Impact of a Remote Primary Care Telehealth Staffing Model on Primary Care Access in the Veterans Health Administration.

BACKGROUND: The Veterans Health Administration (VHA) implemented the Clinical Resource Hub (CRH) program to fill staffing gaps in primary care (PC) clinics via telemedicine and maintain veterans' healthcare access. OBJECTIVE: To evaluate PC wait times before and after CRH implementation. DESIGN: Comparative interrupted time series analysis among a retrospective observational cohort of PC clinics who did and did not use CRH during pre-implementation (October 2018-September 2019) and post-implementation (October 2019-February 2020) periods. PARTICIPANTS: Clinics completing ≥10 CRH visits per month for 2 consecutive months and propensity matched control clinics. MAIN MEASURES: Two measures of patient access (i.e., established, and new patient wait times) and one measure of clinic capacity (i.e., third next available appointment) were assessed. Clinics using CRH were 1:1 propensity score matched across clinical and demographic characteristics. Comparative interrupted time series models used linear mixed effects regression with random clinic-level intercepts and triple interaction (i.e., CRH use, pre- vs. post-implementation, and time) for trend and point estimations. KEY RESULTS: PC clinics using CRH (N = 79) were matched to clinics not using CRH (N = 79). In the 12-month pre-implementation, third next available time increased in CRH clinics (0.16 days/month; 95% CI = [0.07, 0.25]), and decreased in the 5 months post-implementation (-0.58 days/month; 95% CI = [-0.90, -0.27]). Post-implementation third next available time also decreased in control clinics (-0.48 days/month; 95% CI = [-0.81, -0.17]). Comparative differences remained non-significant. There were no statistical differences in established or new patient wait times by CRH user status, CRH implementation, or over time. CONCLUSIONS: In a national VHA telemedicine program developed to provide gap coverage for PC clinics, no wait time differences were observed between clinics using and not using CRH services. This hub-and-spoke telemedicine service is an effective model to provide gap coverage while maintaining access. Further investigation of quality and long-term access remains necessary.

Healthcare Utilization Differences Among Primary Care Patients Using Telemedicine in the Veterans Health Administration: a Retrospective Cohort Study.

BACKGROUND: The COVID-19 pandemic encouraged telemedicine expansion. Research regarding follow-up healthcare utilization and primary care (PC) telemedicine is lacking. OBJECTIVE: To evaluate whether healthcare utilization differed across PC populations using telemedicine. DESIGN: Retrospective observational cohort study using administrative data from veterans with minimally one PC visit before the COVID-19 pandemic (March 1, 2019-February 28, 2020) and after in-person restrictions were lifted (October 1, 2020-September 30, 2021). PARTICIPANTS: All veterans receiving VHA PC services during study period. MAIN MEASURES: Veterans' exposure to telemedicine was categorized as (1) in-person only, (2) telephone telemedicine (≥ 1 telephone visit with or without in-person visits), or (3) video telemedicine (≥ 1 video visit with or without telephone and/or in-person visits). Healthcare utilization 7 days after index PC visit were compared. Generalized estimating equations estimated odds ratios for telephone or video telemedicine versus in-person only use adjusted for patient characteristics (e.g., age, gender, race, residential rurality, ethnicity), area deprivation index, comorbidity risk, and intermediate PC visits within the follow-up window. KEY RESULTS: Over the 2-year study, 3.4 million veterans had 12.9 million PC visits, where 1.7 million (50.7%), 1.0 million (30.3%), and 649,936 (19.0%) veterans were categorized as in-person only, telephone telemedicine, or video telemedicine. Compared to in-person only users, video telemedicine users experienced higher rates per 1000 patients of emergent care (15.1 vs 11.2; p < 0.001) and inpatient admissions (4.2 vs 3.3; p < 0.001). In adjusted analyses, video versus in-person only users experienced greater odds of emergent care (OR [95% CI]:1.18 [1.16, 1.19]) inpatient (OR [95% CI]: 1.29 [1.25, 1.32]), and ambulatory care sensitive condition admission (OR [95% CI]: 1.30 [1.27, 1.34]). CONCLUSIONS: Telemedicine potentially in combination with in-person care was associated with higher follow-up healthcare utilization rates compared to in-person only PC. Factors contributing to utilization differences between groups need further evaluation.

Comparing Federal Communications Commission and Microsoft Estimates of Broadband Access for Mental Health Video Telemedicine Among Veterans: Retrospective Cohort Study.

BACKGROUND: The COVID-19 pandemic highlighted the importance of telemedicine in health care. However, video telemedicine requires adequate broadband internet speeds. As video-based telemedicine grows, variations in broadband access must be accurately measured and characterized. OBJECTIVE: This study aims to compare the Federal Communications Commission (FCC) and Microsoft US broadband use data sources to measure county-level broadband access among veterans receiving mental health care from the Veterans Health Administration (VHA). METHODS: Retrospective observational cohort study using administrative data to identify mental health visits from January 1, 2019, to December 31, 2020, among 1161 VHA mental health clinics. The exposure is county-level broadband percentages calculated as the percentage of the county population with access to adequate broadband speeds (ie, download >25 megabits per second) as measured by the FCC and Microsoft. All veterans receiving VHA mental health services during the study period were included and categorized based on their use of video mental health visits. Broadband access was compared between and within data sources, stratified by video versus no video telemedicine use. RESULTS: Over the 2-year study period, 1,474,024 veterans with VHA mental health visits were identified. Average broadband percentages varied by source (FCC mean 91.3%, SD 12.5% vs Microsoft mean 48.2%, SD 18.1%; P<.001). Within each data source, broadband percentages generally increased from 2019 to 2020. Adjusted regression analyses estimated the change after pandemic onset versus before the pandemic in quarterly county-based mental health visit counts at prespecified broadband percentages. Using FCC model estimates, given all other covariates are constant and assuming an FCC percentage set at 70%, the incidence rate ratio (IRR) of county-level quarterly mental video visits during the COVID-19 pandemic was 6.81 times (95% CI 6.49-7.13) the rate before the pandemic. In comparison, the model using Microsoft data exhibited a stronger association (IRR 7.28; 95% CI 6.78-7.81). This relationship held across all broadband access levels assessed. CONCLUSIONS: This study found FCC broadband data estimated higher and less variable county-level broadband percentages compared to those estimated using Microsoft data. Regardless of the data source, veterans without mental health video visits lived in counties with lower broadband access, highlighting the need for accurate broadband speeds to prioritize infrastructure and intervention development based on the greatest community-level impacts. Future work should link broadband access to differences in clinical outcomes.

Quantifying the Digital Divide: Associations of Broadband Internet with Tele-mental Health Access Before and During the COVID-19 Pandemic.

BACKGROUND: During the COVID-19 pandemic, telemedicine quickly expanded. Broadband speeds may impact equitable access to video-based mental health (MH) services. OBJECTIVE: To identify access disparities in Veterans Health Administration (VHA) MH services based on broadband speed availability. DESIGN: Instrumental variable difference-in-differences study using administrative data to identify MH visits prior to (October 1, 2015-February 28, 2020) and after COVID-19 pandemic onset (March 1, 2020-December 31, 2021) among 1176 VHA MH clinics. The exposure is broadband download and upload speeds categorized as inadequate (download ≤25 Megabits per second - Mbps; upload ≤3 Mbps), adequate (download ≥25 Mbps and <100 Mbps; upload ≥5 Mbps and <100 Mbps), or optimal (download and upload ≥100/100 Mbps) based on data reported to the Federal Communications Commission at the census block and spatially merged to each veteran's residential address. PARTICIPANTS: All veterans receiving VHA MH services during study period. MAIN MEASURES: MH visits were categorized as in-person or virtual (i.e., telephone or video). By patient, MH visits were counted quarterly by broadband category. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient's broadband speed category and quarterly MH visit count by visit type, adjusted for patient demographics, residential rurality, and area deprivation index. KEY RESULTS: Over the 6-year study period, 3,659,699 unique veterans were seen. Adjusted regression analyses estimated the change after pandemic onset versus pre-pandemic in patients' quarterly MH visit count; patients living in census blocks with optimal versus inadequate broadband increased video visit use (incidence rate ratio (IRR) = 1.52, 95% CI = 1.45-1.59; P < 0.001) and decreased in-person visits (IRR = 0.92, 95% CI = 0.90-0.94; P < 0.001). CONCLUSIONS: This study found patients with optimal versus inadequate broadband availability had more video-based and fewer in-person MH visits after pandemic onset, suggesting broadband availability is an important determinant of access-to-care during public health emergencies requiring remote care.

Using Nudges to Reduce Missed Appointments in Primary Care and Mental Health: a Pragmatic Trial.

BACKGROUND: Missed appointments ("no-shows") are a persistent and costly problem in healthcare. Appointment reminders are widely used but usually do not include messages specifically designed to nudge patients to attend appointments. OBJECTIVE: To determine the effect of incorporating nudges into appointment reminder letters on measures of appointment attendance. DESIGN: Cluster randomized controlled pragmatic trial. PATIENTS: There were 27,540 patients with 49,598 primary care appointments, and 9420 patients with 38,945 mental health appointments, between October 15, 2020, and October 14, 2021, at one VA medical center and its satellite clinics that were eligible for analysis. INTERVENTIONS: Primary care (n = 231) and mental health (n = 215) providers were randomized to one of five study arms (four nudge arms and usual care as a control) using equal allocation. The nudge arms included varying combinations of brief messages developed with veteran input and based on concepts in behavioral science, including social norms, specific behavioral instructions, and consequences of missing appointments. MAIN MEASURES: Primary and secondary outcomes were missed appointments and canceled appointments, respectively. STATISTICAL ANALYSIS: Results are based on logistic regression models adjusting for demographic and clinical characteristics, and clustering for clinics and patients. KEY RESULTS: Missed appointment rates in study arms ranged from 10.5 to 12.1% in primary care clinics and 18.0 to 21.9% in mental health clinics. There was no effect of nudges on missed appointment rate in primary care (OR = 1.14, 95%CI = 0.96-1.36, p = 0.15) or mental health (OR = 1.20, 95%CI = 0.90-1.60, p = 0.21) clinics, when comparing the nudge arms to the control arm. When comparing individual nudge arms, no differences in missed appointment rates nor cancellation rates were observed. CONCLUSIONS: Appointment reminder letters incorporating brief behavioral nudges were ineffective in improving appointment attendance in VA primary care or mental health clinics. More complex or intensive interventions may be necessary to significantly reduce missed appointments below their current rates. TRIAL NUMBER: ClinicalTrials.gov, Trial number NCT03850431.

Learning from national implementation of the Veterans Affairs Clinical Resource Hub (CRH) program for improving access to care: protocol for a six year evaluation.

BACKGROUND: The Veterans Affairs (VA) Clinical Resource Hub (CRH) program aims to improve patient access to care by implementing time-limited, regionally based primary or mental health staffing support to cover local staffing vacancies. VA's Office of Primary Care (OPC) designed CRH to support more than 1000 geographically disparate VA outpatient sites, many of which are in rural areas, by providing virtual contingency clinical staffing for sites experiencing primary care and mental health staffing deficits. The subsequently funded CRH evaluation, carried out by the VA Primary Care Analytics Team (PCAT), partnered with CRH program leaders and evaluation stakeholders to develop a protocol for a six-year CRH evaluation. The objectives for developing the CRH evaluation protocol were to prospectively: 1) identify the outcomes CRH aimed to achieve, and the key program elements designed to achieve them; 2) specify evaluation designs and data collection approaches for assessing CRH progress and success; and 3) guide the activities of five geographically dispersed evaluation teams. METHODS: The protocol documents a multi-method CRH program evaluation design with qualitative and quantitative elements. The evaluation's overall goal is to assess CRH's return on investment to the VA and Veterans at six years through synthesis of findings on program effectiveness. The evaluation includes both observational and quasi-experimental elements reflecting impacts at the national, regional, outpatient site, and patient levels. The protocol is based on program evaluation theory, implementation science frameworks, literature on contingency staffing, and iterative review and revision by both research and clinical operations partners. DISCUSSION: Health systems increasingly seek to use data to guide management and decision-making for newly implemented clinical programs and policies. Approaches for planning evaluations to accomplish this goal, however, are not well-established. By publishing the protocol, we aim to increase the validity and usefulness of subsequent evaluation findings. We also aim to provide an example of a program evaluation protocol developed within a learning health systems partnership.

Implementation of Telehealth for Psychiatric Care in VA Emergency Departments and Urgent Care Clinics.

Objective: To conduct a mixed-methods evaluation of an emergency telehealth intervention in unscheduled settings (emergency department [ED] and urgent care clinic [UCC]) within the Veterans Health Administration (VHA). Materials and Methods: We used the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to conduct a mixed-methods evaluation of a novel telehealth program implemented in the VHA (Hospital System) in March 2020. We compared the 3 months preimplementation (December 1, 2019 through February 29, 2020) with the 3 months postimplementation (April 1, 2020 through June 30, 2020), then followed sustainability through January 31, 2021. Qualitative data were obtained from surveys and semistructured interviews of staff and providers and analyzed with thematic analysis. Results: Patient demographics and dispositions were similar pre- and postimplementation. The telemental health intervention was used in 319 (83%) unscheduled mental health consultations in the postimplementation phase. After implementation, we did not detect adverse trends in length of stay, 7-day revisits, or 30-day mortality. Use remained high with 82% (n = 1,010) of all unscheduled mental health consultations performed by telemental health in the sustainability phase. Staff and clinician interviews identified the following themes in the use of telemental health: (1) enhanced efficiency without compromising quality and safety, (2) initial apprehension, (3) the COVID-19 pandemic, and (4) sustainability after resolution of the COVID-19 pandemic. Conclusions: This mixed-methods evaluation of unscheduled telemental health implementation found that its use was feasible, did not impact the safety and efficacy of mental health consultations, and was highly acceptable and sustainable in unscheduled settings.

Call Center Remote Triage by Nurse Practitioners Was Associated With Fewer Subsequent Face-to-Face Healthcare Visits.

BACKGROUND: In 2015, the Veterans Health Administration (VHA) incorporated nurse practitioners (NPs) into remote triage call centers to supplement registered nurse (RN)-handled calls. OBJECTIVE: To assess 7-day healthcare use following telephone triage by NPs compared to RNs. We hypothesized that NP clinical decision ability may reduce follow-up healthcare. DESIGN: Retrospective observational comparative effectiveness study of clinical and administrative databases. NP routed calls were matched to RN calls based on chief complaint with propensity score matching and multivariate count data models, adjusting for differences in call severity and patient comorbidity. PARTICIPANTS: Callers to a VHA regional call center, April 2015 to March 2019. MAIN MEASURES: Primary care, specialty care, and emergency department (ED) visits plus hospitalizations within 7 days. KEY RESULTS: NP-handled calls (N = 1554) were matched to RN calls (N = 48,024) for the same chief complaint. NP-handled calls, compared to RNs, had lower comorbidities, fewer hospitalizations, and less urgent complaints. Seven-day healthcare use was lower for NP compared to RN calls for specialty care (0.15 vs. 0.20 visits per person [VPP]; p < 0.001), ED (0.11 vs. 0.27 VPP; p < 0.001), and hospitalizations (0.01 vs. 0.04 VPP; p < 0.001), but not primary care (0.43 vs. 0.42 VPP; p = 0.80). In adjusted analyses, estimated avoided in-person visits per 100 calls routed to NPs were 0.7 primary care visits (95% confidence interval [CI] 0.4, 1.0), 2.6 specialty care visits (95% CI 0.0, 5.1), 5.9 ED visits (95% CI 2.7, 9.1), and 1.4 hospital stays (95% CI 0.1, 2.6). Propensity score-matched models comparing NP (N = 1533) to RN (N = 2646) calls had adjusted odds ratios for 7-day healthcare use of 0.75 (primary care), 0.75 (specialty care), and 0.73 (ED) (all p < 0.003). CONCLUSION: Incorporating NPs into a call center was associated with lower in-person healthcare use in the subsequent 7 days compared to routine RN-triaged calls.

Enhancing Usability of Appointment Reminders: Qualitative Interviews of Patients Receiving Care in the Veterans Health Administration.

BACKGROUND: No-shows are a persistent and costly problem in all healthcare systems. Because forgetting is a common cause of no-shows, appointment reminders are widely used. However, qualitative research examining appointment reminders and how to improve them is lacking. OBJECTIVE: To understand how patients experience appointment reminders as part of intervention development for a pragmatic trial of enhanced appointment reminders. DESIGN: Qualitative content analysis PARTICIPANTS: Twenty-seven patients at a single Department of Veterans Affairs hospital and its satellite clinics APPROACH: We conducted five waves of interviews using rapid qualitative analysis, in each wave continuing to ask veterans about their experience of reminders. We double-coded all interviews, used deductive and inductive content analysis to identify themes, and selected quotations that exemplified three themes (limitations, strategies, recommendations). KEY RESULTS: Interviews showed four limitations on the usability of current appointment reminders which may contribute to no-shows: (1) excessive information within reminders; (2) frustrating telephone systems when calling in response to an appointment reminder; (3) missing or cryptic information about clinic logistics; and (4) reminder fatigue. Patients who were successful at keeping appointments often used specific strategies to optimize the usability of reminders, including (1) using a calendar; (2) heightening visibility; (3) piggybacking; and (4) combining strategies. Our recommendations to enhance reminders are as follows: (1) mix up their content and format; (2) keep them short and simple; (3) add a personal touch; (4) include specifics on clinic location and contact information; (5) time reminders based on the mode of delivery; and (6) hand over control of reminders to patients. CONCLUSIONS: Appointment reminders are vital to prevent no-shows, but their usability is not optimized for patients. There is potential for healthcare systems to modify several aspects of the content, timing, and delivery of appointment reminders to be more effective and patient-centered.

Association of Secure Messaging with Primary Care In-Person and Telephone Visits Among Veterans: a Matched Difference-in-Difference Analysis.

BACKGROUND: Secure messaging (SM) between patients and primary care teams has expanded care access but may impact other clinical encounters. OBJECTIVE: To study associations between SM use and primary care in-person and telephone visits in the Veterans Health Administration (VHA). DESIGN: The SM feature of VHA's patient portal, MyHealtheVet, supports asynchronous communication between patients and primary care teams. To study the impact of SM on in-person and telephone visits, two analyses were performed: (1) a retrospective pre-/post-analysis comparing changes after initiating SM use and (2) a difference-in-difference comparison among SM users and non-users 1 year before and after index SM use. Matching to non-users was by primary care team, demographics, and predicted propensity of SM use by Nosos comorbidity score and drive time to clinic. PATIENTS: In 2016, 154,053 Veterans initiated SM from all primary care patients (N = 5,891,893); 25,683 were propensity-matched to controls (N = 49,266) from the same primary care team not using SM. MAIN MEASURES: Primary care provider in-person visits and telephone contacts between patients and their primary care team were assessed 1 year prior and post index SM. KEY RESULTS: Overall, primary care in-person visits decreased 13.3% (p < 0.0001); telephone visits increased 13.5% (p < 0.0001). In the matched analysis, in-person primary care visits decreased by 16.0% (p < 0.0001) by SM users and 9.9% (p < 0.0001) among controls, resulting in a across-group decrease of 6.1% in-person visits after SM initiation. Telephone visits increased by 11.0% (p < 0.0001) for SM users and 4.5% for controls (p < 0.0001) resulting in an across-group increase of 6.5% telephone visits after SM initiation. CONCLUSIONS: Use of SM was associated with decreased in-person visits and increased telephone visits. This may improve clinic appointment availability, while increasing time commitments for providers for non-traditional forms of access.

Perceived Need and Potential Applications of a Telehospitalist Service in Rural Areas.

Background: Rural hospitals struggle to staff inpatient services and may not have the clinical expertise to achieve optimal outcomes. Telehospitalist services could address these problems by bringing hospital medicine expertise to rural communities. Introduction: Veterans Health Administration (VHA) rural hospitals need staffing alternatives to address gaps in inpatient coverage. This needs assessment identified perceived need for telehospitalist services as well as potential applications, benefits, and barriers from an administration perspective. Materials and Methods: We used a rapid qualitative assessment approach based on semistructured interviews with 15 physician administrators at 12 rural and low-complexity hospitals in VHA in 2018. Results: We identified a range of needs that could be addressed by telehospitalist services, including direct care delivery, support for local providers, and on-demand coverage to fill staffing gaps. Potential benefits included cost reductions, improved care quality, education, and addressing feelings of insular practice. Potential barriers included provider buy-in, cost, and technological limitations. Discussion: Our findings suggest that telehospitalist services could address inpatient coverage gaps, but with a range of views on how the service could be deployed. Telehospitalist services providing intermittent coverage could meet unmet clinical needs at appropriate economies of scale. Administrators were enthusiastic about applying innovative inpatient telemedicine initiatives, but perceived staff reluctance. The dynamic and multidisciplinary nature of inpatient care requires program acceptance at multiple levels, which may account for why it traditionally lags behind outpatient telemedicine. Conclusions: Rural hospital physician administrators perceived telehospitalist models as a viable option to address staffing needs and improve quality of care.

Use of the Veterans' Choice Program and Attrition From Veterans Health Administration Primary Care.

BACKGROUND: Concerns over timely access and waiting times for appointments in the Veterans Health Administration (VHA) spurred the push towards greater privatization. In 2014, VHA increased the provision of care from community providers through the Veterans' Choice Program (Choice). OBJECTIVES: We examined the characteristics of patients and practices more likely to use Choice care and whether using Choice care affected patients' attrition from VHA primary care. STUDY DESIGN: We conducted a longitudinal study of VHA primary care users in the fiscal year 2015 and their attrition 2 years later. In the multivariate analysis, we examined whether attrition from VHA primary care was related to prior use of Choice care. SUBJECTS: A total of 1.4 million nonelderly patients diagnosed with chronic conditions. MEASURES: Choice outpatient care utilization was measured in the baseline year. Attrition was measured as not receiving any VHA primary care in 2 subsequent years. RESULTS: In our cohort, 93,710 (7%) patients used some Choice outpatient care, and these patients were more likely to be female, White or Hispanic, to have more primary care utilization at baseline, and to have long driving distances to VHA care. Practices which sent more patients out for Choice care had lower mean scores for patient-centered medical home implementation and longer mean waiting times for appointments. In the adjusted analysis, the probability of attrition was significantly lower (-0.009) among patients who used Choice outpatient care (0.036) versus patients who did not (0.044) (P<0.001). CONCLUSION: The use of community outpatient providers in the Choice program was associated with less attrition from VHA primary care.

Potentially avoidable inter-facility transfer from Veterans Health Administration emergency departments: A cohort study.

BACKGROUND: Inter-facility transfer is an important strategy for improving access to specialized health services, but transfers are complicated by over-triage, under-triage, travel burdens, and costs. The purpose of this study is to describe ED-based inter-facility transfer practices within the Veterans Health Administration (VHA) and to estimate the proportion of potentially avoidable transfers. METHODS: This observational cohort study included all patients treated in VHA EDs between 2012 and 2014 who were transferred to another VHA hospital. Potentially avoidable transfers were defined as patients who were either discharged from the receiving ED or admitted to the receiving hospital for ≤1 day without having an invasive procedure performed. We conducted facility- and diagnosis-level analyses to identify subgroups of patients for whom potentially avoidable transfers had increased prevalence. RESULTS: Of 6,173,189 ED visits during the 3-year study period, 18,852 (0.3%) were transferred from one VHA ED to another VHA facility. Rural residents were transferred three times as often as urban residents (0.6% vs. 0.2%, p < 0.001), and 22.8% of all VHA-to-VHA transfers were potentially avoidable transfers. The 3 disease categories most commonly associated with inter-facility transfer were mental health (34%), cardiac (12%), and digestive diagnoses (9%). CONCLUSIONS: VHA inter-facility transfer is commonly performed for mental health and cardiac evaluation, particularly for patients in rural settings. The proportion that are potentially avoidable is small. Future work should focus on improving capabilities to provide specialty evaluation locally for these conditions, possibly using telehealth solutions.

Sequelae of an Evidence-based Approach to Management for Access to Care in the Veterans Health Administration.

BACKGROUND: Access to health care is a critical concept in the design, delivery, and evaluation of high quality care. Meaningful evaluation of access requires research evidence and the integration of perspectives of patients, providers, and administrators. OBJECTIVE: Because of high-profile access challenges, the Department of Veterans Affairs (VA) invested in research and implemented initiatives to address access management. We describe a 2-year evidence-based approach to improving access in primary care. METHODS: The approach included an Evidence Synthesis Program (ESP) report, a 22-site in-person qualitative evaluation of VA initiatives, and in-person and online stakeholder panel meetings facilitated by the RAND corporation. Subsequent work products were disseminated in a targeted strategy to increase impact on policy and practice. RESULTS: The ESP report summarized existing research evidence in primary care management and an evaluation of ongoing initiatives provided organizational data and novel metrics. The stakeholder panel served as a source of insights and information, as well as a knowledge dissemination vector. Work products included the ESP report, a RAND report, peer-reviewed manuscripts, presentations at key conferences, and training materials for VA Group Practice Managers. Resulting policy and practice implications are discussed. CONCLUSIONS: The commissioning of an evidence report was the beginning of a cascade of work including exploration of unanswered questions, novel research and measurement discoveries, and policy changes and innovation. These results demonstrate what can be achieved in a learning health care system that employs evidence and expertise to address complex issues such as access management.

Creating and disseminating a home-based cardiac rehabilitation program: experience from the Veterans Health Administration.

BACKGROUND: Cardiac rehabilitation (CR) programs provide significant benefit for people with cardiovascular disease. Despite these benefits, such services are not universally available. We designed and evaluated a national home-based CR (HBCR) program in the Veterans Health Administration (VHA). The primary aim of the study was to examine barriers and facilitators associated with site-level implementation of HBCR. METHODS: This study used a convergent parallel mixed-methods design with qualitative data to analyze the process of implementation, quantitative data to determine low and high uptake of the HBCR program, and the integration of the two to determine which facilitators and barriers were associated with adoption. Data were drawn from 16 VHA facilities, and included semi-structured interviews with multiple stakeholders, document analysis, and quantitative analysis of CR program attendance codes. Qualitative data were analyzed using the Consolidated Framework for Implementation Research codes including three years of document analysis and 22 interviews. RESULTS: Comparing high and low uptake programs, readiness for implementation (leadership engagement, available resources, and access to knowledge and information), planning, and engaging champions and opinion leaders were key to success. High uptake sites were more likely to seek information from the external facilitator, compared to low uptake sites. There were few adaptations to the design of the program at individual sites. CONCLUSION: Consistent and supportive leadership, both clinical and administrative, are critical elements to getting HBCR programs up and running and sustaining programs over time. All sites in this study had external funding to develop their program, but high adopters both made better use of those resources and were able to leverage existing resources in the setting. These data will inform broader policy regarding use of HBCR services.

Using Video Telehealth to Facilitate Inhaler Training in Rural Patients with Obstructive Lung Disease.

BACKGROUND: Proper inhaler technique is important for effective drug delivery and symptom control in chronic obstructive pulmonary disease (COPD) and asthma, yet not all patients receive inhaler instructions. INTRODUCTION: Using a retrospective chart review of participants in a video telehealth inhaler training program, the study compared inhaler technique within and between monthly telehealth visits and reports associated with patient satisfaction. MATERIALS AND METHODS: Seventy-four (N = 74) rural patients prescribed ≥1 inhaler participated in three to four pharmacist telehealth inhaler training sessions using teach-to-goal (TTG) methodology. Within and between visit inhaler technique scores are compared, with descriptive statistics of pre- and postprogram survey results including program satisfaction and computer technical issues. Healthcare utilization is compared between pre- and post-training periods. RESULTS: Sixty-nine (93%) patients completed all three to four video telehealth inhaler training sessions. During the initial visit, patients demonstrated improvement in inhaler technique for metered dose inhalers (albuterol, budesonide/formoterol), dry powder inhalers (formoterol, mometasone, tiotropium), and soft mist inhalers (ipratropium/albuterol) (p < 0.01 for all). Improved inhaler technique was sustained at 2 months (p < 0.01). Ninety-four percent of participants were satisfied with the program. Although technical issues were common, occurring among 63% of attempted visits, most of these visits (87%) could be completed. There was no significant difference in emergency department visits and hospitalizations pre- and post-training. DISCUSSION: This study demonstrated high patient acceptance of video telehealth training and objective improvement in inhaler technique. CONCLUSIONS: Video telehealth inhaler training using the TTG methodology is a promising program that improved inhaler technique and access to inhaler teaching for rural patients with COPD or asthma.

Association between Renal Function and Bleeding Risk for Dabigatran after Switching from Warfarin.

BACKGROUND: There is a higher risk of gastrointestinal (GI) bleeding in patients treated with dabigatran versus warfarin. We analyzed the impact of renal function on the relative risk of bleeding in patients converted to dabigatran. METHODS: Patients aged ≥65 years who received anticoagulation with warfarin for a minimum of 6 months and subsequently converted to dabigatran or remained on warfarin were studied. Data sources included VA National Patient Care, and VA Decision Support System National Pharmacy and Laboratory. Each patient who converted to dabigatran 150 mg twice daily was matched by propensity score with 2 patients on warfarin who did not convert. Outcomes included rates of hospital admission for GI or other major bleeding and mortality, stratified by estimated glomerular filtration rate (eGFR). RESULTS: Study population included 864 patients who converted and 1,710 patients who did not convert to dabigatran. In patients with eGFR 50-80 ml/min/1.73 m², the hazard of GI bleeding in patients who initiated dabigatran was nearly 3 times higher, (4.1 vs. 1.3 per 100 patient years; hazards ratio 2.94; 95% CI 1.24-7.02; p = 0.015), compared to patients who remained on warfarin. There were relatively few patients with eGFR <50 or >80 ml/min/1.73 m2, and relatively few bleeding events outside the GI tract. CONCLUSIONS: Prescribing healthcare providers should exercise caution and close monitoring for bleeding complications when converting from warfarin to dabigatran, even in patients with renal function in the range considered safe for dabigatran use as per current recommendations.

Aligning complex processes and electronic health record templates: a quality improvement intervention on inpatient interdisciplinary rounds.

BACKGROUND: Interdisciplinary rounds (IDR) with documentation have become a standard of care, but the process has been incompletely described in academic general medical settings. Checklists are promoted, yet standardized formats may not reflect the variability and work flow of rounds or support the cognitive development of medical trainees. We describe IDR processes in an academic general medicine inpatient setting and present a rapid cycle quality improvement (QI) project that improved IDR documentation rates in the electronic health record. METHODS: The project team observed existing daily IDR rounds on two medical inpatient units at the Iowa City VA Medical Center, with three resident teams and maximum census of 42 patients. The major intervention was a redesigned note template, with accompanying resident educational materials. The primary outcome was note completion rates by charge nurses; IDR team member satisfaction and participation, discussion time and balancing metrics (i.e., excess bed days of care, length of stay, and 30-day readmissions) were also assessed. RESULTS: An electronic template and accompanying educational materials designed to parallel the heuristic problem-solving activities of the IDR team led to improvements in IDR note completion rates from 27 to 69 %. Team member satisfaction was high and participation was stable. Discussion time per patient increased modestly, but varied widely between resident teams and by patient. Balancing metrics were unchanged. Unstructured evaluation indicated that documentation times were reduced, and IDR documentation became more timely and useful. CONCLUSIONS: IDR notes designed to support the problem-solving processes of an interdisciplinary group improved the timeliness and perceived value of IDR documentation and met regulatory standards. Aligning complex processes and educational and documentation needs during IDR may create an efficient opportunity for sustainable interdisciplinary work and learning in an academic setting.