Cross Disciplinary Role Agreement is Needed When Coordinating Long-Term Opioid Prescribing for Cancer: a Qualitative Study.

BACKGROUND: Cancer pain is highly prevalent and often managed in primary care or by oncology providers in combination with primary care providers. OBJECTIVES: To understand interdisciplinary provider experiences coordinating opioid pain management for patients with chronic cancer-related pain in a large integrated healthcare system. DESIGN: Qualitative research. PARTICIPANTS: We conducted 20 semi-structured interviews with interdisciplinary providers in two large academically affiliated VA Medical Centers and their associated community-based outpatient clinics. Participants included primary care providers (PCPs) and oncology-based personnel (OBPs). APPROACH: We deductively identified 94 examples of care coordination for cancer pain in the 20 interviews. We secondarily used an inductive open coding approach and identified themes through constant comparison coming to research team consensus. RESULTS: Theme 1: PCPs and OBPs generally believed one provider should handle all opioid prescribing for a specific patient, but did not always agree on who that prescriber should be in the context of cancer pain. Theme 2: There are special circumstances where having multiple prescribers is appropriate (e.g., a pain crisis). Theme 3: A collaborative process to opioid cancer pain management would include real-time communication and negotiation between PCPs and oncology around who will handle opioid prescribing. Theme 4: Providers identified multiple barriers in coordinating cancer pain management across disciplines. CONCLUSIONS: Our findings highlight how real-time negotiation about roles in opioid pain management is needed between interdisciplinary clinicians. Lack of cross-disciplinary role agreement may result in delays in clinically appropriate cancer pain management.

Hepatitis C virus-related complications are increasing in women veterans: A national cohort study.

There are gender-specific variations in the epidemiology and clinical course of hepatitis C virus (HCV) infection. However, few long-term longitudinal studies have examined trends in the incidence and prevalence of serious liver complications among women compared with men with HCV infection. We used the Veterans Administration Corporate Data Warehouse to identify all veterans with positive HCV viraemia from January 2000 to December 2013. We calculated gender-specific annual incidence and prevalence rates of cirrhosis, decompensated cirrhosis and hepatocellular cancer (HCC) adjusting for age, diabetes, HIV and alcohol use. We also calculated the average annual per cent change (AAPC) for each outcome by gender using piecewise linear regression in the Joinpoint software. We identified 264 409 HCV-infected veterans during 2000-2013, of whom 7162 (2.7%) were women. There were statistically significant increases over time in the incidence rates of cirrhosis, decompensated cirrhosis and HCC for both men and women. The annual-adjusted incidence rates of cirrhosis, decompensated cirrhosis and HCC were higher in men than women for all study years. However, these complications increased at a similar rate in both groups. Specifically, the AAPC for cirrhosis was 13.1 and 15.2, while it was 15.6 and 16.9 for decompensated cirrhosis and 21.0 and 25.3 for HCC in men and women, respectively (all test of parallelism not significant). The results were similar in the prevalence analyses, although AAPCs were slightly smaller for each outcome. In conclusion, we found an ongoing upward trend in the incidence and prevalence of HCV complications in this cohort of HCV-infected women. This increase in cirrhosis complications in women with active HCV infection is similar to those in men. With cure from HCV now becoming a reality, most of the projected burden of HCV is potentially preventable. However, benefits of HCV treatment will need to extend to all patients in order to stem the rising tide of HCV complications.

Palliative Care Quality Indicators for Patients with End-Stage Liver Disease Due to Cirrhosis.

BACKGROUND AND AIMS: There are guidelines for the medical management of cirrhosis and associated quality indicators (QIs), but QIs focusing on standards for palliative aspects of care are needed. METHODS: We convened a 9-member, multidisciplinary expert panel and used RAND/UCLA modified Delphi methods to develop palliative care quality indicators for patients with cirrhosis. Experts were provided with a report based on a systematic review of the literature that contained evidence concerning the proposed candidate QIs. Panelists rated QIs prior to a planned meeting using a standard 9-point RAND appropriateness scale. These ratings guided discussion during a day-long phone conference meeting, and final ratings were then provided by panel members. Final QI scores were computed and QIs with a final median score of greater than or equal to 7, and no disagreement was included in the final set. RESULTS: Among 28 candidate QIs, the panel rated 19 as valid measures of quality care. These 19 quality indicators cover care related to information and care planning (13) and supportive care (6). CONCLUSIONS: These QIs are evidence-based process measures of care that may be useful to improve the quality of palliative care. Research is needed to better understand the quality of palliative care provided to patients with cirrhosis.

Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses.

OBJECTIVES: We examined print, broadcast and social media reports about health care systems' disclosures of large scale adverse events to develop future effective messaging. STUDY DESIGN: Directed content analysis. METHODS: We systematically searched four communication databases, YouTube and Really Simple Syndication (RSS) feeds relating to six disclosures of lapses in infection control practices in the Department of Veterans Affairs occurring between 2009 and 2012. We assessed these with a coding frame derived from effective crisis and risk communication models. RESULTS: We identified 148 unique media reports. Some components of effective communication (discussion of cause, reassurance, self-efficacy) were more present than others (apology, lessons learned). Media about 'promoting secrecy' and 'slow response' appeared in reports when time from event discovery to patient notification was over 75 days. Elected officials' quotes (n = 115) were often negative (83%). Hospital officials' comments (n = 165) were predominantly neutral (92%), and focused on information sharing. CONCLUSIONS: Health care systems should work to ensure that they develop clear messages focused on what is not well covered by the media, including authentic apologies, remedial actions taken, and shorten the timeframe between event identification and disclosure to patients.

Uptake and utilization of directly acting antiviral medications for hepatitis C infection in U.S. veterans.

New drugs therapies have revolutionized the treatment of hepatitis C virus (HCV) infection. The objectives of this study were to evaluate uptake and utilization of boceprevir and telaprevir in the Department of Veterans Affairs (VA). We evaluated whether therapies conformed to response-guided protocols, whether they replaced standard interferon plus ribavirin treatment, and whether IL-28B was used to guide treatment. We performed an administrative data-based analysis of all patients receiving pharmacologic treatment for HCV in VA from October 2009 to July 2013. There were 12 737 new HCV prescriptions in VA during this time, with 5564 boceprevir or telaprevir prescriptions (44%) and 7173 prescriptions (56%) written for standard interferon plus ribavirin treatment. Prescriptions for the new treatments heavily favoured boceprevir vs telaprevir (83% vs 17%). Sixty-two percent (62%) of boceprevir-treated patients completed their minimum-specified protocol, while 69.2% of telaprevir-treated patients completed their minimum-specified protocol. From October 2010 to July 2012, 4090 patients had an IL-28B test; less than 16% of these tests guided subsequent HCV prescriptions. Uptake of boceprevir and telaprevir was rapid; the number of patients initiating treatment approximately doubled in the period after their introduction. While new prescriptions favor boceprevir or telaprevir over standard interferon plus ribavirin therapy, there appears to still be a strong role of interferon plus ribavirin in treating HCV patients. This work can inform our understanding of how other new effective HCV therapies will be used, their diffusion, and the timing of their diffusion in actual clinical practice.

Performance and usability testing of an automated tool for detection of peripheral artery disease using electronic health records.

Peripheral artery disease (PAD) is a common cardiovascular disorder that is frequently underdiagnosed, which can lead to poorer outcomes due to lower rates of medical optimization. We aimed to develop an automated tool to identify undiagnosed PAD and evaluate physician acceptance of a dashboard representation of risk assessment. Data were derived from electronic health records (EHR). We developed and compared traditional risk score models to novel machine learning models. For usability testing, primary and specialty care physicians were recruited and interviewed until thematic saturation. Data from 3168 patients with PAD and 16,863 controls were utilized. Results showed a deep learning model that utilized time engineered features outperformed random forest and traditional logistic regression models (average AUCs 0.96, 0.91 and 0.81, respectively), P < 0.0001. Of interviewed physicians, 75% were receptive to an EHR-based automated PAD model. Feedback emphasized workflow optimization, including integrating risk assessments directly into the EHR, using dashboard designs that minimize clicks, and providing risk assessments for clinically complex patients. In conclusion, we demonstrate that EHR-based machine learning models can accurately detect risk of PAD and that physicians are receptive to automated risk detection for PAD. Future research aims to prospectively validate model performance and impact on patient outcomes.

The hepatitis C self-management programme: a randomized controlled trial.

Chronic hepatitis C (HCV) infection afflicts millions of people worldwide. While antiviral treatments are effective for some patients, many either cannot or choose not to receive antiviral treatment. Education about behavioural changes like alcohol avoidance and symptom management, in contrast, is universally recommended, particularly in HCV-infected persons from disadvantaged groups where liver risk factors are most prevalent. Self-management interventions are one option for fostering improved HCV knowledge and health-related quality of life (HRQOL). One hundred and thirty-two patients with VA with HCV (mean age of 54.6, 95% men, 41% ethnic minority, 83% unmarried, 72% unemployed/disabled, 48% homeless in last 5 years) were randomized to either a 6-week self-management workshop or an information-only intervention. The weekly 2-h self-management sessions were based on cognitive-behavioural principles and were adapted from an existing self-management programme that has been efficacious with other chronic diseases. HCV-specific modules were added. Outcomes including HRQOL, HCV knowledge, self-efficacy, depression, energy and health distress were measured at baseline and 6 weeks later. Data were analysed using ANOVA. When compared to the information-only group, participants attending the self-management workshop improved more on HCV knowledge (P < 0.001), HCV self-efficacy (P = 0.011), and SF-36 energy/vitality (P = 0.040). Similar trends were found for SF-36 physical functioning (P = 0.055) and health distress (P = 0.055). Attending the self-management programme improved disease knowledge and HRQOL 6 weeks later in this disadvantaged population. The intervention can improve the health of people with hepatitis C, independent of antiviral therapy. Future research will study longer-term outcomes, effects on antiviral treatment and costs.

Methods for improving efficiency in quality measurement: the example of pain screening.

OBJECTIVE: Collecting unnecessary data when assessing quality of care wastes valuable resources. We evaluated three approaches for estimating quality-measure adherence and determined minimum visit data required to achieve accurate estimates. DESIGN: We abstracted medical records for calculating physician-level pain screening rates as: visit-specific, using single-visit data for each patient; visit-level average, using data for all patients and visits; and patient-level average, using data from a subset of patients and visits. SETTING: VA Greater Los Angeles Health-care System, 2006. PARTICIPANTS: One hundred and six patients with Stage IV solid tumors. INTERVENTION: Pain screening at every medical encounter, measured by a 0-10 numeric rating scale and reported to the national Medicare insurance program under a 'pay-for-reporting' program. MAIN OUTCOME MEASURES: Amount of visit data needed to reach the smallest 95% confidence interval (CI) and stable pain screening estimates. RESULTS: Pain screening occurred at 22% (23/106; 95% CI: 14-30%) of initial visits and 50% (8/16; 95% CI: 25-75%) of single visits. Across all visits, screening adherence averaged 34% when estimated at the visit-level precision and 30% at the patient level. Maximum patient-level precision was reached at visit 4 (95% CI: ± 8%) and visit level at visit 14 (95% CI: ± 6%). Using patient-level and visit-level approaches, estimates stabilized at visits 8 and 11, respectively, and reached within 1 percentage point of the steady-state value at visits 4 and 9. CONCLUSION: To address low-pain screening among cancer patients, an oncology pain screening measure may be most efficiently evaluated with data from a sample of patients and visits. This approach may be valid for visit-level quality measures in other settings.

Opportunities for improving medication use and monitoring in gout.

PURPOSE: To study patterns and predictors of medication use and laboratory monitoring in gout. METHODS: In a cohort of veterans with a diagnosis of gout prescribed allopurinol, colchicine or probenecid, quality of care was assessed by examining adherence to the following evidence-based recommendations: (1) whether patients starting a new allopurinol prescription (a) received continuous allopurinol, (b) received colchicine prophylaxis, (c) achieved the target uric acid level of

Barriers to hepatitis C treatment in the era of direct-acting anti-viral agents.

BACKGROUND: Direct-acting anti-virals (DAA) are safe, effective treatment of hepatitis C virus (HCV). Suboptimal linkage to specialists and access to DAAs are the leading barriers to treatment; however, data are limited. AIM: To determine predictors of follow-up, receipt of DAAs, and reasons for the lack thereof. METHODS: We used clinical data from retrospective cohort of HCV-infected patients with previously established HCV care in the US Department of Veterans Affairs to examine predictors of follow-up in HCV clinics and DAA treatment (during 12/1/2013-4/30/2015). We then conducted a structured review of medical charts of HCV patients to determine reasons for lack of follow-up and treatment. RESULTS: We identified 84 221 veterans who were previously seen in HCV clinics during the pre-DAA era. Of these, 47 165 (56.0%) followed-up in HCV specialty clinics, 13 532 (28.7%) of whom received DAAs. Older age, prior treatment, presence of cirrhosis or HCC, HIV/HBV co-infection and psychiatric illness were predictors of follow-up. Alcohol/drug abuse and medical co-morbidity were predictors of lack of treatment. Of the 905 prospectively recruited patients, 56.2% patients had a specialist visit and 28% received DAAs. Common reasons for lack of follow-up were relocation (n = 148, 37.4%) and missed/cancelled appointments (n = 63, 15.9%). Reasons for lack of treatment included waiting for newer therapy (n = 99, 38.8%), co-morbidities (n = 66, 25.9%) and alcohol/drug abuse (n = 63, 24.7%). CONCLUSIONS: Half of patients with established HCV care were followed-up in the DAA era and only 29% received DAAs. Targeted efforts focusing on patient and system-levels may improve the reach of treatment with the new DAAs.

Unmet need for recommended preventive health services among clients of California syringe exchange programs: implications for quality improvement.

BACKGROUND: Comprehensive preventive services are recommended for injection drug users (IDU), including screening tests, vaccinations, risk reduction counseling, and sterile syringes. Syringe exchange programs (SEP) may facilitate receipt of preventive services by IDUs, but whether SEP clients receive recommended preventive care is not known. We examined use of recommended preventive services by clients of 23 SEPs throughout California. METHODS: Five hundred and sixty SEP clients were recruited from 23 SEPs throughout California between March and September 2003. Receipt of 10 recommended preventive services and source of care (SEP versus non-SEP providers) was ascertained from client interviews. RESULTS: On average, SEP clients received only 13% of recommended preventive services and 49% of clients received none of the recommended services. Of services that were received, 76% were received from SEPs. In multivariate analysis, use of drug treatment and more frequent SEP visits were associated with receipt of recommended preventive services by clients. CONCLUSIONS: SEPs are often the only source of preventive care for their IDU clients. Still, SEP clients fail to receive most recommended preventive services. Interventions to increase use of preventive services and improve the quality of preventive care received by IDUs, such as increased access to drug treatment and SEPs, are needed.

Religiousness and spirituality among HIV-infected Americans.

PURPOSE: To describe the demographic and clinical factors associated with the importance of religiousness and spirituality among patients with human immunodeficiency virus (HIV) infection in the United States. METHODS: Longitudinal study of a nationally representative cohort of 2266 patients receiving care for HIV infection surveyed in 1996 and again in 1998. Measures included 12 items assessing religious affiliation and attendance, the importance of religion and spirituality in life, and religious and spiritual practices. Multi-item religiousness and spirituality scales were constructed. RESULTS: Eighty percent of respondents reported a religious affiliation. Sixty-five percent affirmed that religion and 85% that spirituality was "somewhat" or "very" important in their lives. A majority indicated that they "sometimes" or "often" rely on religious or spiritual means when making decisions (72%) or confronting problems (65%). Women, nonwhites, and older patients were more religious and spiritual. Residents of regions other than the western United States reported higher religiousness. High school graduates were more religious and spiritual than those with less education. Patients who did not report one of the risk factors assessed for HIV infection had higher religiousness scores than injection drug users (IDUs). Women, nonwhites other than Hispanics, patients older than 45 years of age compared to those between 18 and 34 years of age, and more educated patients reported higher spirituality. Clinical stage was not associated with religiousness or spirituality. CONCLUSIONS: A large majority of HIV-infected patients in the United States affirm the importance of religiousness and spirituality. These findings support a comprehensive, humanistic approach to the care of HIV-infected patients.

A new approach for measuring quality of care for women with hypertension.

BACKGROUND: Guidelines for care of hypertensive patients have proliferated recently, yet quality assessment remains difficult in the absence of well-defined measurement systems. Existing systems have not always linked process measures to blood pressure outcomes. METHODS: A quality measurement system was developed and tested on hypertensive women in a West Coast health plan. An expert panel selected clinically detailed, evidence-explicit indicators using a modified Delphi method. Thirteen indicators (1 screening, 5 diagnostic, 5 treatment, and 2 follow-up indicators) were selected by this process. Trained nurses used a laptop-based tool to abstract data from medical records for the most recent 2 years of care. RESULTS: Of 15 004 eligible patients with hypertensive and other chronic disease codes, 613 patients were sampled, all eligible for the screening indicator. Of these, 234 women with an average blood pressure of 140/90 mm Hg or more, or a documented diagnosis of hypertension, were studied for the remaining indicators. The average woman received 64% of the recommended care. Most patients did not receive adequate initial history, physical examination, or laboratory tests. Only 37% of hypertensive women with persistent elevations to more than 160/90 mm Hg had changes in therapy or lifestyle recommended. The average adherence proportion to all indicators was lower in patients with uncontrolled blood pressure (>140/90 mm Hg) than in those with controlled blood pressure (54% vs 73%; P<.001). CONCLUSIONS: Quality of hypertensive care falls short of indicators based on randomized controlled trials and national guidelines. Poor performance in essential care processes is associated with poor blood pressure control.

Are insulin and hypertension independently related?

Hyperinsulinemia has been proposed as the common pathogenetic mechanism of obesity, non-insulin-dependent diabetes mellitus, and hypertension. We examined the cross-sectional relationship between fasting and postchallenge insulin levels and hypertensive status in a population-based study of 653 men and 784 women, aged 50 to 93 years, in Rancho Bernardo, California. Hypertensive subjects had slightly but not significantly higher fasting plasma insulin levels than did normotensive subjects, but significantly higher postchallenge insulin levels. After stratification for obesity and glucose intolerance, there was no significant difference between the mean age-adjusted fasting or postchallenge insulin levels of those with and those without hypertension in 12 possible subgroups. Analysis of variance of both fasting and postchallenge insulin levels also failed to reveal a significant relationship between insulin and hypertensive status after adjusting for age, sex, body mass index, and diabetes. The current study does not support the hypothesis that insulin is independently associated with hypertension.

Justification for a new cohort study of people aging with and without HIV infection.

This supplement contains a series of papers supporting the justification, design, and implementation of a longitudinal cohort study of an aging HIV-positive and HIV-negative veteran population called the Veterans Aging Cohort Study (VACS). Although the papers cover a wide range of topics and several papers address methodologic issues not unique to a study of aging veterans, all are motivated by a unifying set of assumptions. Specifically: (a) HIV/AIDS is a chronic disease in an aging population; (b) conditions among HIV-positive and -negative patients in care have overlapping etiologies; (c) individuals with pre-existing organ injury are at increased risk for iatrogenic injury; (d) cohort studies are uniquely suited to the study of chronic disease complicated by aging, comorbid conditions, drug toxicities, and substance use/abuse; (e) VACS is well positioned to study HIV as a chronic disease in an aging population.

Studies in space orientation. II. Perception of the upright with displaced visual fields and with body tilted.

To overcome certain disadvantages of the tilted-mirror situation as a technique for separating visual and postural determinants of the perceived upright, a new procedure was developed. The S was presented with a small tilted room, on the back wall of which was a rod which he had to adjust to the true upright. In a first test, judgments of the rod were obtained with body upright, and under three different conditions of the field: (a) The S, standing at a distance from the tilted scene, viewed it through a tube which restricted his view to the interior of the scene. (b) The S stood directly in front of the scene without a tube. (c) The S stood at a distance from the scene, without a tube, so that he saw not only the tilted scene but the outer upright room as well. Under all three conditions the perceived vertical and horizontal were displaced significantly in the direction of the axes of the tilted scene. When an outer upright field was present, as in the third condition, the effect of the tilted scene upon the perceived upright diminished. In another experiment, judgments of the rod were obtained with body tilted, both to the same side as the field and to the opposite side. It was found that tilting the body resulted in an increased tendency to accept the tilted field as a basis for judging the upright. Not only were the perceived vertical and horizontal displaced further in the direction of the tilted scene, but a number of Ss perceived the tilted scene as fully upright. In another experiment there was found a tendency for the tilted scene to right itself with prolonged observation. In some cases the righting was complete, so that at the end of the observation period, the tilted scene was perceived to be fully upright. Under all conditions, striking individual differences were found in the extent to which the perceived upright was affected by the surrounding tilted field. There is evidence of considerably consistency in a person's performance under the different conditions employed.

Do we understand the effects of 'managed care' in ophthalmology? A review and analysis.

Little has been published that directly assesses the effect of structures for providing managed care or the effects of capitated, prepaid financing on the cost and quality of eye care services. Managed care organizations use fewer ophthalmologists and may provide more screening for diabetic retinopathy. Studies of nonophthalmologic care show lower patient satisfaction with care, and mixed effects on cost, quality of care, and access to care, but are difficult to generalize to eye care. We reviewed the published peer-reviewed literature about this topic. Notable gaps exist in the knowledge of critical elements of the influence of managed care on providing eye care and on patient outcomes. Existing measures of quality, cost, satisfaction, and access could easily be adapted for use in evaluating the influence of managed care and guiding health care policy.

Development of a quality of care measurement system for children and adolescents. Methodological considerations and comparisons with a system for adult women.

OBJECTIVES: To describe the development of a pediatric quality of care measurement system designed to cover multiple clinical topics that could be applied to enrollees in managed care organizations and to compare the development of this system with the concurrent development of a similar system for adult women. DESIGN: Indicators were developed for 21 pediatric (ages 0-18 years) clinical topics and 20 adult (ages 17-50 years) women's clinical topics. Indicators were classified by the strength of evidence supporting them. A modified Delphi method was used to obtain validity and feasibility ratings from a pediatric expert panel and an adult women's expert panel. Indicators were categorized by type of care (preventive, acute, or chronic), function (screening, diagnosis, treatment, or follow up), and modality (history, physical examination, laboratory/radiology study, medication, other intervention, or other contact). RESULTS: Of 557 pediatric and 391 adult women's proposed indicators, 453 (81%) and 340 (87%), respectively, were retained by the 2 expert panels. A lower percentage of final pediatric indicators than adult indicators were based on randomized, controlled trials and other rigorous studies (18% vs 40%, P < .001). The expert panels were more likely to retain indicators based on rigorous studies (93% retained) than on descriptive studies and expert opinion (81% retained, P < .001). A higher percentage of pediatric indicators than women's indicators were for preventive care (30% vs 11%, P < .001) and a lower percentage were for acute care (36% vs 49%, P < .001) or chronic care (34% vs 41%, P = .06). CONCLUSIONS: This study contributes to the field of pediatric quality of care assessment by providing many more indicators than have been available previously and by documenting the strength of evidence supporting these indicators. Formal consensus methods are essential for the development of pediatric quality measures because the evidence base for pediatric care is more limited than for adult care.

Developing a clinical performance measure.

BACKGROUND: Clinical performance measurement is an increasingly important way for public and private purchasers alike to compare the value of health services provided by competing health delivery systems. The widespread use of performance measures has increased the demand for development of new measures that cover previously unevaluated aspects of care. METHODS: Four steps required to develop a clinical performance measure that is suitable for making comparisons among health delivery systems are discussed: (1) choosing clinical areas to measure, (2) selecting performance indicators within each area, (3) designing specifications for consistent implementation of a measure, and (4) evaluating the scientific strength of a measure. RESULTS: The application of these steps to developing measures of quality for hypertension is provided, with an emphasis on a measure of adequacy of control of blood pressure. CONCLUSIONS: Developing useful clinical performance measures requires careful attention to methodologic issues. Following the steps outlined in this paper should enhance the quality of future measurement development.