Leslie Taylor

Implementation of the Patient-Centered Medical Home in the Veterans Health Administration: Associations With Patient Satisfaction, Quality of Care, Staff Burnout, and Hospital and Emergency Department Use

IMPORTANCE In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation. OBJECTIVES To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes. DESIGN, SETTING, AND PARTICIPANTS We conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and (3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care. MAIN OUTCOMES AND MEASURES Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout. RESULTS Fifty-three items were included in the PACT Implementation Progress Index (Pi2). Compared with the 87 clinics in the lowest decile of the Pi2, the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care-sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency department use (188 vs 245 visits per 1000 patients; P < .001). CONCLUSIONS AND RELEVANCE The extent of PCMH implementation, as measured by the Pi2, was highly associated with important outcomes for both patients and providers. This measure will be used to track the effectiveness of implementing PACT over time and to elucidate the correlates of desired health outcomes.

Multiple imputation methods for treatment noncompliance and nonresponse in randomized clinical trials

Randomized clinical trials are a powerful tool for investigating causal treatment effects, but in human trials there are oftentimes problems of noncompliance which standard analyses, such as the intention-to-treat or as-treated analysis, either ignore or incorporate in such a way that the resulting estimand is no longer a causal effect. One alternative to these analyses is the complier average causal effect (CACE) which estimates the average causal treatment effect among a subpopulation that would comply under any treatment assigned. We focus on the setting of a randomized clinical trial with crossover treatment noncompliance (e.g., control subjects could receive the intervention and intervention subjects could receive the control) and outcome nonresponse. In this article, we develop estimators for the CACE using multiple imputation methods, which have been successfully applied to a wide variety of missing data problems, but have not yet been applied to the potential outcomes setting of causal inference. Using simulated data we investigate the finite sample properties of these estimators as well as of competing procedures in a simple setting. Finally we illustrate our methods using a real randomized encouragement design study on the effectiveness of the influenza vaccine.

A First Look at PCMH Implementation for Minority Veterans: Room for Improvement.

Background:Implementation of Patient Aligned Care Teams (PACT), a patient-centered medical home model, has been inconsistent among the >900 primary care facilities in the Veterans Health Administration. Objective:Estimate if the degree of PACT implementation at a facility varied with the percentage of minority veteran patients at the facility. Research Design:Cross-sectional, facility-level analysis of PACT implementation measures in 2012. Subjects:Veterans Health Administration hospital-based and community-based primary care facilities. Measures:We used a previously validated PACT Implementation Progress Index (Pi2) and its 8 domains: access, continuity of care, care coordination, comprehensiveness, self-management support, and patient-centered care and communication, shared decision-making domains, and team functioning. Facilities were categorized as low (<5.2%, n=208), medium (5.2%–25.8%, n=413), and high (>25.8%, n=206) percent minority based on the percent of their own veteran population. Results:Most minority veterans received care in high minority (69%) and medium minority facilities (29%). In adjusted analyses, medium and high minority facilities scored 0.773 (P=0.009) and 0.930 (P=0.008) points lower on the Pi2 score relative to low minority facilities. Relative to low minority facilities, both medium and high minority facilities were less likely of having high Pi2 scores (≥2) and more likely of having low Pi2 scores (⩽−2). Both medium and high minority facilities had the same 3 domain scores lower than low minority facilities (care coordination, comprehensiveness, and self-management). Conclusion:Overall PACT implementation varied with respect to the racial/ethnic composition of a facility, with medium and high minority facilities having a lower implementation scores.

Peer Support for Achieving Independence in Diabetes (Peer-AID): Design, methods and baseline characteristics of a randomized controlled trial of community health worker assisted diabetes self-management support ☆

BACKGROUND & OBJECTIVES Community health workers (CHWs) may be an important mechanism to provide diabetes self-management to disadvantaged populations. We describe the design and baseline results of a trial evaluating a home-based CHW intervention. METHODS & RESEARCH DESIGN Peer Support for Achieving Independence in Diabetes (Peer-AID) is a randomized, controlled trial evaluating a home-based CHW-delivered diabetes self-management intervention versus usual care. The study recruited participants from 3 health systems. Change in A1c measured at 12 months is the primary outcome. Changes in blood pressure, lipids, health care utilization, health-related quality of life, self-efficacy and diabetes self-management behaviors at 12 months are secondary outcomes. RESULTS A total of 1438 patients were identified by a medical record review as potentially eligible, 445 patients were screened by telephone for eligibility and 287 were randomized. Groups were comparable at baseline on socio-demographic and clinical characteristics. All participants were low-income and were from diverse racial and ethnic backgrounds. The mean A1c was 8.9%, mean BMI was above the obese range, and non-adherence to diabetes medications was high. The cohort had high rates of co-morbid disease and low self-reported health status. Although one-third reported no health insurance, the mean number of visits to a physician in the past year was 5.7. Trial results are pending. CONCLUSIONS Peer-AID recruited and enrolled a diverse group of low income participants with poorly controlled type 2 diabetes and delivered a home-based diabetes self-management program. If effective, replication of the Peer-AID intervention in community based settings could contribute to improved control of diabetes in vulnerable populations.

Teledermatology in the diagnosis of melanoma.

Summary We conducted a retrospective chart review of US Veterans in the Pacific Northwest area to compute melanoma incidence and Breslow depth at diagnosis. We compared Veterans with access to teledermatology (TD) and those without (non-TD). We identified pathology-confirmed primary melanomas in Veterans who had had at least one encounter at a VA facility during a 3-year study period. The age-adjusted melanoma incidence for all, TD and non-TD Veterans was 36, 15 and 57 per 100,000, respectively. The mean Breslow depth was significantly greater in the TD group (P = 0.03). Although a higher proportion of thin (Breslow depth ≤1 mm) TD melanomas were mitotically active, this difference was not significant. We also found that 180 (40%) of the non-TD (face-to-face) diagnosed melanomas were from Veterans living in areas where TD was available. This suggests that the higher melanoma incidence in the non-TD group was mainly due to under-utilization of TD services. The study demonstrated that the TD service was not fully utilized in the VISN20 region, although the reasons for this are not clear. Where TD was utilized it tended to diagnose more advanced melanomas with worse initial prognosis.

Patient-centered Medical Home Implementation and Burnout Among Va Primary Care Employees

Burnout is widespread throughout primary care and is associated with negative consequences for providers and patients. The relationship between the patient-centered medical home model and burnout remains unclear. Using survey data from 8135 and 7510 VA primary care employees in 2012 and 2013, respectively, we assessed whether clinic-level medical home implementation was independently associated with burnout prevalence and estimated whether burnout changed among this workforce from 2012 to 2013. Adjusting for differences in respondent and clinic characteristics, we found that burnout was common among primary care employees, increased by 3.9% from 2012 to 2013, and was not associated with the extent of medical home implementation.

Evidence-based chronic ulcer care and lower limb outcomes among Pacific Northwest veterans

Evidence‐based ulcer care guidelines detail optimal components of care for treatment of ulcers of different etiologies. We investigated the impact of providing specific evidence‐based ulcer treatment components on healing outcomes for lower limb ulcers (LLU) among veterans in the Pacific Northwest. Components of evidence‐based ulcer care for venous, arterial, diabetic foot ulcers/neuropathic ulcers were abstracted from medical records. The outcome was ulcer healing. Our analysis assessed the relationship between evidence‐based ulcer care by etiology, components of care provided, and healing, while accounting for veteran characteristics. A minority of veterans in all three ulcer‐etiology groups received the recommended components of evidence‐based care in at least 80% of visits. The likelihood of healing improved when assessment for edema and infection were performed on at least 80% of visits (hazard ratio [HR] = 3.20, p = 0.009 and HR = 3.54, p = 0.006, respectively) in patients with venous ulcers. There was no significant association between frequency of care components provided and healing among patients with arterial ulcers. Among patients with diabetic/neuropathic ulcers, the chance of healing increased 2.5‐fold when debridement was performed at 80% of visits (p = 0.03), and doubled when ischemia was assessed at the first visit (p = 0.045). Veterans in the Pacific Northwest did not uniformly receive evidence‐based ulcer care. Not all evidence‐based ulcer care components were significantly associated with healing. At a minimum, clinicians need to address components of ulcer care associated with improved ulcer healing.

Medicare-VHA dual use is associated with poorer chronic wound healing

Veterans who use Veterans Health Affairs (VHA) have the option of enrolling in and obtaining care from other non‐VA sources. Dual system use may improve care by increasing options or it may result in poorer outcomes because of fragmented care. Our objective was to assess whether dual system use of VHA and Medicare for wound care was associated with chronic wound healing. We conducted a retrospective cohort study of 227 Medicare‐enrolled VHA users in the Pacific Northwest who had an incident, chronic lower limb wound between October 1, 2006 and September 30, 2007 identified through VHA chart review. All wounds were followed until resolution or for up to one year. Dual system wound care was identified through Medicare claims during follow‐up. We used a proportional hazards model to compare wound healing among VHA‐exclusive and dual wound care users, using a time‐varying measure of dual use and treating amputation and death as competing risks. About 18.1% of subjects were classified as dual wound care users during follow‐up. After adjustment using propensity scores, dual use was associated with a significantly lower hazard of wound healing compared to VHA‐exclusive use (HR = 0.63, 95%CI: 0.39–0.99, p = 0.047). Hazards for the competing risks, amputation (HR = 4.23, 95% CI: 1.61–11.15, p = 0.003) and death (HR = 3.08, 95%CI: 1.11–8.56, p = 0.031), were significantly higher for dual users compared to VHA‐exclusive users. Results were similar in inverse probability of treatment weighted analyses and in sensitivity analyses that excluded veterans enrolled in a Medicare managed care plan and that used a revised wound resolution date based on Medicare claims data, but were not always statistically significant. Overall, dual wound care use was associated with substantially poorer wound healing compared to VHA‐exclusive wound care use. VHA may need to design programs or policies that support and improve care coordination for veterans needing chronic wound care.

Veteran peer Coaches Optimizing and Advancing Cardiac Health (Vet-COACH); design and rationale for a randomized controlled trial of peer support among Veterans with poorly controlled hypertension and other CVD risks

BACKGROUND Peer support can improve health for patients with chronic conditions; however, evidence for disease prevention is less clear and peer recruitment strategies are not well described. This paper describes a study protocol to evaluate a peer support intervention to improve hypertension control and reduce cardiovascular disease (CVD) risk. METHODS & RESEARCH DESIGN Target enrollment for this two-site study is n = 400. Eligibility criteria include Veterans enrolled in Veterans Health Administration (VHA) primary care with poorly controlled hypertension and one other cardiovascular disease risk (smoking, overweight/obesity, or hyperlipidemia) who live in census tracts with high rates of hypertension. Enrolled participants are randomized to a home-based peer delivered self-management intervention (5 home visits and 5 phone calls with a peer health coach) versus usual care. The primary outcome is a change in systolic blood pressure (SBP) and secondary outcomes include change in CVD risk and health care use. RESULTS Trial results are pending and participant enrollment is ongoing. We recruited peer coaches from Veterans who lived in census tracks with the highest rates of hypertension. To recruit Veteran peer coaches, we asked primary care providers (n = 41) and team nurses (n = 35) to nominate patients who they thought would be a good fit for the peer coach position (based on successful self-management and health care navigation) (n = 73 nominated from 964 patients). We interviewed 12 Veterans and trained 5 peer coaches. CONCLUSIONS Results of this trial will inform peer support programs targeted to provide community-based delivery of prevention services to patients in high-risk areas. TRIAL REGISTRATION Clinicaltrial.gov identifier NCT02697422 TRIAL STATUS: Enrollment for the randomized trial phase began in September 2017 and will be complete September 2019.

Clinical Quality and the Patient-Centered Medical Home

Services Research, American Cancer Society, 250 Williams St NW, Atlanta, GA 30303 (stacey.fedewa@cancer.org). Published Online: April 24, 2017. doi:10.1001/jamainternmed.2017.0340 Author Contributions: Dr Fedewa had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition, analysis, or interpretation of data: Fedewa, Brawley, Jemal. Drafting of the manuscript: Fedewa, Brawley. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Fedewa, Brawley. Administrative, technical, or material support: Fedewa. Supervision: Fedewa, Jemal. Conflict of Interest Disclosures: None reported. Funding/Support: This study was supported by the American Cancer Society. Role of the Funder/Sponsor: Staff members of the Surveillance and Health Services Research Program of the American Cancer Society played a role in the design and conduct of the study; and collection, management, analysis, and interpretation of the data. No staff members at the American Cancer Society, other than the study authors, played any role in the preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. 1. Moyer VA; U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(2):120-134. 2. Wolf AM, Wender RC, Etzioni RB, et al; American Cancer Society Prostate Cancer Advisory Committee. American Cancer Society guideline for the early detection of prostate cancer: update 2010. CA Cancer J Clin. 2010;60(2):70-98. 3. Jemal A, Fedewa SA, Ma J, et al. Prostate cancer incidence and PSA testing patterns in relation to USPSTF screening recommendations. JAMA. 2015;314 (19):2054-2061. 4. US Department of Health and Human Services. National Health Interview Survey: Survey Description. Hyattsville, MD: National Center for Health Statistics; 2016. 5. Rauscher GH, Johnson TP, Cho YI, Walk JA. Accuracy of self-reported cancer-screening histories: a meta-analysis. Cancer Epidemiol Biomarkers Prev. 2008;17(4):748-757. 6. Hu JC, Nguyen P, Mao J, et al. Increase in prostate cancer distant metastases at diagnosis in the United States [published online December 29, 2016]. JAMA Oncol. doi:10.1001/jamaoncol.2016.5465