Dual utilization of Medicare and VA outpatient care among Veterans with spinal cord injuries and disorders.

OBJECTIVE: Veterans with spinal cord injuries and disorders (SCI/D) utilizing Veterans Affairs healthcare facilities are also Medicare eligible. Use of multiple health care systems potentially duplicates or fragments care in this population; yet little is known about those using multiple systems. This study describes dual use of services paid for by VA and Medicare among Veterans with SCI/D. DESIGN: Retrospective, cross-sectional, observational study. PARTICIPANTS: Veterans with SCI/D (n = 13,902) who received healthcare services within the VA SCI System of Care and were eligible for or enrolled in Medicare in 2011. INTERVENTIONS: N/A. OUTCOME MEASURES: Patient characteristics, average number of visits and patient level frequencies of reasons for visits were determined for individuals within healthcare utilization (VA only, Medicare only, or dual VA/Medicare) groups. Multinomial logistic regression analyses were used to investigate associations of patient variables on dual use. RESULTS: 65.3% of Veterans with SCI/D were VA only users for outpatient encounters, 4.4% had encounters paid for by Medicare only, and 30.3% were dual users. Veterans were less likely to be VA only users if they were older than 69 and if they had been injured for greater than ten years. African American Veterans with SCI (compared to white) were more likely to be VA only users. CONCLUSION: A substantial number (∼30%) of Veterans with SCI/D are dual users. These numbers highlight the importance of improved strategies to coordinate care and increase health information sharing across systems.

Implementing patient safety and quality improvement in dermatology. Part 1: Patient safety science.

Patient safety (PS) and quality improvement (QI) have gained momentum over the last decade and are becoming more integrated into medical training, physician reimbursement, maintenance of certification, and practice improvement initiatives. While PS and QI are often lumped together, they differ in that PS is focused on preventing adverse events while QI is focused on continuous improvements to improve outcomes. The pillars of health care as defined by the 1999 Institute of Medicine report "To Err is Human: Building a Safer Health System" are safety, timeliness, effectiveness, efficiency, equity, and patient-centered care. Implementing a safety culture is dependent on all levels of the health care system. Part 1 of this CME will provide dermatologists with an overview of how PS fits into our current health care system and will include a focus on basic QI/PS terminology, principles, and processes. This article also outlines systems for the reporting of medical errors and sentinel events and the steps involved in a root cause analysis.

Implementing patient safety and quality improvement in dermatology. Part 2: Quality improvement science.

Quality improvement (QI) in medicine is reliant on a team-based approach and an understanding of core QI principles. Part 2 of this continuing medical education series outlines the steps of performing a QI project, from identifying QI opportunities, to carrying out successive Plan-Do-Study-Act cycles, to hard-wiring improvements into the system. QI frameworks will be explored and readers will understand how to interpret basic QI data.

Stroke Caregiver Depression: Qualitative Comparison of Treatment Responders and Nonresponders at 1 Year.

BACKGROUND: Mixed-method studies can shed light on the mechanisms through which interventions effectively reduce caregiver depression. OBJECTIVE: The objective of this qualitative study was to understand factors contributing to reduced depressive symptoms in stroke caregiver treatment responders compared with nonresponders. METHODS: A mixed-methods explanatory sequential design was used to assess cognitive behavioral coping use and helpfulness in reducing depression among experimental study treatment responders and nonresponders. Using purposive sampling at 1-year of caregiving, we selected responders who were not depressed or demonstrated reduction to probable depression and nonresponders whose scores indicated worsened or new depression. Participants responded to semistructured interviews on life changes and the use and helpfulness of intervention coping strategies. Thematic analysis identified codes and themes. RESULTS: Twelve of 25 participants were responders. We identified 2 overarching outcome themes: "It was about me, changing to make life better" (responders) and "Lamenting our changed lives" (nonresponders). Five subthemes related to coping were identified. Whereas responders coped actively and were less dependent on the counseling relationship, nonresponders were passive in coping and more dependent on the initial counseling relationship. Anger or previous psychologic treatment was found in more than a quarter of nonresponders and in no responders. Negative life change was found in 9 of 13 nonresponders compared with 1 responder. CONCLUSION: Findings support the helpfulness of cognitive behavioral coping. For many caregivers, engagement interviews and a more intense, longer intervention, such as stepped care and anger management, are indicated to mitigate treatment resistance and depressive symptoms, respectively.

Allied Health Professionals Utilization of Standard Measures: Assessing Measurement Practice in Physical Medicine and Rehabilitation.

Hundreds of standard measures have been developed to assess a diverse array of conditions, characteristics, and outcomes essential to the practice of medical rehabilitation. These measures provide a common metric needed to coordinate care, communicate with stakeholders, and assess treatment efficacy. Allied health professionals typically rely on functional measures that correspond to their discipline and scope of practice, yet functional outcomes may be dependent on psychological and social (psychosocial) factors that affect a client's capacity to engage and actively participate in their care. The purpose of this study was to describe and compare the use of standard measures by allied health professionals, assess attitudes and beliefs regarding the use of these measures, and identify opportunities to enhance the utilization of these measures in regular clinical practice. To these ends, a 144-item survey was developed and administered to a national sample of 92 clinicians (physical and occupational therapy, recreational therapy, speech-language pathology, psychology and social work). Results indicate that a majority of participants reported using both functional and psychosocial measures. The three most assessed domains across disciplines were physical function (74%), activities of daily living (67%), and vital signs (57%), while speech and vocational assessments were measured less frequently. Utilization of psychological and social measures overall ranged from 39% for measures of community participation to 14% for work and economic outcomes. As function often plays a critical role in recovery, opportunities to enhance care may be realized by using a more comprehensive assessment strategy that includes both functional and psychosocial measures.

Establishing the Factor Structure of a Health-Related Quality of Life Measurement System for Caregivers of Persons Living With Traumatic Brain Injury.

OBJECTIVES: To understand the factor structure of health-related quality of life specific to caregivers of people living with traumatic brain injury (TBI). DESIGN: Prospective, cross-sectional data collection. SETTING: Three TBI Model Systems rehabilitation hospitals, an academic medical center, and a military medical treatment facility. PARTICIPANTS: Caregivers (N=558) of people who have sustained a TBI (344 caregivers of civilians and 214 caregivers of service members or veterans; 85% women; 58% spouses; mean age, 46.12±14.07y) who have provided care for an average of 5.82±5.40 years. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: The Traumatic Brain Injury Caregiver Quality of Life (TBI-CareQOL) measurement system including 10 Patient-Reported Outcomes Measurement Information System item banks (anger, anxiety, depression, social isolation, sleep disturbance, fatigue, ability to participate in social roles and activities, satisfaction with social roles and activities, emotional support, informational support) and 5 TBI-CareQOL banks (feelings of loss-self, feelings of loss-person with TBI, feeling trapped, caregiver-specific anxiety, caregiver strain). RESULTS: Confirmatory factor analysis model fit indices were compared for 14 empirically derived and 5 theoretically derived models. Confirmatory factor analysis results indicated that the best model fit was for a 6-factor model with dimensions that included mental health, social support, social participation, social isolation, physical health, and caregiver emotion. CONCLUSIONS: Results indicated that a 6-factor model provided the best model fit for health-related quality of life in caregivers of individuals with TBI. These results have utility for both research and clinical applications. Establishing the TBI-CareQOL's factor structure provides preliminary evidence of the measurement system's construct validity, helps inform the selection of measures for specific research or clinical interventions, and informs the development of composite scores.

Health Care Utilization Among Homeless Veterans in Chicago.

INTRODUCTION: The U.S. Department of Veterans Affairs (VA), the single largest health care system in the United States, provides comprehensive medical and behavioral health services to more than 9 million Veterans. The size and scope of the VA's system of care allow health care providers, policymakers, and community stakeholders to conduct detailed analyses of health care utilization among Veterans; however, these analyses do not include health care encounters that occur outside VA. Although many Veterans obtain care in non-VA settings, understanding health care utilization among vulnerable populations of Veterans, including those who are homeless or at risk of becoming homeless, is needed to identify potential opportunities to enhance access and reduce fragmentation of care. MATERIALS AND METHODS: VA administrative data were merged with data from the Chicago HealthLNK Data Repository to identify Veterans eligible for VA services who were homeless, or at risk of becoming homeless, in the greater Chicago metropolitan area for the years 2010-2012. RESULTS: During the 3-year study period, about 208,554 Veterans were registered for care at two VA medical centers located in the City of Chicago and an adjacent suburb. Of those, 13,948 were identified as homeless or at risk of becoming homeless. Results suggest that 17% (n = 2,309) of Veterans in this sample received some or all of their care in the community. Much of the care these Veterans received was for chronic health conditions, substance use, and mental health disorders. CONCLUSIONS: Veterans eligible for VA servicers who are homeless, or at risk of becoming homeless, frequently sought care in the community for a variety of chronic health conditions. Health information exchanges and partner-based registries may represent an important tool for identifying vulnerable Veteran populations while reducing duplication of care.

Evaluating the Use of Medicare Part D in the Veteran Population With Spinal Cord Injury/Disorder.

OBJECTIVE: To examine the different sources of medications, the most common drug classes filled, and the characteristics associated with Medicare Part D pharmacy use in veterans with spinal cord injury/disorder (SCI/D). DESIGN: Retrospective, cross-sectional, observational study. SETTING: Outpatient clinics and pharmacies. PARTICIPANTS: Veterans (N=13,442) with SCI/D using Medicare or Veteran Affairs pharmacy benefits. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Characteristics and top 10 most common drug classes were examined in veterans who (1) used VA pharmacies only; (2) used both VA and Medicare Part D pharmacies; or (3) used Part D pharmacies only. Chi-square tests and multinomial logistic regression analyses were used to determine associations between various patient variables and source of medications. Patient level frequencies were used to determine the most common drug classes. RESULTS: A total of 13,442 veterans with SCI/D were analyzed in this study: 11,788 (87.7%) used VA pharmacies only, 1281 (9.5%) used both VA and Part D pharmacies, and 373 (2.8%) used Part D pharmacies only. Veterans older than 50 years were more likely to use Part D pharmacies, whereas those with traumatic injury, or secondary conditions, were less associated with the use of Part D pharmacies. Opioids were the most frequently filled drug class across all groups. Other frequently used drug classes included skeletal muscle relaxants, gastric medications, antidepressants (other category), anticonvulsants, and antilipemics. CONCLUSIONS: Approximately 12% of veterans with SCI/D are receiving medication outside the VA system. Polypharmacy in this population of veterans is relatively high, emphasizing the importance of health information exchange between systems for improved care for this medically complex population.

Scoping review to develop common data elements for lumbar spinal stenosis.

BACKGROUND CONTEXT: Common data elements (CDE) represent an important tool for understanding and classifying health outcomes across settings. Although CDEs have been developed for a number of disorders, to date CDEs for lumbar spinal stenosis (LSS) have not been fully developed. To facilitate the identification of CDEs and measures to assess them, this technical study leverages the International Classification of Functioning, Disability and Health (ICF), peer-reviewed research, and a panel of experts to identify CDEs specific to LSS. PURPOSE: The study aimed to define CDEs for disease characteristics and outcomes of LSS using the World Health Organization's ICF taxonomy, and to facilitate the selection of assessment instruments for research and clinical care. DESIGN: This is a scoping review using a modified Delphi approach with a technical expert panel composed of clinicians and scientists representing the academia, policy and advocacy stakeholders, and professional associations with expertise in LSS. METHODS: This is a scoping review to identify measures that assess LSS symptoms. Thirty-one subject matter experts (SMEs) prioritized ICF codes and evaluated instruments measuring specific domains. We used a modified Delphi technique to evaluate item-level content and achieve consensus. RESULTS: SMEs prioritized 53 ICF codes; 3 received 100% endorsement, 27 received ≥90% endorsement, whereas the remaining 23 received ≥80% endorsement. Prioritized ICF codes represent diverse domains, including pain, activities and participation, and emotional well-being. The review yielded 58 instruments; we retained 24 for content analysis. CONCLUSIONS: The retained instruments adequately represent the ICFs activities and participation, and body function domains. Body structure and environmental factors were assessed infrequently. Adoption of these CDEs may guide clinical decision making and facilitate comparative effectiveness trials for interventions focused on LSS.

Development and use of a knowledge translation tool: the rehabilitation measures database.

Clinical translation of research evidence is a challenge for rehabilitation clinicians. Publicly accessible and free, online educational resources that summarize research evidence can support implementation of research evidence into practice. Several online resources have been developed recently to overcome common knowledge translation barriers. The Rehabilitation Measures Database (RMD) is a free, web-based searchable database of standardized instruments that was designed to support knowledge translation. It helps clinicians select valid and sensitive instruments for screening patients, monitoring progress, and assessing rehabilitation outcomes. The RMD was developed using feedback from focus groups and beta-test participants. Since its launch in 2011, RMD use has grown to an average of 1851 hits per day from 168 countries. As of September 2013, 202 instrument summaries are viewable in the RMD. Most summaries are linked to copies of the instrument or to purchase instructions. A challenge in updating and expanding the RMD is securing the resources to ensure its future. Collaborative relationships with professional associations and graduate programs in the health sciences are critical in sustaining this resource.

The stroke caregiver unmet resource needs scale: development and psychometric testing.

The purposes of this study were to develop and validate a measure of unmet resource needs of the caregivers of survivors of stroke and to describe the caregivers' unmet needs during 1 year. A longitudinal, descriptive design was used to test the reliability and validity of the Unmet Resource Needs (URN) measure. Item development was based on literature review and preliminary study findings. A stress and coping conceptual model framed the hypotheses. Psychometric testing was based on 6-month postdischarge data (n = 166). Content and structural construct validity, internal consistency reliability through 1 year, and concurrent validity were tested. Change in URN over time was examined. Content validity was supported by floor and ceiling effects less than 5%. Principal axis factoring yielded a 12-item, two-factor solution reflecting general and technology unmet needs. Internal consistency reliability was satisfactory for the total scale and subscales at all times, excepting the baseline three-item technology scale (α = .56). Concurrent validity was supported by significant correlations with model constructs (threat, positive problem solving, depression, preparedness; p < .01) in the expected direction. Functional status and resource use were not associated with the URN. Repeated measures analysis of variance (n = 123) indicated a significant decrease in unmet needs from baseline to 3, 6, and 12 months postdischarge (p < .001). Nevertheless, 42% reported one or more unmet needs at year 1. Assessment and counseling on unmet needs is indicated throughout the caregiving trajectory to reduce negative outcomes.

A problem-solving early intervention for stroke caregivers: one year follow-up.

PURPOSE: The study purposes were to assess the efficacy of a caregiver problem-solving intervention (CPSI) on stroke caregiver physical and psychosocial adaptation compared with a wait-list control (WLC) treatment, and to assess the mediation effects of coping on outcomes. METHODS: A stress and coping model guided the study design. Outcomes were depression, anxiety, preparedness, life changes, and family functioning. CPSI started during acute rehabilitation and continued 3 months postdischarge. Data were collected at baseline (T1), postintervention (T2), and 6 (T3) and 12 months postdischarge (T4). RESULTS: Of 255 caregivers, 75% were depressed at baseline. Repeated measures ANOVA of study completers (n = 121) indicated improved T2 depression, life change, and health (ps < .04) favoring the CPSI group. Improvements faded by 6 months. Although no group differences in outcomes were found in the intention-to-treat analysis, growth curve modeling indicated a difference in depression rate of change, favoring the CPSI (p = .04). Perceived health, threat appraisal and rational problem-solving were significant mediators (ps < .05). CONCLUSIONS: Findings provide direction for future interventions to promote and sustain healthy caregiver adaptation.