Patient Surgical Outcomes When Surgery Residents Are the Primary Surgeon by Intensity of Surgical Attending Supervision in Veterans Affairs Medical Centers.

Objective: Using health records from the Department of Veterans Affairs (VA), the largest healthcare training platform in the United States, we estimated independent associations between the intensity of attending supervision of surgical residents and 30-day postoperation patient outcomes. Background: Academic leaders do not agree on the level of autonomy from supervision to grant surgery residents to best prepare them to enter independent practice without risking patient outcomes. Methods: Secondary data came from a national, systematic 1:8 sample of n = 862,425 teaching encounters where residents were listed as primary surgeon at 122 VA medical centers from July 1, 2004, through September 30, 2019. Independent associations between whether attendings had scrubbed or not scrubbed on patient 30-day all-cause mortality, complications, and 30-day readmission were estimated using generalized linear-mixed models. Estimates were tested for any residual confounding biases, robustness to different regression models, stability over time, and validated using moderator and secondary factors analyses. Results: After accounting for potential confounding factors, residents supervised by scrubbed attendings in 733,997 nonemergency surgery encounters had fewer deaths within 30 days of the operation by 14.2% [0.3%, 29.9%], fewer case complications by 7.9% [2.0%, 14.0%], and fewer readmissions by 17.5% [11.2%, 24.2%] than had attendings not scrubbed. Over the 15 study years, scrubbed surgery attendings may have averted an estimated 13,700 deaths, 43,600 cases with complications, and 73,800 readmissions. Conclusions: VA policies on attending surgeon supervision have protected patient safety while allowing residents in selected teaching encounters to have limited autonomy from supervision.

75 Years of the Historic Partnership Between the VA and Academic Medical Centers.

Background: The US Department of Veterans Affairs (VA) conducts the largest health professions education program in the country in partnership with academic medical, nursing, and associated health programs across the nation. After World War II, the VA was pressed to meet the increasing population of veterans needing health care and faced challenges in recruiting clinicians. Observations: The passage of 2 legislative actions, the Servicemen's Readjustment Act and Public Law 79-293, and a key policy memorandum set the foundation for the partnership between the VA and academic medical centers that led to improved medical care for veterans and expansion of health professions education for the VA and the nation. Conclusions: Since passage of these actions, the VA-academic health professions education partnership has grown to involve 113,000 trainees rotating through 150 VA medical centers annually from more than 1400 colleges and universities.

Health Systems Education Leadership: Learning From the VA Designated Education Officer Role.

Background: The US Department of Veterans Affairs designated education officer (DEO) is a unique facility-based leadership role responsible for training of > 40 health professions in cooperation with affiliated academic institutions. Methods: We conducted mixed methods analyses of data from a DEO needs assessment. Quantitative analysis identified differences between DEOs who are physicians and DEOs who are other professions on role characteristics and self-perceived task effectiveness. Qualitative analysis using rapid analysis procedures was applied to open-ended responses on facilitators and barriers. Results: Responses were received from 127 DEOs (96% response rate). About 80% were physicians. There were no statistically significant differences between physician and other professional DEOs self-ratings for general tasks. For profession-specific tasks, physician DEOs were significantly less confident than other professional DEOs in working with associated health (P < .001-.01) and nurse training programs (P < .001-.03). DEOs identified multiple facilitators that assist their individual effectiveness (eg, training, mentorship, communication) and common barriers (eg, not enough staff). Conclusions: Our findings are supportive of individuals from various health disciplines serving in the DEO role with responsibilities that span multiple health profession training programs. Future quantitative and qualitative work should include additional measures of individual and organizational characteristics, and actual measures of educational effectiveness.

Assessing Physician Resident Contributions to Outpatient Clinical Workload.

BACKGROUND: Graduate medical education is centered in hospitals despite a care system where patients mostly receive their care in an outpatient setting. Such gaps may exist because of inadequate funding for residency positions in community and hospital-based clinics. OBJECTIVE: Determine if physician residents' contribution to outpatient workload offsets their costs for supervision, salary, and fringe benefits as residents acquire skills to become independent practitioners. RESEARCH DESIGN: VA's electronic patient records from 2005 through 2018 were analyzed using generalized linear mixed models to estimate resident and staff contributions to workload in relative value units. MEASURES: Resident participation rate is resident contributed workload net of supervision as a percent of total clinic workload. Productivity is per diem resident workload as a percent of per diem staff workload. Efficiency is per dollar resident workload as a percent of per dollar staff workload. Progressive independence is annual rate of change in resident productivity. RESULTS: Average participation rates varied by specialty from 6% to 22%, with 11% (primary care) and 13% (psychiatry). Productivity rates ranged from 21% to 94%, with 57% (primary care) and 61% (psychiatry). Efficiency rates varied from 0.63 to 3.81, with 1.69 (primary care), 1.89 (psychiatry). Progressive independence rates varied from 2.7%/year (psychiatry) to 39.7%/year (specialty care). CONCLUSIONS: Although residents rotating through most VA clinics generate revenue to cover their direct costs as they learn, some federal subsidies may be necessary to encourage hospital- and community-based clinics to accept residents from the less profitable primary care and mental health specialties.

Perspectives on Training and Working in the VHA: Implications for Primary Care Physician Recruitment and Retention.

PURPOSE: The primary care physician shortage in the United States presents significant challenges for health systems seeking to maintain a sufficient primary care workforce. Perspectives on training or working in primary care in the Veterans Health Administration (VHA) may yield insights into strategic recruitment to make the VHA and other health systems more attractive to primary care physicians. The authors sought to understand the experiences of resident and staff physicians with limited tenure within VHA primary care to identify factors to guide health systems in improving recruitment and retention. METHOD: This qualitative exploratory study was conducted from June 2018 to October 2019 with 24 internal medicine residents and 30 staff physicians in VHA primary care. Heterogeneity was ensured by sampling for geographical region, rurality, and gender within each cohort. The authors conducted semistructured interviews to ascertain perspectives on training and employment preferences at VHA and non-VHA sites. Combined content analysis was used to generate findings. RESULTS: The authors identified 4 key themes, centered around shared values and the VHA's mission-driven culture: the VHA "community" was perceived as unique and a major contributor to job satisfaction; facility-level leadership support was important to perceptions of workplace culture around harassment; the VHA primary care delivery model allowed residents and staff physicians to get patients needed care but did not always live up to its potential; and VHA employment was better than expected, but the process of getting hired was a challenge. CONCLUSIONS: Mission and workplace culture may serve important roles in the desirability of health systems for prospective physicians and the job satisfaction of physicians who work in these systems. Physician recruitment efforts based on these attributes may yield the most success in maintaining a sufficient physician workforce.

Veterans Affairs Graduate Medical Education Expansion Addresses U.S. Physician Workforce Needs.

The United States has a well-trained, highly specialized physician workforce yet continues to have care gaps across the nation. Deficiencies in primary care and mental health specialties are most frequently cited, though critical shortages in multiple disciplines exist, particularly in rural areas. Sponsoring institutions of physician graduate medical education (GME) have created rural residency tracks with modest federal funding and minimal incentives, though efforts targeting shortages in these specialties and geographic locations have been limited. In response to access problems in the Veterans Health Administration, Department of Veterans Affairs (VA), the second largest federal funder of GME with the most expansive clinical education platform, Congress passed the Veterans Access, Choice, and Accountability Act of 2014. This act directed the VA and provided funding to establish 1,500 new positions, a 15% expansion of VA-funded positions at the time. Priority for position selection was given to primary care, mental health, and any other specialties the secretary of VA determined appropriate. Importantly, priority was also given to VA facilities with documented physician shortages, those that did not have GME training programs, those in communities with high concentrations of veterans, and those in health profession shortage areas. Many rural facilities match this profile and were targeted for this initiative. At the conclusion of fiscal year 2021, 1,490 positions had been authorized, and 21 of the 22 VA medical centers previously without GME activity had added residents or were planning to soon. Of the authorized positions, 42% are in primary care, 24% in mental health, and 34% in critically needed additional specialties. Targeted GME expansion in the VA, the largest integrated health care system in the nation, has been successful in addressing physician GME training that aligns with physician shortages and may serve as a model to address national physician specialty and geographic workforce needs.

Program Profile: The Expansion of Associated Health Training in the VA.

PURPOSE: Approximately 21,000 US Department of Veterans Affairs (VA) health professions trainees per year are in associated health (AH) occupations. We describe the VA Office of Academic Affiliation's expansion of AH education in recent years and highlight the importance of increasing AH education broadly in the United States. Our focus is on the growing role of AH education in the VA over the past decade by describing the demand for AH professionals in all clinical settings; scope of funded AH training in the VA; and targeted AH education expansion efforts. OBSERVATIONS: The VA provides clinical training for more than 40 AH professions and provides funding for 17 of these professions. Expansion efforts in AH over the past 10 years have yielded a 33% increase in stipend-funded positions and targeted interprofessional training, VA strategic initiatives, rural populations, and conversion of pregraduate-degree positions to postgraduate-degree positions. CONCLUSIONS: In order to meet the complex health care needs of our nation, continued attention to interprofessional care and health professions education is of paramount importance. The VA has worked to address these broad needs and to meet the needs of veterans through increasing stipend-funded AH training positions by 33% and directly targeting high-need clinical areas. Ongoing expansion is anticipated in the areas of postgraduate-degree training and rural training.

Honoring those who have served: how can health professionals provide optimal care for members of the military, veterans, and their families?

With over one million service members separating from the military over the next several years, it seems prudent to ask whether U.S. health care professionals and systems of care are prepared to evaluate and treat the obvious and more subtle injuries ascribed to military deployment and combat. The authors suggest that several systemic interventions-adding military health history sections to electronic health records, history and physical diagnosis textbooks, and licensing exams while also ensuring that this content is adequately covered in undergraduate and graduate health professional training-will enable all health care professionals to provide service members and veterans with the high-quality care that they deserve. The authors also highlight the U.S. Department of Veterans Affairs' recent innovations in education and care delivery, which are enhancing the education of thousands of students and residents, who will be better prepared to care for veterans after receiving this training.

A formalized teaching, practice, and research partnership with the Veterans Affairs North Texas Health Care System: a model for advancing academic partnerships.

In 1999, the Texas Tech University Health Sciences Center School of Pharmacy expanded its Dallas/Fort Worth presence by creating a regional campus for pharmacy students in their third and fourth years (P3 and P4 years) of the program. This expansion was driven by the need for additional practice sites. The VANTHCS was an obvious choice for the school due to the similarity of missions for clinical practice, education, and research. The VANTHCS and pharmacy school renovated a 4,000 square foot building, which includes classrooms, conference rooms, a student lounge, and faculty offices (expanded to 8,000 square feet in 2003). To date, the school has invested $1 million in the building. From a practice perspective, VANTHCS purchases faculty professional services from the school to augment its clinical specialist staff. These professional practice contracts provide VANTHCS with 12 additional clinical pharmacy specialists serving 50% of their time in multiple specialty areas. The collaboration has also allowed for expansion of clinical teaching, benefitting both institutions. In addition to the pharmacy student interns on P3 and P4 practice experiences, the collaboration allows for 8 to 10 postgraduate pharmacy residents to train with VANTHCS clinical specialists and school faculty members each year. The VANTHCS/pharmacy school collaboration has clearly enhanced the ability of both institutions to exceed their teaching, research, and practice goals in a cost-effective manner.

Surgical resident supervision in the operating room and outcomes of care in Veterans Affairs hospitals.

BACKGROUND: There has been concern that a reduced level of surgical resident supervision in the operating room (OR) is correlated with worse patient outcomes. Until September 2004, Veterans' Affairs (VA) hospitals entered in the surgical record level 3 supervision on every surgical case when the attending physician was available but not physically present in the OR or the OR suite. In this study, we assessed the impact of level 3 on risk-adjusted morbidity and mortality in the VA system. METHODS: Surgical cases entered into the National Surgical Quality Improvement Program database between 1998 and 2004, from 99 VA teaching facilities, were included in a logistic regression analysis for each year. Level 3 versus all other levels of supervision were forced into the model, and patient characteristics then were selected stepwise to arrive at a final model. Confidence limits for the odds ratios were calculated by profile likelihood. RESULTS: A total of 610,660 cases were available for analysis. Thirty-day mortality and morbidity rates were reported in 14,441 (2.36%) and 63,079 (10.33%) cases, respectively. Level 3 supervision decreased from 8.72% in 1998 to 2.69% in 2004. In the logistic regression analysis, the odds ratios for mortality for level 3 ranged from .72 to 1.03. Only in the year 2000 were the odds ratio for mortality statistically significant at the .05 level (odds ratio, .72; 95% confidence interval, .594-.858). For morbidity, the odds ratios for level 3 supervision ranged from .66 to 1.01, and all odds ratios except for the year 2004 were statistically significant. CONCLUSIONS: Between 1998 and 2004, the level of resident supervision in the OR did not affect clinical outcomes adversely for surgical patients in the VA teaching hospitals.

Effects of sustained audit/feedback on self-reported health status of primary care patients.

PURPOSE: Because limited audit/feedback of health status information has yielded mixed results, we evaluated the effects of a sustained program of audit/feedback on patient health and satisfaction. METHODS: We conducted a group-randomized effectiveness trial in which firms within Veterans Administration general internal medicine clinics served as units of randomization, intervention, and analysis. Respondents to a baseline health inventory were regularly mailed the 36-Item Short Form (SF-36) and, as relevant, questionnaires about six chronic conditions (ischemic heart disease, diabetes, chronic obstructive pulmonary disease, depression, alcohol use, and hypertension) and satisfaction with care. Data were reported to primary providers at individual patient visits and in aggregate during a 2-year period. RESULTS: Baseline forms were mailed to 34,050 patients; of the 22,413 respondents, 15,346 completed and returned follow-up surveys. Over the 2-year study, the difference between intervention and control groups (as measured by difference in average slope) was -0.26 (95% confidence interval [CI]: -0.79 to 0.27; P=0.28) for the SF-36 Physical Component Summary score and -0.53 (95% CI: -1.09 to 0.03; P=0.06) for the SF-36 Mental Component Summary score. No significant differences emerged after adjusting for deaths. There were no significant differences in condition-specific measures or satisfaction between groups after adjustment for provider type, panel size, and number of intervention visits, or after analysis of patients who completed all forms. CONCLUSION: An elaborate, sustained audit/feedback program of general and condition-specific measures of health/satisfaction did not improve outcomes. To be effective, such data probably should be incorporated into a comprehensive chronic disease management program.

Improving blood pressure control in diabetes: limitations of a clinical reminder in influencing physician behavior.

INTRODUCTION: Hypertension should be aggressively treated, especially in diabetic patients. But studies of physician prescribing habits reveal that physicians often delay making medication changes or initiating antihypertensive therapy. A chart-based reminder was designed to improve physician medication prescribing in this clinical situation. METHODS: A randomized controlled trial was conducted at the Veterans Affairs Medical Center in Richmond, Virginia. Patients with diabetes and hypertension were selected. A highly visible chart reminder was applied to the front of outpatient charts in the intervention group practice. A chart review was conducted to assess physician-directed medication changes. A successful outcome was defined as any antihypertensive medication increase or addition at that same visit. RESULTS: Physicians were more likely to intensify antihypertensive medication as the blood pressure increased regardless of the reminder. Overall, only 33% of visits resulted in a medication change, even though 93% of patients had elevations over target blood pressure at the follow-up visit. Physicians in the intervention and control groups made changes to medication at similar rates (chi 2 = 0.621, p = .511). DISCUSSION: In this study, a chart reminder failed to improve physician compliance with the clinical guideline for hypertension management in diabetics, Sixth Report of the Joint National Committee on the Detection, Evaluation, Prevention and Treatment of High Blood Pressure. To inform the design of effective intervention strategies, further research should explore specific barriers to guideline adherence in this clinical situation.