Using a person-centered approach in clinical care for patients with complex chronic conditions: Perspectives from healthcare professionals caring for Veterans with COPD in the U.S. Veterans Health Administration's Whole Health System of Care.

BACKGROUND: The largest nationally integrated health system in the United States, the Veterans Health Administration (VHA), has been undergoing a transformation toward a Whole Health (WH) System of Care. WH Clinical Care, a component of this system, includes holistically assessing the Veteran's life context, identifying what really matters to the Veteran, collaboratively setting and monitoring personal health and well-being goals, and equipping the Veteran with access to conventional and complementary and integrative health resources. Implementation of WH Clinical Care has been challenging. Understanding healthcare professionals' perspectives on the value of and barriers and facilitators to practicing WH Clinical Care holds relevance for not only VHA's efforts but also other health systems, in the U.S. and internationally, that are engaged in person-centered care implementation. OBJECTIVES: We sought to understand perspectives of healthcare professionals at VHA on providing WH Clinical Care to Veterans with COPD, as a lens to understand the broader issue of WH Clinical Care for Veterans living with complex chronic conditions. DESIGN: We interviewed 25 healthcare professionals across disciplines and services at a VA Medical Center in 2020-2021, including primary care providers, pulmonologists, palliative care providers, and chaplains. Interview transcripts were analyzed using qualitative content analysis. KEY RESULTS: Each element of WH Clinical Care raised complex questions and/or concerns, including: (1) the appropriate depth/breadth of inquiry in person-centered assessment; (2) the rationale for elicitation of what really matters; (3) the feasibility and appropriate division of labor in personal health goal setting and planning; and (4) challenges related to referring Veterans to a broad spectrum of supportive services. CONCLUSIONS: Efforts to promote person-centered care must account for healthcare professionals' existing comfort with its elements, advocate for a team-based approach, and continue to grapple with the conflicting structural conditions and organizational imperatives.

Partnered implementation of the veteran sponsorship initiative: protocol for a randomized hybrid type 2 effectiveness-implementation trial.

BACKGROUND: The USA is undergoing a suicide epidemic for its youngest Veterans (18-to-34-years-old) as their suicide rate has almost doubled since 2001. Veterans are at the highest risk during their first-year post-discharge, thus creating a "deadly gap." In response, the nation has developed strategies that emphasize a preventive, universal, and public health approach and embrace the value of community interventions. The three-step theory of suicide suggests that community interventions that reduce reintegration difficulties and promote connectedness for Veterans as they transition to civilian life have the greatest likelihood of reducing suicide. Recent research shows that the effectiveness of community interventions can be enhanced when augmented by volunteer and certified sponsors (1-on-1) who actively engage with Veterans, as part of the Veteran Sponsorship Initiative (VSI). METHOD/DESIGN: The purpose of this randomized hybrid type 2 effectiveness-implementation trial is to evaluate the implementation of the VSI in six cities in Texas in collaboration with the US Departments of Defense, Labor and Veterans Affairs, Texas government, and local stakeholders. Texas is an optimal location for this large-scale implementation as it has the second largest population of these young Veterans and is home to the largest US military installation, Fort Hood. The first aim is to determine the effectiveness of the VSI, as evidenced by measures of reintegration difficulties, health/psychological distress, VA healthcare utilization, connectedness, and suicidal risk. The second aim is to determine the feasibility and potential utility of a stakeholder-engaged plan for implementing the VSI in Texas with the intent of future expansion in more states. The evaluators will use a stepped wedge design with a sequential roll-out to participating cities over time. Participants (n=630) will be enrolled on military installations six months prior to discharge. Implementation efforts will draw upon a bundled implementation strategy that includes strategies such as ongoing training, implementation facilitation, and audit and feedback. Formative and summative evaluations will be guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework and will include interviews with participants and periodic reflections with key stakeholders to longitudinally identify barriers and facilitators to implementation. DISCUSSION: This evaluation will have important implications for the national implementation of community interventions that address the epidemic of Veteran suicide. Aligned with the Evidence Act, it is the first large-scale implementation of an evidence-based practice that conducts a thorough assessment of TSMVs during the "deadly gap." TRIAL REGISTRATION: ClinicalTrials.gov ID number: NCT05224440 . Registered on 04 February 2022.

Accessibility to Medication for Opioid Use Disorder After Interventions to Improve Prescribing Among Nonaddiction Clinics in the US Veterans Health Care System.

Importance: With increasing rates of opioid use disorder (OUD) and overdose deaths in the US, increased access to medications for OUD (MOUD) is paramount. Rigorous effectiveness evaluations of large-scale implementation initiatives using quasi-experimental designs are needed to inform expansion efforts. Objective: To evaluate a US Department of Veterans Affairs (VA) initiative to increase MOUD use in nonaddiction clinics. Design, Setting, and Participants: This quality improvement initiative used interrupted time series design to compare trends in MOUD receipt. Primary care, pain, and mental health clinics in the VA health care system (n = 35) located at 18 intervention facilities and nonintervention comparison clinics (n = 35) were matched on preimplementation MOUD prescribing trends, clinic size, and facility complexity. The cohort of patients with OUD who received care in intervention or comparison clinics in the year after September 1, 2018, were evaluated. The preimplementation period extended from September 1, 2017, through August 31, 2018, and the postimplementation period from September 1, 2018, through August 31, 2019. Exposures: The multifaceted implementation intervention included education, external facilitation, and quarterly reports. Main Outcomes and Measures: The main outcomes were the proportion of patients receiving MOUD and the number of patients per clinician prescribing MOUD. Segmented logistic regression evaluated monthly proportions of MOUD receipt 1 year before and after initiative launch, adjusting for demographic and clinical covariates. Poisson regression models examined yearly changes in clinician prescribing over the same time frame. Results: Overall, 7488 patients were seen in intervention clinics (mean [SD] age, 53.3 [14.2] years; 6858 [91.6%] male; 1476 [19.7%] Black, 417 [5.6%] Hispanic; 5162 [68.9%] White; 239 [3.2%] other race [including American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, and multiple races]; and 194 [2.6%] unknown) and 7558 in comparison clinics (mean [SD] age, 53.4 [14.0] years; 6943 [91.9%] male; 1463 [19.4%] Black; 405 [5.4%] Hispanic; 5196 [68.9%] White; 244 [3.2%] other race; 250 [3.3%] unknown). During the preimplementation year, the proportion of patients receiving MOUD in intervention clinics increased monthly by 5.0% (adjusted odds ratio [AOR], 1.05; 95% CI, 1.03-1.07). Accounting for this preimplementation trend, the proportion of patients receiving MOUD increased monthly by an additional 2.3% (AOR, 1.02; 95% CI, 1.00-1.04) during the implementation year. Comparison clinics increased by 2.6% monthly before implementation (AOR, 1.03; 95% CI, 1.01-1.04), with no changes detected after implementation. Although preimplementation-year trends in monthly MOUD receipt were similar in intervention and comparison clinics, greater increases were seen in intervention clinics after implementation (AOR, 1.04; 95% CI, 1.01-1.08). Patients treated with MOUD per clinician in intervention clinics saw greater increases from before to after implementation compared with comparison clinics (incidence rate ratio, 1.50; 95% CI, 1.28-1.77). Conclusions and Relevance: A multifaceted implementation initiative in nonaddiction clinics was associated with increased MOUD prescribing. Findings suggest that engagement of clinicians in general clinical settings may increase MOUD access.

Health Care for Our Nation's Veterans: A Policy Paper From the American College of Physicians.

The Veterans Health Administration (VHA) is the United States' largest integrated health care delivery system, serving over 9 million enrollees at nearly 1300 health care facilities. In addition to providing health care to the nation's military veterans, the VHA has a research and development program, trains thousands of medical residents and other health care professionals, and conducts emergency preparedness and response activities. The VHA has been celebrated for delivering high-quality care to veterans, early adoption of electronic medical records, and high patient satisfaction. However, the system faces challenges, including implementation of an expanded community care program, modernization of its electronic medical records system, and providing care to a population with complex needs. The position paper offers policy recommendations on VHA funding, the community care program, medical and health care professions training, and research and development.

Factors affecting primary care implementation for older veterans with multimorbidity in Veterans Health Administration (VA).

OBJECTIVE: To identify factors affecting implementation of Geriatric Patient-Aligned Care Teams (GeriPACTs), a patient-centered medical home model for older adults with complex care needs including multiple chronic conditions (MCC), designed to provide them with comprehensive, managed, and coordinated primary care. DATA SOURCES: Qualitative data were collected from key informants at eight Veterans Health Administration Medical Centers geographically spread across the United States. STUDY DESIGN: Guided by the Consolidated Framework for Implementation Research (CFIR), we collected prospective primary data through semi-structured interviews with GeriPACT team members (e.g., physicians, nurses, social workers, pharmacists), leaders (e.g., executive leaders, middle managers), and other staff referring to the program. DATA COLLECTION: We conducted in-person, semi-structured interviews with 134 key informants. Interviews were recorded with permission and professionally transcribed. Transcripts were coded in Nvivo 11. We used directed content analysis to identify key factors affecting GeriPACT implementation across sites. PRINCIPAL FINDINGS: Five key factors affected GeriPACT implementation-five CFIR constructs within two CFIR domains. Within the intervention characteristics domain, two constructs emerged, namely, (1) the structure of the GeriPACT model and (2) design, quality, and packaging. Within the inner setting domain, we identified three constructs, namely, (1) available resources (e.g., staffing and space, and infrastructure and information technology), (2) leadership support and engagement, and (3) networks and communications including teamwork, communication, and coordination. CONCLUSIONS: Older veterans with MCC have complex primary care needs requiring high levels of care management and coordination. Knowing what key factors affect GeriPACT implementation is critical. Study findings also contribute to the growing implementation science literature on applying CFIR to evaluate factors that affect program implementation, especially to aging research. Further studies on MCC-focused specialty primary care will help facilitate patient-centered care provision for older adults' complex health needs while also leveraging synergistic work across factors affecting implementation.

Outcomes of a randomized quality improvement trial for high-risk Veterans in year two.

OBJECTIVE: The Veterans Health Administration (VHA) conducted a randomized quality improvement evaluation to determine whether augmenting patient-centered medical homes with Primary care Intensive Management (PIM) decreased utilization of acute care and health care costs among patients at high risk for hospitalization. PIM was cost-neutral in the first year; we analyzed changes in utilization and costs in the second year. DATA SOURCES: VHA administrative data for five demonstration sites from August 2013 to March 2019. DATA SOURCES: Administrative data extracted from VHA's Corporate Data Warehouse. STUDY DESIGN: Veterans with a risk of 90-day hospitalization in the top 10th percentile and recent hospitalization or emergency department (ED) visit were randomly assigned to usual primary care vs primary care augmented by PIM. PIM included interdisciplinary teams, comprehensive patient assessment, intensive case management, and care coordination services. We compared the change in mean VHA inpatient and outpatient utilization and costs (including PIM expenses) per patient for the 12-month period before randomization and 13-24 months after randomization for PIM vs usual care using difference-in-differences. PRINCIPAL FINDINGS: Both PIM patients (n = 1902) and usual care patients (n = 1882) had a mean of 5.6 chronic conditions. PIM patients had a greater number of primary care visits compared to those in usual care (mean 4.6 visits/patient/year vs 3.7 visits/patient/year, p < 0.05), but ED visits (p = 0.45) and hospitalizations (p = 0.95) were not significantly different. We found a small relative increase in outpatient costs among PIM patients compared to those in usual care (mean difference + $928/patient/year, p = 0.053), but no significant differences in mean inpatient costs (+$245/patient/year, p = 0.97). Total mean health care costs were similar between the two groups during the second year (mean difference + $1479/patient/year, p = 0.73). CONCLUSIONS: Approaches that target patients solely based on the high risk of hospitalization are unlikely to reduce acute care use or total costs in VHA, which already offers patient-centered medical homes.

Perceptions of legal legitimacy in veterans treatment courts: A test of a modified version of procedural justice theory.

OBJECTIVE: Perceptions of the legitimacy of a society's legal system help explain individual responses to courts and legal actors. Normative considerations such as fair and respectful treatment as well as social identification have demonstrated the ability to enhance perceived legal legitimacy and future cooperation. Veterans treatment courts (VTCs) are a rapidly disseminating and understudied intervention. Their targeting of a socially esteemed group presents an interesting venue to explore normative theories of justice. The present study tested a modified version of Tyler's theory of procedural justice in this setting. HYPOTHESES: We hypothesized that procedural justice, social bonds, and receipt of gratitude for military service would be positively associated with veteran identity and legal legitimacy. We further hypothesized that participants' identification as veterans would mediate the relationships between the three independent variables and legitimacy. METHOD: A cross-sectional survey design was used with a convenience sample (N = 191) of participants in two VTCs. Analyses controlled for race, ethnicity, recidivism risk, and combat exposure. RESULTS: Perceptions of procedural justice, social bonds, and receipt of gratitude were positively associated with veteran identity and perceptions of legal legitimacy. Further, veteran identity was found to be a significant mediator between the first three constructs and legal legitimacy. CONCLUSIONS: The results support the importance of procedural justice in explaining perceptions of legal legitimacy in a novel context that is rapidly proliferating and understudied and has unique social identity considerations. The addition of gratitude and veteran identity to Tyler's model raises implications for VTC practice and further inquiry. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Applied Rapid Qualitative Analysis to Develop a Contextually Appropriate Intervention and Increase the Likelihood of Uptake.

BACKGROUND: Rapid approaches to collecting and analyzing qualitative interview data can accelerate discovery timelines and intervention development while maintaining scientific rigor. We describe the application of these methods to a program designed to improve care coordination between the Veterans Health Administration (VHA) and community providers. METHODS: Care coordination between VHA and community providers can be challenging in rural areas. The Telehealth-based Coordination of Non-VHA Care (TECNO Care) intervention was designed to improve care coordination among VHA and community providers. To ensure contextually appropriate implementation of TECNO Care, we conducted preimplementation interviews with veterans, VHA administrators, and VHA and community providers involved in community care. Using both a rapid approach and qualitative analysis, an interviewer and 1-2 note-taker(s) conducted interviews. RESULTS: Over 5 months, 18 stakeholders were interviewed and we analyzed these data to identify how best to deliver TECNO Care. Responses relevant to improving care coordination include health system characteristics; target population; metrics and outcomes; challenges with the current system; and core components. Veterans who frequently visit VHA or community providers and are referred for additional services are at risk for poor outcomes and may benefit from additional care coordination. Using these data, we designed TECNO Care to include information on VHA services and processes, assist in the timely completion of referrals, and facilitate record sharing. CONCLUSION: Rapid qualitative analysis can inform near real-time intervention development and ensure relevant content creation while setting the stage for stakeholder buy-in. Rigorous and timely analyses support the delivery of contextually appropriate, efficient, high-value patient care.

Interorganizational Care Coordination of Rural Veterans by Veterans Affairs and Community Care Programs: A Systematic Review.

BACKGROUND: In the unique context of rural Veterans' health care needs, expansion of US Department of Veterans Affairs and Community Care programs under the MISSION Act, and the uncertainties of coronavirus disease 2019 (COVID-19), it is critical to understand what may support effective interorganizational care coordination for increased access to high-quality care. OBJECTIVES: We conducted a systematic review to examine the interorganizational care coordination initiatives that Veterans Affairs (VA) and community partners have pursued in caring for rural Veterans, including challenges and opportunities, organizational domains shaping care coordination, and among these, initiatives that improve or impede health care outcomes. RESEARCH DESIGN: We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search 2 electronic databases (PubMed and Embase) for peer-reviewed articles published between January 2009 and May 2020. Building on prior research, we conducted a systematic review. RESULTS: Sixteen articles met our criteria. Each captured a unique health care focus while examining common challenges. Four organizational domains emerged: policy and administration, culture, mechanisms, and relational practices. Exemplars highlight how initiatives improve or impede rural health care delivery. CONCLUSIONS: This is the first systematic review, to our knowledge, examining interorganizational care coordination of rural Veterans by VA and Community Care programs. Results provide exemplars of interorganizational care coordination domains and program effectiveness. It suggests that partners' efforts to align their coordination domains can improve health care, with rurality serving as a critical contextual factor. Findings are important for policies, practices, and research of VA and Community Care partners committed to improving access and health care for rural Veterans.

Big Data in the Veterans Health Administration: A Nursing Informatics Perspective.

PURPOSE: This article reviews the missions of the U.S. Department of Veterans Affairs (VA) and the evolution of its electronic health record (EHR), the Veterans Health Information Systems and Technology Architecture (VistA). This system, along with its clinical graphical user interface the Computerized Patient Record System, form a key link in VA health care. A Veteran who receives healthcare through the VA can have their EHR accessed by clinicians at any VA healthcare facility across the United States and its territories. Data aggregated daily at a corporate data warehouse supports VA quality improvement and research. ORGANIZING CONSTRUCT: Serving over 9 million Veterans, the VA is one of the largest integrated healthcare systems in the United States. It has been a leader in the development and use of healthcare informatics, EHR, and big data analytics for over 30 years. Nurses engaged in major roles in the evolution of these developments. CONCLUSIONS: With over 500 nurses as members, the Office of Nursing Informatics' Field Alliance demonstrates the VA's continuing commitment to fostering nursing informatics. The commitment includes investment by the VA to develop nursing informaticists from among its own staff. CLINICAL RELEVANCE: Exemplars of the impact of nursing informatics are shared. Future directions include an EHR that begins during military service and follows the Veteran into VA health care.

Garnering Support for Complementary and Integrative Health Implementation: A Qualitative Study of VA Healthcare Organization Leaders.

Objectives: Healthcare organization leaders' support is critical for successful implementation of new practices, including complementary and integrative health (CIH) therapies. Yet little is known about how to garner this support and what motivates leaders to support these therapies. We examined reasons leaders provided or withheld support for CIH therapy implementation, using a multilevel lens to understand motivations influenced by individual, interpersonal, organizational, and system determinants. Design and setting: We conducted qualitative interviews with leaders in seven Veterans Health Administration medical centers that offered at least three CIH therapies to Veterans and were identified as early adopters of CIH therapies. Subjects: Participants included 12 executive leaders and 34 leaders of key clinical services, including primary care, mental health, physical medicine and rehabilitation, and pain. Measures: We used a thematic analysis to examine leaders' narratives of barriers and facilitators to implementation including their attitudes toward CIH therapies, perceptions of evidence, engagement in implementation, and decisions to provide concrete support for CIH therapies. Drawing from Greenhalgh's Diffusion of Innovation framework, we organized themes according to the influence of individual determinants, two levels of inner setting, and outer system context on CIH implementation. Results: Leaders' decisions to provide or withhold support were driven by considerations across multiple levels including (1) individual attitudes/knowledge, perceptions of evidence, and personal experiences; (2) interpersonal interactions with trusted brokers, patients, and loved ones/colleagues/staff; (3) organizational concerns surrounding relative priorities, local resources, and metrics/quality/safety; and (4) system-level policy, bureaucracy, and interorganizational networks. These considerations interacted across levels, with components at organizational and system levels sometimes prevailing over individual perceptions and experiences. Conclusions: Garnering leaders' support for CIH therapy implementation should address their considerations at multiple levels. Implementation strategies designed to shift individual attitudes alone may be insufficient for securing leaders' support without attention to broader organizational and system-level contextual issues.

Complementary and Integrative Health Approaches Offered in the Veterans Health Administration: Results of a National Organizational Survey.

Introduction: Certain complementary and integrative health (CIH) approaches have increasingly gained attention as evidence-based nonpharmacological options for pain, mental health, and well-being. The Veterans Health Administration (VA) has been at the forefront of providing CIH approaches for years, and the 2016 Comprehensive Addiction and Recovery Act mandated the VA expand its provision of CIH approaches. Objective/Design: To conduct a national organizational survey to document aspects of CIH approach implementation from August 2017 to July 2018 at the VA. Participants: CIH program leads at VA medical centers and community-based outpatient clinics (n = 196) representing 289 sites participated. Measures: Delivery of 27 CIH and other nonpharmacologic approaches was measured, including types of departments and providers, visit format, geographic variations, and implementation challenges. Results: Respondents reported offering a total of 1,568 CIH programs nationally. Sites offered an average of five approaches (range 1-23), and 63 sites offered 10 or more approaches. Relaxation techniques, mindfulness, guided imagery, yoga, and meditation were the top five most frequently offered. The most approaches were offered in physical medicine and rehabilitation, primary care, and within integrative/whole health programs, and VA non-Doctor of Medicine clinical staff were the most common type of CIH provider. Only 13% of sites reported offering CIH approaches through telehealth at the time. Geographically, southwestern sites offered the smallest number of approaches. Implementation challenges included insufficient staffing, funding, and space, hiring/credentialing, positioning CIH as a priority, and high patient demand. Conclusions: The provision of CIH approaches was widespread at the VA in 2017-2018, with over half of responding sites offering five or more approaches. As patients seek nonpharmacologic options to address their pain, anxiety, depression, and well-being, the nation's largest integrated health care system is well-positioned to meet that demand. Providing these therapies might not only increase patient satisfaction but also their health and well-being with limited to no adverse events.

Converting a Geriatrics Clinic to Virtual Visits during COVID-19: A Case Study.

BACKGROUND: To characterize the experience of converting a geriatrics clinic to telehealth visits in early stages of a pandemic. DESIGN: An organizational case study with mixed methods evaluation from the first 8 weeks of converting a geriatrics clinic from in-person visits to video and telephone visits. SETTING: Veteran's Health Administration in Northern California Participants Community-dwelling older Veterans receiving care at VA Palo Alto Geriatrics clinic. Veterans had a mean age of 85.7 (SD = 6.8) and 72.1% had cognitive impairment. INTERVENTION: Veterans with face-to-face appointments were converted to video or telephone visits to mitigate exposure to community spread of COVID-19. MEASUREMENTS: Thirty-two patient evaluations and 80 clinician feedback evaluations were completed. This provided information on satisfaction, care access during pandemic, and travel and time savings. RESULTS: Of the 62 scheduled appointments, 43 virtual visits (69.4%) were conducted. Twenty-six (60.5%) visits were conducted via video, 17 (39.5%) by telephone. Virtual visits saved patients an average of 118.6 minutes each. Patients and providers had similar, positive perceptions about telehealth to in-person visit comparison, limiting exposure, and visit satisfaction. After the telehealth appointment, patients indicated greater comfort with using virtual visits in the future. Thirty-one evaluations included comments for qualitative analysis. We identified 3 main themes of technology set-up and usability, satisfaction with visit, and clinical assessment and communication. CONCLUSION: During a pandemic that has limited the ability to safely conduct inperson services, virtual formats offer a feasible and acceptable alternative for clinically-complex older patients. Despite potential barriers and additional effort required for telehealth visits, patients expressed willingness to utilize this format. Patients and providers reported high satisfaction, particularly with the ability to access care similar to in-person while staying safe. Investing in telehealth services during a pandemic ensures that vulnerable older patients can access care while maintaining social distancing, an important safety measure.

Interorganizational Context When Implementing Multisector Partnered Programs: A Qualitative Analysis of Veteran Directed Care.

As the number of Veterans enrolled in the Veterans Health Administration (VHA) and at risk for needing Long Term Services and Supports increases, VHA is shifting from institutional to Home and Community Based Services, such as the Veteran-Directed Care (VDC) program. VDC is a multi-sector program implemented as a collaboration between individual VHA medical centers (VAMCs) and Aging and Disability Network Agencies (ADNAs), entities that sit outside the VHA. Factors that affect establishment of effective multi-sector programs such as VDC are poorly understood, limiting ability to effectively deliver and scale programs. We conducted a qualitative study to describe factors affecting the interorganizational implementation context of VDC. Using constructs from the Consolidated Framework for Implementation Research (CFIR), we interviewed VDC coordinators from seven different VAMC-ADNA partnerships that initiated the VDC program between 2017 and 2018. We identified eight CFIR determinants which manifested similarly for the VAMCs and ADNAs: evidence strength and quality, relative advantage, adaptability, tension for change, access to knowledge and information, self-efficacy; engaging, and champions. We identified three CFIR determinants that varied dramatically across VAMCs and ADNAs: available resources, implementation climate, and relative priority. Our results suggest that interorganizational context plays a critical and dynamic role within multi-sector collaborations.

Construction and Use of Body Weight Measures from Administrative Data in a Large National Health System: A Systematic Review.

OBJECTIVE: Administrative data are increasingly used in research and evaluation yet lack standardized guidelines for constructing measures using these data. Body weight measures from administrative data serve critical functions of monitoring patient health, evaluating interventions, and informing research. This study aimed to describe the algorithms used by researchers to construct and use weight measures. METHODS: A structured, systematic literature review of studies that constructed body weight measures from the Veterans Health Administration was conducted. Key information regarding time frames and time windows of data collection, measure calculations, data cleaning, treatment of missing and outlier weight values, and validation processes was collected. RESULTS: We identified 39 studies out of 492 nonduplicated records for inclusion. Studies parameterized weight outcomes as change in weight from baseline to follow-up (62%), weight trajectory over time (21%), proportion of participants meeting weight threshold (46%), or multiple methods (28%). Most (90%) reported total time in follow-up and number of time points. Fewer reported time windows (54%), outlier values (51%), missing values (34%), or validation strategies (15%). CONCLUSIONS: A high variability in the operationalization of weight measures was found. Improving methods to construct clinical measures will support transparency and replicability in approaches, guide interpretation of findings, and facilitate comparisons across studies.

Association of a Multisite Interprofessional Education Initiative With Quality of Primary Care.

Importance: Studies have shown that interprofessional education (IPE) improves learner proficiencies, but few have measured the association of IPE with patient outcomes, such as clinical quality. Objective: To estimate the association of a multisite IPE initiative with quality of care. Design, Setting, and Participants: This study used difference-in-differences analysis of US Department of Veterans Affairs (VA) electronic health record data from July 1, 2008, to June 30, 2015. Patients cared for by resident clinicians in 5 VA academic primary care clinics that participated in the Centers of Excellence in Primary Care Education (CoEPCE), an initiative designed to promote IPE among physician, nurse practitioner, pharmacist, and psychologist trainees, were compared with patients cared for by resident clinicians in 5 regionally matched non-CoEPCE clinics using data for the 3 academic years (ie, July 1 to June 30) before and 4 academic years after the CoEPCE launch. Analysis was conducted from January 18, 2018, to January 17, 2019. Main Outcomes and Measures: Among patients with diabetes, outcomes included annual hemoglobin A1c, poor hemoglobin A1c control (ie, <9% or unmeasured), and annual renal test; among patients 65 years and older, outcomes included prescription of high-risk medications; among patients with hypertension, outcomes included hypertension control (ie, blood pressure, <140/90 mm Hg); and among all patients, outcomes included timely mental health referrals, primary care mental health integrated visits, and hospitalizations for ambulatory care-sensitive conditions. Results: A total of 44 527 patients contributed 107 686 patient-years; 49 279 (45.8%) were CoEPCE resident patient-years (mean [SD] patient age, 59.3 [15.2] years; 26 206 [53.2%] white; 8073 [16.4%] women; mean [SD] patient Elixhauser comorbidity score, 12.9 [15.1]), and 58 407 (54.2%) were non-CoEPCE resident patient-years (mean [SD] patient age, 61.8 [15.3] years; 43 912 [75.2%] white; 4915 [8.4%] women; mean [SD] patient Elixhauser comorbidity score, 13.8 [15.7]). Compared with resident clinicians who did not participate in the CoEPCE initiative, CoEPCE training was associated with improvements in the proportion of patients with diabetes with poor hemoglobin A1c control (-4.6 percentage points; 95% CI, -7.5 to -1.8 percentage points; P < .001), annual renal testing among patients with diabetes (3.2 percentage points; 95% CI, 0.6 to 5.7 percentage points; P = .02), prescription of high-risk medications among patients 65 years and older (-2.3 percentage points; 95% CI, -4.0 to -0.6 percentage points; P = .01), and timely mental health referrals (1.6 percentage points; 95% CI, 0.6 to 2.6 percentage points; P = .002). Fewer patients cared for by CoEPCE resident clinicians had a hospitalization for an ambulatory care-sensitive condition compared with patients cared for by non-CoEPCE resident clinicians in non-CoEPCE clinics (-0.4 percentage points; 95% CI, -0.9 to 0.0 percentage points; P = .01). Sensitivity analyses with alternative comparison groups yielded similar results. Conclusions and Relevance: In this study, the CoEPCE initiative was associated with modest improvements in quality of care. Implementation of IPE was associated with improvements in patient outcomes and may potentiate delivery system reform efforts.

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.