Help-seeking from clergy and spiritual counselors among veterans with depression and PTSD in primary care.

Little is known about the prevalence or predictors of seeking help for depression and PTSD from spiritual counselors and clergy. We describe openness to and actual help-seeking from spiritual counselors among primary care patients with depression. We screened consecutive VA primary care patients for depression; 761 Veterans with probable major depression participated in telephone surveys (at baseline, 7 months, and 18 months). Participants were asked about (1) openness to seeking help for emotional problems from spiritual counselors/clergy and (2) actual contact with spiritual counselors/clergy in the past 6 months. At baseline, almost half of the participants, 359 (47.2%), endorsed being "very" or "somewhat likely" to seek help for emotional problems from spiritual counselors; 498 (65.4%) were open to a primary care provider, 486 (63.9%) to a psychiatrist, and 409 (66.5%) to another type of mental health provider. Ninety-one participants (12%) reported actual spiritual counselor/clergy consultation. Ninety-five (10.3%) participants reported that their VA providers had recently asked them about spiritual support; the majority of these found this discussion helpful. Participants with current PTSD symptoms, and those with a mental health visit in the past 6 months, were more likely to report openness to and actual help-seeking from clergy. Veterans with depression and PTSD are amenable to receiving help from spiritual counselors/clergy and other providers. Integration of spiritual counselors/clergy into care teams may be helpful to Veterans with PTSD. Training of such providers to address PTSD specifically may also be desirable.

Does screening for pain correspond to high quality care for veterans?

BACKGROUND: Routine numeric screening for pain is widely recommended, but its association with overall quality of pain care is unclear. OBJECTIVE: To assess adherence to measures of pain management quality and identify associated patient and provider factors. DESIGN: A cross-sectional visit-based study. PARTICIPANTS: One hundred and forty adult VA outpatient primary care clinic patients reporting a numeric rating scale (NRS) of moderate to severe pain (four or more on a zero to ten scale). Seventy-seven providers completed a baseline survey regarding general pain management attitudes and a post-visit survey regarding management of 112 participating patients. MEASUREMENT AND MAIN RESULTS: We used chart review to determine adherence to four validated process quality indicators (QIs) including noting pain presence, pain character, and pain control, and intensifying pharmacological intervention. The average NRS was 6.7. Seventy-three percent of charts noted the presence of pain, 13.9% the character, 23.6% the degree of control, and 15.3% increased pain medication prescription. Charts were more likely to include documentation of pain presence if providers agreed that "patients want me to ask about pain" and "pain can have negative consequences on patient's functioning". Charts were more likely to document character of pain if providers agreed that "patients are able to rate their pain". Patients with musculoskeletal pain were less likely to have chart documentation of character of pain. CONCLUSIONS: Despite routine pain screening in VA, providers seldom documented elements considered important to evaluation and treatment of pain. Improving pain care may require attention to all aspects of pain management, not just screening.

Factors associated with clinician intention to address diverse aspects of pain in seriously ill outpatients.

BACKGROUND: Pain is a common, often undertreated problem among patients with palliative needs. OBJECTIVES: To evaluate clinician factors associated with intention to address diverse aspects of pain. DESIGN: Clinicians reviewed a clinical vignette describing a frail elderly patient with advanced hormone-refractory metastatic prostate cancer, depression, and pain not on analgesic therapy. Clinicians were surveyed about their intentions for treatment. PARTICIPANTS: All 280 primary care and specialist clinicians working in 19 hospital and community-based primary care, oncology, and cardiology clinics at eight geographically dispersed sites in two large VA hospital systems. MAIN MEASURES: Endpoints were clinician intention to deliver guideline-concordant care: prescribe opioids/antidepressants, assess existential wellbeing, and offer mental health referral. Demographic and behavioral measures were evaluated in association with endpoints. KEY RESULTS: Of 208 (74%) responding practitioners, 189 were responsible for prescribing decisions. Of those, 86, 77, 75, and 69 were "very"/"somewhat likely" to prescribe opioids, antidepressants, refer to a mental health specialist, or assess existential wellbeing, respectively. Factors associated with greater intent to prescribe an opioid or antidepressant included female gender, being an attending physician, being a primary care clinician, and greater confidence in pain management skills. Greater trust in the validity of pain ratings was associated with intent to prescribe an antidepressant and assess existential wellbeing. Prescribing opioids was less likely if perceived as an administrative burden. Assessing existential wellbeing was less likely if time constraints were perceived a barrier to evaluating pain. Female gender was the only factor associated with intent to refer to a mental health specialist. CONCLUSIONS: Our findings suggest useful targets for improving pain management include bolstering clinician confidence in pain management and their trust in pain ratings.

Addressing patients' concerns about pain management and addiction risks.

Fear of engendering addiction is frequently reported as both a provider and a patient barrier to effective pain management. In this study, a clinical scenario ascertained nursing staff members' usual practice in addressing addiction fears for patients with concerns about the addictive potential of pain medication. One hundred forty-five Veterans Health Administration nursing staff members from eight ambulatory care sites were queried to identify variables associated with proclivity to address patient fears about addiction risks in a population where pain is prevalent and the risk for substance abuse is high. Regarding addressing addiction concerns, 66% of nursing staff were very likely, 16% somewhat likely, 9% unsure, 6% somewhat unlikely, and 2% very unlikely to take action. Health technicians were less likely to address addiction concerns than registered or licensed vocational nurses (odds ratio [OR] 0.116; p=.004). Nursing staff with more years' experience (OR 1.070; p=.005) and higher levels of self-efficacy/confidence (OR 1.380; p=.001) were more likely to engage in discussions related to addiction risks. Targeted efforts to improve pain management activities should focus on retaining experienced nursing staff in initial assessment positions and improving the skills and confidence of less experienced and less skilled staff.

Using evidence-based quality improvement methods for translating depression collaborative care research into practice.

OBJECTIVE: Translating Initiatives in Depression into Effective Solution (TIDES) aimed to translate research-based collaborative care for depression into an approach for the Veterans Health Administration (VA). SITES: Three multistate administrative regions and seven of their medium-sized primary care practices. INTERVENTION: Researchers assisted regional leaders in adapting research-based depression care models using evidence-based quality improvement (EBQI) methods. EVALUATION: We evaluated model fidelity and impacts on patients. Trained nurse depression care managers collected data on patient adherence and outcomes. RESULTS: Among 72% (128) of the 178 patients followed in primary care with depression care manager assistance during the 3-year study period, mean PHQ-9 scores dropped from 15.1 to 4.7 (p < .001). A total of 87% of patients achieved a PHQ-9 score lower than 10 (no major depression). 62% achieved a score lower than six (symptom resolution). Care managers referred 28% (50) TIDES patients to mental health specialty (MHS). In the MHS-referred group, mean PHQ-9 scores dropped from 16.4 to 9.0 (p < .001). A total of 58% of MHS-referred patients achieved a PHQ-9 score lower than 10, and 40%, a score less than 6. Over the 2 years following the initial development phase reported here, national policymakers endorsed TIDES through national directives and financial support. CONCLUSIONS: TIDES developed an evidence-based depression collaborative care prototype for a large health care organization (VA) using EBQI methods. As expected, care managers referred sicker patients to mental health specialists; these patients also improved. Overall, TIDES achieved excellent overall patient outcomes, and the program is undergoing national spread.

A comparative study of pain in heart failure and non-heart failure veterans.

BACKGROUND: Progress has been made in addressing pain in specific diseases such as cancer, but less attention has focused on understanding pain in nonmalignant states, including heart failure (HF). METHODS AND RESULTS: From March 2006 to June 2007, 672 veterans were surveyed and scores for the Brief Pain Inventory, pain distress, clinically significant pain levels (moderate to severe pain), and pain locations were compared using univariate and multivariate models. Fifteen percent of the final sample had HF (95/634). In our study, the HF patients were older (P < .000), reported lower levels of general health (P = .018), had more co-morbidities (P < .000), were more likely to have a history of cancer (P = .035), and suffered more chest pain and fewer headaches (P = .026, P = .03, respectively) than their non-HF cohorts. When controlling for age, co-morbidity and cancer disorders, HF and non-HF patients did not differ in pain severity, interference, distress or locations. Of the patients currently experiencing pain, 67.3% of HF patients and 68.4% of non-HF patients rated their pain as moderate or severe (pain >or=4 on a 0 to 10 scale). CONCLUSIONS: Although HF has not been identified as a painful condition, this study suggests the burden of pain is significant for both HF and non-HF ambulatory care patients.

Early identification of co-occurring pain, depression and anxiety.

BACKGROUND: Depression and anxiety frequently co-occur with pain and may affect treatment outcomes. Early identification of these co-occurring psychiatric conditions during routine pain screening may be critical for optimal treatment. OBJECTIVE: To determine aspects of pain related to psychological distress, and, among distressed patients, to determine whether pain factors are related to provider identification of distress. DESIGN: Cross-sectional interview of primary care patients and their providers participating in a Veteran's Administration HELP-Vets study. SUBJECTS: A total of 528 predominately male Veterans MEASUREMENTS AND MAIN RESULTS: We measured self-reported pain, including a 0-10 numeric rating scale and interference items from the Brief Pain Inventory. To evaluate distress, brief indicators of depression, anxiety and PTSD were combined. A substantial number of patients had psychological distress (41%), which was even higher (62%) among patients with moderate-severe current pain. Only 29% of those with distress reported talking to their provider about emotional problems during their visit. In multivariate analyses, other pain factors related to distress included interference with enjoyment of life and relationships with others, pain in multiple locations and joint pains. Prior diagnoses of depression and anxiety were also related to current distress. Only prior diagnosis and patient reported headaches and sleep interference because of pain were related to provider identification of distress. CONCLUSIONS: VA patients with moderate-severe pain are at high risk for psychological distress, which often goes unrecognized. Providers need to be more vigilant to mental health problems in patients experiencing high pain levels. Targeted screening for co-occurring conditions is warranted.

Exploring alternative approaches to routine outpatient pain screening.

OBJECTIVE: To evaluate potential alternatives to the numeric rating scale (NRS) for routine pain screening. DESIGN: Cross-sectional. SETTING: Nineteen Veterans Affairs outpatient clinics in Southern California at two hospitals and six community sites. PATIENTS: Five hundred twenty-eight veterans from primary care, cardiology, and oncology clinics sampled in proportion to the total number of visits made to each clinic during the previous year. METHODS: Veterans were approached following clinic visits to complete researcher-administered surveys about their clinic experience. Using the Brief Pain Inventory (BPI) interference scale of > or =5 as a reference standard for important unrelieved pain, we evaluated potential alternative pain screening items and item combinations by analyzing sensitivity and specificity, area under the receiver operating curve (AUC), and likelihood ratios. RESULTS: Of the veterans, 43.6% had unrelieved pain as measured by the reference standard. Approximately half had painful musculoskeletal diagnoses and one-third had comorbid mental health or substance use disorders. The fifth vital sign detected pain less accurately than did an NRS with a 1-week timeframe and an item assessing pain-related bother over the past week. AUCs were 0.79, 0.86, and 0.86, respectively. A sequential approach combining the pain-related bother and NRS with a 1-week timeframe items had good discriminatory ability. CONCLUSIONS: Alternative single or combined pain screening strategies assessing pain-related bother may improve routine pain detection.

Availability of gynecologic services in the department of veterans affairs.

PURPOSE: The optimum approach to providing the Congressionally mandated gender-specific services for which women veterans are eligible is unknown. We evaluated onsite availability of gynecologic services, clinic type and staffing arrangements, and the impact of having a gynecology clinic (GYN) and/or an obstetrician gynecologist (OBGYN) routinely available. METHODS: We analyzed data from the 2001 national VHA Survey of Women Veterans Health Programs and Practices (n = 136 sites; response rate, 83%). We assessed availability of gynecologic services, and evaluated differences in availability by clinic type (designated women's health provider in primary care [PC], separate women's health clinic for primary care [WHC], and/or separate GYN) and staffing arrangements (OBGYN routinely involved versus not). MAIN FINDINGS: Out of 133 sites, 77 sites (58%) offered services through a GYN and 56 sites (42%) did not have GYN. Seventy-two (54%) sites had a WHC. More sites with an OBGYN provided endometrial biopsies (91% vs. 20%), IUD insertion (85% vs. 14%), infertility evaluation (56% vs. 23%), infertility treatment (25% vs. none), gynecologic surgery (65 vs. 28%), p < .01. In comparison to sites without WHC, those with WHC were more likely to offer services onsite: endometrial biopsy odds ratio (OR) 6.0 (95% confidence interval [CI], 2.0-18.1); IUD insertion 4.4 (1.6-12.2); infertility evaluation 2.8 (1.2-6.3); and gynecologic surgery 2.3 (1.0-5.4). CONCLUSION: As the VA develops strategic plans for accommodating the growing number of women veterans, leaders should consider focusing on establishing WHC for primary care and routine availability of OBGYN or other qualified clinicians, rather than establishing separate GYN.

Effectiveness of an on-call counselor at increasing smoking treatment.

BACKGROUND: Smoking cessation programs are very effective, but little is known about how to get smokers to attend these programs. OBJECTIVE: To evaluate whether an "on-call" counselor increased smoking cessation program referrals and attendance. DESIGN: We randomly assigned 1 of 2 primary care teams at the Sepulveda VA Ambulatory Care Center to intervention and the other to usual care. The intervention team had access to an on-call counselor who provided counseling and care coordination. Social marketing efforts included educational outreach, provider feedback, and financial incentives. MEASUREMENTS: Baseline telephone interviews with a sample of 482 smokers were conducted, covering smoking history, health status, and smoking cessation treatments. Follow-up surveys were conducted at mid-intervention (n = 251) and post-intervention (n = 251). RESULTS: Two hundred ninety-six patients were referred to the on-call counselor, who counseled each patient in person and provided follow-up calls. The counselor referred 45% to the on-site program, and 27% to telephone counseling; of these, half followed through on the referral; 28% declined referral. Patients on the intervention team were more likely to report being counseled about smoking (68% vs 56%; odds ratio [OR] 1.7, CI 1.0-2.9) and referred to a cessation program (38% vs 23%; OR 2.1, CI 1.2-3.6); having attended the program (11% vs 4%; OR 3.6, CI 1.2-10.5); and receiving a prescription for bupropion (17% vs 8%) (OR 2.3, CI 1.1-5.1). The effect was not sustained after the case management period. CONCLUSIONS: Having access to an on-call counselor with case management increased rates of smoking cessation counseling, referral, and treatment. The intervention could be reproduced by other health care systems.

Perceived barriers to weight management in primary care--perspectives of patients and providers.

BACKGROUND: Despite the consequences of overweight and obesity, effective weight management is not occurring in primary care. OBJECTIVE: To identify beliefs about obesity that act as barriers to weight management in primary care by surveying both patients and providers and comparing their responses. DESIGN: Anonymous, cross-sectional, self-administered survey of patients and providers of a Veteran's Administration Primary Care Clinic, distributed at the clinic site. SUBJECTS: Forty-eight Internal Medicine providers and 488 patients. MEASUREMENTS: Beliefs, attitudes, and experiences with weight management as well as demographic characteristics were collected through a questionnaire. RESULTS: Providers and patients differed significantly on many beliefs about weight. Providers were more likely than patients to perceive that patients lack self-control to stay on a diet and that fattening food in society and lack of time for exercise were prime factors in weight gain. They also expressed more interest in helping patients with weight management than patients desiring this. Patients were more likely to state that weight problems should be managed on one's own, talking to a provider is not helpful, providers blame them for their weight problem, and that appointments contain sufficient time for weight discussion. CONCLUSION: Providers and patients emphasize different barriers to weight management. Providers need to be aware of the beliefs that their patients hold to improve weight management discussions and interventions in primary care.

Assessing the structure of smoking cessation care in the Veterans Health Administration.

PURPOSE: National smoking cessation practice guidelines offer recommendations regarding the processes and structure of care. Facilities routinely measure the processes of care but not the structure of care. This pilot study assessed the structure of smoking cessation care at Veterans Health Administration facilities. METHODS: Key informants at 18 sites completed a brief checklist survey adapted from national smoking cessation guidelines. Responses were compared with detailed site surveys. RESULTS: Guideline adherence was seen in identifying smokers and treating inpatient smokers. Areas of low adherence include offering incentives and defining staff responsibilities. The checklist survey showed poor correspondence with the detailed survey, with low agreement on systematic screening (kappa = .21) and higher agreement on primary care prescribing authority (kappa = .53). DISCUSSION: This pilot survey provides a potential rapid method for assessing adherence to systems recommendations from the national smoking cessation guidelines. The relatively low agreement with a more detailed survey suggests that the two surveys may have been measuring different aspects of smoking cessation care.

Ethnic disparities in the use of nicotine replacement therapy for smoking cessation in an equal access health care system.

PURPOSE: To examine ethnic variations in the use of nicotine replacement therapy (NRT) in an equal access health care system. DESIGN: Cross-sectional survey. SETTING: Eighteen Veterans Affairs medical and ambulatory care centers. SUBJECTS: A cohort of male current smokers (n = 1606). MEASURES: Use of NRT (nicotine patch or nicotine gum), ethnicity, sociodemographics, health status, smoking-related history, and facility prescribing policy. RESULTS: Overall, only 34% of African-American and 26% of Hispanic smokers have ever used NRT as a cessation aid compared with 50% of white smokers. In the past year, African-American smokers were most likely to have attempted quitting. During a serious past-year quit attempt, however African-American and Hispanic smokers reported lower rates of NRT use than white smokers (20% vs. 22% vs. 34%, respectively, p = .001). In multivariate analyses, ethnicity was independently associated with NRT use during a past-year quit attempt. Compared with white smokers, African-American (adjusted odds ratio, .53; 95% confidence interval, .34-.83) and Hispanic (adjusted odds ratio, .55; 95% confidence interval, .28-1.08) smokers were less likely to use NRT. CONCLUSIONS: Assessment of variations in use of NRT demonstrates that African-American and Hispanic smokers are less likely to use NRT during quit attempts. Future research is needed on the relative contributions of patient, physician, and system features to gaps in guideline implementation to provide treatment for ethnic minority smokers.

Smokers' interest in quitting and services received: using practice information to plan quality improvement and policy for smoking cessation.

Given the prevalence of smoking, its impact, and the benefits of cessation, helping smokers quit should be a top priority for health care organizations. To restructure health care delivery and guide future policy, the authors used baseline survey data from an 18-site Veterans Health Administration group randomized trial to assess the level of interest in quitting smoking for a practice population and determine what smoking cessation services they reported receiving. Among 1941 current smokers, 55% did not intend to quit in the next 6 months, and the remainder intended to quit in the next month (13%) to 6 months (32%). Forty-five percent reported a quit attempt in the prior year. While nearly two thirds of smokers reported being counseled about cessation within the past year, only 29% were referred to a cessation program, and 25% received a prescription for nicotine patches. Tobacco control efforts within this population should focus on increasing the rate of assisting patients with quitting.

Smoking cessation care received by veterans with chronic obstructive pulmonary disease.

Smoking is the main cause of chronic obstructive pulmonary disease (COPD), and smoking cessation is the only effective intervention to slow its progression. We examined whether smokers with COPD received more cessation services than smokers without COPD. Current smokers from 18 Veterans Health Administration primary care clinics completed baseline and 12 month follow-up surveys (baseline n = 1,941; 12 month n = 1,080), composed of validated questions on smoking habits, history, and attitudes; health/functional status; and sociodemographics. Both at baseline and 12 month follow-up, smokers with COPD were more likely to report that they had been advised to quit, prescribed nicotine patches, or referred to a smoking cessation program within the last year. However, the rate of quitting smoking was the same for smokers with COPD and smokers without COPD. The increase in cessation services received by smokers with COPD was noted primarily among smokers not interested in quitting. New approaches may be required, particularly to help smokers not interested in quitting.

Family involvement, medication adherence, and depression outcomes among patients in veterans affairs primary care.

OBJECTIVE Family involvement and social support are associated with recovery from mental disorders. This project explored how family involvement in health care and social support among depressed veterans in primary care related to medication adherence and depression outcomes. METHODS During a longitudinal telephone survey, 761 Veterans Affairs (VA) primary care patients (mean age=60 years) with probable major depression were asked about depression symptoms, self-reported health, medication adherence, social support, family involvement with care, and satisfaction with clinicians' efforts to involve the patients' families in their care. Follow-up interviews at seven and 18 months assessed depression severity and medication adherence. RESULTS Most participants lived with others (71%) and reported moderately high social support. Most participants (62%) reported being very likely to discuss treatment of a major medical condition with family, but 64% reported that VA providers had not involved the participants' family in their care within the prior six months. In multivariate regression analyses, lower depression severity and better medication adherence over time were significantly linked to higher satisfaction with limited efforts by clinicians to involve families in care. Neither social support nor the extent of family involvement by itself was associated with outcomes. CONCLUSIONS The results suggested a link between patient satisfaction with family involvement by clinicians and clinical outcomes among depressed veterans. In addition, clinician responsiveness to patient wishes may be more important than the amount of family involvement per se. Further research is needed to clarify when and how clinicians should involve a patient's family in depression treatment in primary care.

Gender differences in smoking and smoking cessation treatment: an examination of the organizational features related to care.

OBJECTIVES: Veterans experience a particularly heavy burden with smoking rates higher than the general population, and the smoking prevalence for women Veterans has increased in recent years. We examined differences in smoking prevalence and treatment by gender for Veterans receiving at least some of their care at a VA facility, and examined the degree to which organizational factors may be associated with reductions in gender disparities in smoking cessation treatment. METHODS: We merged national organizational-level data focused on primary care (sites = 225) and women's health (sites = 195) with patient-level survey data (n = 15,033 smokers). Organizational measures focused on smoking cessation-specific structure and processes in primary care and women's health. Primary outcomes were patient-reported receipt of smoking cessation treatments-advised to quit, medication recommendation, and other treatment recommendation. We used multi-level, random-intercept logistic regression. RESULTS: In 2007, 29% of women and 23% of men were smokers. Overall, 83% of smokers reported they had been advised to quit, 62% recommended medications, and 60% recommended other treatments. Women were more likely to report being advised to quit (odds ratio, 1.33; 95% confidence interval, 1.07-1.64) but equally likely as men to have medications or other treatment recommended. Organizational factors did not eliminate the gender differences in being advised to quit. CONCLUSION: Despite having equivalent or higher smoking cessation treatment rates, women Veterans were more likely to smoke than men. With the rapid growth of women entering VA care, the need for effective gender-focused and gender-sensitive smoking cessation care arrangements is critical for the future health of women who have served.

Prescription sharing, alcohol use, and street drug use to manage pain among veterans.

CONTEXT: Efforts to promote awareness and management of chronic pain have been accompanied by a troubling increase in prescription medication abuse. At the same time, some patients may misuse substances in an effort to manage chronic pain. OBJECTIVES: This study examines self-reported substance misuse for pain management among veterans and identifies the contributing factors. METHODS: We analyzed cross-sectional data from the Help Veterans Experience Less Pain study. RESULTS: Of 343 veterans, 35.3% reported an aberrant pain management behavior (24% reported using alcohol, 11.7% reported using street drugs, and 16.3% reported sharing prescriptions to manage pain). Poorer mental health, younger age, substance use disorders (SUDs), number of nonpain symptoms, and greater pain severity and interference were associated with aberrant pain management behaviors. In multivariate analysis, SUDs (odds ratio [OR]: 3.9, 95% confidence interval [CI]: 2.3-6.7, P<0.000) and poorer mental health (OR: 2.3, 95% CI: 1.3-4.3, P=0.006) were associated with using alcohol or street drugs to manage pain; SUDs (OR: 2.4, 95% CI: 1.3-4.4, P=0.006) and pain interference (OR: 1.1, 95% CI: 1.0-1.2, P=0.047) were associated with prescription sharing; and SUDs (OR: 3.6, 95% CI: 2.2-6.1, P<0.000) and number of nonpain symptoms (OR: 6.5, 95% CI: 1.2-35.4, P=0.031) were associated with any aberrant pain management behavior. CONCLUSION: Veterans with a history of SUDs, greater pain interference, more nonpain symptoms, and mental health concerns should be carefully managed to deter substance misuse for pain management.

Implementing collaborative care for depression treatment in primary care: a cluster randomized evaluation of a quality improvement practice redesign.

BACKGROUND: Meta-analyses show collaborative care models (CCMs) with nurse care management are effective for improving primary care for depression. This study aimed to develop CCM approaches that could be sustained and spread within Veterans Affairs (VA). Evidence-based quality improvement (EBQI) uses QI approaches within a research/clinical partnership to redesign care. The study used EBQI methods for CCM redesign, tested the effectiveness of the locally adapted model as implemented, and assessed the contextual factors shaping intervention effectiveness. METHODS: The study intervention is EBQI as applied to CCM implementation. The study uses a cluster randomized design as a formative evaluation tool to test and improve the effectiveness of the redesign process, with seven intervention and three non-intervention VA primary care practices in five different states. The primary study outcome is patient antidepressant use. The context evaluation is descriptive and uses subgroup analysis. The primary context evaluation measure is naturalistic primary care clinician (PCC) predilection to adopt CCM.For the randomized evaluation, trained telephone research interviewers enrolled consecutive primary care patients with major depression in the evaluation, referred enrolled patients in intervention practices to the implemented CCM, and re-surveyed at seven months. RESULTS: Interviewers enrolled 288 CCM site and 258 non-CCM site patients. Enrolled intervention site patients were more likely to receive appropriate antidepressant care (66% versus 43%, p = 0.01), but showed no significant difference in symptom improvement compared to usual care. In terms of context, only 40% of enrolled patients received complete care management per protocol. PCC predilection to adopt CCM had substantial effects on patient participation, with patients belonging to early adopter clinicians completing adequate care manager follow-up significantly more often than patients of clinicians with low predilection to adopt CCM (74% versus 48%%, p = 0.003). CONCLUSIONS: Depression CCM designed and implemented by primary care practices using EBQI improved antidepressant initiation. Combining QI methods with a randomized evaluation proved challenging, but enabled new insights into the process of translating research-based CCM into practice. Future research on the effects of PCC attitudes and skills on CCM results, as well as on enhancing the link between improved antidepressant use and symptom outcomes, is needed. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00105820.

Nursing staff, patient, and environmental factors associated with accurate pain assessment.

CONTEXT: Although pain ranks highly among reasons for seeking care, routine pain assessment is often inaccurate. OBJECTIVES: This study evaluated factors associated with nurses (e.g., registered) and other nursing support staff (e.g., licensed vocational nurses and health technicians) discordance with patients in estimates of pain in a health system where routine pain screening using a 0-10 numeric rating scale (NRS) is mandated. METHODS: This was a cross-sectional, visit-based, cohort study that included surveys of clinic outpatients (n=465) and nursing staff (n=94) who screened for pain as part of routine vital sign measurement during intake. These data were supplemented by chart review. We compared patient pain levels documented by the nursing staff (N-NRS) with those reported by the patient during the study survey (S-NRS). RESULTS: Pain underestimation (N-NRSS-NRS) in 7% of the cases. Nursing staff used informal pain-screening techniques that did not follow established NRS protocols in half of the encounters. Pain underestimation was positively associated with more years of nursing staff work experience and patient anxiety or post-traumatic stress disorder and negatively associated with better patient-reported health status. Pain overestimation was positively associated with nursing staff's use of the full NRS protocol and with a distracting environment in which patient vitals were taken. CONCLUSION: Despite a long-standing mandate, pain-screening implementation falls short, and informal screening is common.