Kelly H. Burkitt

A Preliminary Model of Wheelchair Service Delivery

OBJECTIVE To integrate and expand on previously published models of wheelchair service delivery, and provide a preliminary framework for developing more comprehensive, descriptive models of wheelchair service delivery for adults with spinal cord injury within the U.S. health care system. DESIGN Literature review and a qualitative analysis of in-depth interviews. SETTING Not applicable. PARTICIPANTS Ten academic, clinical, regulatory, and industry experts (Department of Veterans Affairs [VA] and non-VA) in wheelchair service delivery. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Interviewees were asked to discuss the full range of variables and stakeholders involved in wheelchair service delivery, and to limit their scope to the provision of primary subsequent or replacement chairs (not backup chairs) to adults within the United States. RESULTS Most experts we interviewed stressed that clients who require a wheelchair play a central role in the wheelchair service delivery process. Providers (including clinicians, rehabilitation engineers, and rehabilitation counselors) are also critical stakeholders. More so than in other health care settings, suppliers play an integral role in the provision of wheelchairs to clients and may significantly influence the appropriateness of the wheelchair provided. Suppliers often have a direct role in wheelchair service delivery through their interactions with the clinician and/or client. This model also identified a number of system-level factors (including facility administration and standards, policies, and regulations) that influence wheelchair service delivery and ultimately the appropriateness of the wheelchair provided. CONCLUSIONS We developed a detailed, descriptive model of wheelchair service delivery that integrates the delivery process and device outcomes, and includes the patient-level, provider-level, and system-level factors that may directly influence those processes and outcomes. We believe that this detailed model can help clinicians and researchers describe and consider the complexities of wheelchair service delivery. It can be used to identify factors that may be related to disparities in wheelchair service delivery and in the appropriateness of the wheelchair prescribed. Further, this model can help researchers and clinicians identify factors that may be related to disparities in wheelchair service delivery, and intervene to reduce such disparities.

Examining implicit bias of physicians who care for individuals with spinal cord injury: A pilot study and future directions.

Abstract Context Despite evidence that healthcare providers have implicit biases that can impact clinical interactions and decisions, implicit bias among physicians caring for individuals with spinal cord injury (SCI) has not been examined. Objective Conduct a pilot study to examine implicit racial bias of SCI physicians and its association with functioning and wellbeing for individuals with SCI. Design Combined data from cross-sectional surveys of individuals with SCI and their SCI physicians. Setting Four national SCI Model Systems sites. Participants Individuals with SCI (N = 162) and their SCI physicians (N = 14). Outcome measures SCI physicians completed online surveys measuring implicit racial (pro-white/anti-black) bias. Individuals with SCI completed questionnaires assessing mobility, physical independence, occupational functioning, social integration, self-reported health, depression, and life satisfaction. We used multilevel regression analyses to examine the associations of physician bias and outcomes of individuals with SCI. Results Physicians had a mean bias score of 0.62 (SD = 0.35), indicating a strong pro-white/anti-black bias. Greater physician bias was associated with disability among individuals with SCI in the domain of social integration (odds ratio = 4.80, 95% confidence interval (CI) = 1.44, 16.04), as well as higher depression (B = 3.24, 95% CI = 1.06, 5.41) and lower life satisfaction (B = −4.54, 95% CI= −8.79, −0.28). Conclusion This pilot study indicates that SCI providers are susceptible to implicit racial bias and provides preliminary evidence that greater implicit racial bias of physicians is associated with poorer psychosocial health outcomes for individuals with SCI. It demonstrates the feasibility of studying implicit bias among SCI providers and provides guidance for future research on physician bias and patient outcomes.

Veteran, Primary Care Provider, and Specialist Satisfaction With Electronic Consultation

Background Access to specialty care is challenging for veterans in rural locations. To address this challenge, in December 2009, the Veterans Affairs (VA) Pittsburgh Healthcare System (VAPHS) implemented an electronic consultation (e-consult) program to provide primary care providers (PCPs) and patients with enhanced specialty care access. Objective The aim of this quality improvement (QI) project evaluation was to: (1) assess satisfaction with the e-consult process, and (2) identify perceived facilitators and barriers to using the e-consult program. Methods We conducted semistructured telephone interviews with veteran patients (N=15), Community Based Outpatient Clinic (CBOC) PCPs (N=15), and VA Pittsburgh specialty physicians (N=4) who used the e-consult program between December 2009 to August 2010. Participants answered questions regarding satisfaction in eight domains and identified factors contributing to their responses. Results Most participants were white (patients=87%; PCPs=80%; specialists=75%) and male (patients=93%; PCPs=67%; specialists=75%). On average, patients had one e-consult (SD 0), PCPs initiated 6 e-consults (SD 6), and VAPHS specialists performed 17 e-consults (SD 11). Patients, PCPs, and specialty physicians were satisfied with e-consults median (range) of 5.0 (4-5) on 1-5 Likert-scale, 4.0 (3-5), and 3.5 (3-5) respectively. The most common reason why patients and specialists reported increased overall satisfaction with e-consults was improved communication, whereas improved timeliness of care was the most common reason for PCPs. Communication was the most reported perceived barrier and facilitator to e-consult use. Conclusions Veterans and VA health care providers were satisfied with the e-consult process. Our findings suggest that while the reasons for satisfaction with e-consult differ somewhat for patients and physicians, e-consult may be a useful tool to improve VA health care system access for rural patients.

The Association of Race, Cultural Factors, and Health-Related Quality of Life in Persons With Spinal Cord Injury

OBJECTIVE To examine the association of race and cultural factors with quality-of-life factors (participation, life satisfaction, perceived health status) in people with spinal cord injury (SCI). DESIGN Cross-sectional multisite study using structured questionnaires. SETTING Six National SCI Model Systems centers. PARTICIPANTS People with SCI (N=275; age ≥16y; SCI with discernable neurologic impairments; used power or manual wheelchair for >1y as primary means of mobility; nonambulatory except for exercise purposes). INTERVENTIONS None. MAIN OUTCOME MEASURES Participation (Craig Handicap Assessment and Reporting Technique Short Form); satisfaction (Satisfaction With Life Scale); and perceived health status (2 items from 36-Item Short Form Health Survey). RESULTS African American (n=96) with SCI reported more experiences of discrimination in health care, greater perceived racism, more health care system distrust, and lower health literacy than whites (n=156; P range, <.001-<.05). Participants who reported experiencing more discrimination in health care reported better occupational functioning (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.07-2.09; P<.05). Those who perceived more racism in health care settings reported better occupational functioning (OR, 1.65; 95% CI, 1.12-2.43; P<.05) and greater perceived health (β=.36; 95% CI, .05-.68; P<.05). Those who reported more distrust in the health care system reported better current health compared with 1 year ago (β=.38; 95% CI, .06-.69; P<.05). Those who reported better communication with their health care provider reported higher levels of mobility (OR, 1.5; 95% CI, 1.05-2.13; P<.05) and better general health (β=.27; 95% CI, .01-.53; P<.05). CONCLUSIONS In this cross-sectional study of people with SCI, higher levels of perceived discrimination and racism and better communication with health care providers were associated with an increase in participation and functioning and improvements in perceptions of well-being. These associations are different from those reported in other study populations and warrant confirmation in future prospective studies.

Physical activity counseling in overweight and obese primary care patients: Outcomes of the VA-STRIDE randomized controlled trial.

The purpose of this 2-arm randomized clinical trial was to evaluate the effectiveness of a 12-month, expert system-based, print-delivered physical activity intervention in a primary care Veteran population in Pittsburgh, Pennsylvania. Participants were not excluded for many health conditions that typically are exclusionary criteria in physical activity trials. The primary outcome measures were physical activity reported using the Community Healthy Activities Model Program for Seniors (CHAMPS) questionnaire and an accelerometer-based activity assessment at baseline, 6, and 12 months. Of the 232 Veterans enrolled in the study, 208 (89.7%) were retained at the 6-month follow-up and 203 (87.5%) were retained at 12 months. Compared to the attention control, intervention participants had significantly increased odds of meeting the U.S. recommended guideline of ≥ 150 min/week of at least moderate-intensity physical activity at 12 months for the modified CHAMPS (odds ratio [OR] = 2.86; 95% CI: 1.03–7.96; p = 0.04) but not at 6 months (OR = 1.54; 95% CI: 0.56–4.23; p = 0.40). Based on accelerometer data, intervention participants had significantly increased odds of meeting ≥ 150 min/week of moderate-equivalent physical activity at 6 months (OR = 6.26; 95% CI: 1.26–31.22; p = 0.03) and borderline significantly increased odds at 12 months (OR = 4.73; 95% CI: 0.98–22.76; p = 0.053). An expert system physical activity counseling intervention can increase or sustain the proportion of Veterans in primary care meeting current recommendations for moderate-intensity physical activity. Trial Registration Clinical trials.gov identifier: NCT00731094 URL: http://www.clinicaltrials.gov/ct2/show/NCT00731094.

Recruitment of veterans from primary care into a physical activity randomized controlled trial: the experience of the VA-STRIDE study

BackgroundMuch of the existing literature on physical activity (PA) interventions involves physically inactive individuals recruited from community settings rather than clinical practice settings. Recruitment of patients into interventions in clinical practice settings is difficult due to limited time available in the clinic, identification of appropriate personnel to efficiently conduct the process, and time-consuming methods of recruitment. The purpose of this report is to describe the approach used to identify and recruit veterans from the Veterans Affairs (VA) Pittsburgh Healthcare System Primary Care Clinic into a randomized controlled PA study.MethodsA sampling frame of veterans was developed using the VA electronic medical record. During regularly scheduled clinic appointments, primary care providers (PCPs) screened identified patients for safety to engage in moderate-intensity PA and willingness to discuss the study with research staff members. Research staff determined eligibility with a subsequent telephone screening call and scheduled a research study appointment, at which time signed informed consent and baseline measurements were obtained.ResultsOf the 3,482 veterans in the sampling frame who were scheduled for a primary care appointment during the study period, 1,990 (57.2%) were seen in the clinic and screened by the PCP; moderate-intensity PA was deemed safe for 1,293 (37.1%), 871 (25.0%) agreed to be contacted for further screening, 334 (9.6%) were eligible for the study, and 232 (6.7%) enrolled.ConclusionsUsing a semiautomated screening approach that combined an electronically-derived sampling frame with paper and pencil prescreening by PCPs and research staff, VA-STRIDE was able to recruit 1 in 15 veterans in the sampling frame. Using this approach, a high proportion of potentially eligible veterans were screened by their PCPs.Trial registrationClinical trials.gov identifier: NCT00731094.

Beyond β: Lessons Learned from Implementation of the Department of Veterans Affairs Methicillin‐Resistant Staphylococcus aureus Prevention Initiative

To describe the key strategies and potential pitfalls involved with implementing the Department of Veterans Affairs (VA) Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention Initiative in a qualitative evaluation, we conducted in-depth interviews with MRSA Prevention Coordinators at 17 VA beta sites at 2 time points during program implementation.

Assessing Processes of Care to Promote Timely Initiation of Antibiotic Therapy for Emergency Department Patients Hospitalized for Pneumonia

BACKGROUND A mixed-methods quality improvement (QI) project for patients with pneumonia hospitalized from the emergency department (ED) was undertaken to (1) delineate the basic steps in the flow of patient care from presentation in the ED to time to first antibiotic dose (TFAD), (2) identify perceived barriers to and facilitators of reduced TFAD within these steps, (3) describe QI strategies to improve TFAD rates, and (4) identify perceived strategies for facilities to enhance performance. METHODS The QI project was conducted at 10 lower- and 10 higher-performing Veterans Affairs hospitals on the basis of the proportion of patients whose TFAD was within four hours of presentation. An ED physician, an ED nurse, a radiologist, a pharmacist, and a quality manager from each site were invited to participate in a survey and focus group. RESULTS Of the 82 survey participants, 59 (72%) perceived that ordering and performing the chest radiograph was the step most frequently resulting in TFAD delays. Medical provider assessment, chest radiograph interpretation, ordering/obtaining blood cultures, and ordering/administering initial antibiotic therapy also caused TFAD delays. The most commonly perceived barriers were patient and x-ray equipment transportation delays and communication delays between providers. The most frequently used strategies to reduce TFAD were stocking antibiotics in the ED and physician education. Focus groups emphasized the importance of multifaceted QI approaches and a top-down hospital leadership style to improve TFAD performance. DISCUSSION TFAD relies on a series of complex, stepwise processes of care that involve numerous hospital departments and is often delayed by well-described barriers. Addressing these barriers, as well as involving facility leadership in setting institutional QI goals, could possibly improve performance on this pneumonia quality measure.