Barbara Simon

To use or not to use

AbstractBACKGROUND AND OBJECTIVE: Effects of advances in Department of Veterans Affairs (VA) women’s health care on women veterans’ health care decision making are unknown. Our objective was to determine why women veterans use or do not use VA health care. DESIGN AND PARTICIPANTS: Cross-sectional survey of 2,174 women veteran VA users and VA-eligible nonusers throughout southern California and southern Nevada. MEASUREMENTS: VA utilization, attitudes toward care, and socio-demographics. RESULTS: Reasons cited for VA use included affordability (67.9%); women’s health clinic (WHC) availability (58.8%); quality of care (54.8%); and convenience (47.9%). Reasons for choosing health care in non-VA settings included having insurance (71.0%); greater convenience of non-VA care (66.9%); lack of knowledge of VA eligibility and services (48.5%); and perceived better non-VA quality (34.5%). After adjustment for sociodemographics, health characteristics, and VA priority group, knowledge deficits about VA eligibility and services and perceived worse VA care quality predicted outside health care use. VA users were less likely than non-VA users to have after-hours access to nonemergency care, but more likely to receive both general and gender-related care from the same clinic or provider, to use a WHC for gender-related care, and to consider WHC availability very important. CONCLUSIONS: Lack of information about VA, perceptions of VA quality, and inconvenience of VA care, are deterrents to VA use for many women veterans. VA WHCs may foster VA use. Educational campaigns are needed to fill the knowledge gap regarding women veterans’ VA eligibility and advances in VA quality of care, while VA managers consider solutions to after-hours access barriers.

Quality improvement implementation in the nursing home

OBJECTIVE To examine quality improvement (QI) implementation in nursing homes, its association with organizational culture, and its effects on pressure ulcer care. DATA SOURCES/STUDY SETTING Primary data were collected from staff at 35 nursing homes maintained by the Department of Veterans Affairs (VA) on measures related to QI implementation and organizational culture. These data were combined with information obtained from abstractions of medical records and analyses of an existing database. STUDY DESIGN A cross-sectional analysis of the association among the different measures was performed. DATA COLLECTION/EXTRACTION METHODS Completed surveys containing information on QI implementation, organizational culture, employee satisfaction, and perceived adoption of guidelines were obtained from 1,065 nursing home staff. Adherence to best practices related to pressure ulcer prevention was abstracted from medical records. Risk-adjusted rates of pressure ulcer development were calculated from an administrative database. PRINCIPAL FINDINGS Nursing homes differed significantly (p<.001) in their extent of QI implementation with scores on this 1 to 5 scale ranging from 2.98 to 4.08. Quality improvement implementation was greater in those nursing homes with an organizational culture that emphasizes innovation and teamwork. Employees of nursing homes with a greater degree of QI implementation were more satisfied with their jobs (a 1-point increase in QI score was associated with a 0.83 increase on the 5-point satisfaction scale, p<.001) and were more likely to report adoption of pressure ulcer clinical guidelines (a 1-point increase in QI score was associated with a 28 percent increase in number of staff reporting adoption, p<.001). No significant association was found, though, between QI implementation and either adherence to guideline recommendations as abstracted from records or the rate of pressure ulcer development. CONCLUSIONS Quality improvement implementation is most likely to be successful in those VA nursing homes with an underlying culture that promotes innovation. While QI implementation may result in staff who are more satisfied with their jobs and who believe they are providing better care, associations with improved care are uncertain.

Perceived Barriers to Weight Management in Primary Care—Perspectives of Patients and Providers

BackgroundDespite the consequences of overweight and obesity, effective weight management is not occurring in primary care.ObjectiveTo identify beliefs about obesity that act as barriers to weight management in primary care by surveying both patients and providers and comparing their responses.DesignAnonymous, cross-sectional, self-administered survey of patients and providers of a Veteran’s Administration Primary Care Clinic, distributed at the clinic site.SubjectsForty-eight Internal Medicine providers and 488 patients.MeasurementsBeliefs, attitudes, and experiences with weight management as well as demographic characteristics were collected through a questionnaire.ResultsProviders 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.ConclusionProviders 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.

How Reliable is Pain as the Fifth Vital Sign

Background: Although many health care organizations require routine pain screening (eg, “5th vital sign”) with the 0 to 10 numeric rating scale (NRS), its accuracy has been questioned; here we evaluated its accuracy and potential causes for error. Methods: We randomly surveyed veterans and reviewed their charts after outpatient encounters at 2 hospitals and 6 affiliated community sites. Using correlation and receiver operating characteristic analysis, we compared the routinely measured “5th vital sign” (nurse-recorded NRS) with a research-administered NRS (research-recorded NRS) and the Brief Pain Inventory (BPI). Results: During 528 encounters, nurse-recorded NRS and research-recorded NRS correlated moderately (r = 0.627), as did nurse-recorded NRS and BPI severity scales (r = 0.613 for pain during the last 24 hours and r = 0.588 for pain during the past week). Correlation with BPI interference was lower (r = 0.409). However, the research-recorded NRS correlated substantially with the BPI severity during the past 24 hours (r = 0.870) and BPI severity during the last week (r = 0.840). Receiver operating characteristic analysis showed similar results. Of the 98% of cases where a numeric score was recorded, 51% of patients reported their pain was rated qualitatively, rather than with a 0 to 10 scale, a practice associated with pain underestimation (χ2 = 64.04, P < .001). Conclusion: Though moderately accurate, the outpatient “5th vital sign” is less accurate than under ideal circumstances. Personalizing assessment is a common clinical practice but may affect the performance of research tools such as the NRS adopted for routine use.

Adherence to Pressure Ulcer Prevention Guidelines: Implications for Nursing Home Quality

OBJECTIVES: This study aims to assess overall nursing home (NH) implementation of pressure ulcer (PU) prevention guidelines and variation in implementation rates among a geographically diverse sample of NHs.

Exposure to automated drug alerts over time: effects on clinicians' knowledge and perceptions.

Objective:We tested whether interval exposure to an automated drug alert system that included approximately 2000 drug–drug interaction alerts increased recognition of selected interacting drug pairs. We also examined other perceptions about computerized order entry. Research Design:We administered cross-sectional surveys in 2000 and 2002 that included more than 260 eligible clinicians in each time period. Subjects:We studied clinicians practicing in ambulatory settings within a Southern California Veterans Affairs Healthcare System and who responded to both surveys (97 respondents). Measures:We sought to measure (1) recognition of selected drug–drug and drug–condition interactions and (2) other benefits and barriers to using automated drug alerts. Results:Clinicians correctly categorized similar percentages of the 7 interacting drug–drug pairs at baseline and follow-up (53% vs. 54%, P = 0.51) but improved their overall recognition of the 3 contraindicated drug–drug pairs (51% vs. 60%, P = 0.01). No significant changes from baseline to follow-up were found for the 8 interacting drug–condition pairs (60% vs. 62%, P = 0.43) or the 4 contraindicated drug–condition pairs (52% vs. 56%, P = 0.24). More providers preferred using order entry at follow-up than baseline (63% vs. 45%, P < 0.001). Signal-to-noise ratio remained the biggest reported problem at follow-up and baseline (54 vs. 57%, P = 0.75). In 2002, clinicians reported seeing a median of 5 drug alerts per week (representing approximately 12.5% of prescriptions entered), with a median 5% reportedly leading to an action. Conclusions:Interval exposure to automated drug alerts had little to no effect on recognition of selected drug–drug interactions. The primary perceived barrier to effective utilization of drug alerts remained the same over time.

Availability of comprehensive women's health care through Department of Veterans Affairs Medical Center.

Despite increased numbers of women veterans, little is known about health services delivery to women across the Department of Veterans Affairs (VA). To assess VA availability of womens health services, we surveyed the senior clinician at each VA site serving 400 or more women veterans. We found that virtually all sites have developed arrangements, either directly or through off-site contracts, to ensure availability of comprehensive womens health care. On-site care, however, is routinely available only for basic services. Future work should evaluate cost and quality trade-offs between using non-VA sites to increase specialized service availability and using VA sites to enhance continuity of care.

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

BackgroundMeta-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.MethodsThe 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.ResultsInterviewers 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).ConclusionsDepression 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 RegistrationClinicalTrials.gov: NCT00105820

Increasing the Impact of Quality Improvement on Health: An Expert Panel Method for Setting Institutional Priorities

BACKGROUND Successful implementation of modern ongoing quality improvement (QI) methods requires investment of institutional resources, but can produce significant improvements in medical care. A health care organizations goals and objectives for improving care are expressed in strategic plan documents, which could provide a framework for planning quality improvement initiatives. However, institutional strategic planning processes are often not well linked to QI staff and resources. We developed the Quality Action Program (QAP) to connect QI to strategic planning. HISTORY In 1991, Sepulveda VHAMC implemented a major primary care initiative, documented in a comprehensive strategic plan. The QAP was developed to enable the initiative to be evaluated within a QI context. THREE-ROUND EXPERT PANEL PROCESS: To carry out the QAP, members of an institutions quality council engage in a structured consensus process. The first round involves reading educational materials and filling out a quality action survey the second round includes participation in an expert panel meeting, and the third round involves making final priority rankings. EIGHT-STEP QAP IMPLEMENTATION PLAN: QI staff carry out activities to prepare for and carry out the three-round expert panel process. RESULTS QAP induced significant institutional QI activity directed toward achieving the top-ranked QI criterion--ensuring continuity of care. Continuity of care improved significantly over time between the pre- and post-QAP periods. CONCLUSIONS Expert panel methods can be used to link strategic plan goals and objectives to QI efforts.

Human subjects protection issues in QUERI implementation research: QUERI Series.

BackgroundHuman Subjects protections approaches, specifically those relating to research review board oversight, vary throughout the world. While all are designed to protect participants involved in research, the structure and specifics of these institutional review boards (IRBs) can and do differ. This variation affects all types of research, particularly implementation research.MethodsIn 2001, we began a series of inter-related studies on implementing evidence-based collaborative care for depression in Veterans Health Administration primary care. We have submitted more than 100 IRB applications, amendments, and renewals, and in doing so, we have interacted with 13 VA and University IRBs across the United States (U.S.). We present four overarching IRB-related themes encountered throughout the implementation of our projects, and within each theme, identify key challenges and suggest approaches that have proved useful. Where applicable, we showcase process aids developed to assist in resolving a particular IRB challenge.ResultsThere are issues unique to implementation research, as this type of research may not fit within the traditional Human Subjects paradigm used to assess clinical trials. Risks in implementation research are generally related to breaches of confidentiality, rather than health risks associated with traditional clinical trials. The implementation-specific challenges discussed are: external validity considerations, Plan-Do-Study-Act cycles, risk-benefit issues, the multiple roles of researchers and subjects, and system-level unit of analysis.DiscussionSpecific aspects of implementation research interact with variations in knowledge, procedures, and regulatory interpretations across IRBs to affect the implementation and study of best methods to increase evidence-based practice. Through lack of unambiguous guidelines and local liability concerns, IRBs are often at risk of applying both variable and inappropriate or unnecessary standards to implementation research that are not consistent with the spirit of the Belmont Report (a summary of basic ethical principles identified by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research), and which impede the conduct of evidence-based quality improvement research. While there are promising developments in the IRB community, it is incumbent upon implementation researchers to interact with IRBs in a manner that assists appropriate risk-benefit determinations and helps prevent the process from having a negative impact on efforts to reduce the lag in implementing best practices.