Impact of Referring High-Risk Patients to Intensive Outpatient Primary Care Services: A Propensity Score-Matched Analysis.

BACKGROUND: Many healthcare systems have implemented intensive outpatient primary care programs with the hopes of reducing healthcare costs. OBJECTIVE: The Veterans Health Administration (VHA) piloted primary care intensive management (PIM) for patients at high risk for hospitalization or death, or "high-risk." We evaluated whether a referral model would decrease high-risk patient costs. DESIGN: Retrospective cohort study using a quasi-experimental design comparing 456 high-risk patients referred to PIM from October 2017 to September 2018 to 415 high-risk patients matched on propensity score. PARTICIPANTS: Veterans in the top 10th percentile of risk for 90-day hospitalization or death and recent hospitalization or emergency department (ED) visit. INTERVENTION: PIM consisted of interdisciplinary teams that performed comprehensive assessments, intensive case management, and care coordination services. MAIN OUTCOMES AND MEASURES: Change in VHA and non-VHA outpatient utilization, inpatient admissions, and costs 12 months pre- and post-index date. KEY RESULTS: Of the 456 patients referred to PIM, 301 (66%) enrolled. High-risk patients referred to PIM had a marginal reduction in ED visits (- 0.7; [95% CI - 1.50 to 0.08]; p = 0.08) compared to propensity-matched high-risk patients; overall outpatient costs were similar. High-risk patients referred to PIM had similar number of medical/surgical hospitalizations (- 0.2; [95% CI, - 0.6 to 0.16]; p = 0.2), significant increases in length of stay (6.36; [CI, - 0.01 to 12.72]; p = 0.05), and higher inpatient costs ($22,628, [CI, $3587 to $41,669]; p = 0.02) than those not referred to PIM. CONCLUSIONS AND RELEVANCE: VHA intensive outpatient primary care was associated with higher costs. Referral to intensive case management programs targets the most complex patients and may lead to increased utilization and costs, particularly in an integrated healthcare setting with robust patient-centered medical homes. TRIAL REGISTRATION: PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project (PIM2). NCT04521816. https://clinicaltrials.gov/study/NCT04521816.

The association between self-Esteem, stigma, and mental health among South African youth living with HIV: the need for integrated HIV care services.

Treatment among pYLHIV focuses on their physical health. However, they also experience depression and anxiety, compounded by developmental challenges and the stress of managing a chronic illness. However, limited services are available to help pYLHIV manage the emotional stressors of living with a stigmatized condition. Data are from 37 caregiver-child dyads in the VUKA EKHAYA study, in Durban, South Africa. Outcomes were self-esteem and stigma. Predictors included symptoms of depression and anxiety, and HIV treatment and transmission knowledge. Outcomes and predictors were standardized (mean: 0, standard deviation: 1). Pearson correlation, bivariate and multivariate associations between predictors and outcomes were examined. Self-esteem was negatively correlated with symptoms of anxiety (r=-0.5675; p<0.001) and depression (r=-0.6836; p<0.001), suggesting higher self-concept was correlated with fewer symptoms. In multivariate analyses, increased depressive and anxiety symptoms were associated with lower self-esteem, B=0.68 and 0.57, respectively. Higher depressive and anxiety symptoms connected to more internalized stigma B=0.38 and 0.34, respectively. Conversely, HIV knowledge was not related to self-esteem or stigma. HIV treatment and transmission knowledge are not enough to reduce stigma and improve the self-esteem of pYLHIV. Integrated mental and physical health care is needed to help pYLHIV manage psychological stressors that can mitigate their emotional wellbeing.

Provider perceptions of challenges to identifying women Veterans with hazardous substance use.

BACKGROUND: Approximately one-third of women Veterans Health Administration (VHA) users have substance use disorders (SUD). Early identification of hazardous substance use in this population is critical for the prevention and treatment of SUD. We aimed to understand challenges to identifying women Veterans with hazardous substance use to improve future referral, evaluation, and treatment efforts. METHODS: Design: We conducted a secondary analysis of semi-structured interviews conducted with VHA interdisciplinary women's SUD providers at VA Greater Los Angeles Healthcare System. PARTICIPANTS: Using purposive and snowball sampling we interviewed 17 VHA providers from psychology, social work, women's health, primary care, and psychiatry. APPROACH: Our analytic approach was content analysis of provider perceptions of identifying hazardous substance use in women Veterans. RESULTS: Providers noted limitations across an array of existing identification methodologies employed to identify women with hazardous substance use and believed these limitations were abated through trusting provider-patient communication. Providers emphasized the need to have a process in place to respond to hazardous use when identified. Provider level factors, including provider bias, and patient level factors such as how they self-identify, may impact identification of women Veterans with hazardous substance use. Tailoring language to be sensitive to patient identity may help with identification in women Veterans with hazardous substance use or SUD who are not getting care in VHA but are eligible as well as those who are not eligible for care in VHA. CONCLUSIONS: To overcome limitations of existing screening tools and processes of identifying and referring women Veterans with hazardous substance use to appropriate care, future efforts should focus on minimizing provider bias, building trust in patient-provider relationships, and accommodating patient identities.

What makes team communication effective: a qualitative analysis of interprofessional primary care team members' perspectives.

Although numerous scholars have emphasized the need for effective communication between members of interprofessional teams, few studies provide a clear understanding of what constitutes effective team communication in primary care settings, specifically where patient-centered medical home (PCMH) teams have been implemented. This paper describes the elements of effective communication as perceived by members of interprofessional PCMH primary care teams, and identifies elements of effective communication that have persisted over time. Using transcribed text from 75 semi-structured interviews, we applied the grounded theory method of constant comparison to categorize emergent themes relating to elements of team communication. Interprofessional PCMH team members described the elements of effective communication as: 1) shared knowledge, 2) situation/goal awareness, 3) problem-solving, 4) mutual respect; and communication that is 5) transparent, 6) timely, 7) frequent, 8) consistent, and 9) parsimonious. Parsimony is an emergent theme that may be especially relevant for interprofessional PCMH teams challenged with structured clinic schedules. Future work could focus on understanding how to teach and sustain effective parsimonious communication. Comprehensive quality improvement efforts incorporating a variety of strategies, including team communication training, information and communication technologies, and standardized communication tools may facilitate communication of pertinent patient information in a brief and concise manner.

Periodic reflections: a method of guided discussions for documenting implementation phenomena.

BACKGROUND: Ethnography has been proposed as a valuable method for understanding how implementation occurs within dynamic healthcare contexts, yet this method can be time-intensive and challenging to operationalize in pragmatic implementation. The current study describes an ethnographically-informed method of guided discussions developed for use by a multi-project national implementation program. METHODS: The EMPOWER QUERI is conducting three projects to implement innovative care models in VA women's health for high-priority health concerns - prediabetes, cardiovascular risk, and mental health - utilizing the Replicating Effective Programs (REP) implementation strategy enhanced with stakeholder engagement and complexity science. Drawing on tenets of ethnographic research, we developed a lightly-structured method of guided "periodic reflections" to aid in documenting implementation phenomena over time. Reflections are completed as 30-60 min telephone discussions with implementation team members at monthly or bi-monthly intervals, led by a member of the implementation core. Discussion notes are coded to reflect key domains of interest and emergent themes, and can be analyzed singly or in triangulation with other qualitative and quantitative assessments to inform evaluation and implementation activities. RESULTS: Thirty structured reflections were completed across the three projects during a 15-month period spanning pre-implementation, implementation, and sustainment activities. Reflections provide detailed, near-real-time information on projects' dynamic implementation context, including characteristics of implementation settings and changes in the local or national environment, adaptations to the intervention and implementation plan, and implementation team sensemaking and learning. Reflections also provide an opportunity for implementation teams to engage in recurring reflection and problem-solving. CONCLUSIONS: To implement new, complex interventions into dynamic organizations, we must better understand the implementation process as it unfolds in real time. Ethnography is well suited to this task, but few approaches exist to aid in integrating ethnographic insights into implementation research. Periodic reflections show potential as a straightforward and low-burden method for documenting events across the life cycle of an implementation effort. They offer an effective means for capturing information on context, unfolding process and sensemaking, unexpected events, and diverse viewpoints, illustrating their value for use as part of an ethnographically-minded implementation approach. TRIAL REGISTRATION: The two implementation research studies described in this article have been registered as required: Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans (NCT02991534); and Implementation of Tailored Collaborative Care for Women Veterans (NCT02950961).

Interprofessional training and team function in patient-centred medical home: Findings from a mixed method study of interdisciplinary provider perspectives.

Transitioning from profession-specific to interprofessional (IP) models of care requires major change. The Veterans Assessment and Improvement Laboratory (VAIL), is an initiative based in the United States that supports and evaluates the Veterans Health Administration's (VAs) transition of its primary care practices to an IP team based patient-centred medical home (PCMH) care model. We postulated that modifiable primary care practice organizational climate factors impact PCMH implementation. VAIL administered a survey to 322 IP team members in primary care practices in one VA administrative region during early implementation of the PCMH and interviewed 79 representative team members. We used convergent mixed methods to study modifiable organizational climate factors in relationship to IP team functioning. We found that leadership support and job satisfaction were significantly positively associated with team functioning. We saw no association between team functioning and either role readiness or team training. Qualitative interview data confirmed survey findings and explained why the association with IP team training might be absent. In conclusion, our findings demonstrate the importance of leadership support and individual job satisfaction in producing highly functioning PCMH teams. Based on qualitative findings, we hypothesize interprofessional training is important, however, inconsistencies in IP training delivery compromise its potential benefit. Future implementation efforts should improve standardization of training process and train team members together. Interprofessional leadership coordination of interprofessional training is warranted.

BRCA1 tumour suppression occurs via heterochromatin-mediated silencing.

Mutations in the tumour suppressor gene BRCA1 lead to breast and/or ovarian cancer. Here we show that loss of Brca1 in mice results in transcriptional de-repression of the tandemly repeated satellite DNA. Brca1 deficiency is accompanied by a reduction of condensed DNA regions in the genome and loss of ubiquitylation of histone H2A at satellite repeats. BRCA1 binds to satellite DNA regions and ubiquitylates H2A in vivo. Ectopic expression of H2A fused to ubiquitin reverses the effects of BRCA1 loss, indicating that BRCA1 maintains heterochromatin structure via ubiquitylation of histone H2A. Satellite DNA de-repression was also observed in mouse and human BRCA1-deficient breast cancers. Ectopic expression of satellite DNA can phenocopy BRCA1 loss in centrosome amplification, cell-cycle checkpoint defects, DNA damage and genomic instability. We propose that the role of BRCA1 in maintaining global heterochromatin integrity accounts for many of its tumour suppressor functions.

Depression Quality of Care: Measuring Quality over Time Using VA Electronic Medical Record Data.

BACKGROUND: The Veterans Health Administration (VA) has invested substantially in evidence-based mental health care. Yet no electronic performance measures for assessing the level at which the population of Veterans with depression receive appropriate care have proven robust enough to support rigorous evaluation of the VA's depression initiatives. OBJECTIVE: Our objectives were to develop prototype longitudinal electronic population-based measures of depression care quality, validate the measures using expert panel judgment by VA and non-VA experts, and examine detection, follow-up and treatment rates over a decade (2000-2010). We describe our development methodology and the challenges to creating measures that capture the longitudinal course of clinical care from detection to treatment. DESIGN AND PARTICIPANTS: Data come from the National Patient Care Database and Pharmacy Benefits Management Database for primary care patients from 1999 to 2011, from nine Veteran Integrated Service Networks. MEASURES: We developed four population-based quality metrics for depression care that incorporate a 6-month look back and 1-year follow-up: detection of a new episode of depression, 84 and 180 day follow-up, and minimum appropriate treatment 1-year post detection. Expert panel techniques were used to evaluate the measure development methodology and results. Key challenges to creating valid longitudinal measures are discussed. KEY RESULTS: Over the decade, the rates for detection of new episodes of depression remained stable at 7-8 %. Follow-up at 84 and 180 days were 37 % and 45 % in 2000 and increased to 56 % and 63 % by 2010. Minimum appropriate treatment remained relatively stable over the decade (82-84 %). CONCLUSIONS: The development of valid longitudinal, population-based quality measures for depression care is a complex process with numerous challenges. If the full spectrum of care from detection to follow-up and treatment is not captured, performance measures could actually mask the clinical areas in need of quality improvement efforts.

Application of a nonrandomized stepped wedge design to evaluate an evidence-based quality improvement intervention: a proof of concept using simulated data on patient-centered medical homes.

BACKGROUND: Stepped wedge designs have gained recognition as a method for rigorously assessing implementation of evidence-based quality improvement interventions (QIIs) across multiple healthcare sites. In theory, this design uses random assignment of sites to successive QII implementation start dates based on a timeline determined by evaluators. However, in practice, QII timing is often controlled more by site readiness. We propose an alternate version of the stepped wedge design that does not assume the randomized timing of implementation while retaining the method's analytic advantages and applying to a broader set of evaluations. To test the feasibility of a nonrandomized stepped wedge design, we developed simulated data on patient care experiences and on QII implementation that had the structures and features of the expected data from a planned QII. We then applied the design in anticipation of performing an actual QII evaluation. METHODS: We used simulated data on 108,000 patients to model nonrandomized stepped wedge results from QII implementation across nine primary care sites over 12 quarters. The outcome we simulated was change in a single self-administered question on access to care used by Veterans Health Administration (VA), based in the United States, as part of its quarterly patient ratings of quality of care. Our main predictors were QII exposure and time. Based on study hypotheses, we assigned values of 4 to 11 % for improvement in access when sites were first exposed to implementation and 1 to 3 % improvement in each ensuing time period thereafter when sites continued with implementation. We included site-level (practice size) and respondent-level (gender, race/ethnicity) characteristics that might account for nonrandomized timing in site implementation of the QII. We analyzed the resulting data as a repeated cross-sectional model using HLM 7 with a three-level hierarchical data structure and an ordinal outcome. Levels in the data structure included patient ratings, timing of adoption of the QII, and primary care site. RESULTS: We were able to demonstrate a statistically significant improvement in adoption of the QII, as postulated in our simulation. The linear time trend while sites were in the control state was not significant, also as expected in the real life scenario of the example QII. CONCLUSIONS: We concluded that the nonrandomized stepped wedge design was feasible within the parameters of our planned QII with its data structure and content. Our statistical approach may be applicable to similar evaluations.

Building capacity in VA to provide emergency gynecology services for women.

BACKGROUND: Visits to Veterans Administration (VA) emergency departments (EDs) are increasingly being made by women. A 2011 national inventory of VA emergency services for women revealed that many EDs have gaps in their resources and processes for gynecologic emergency care. OBJECTIVES: To guide VA in addressing these gaps, we sought to understand factors acting as facilitators and/or barriers to improving VA ED capacity for, and quality of, emergency gynecology care. RESEARCH DESIGN: Semistructured interviews with VA emergency and women's health key informants. SUBJECTS: ED directors/providers (n=14), ED nurse managers (n=13), and Women Veteran Program Managers (n=13) in 13 VA facilities. RESULTS: Leadership, staff, space, demand, funding, policies, and community were noted as important factors influencing VA EDs building capacity and improving emergency gynecologic care for women Veterans. These factors are intertwined and cross multiple organizational levels so that each ED's capacity is a reflection not only of its own factors, but also those of its local medical center and non-VA community context as well as VA regional and national trends and policies. CONCLUSIONS: Policies and quality improvement initiatives aimed at building VA's emergency gynecologic services for women need to be multifactorial and aimed at multiple organizational levels. Policies need to be flexible to account for wide variations across EDs and their medical center and community contexts. Approaches that build and encourage local leadership engagement, such as evidence-based quality improvement methodology, are likely to be most effective.

Engaging healthcare teams to increase access to medications for opioid use disorder.

OBJECTIVE: To assess the effectiveness of evidence-based quality improvement (EBQI) as an implementation strategy to expand the use of medications for opioid use disorder (MOUD) within nonspecialty settings. DATA SOURCES AND STUDY SETTING: We studied eight facilities in one Veteran Health Administration (VHA) region from October 2015 to September 2022 using administrative data. STUDY DESIGN: Initially a pilot, we sequentially engaged seven of eight facilities from April 2018 to September 2022 using EBQI, consisting of multilevel stakeholder engagement, technical support, practice facilitation, and data feedback. We established facility-level interdisciplinary quality improvement (QI) teams and a regional-level cross-facility collaborative. We used a nonrandomized stepped wedge design with repeated cross sections to accommodate the phased implementation. Using aggregate facility-level data from October 2015 to September 2022, we analyzed changes in patients receiving MOUD using hierarchical multiple logistic regression. DATA COLLECTION/EXTRACTION METHODS: Eligible patients had an opioid use disorder (OUD) diagnosis from an outpatient or inpatient visit in the previous year. Receiving MOUD was defined as having been prescribed an opioid agonist or antagonist treatment or a visit to an opioid substitution clinic. PRINCIPAL FINDINGS: The probability of patients with OUD receiving MOUD improved significantly over time for all eight facilities (average marginal effect [AME]: 0.0057, 95% CI: 0.0044, 0.0070) due to ongoing VHA initiatives, with the probability of receiving MOUD increasing by 0.577 percentage points, on average, each quarter, totaling 16 percentage points during the evaluation period. The seven facilities engaging in EBQI experienced, on average, an additional 5.25 percentage point increase in the probability of receiving MOUD (AME: 0.0525, 95%CI: 0.0280, 0.0769). EBQI duration was not associated with changes. CONCLUSIONS: EBQI was effective for expanding access to MOUD in nonspecialty settings, resulting in increases in patients receiving MOUD exceeding those associated with temporal trends. Additional research is needed due to recent MOUD expansion legislation.

Implementing evidence-based practices to improve primary care for high-risk patients: study protocol for the VA high-RIsk VETerans (RIVET) type III effectiveness-implementation trial.

BACKGROUND: Patients with significant multimorbidity and other factors that make healthcare challenging to access and coordinate are at high risk for poor health outcomes. Although most (93%) of Veterans' Health Administration (VHA) patients at high risk for hospitalization or death ("high-risk Veterans") are primarily managed by primary care teams, few of these teams have implemented evidence-based practices (EBPs) known to improve outcomes for the high-risk patient population's complex healthcare issues. Effective implementation strategies could increase adoption of these EBPs in primary care; however, the most effective implementation strategies to increase evidence-based care for high-risk patients are unknown. The high-RIsk VETerans (RIVET) Quality Enhancement Research Initiative (QUERI) will compare two variants of Evidence-Based Quality Improvement (EBQI) strategies to implement two distinct EBPs for high-risk Veterans: individual coaching (EBQI-IC; tailored training with individual implementation sites to meet site-specific needs) versus learning collaborative (EBQI-LC; implementation sites trained in groups to encourage collaboration among sites). One EBP, Comprehensive Assessment and Care Planning (CACP), guides teams in addressing patients' cognitive, functional, and social needs through a comprehensive care plan. The other EBP, Medication Adherence Assessment (MAA), addresses common challenges to medication adherence using a patient-centered approach. METHODS: We will recruit and randomize 16 sites to either EBQI-IC or EBQI-LC to implement one of the EBPs, chosen by the site. Each site will have a site champion (front-line staff) who will participate in 18 months of EBQI facilitation. ANALYSIS: We will use a mixed-methods type 3 hybrid Effectiveness-Implementation trial to test EBQI-IC versus EBQI-LC versus usual care using a Concurrent Stepped Wedge design. We will use the Practical, Robust Implementation and Sustainability Model (PRISM) framework to compare and evaluate Reach, Effectiveness, Adoption, Implementation, and costs. We will then assess the maintenance/sustainment and spread of both EBPs in primary care after the 18-month implementation period. Our primary outcome will be Reach, measured by the percentage of eligible high-risk patients who received the EBP. DISCUSSION: Our study will identify which implementation strategy is most effective overall, and under various contexts, accounting for unique barriers, facilitators, EBP characteristics, and adaptations. Ultimately this study will identify ways for primary care clinics and teams to choose implementation strategies that can improve care and outcomes for patients with complex healthcare needs. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05050643. Registered September 9th, 2021, https://clinicaltrials.gov/study/NCT05050643 PROTOCOL VERSION: This protocol is Version 1.0 which was created on 6/3/2020.

The role of mental health in mediating the relationship between social support and optimal ART adherence.

Optimal adherence to antiretroviral therapy (ART) is essential for reducing mortality and morbidity in persons living with HIV/AIDS (PLWHA), as well as for reducing the risk of further HIV transmission. While studies have identified psychosocial factors such as lack of social support and poor mental health status as important barriers to optimal ART adherence, few studies have explored the potential of a mediation effect of psychosocial factors on the relationship between social support and optimal ART adherence. This paper assessed whether mental health status mediated the relationship between social support and optimal ART adherence among a cross-sectional sample of 202 persons living with HIV who were recruited from HIV clinical care sites and community-based organizations in Los Angeles County (LAC). Participants completed a survey that included social support items from the Medical Outcome Study: Social Support Survey (MOS-SSS) Instrument, mental health measures from the Medical Outcomes Study Short Form (SF-12), and ART adherence based on self-report. Among those currently taking ART, 61.7% reported having optimal adherence. Social support was significantly associated with a high score on the mental health status scale (AOR =2.90; 95% CI=1.14-5.78) and optimal ART adherence (AOR=1.81; 95% CI=1.81; 95% CI=1.18-2.79). When mental health status was introduced into the model, the association between social support and optimal ART adherence was no longer significant. Our findings suggest the HIV interventions targeting social support to improve ART adherence will likely be most successful if the support bolsters the mental health of the participants. Clearly, better understanding the relationships among social support, mental health, and ART adherence will be critical for development and implementation of future ART adherence interventions.

Neprilysin-2 is an important ß-amyloid degrading enzyme.

Proteases that degrade the amyloid-ß peptide (Aß) are important in protecting against Alzheimer's disease (AD), and understanding these proteases is critical to understanding AD pathology. Endopeptidases sensitive to inhibition by thiorphan and phosphoramidon are especially important, because these inhibitors induce dramatic Aß accumulation (∼30- to 50-fold) and pathological deposition in rodents. The Aß-degrading enzyme neprilysin (NEP) is the best known target of these inhibitors. However, genetic ablation of NEP results in only modest increases (∼1.5- to 2-fold) in Aß, indicating that other thiorphan/phosphoramidon-sensitive endopeptidases are at work. Of particular interest is the NEP homolog neprilysin 2 (NEP2), which is thiorphan/phosphoramidon-sensitive and degrades Aß. We investigated the role of NEP2 in Aß degradation in vivo through the use of gene knockout and transgenic mice. Mice deficient for the NEP2 gene showed significant elevations in total Aß species in the hippocampus and brainstem/diencephalon (∼1.5-fold). Increases in Aß accumulation were more dramatic in NEP2 knockout mice crossbred with APP transgenic mice. In NEP/NEP2 double-knockout mice, Aß levels were marginally increased (∼1.5- to 2-fold), compared with NEP(-/-)/NEP2(+/+) controls. Treatment of these double-knockout mice with phosphoramidon resulted in elevations of Aß, suggesting that yet other NEP-like Aß-degrading endopeptidases are contributing to Aß catabolism.

Demographic Differences Among US Department of Veterans Affairs Patients Referred for Genetic Consultation to a Centralized VA Telehealth Program, VA Medical Centers, or the Community.

Importance: Telehealth enables access to genetics clinicians, but impact on care coordination is unknown. Objective: To assess care coordination and equity of genetic care delivered by centralized telehealth and traditional genetic care models. Design, Setting, and Participants: This cross-sectional study included patients referred for genetic consultation from 2010 to 2017 with 2 years of follow-up in the US Department of Veterans Affairs (VA) health care system. Patients were excluded if they were referred for research, cytogenetic, or infectious disease testing, or if their care model could not be determined. Exposures: Genetic care models, which included VA-telehealth (ie, a centralized team of genetic counselors serving VA facilities nationwide), VA-traditional (ie, a regional service by clinical geneticists and genetic counselors), and non-VA care (ie, community care purchased by the VA). Main Outcomes and Measures: Multivariate regression models were used to assess associations between patient and consultation characteristics and the type of genetic care model referral; consultation completion; and having 0, 1, or 2 or more cancer surveillance (eg, colonoscopy) and risk-reducing procedures (eg, bilateral mastectomy) within 2 years following referral. Results: In this study, 24 778 patients with genetics referrals were identified, including 12 671 women (51.1%), 13 193 patients aged 50 years or older (53.2%), 15 639 White patients (63.1%), and 15 438 patients with cancer-related referrals (62.3%). The VA-telehealth model received 14 580 of the 24 778 consultations (58.8%). Asian patients, American Indian or Alaskan Native patients, and Hawaiian or Pacific Islander patients were less likely to be referred to VA-telehealth than White patients (OR, 0.54; 95% CI, 0.35-0.84) compared with the VA-traditional model. Completing consultations was less likely with non-VA care than the VA-traditional model (OR, 0.45; 95% CI, 0.35-0.57); there were no differences in completing consultations between the VA models. Black patients were less likely to complete consultations than White patients (OR, 0.84; 95% CI, 0.76-0.93), but only if referred to the VA-telehealth model. Patients were more likely to have multiple cancer preventive procedures if they completed their consultations (OR, 1.55; 95% CI, 1.40-1.72) but only if their consultations were completed with the VA-traditional model. Conclusions and Relevance: In this cross-sectional study, the VA-telehealth model was associated with improved access to genetics clinicians but also with exacerbated health care disparities and hindered care coordination. Addressing structural barriers and the needs and preferences of vulnerable subpopulations may complement the centralized telehealth approach, improve care coordination, and help mitigate health care disparities.

Reducing Rejected Fecal Immunochemical Tests Received in the Laboratory for Colorectal Cancer Screening.

BACKGROUND: Colorectal cancer (CRC) screening decreases CRC incidence; however, many patients are not successfully screened. PURPOSE: To improve screening rates at our institution by decreasing the rate of rejected fecal immunochemical tests (FITs), a means of CRC screening, from 28.6% to <10% by December 2017. METHODS: Specimens were rejected for the following reasons: expired specimen, lack of recorded collection date/time, lack of physician orders, incomplete patient information, and illegible handwriting. Multidisciplinary teams devised the following interventions: FIT envelope reminder stickers, automated FIT patient reminder phone calls, a laboratory standard operating procedure, an accessioning process at satellite laboratories, revisions to a clinical reminder when offering FIT, and provision of FIT-compatible printers to clinics. RESULTS: Total specimens received each month ranged from 647 to 970. Fecal immunochemical test rejection rates fell from 28.6% in June 2017 to 6.9% in December 2017 with a statistically significant decrease (p-value = .015) between the intervention period (May 2017-October 2017) and the postintervention period (November 2017-May 2018). CONCLUSIONS: Targeted interventions with stakeholder involvement are essential in reducing the rejection rate. IMPLICATIONS: The decreased rejection rate saves resources by decreasing the need to rescreen patients whose specimens were rejected, and may improve CRC screening rates.

What Should Health Care Systems Consider When Implementing Complementary and Integrative Health: Lessons from Veterans Health Administration.

OBJECTIVES: Health care systems are increasingly interested in becoming whole health systems that include complementary and integrative health (CIH) approaches. The nation's largest health care system, the Veterans Health Administration (VA), has been transforming to such a system. However, anecdotal evidence suggested that many VA medical centers have faced challenges in implementing CIH approaches, whereas others have flourished. We report on a large-scale, research-operations partnered effort to understand the challenges faced by VA sites and the strategies used to address these to better support VAs implementation of CIH nationally. DESIGN: We conducted semi-structured, in-person qualitative interviews with 149 key stakeholders at 8 VA medical centers, with content based on Greenhalgh's implementation framework. For analysis, we identified a priori categories of content aligned with Greenhalgh's framework and then generated additional categories developed inductively, capturing additional implementation experiences. These categories formed a template to aid in coding data. RESULTS: VA sites commonly reported that nine key factors facilitated CIH implementation: (1) organizing individual CIH approaches into one program instead of spreading across several departments; (2) having CIH strategic plans and steering committees; (3) strong, professional, and enthusiastic CIH program leads and practitioners; (4) leadership support; (5) providers' positive attitudes toward CIH; (6) perceptions of patients' attitudes; (7) demonstrating evidence of CIH effectiveness; (8) champions; and (9) effectively marketing. Common challenges included are: (1) difficulties in hiring; (2) insufficient/inconsistent CIH funding; (3) appropriate patient access to CIH approaches; (4) difficulties in coding/documenting CIH use; (5) insufficient/inappropriate space; (6) insufficient staff's and provider's time; and (7) the health care cultural and geographic environments. Sites also reported several successful strategies supporting CIH implementation. CONCLUSIONS: VA sites experience both success and challenges with implementing CIH approaches and have developed a wide range of strategies to support their implementation efforts. This information is potentially useful to other health care organizations considering how best to support CIH provision.

How middle managers facilitate interdisciplinary primary care team functioning.

BACKGROUND: The Veterans Health Administration (VA) primary care is organized as a Patient Centered Medical Home (PCMH) that is based on continuity management of patient panels by interdisciplinary "teamlets" consisting of primary care providers, nurses, and clerical associates. While the teamlets are envisioned as interdisciplinary in this model, teamlet members may continue to report separately to middle management supervisors within their respective disciplines. Little is known about the role of middle managers in medical home implementation; therefore, the study purpose is to examine and characterize teamlet members' perceptions of middle managers' role in primary care operations and teamlet functioning in an outpatient setting. METHODS: This study applied a formal qualitative data collection method and analysis based on semi-structured interviews of 79 frontline interdisciplinary staff (primary care providers, nurses, and clerical associates) in VA Patient Aligned Care Teams (PACT) teamlets. Interviews were analyzed using a method of constant comparison. RESULTS: Teamlet members recognize that their supervising middle managers are essential to daily functioning of PACT teamlets in terms of clarifying roles and responsibilities, setting expectations, providing coverage strategies, supporting conflict resolution, and facilitating teamlet-initiated innovation. Teamlet members identified challenges when middle manager involvement was lacking. CONCLUSION: Within a multilevel system, frontline interdisciplinary staff continue to perceive the need for leadership by middle managers from their own professional disciplines for solving interdisciplinary problems, setting role-specific schedules and expectations, and fostering innovation. As such, greater focus on the structure and training of middle managers for participation in PCMH models is needed.

Racial/Ethnic Disparities in Mortality Across the Veterans Health Administration.

Purpose: Equal-access health care systems such as the Veterans Health Administration (VHA) reduce financial and nonfinancial barriers to care. It is unknown if such systems mitigate racial/ethnic mortality disparities, such as those well documented in the broader U.S. population. We examined racial/ethnic mortality disparities among VHA health care users, and compared racial/ethnic disparities in VHA and U.S. general populations. Methods: Linking VHA records for an October 2008 to September 2009 national VHA user cohort, and National Death Index records, we assessed all-cause, cancer, and cardiovascular-related mortality through December 2011. We calculated age-, sex-, and comorbidity-adjusted mortality hazard ratios. We computed sex-stratified, age-standardized mortality risk ratios for VHA and U.S. populations, then compared racial/ethnic disparities between the populations. Results: Among VHA users, American Indian/Alaskan Natives (AI/ANs) had higher adjusted all-cause mortality, whereas non-Hispanic Blacks had higher cause-specific mortality versus non-Hispanic Whites. Asians, Hispanics, and Native Hawaiian/Other Pacific Islanders had similar, or lower all-cause and cause-specific mortality versus non-Hispanic Whites. Mortality disparities were evident in non-Hispanic-Black men compared with non-Hispanic White men in both VHA and U.S. populations for all-cause, cardiovascular, and cancer (cause-specific) mortality, but disparities were smaller in VHA. VHA non-Hispanic Black women did not experience the all-cause and cause-specific mortality disparity present for U.S. non-Hispanic Black women. Disparities in all-cause and cancer mortality existed in VHA but not in U.S. population AI/AN men. Conclusion: Patterns in racial/ethnic disparities differed between VHA and U.S. populations, with fewer disparities within VHAs equal-access system. Equal-access health care may partially address racial/ethnic mortality disparities, but other nonhealth care factors should also be explored.