Home and Community-Based Service Use Varies by Health Care Team and Comorbidity Level of Veterans with Dementia.

Home and community-based services (HCBSs) such as home care and adult day centers are vital to supporting adults with dementia in community settings. We investigated whether HCBS use (use of both home care and adult day, use of one service, and use of neither service) varied between adults receiving care from three types of health-care teams with case management from social workers and nurses, and by comorbidity level, using 2019 data of 143,281 patients with dementia in the Veterans Health Administration. We compared HCBS use by patients' type of case-managed team (Home-Based Primary Care, geriatrics-based primary care, and dementia-focused specialty care) to patients in none of these teams, stratified by patients' non-dementia comorbidities (<4 or ≥4). Each type of health-care team was associated with both home care and adult day services, at each level of comorbidity. Home-Based Primary Care was most consistently associated with other forms of HCBS use, followed by Dementia Clinics and geriatrics-based primary care, for patients with ≥4 non-dementia comorbidities. Our findings suggest that case management in primary and specialty care settings is a contributor to the use of critical community supports by patients with the most complex needs.

Organizational readiness to change as a leverage point for improving safety: a national nursing home survey.

BACKGROUND: A stronger safety climate in nursing homes may reduce avoidable adverse events. Yet efforts to strengthen safety climate may fail if nursing homes are not ready to change. To inform improvement efforts, we examined the link between organizational readiness to change and safety climate. METHODS: Seven safety climate domains and organizational readiness to change were measured with validated Community Living Center/CLC Employee Survey of Attitudes about Resident Safety and Organizational Readiness to Change Assessment. Safety climate domains comprised of safety priorities, supervisor commitment to safety, senior management commitment to safety, safety attitudes, environmental safety, coworker interactions around safety, and global rating of CLC. We specified models with and without readiness to change to explain CLC- and person-level variance in safety climate domains. RESULTS: One thousand three hundred ninety seven workers (frontline staff and managers) responded from 56 US Veterans Health Administration CLCs located throughout the US. Adding readiness to change reduced baseline CLC-level variance of outcomes (2.3-9.3%) by > 70% for interpersonal domains (co-workers, supervisors, and senior management). Readiness to change explained person-level variance of every safety climate domain (P < 0.05), especially for interpersonal domains. CONCLUSIONS: Organizational readiness to change predicted safety climate. Safety climate initiatives that address readiness to change among frontline staff and managers may be more likely to succeed and eventually increase resident safety.

Participating in Complementary and Integrative Health Approaches Is Associated With Veterans' Patient-reported Outcomes Over Time.

BACKGROUND: Veterans Affairs is dedicated to providing a Whole Health approach to care, including offering complementary and integrative health (CIH) approaches to Veterans. OBJECTIVE: The objective of this study was to examine the association of CIH participation with Veterans' patient-reported outcomes over time. RESEARCH DESIGN: A survey of patient-reported outcomes at 5 timepoints: baseline, 2, 4, 6, and 12 months. SUBJECTS: Veterans participating in any type of CIH approach at 2 Veterans Affairs medical centers. MEASURES: Mixed hierarchical models with repeated variables were used to test the hypothesis that participating in any CIH approach would be associated with Veterans' overall physical/mental health [Patient-Reported Outcomes Measurement Information System 28 (PROMIS 28)], pain intensity, perceived stress (Perceived Stress Scale-4), and engagement in their care (Patient Activation Measure-13), controlling for age, male sex, site, participation in other CIH approaches, and surveys completed. RESULTS: We received 401 surveys from 119 Veterans (72% male, age range: 29-85 y) across all timepoints. Yoga participation was related to decreases in perceived stress (P<0.001), while tai chi participation was associated with improvements in overall PROMIS 28 physical and mental health functioning (P<0.02). Specific types of CIH were associated with significant improvements in PROMIS 28 subscales: meditation participation with physical functioning at 2, 6, and 12 months; tai chi participation with anxiety at 2 and 6 months, and ability to participate in social role activities at 2 months. No CIH approach was associated with Veterans' pain or engagement in their care. CONCLUSION: As specific CIH approaches are associated with improvements in patient-reported outcomes, clinicians, Veterans, and family members may use this information in discussions of nonpharmacological options to address health and well-being.

Patient Use of Electronic Prescription Refill and Secure Messaging and Its Association With Undetectable HIV Viral Load: A Retrospective Cohort Study.

BACKGROUND: Electronic personal health records (PHRs) can support patient self-management of chronic conditions. Managing human immunodeficiency virus (HIV) viral load, through taking antiretroviral therapy (ART) is crucial to long term survival of persons with HIV. Many persons with HIV have difficulty adhering to their ART over long periods of time. PHRs contribute to chronic disease self-care and may help persons with HIV remain adherent to ART. Proportionally veterans with HIV are among the most active users of the US Department of Veterans Affairs (VA) PHR, called My HealtheVet. Little is known about whether the use of the PHR is associated with improved HIV outcomes in this population. OBJECTIVE: The objective of this study was to investigate whether there are associations between the use of PHR tools (electronic prescription refill and secure messaging [SM] with providers) and HIV viral load in US veterans. METHODS: We conducted a retrospective cohort study using data from the VA's electronic health record (EHR) and the PHR. We identified veterans in VA care from 2009-2012 who had HIV and who used the PHR. We examined which ones had achieved the positive outcome of suppressed HIV viral load, and whether achievement of this outcome was associated with electronic prescription refill or SM. From 18,913 veterans with HIV, there were 3374 who both had a detectable viral load in 2009 and who had had a follow-up viral load test in 2012. To assess relationships between electronic prescription refill and viral control, and SM and viral control, we fit a series of multivariable generalized estimating equation models, accounting for clustering in VA facilities. We adjusted for patient demographic and clinical characteristics associated with portal use. In the initial models, the predictor variables were included in dichotomous format. Subsequently, to evaluate a potential dose-effect, the predictor variables were included as ordinal variables. RESULTS: Among our sample of 3374 veterans with HIV who received VA care from 2009-2012, those who had transitioned from detectable HIV viral load in 2009 to undetectable viral load in 2012 tended to be older (P=.004), more likely to be white (P<.001), and less likely to have a substance use disorder, problem alcohol use, or psychosis (P=.006, P=.03, P=.004, respectively). There was a statistically significant positive association between use of electronic prescription refill and change in HIV viral load status from 2009-2012, from detectable to undetectable (OR 1.36, CI 1.11-1.66). There was a similar association between SM use and viral load status, but without achieving statistical significance (OR 1.28, CI 0.89-1.85). Analyses did not demonstrate a dose-response of prescription refill or SM use for change in viral load. CONCLUSIONS: PHR use, specifically use of electronic prescription refill, was associated with greater control of HIV. Additional studies are needed to understand the mechanisms by which this may be occurring.

Using Mixed Methods to Examine the Role of Veterans' Illness Perceptions on Depression Treatment Utilization and HEDIS Concordance.

BACKGROUND: Although depression screening occurs annually in the Department of Veterans Affairs (VA) primary care, many veterans may not be receiving guideline-concordant depression treatment. OBJECTIVES: To determine whether veterans' illness perceptions of depression may be serving as barriers to guideline-concordant treatment. RESEARCH DESIGN: We used a prospective, observational design involving a mailed questionnaire and chart review data collection to assess depression treatment utilization and concordance with Healthcare Effectiveness Data and Information Set guidelines adopted by the VA. The Self-Regulation Model of Illness Behavior guided the study. SUBJECTS: Veterans who screened positive for a new episode of depression at 3 VA primary care clinics in the US northeast. MEASURES: The Illness Perceptions Questionnaire-Revised, measuring patients' perceptions of their symptoms, cause, timeline, consequences, cure or controllability, and coherence of depression and its symptoms, was our primary measure to calculate veterans' illness perceptions. Treatment utilization was assessed 3 months after the positive depression screen through chart review. Healthcare Effectiveness Data and Information Set (HEDIS) guideline-concordant treatment was determined according to a checklist created for the study. RESULTS: A total of 839 veterans screened positive for a new episode of depression from May 2009-June 2011; 275 (32.8%) completed the survey. Ninety-two (33.9%) received HEDIS guideline-concordant depression treatment. Veterans' illness perceptions of their symptoms, cause, timeline, and controllability of depression predicted receiving guideline-concordant treatment. CONCLUSIONS: Many veterans are not receiving guideline-concordant treatment for depression. HEDIS guideline measures may not be assessing all aspects of quality depression care. Conversations about veterans' illness perceptions and their specific needs are encouraged to ensure that appropriate treatment is achieved.

Outcomes of anticoagulation therapy in patients with mental health conditions.

BACKGROUND: Patients with mental health conditions (MHCs) experience poor anticoagulation control when using warfarin, but we have limited knowledge of the association between specific mental illness and warfarin treatment outcomes. OBJECTIVE: To examine the relationship between the severity of MHCs and outcomes of anticoagulation therapy. DESIGN: Retrospective cohort analysis. PARTICIPANTS: We studied 103,897 patients on warfarin for 6 or more months cared for by the Veterans Health Administration during fiscal years 2007-2008. We identified 28,216 patients with MHCs using ICD-9 codes: anxiety disorders, bipolar disorder, depression, post-traumatic stress disorder, schizophrenia, and other psychotic disorders. MAIN MEASURES: Outcomes included anticoagulation control, as measured by percent time in the therapeutic range (TTR), as well as major hemorrhage. Predictors included different categories of MHC, Global Assessment of Functioning (GAF) scores, and psychiatric hospitalizations. KEY RESULTS: Patients with bipolar disorder, depression, and other psychotic disorders experienced TTR decreases of 2.63 %, 2.26 %, and 2.92 %, respectively (p < 0.001), after controlling for covariates. Patients with psychotic disorders other than schizophrenia experienced increased hemorrhage after controlling for covariates [hazard ratio (HR) 1.24, p = 0.03]. Having any MHC was associated with a slightly increased hazard for hemorrhage (HR 1.19, p < 0.001) after controlling for covariates. CONCLUSION: Patients with specific MHCs (bipolar disorder, depression, and other psychotic disorders) experienced slightly worse anticoagulation control. Patients with any MHC had a slightly increased hazard for major hemorrhage, but the magnitude of this difference is unlikely to be clinically significant. Overall, our results suggest that appropriately selected patients with MHCs can safely receive therapy with warfarin.

Capturing the Dynamics of Homelessness Through Ethnography and Mobile Technology: Protocol for the Development and Testing of a Smartphone Technology-Supported Intervention.

BACKGROUND: US military veterans who have experienced homelessness often have high rates of housing transition. Disruptions caused by these transitions likely exacerbate this population's health problems and interfere with access to care and treatment engagement. Individuals experiencing homelessness increasingly use smartphones, contributing to improved access to medical and social services. Few studies have used smartphones as a data collection tool to systematically collect information about the daily life events that precede and contribute to housing transitions, in-the-moment emotions, behaviors, geographic movements, and perceived social support. OBJECTIVE: The study aims to develop and test a smartphone app to collect longitudinal data from veterans experiencing homelessness (VEH) and to evaluate the feasibility and acceptability of using the app in a population that is unstably housed or homeless. METHODS: This study's design had 3 phases. Phase 1 used ethnographic methods to capture detailed data on day-to-day lived experiences of up to 30 VEH on topics such as housing stability, health, and health behaviors. Phase 2 involved focus groups and usability testing to develop and refine mobile phone data collection methods. Phase 3 piloted the smartphone mobile data collection with 30 VEH. We included mobile ethnography, real-time surveys through an app, and the collection of GPS data in phase 3. RESULTS: The project was launched in June 2020, and at this point, some data collection and analysis for phases 1 and 2 are complete. This project is currently in progress. CONCLUSIONS: This multiphase study will provide rich data on the context and immediate events leading to housing transitions among VEH. This study will ensure the development of a smartphone app that will match the actual needs of VEH by involving them in the design process from the beginning. Finally, this study will offer important insights into how best to develop a smartphone app that can help intervene among VEH to reduce housing transitions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/53022.

Identifying the risks of anticoagulation in patients with substance abuse.

BACKGROUND: Warfarin is effective in preventing thromboembolic events, but concerns exist regarding its use in patients with substance abuse. OBJECTIVE: Identify which patients with substance abuse who receive warfarin are at risk for poor outcomes. DESIGN: Retrospective cohort study. Diagnostic codes, lab values, and other factors were examined to identify risk of adverse outcomes. PATIENTS: Veterans AffaiRs Study to Improve Anticoagulation (VARIA) database of 103,897 patients receiving warfarin across 100 sites. MAIN MEASURES: Outcomes included percent time in therapeutic range (TTR), a measure of anticoagulation control, and major hemorrhagic events by ICD-9 codes. RESULTS: Nonusers had a higher mean TTR (62 %) than those abusing alcohol (53 %), drugs (50 %), or both (44 %, p < 0.001). Among alcohol abusers, an increasing ratio of the serum hepatic transaminases aspartate aminotransferase/alanine aminotransferase (AST:ALT) correlated with inferior anticoagulation control; normal AST:ALT ≤ 1.5 predicted relatively modest decline in TTR (54 %, p < 0.001), while elevated ratios (AST:ALT 1.50-2.0 and > 2.0) predicted progressively poorer anticoagulation control (49 % and 44 %, p < 0.001 compared to nonusers). Age-adjusted hazard ratio for major hemorrhage was 1.93 in drug and 1.37 in alcohol abuse (p < 0.001 compared to nonusers), and remained significant after also controlling for anticoagulation control and other bleeding risk factors (1.69 p < 0.001 and 1.22 p = 0.003). Among alcohol abusers, elevated AST:ALT >2.0 corresponded to more than three times the hemorrhages (HR 3.02, p < 0.001 compared to nonusers), while a normal ratio AST:ALT ≤ 1.5 predicted a rate similar to nonusers (HR 1.19, p < 0.05). CONCLUSIONS: Anticoagulation control is particularly poor in patients with substance abuse. Major hemorrhages are more common in both alcohol and drug users. Among alcohol abusers, the ratio of AST/ALT holds promise for identifying those at highest risk for adverse events.

Using the patient safety indicators to detect potential safety events among US veterans with psychotic disorders: clinical and research implications.

OBJECTIVE: Patients with psychotic disorders often experience poorer health outcomes, but whether they experience increased risks of medical errors/patient safety events is less clear. A single state-level US study found acute care inpatients with schizophrenia were at higher risk of incurring some of the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs). We examined a nationwide sample of US Veteran's Health Administration (VHA) acute care inpatients to determine the rates observed among patients with psychotic disorders for a larger set of PSIs. DESIGN: Retrospective cohort analysis using administrative data. PARTICIPANTS: and SETTING: Veterans with (n = 50 328) and without (n = 1 812 897) psychotic disorders (schizophrenia/schizoaffective disorder and other psychoses) admitted for acute care to US VHA hospitals during fiscal years 2003-06. METHODS: and MAIN OUTCOME MEASURES: PSI rates were calculated using AHRQ's PSI software. RESULTS: Patients with psychotic disorders had significantly higher rates of postoperative respiratory failure, postoperative wound dehiscence and decubitus ulcer than those without psychotic disorders, although postoperative respiratory failures rates were not significantly higher among patients specifically diagnosed with schizophrenia. Patients with psychotic disorders had significantly lower rates of accidental puncture/laceration, foreign body left in during procedure and failure to rescue. However, the odds of failure to rescue were not significantly lower among surgical patients (the current focus of this PSI). CONCLUSIONS: Acute care inpatient veterans with psychotic disorders experienced higher rates of several PSIs, but lower rates of others. Whether lower rates of certain PSIs reflect better or worse care for this population is uncertain.

Nursing Home Senior Managers and Direct Care Staff: Are There Differences in Their Perceptions of Safety Climate?

OBJECTIVES: Improving nursing home safety is important to the quality of resident care. Increasing evidence points to the relationship between actual safety and a strong safety climate, i.e., staff agreement about safety norms. This national study focused on Veterans Health Administration nursing homes (Community Living Centers [CLCs]), assessing direct care staff and senior managers' agreement about safety norms. METHODS: We recruited all 134 CLCs to participate in the previously validated CLC Employee Survey of Attitudes about Resident Safety. To assess whether safety climate domains (7) differed by management level and by direct care staff occupation, we estimated multilevel linear regression models with random effects clustered by CLCs, medical center, Department of Veterans Affairs 2017 integrated service network (n = 20), and region. RESULTS: Of the 5288 individuals we e-mailed, 1397 (25.7%) completed surveys, with participation from 56 CLCs or 41.8% of 134 CLCs. In our analysis of 1316 nurses, nursing assistants, clinicians/specialists, and senior managers, senior managers rated co-worker interactions around safety (P < 0.0013) and overall safety in their CLC (P < 0.0001) more positively than did direct care staff. In contrast, on these same two domains, direct care groups had similar perceptions, though differing significantly in safety priorities, safety attitudes, and senior management commitment to safety. CONCLUSIONS: In this national sample of nursing homes in one of the largest integrated U.S. healthcare systems, direct care staff generally perceived weaker safety processes than did senior managers, pointing to future targets for interventions to strengthen safety climate.

Safety Climate Associated With Adverse Events in Nursing Homes: A National VA Study.

OBJECTIVES: Adverse events in nursing homes are leading causes of morbidity and mortality, prompting facilities to investigate their antecedents. This study examined the contribution of safety climate-how frontline staff typically think about safety and act on safety issues-to adverse events in Veterans Affairs (VA) nursing homes or Community Living Centers (CLCs). DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: A total of 56 CLCs nationwide, 1397 and 1645 CLC staff (including nurses, nursing assistants, and clinicians/specialists), respectively, responded to the CLC Employee Survey of Attitudes about Resident Safety (CESARS) in 2017 and 2018. METHODS: Adverse events (pressure ulcers, falls, major injuries from falls, and catheter use) were measured using the FY2017-FY2018 Minimum Data Set (MDS). Safety climate was defined as 7 CESARS domains (safety priorities, supervisor commitment to safety, senior management commitment to safety, personal attitudes toward safety, environmental safety, coworker interactions around safety, and global rating of CLC). The associations between safety climate domains and each adverse event were determined separately for each frontline group, using beta-logistic regression with random effects. RESULTS: Better ratings of supervisor commitment to safety were associated with lower rates of major injuries from falls [odds ratio (OR) 0.33, 95% confidence interval (CI) 0.11-0.97, clinicians] and catheter use (OR 0.42, 95% CI 0.21-0.85, nurses), and better ratings of environmental safety were associated with lower rates of pressure ulcers (OR 0.23, 95% CI 0.09-0.61, clinicians), major injuries from falls (OR 0.48, 95% CI 0.24-0.93, nurses), and catheter use (OR 0.55, 95% CI 0.32-0.93, nursing assistants). Better global CLC ratings were associated with higher rates of catheter use. No other safety climate domains had significant associations. CONCLUSIONS AND IMPLICATIONS: Nursing homes may reduce adverse events by fostering supportive supervision of frontline staff and a safer physical environment.

Relationship Between Work Experience and Safety Climate in Veterans Affairs Nursing Homes Nationwide.

OBJECTIVES: Staff values and beliefs about resident safety (safety climate) represent one potential driver of nursing home safety. Staff with more work experience (length of service) may possess richer knowledge of resident safety for strengthening safety climate. We investigated the association of length of service with safety climate in the U.S. Department of Veterans Affairs nursing homes or Community Living Centers (CLCs). METHODS: Fifty-six of 134 CLCs participated in 2017 and then 2018 in the previously validated CLC Employee Survey of Attitudes about Resident Safety, which comprised 7 safety climate domains and employee characteristics. We conducted 2 cross-sectional analyses of length of service on each safety climate domain, controlling for occupation, shift, work hours, and clustering by VA hospital, service network, and geographic region, in mixed random-effect regression models. RESULTS: A total of 1397 and 1645 staff participated in the survey (26% and 28% response rates) at round 1 and 2, respectively. At each round participants working greater than 6 months were less positive than those working less than 6 months about supervisor commitment to safety, coworker interactions around safety, and CLC global ratings. CONCLUSIONS: Differences in work experience contributed to incongruence in perceptions about supervisors, coworkers, and the facility. Workers with more experience may have higher perceived job aptitude and thus higher expectations of supervisory recognition and more criticisms of coworkers. Pairing experienced workers with newer ones may narrow the knowledge gap and increase collaboration. Huddles, team meetings, and organizational initiatives represent opportunities to recognize and leverage experienced workers' accumulated safety knowledge.

Comparing safety climate in naval aviation and hospitals: implications for improving patient safety.

BACKGROUND: Evidence of variation in safety climate suggests the need for improvement among at least some hospitals. However, comparisons only among hospitals may underestimate the improvement required. Comparison of hospitals with analogous industries may provide a broader perspective on the safety status of our nation's hospitals. PURPOSE: The purpose of this study was to compare safety climate among hospital workers with personnel from naval aviation, an organization that operates with high reliability despite intrinsically hazardous conditions. METHODOLOGY: We surveyed a random sample of health care workers in 67 U.S. hospitals and, for generalizability, 30 veterans affairs hospitals using questions comparable with those posed at approximately the same time (2007) to a census of personnel from 35 squadrons of U.S. naval aviators. We received 13,841 (41%) completed surveys in U.S. hospitals, 5,511 (50%) in veterans affairs hospitals, and 14,854 (82%) among naval aviators. We examined differences in respondents' perceptions of safety climate at their institution overall and for 16 individual items. FINDINGS: Safety climate was three times better on average among naval aviators than among hospital personnel. Naval aviators perceived a safer climate (up to seven times safer) than hospital personnel with respect to each of the 16 survey items. Compared with hospital managers, naval commanders perceived climate more like frontline personnel did. When contrasting naval aviators with hospital personnel working in comparably hazardous areas, safety climate discrepancies increased rather than decreased. One individual hospital performed as well as naval aviation on average, and at least one hospital outperformed the Navy benchmark for all but three individual survey items. PRACTICE IMPLICATIONS: Results suggest that hospitals have not sufficiently created a uniform priority of safety. However, if each hospital performed as well as the top-performing hospital in each area measured, hospitals could achieve safety climate levels comparable with naval aviation. Major interventions to bolster hospital safety climate continue to be required to improve patient safety.

Recruitment of hospitals for a safety climate study: facilitators and barriers.

BACKGROUND: Despite increasing emphasis on safety culture assessment, little is known about the factors that affect hospitals' participation in such studies. Factors affecting recruitment of 30 Department of Veterans Affairs (VA) hospitals into a study to evaluate perceptions of safety culture, or safety "climate," were examined. METHODS: To minimize selection bias, hospitals were recruited that represented the spectrum of safety performance on the basis of Patient Safety Indicator scores. Invitations and additional mailings, informational conference calls, and personal contact with hospitals were used to encourage participation. Investigators worked closely with hospitals' key stakeholders to obtain support and buy-in for the study. Relationships among safety performance, organizational culture, and other hospital characteristics with hospitals' participation and ease of recruitment were examined. Findings were compared with those of a companion study in the non-VA setting. RESULTS: Despite attempts to optimize recruitment, it was necessary to contact more than 90 hospitals to obtain a 30-hospital sample. Having a more entrepreneurial culture (associated with risk-taking, innovation, and quality improvement) was significantly related to shorter recruitment time in VA and non-VA settings. Safety performance was significantly related to participation in the VA (that is, "better-performing" hospitals were more likely to be recruited than "lower-performing" hospitals), but not in the non-VA study, where recruitment was based on size and region. DISCUSSION: Researchers should recruit representative samples of hospitals based on measures of safety performance. Hospital selection bias could lead to erroneous findings, ultimately impeding efforts to improve safety within organizations.

The relationship between nursing home quality and costs: Evidence from the VA.

Ensuring quality of care in nursing homes is a public health priority, yet how nursing home quality relates to cost is not well understood. This paper addresses this relationship for 132 VA community living centers (nursing homes), for fiscal years 2014 and 2015. We estimated cost models using the VA Decision Support System which tracks total direct costs and nursing direct costs for individual resident segments of care. We summed residents' total costs and nursing costs to the community living center level for each year. Annual facility costs then were regressed on quality of care measured with composite scores based on 13 distinct adverse events. Results indicated that higher quality was associated with higher predicted cost. However, we did not find evidence that higher costs were driven by high nurse staffing levels.

Individual Treatment of Posttraumatic Stress Disorder Using Mantram Repetition: A Randomized Clinical Trial.

OBJECTIVE: Previous studies suggest that group "mantram" (sacred word) repetition therapy, a non-trauma-focused complementary therapy for posttraumatic stress disorder (PTSD), may be an effective treatment for veterans. The authors compared individually delivered mantram repetition therapy and another non-trauma-focused treatment for PTSD. METHOD: The study was a two-site, open-allocation, blinded-assessment randomized trial involving 173 veterans diagnosed with military-related PTSD from two Veterans Affairs outpatient clinics (January 2012 to March 2014). The mantram group (N=89) learned skills for silent mantram repetition, slowing thoughts, and one-pointed attention. The comparison group (N=84) received present-centered therapy, focusing on currently stressful events and problem-solving skills. Both treatments were delivered individually in eight weekly 1-hour sessions. The primary outcome measure was change in PTSD symptom severity, as measured by the Clinician-Administered PTSD Scale (CAPS) and by self-report. Secondary outcome measures included insomnia, depression, anger, spiritual well-being, mindfulness, and quality of life. Intent-to-treat analysis was conducted using linear mixed models. RESULTS: The mantram group had significantly greater improvements in CAPS score than the present-centered therapy group, both at the posttreatment assessment (between-group difference across time, -9.98, 95% CI=-3.63, -16.00; d=0.49) and at the 2-month follow-up (between-group difference, -9.34, 95% CI=-1.50, -17.18; d=0.46). Self-reported PTSD symptom severity was also lower in the mantram group compared with the present-centered therapy group at the posttreatment assessment, but there was no difference at the 2-month follow-up. Significantly more participants in the mantram group (59%) than in the present-centered therapy group (40%) who completed the 2-month follow-up no longer met criteria for PTSD (p<0.04). However, the percentage of participants in the mantram group (75%) compared with participants in the present-centered therapy group (61%) who experienced clinically meaningful changes (≥10-point improvements) in CAPS score did not differ significantly between groups. Reductions in insomnia were significantly greater for participants in the mantram group at both posttreatment assessment and 2-month follow-up. CONCLUSIONS: In a sample of veterans with PTSD, individually delivered mantram repetition therapy was generally more effective than present-centered therapy for reducing PTSD symptom severity and insomnia.

Impact of Intervention to Improve Nursing Home Resident-Staff Interactions and Engagement.

Background and Objectives: For nursing home residents, positive interactions with staff and engagement in daily life contribute meaningfully to quality of life. We sought to improve these aspects of person-centered care in an opportunistic snowball sample of six Veterans Health Administration nursing homes (e.g., Community Living Centers-CLCs) using an intervention that targeted staff behavior change, focusing on improving interactions between residents and staff and thereby ultimately aiming to improve resident engagement. Research Design and Methods: We grounded this mixed-methods study in the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change. We implemented the intervention by (a) using a set of evidence-based practices for implementing quality improvement and (b) combining primarily CLC-based staff facilitation with some researcher-led facilitation. Validated resident and staff surveys and structured observations collected pre and post intervention, as well as semi-structured staff interviews conducted post intervention, helped assess intervention success. Results: Sixty-two CLC residents and 308 staff members responded to the surveys. Researchers conducted 1,490 discrete observations. Intervention implementation was associated with increased staff communication with residents during the provision of direct care and decreased negative staff interactions with residents. In the 66 interviews, staff consistently credited the intervention with helping them (a) develop awareness of the importance of identifying opportunities for engagement and (b) act to improve the quality of interactions between residents and staff. Discussion and Implications: The intervention proved feasible and influenced staff to make simple enhancements to their behaviors that improved resident-staff interactions and staff-assessed resident engagement.

Continued Use of Warfarin in Veterans with Atrial Fibrillation After Dementia Diagnosis.

OBJECTIVES: To determine the effectiveness of warfarin in older adults with dementia. DESIGN: Retrospective cohort study. SETTING: Department of Veterans Affairs national healthcare system. PARTICIPANTS: Veterans aged 65 and older (73% aged ≥75, 99% male, 91% white) who had been receiving warfarin for nonvalvular atrial fibrillation for at least 6 months, were newly diagnosed with dementia in fiscal year 2007 or 2008, and were not enrolled in Medicare Advantage (n = 2,572). MEASUREMENTS: The onset of dementia was defined according to International Classification of Diseases, Ninth Revision, code. Participants were followed for up to 4 years for persistence of warfarin therapy, anticoagulation control, major hemorrhage, ischemic stroke, and all-cause mortality. RESULTS: The average CHADS2 score was 3.3 ± 1.3. After a diagnosis of dementia, 405 individuals (16%) persisted on warfarin therapy. Unadjusted Cox proportional hazards analysis demonstrated a protective effect of warfarin in prevention of ischemic stroke (hazard ratio (HR) = 0.64, 95% confidence interval (CI) = 0.46-0.89, P = .008), major bleeding (HR = 0.72, 95% CI = 0.55-0.94, P = .02), and all-cause mortality (HR = 0.66, 95% CI = 0.55-0.79, P < .001). Using propensity score matching, the protective effect of continuing warfarin persisted in prevention of stroke (HR = 0.74, 95% CI = 0.54-0.996, P = .047) and mortality (HR = 0.72, 95% CI = 0.60-0.87, P < .001), with no statistically significant decrease in risk of major bleeding (HR = 0.78, 95% CI = 0.61-1.01, P = .06). CONCLUSION: Discontinuing warfarin after a diagnosis of dementia is associated with a significant increase in stroke and mortality.

An analysis of patient-provider secure messaging at two Veterans Health Administration medical centers: message content and resolution through secure messaging.

OBJECTIVE: We sought to understand how patients and primary care teams use secure messaging (SM) to communicate with one another by analyzing secure message threads from 2 Department of Veterans Affairs facilities. METHODS: We coded 1000 threads of SM communication sampled from 40 primary care teams. RESULTS: Most threads (94.5%) were initiated by patients (90.4%) or caregivers (4.1%); only 5.5% were initiated by primary care team members proactively reaching out to patients. Medication renewals and refills (47.2%), scheduling requests (17.6%), medication issues (12.9%), and health issues (12.7%) were the most common patient-initiated requests, followed by referrals (7.0%), administrative issues (6.5%), test results (5.4%), test issues (5.2%), informing messages (4.9%), comments about the patient portal or SM (4.1%), appreciation (3.9%), self-reported data (2.8%), life issues (1.5%), and complaints (1.5%). Very few messages were clinically urgent (0.7%) or contained other potentially challenging content. Message threads were mostly short (2.7 messages), comprising an average of 1.35 discrete content types. A substantial proportion of issues (24.2%) did not show any evidence of being resolved through SM. Time to response and extent of resolution via SM varied by message content. Proactive SM use by teams varied, but was most often for test results (32.7%), medication-related issues (21.8%), medication renewals (16.4%), or scheduling issues (18.2%). CONCLUSIONS: The majority of messages were transactional and initiated by patients or caregivers. Not all content categories were fully addressed over SM. Further education and training for both patients and clinical teams could improve the quality and efficiency of SM communication.

Longitudinal Pressure Ulcer Rates After Adoption of Culture Change in Veterans Health Administration Nursing Homes.

OBJECTIVES: To examine facility-level pressure ulcer (PrU) development rates and variations in these rates after a system-wide adoption of culture change in Veterans Health Administration (VHA) nursing homes. DESIGN: Four-year retrospective longitudinal design. SETTING: VHA facilities (N=109) representing 132 nursing homes known as community living centers (CLCs). PARTICIPANTS: VHA nursing home residents. MEASUREMENTS: PrUs were identified using fiscal year (FY) 2008-11 Minimum Data Set (MDS) data. PrU development was defined as a Stage 2 or larger PrU on an MDS assessment with no PrU on the previous assessment. A risk adjustment model was developed using 105,274 MDS observations to predict the likelihood of PrUs (c-statistic=0.72). A Bayesian hierarchical model that adjusted for differences in the precision of PrU rates from different-size facilities was used to calculate smoothed risk-adjusted (SRA) rates for each facility. The statistical significance of the trend over the 4 years was determined by examining the 95% interval estimate for the slope. RESULTS: Over the 4-year period, the beginning of which coincided with the VHA's system-wide adoption of culture change as a performance measure, median SRA facility PrU development rates were fairly consistent at approximately 4%. The range in SRA rates declined over the years, from a 14.8-percentage point spread to 10.1-percentage point spread. Some facilities had significantly improving SRA rates (e.g., declined steadily from 5.5% to 3.9%) and some had significantly worsening SRA rates (e.g., increased steadily from 5.1% to 7.9%). Seven sites had significantly improving rates (P<.001) that were below the median across all 4 years. CONCLUSION: A system-wide culture change implementation did not affect CLC PrU development rates, but there was significant variation in facility rates, and some facilities had sustained high performance.