Examining the surgical stress effects (SSE) framework in practice: A qualitative assessment of perceived sources and consequences of intraoperative stress in surgical teams.

BACKGROUND: Surgical adverse events persist despite extensive improvement efforts. Emotional and behavioral responses to stressors may influence intraoperative performance, as illustrated in the surgical stress effects (SSE) framework. However, the SSE has not been assessed using "real world" data. METHODS: We conducted semi-structured interviews with all surgical team roles at one midwestern VA hospital and elicited narratives involving intraoperative stress. Two coders inductively identified codes from transcripts. The team identified themes among codes and assessed concordance with the SSE framework. RESULTS: Throughout 28 interviews, we found surgical stress was ubiquitous, associated with a variety of factors, including adverse events. Stressors often elicited frustration, anger, fear, and anxiety; behavioral reactions to negative emotions frequently were perceived to degrade individual/team performance and compromise outcomes. Narratives were consistent with the SSE framework and support adding a process outcome (efficiency) and illustrating how adverse events can feedback and acutely increase job demands and stress. CONCLUSION: This qualitative study describes narratives of intraoperative stress, finding they are consistent with the SSE while also allowing minor improvements to the current framework.

Veterans Affairs Providers' Beliefs About the Contributors to and Responsibility for Reducing Racial and Ethnic Health Care Disparities.

Purpose: Providers' beliefs about the causes of disparities and the entities responsible for addressing these disparities are important in designing disparity-reduction interventions aimed at providers. This secondary analysis of a larger study is aimed at evaluating perceptions of providers regarding the underlying causes of racial health care disparities and their views of who is responsible for reducing them. Methods: We surveyed 232 providers at 3 Veterans Affairs (VA) Medical Centers. Results: Sixty-nine percent of participants believed that minority patients in the United States receive lower quality health care. Most participants (64%) attributed differences in quality of care for minority patients in the VA health care system primarily to patients' socioeconomic status, followed by patient behavior (43%) and provider behaviors (33%). In contrast, most participants believed that the VA and other health care organizations (75%) and providers (70%) bear the responsibility for reducing disparities, while less than half (45%) believed that patients were responsible. Among provider-level contributors to disparities, providers' poor communication was the most widely endorsed (48%), while differences in prescribing of medications (13%) and in provision of specialty referrals (12%) were the least endorsed. Conclusions: Although most providers in the study did not believe that providers contribute to disparities, they do believe that they, along with health care organizations, have the responsibility to help reduce them. Interventions might focus on directly offering providers concrete ways that they can help reduce disparities, rather than focusing on simply raising awareness about disparities and their contributions to them.

Communicating with providers about racial healthcare disparities: The role of providers' prior beliefs on their receptivity to different narrative frames.

OBJECTIVE: Evaluate narratives aimed at motivating providers with different pre-existing beliefs to address racial healthcare disparities. METHODS: Survey experiment with 280 providers. Providers were classified as high or low in attributing disparities to providers (HPA versus LPA) and were randomly assigned to a non-narrative control or 1 of 2 narratives: "Provider Success" (provider successfully resolved problem involving Black patient) and "Provider Bias" (Black patient experienced racial bias, which remained unresolved). Participants' reactions to narratives (including identification with narrative) and likelihood of participating in disparities-reduction activities were immediately assessed. Four weeks later, participation in those activities was assessed, including self-reported participation in a disparities-reduction training course (primary outcome). RESULTS: Participation in training was higher among providers randomized to the Provider Success narrative compared to Provider Bias or Control. LPA participants had higher identification with Provider Success than Provider Bias narratives, whereas among HPA participants, differences in identification between the narratives were not significant. CONCLUSIONS: Provider Success narratives led to greater participation in training than Provider Bias narratives, although providers' pre-existing beliefs influenced the narrative they identified with. PRACTICE IMPLICATIONS: Provider Success narratives may be more effective at motivating providers to address disparities than Provider Bias narratives, though more research is needed.

A comparison of small monetary incentives to convert survey non-respondents: a randomized control trial.

BACKGROUND: Maximizing response rates is critically important in order to provide the most generalizable and unbiased research results. High response rates reduce the chance of respondents being systematically different from non-respondents, and thus, reduce the risk of results not truly reflecting the study population. Monetary incentives are often used to improve response rates, but little is known about whether larger incentives improve response rates in those who previously have been unenthusiastic about participating in research. In this study we compared the response rates and cost-effectiveness of a $5 versus $2 monetary incentive accompanying a short survey mailed to patients who did not respond or refused to participate in research study with a face-to-face survey. METHODS: 1,328 non-responders were randomly assigned to receive $5 or $2 and a short, 10-question survey by mail. Reminder postcards were sent to everyone; those not returning the survey were sent a second survey without incentive. Overall response rates, response rates by incentive condition, and odds of responding to the larger incentive were calculated. Total costs (materials, postage, and labor) and incremental cost-effectiveness ratios were also calculated and compared by incentive condition. RESULTS: After the first mailing, the response rate within the $5 group was significantly higher (57.8% vs. 47.7%, p<.001); after the second mailing, the difference narrowed by 80%, resulting in a non-significant difference in cumulative rates between the $5 and $2 groups (67.3% vs. 65.4%, respectively, p=.47). Regardless of incentive or number of contacts, respondents were significantly more likely to be male, white, married, and 50-75 years old. Total costs were higher with the larger versus smaller incentive ($13.77 versus $9.95 per completed survey). CONCLUSIONS: A $5 incentive provides a significantly higher response rate than a $2 incentive if only one survey mailing is used but not if two survey mailings are used.

Lack of follow-up after fecal occult blood testing in older adults: inappropriate screening or failure to follow up?

BACKGROUND: It is unclear whether lack of follow-up after screening fecal occult blood testing (FOBT) in older adults is due to screening patients whose comorbidity or preferences do not permit follow-up vs failure to complete follow-up in healthy patients. METHODS: A prospective cohort study of 2410 patients 70 years or older screened with FOBT was conducted at 4 Veteran Affairs (VA) medical centers from January 1 to December 31, 2001. The main outcome measure was receipt of follow-up within 1 year of FOBT based on national VA and Medicare data. For patients with positive FOBT results, age and Charlson comorbidity scores were evaluated as potential predictors of receiving a complete colon evaluation (colonoscopy or sigmoidoscopy plus barium enema), and medical records were reviewed to determine reasons for lack of follow-up. RESULTS: A total of 212 patients (9%) had positive FOBT results; 42% received a complete colon evaluation within 1 year. Age and comorbidity were not associated with receipt of a complete follow-up, which was similar among patients 70 to 74 years old with a Charlson score of 0 compared with patients 80 years or older with a Charlson score of 1 or higher (48% vs 41%; P=.28). The VA site, number of positive FOBT cards, and number of VA outpatient visits were predictors. Of 122 patients who did not receive a complete follow-up within 1 year, 38% had documentation that comorbidity or preferences did not permit follow-up, and over the next 5 years 76% never received a complete follow-up. CONCLUSIONS: While follow-up after positive FOBT results was low regardless of age or comorbidity, screening patients in whom complete evaluation would not be pursued substantially contributes to lack of follow-up. Efforts to improve follow-up should address the full chain of decision making, including decisions to screen and decisions to follow up.

Variation in estimates of limited health literacy by assessment instruments and non-response bias.

OBJECTIVES: This paper compares estimates of poor health literacy using two widely used assessment tools and assesses the effect of non-response on these estimates. STUDY DESIGN AND SETTING: A total of 4,868 veterans receiving care at four VA medical facilities between 2004 and 2005 were stratified by age and facility and randomly selected for recruitment. Interviewers collected demographic information and conducted assessments of health literacy (both REALM and S-TOFHLA) from 1,796 participants. Prevalence estimates for each assessment were computed. Non-respondents received a brief proxy questionnaire with demographic and self-report literacy questions to assess non-response bias. Available administrative data for non-participants were also used to assess non-response bias. RESULTS: Among the 1,796 patients assessed using the S-TOFHLA, 8% had inadequate and 7% had marginal skills. For the REALM, 4% were categorized with 6th grade skills and 17% with 7-8th grade skills. Adjusting for non-response bias increased the S-TOFHLA prevalence estimates for inadequate and marginal skills to 9.3% and 11.8%, respectively, and the REALM estimates for < or = 6th and 7-8th grade skills to 5.4% and 33.8%, respectively. CONCLUSIONS: Estimates of poor health literacy varied by the assessment used, especially after adjusting for non-response bias. Researchers and clinicians should consider the possible limitations of each assessment when considering the most suitable tool for their purposes.

Randomized trial showed that an "embedded" survey strategy optimized authorization rates compared with two "after survey" strategies in veterans with PTSD.

OBJECTIVES: To test methods to optimize mail survey response and authorization rates (i.e., allowing one's survey to be linked to medical records) when the survey is sensitive and the targeted population has a mental disorder. STUDY DESIGN AND SETTING: Randomized controlled trial of 1,099 veterans treated for posttraumatic stress disorder (PTSD) at a Midwestern Veteran Affairs Medical Center. Subjects were randomized to one of three groups: (1) Health Insurance Portability and Accountability Act (HIPAA) authorization form embedded in the survey (checking "yes" for consent); (2) HIPAA form requiring signature for consent sent after the survey; or (3) HIPAA form requiring a signature and social security number (SSN) for consent sent after the survey. RESULTS: The "embedded" strategy yielded the lowest survey response rate (67.5%) but highest authorization rate (59.1%). Requiring respondents' signatures and SSNs after the survey was returned generated the highest survey response rate (74.2%) but lowest authorization rate (48.7%). However, the response rate difference was not statistically significant. Reported emotional upset was low (1.5%) and primarily directed to the survey, not the HIPAA form. Older age and greater trustfulness were associated with higher authorization rates. CONCLUSION: Even with our most optimized strategy, authorization rates were disappointingly low.

The effect of perceived racial discrimination on bodily pain among older African American men.

OBJECTIVES: We examined the extent to which experiences of racial discrimination are associated with bodily pain reported by African American men. METHODS: The study sample consisted of 393 African American male veterans who responded to a national survey of patients aged 50-75 who received care from the Veterans Health Administration (VHA). Veterans were surveyed by mail, with a telephone follow-up. The response rate for African Americans in the sample was 60.5%. Pain (assessed using the bodily pain subscale of the 36-item short-form health survey), experiences of discrimination, employment, education, and income were obtained through the survey. Age, race, and mental health comorbidities were obtained from VA administrative data. Multiple regression analysis adjusting for item non-response (via imputation) and unit non-response (via propensity scores and weighting) was used to assess the association between racial discrimination and likelihood of experiencing moderate or severe pain over the past 4 weeks. RESULTS: Experiences of racial discrimination were associated with greater bodily pain (beta = -0.25, P < 0.0001), even after controlling for socioeconomic and health-related characteristics. CONCLUSION: Perceived racial discrimination was associated with greater pain among a sample of older African American male patients in the VA. Additional research is needed to replicate this finding among other populations of African Americans.

Timely follow-up of positive fecal occult blood tests strategies associated with improvement.

BACKGROUND: In light of previous research indicating that many patients fail to receive timely diagnostic follow-up of positive colorectal cancer (CRC) screening tests, the Veterans Health Administration (VA) initiated a national CRC diagnosis quality-improvement (QI) effort. PURPOSE: This article documents the percent of patients receiving follow-up within 60 days of a positive CRC screening fecal occult blood test (FOBT) and identifies improvement strategies that predict timely follow-up. METHODS: In 2007, VA facilities completed a survey in which they indicated the degree to which they had implemented a series of improvement strategies and described barriers to improvement. Three types of strategies were assessed: developing QI infrastructure, improving care delivery processes, and building gastroenterology capacity. Survey data were merged with a measure of 60-day positive-FOBT follow-up. Facility-level predictors of timely follow-up were identified and relationships among categories of improvement strategies were assessed. Data were analyzed in 2008. RESULTS: The median facility-reported 60-day follow-up rate for positive screening FOBTs was 24.5%. Several strategies were associated with timeliness of follow-up. The relationship between the implementation of QI infrastructure strategies and timely follow-up was mediated by the implementation of process-change strategies. Although constraints on gastroenterology capacity were often sited as a key barrier, implementation of strategies to address this issue was unassociated with timely follow-up. CONCLUSIONS: Developing QI infrastructure appears to be an effective strategy for improving FOBT follow-up when this work is followed by process improvements. Increasing gastroenterology capacity may be more difficult than improving processes of care.

Impact of age and comorbidity on colorectal cancer screening among older veterans.

BACKGROUND: The Veterans Health Administration, the American Cancer Society, and the American Geriatrics Society recommend colorectal cancer screening for older adults unless they are unlikely to live 5 years or have significant comorbidity that would preclude treatment. OBJECTIVE: To determine whether colorectal cancer screening is targeted to healthy older patients and is avoided in older patients with severe comorbidity who have life expectancies of 5 years or less. DESIGN: Cohort study. SETTING: Veterans Affairs (VA) medical centers in Minneapolis, Minnesota; Durham, North Carolina; Portland, Oregon; and West Los Angeles, California, with linked national VA and Medicare administrative claims. PATIENTS: 27 068 patients 70 years or older who had an outpatient visit at 1 of 4 VA medical centers in 2001 or 2002 and were due for screening. MEASUREMENTS: The main outcome was receipt of fecal occult blood testing (FOBT), colonoscopy, sigmoidoscopy, or barium enema in 2001 or 2002, on the basis of national VA and Medicare claims. Charlson-Deyo comorbidity scores at the start of 2001 were used to stratify patients into 3 groups ranging from no comorbidity (score of 0) to severe comorbidity (score > or =4), and 5-year mortality was determined for each group. RESULTS: 46% of patients were screened from 2001 through 2002. Only 47% of patients with no comorbidity were screened despite having life expectancies greater than 5 years (5-year mortality, 19%). Although the incidence of screening decreased with age and worsening comorbidity, it was still 41% for patients with severe comorbidity who had life expectancies less than 5 years (5-year mortality, 55%). The number of VA outpatient visits predicted screening independent of comorbidity, such that patients with severe comorbidity and 4 or more visits had screening rates similar to or higher than those of healthier patients with fewer visits. LIMITATIONS: Some tests may have been performed for nonscreening reasons. The generalizability of findings to persons who do not use the VA system is uncertain. CONCLUSION: Advancing age was inversely associated with colorectal cancer screening, whereas comorbidity was a weaker predictor. More attention to comorbidity is needed to better target screening to older patients with substantial life expectancies and avoid screening older patients with limited life expectancies. primary funding source: VA Health Services Research and Development.

Communicating information to families of polytrauma patients: a narrative literature review.

Family caregivers of U.S. servicemembers with polytraumatic injuries (injuries to multiple body systems) need support and information to care for their family members. Providing information to patients'families may reduce stress and increase coping abilities. Because the field of polytrauma research is new and evidence is lacking, providers rely on traumatic brain injury (TBI) research to guide their practice. This article presents a narrative literature review on the information needs of families of patients with TBI. It summarizes the types of needed information, the most appropriate time to provide information, and the best approaches for providing information. Future research on information needs is critical if polytrauma rehabilitation providers are to effectively support families in their caregiving roles. Such research likely will benefit caregivers of patients with polytrauma who acquire their injuries as civilians, as well. Research gaps are identified with regard to the information needs of families of patients with TBI; these gaps also are applicable to polytrauma caregivers. Additional research areas are highlighted in light of the new polytrauma population.

Randomized trial showed requesting medical records with a survey produced a more representative sample than requesting separately.

OBJECTIVES: The objective of the study was to compare the effect of two approaches to requesting medical records on survey response rates, sample representativeness, and the quality of self-reported screening. STUDY DESIGN AND SETTING: Eight hundred ninety veterans aged 50-75 years from the Minneapolis VA Medical Center were randomly assigned to (1) records request included with a colorectal cancer screening survey ("with-survey" group) or (2) request in a separate mailing following a completed survey ("after-survey" group). Analyses compared response rates, the proportion and characteristics of patients providing records, and the validity of self-reported screening, by group. RESULTS: Response rates did not vary by group (with-survey 76%; after-survey 78%, P=0.45). 54% of with-survey and 47% of after-survey participants provided complete medical records (P = 0.06). In the with-survey group, patients with complete medical records were significantly more likely to be married and to have a diagnosis of posttraumatic stress disorder; in the after-survey group, they were more likely to be aged 65-75 years, Caucasian, to have a family history of colorectal cancer, and to report being screened. Validity of self-reported screening did not vary significantly by group. CONCLUSION: The with-survey approach did not significantly reduce response rates or the quality of self-reported screening and produced a higher number and more representative sample with complete records.

Gender differences in colorectal cancer screening barriers and information needs.

CONTEXT: Several prior studies have found that women are less likely to be screened for colorectal cancer (CRC) than men. While the source of this screening differential is unknown, recent studies suggest gender differences in barriers to screening might explain the disparity. OBJECTIVE: This formative study was designed to explore CRC screening barriers, attitudes and preferences by gender. METHODOLOGY: Focus group interviews with groups stratified by gender and screening status. Participants included 27 females and 43 males between the ages of 50 and 75 years who receive primary care at the Minneapolis VA Medical Center. We conducted interpretive and grounded text analysis of semi-structured focus group interviews to assess how knowledge, experiences and sociocultural norms shape female and male preferences and barriers to current CRC screening guidelines. RESULTS: Female and male participants reported similar preferences for CRC screening mode, but there were notable differences in the barriers and facilitators to screening. Key findings suggest that women viewed the preparation for endoscopic procedures as a major barrier to screening while men did not; women and men expressed different fears and information preferences regarding endoscopic procedures; and women perceive CRC as a male disease thus feeling less vulnerable to CRC. Gender-specific barriers may explain women's lower rate of screening for CRC. CONCLUSION: Colorectal cancer screening promotion interventions, decision aids and clinical practice may benefit by being tailored by gender.

Promoting repeat mammography use: insights from a systematic needs assessment.

This article describes the process and outcome of a needs assessment conducted to guide the development of interventions to increase repeat mammography use among participants in a federally funded cancer screening program. Health behavior theory and data from a phone survey are used to uncover key barriers to repeat mammography use and to identify fruitful intervention approaches for modifying them. Estimates of (a) compliance with mammography guidelines, (b) readiness to adopt regular mammography use, (c) the most common reasons for not being rescreened, and (d) population attributable risks associated with various predictors of repeat mammography use are presented and, with guidance from the transtheoretical model of behavior change, used to make inferences about the type of intervention strategies most appropriate for promoting repeat mammography use in this population.