Walking the leadership walk: Integrating inclusivity in a large-scale health care organization.

This article focuses on the roles, actions, and resources developed by a group of leaders from the Office of Mental Health and Suicide Prevention (OMHSP) within the Department of Veterans Affairs during the unprecedented times of spring of 2020, when society was shaken by the fears and challenges of COVID-19 as well as social unrest sparked by the murder of George Floyd. We share a summary of our efforts to move beyond platitudes and statements and bring meaningful and sustainable change in justice, equity, diversity, and inclusion within OMHSP and across mental health services in Department of Veterans Affairs. This article is written through the lens of the founding members of the OMHSP's Diversity, Equity, and Inclusion Steering Committee. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Surveying the Landscape of Quality-of-Care Measures for Mental and Substance Use Disorders.

OBJECTIVE: Quality measures that are used to evaluate health care services have a central role in monitoring and incentivizing quality improvement and the provision of evidence-based treatment. This systematic scan aimed to catalog quality-of-care measures for mental and substance use disorders and assess gaps and redundancies to inform efforts to develop and retire measures. METHODS: Quality measure inventories were analyzed from six organizations that evaluate health care quality in the United States. Measures were included if they were defined via symptoms or diagnoses of mental and substance use disorders or specialty treatments or treatment settings for adults. RESULTS: Of 4,420 measures analyzed, 635 (14%) met inclusion criteria, and 376 unique quality-of-care measure constructs were cataloged and characterized. Symptoms or diagnoses of disorders were most commonly used to define measures (46%, N=172). Few measures were available for certain disorders (e.g., anxiety disorders), evidence-based treatments (e.g., psychotherapy), and quality domains (e.g., equity). Only one in four measures was endorsed by the National Quality Forum, which independently and critically evaluates quality measures. Among measures that were actively in use for national quality improvement initiatives (N=319), process measures (57%) were most common, followed by outcome measures (30%), the latter of which focused most often on experience of care. CONCLUSIONS: A vast landscape of mental and substance use disorder quality-of-care measures currently exists, and continued efforts to harmonize duplicative measures and to develop measures for underrepresented evidence-based treatments and quality domains are warranted. The authors recommend reinvesting in a national, centralized system for measure curation, with a stakeholder-centered process for independent measure review and endorsement.

Computer-delivered brief alcohol intervention for patients with liver disease: a randomized controlled trial.

BACKGROUND AND AIMS: Reducing alcohol consumption by liver disease patients can reduce morbidity and mortality. This study compared a computer-delivered brief alcohol intervention (cBAI) with standard care in a sample of US military veterans with liver disease. DESIGN: Multi-site, randomized controlled trial of a cBAI plus standard care (n = 67) versus standard care only (n = 71). Participants were assessed at baseline and 3- and 6-month follow-up. SETTING: US Veterans Health Administration liver clinics. PARTICIPANTS: Participants were mostly male and diagnosed with hepatitis C. INTERVENTIONS AND COMPARATORS: A cBAI tailored to veterans with liver disease and consisting of assessment and personalized feedback. Standard care was brief education and advice about alcohol and liver disease. MEASUREMENT: Primary outcomes were self-reported number of drinking days and unhealthy drinking days (defined as more than two drinks for men and more than one for women) in the past 30 days at 6-month follow-up. Secondary outcomes were these two variables at 3-month follow-up, and drinks consumed per drinking day, depression and overall health at 3- and 6-month follow-ups. Missing data were imputed using multiple imputation. FINDINGS: Compared with standard care, cBAI participants reported significantly fewer drinking days at 6-month follow-up and fewer unhealthy drinking days at both 3- and 6-month follow-ups. Least square means (LS-means) for number of drinking days were 3.78 for the cBAI condition and 6.89 for the standard care condition at 6 months [LS-mean ratio = 3.78/6.89 = 0.55, 95% confidence interval (CI) = 0.34, 0.89]. LS-means for number of unhealthy drinking days were 1.04 for the cBAI condition and 2.57 for the standard care condition at 3-month follow-up (LS-mean ratio = 1.04/2.57 = 0.41, 95% CI = 0.19, 0.85). At 6-months follow-up, LS-means were 1.18 for the cBAI condition and 2.75 for the standard care condition (LS-mean ratio = 1.18/2.75 = 0.43, 95% CI = 0.20, 0.91). CONCLUSIONS: A computer-delivered brief alcohol intervention reduced drinking days and unhealthy drinking days at 6-month follow up in military veterans with liver disease compared with brief education and advice to reduce consumption.

Cost-effectiveness of Treatments for Opioid Use Disorder.

Importance: Opioid use disorder (OUD) is a significant cause of morbidity and mortality in the US, yet many individuals with OUD do not receive treatment. Objective: To assess the cost-effectiveness of OUD treatments and association of these treatments with outcomes in the US. Design and Setting: This model-based cost-effectiveness analysis included a US population with OUD. Interventions: Medication-assisted treatment (MAT) with buprenorphine, methadone, or injectable extended-release naltrexone; psychotherapy (beyond standard counseling); overdose education and naloxone distribution (OEND); and contingency management (CM). Main Outcomes and Measures: Fatal and nonfatal overdoses and deaths throughout 5 years, discounted lifetime quality-adjusted life-years (QALYs), and costs. Results: In the base case, in the absence of treatment, 42 717 overdoses (4132 fatal, 38 585 nonfatal) and 12 660 deaths were estimated to occur in a cohort of 100 000 patients over 5 years, and 11.58 discounted lifetime QALYs were estimated to be experienced per person. An estimated reduction in overdoses was associated with MAT with methadone (10.7%), MAT with buprenorphine or naltrexone (22.0%), and when combined with CM and psychotherapy (range, 21.0%-31.4%). Estimated deceased deaths were associated with MAT with methadone (6%), MAT with buprenorphine or naltrexone (13.9%), and when combined with CM, OEND, and psychotherapy (16.9%). MAT yielded discounted gains of 1.02 to 1.07 QALYs per person. Including only health care sector costs, methadone cost $16 000/QALY gained compared with no treatment, followed by methadone with OEND ($22 000/QALY gained), then by buprenorphine with OEND and CM ($42 000/QALY gained), and then by buprenorphine with OEND, CM, and psychotherapy ($250 000/QALY gained). MAT with naltrexone was dominated by other treatment alternatives. When criminal justice costs were included, all forms of MAT (with buprenorphine, methadone, and naltrexone) were associated with cost savings compared with no treatment, yielding savings of $25 000 to $105 000 in lifetime costs per person. The largest cost savings were associated with methadone plus CM. Results were qualitatively unchanged over a wide range of sensitivity analyses. An analysis using demographic and cost data for Veterans Health Administration patients yielded similar findings. Conclusions and Relevance: In this cost-effectiveness analysis, expanded access to MAT, combined with OEND and CM, was associated with cost-saving reductions in morbidity and mortality from OUD. Lack of widespread MAT availability limits access to a cost-saving medical intervention that reduces morbidity and mortality from OUD. Opioid overdoses in the US likely reached a record high in 2020 because of COVID-19 increasing substance use, exacerbating stress and social isolation, and interfering with opioid treatment. It is essential to understand the cost-effectiveness of alternative forms of MAT to treat OUD.

Reasons for under-use of prescribed opioid medications by patients in pain.

BACKGROUND: With the growth in opioid therapy for the treatment of chronic pain, health care providers have focused their attention on avoiding over-use of opioid medications, specifically to avoid addiction, dependency, and other misuse. Qualitative and quantitative reviews of medication adherence, in contrast, focus primarily on why patients under-use or do not take their medications as prescribed and find nonadherence rates of approximately 25%. OBJECTIVE: To identify the prevalence of under-use of opioid medications and the reasons and implications of under-use. DESIGN: As part of a variety of structured assessments, subjects were asked detailed questions about how they used their opioid medication in their daily lives. PARTICIPANTS: One hundred ninety-one veterans who received an opioid prescription for any pain problem within the 12 months before the interview. MEASURES: We defined a patient who under-used his/her medication as one who took less than their prescribed dose of medication and reported that pain impaired their ability to engage in normal daily activities. RESULTS: Under-use of opioids (20%) was more common than over-use (9%), consistent with research on medication adherence. Patients who under-used their opioids offered the same reasons for under-use that patients report for other medications. However, while under-users reported more pain than other opioid users they filled only slightly fewer opioid prescriptions. Communication problems between patients and providers about opioids were common. CONCLUSIONS: Improved communication between patients and providers and shared decision-making regarding opioid prescriptions may improve pain management and minimize the problems associated with over-prescription of opioids (i.e., diversion).

Evaluation of the acceptability and usability of a decision support system to encourage safe and effective use of opioid therapy for chronic, noncancer pain by primary care providers.

OBJECTIVE: To develop and evaluate a clinical decision support system (CDSS) named Assessment and Treatment in Healthcare: Evidenced-Based Automation (ATHENA)-Opioid Therapy, which encourages safe and effective use of opioid therapy for chronic, noncancer pain. DESIGN: CDSS development and iterative evaluation using the analysis, design, development, implementation, and evaluation process including simulation-based and in-clinic assessments of usability for providers followed by targeted system revisions. RESULTS: Volunteers provided detailed feedback to guide improvements in the graphical user interface, and content and design changes to increase clinical usefulness, understandability, clinical workflow fit, and ease of completing guideline recommended practices. Revisions based on feedback increased CDSS usability ratings over time. Practice concerns outside the scope of the CDSS were also identified. CONCLUSIONS: Usability testing optimized the CDSS to better address barriers such as lack of provider education, confusion in dosing calculations and titration schedules, access to relevant patient information, provider discontinuity, documentation, and access to validated assessment tools. It also highlighted barriers to good clinical practice that are difficult to address with CDSS technology in its current conceptualization. For example, clinicians indicated that constraints on time and competing priorities in primary care, discomfort in patient-provider communications, and lack of evidence to guide opioid prescribing decisions impeded their ability to provide effective, guideline-adherent pain management. Iterative testing was essential for designing a highly usable and acceptable CDSS; however, identified barriers may limit the impact of the ATHENA-Opioid Therapy system and other CDSS on clinical practices and outcomes unless CDSS are paired with parallel initiatives to address these issues.

Women Veterans' Perspectives on How to Make Veterans Affairs Healthcare Settings More Welcoming to Women.

PURPOSE: Women veterans are a rapidly increasing subset of the Veterans Affairs (VA) patient population but remain a numerical minority. Men veteran-dominated health care settings pose unique considerations for providing care to women veterans in a comfortable and welcoming environment. We analyzed patient suggestions on how to make the VA more welcoming to women. METHODS: We surveyed a convenience sample of women veteran patients who visited 1 of 26 VA locations in August and September of 2017. Women veterans were invited to complete brief anonymous questionnaires that included questions about harassment experiences and feeling welcome at the VA, and an open-ended question about suggestions to make the VA more welcoming to women. We analyzed data from the open-ended question using the constant comparison method. RESULTS: Among respondents (N = 1,303), 85% felt welcome at the VA. Overall, 29% answered the open-ended prompt for a total of 490 distinct responses: 260 comments and 230 suggestions. Comments included praise for the VA (67%) and stories about feeling uncomfortable or harassed in the VA (26%). Suggestions included those related to VA staff (31%), the environment of care (18%), additional resources for women veterans (18%), clinical services for women veterans (15%), changing men veterans' behavior toward women veterans at the VA (5%), and making the treatment of women and men the same (5%). CONCLUSIONS: Although most women veterans felt welcome in the VA, patient-centered suggestions offer opportunities for making the VA more welcoming to women. Soliciting patient suggestions and increasing awareness of how feeling welcome is experienced by patients are first steps to health care settings becoming more inclusive.

Adapting a computer-delivered brief alcohol intervention for veterans with Hepatitis C.

OBJECTIVE: This study adapted an existing computer-delivered brief alcohol intervention (cBAI) for use in Veterans with the hepatitis C virus (HCV) and examined its acceptability and feasibility in this patient population. METHODS: A four-stage model consisting of initial pilot testing, qualitative interviews with key stakeholders, development of a beta version of the cBAI, and usability testing was used to achieve the study objectives. RESULTS: In-depth interviews gathered feedback for modifying the cBAI, including adding HCV-related content such as the health effects of alcohol on liver functioning, immune system functioning, and management of HCV, a preference for concepts to be displayed through "newer looking" graphics, and limiting the use of text to convey key concepts. Results from usability testing indicated that the modified cBAI was acceptable and feasible for use in this patient population. CONCLUSIONS: The development model used in this study is effective for gathering actionable feedback that can inform the development of a cBAI and can result in the development of an acceptable and feasible intervention for use in this population. Findings also have implications for developing computer-delivered interventions targeting behavior change more broadly.

Finding the best available evidence: what's new?

The voluminous growth of the health literature paired with time constraints of practitioners can make it difficult to implement evidence-based medicine (EBM). New and better resources that summarize and/or synthesize the literature are available to facilitate the integration of evidence into practice. Understanding how such resources work and how to use them is an important step in finding evidence for patient care. By using a clinical scenario concerning abdominal aortic aneurysm screening, this article describes 3 types of EBM resources from the "4S" model: systems, synopses, and syntheses. The common features of each resource type are discussed and comparisons of selected examples are provided.

Outcomes associated with a cognitive-behavioral chronic pain management program implemented in three public HIV primary care clinics.

In patients with HIV/AIDS, chronic pain is common and analgesics pose serious risks. Cognitive-behavioral therapies (CBT) provide an alternative. This study evaluated feasibility and impact of a CBT-based pain management program in three public primary care clinics for HIV patients. The program included a workbook and 12-weeks of group CBT sessions. HIV-positive patients with chronic moderate to severe pain were invited to participate in the program and were assessed at enrollment, 6, 12, and 24 weeks. Despite only moderate group attendance, program enrollment was associated with significant improvements in pain intensity, pain-related functioning, anxiety and acceptance, and mental health. At 24 weeks, effect sizes for pain outcomes were -0.83 for pain intensity and -0.43 for functioning. The pattern of change in outcomes was consistent with predictions based on cognitive-behavioral theory. Effects were observed at all clinics. Adding CBT-based pain management into primary care may provide important benefits for patients with HIV/AIDS.