Mortality Conversations Between Male Veterans and Their Providers Prior to Dysvascular Lower Extremity Amputation.

BACKGROUND: Among patients facing lower extremity amputation due to dysvascular disease, the mortality risk is very high. Given this, as well as the importance of a patient-centered approach to medical care, informing patients about their possible risk of dying may be important during preoperative shared decision-making. The goal of this investigation was to gain an understanding of patient and provider experiences discussing mortality within the context of amputation within the Veterans Health Administration. METHODS: Semistructured interviews were performed with Veterans with peripheral arterial disease and/or diabetes, vascular and podiatric surgeons, and physical medicine and rehabilitation physicians. Interviews were analyzed using team-based content analysis to identify themes related to amputation-level decisions. RESULTS: We interviewed 22 patients and 21 surgeons and physicians and identified 3 themes related to conversations around mortality: (1) both patients and providers report that mortality conversations are not common prior to amputation; (2) while most providers find value in mortality conversations, some express concerns around engaging in these discussions with patients; and (3) some patients perceive mortality conversations as unnecessary, but many are open to engaging in the conversation. CONCLUSIONS: Providers may benefit from introducing the topic with patients, including providing the context for why mortality conversations may be valuable, with the understanding that patients can always decline to participate should they not be interested or comfortable discussing this issue.

Implementation and Evaluation of a Training Curriculum for Experienced Nurses in Care Coordination: The VA Rural Transitions Nurse Training Program.

BACKGROUND: High-quality transitional care at discharge is essential for improved patient outcomes. Registered nurses (RNs) play integral roles in transitions; however, few receive structured training. PURPOSE: We sought to create, implement, and evaluate an evidence-informed nursing transitional care coordination curriculum, the Transitions Nurse Training Program (TNTP). METHODS: We conceptualized the curriculum using adult learning theory and evaluated with the New World Kirkpatrick Model. Self-reported engagement, satisfaction, acquired knowledge, and confidence were assessed using surveys. Clinical and communication skills were evaluated by standardized patient assessment and behavior sustainment via observation 6 to 9 months posttraining. RESULTS: RNs reported high degrees of engagement, satisfaction, knowledge, and confidence and achieved a mean score of 92% on clinical and communication skills. Posttraining observation revealed skill sustainment (mean score 98%). CONCLUSIONS: Results suggest TNTP is effective for creating engagement, satisfaction, acquired and sustained knowledge, and confidence for RNs trained in transitional care.

The Influence of the Rural Transitions Nurse Program for Veterans on Healthcare Utilization Costs.

BACKGROUND: The Veterans Affairs (VA) Healthcare System Rural Transitions Nurse Program (TNP) addresses barriers veterans face when transitioning from urban tertiary VA hospitals to home. Previous clinical evaluations of TNP have shown that enrolled veterans were more likely to follow up with their primary care provider within 14 days of discharge and experience a significant reduction in mortality within 30 days compared to propensity-score matched controls. OBJECTIVE: Examine changes from pre- to post-hospitalization in total, inpatient, and outpatient 30-day healthcare utilization costs for TNP enrollees compared to controls. DESIGN: Quantitative analyses modeling the changes in cost via multivariable linear mixed-effects models to determine the association between TNP enrollment and changes in these costs. PARTICIPANTS: Veterans meeting TNP eligibility criteria who were discharged home following an inpatient hospitalization at one of the 11 implementation sites from April 2017 to September 2019. INTERVENTION: The four-step TNP transitional care intervention. MAIN MEASURES: Changes in 30-day total, inpatient, and outpatient healthcare utilization costs were calculated for TNP enrollees and controls. KEY RESULTS: Among 3001 TNP enrollees and 6002 controls, no statistically significant difference in the change in total costs (p = 0.65, 95% CI: (- $675, $350)) was identified. However, on average, the increase in inpatient costs from pre- to post-hospitalization was approximately $549 less for TNP enrollees (p = 0.02, 95% CI: (- $856, - $246)). The average increase in outpatient costs from pre- to post-hospitalization was approximately $421 more for TNP enrollees compared to controls (p = 0.003, 95% CI: ($109, $671)). CONCLUSIONS: Although we found no difference in change in total costs between veterans enrolled in TNP and controls, TNP was associated with a smaller increase in direct inpatient medical costs and a larger increase in direct outpatient medical costs. This suggests a shifting of costs from the inpatient to outpatient setting.

Sustainment stories: a qualitative analysis of barriers to sustainment of the National Rural Transitions of Care Nurse Program.

BACKGROUND: Understanding how to successfully sustain evidence-based care coordination interventions across diverse settings is critical to ensure that patients continue to receive high quality care even after grant funding ends. The Transitions Nurse Program (TNP) is a national intervention in the Veterans Administration (VA) that coordinates care for high risk veterans transitioning from acute care VA medical centers (VAMCs) to home. As part of TNP, a VA facility receives funding for a full-time nurse to implement TNP, however, this funding ends after implementation. In this qualitative study we describe which elements of TNP sites planned to sustain as funding concluded, as well as perceived barriers to sustainment. METHODS: TNP was implemented between 2016 and 2020 at eleven VA medical centers. Three years of funding was provided to each site to support hiring of staff, implementation and evaluation of the program. At the conclusion of funding, each site determined if they would sustain components or the entirety of the program. Prior to the end of funding at each site, we conducted midline and exit interviews with Transitions nurses and site champions to assess plans for sustainment and perceived barriers to sustainment. Interviews were analyzed using iterative, team-based inductive deductive content analysis to identify themes related to planned sustainment and perceived barriers to sustainment. RESULTS: None of the 11 sites planned to sustain TNP in its original format, though many of the medical centers anticipated offering components of the program, such as follow up calls after discharge to rural areas, documented warm hand off to PACT team, and designating a team member as responsible for patient rural discharge follow up. We identified three themes related to perceived sustainability. These included: 1) Program outcomes that address leadership priorities are necessary for sustainment.; 2) Local perceptions of the need for TNP or redundancy of TNP impacted perceived sustainability; and 3) Lack of leadership buy-in, changing leadership priorities, and leadership turnover are perceived barriers to sustainment. CONCLUSIONS: Understanding perceived sustainability is critical to continuing high quality care coordination interventions after funding ends. Our findings suggest that sustainment of care coordination interventions requires an in-depth understanding of the facility needs and local leadership priorities, and that building adaptable programs that continually engage key stakeholders is essential.

Gaps in Hospital and Skilled Nursing Facility Responsibilities During Transitions of Care: a Comparison of Hospital and SNF Clinicians' Perspectives.

BACKGROUND: Adverse outcomes are common in transitions from hospital to skilled nursing facilities (SNFs). Gaps in transitional care processes contribute to these outcomes, but it is unclear whether hospital and SNF clinicians have the same perception about who is responsible for filling these gaps in care transitions. OBJECTIVE: We sought to understand the perspectives of hospital and SNF clinicians on their roles and responsibilities in transitional care processes, to identify areas of congruence and gaps that could be addressed to improve transitions. DESIGN: Semi-structured interviews with interdisciplinary hospital and SNF providers. PARTICIPANTS: Forty-one clinicians across 3 hospitals and 3 SNFs including nurses (8), social workers (7), physicians (8), physical and occupational therapists (12), and other staff (6). APPROACH: Using team-based approach to deductive analysis, we mapped responses to the 10 domains of the Ideal Transitions of Care Framework (ITCF) to identify areas of agreement and gaps between hospitals and SNFs. KEY RESULTS: Although both clinician groups had similar conceptions of an ideal transitions of care, their perspectives included significant gaps in responsibilities in 8 of the 10 domains of ITCF, including Discharge Planning; Complete Communication of Information; Availability, Timeliness, Clarity and Organization of Information; Medication Safety; Educating Patients to Promote Self-Management; Enlisting Help of Social and Community Supports; Coordinating Care Among Team Members; and Managing Symptoms After Discharge. CONCLUSIONS: As hospitals and SNFs increasingly are held jointly responsible for the outcomes of patients transitioning between them, clarity in roles and responsibilities between hospital and SNF staff are needed. Improving transitions of care may require site-level efforts, joint hospital-SNF initiatives, and national financial, regulatory, and technological fixes. In the meantime, building effective hospital-SNF partnerships is increasingly important to delivering high-quality care to a vulnerable older adult population.

Barriers to and Facilitators of Multimodal Chronic Pain Care for Veterans: A National Qualitative Study.

OBJECTIVE: Chronic pain is more common among veterans than among the general population. Expert guidelines recommend multimodal chronic pain care. However, there is substantial variation in the availability and utilization of treatment modalities in the Veterans Health Administration. We explored health care providers' and administrators' perspectives on the barriers to and facilitators of multimodal chronic pain care in the Veterans Health Administration to understand variation in the use of multimodal pain treatment modalities. METHODS: We conducted semi-structured qualitative interviews with health care providers and administrators at a national sample of Veterans Health Administration facilities that were classified as either early or late adopters of multimodal chronic pain care according to their utilization of nine pain-related treatments. Interviews were conducted by telephone, recorded, and transcribed verbatim. Transcripts were coded and analyzed through the use of team-based inductive and deductive content analysis. RESULTS: We interviewed 49 participants from 25 facilities from April through September of 2017. We identified three themes. First, the Veterans Health Administration's integrated health care system is both an asset and a challenge for multimodal chronic pain care. Second, participants discussed a temporal shift from managing chronic pain with opioids to multimodal treatment. Third, primary care teams face competing pressures from expert guidelines, facility leadership, and patients. Early- and late-adopting sites differed in perceived resource availability. CONCLUSIONS: Health care providers often perceive inadequate support and resources to provide multimodal chronic pain management. Efforts to improve chronic pain management should address both organizational and patient-level challenges, including primary care provider panel sizes, accessibility of training for primary care teams, leadership support for multimodal pain care, and availability of multidisciplinary pain management resources.

Variability in skilled nursing facility screening and admission processes: Implications for value-based purchasing.

BACKGROUND: Hospitalized older adults are increasingly admitted to skilled nursing facilities (SNFs) for posthospital care. However, little is known about how SNFs screen and evaluate potential new admissions. In an era of increasing emphasis on postacute care outcomes, these processes may represent an important target for interventions to improve the value of SNF care. PURPOSE: The aim of this study was to understand (a) how SNF clinicians evaluate hospitalized older adults and make decisions to admit patients to an SNF and (b) the limitations and benefits of current practices in the context of value-based payment reforms. METHODS: We used semistructured interviews to understand the perspective of 18 clinicians at three unique SNFs-including physicians, nurses, therapists, and liaisons. All transcripts were analyzed using a general inductive theme-based approach. RESULTS: We found that the screening and admission processes varied by SNF and that variability was influenced by three key external pressures: (a) inconsistent and inadequate transfer of medical documentation, (b) lack of understanding among hospital staff of SNF processes and capabilities, and (c) hospital payment models that encouraged hospitals to discharge patients rapidly. Responses to these pressures varied across SNFs. For example, screening and evaluation processes to respond to these pressures included gaining access to electronic medical records, providing inpatient physician consultations prior to SNF acceptance, and turning away more complex patients for those perceived to be more straightforward rehabilitation patients. CONCLUSIONS: We found facility behavior was driven by internal and external factors with implications for equitable access to care in the era of value-based purchasing. PRACTICE IMPLICATIONS: SNFs can most effectively respond to these pressures by increasing their agency within hospital-SNF relationships and prioritizing more careful patient screening to match patient needs and facility capabilities.

Operationalizing an Implementation Framework to Disseminate a Care Coordination Program for Rural Veterans.

OBJECTIVE: Understanding how to successfully implement care coordination programs across diverse settings is critical for disseminating best practices. We describe how we operationalized the Practical Robust Implementation and Sustainability Model (PRISM) to guide the assessment of local context prior to implementation of the rural Transitions Nurse Program (TNP) at five facilities across the Veterans Health Administration (VHA). METHODS: We operationalized PRISM to create qualitative data collection techniques (interview guides, semi-structured observations, and a group brainwriting premortem) to assess local context, the current state of care coordination, and perceptions of TNP prior to implementation at five facilities. We analyzed data using deductive-inductive framework analysis to identify themes related to PRISM. We adapted implementation strategies at each site using these findings. RESULTS: We identified actionable themes within PRISM domains to address during implementation. The most commonly occurring PRISM domains were "organizational characteristics" and "implementation and sustainability infrastructure." Themes included a disconnect between primary care and hospital inpatient teams, concerns about work duplication, and concerns that one nurse could not meet the demand for the program. These themes informed TNP implementation. CONCLUSIONS: The use of PRISM for pre-implementation site assessments yielded important findings that guided adaptations to our implementation approach. Further, barriers and facilitators to TNP implementation may be common to other care coordination interventions. Generating a common language of barriers and facilitators in care coordination initiatives will enhance generalizability and establish best practices. IMPACT STATEMENTS: TNP is a national intensive care coordination program targeting rural Veterans. We operationalized PRISM to guide implementation efforts. We effectively elucidated facilitators, barriers, and unique contextual factors at diverse VHA facilities. The use of PRISM enhances the generalizability of findings across care settings and may optimize implementation of care coordination interventions in the VHA.

Practical Use of Process Mapping to Guide Implementation of a Care Coordination Program for Rural Veterans.

BACKGROUND: Transitions of care are high risk for vulnerable populations such as rural Veterans, and adequate care coordination can alleviate many risks. Single-center care coordination programs have shown promise in improving transitional care practices. However, best practices for implementing effective transitional care interventions are unknown, and a common pitfall is lack of understanding of the current process at different sites. The rural Transitions Nurse Program (TNP) is a Veterans Health Administration (VA) intervention that addresses the unique transitional care coordination needs of rural Veterans, and it is currently being implemented in five VA facilities. OBJECTIVE: We sought to employ and study process mapping as a tool for assessing site context prior to implementation of TNP, a new care coordination program. DESIGN AND PARTICIPANTS: Observational qualitative study guided by the Lean Six Sigma approach. Data were collected in January-March 2017 through interviews, direct observations, and group sessions with front-line staff, including VA providers, nurses, and administrative staff from five VA Medical Centers and nine rural Patient-Aligned Care Teams. KEY RESULTS: We integrated key informant interviews, observational data, and group sessions to create ten process maps depicting the care coordination process prior to TNP implementation at each expansion site. These maps were used to adapt implementation through informing the unique role of the Transitions Nurse at each site and will be used in evaluating the program, which is essential to understanding the program's impact. CONCLUSIONS: Process mapping can be a valuable and practical approach to accurately assess site processes before implementation of care coordination programs in complex systems. The process mapping activities were useful in engaging the local staff and simultaneously guided adaptations to the TNP intervention to meet local needs. Our approach-combining multiple data sources while adapting Lean Six Sigma principles into practical use-may be generalizable to other care coordination programs.

Brainwriting Premortem: A Novel Focus Group Method to Engage Stakeholders and Identify Preimplementation Barriers.

BACKGROUND: Many health care interventions encounter implementation challenges because of inadequate stakeholder engagement and identification of barriers. The brainwriting premortem technique is the silent sharing of written ideas about why an intervention failed. The method can engage stakeholders and identify barriers more efficiently than traditional brainstorming focus groups. PURPOSE: We evaluated the method during a transition of care intervention in the Veterans Health Administration (VA). Clinicians from 10 VA facilities participated in 10 brainwriting premortem sessions. METHODS: Using descriptive and content analytic methods, we assessed the quantity and quality of ideas generated, facilitator experience, and participant psychological safety. RESULTS: In total, 217 unique ideas were generated. Many were deemed high quality. The written data were immediately available for analysis, allowing rapid feedback and real-time decision making. Participants reported high satisfaction and psychological safety. CONCLUSION: The brainwriting premortem approach is a novel, efficient alternative to brainstorming focus groups that can rapidly inform program implementation at minimal cost.

Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care.

BACKGROUND: Despite a national focus on post-acute care brought about by recent payment reforms, relatively little is known about how hospitalized older adults and their caregivers decide whether to go to a skilled nursing facility (SNF) after hospitalization. OBJECTIVE: We sought to understand to what extent hospitalized older adults and their caregivers are empowered to make a high-quality decision about utilizing an SNF for post-acute care and what contextual or process elements led to satisfaction with the outcome of their decision once in SNF. DESIGN: Qualitative inquiry using the Ottawa Decision Support Framework (ODSF), a conceptual framework that describes key components of high-quality decision-making. PARTICIPANTS: Thirty-two previously community-dwelling older adults (≥ 65 years old) and 22 caregivers interviewed at three different hospitals and three skilled nursing facilities. MAIN MEASURES: We used key components of the ODSF to identify elements of context and process that affected decision-making and to what extent the outcome was characteristic of a high-quality decision: informed, values based, and not associated with regret or blame. KEY RESULTS: The most important contextual themes were the presence of active medical conditions in the hospital that made decision-making difficult, prior experiences with hospital readmission or SNF, relative level of caregiver support, and pressure to make a decision quickly for which participants felt unprepared. Patients described playing a passive role in the decision-making process and largely relying on recommendations from the medical team. Patients commonly expressed resignation and a perceived lack of choice or autonomy, leading to dissatisfaction with the outcome. CONCLUSIONS: Understanding and intervening to improve the quality of decision-making regarding post-acute care supports is essential for improving outcomes of hospitalized older adults. Our results suggest that simply providing information is not sufficient; rather, incorporating key contextual factors and improving the decision-making process for both patients and clinicians are also essential.

Impact of an open enrollment service on costs for Medicare Part D beneficiaries.

OBJECTIVE: The primary objective was to determine total estimated cost savings based on a patient's current medication regimen after comparing available Medicare Part D plans for the upcoming year by using a plan comparison platform. The secondary objective was to determine patient-centered concerns when considering a change in Part D plans. DESIGN: Review of an open enrollment service that included a patient survey and a Part D plan comparison. SETTING: This study took place at a single independent community pharmacy in northwest Alabama. PARTICIPANTS: Fifty-four patients eligible for Medicare Part D were included in this study. MAIN OUTCOME MEASURES: The study was a review of an open enrollment service that aids Medicare beneficiaries in selecting a Part D plan that best fits their needs. It included a patient survey and plan comparison using a plan comparison platform, during the 2015 Medicare open enrollment period (October 15 to December 7). The survey assessed patient demographics, pharmacy preferences, and cost concerns. Survey data were used to aid in plan selection and analysis to determine the most common patient-centered concerns when considering a change in plans. RESULTS: During the open enrollment period, 54 patients compared Medicare Part D plans. The majority of participants were female (57%) and ranged in age from 65-69 years (37%) to 70-74 years (25.9%). The majority of patients reported a preference for independent pharmacies (92.6%). Deductible (40.7%) was the biggest concern for patients when comparing the main cost variables for medication insurance. The average total cost difference per patient per year showed that each patient saved an average of $1166.46. CONCLUSION: The analysis of an independent pharmacy's open enrollment service determined that a plan comparison platform is a valuable tool in helping patients to compare and select cost-effective Medicare Part D prescription plans and in helping patients save money.

Nurses' Role in Managing "The Fit" of Older Adults in Skilled Nursing Facilities.

Post-acute care for older adults often involves transfer to a skilled nursing facility (SNF) following hospital discharge. This transition is often poorly coordinated and leaves older adults at risk for poor health outcomes, but new payment models offer opportunities to align improved care practices with payments. There is a dearth of evidence regarding the role of nursing and its potential to improve hospital to SNF care transitions. Ninety-nine semi-structured interviews were conducted with clinicians, patients, and caregivers from three hospitals and three SNFs. Results indicate a sharp contrast in the roles of hospital nurses-who are often silent partners in post-acute care decision making-and SNF nurses, who take a primary role as managing "the fit" for patients transitioning to a SNF. Nurses are uniquely positioned to make needed changes to culture to adapt to new payment models and improve patient outcomes. [Journal of Gerontological Nursing, 43(12), 11-20.].

When should a provider consider insulin human inhalation powder?

Insulin human inhalation powder, a rapid-acting inhaled insulin, was approved by the FDA in June 2014 for patients with type 1 or type 2 diabetes. For patients reluctant to start insulin therapy because of fear of injections, insulin human inhalation powder may be an alternative. This article discusses appropriate dosing, use, and monitoring.

Leadership and the high reliability transformation: A qualitative study at Truman VA medical center.

The Department of Veterans Affairs (VA) has committed to becoming a High Reliability Organization (HRO). The Truman VA Medical Center (VAMC) successfully implemented and sustained foundational HRO elements over a period with several changes in facility executive leadership. We interviewed current and past leaders at Truman to understand how they retained fidelity to the HRO transformation. We conducted 16 interviews with 14 leaders involved in the HRO transformation and identified three themes related to the Truman HRO transformation: (1) Leadership visibly drove culture change through intentional communication and modeling HRO principles; (2) Leadership deferred to frontline expertise and empowered staff to make changes and to fail; (3) Hiring the right team members for the organizational culture and investing in training can support HRO principles and values. Our findings highlight key actions for leaders in the context of HROs: regularly communicate the significance of HRO, demonstrate behavior consistent with what they hope to see from staff, celebrate failure, allocate time and resources to the creation of hiring frameworks that identify employee skillsets conducive to HRO principles, and substantial and recurring investments in employee development. Importantly, successive executive leaders at Truman VAMC modeled these skills to promote and sustain the HRO transformation.

Cluster-randomized implementation trial of two facilitation strategies to implement a novel information and communications technology at the Veterans Health Administration.

BACKGROUND: Information and communication technologies (ICTs) improve quality and efficiency of healthcare, but effective practices for implementing new ICTs are unknown. From 2019 to 2021, the Veterans Health Administration (VHA) implemented FLOW3, an ICT that facilitates prosthetic limb care. The goal of this study was to compare the impact of two facilitation strategies on FLOW3 adoption, implementation, and sustainment. METHODS: FLOW3 is a computerized workflow management system comprised of three applications that facilitate the three steps for prosthesis authorization. During VHA's implementation of FLOW3, we randomized 60 VHA sites to basic or enhanced facilitation groups. Basic facilitation included a manualized training toolkit and office hours. Enhanced facilitation included basic facilitation plus monthly learning collaboratives and site-specific performance reports. Outcomes included time to adoption of FLOW3 and complete FLOW3 utilization rates during implementation and sustainment periods. We compared outcomes between sites assigned to basic versus enhanced facilitation groups. Results were calculated using both intent-to-treat (ITT) and dose-response analyses. The dose-response analysis used a per-protocol approach and required sites in the enhanced facilitation group to join two of six learning collaboratives; sites that attended fewer were reassigned to the basic group. RESULTS: Randomization assigned 30 sites to enhanced facilitation and 30 to basic. Eighteen of 30 randomized sites were included in the enhanced facilitation group for dose-response analysis. During the implementation period, enhanced facilitation sites were significantly more likely to completely utilize FLOW3 than basic facilitation sites (HR: 0.17; 95% CI: 1.18, 4.53, p = 0.02) based on ITT analysis. In the dose-response analysis, the enhanced group was 2.32 (95% CI: 1.18, 4.53) times more likely to adopt FLOW3 than basic group (p = 0.014). CONCLUSIONS: Enhanced facilitation including a learning collaborative and customized feedback demonstrated greater likelihood for sites to complete a prosthetics consult using FLOW3 throughout our study. We identified statistically significant differences in likelihood of adoption using the dose-response analysis and complete utilization rate using ITT analysis during the implementation period. All sites that implemented FLOW3 demonstrated improvement in completion rate during the sustainment period, but the difference between facilitation groups was not statistically significant. Further study to understand sustainability is warranted.

Implementation of the Acute Inpatient Medicine-High Reliability, Learning Environment, and Workforce Development Initiative (AIM-HI) in rural Veterans Health Administration hospitals: A mixed methods evaluation protocol.

INTRODUCTION: Few rural hospital medicine programs include workforce development training that provides social and professional support for interdisciplinary teams. Even fewer include training that creates supportive learning environments that result in higher staff satisfaction, lower burnout, and reduced turnover. The Acute Inpatient Medicine-High Reliability, Learning Environment, and Workforce Development Initiative (AIM-HI) aims to create supportive learning environments in Veterans Health Administration (VA) rural hospital medicine teams. METHODS: AIM-HI is a type II hybrid implementation study utilizing a convergent mixed methods approach to evaluate the Relational Playbook, a workforce development intervention, and three implementation strategies: behavioral nudges, learning and leadership collaboratives, and leadership coaching. AIM-HI implementation will occur in waves, enrolling additional hospitals every 12 months. In the first wave, AIM-HI will be implemented at three tertiary VA hospitals that treat at least 1000 rural Veterans annually and have an active inpatient hospital medicine program. The primary outcomes in year 1 will be the acceptability, appropriateness, and feasibility of AIM-HI assessed through participant surveys and interviews. In subsequent years, trends in the learning environment, job satisfaction, burnout, and turnover scores will be assessed using a linear mixed-effect model. DISCUSSION: The anticipated impact of AIM-HI is to evaluate the utility of the implementation strategies and assess trends in Playbook intervention outcomes. The Playbook has strong face validity; however, before large-scale adoption across the VA enterprise, it is essential to establish the acceptability, appropriateness, and feasibility of the Playbook and implementation strategies, as well as to gather data on AIM-HI effectiveness.

Aneuploidy rates and likelihood of obtaining a usable embryo for transfer among in vitro fertilization cycles using preimplantation genetic testing for monogenic disorders and aneuploidy compared with in vitro fertilization cycles using preimplantation genetic testing for aneuploidy alone.

OBJECTIVE: To compare aneuploidy rates among in vitro fertilization (IVF) cycles using preimplantation genetic testing for monogenic disorders (PGT-M) and aneuploidy (PGT-A) compared with IVF cycles using PGT-A alone, and to determine the likelihood of obtaining at least one usable embryo in cycles using PGT-M+PGT-A compared with cycles using PGT-A alone. DESIGN: Retrospective cohort study. SETTING: Single genetics laboratory. PATIENT(S): All IVF cycles for patients aged 18-45 undergoing PGT-A with or without concurrent PGT-M at a single genetics laboratory from November 2019 to March 2023. INTERVENTION(S): Use of PGT-M+PGT-A vs. use of PGT-A alone. MAIN OUTCOME MEASURE(S): Per cycle aneuploidy rate stratified by age, and per cycle likelihood of obtaining at least one usable embryo stratified by age and inheritance pattern of monogenic disease. RESULT(S): A total of 72,522 IVF cycles were included; 4,255 cycles (5.9%) using PGT-M+PGT-A and 68,267 cycles (94.1%) using PGT-A alone. The PGT-M+PGT-A group was younger than the PGT-A alone group (<35 years old: 56.1% vs. 30.5%). The majority of PGT-M cycles were performed for autosomal dominant pathogenic variants (42.4%), followed by autosomal recessive (36.5%), X-linked dominant (13.3%), and X-linked recessive (7.5%). The median number of embryos biopsied was higher in PGT-A alone compared with PGT-M+PGT-A cycles for patients aged <35, but it was equivalent in all other age groups. Age stratified aneuploidy rates did not significantly differ between PGT-M+PGT-A compared with PGT-A alone cycles. The probability of having a usable embryo declined with increasing age across all inheritance patterns. Compared with PGT-A alone, PGT-M+PGT-A cycles for patients aged ≤40 across all inheritance patterns were significantly less likely to yield a usable embryo, except in cycles for autosomal recessive diseases in the 38-40 age group and X-linked recessive diseases in the 35-37 age group. There were no consistent differences seen between groups in patients over 40. Cycles for patients with autosomal dominant diseases had the lowest likelihood of yielding a usable embryo for patients aged <43. CONCLUSION(S): In vitro fertilization cycles using PGT-M+PGT-A have similar age-specific aneuploidy rates to those using PGT-A alone. Cycles for patients ≤40 using PGT-M+PGT-A are significantly less likely to yield a usable embryo compared with those using PGT-A alone.

An implementation strategy postmortem method developed in the VA rural Transitions Nurse Program to inform spread and scale-up.

BACKGROUND: High-quality implementation evaluations report on intervention fidelity and adaptations made, but a practical process for evaluating implementation strategies is needed. A retrospective method for evaluating implementation strategies is also required as prospective methods can be resource intensive. This study aimed to establish an implementation strategy postmortem method to identify the implementation strategies used, when, and their perceived importance. We used the rural Transitions Nurse Program (TNP) as a case study, a national care coordination intervention implemented at 11 hospitals over three years. METHODS: The postmortem used a retrospective, mixed method, phased approach. Implementation team and front-line staff characterized the implementation strategies used, their timing, frequency, ease of use, and their importance to implementation success. The Expert Recommendations for Implementing Change (ERIC) compilation, the Quality Enhancement Research Initiative phases, and Proctor and colleagues' guidance were used to operationalize the strategies. Survey data were analyzed descriptively, and qualitative data were analyzed using matrix content analysis. RESULTS: The postmortem method identified 45 of 73 ERIC strategies introduced, including 41 during pre-implementation, 37 during implementation, and 27 during sustainment. External facilitation, centralized technical assistance, and clinical supervision were ranked as the most important and frequently used strategies. Implementation strategies were more intensively applied in the beginning of the study and tapered over time. CONCLUSIONS: The postmortem method identified that more strategies were used in TNP than planned and identified the most important strategies from the perspective of the implementation team and front-line staff. The findings can inform other implementation studies as well as dissemination of the TNP intervention.

National Trends in Hospital Performance in Guideline-Recommended Pharmacologic Treatment for Heart Failure at Discharge.

BACKGROUND: The use of recommended heart failure (HF) medications has improved over time, but opportunities for improvement persist among women and at rural hospitals. OBJECTIVES: This study aims to characterize national trends in performance in the use of guideline-recommended pharmacologic treatment for HF at U.S. Department of Veterans Affairs (VA) hospitals, at which medication copayments are modest. METHODS: Among patients discharged from VA hospitals with HF between January 1, 2013, and December 31, 2019, receipt of all guideline-recommended HF pharmacotherapy among eligible patients was assessed, consisting of evidence-based beta-blockers; angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor neprilysin inhibitors; mineralocorticoid receptor antagonists; and oral anticoagulation. RESULTS: Of 55,560 patients at 122 hospitals, 32,304 (58.1%) received all guideline-recommended HF medications for which they were eligible. The proportion of patients receiving all recommended medications was higher in 2019 relative to 2013 (OR: 1.54; 95% CI: 1.44-1.65). The median of hospital performance was 59.1% (Q1-Q3: 53.2%-66.2%), improving with substantial variation across sites from 2013 (median 56.4%; Q1-Q3: 50.0%-62.0%) to 2019 (median 65.7%; Q1-Q3: 56.3%-73.5%). Women were less likely to receive recommended therapies than men (adjusted OR [aOR]: 0.84; 95% CI: 0.74-0.96). Compared with non-Hispanic White patients, non-Hispanic Black patients were less likely to receive recommended therapies (aOR: 0.83; 95% CI: 0.79-0.87). Urban hospital location was associated with lower likelihood of medication receipt (aOR: 0.73; 95% CI: 0.59-0.92). CONCLUSIONS: Forty-two percent of patients did not receive all recommended HF medications at discharge, particularly women, minority patients, and those receiving care at urban hospitals. Rates of use increased over time, with variation in performance across hospitals.