surveyed 7,434 individuals in 10 major world regions about body weight ideals and body dissatisfaction. Participants completed the female Contour Drawing Figure Rating Scale (CDFRS) and self-reported their exposure to Western and local media. Results indicated there were significant cross-regional differences in the ideal female figure and body dissatisfaction, but effect sizes were small across high-socioeconomic-status (SES) sites. Within cultures, heavier bodies were preferred in low-SES sites compared to high-SES sites in Malaysia and South Africa (ds = 1.94-2.49) but not in Austria. Participant age, body mass index (BMI), and Western media exposure predicted body weight ideals. BMI and Western media exposure predicted body dissatisfaction among women. Our results show that body dissatisfaction and desire for thinness is commonplace in high-SES settings across world regions, highlighting the need for international attention to this problem.