Effectiveness of the VA-Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program: An observational cohort study.

BACKGROUND: As the Department of Veterans Affairs (VA) healthcare system seeks to expand access to comprehensive geriatric assessments, evidence-based models of care are needed to support community-dwelling older persons. We evaluated the VA Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program's effect on mortality and readmissions, as well as patient, caregiver, and staff satisfaction. METHODS: This retrospective cohort included patients admitted to the Richard L. Roudebush VA hospital (2010-2019) who received VA-GRACE services post-discharge and usual care controls who were potentially eligible for VA-GRACE but did not receive services. The VA-GRACE program provided home-based comprehensive, multi-disciplinary geriatrics assessment, and ongoing care. Primary outcomes included 90-day and 1-year all-cause readmissions and mortality, and patient, caregiver, and staff satisfaction. We used propensity score modeling with overlapping weighting to adjust for differences in characteristics between groups. RESULTS: VA-GRACE patients (N = 683) were older than controls (N = 4313) (mean age 78.3 ± 8.2 standard deviation vs. 72.2 ± 6.9 years; p < 0.001) and had greater comorbidity (median Charlson Comorbidity Index 3 vs. 0; p < 0.001). VA-GRACE patients had higher 90-day readmissions (adjusted odds ratio [aOR] 1.55 [95%CI 1.01-2.38]) and higher 1-year readmissions (aOR 1.74 [95%CI 1.22-2.48]). However, VA-GRACE patients had lower 90-day mortality (aOR 0.31 [95%CI 0.11-0.92]), but no statistically significant difference in 1-year mortality was observed (aOR 0.88 [95%CI 0.55-1.41]). Patients and caregivers reported that VA-GRACE home visits reduced travel burden and the program linked Veterans and caregivers to needed resources. Primary care providers reported that the VA-GRACE team helped to reduce their workload, improved medication management for their patients, and provided a view into patients' daily living situation. CONCLUSIONS: The VA-GRACE program provides comprehensive geriatric assessments and care to high-risk, community-dwelling older persons with high rates of satisfaction from patients, caregivers, and providers. Widespread deployment of programs like VA-GRACE will be required to support Veterans aging in place.

Assessment of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) Program for Improving Quality of Care for Transient Ischemic Attack: A Nonrandomized Cluster Trial.

Importance: Patients with transient ischemic attack (TIA) are at high risk of recurrent vascular events. Timely management can reduce that risk by 70%; however, gaps in TIA quality of care exist. Objective: To assess the performance of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) intervention to improve TIA quality of care. Design, Setting, and Participants: This nonrandomized cluster trial with matched controls evaluated a multicomponent intervention to improve TIA quality of care at 6 diverse medical centers in 6 geographically diverse states in the US and assessed change over time in quality of care among 36 matched control sites (6 control sites matched to each PREVENT site on TIA patient volume, facility complexity, and quality of care). The study period (defined as the data period) started on August 21, 2015, and extended to May 12, 2019, including 1-year baseline and active implementation periods for each site. The intervention targeted clinical teams caring for patients with TIA. Intervention: The quality improvement (QI) intervention included the following 5 components: clinical programs, data feedback, professional education, electronic health record tools, and QI support. Main Outcomes and Measures: The primary outcome was the without-fail rate, which was calculated as the proportion of veterans with TIA at a specific facility who received all 7 guideline-recommended processes of care for which they were eligible (ie, anticoagulation for atrial fibrillation, antithrombotic use, brain imaging, carotid artery imaging, high- or moderate-potency statin therapy, hypertension control, and neurological consultation). Generalized mixed-effects models with multilevel hierarchical random effects were constructed to evaluate the intervention associations with the change in the mean without-fail rate from the 1-year baseline period to the 1-year intervention period. Results: Six facilities implemented the PREVENT QI intervention, and 36 facilities were identified as matched control sites. The mean (SD) age of patients at baseline was 69.85 (11.19) years at PREVENT sites and 71.66 (11.29) years at matched control sites. Most patients were male (95.1% [154 of 162] at PREVENT sites and 94.6% [920 of 973] at matched control sites at baseline). Among the PREVENT sites, the mean without-fail rate improved substantially from 36.7% (58 of 158 patients) at baseline to 54.0% (95 of 176 patients) during a 1-year implementation period (adjusted odds ratio, 2.10; 95% CI, 1.27-3.48; P = .004). Comparing the change in quality at the PREVENT sites with the matched control sites, the improvement in the mean without-fail rate was greater at the PREVENT sites than at the matched control sites (36.7% [58 of 158 patients] to 54.0% [95 of 176 patients] [17.3% absolute improvement] vs 38.6% [345 of 893 patients] to 41.8% [363 of 869 patients] [3.2% absolute improvement], respectively; absolute difference, 14%; P = .008). Conclusions and Relevance: The implementation of this multifaceted program was associated with improved TIA quality of care across the participating sites. The PREVENT QI program is an example of a health care system using QI strategies to improve performance, and may serve as a model for other health systems seeking to provide better care. Trial Registration: ClinicalTrials.gov Identifier: NCT02769338.

Polysomnography Utilization in Veterans Presenting Acutely with Ischemic Stroke or Transient Ischemic Attack.

INTRODUCTION: Obstructive sleep apnea (OSA) is an independent cerebrovascular risk factor and highly prevalent in patients with ischemic stroke and transient ischemic attack (TIA). Timely diagnosis and treatment of OSA is important as clinical data suggest that treatment of OSA in the setting of acute ischemic stroke improves functional outcomes. We aimed to assess polysomnography (PSG) utilization in US. Veterans with acute stroke or TIA over a 2-year period. METHODS: Veterans with acute ischemic stroke or TIA presenting to a Veterans Administration Medical Center (VAMC) between October 1, 2015, and June 30, 2017, were included. Demographic, clinical data, and PSG within 12 months of hospital discharge were obtained from the VA Corporate Data Warehouse to determine the rate of PSG testing among those with acute ischemic stroke or TIA. Fisher's exact test and two-sample t tests were used to compare demographic and clinical characteristics for those receiving and not receiving PSG. Mixed effect logistic regression was used to model the association of clinical and demographic characteristics with PSG receipt. RESULTS: In fiscal years (FYs) 2016 and 2017, 9,200 Veterans were admitted to a VAMC with ischemic stroke (6,011) or TIA (3,089). Veterans were elderly (70.5 ± 11.1 years), predominantly male (95.7%), and largely Caucasian (68.0% Caucasian, 26.3% African-American). Just 6.0% of Veterans underwent PSG within 1 year of acute ischemic stroke or TIA in FY 2016, compared to 6.2% in FY 2017 (p = 0.72). Compared to Veterans ≥80 years, those <60 had adjusted OR of 6.73 (4.10-11.05), those 60-69 had OR 4.29 (2.73-6.74), and those 70-79 had OR 2.63 (1.66-4.18) of having PSG. Veterans with diabetes or heart failure had significantly higher odds, whereas those with dementia had significantly lower odds of receiving PSG. CONCLUSION: PSG utilization among US Veterans is low and stable over time, despite recent guidelines recommending PSG among those having stroke or TIA. Older Veterans and those with dementia were unlikely to get PSG, representing especially vulnerable populations.

The prospectively-reported implementation update and score (PRIUS): a new method for capturing implementation-related developments over time.

BACKGROUND: Implementation of new programs within healthcare systems can be extraordinarily complex. Individuals within the same healthcare organization often have different perspectives on how implementation of a new program unfolds over time, and it is not always clear in the midst of implementation what issues are most important or how to address them. An implementation support team within the Veterans Health Administration (VHA) sought to develop an efficient method for eliciting an ongoing, detailed and nuanced account of implementation progress from multiple viewpoints that could support and inform active implementation of two new VHA programs. METHODS: The new Prospectively-Reported Implementation Update and Score ("PRIUS") provided a quick, structured, prospective and open-ended method for individuals to report on implementation progress. PRIUS updates were submitted approximately twice a month. Responding to the prompt "What are some things that happened over the past two weeks that seem relevant from your perspective to the implementation of this project?", individuals scored each update with a number ranging from + 3 to - 3. RESULTS: In 2016-17, individuals submitted over 600 PRIUS updates across the two QI projects. PRIUS-based findings included that staff from different services reported fundamentally different perspectives on program implementation. Rapid analysis and reporting of the PRIUS data led directly to changes in implementation. CONCLUSIONS: The PRIUS provided an efficient, structured method for developing a granular and context-sensitive account of implementation progress. The approach appears to be highly adaptable to a wide range of settings and interventions.

Prime movers: Advanced practice professionals in the role of stroke coordinator.

BACKGROUND AND PURPOSE: Following a stroke quality improvement clustered randomized trial and a national acute ischemic stroke (AIS) directive in the Veterans Health Administration in 2011, this comparative case study examined the role of advanced practice professionals (APPs) in quality improvement activities among stroke teams. METHODS: Semistructured interviews were conducted at 11 Veterans Affairs medical centers annually over a 3-year period. A multidisciplinary team analyzed interviews from clinical providers through a mixed-methods, data matrix approach linking APPs (nurse practitioners and physician assistants) with Consolidated Framework for Implementation Research constructs and a group organization measure. CONCLUSION: Five of 11 facilities independently chose to staff stroke coordinator positions with APPs. Analysis indicated that APPs emerged as boundary spanners across services and disciplines who played an important role in coordinating evidence-based, facility-level approaches to AIS care. The presence of APPs was related to engaging in group-based evaluation of performance data, implementing stroke protocols, monitoring care through data audit, convening interprofessional meetings involving planning activities, and providing direct care. IMPLICATIONS FOR PRACTICE: The presence of APPs appears to be an influential feature of local context crucial in developing an advanced, facility-wide approach to stroke care because of their boundary spanning capabilities.

National implementation of acute stroke care centers in the Veterans Health Administration (VHA): formative evaluation of the field response.

BACKGROUND: In 2011, the Veterans Health Administration (VHA) released the Acute Ischemic Stroke (AIS) Directive, which mandated reorganization of acute stroke care, including self-designation of stroke centers as Primary (P), Limited Hours (LH), or Supporting (S). OBJECTIVES: In partnership with the VHA Offices of Emergency Medicine and Specialty Care Services, the VA Stroke QUERI conducted a formative evaluation in a national sample of three levels of stroke centers in order to understand barriers and facilitators. DESIGN AND APPROACH: The evaluation consisted of a mixed-methods assessment that included a qualitative assessment of data from semi-structured interviews with key informants and a quantitative assessment of stroke quality-of-care data reporting practices by facility characteristics. PARTICIPANTS: The final sample included 38 facilities (84 % participation rate): nine P, 24 LH, and five S facilities. In total, we interviewed 107 clinicians and 16 regional Veterans Integrated Service Network (VISN) leaders. RESULTS: Across all three levels of stroke centers, stroke teams identified the specific need for systematic nurse training to triage and initiate stroke protocols. The most frequently reported barriers centered around quality-of-care data collection. A low number of eligible veterans arriving at the VAMC in a timely manner was another major impediment. The LH and S facilities reported some unique barriers: access to radiology and neurology services; EMS diverting stroke patients to nearby stroke centers, maintaining staff competency, and a lack of stroke clinical champions. Solutions that were applied included developing stroke order sets and templates to provide systematic decision support, implementing a stroke code in the facility for a coordinated response to stroke, and staff resource allocation and training. Data reporting by facility evaluation demonstrated that categorizing site volume did indicate a lower likelihood of reporting among VAMCs with 25-49 acute stroke admissions per year. CONCLUSIONS: The AIS Directive brought focused attention to reorganizing stroke care across a wide range of facility types. Larger VA facilities tended to follow established practices for organizing stroke care, but the unique addition of the LH designation presented some challenges. S facilities tended to report a lack of a coordinated stroke team and champion to drive process changes.

Geographic variation in poststroke depression among veterans with acute stroke.

This study compared patterns of poststroke depression (PSD) detection among veterans with acute stroke in eight U.S. geographic regions. Department of Veterans Affairs (VA) medical and pharmacy data as well as Medicare data were used. International Classification of Diseases-9th Revision depression codes and antidepressant medication dispensing were applied to define patients' PSD status 12 months poststroke. Logistic regression models were fit to compare VA PSD diagnosis and overall PSD detection between the regions. The use of VA medical data alone may underestimate the rate of PSD. Geographic variation in PSD detection depended on the data used. If VA medical data alone were used, we found no significant variation. If VA medical data were used along with Medicare and VA pharmacy data, we observed a significant variation in overall PSD detection across the regions after adjusting for potential risk factors. VA clinicians and policy makers need to consider enrollees' use of services outside the system when conducting program evaluation. Future research on PSD among veteran patients should use VA medical data in combination with Medicare and VA pharmacy data to obtain a comprehensive understanding of patients' PSD.

Barriers and facilitators to exercise among stroke survivors.

Physical activity after stroke may prevent disability and stroke recurrence; yet, physical impairments may inhibit poststroke exercise and subsequently limit recovery. The goal of this study was to elicit barriers to and facilitators of exercise after stroke. We conducted three focus groups and achieved content saturation from 13 stroke survivors--eight men and five women--85% of whom were African American and 15% White, with a mean age of 59 years. We coded and analyzed the transcripts from the focus groups for common themes. Participants across groups reported three barriers (physical impairments from stroke, lack of motivation, and environmental factors) and three facilitators (motivation, social support, and planned activities to fill empty schedule) to exercise after stroke. Exercise activity can provide a purpose and structure to a stroke survivor's daily schedule, which may be interrupted after stroke. In addition, receiving social support from peers and providers, as well as offering stroke-specific exercise programming, may enhance physical activity of stroke survivors including those with disabilities. We intend to incorporate these findings into a post-stroke self-management exercise program.

Relationships between exercise self-definitions and exercise participation among urban women in primary care.

Exercising prevents the development of coronary artery disease and reduces the incidence of cardiovascular risk factors; however, the mechanisms that underlie participation in an exercise program are not well understood. On the basis of theories of the self, we hypothesized that exercise self-definitions would be significantly related to exercise participation and that such definitions would increase over time. The study sample consisted of 192 middle-aged to older women who were leading a mostly sedentary life and the majority had at least one cardiovascular risk factor. Exercise participation was defined as the number of exercise sessions completed at 8 and 24 weeks. We found an interesting pattern of significant relationships between exercise definitions and exercise participation. Six-month scores were significantly higher than baseline scores, suggesting that exercise self-definitions strengthened over time. If this result is found to be supported in future studies, nurses may want to consider assessing self-definitions when helping patients initiate and maintain an exercise program.

Risk factors for nonelective hospitalization in frail and older adult, inner-city outpatients.

PURPOSE: In our study, we sought to improve the accuracy of predicting the risk of hospitalization and to identify older, inner-city patients who could be targeted for preventive interventions. DESIGN AND METHODS: Participants (56% were African American) in a randomized trial were from a primary care practice and included 1,041 patients living in the inner city who were either > or = 75 years of age or were > or = 50 years of age with severe disease. As a secondary analysis, we assessed patient characteristics at baseline involving five domains of health, including utilization and satisfaction. We followed participants for 12 months and recorded the occurrence of nonelective hospitalization within the study period. We developed a multivariate model using logistic regression to predict this outcome. RESULTS: The following patient characteristics independently predicted an increased risk for nonelective hospitalization: having the diagnosis of congestive heart failure, diabetes mellitus, or anemia; and having more medications prescribed, having a lower body mass index, and having more emergency department visits during the previous year. Better physical functioning reduced the risk of hospitalization. IMPLICATIONS: Moderate accuracy of a prediction model (0.73) was observed. In addition to focusing on patients with chronic disease, helping them maintain physical functioning may help reduce nonelective hospitalization.

The effects of health and environment on exercise-class participation in older, urban women.

This research investigated the effects of health and environmental factors on the dropout and intermittent nonattendance of an exercise program designed specifically for older, female, primary-care patients living in the inner city. Class-attendance records (n = 21,538) from a cohort 110 women were analyzed. Women who dropped out early had poorer perceived health and were more likely to report pain as an exercise barrier at baseline. Those who lived in a census tract where a larger percentage of workers walk to work were less likely to drop out early. Intermittent nonattendance was associated with adverse weather conditions including heat index above 90 degrees F, wind-chill index below 20 degrees F, overcast sky, and snow. Better attendance was associated with greater atmospheric pressure, as well as lower number of sunlight hours per day. This research highlights the need to better understand environmental barriers when promoting physical activities in older women.