Development of a progressive audiologic tinnitus management program for Veterans with tinnitus.

Tinnitus is the most prevalent service-connected disability awarded to Veterans. However, clinical protocols for management of tinnitus have been inconsistent across Department of Veterans Affairs (VA) medical centers. A study was funded to develop and pilot test a protocol to provide tinnitus services consistently across VA audiology clinics. Drawing on a series of prior VA and external research projects, a clinical model was formulated, supporting materials in multimedia were developed, and a pilot study was conducted. Five hierarchical levels of care were defined and labeled the Progressive Audiologic Tinnitus Management (PATM) model. The model facilitates access to medical services for tinnitus and includes detailed protocols for evaluation, education, and counseling of patients. Patients at each level of care have the option to "progress" to the next level of PATM if further services are required. Clinical procedures were defined for each level and materials were produced for audiologists and patients. The PATM model was then piloted with clinical patients at the James A. Haley Veterans' Hospital (JAHVH) in Tampa, Florida. Throughout the pilot study, feedback from patients and clinicians was carefully noted. Training materials for audiologists, incorporation of the protocol into clinic activities, and patient outcomes were evaluated. The model was implemented within the JAHVH Audiology Clinic and to assist Veterans with tinnitus management. The most notable finding was how little tinnitus-specific intervention was required for the majority of patients. This finding supports a clinical model that offers stepped-care ("progressive") levels of care until tinnitus management is achieved by the patient.

Pilot study to develop telehealth tinnitus management for persons with and without traumatic brain injury.

Tinnitus, or "ringing in the ears," affects 10%-15% of adults; cases can be problematic and require lifelong management. Many people who have experienced traumatic brain injury (TBI) also experience tinnitus. We developed Progressive Tinnitus Management (PTM), which uses education and counseling to help patients learn how to self-manage their reactions to tinnitus. We adapted PTM by delivering the intervention via telephone and by adding cognitive-behavioral therapy. A pilot study was conducted to evaluate the feasibility and potential efficacy of this approach for individuals with and without TBI. Participants with clinically significant tinnitus were recruited into three groups: probable symptomatic mild TBI (n = 15), moderate to severe TBI (n = 9), and no symptomatic TBI (n = 12). Participants received telephone counseling (six sessions over 6 months) by an audiologist and a psychologist. Questionnaires were completed at baseline, 12 weeks, and 24 weeks. All groups showed trends reflecting improvement in self-perceived functional limitations due to tinnitus. A follow-up randomized clinical study is underway.

Using formative evaluation in an implementation project to increase vaccination rates in high-risk veterans: QUERI Series.

BACKGROUND: Implementation of research into practice in health care systems is a challenging and often unsuccessful endeavor. The United States Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) research teams include formative evaluations (FE) in their action-oriented VA implementation projects to identify critical information about the processes of implementation that can guide adjustments to project activities, in order to better meet project goals. This article describes the development and use of FE in an action-oriented implementation research project. METHODS: This two-year action-oriented implementation research project was conducted at 23 VA Spinal Cord Injury (SCI) Centers, and targeted patients, staff and the system of care, such as administration and information technology. Data for FE were collected by electronic and paper surveys, semi-structured and open-ended interviews, notes during conference calls, and exchange of e-mail messages. Specific questions were developed for each intervention (designed to improve vaccination rates for influenza in veterans with spinal cord injury and disorder); informants were selected for their knowledge of interventions and their use in SCI Centers. RESULTS: Data from FE were compiled separately for each intervention to describe barriers to progress and guide adjustments to implementation activities. These data addressed the processes of implementing the interventions, problem-solving activities and the status of interventions at SCI Centers. CONCLUSION: Formative evaluations provided the project team with a broad view of the processes of implementing multi-targeted interventions as well as the evolving status of the related best practice. Using FE was useful, although the challenges of conducting FE for non-field researchers should be addressed. Work is needed to develop methods for conducting FE across multiple sites, as well as acknowledging variations in local contexts that affect implementation of interventions.

Role of "external facilitation" in implementation of research findings: a qualitative evaluation of facilitation experiences in the Veterans Health Administration.

BACKGROUND: Facilitation has been identified in the literature as a potentially key component of successful implementation. It has not, however, either been well-defined or well-studied. Significant questions remain about the operational definition of facilitation and about the relationship of facilitation to other interventions, especially to other change agent roles when used in multi-faceted implementation projects. Researchers who are part of the Quality Enhancement Research Initiative (QUERI) are actively exploring various approaches and processes, including facilitation, to enable implementation of best practices in the Veterans Health Administration health care system - the largest integrated healthcare system in the United States. This paper describes a systematic, retrospective evaluation of implementation-related facilitation experiences within QUERI, a quality improvement program developed by the US Department of Veterans Affairs. METHODS: A post-hoc evaluation was conducted through a series of semi-structured interviews to examine the concept of facilitation across several multi-site QUERI implementation studies. The interview process is based on a technique developed in the field of education, which systematically enhances learning through experience by stimulating recall and reflection regarding past complex activities. An iterative content analysis approach relative to a set of conceptually-based interview questions was used for data analysis. FINDINGS: Findings suggest that facilitation, within an implementation study initiated by a central change agency, is a deliberate and valued process of interactive problem solving and support that occurs in the context of a recognized need for improvement and a supportive interpersonal relationship. Facilitation was described primarily as a distinct role with a number of potentially crucial behaviors and activities. Data further suggest that external facilitators were likely to use or integrate other implementation interventions, while performing this problem-solving and supportive role. PRELIMINARY CONCLUSIONS: This evaluation provides evidence to suggest that facilitation could be considered a distinct implementation intervention, just as audit and feedback, educational outreach, or similar methods are considered to be discrete interventions. As such, facilitation should be well-defined and explicitly evaluated for its perceived usefulness within multi-intervention implementation projects. Additionally, researchers should better define the specific contribution of facilitation to the success of implementation in different types of projects, different types of sites, and with evidence and innovations of varying levels of strength and complexity.

The role of formative evaluation in implementation research and the QUERI experience.

This article describes the importance and role of 4 stages of formative evaluation in our growing understanding of how to implement research findings into practice in order to improve the quality of clinical care. It reviews limitations of traditional approaches to implementation research and presents a rationale for new thinking and use of new methods. Developmental, implementation-focused, progress-focused, and interpretive evaluations are then defined and illustrated with examples from Veterans Health Administration Quality Enhancement Research Initiative projects. This article also provides methodologic details and highlights challenges encountered in actualizing formative evaluation within implementation research.

Lessons learned about implementing research evidence into clinical practice. Experiences from VA QUERI.

The mission of the Veterans Health Administration's (VHA) quality enhancement research initiative (QUERI) is to enhance the quality of VHA health care by implementing clinical research findings into routine care. This paper presents lessons that QUERI investigators have learned through their initial attempts to pursue the QUERI mission. The lessons in this paper represent those that were common across multiple QUERI projects and were mutually agreed on as having substantial impact on the success of implementation. While the lessons are consistent with commonly recognized ingredients of successful implementation efforts, the examples highlight the fact that, even with a thorough knowledge of the literature and thoughtful planning, unexpected circumstances arise during implementation efforts that require flexibility and adaptability. The findings stress the importance of utilizing formative evaluation techniques to identify barriers to successful implementation and strategies to address these barriers.

Issues of importance to patients seeking care from members of the AOFAS: a preliminary report of the outcomes committee of the AOFAS.

BACKGROUND: The purpose of this multi-center study was to examine the outcomes of importance for patients seeking treatment for foot and ankle disorders. An improved understanding of patient outcome preferences will assist surgeons in improving patient satisfaction. METHODS: An open-ended priority function questionnaire was administered to 235 patients presenting as new patients to five different outpatient locations. The questionnaire was designed to identify activities of importance to patients and was based on the McMaster Toronto Arthritis (MACTAR) patient preference disability questionnaire. Subjects were asked to list the specific activities that were limited by their condition. Open-ended answers were written on five blank spaces and then ranked as to their importance. The visual analog pain scale was recorded as a measure of the severity of the patient's symptoms at the time the response was made. The outpatient settings were two university hospitals, two private offices with academic affiliation, and one private office. Two hundred thirty-five surveys were collected between September and November of 2000; 227 surveys were acceptable for analysis. The respondents included 132 females (58.1%), 94 males (41.4%) and one patient who did not specify his gender (0.4%). The mean age was 45.8 (range 18 to 83) years. RESULTS: Average pain at the time of assessment was 2.7 on a scale of 0 to 9 and was reported to increase to 4.8 in a typical day. The most frequently ranked limitations were difficulty with walking (159), running (73), standing (55), and exercise (54). Walking also was the issue ranked as the highest priority (77 of 159), while running (11 of 73), standing (10 of 55) and exercise (3 of 54) were assigned lesser priority values. Only 68 of 227 respondents failed to list walking as an issue. Work, sleep, and social activities were not commonly cited as issues of importance. CONCLUSION: Patients presenting to office practices identified as specializing in foot and ankle disorders are predominantly middle-aged women in mild to moderate pain. Walking is the function most frequently identified as a problem and ranked as the highest priority for improvement. Social limitations were unlikely to be named as a limitation in this population.

Staff influenza vaccination: lessons learned.

Respiratory complications are the top cause of morbidity and mortality among persons with spinal cord injury/disorders (SCI/D). One method to protect patients with SCI/D from complications is to reduce exposure to influenza through vaccination of health care workers (HCWs). This study examined the extent to which HCWs promoted safe, quality care for patients with SCI/D as related to their beliefs about, and receipt/non-receipt, of influenza vaccination. Surveys were distributed to HCWs at 23 SCI/D centers within the Veterans Health Administration (VHA). Vaccination rates, reasons for receipt/non-receipt, and possible associations were examined. The response rate was 53% (n = 820). The SCI/D staff influenza vaccination rate was 50%, with the lowest rates among nurses. The most common reason for vaccination was self-protection. The most common reason for not being vaccinated was concern about side effects. Of providers who recommended the vaccine to patients, significantly more (60%) received the vaccine; p = .000.

Understanding a VA preventive care clinical reminder: lessons learned.

This article presents "lessons learned" about using a computerized clinical reminder (CCR) for influenza in spinal cord injury (SCI) centers in the Veterans Health Administration (VHA). Although research has shown that use of a CCR increases adherence to preventive care measures, technical and administrative issues affect its use by nurses. CCR is a term for a reminder in a patient's electronic medical record to initiate a preventive care activity. Qualitative data about using the CCR for influenza were collected from staff using semi-structured interviews, e-mail questionnaires, and telephone calls. Once issues were identified, follow-up activities included discussions with local and national experts and problem-solving activities. The investigators identified two national issues about the CCR for influenza: the taxonomy to identify patients with SCI, and the "due date" for influenza vaccine. Local issues included authorization for nurses to use the CCR, ease of use of the CCR for inpatients and outpatients, connectivity of the medication tracking program for inpatients with the electronic medical record, configuration of the CCR in the electronic medical record, training, and technical support.

Attitudes and practices regarding influenza vaccination among healthcare workers providing services to individuals with spinal cord injuries and disorders.

OBJECTIVE: To examine influenza vaccination status and predictors for vaccine receipt among healthcare workers (HCWs) caring for patients with spinal cord injuries and disorders. DESIGN: Cross-sectional, nationwide anonymous survey. SETTING: Twenty-three Veterans Affairs spinal cord injury centers. PARTICIPANTS: One thousand five hundred fifty-six HCWs. METHODS: The primary outcome was staff vaccination status. Independent variables included staff demographic and employment characteristics, health status, attitudes and beliefs about the vaccine, and implications for its use. RESULTS: The staff vaccination rate was 51%. Leading motivators of vaccine receipt were self-protection (77%) and patient protection (49%). The most common reasons for nonreceipt were concerns about side effects (49%), preventive quality (20%), and inconvenience (14%). Logistic regression results suggested that age of 50 years or older (OR, 1.47; P = .021), male gender (OR, 2.50; P < .001), strong belief in vaccine effectiveness (OR, 19.03; P = .008), and importance of HCW vaccination (OR, 20.50; P = .005) significantly increased the probability of vaccination. Recommending the vaccine to coworkers, patients, or patients' families was also associated with HCW vaccination (OR, 3.20; P < .001). Providers who did not believe the vaccine was protective (P < .001) or effective (P < .001) were less likely to recommend it to patients. CONCLUSIONS: Strategies to increase vaccination rates among HCWs should address concerns about side effects, effectiveness, and protective value of the vaccine and access to it. The impact of provider recommendations should be stressed. Vaccination and subsequent prevention of illness may limit morbidity and mortality, thus benefiting HCWs, healthcare facilities, and patients.

A comparison of multiple data sources to identify vaccinations for veterans with spinal cord injuries and disorders.

Monitoring vaccination activity requires regular access to information about patient vaccination status. This report describes our experience using multiple Department of Veterans Affairs (VA) data sources to determine availability and completeness of vaccination information for veterans with spinal cord injuries and disorders (SCI&D). Administrative and clinical databases were limited to coding vaccine administration, undercounted vaccinations, and were unable to account for whether the vaccine was offered and the reasons for nonreceipt. Medical record review provided more detail but was labor intensive and costly. Patient surveys provided the richest information but were costly, time-consuming, and based on a sample of patients. Agreement was poor between data sources. This report suggests that while VA is well positioned to use national databases for clinical care decisions and to inform policy, vaccination data were incomplete. Electronic records must include data that are consistently entered and validated before they can be useful for care management and decision making.

Influenza vaccination among veterans with spinal cord injury: Part 1. A survey of attitudes and behavior.

BACKGROUND/OBJECTIVE: Persons with spinal cord injury and disorders (SCID) are at increased risk of developing influenza, pneumonia, and ensuing complications. Influenza vaccine has been shown to be effective, yet vaccination rates have been low in this population. To improve these rates, barriers and facilitators to receiving influenza vaccine in this population were identified. METHODS: A cross-sectional telephone survey was conducted with a convenience sample of patients at 13 Department of Veterans Affairs (VA) Spinal Cord Injury (SCI) Centers between September and November 2000. Survey questions assessed perceptions regarding the influenza vaccine. RESULTS: Participants interviewed (N = 377) had a mean age of 58.6 years and were predominantly male and white. Most had had received the influenza vaccine at some time in the past; however, 35% had not received it in the previous year. The most common reason reported for not being vaccinated was the belief that it was not important. Those who knew the best time to be vaccinated were more likely to have been vaccinated the previous year (OR = 3.57, 95%, CI: 2.12-6.01). Other predictors of vaccination included being married, being aged 65 and older, and being aware that the vaccine was a good way to prevent some pulmonary problems that can result from influenza. CONCLUSIONS: Barriers to vaccination include poor understanding of the seriousness of influenza and of the vulnerability of someone with SCID to respiratory complications. Availability of the influenza vaccine at VA facilities and knowledge of when to be vaccinated were facilitators. Providers should use every opportunity to vaccinate patients and provide education about the value of influenza vaccination and when to be vaccinated.

Influenza vaccination among veterans with spinal cord injury: Part 2. Increasing vaccination rates.

BACKGROUND/OBJECTIVE: Respiratory complications are the leading cause of morbidity and mortality among individuals with spinal cord injury (SCI). Influenza vaccination is effective in reducing the likelihood of contracting influenza and of subsequent respiratory complications, hospitalizations, and deaths. Historically, vaccination rates for veterans with SCI treated in Veterans Affairs (VA) facilities have been low. The objective of this study was to increase vaccination rates in this population using a multipronged strategy. METHODS: A quasi-experimental design involving 2,284 veterans treated at 8 VA SCI Centers was used. Patients at 4 centers received reminder letters and educational materials tailored to SCI. Provider education included mailed reminders and posters in SCI clinical areas. Clinical champions were identified at each site. Four other centers, matched to the study sites in program size and prior vaccination rates, served as comparison sites providing usual care. Vaccination rates were assessed using mailed surveys with telephone follow-up. RESULTS: The influenza vaccination rate was significantly higher in the intervention group than in the comparison group (60.5% vs 54.3%; P = 0.01 ). Vaccine recipients were older than nonrecipients (mean age 60.8 vs 53.1 years; P < 0.0001). Reasons for not receiving a vaccination included refusal, feeling that being vaccinated was not worth the trouble, and not believing that the vaccine would prevent influenza. CONCLUSIONS: Use of low-cost mailed reminders and educational materials resulted in significantly higher vaccination rates. Further efforts to reach targeted subgroups of nonrecipients, such as patients who are younger or from an ethnic minority, are warranted.