Megan E. Vanneman

Hospital adoption of automated surveillance technology and the implementation of infection prevention and control programs

BACKGROUND This research analyzes the relationship between hospital use of automated surveillance technology (AST) for identification and control of hospital-acquired infections (HAI) and implementation of evidence-based infection control practices. Our hypothesis is that hospitals that use AST have made more progress implementing infection control practices than hospitals that rely on manual surveillance. METHODS A survey of all acute general care hospitals in California was conducted from October 2008 through January 2009. A structured computer-assisted telephone interview was conducted with the quality director of each hospital. The final sample includes 241 general acute care hospitals (response rate, 83%). RESULTS Approximately one third (32.4%) of Californias hospitals use AST for monitoring HAI. Adoption of AST is statistically significant and positively associated with the depth of implementation of evidence-based practices for methicillin-resistant Staphylococcus aureus and ventilator-associated pneumonia and adoption of contact precautions and surgical care infection practices. Use of AST is also statistically significantly associated with the breadth of hospital implementation of evidence-based practices across all 5 targeted HAI. CONCLUSION Our findings suggest that hospitals using AST can achieve greater depth and breadth in implementing evidenced-based infection control practices.

Mandatory Public Reporting Of Hospital-Acquired Infection Rates: A Report From California

One way to motivate hospitals to improve patient safety is to publicly report their rates of hospital-acquired infections, as California is starting to do this year. We conducted a baseline study of Californias acute care hospitals just before mandatory reporting of hospital-acquired infection rates to the state began, in 2008. We found variability in many areas: For example, 70.1 percent of hospitals said that they were fully implementing evidence-based guidelines to fight infection by methicillin-resistant Staphylococcus aureus, but 22.8 percent of hospitals had not adopted any. Our analysis showed that rural hospitals, many of which lack resources to implement needed procedures, faced the greatest challenges in reporting and improving infection rates. Our findings should be of interest to Medicare policy makers who will implement the hospital-acquired infection performance measures in the Affordable Care Act, and to leaders in the thirty-eight states that have enacted legislation requiring reports of hospital-acquired infection rates. Californias baseline data also present a unique opportunity to assess the impact of mandatory and public reporting laws.

Patient Safety Climate: Variation in Perceptions by Infection Preventionists and Quality Directors

Background. Healthcare-associated infections (HAIs) are an important patient safety issue, and safety climate is an important organizational factor. This study explores perceptions of infection preventionists (IPs) and quality directors (QDs) regarding two safety microclimates, Senior Management Engagement (SME) and Leadership on Patient Safety (LOPS), across California hospitals. Methods. This was an analysis of two cross-sectional surveys. We conducted Wilcoxon signed-rank test, univariate analyses, and a multivariate ordinary least square regression. Results. There were 322 eligible hospitals; 149 hospitals (46.3%) responded to both surveys. The IP response rate was 59%, and the QD response rate was 79.5%. We found IPs perceived SME more positively than did QDs (21.4 vs. 20.4, P < 0.01). No setting characteristics predicted variation in perceptions. Presence of an independent budget predicted more positive perceptions of microclimates across personnel types (P < 0.01). Conclusions. Differences in perceptions continue to exist between essential leaders in acute health care settings which could have critical effects on outcomes such as HAIs. Having an independent budget for the infection prevention and control department may enhance the overall safety climate and in turn patient care.

Are Improvements in Measured Performance Driven by Better Treatment or "Denominator Management"?

ABSTRACTBACKGROUNDProcess measures of healthcare quality are usually formulated as the number of patients who receive evidence-based treatment (numerator) divided by the number of patients in the target population (denominator). When the systems being evaluated can influence which patients are included in the denominator, it is reasonable to wonder if improvements in measured quality are driven by expanding numerators or contracting denominators.OBJECTIVEIn 2003, the US Department of Veteran Affairs (VA) based executive compensation in part on performance on a substance use disorder (SUD) continuity-of-care quality measure. The first goal of this study was to evaluate if implementing the measure in this way resulted in expected improvements in measured performance. The second goal was to examine if the proportion of patients with SUD who qualified for the denominator contracted after the quality measure was implemented, and to describe the facility-level variation in and correlates of denominator contraction or expansion.DESIGNUsing 40 quarters of data straddling the implementation of the performance measure, an interrupted time series design was used to evaluate changes in two outcomes.PARTICIPANTSAll veterans with an SUD diagnosis in all VA facilities from fiscal year 2000 to 2009.MAIN MEASURESThe two outcomes were 1) measured performance—patients retained/patients qualified and 2) denominator prevalence—patients qualified/patients with SUD program contact.KEY RESULTSMeasured performance improved over time (P < 0.001). Notably, the proportion of patients with SUD program contact who qualified for the denominator decreased more rapidly after the measure was implemented (p = 0.02). Facilities with higher pre-implementation denominator prevalence had steeper declines in denominator prevalence after implementation (p < 0.001).CONCLUSIONSThese results should motivate the development of measures that are less vulnerable to denominator management, and also the exploration of “shadow measures” to monitor and reduce undesirable denominator management.

Impact of participation in the California Healthcare-Associated Infection Prevention Initiative on adoption and implementation of evidence-based practices for patient safety and health care–associated infection rates in a cohort of acute care general hospitals

BACKGROUND In 2008, hospitals were selected to participate in the California Healthcare-Associated Infection Prevention Initiative (CHAIPI). This research evaluates the impact of CHAIPI on hospital adoption and implementation of evidence-based patient safety practices and reduction of health care-associated infection (HAI) rates. METHODS Statewide computer-assisted telephone surveys of Californias general acute care hospitals were conducted in 2008 and 2010 (response rates, 80% and 76%, respectively). Difference-in-difference analyses were used to compare changes in process and HAI rate outcomes in CHAIPI hospitals (n = 34) and non-CHAIPI hospitals (n = 149) that responded to both waves of the survey. RESULTS Compared with non-CHAIPI hospitals, CHAIPI hospitals demonstrated greater improvements between 2008 and 2010 in adoption (P = .021) and implementation (P = .012) of written evidence-based practices for overall patient safety and prevention of HAIs and in assessing their compliance (P = .033) with these practices. However, there were no significant differences in the changes in HAI rates between CHAIPI and non-CHAIPI hospitals over this time period. CONCLUSIONS Participation in the CHAIPI collaborative was associated with significant improvements in evidence-based patient safety practices in hospitals. However, determining how evidence-based practices translate into changes in HAI rates may take more time. Our results suggest that all hospitals be offered the opportunity to participate in an active learning collaborative to improve patient safety.

Iraq and Afghanistan Veterans’ Use of Veterans Health Administration and Purchased Care Before and After Veterans Choice Program Implementation

Background: The Veterans Choice Program (VCP), enacted by Congress after concerns surfaced about access, enables veterans to receive care outside Veterans Health Administration (VHA) facilities. Veterans who face long wait times, large driving distances, or particular hardships are eligible for VCP. Prior purchased care programs were comparatively limited in scope. Objectives: We sought to describe utilization of VHA-provided and purchased outpatient care by veterans eligible for VCP before and after VCP implementation. We focused on veterans recently eligible for VHA as they are of particular policy relevance and might have less established care patterns. Research Design: We identified all Iraq and Afghanistan veterans who were eligible for VCP in 2015. We tabulated their use of VHA and purchased outpatient care for 3 years before (FY2012–2014) and 1 year after VCP implementation (FY2015). Subjects: Our study population consisted of 214,449 Iraq and Afghanistan veterans who were eligible for VCP due to wait-time, distance, or hardship issues. Results: In the first year of the program, 3821 (2%) of these Iraq and Afghanistan veterans used non-VHA services through VCP. Per capita VHA utilization tended to decline slightly after VCP implementation, but these changes varied by type of outpatient care. Conclusions: There was low uptake of VCP services in the first year of the program. Data from additional years are needed to better understand the impact of this policy.

Patient-aligned Care Team Engagement to Connect Veterans Experiencing Homelessness With Appropriate Health Care

Background: Veterans experiencing homelessness frequently use emergency and urgent care (ED). Objective: To examine the effect of a Patient-aligned Care Team (PACT) model tailored to the unique needs of Veterans experiencing homelessness (H-PACT) on frequency and type of ED visits in Veterans Health Administration (VHA) medical facilities. Research Design: During a 12-month period, ED visits for 3981 homeless Veterans enrolled in (1) H-PACT at 20 VHA medical centers (enrolled) were compared with those of (2) 24,363 homeless Veterans not enrolled in H-PACT at the same sites (nonenrolled), and (3) 23,542 homeless Veterans at 12 non-H-PACT sites (usual care) using a difference-in-differences approach. Measure(s): The primary outcome was ED and other health care utilization and the secondary outcome was emergent (not preventable/avoidable) ED visits. Results: H-PACT enrollees were predominantly white males with a higher baseline Charlson comorbidity index. In comparing H-PACT enrollees with usual care, there was a significant decrease in ED usage among the highest ED utilizers (difference-in-differences, −4.43; P<0.001). The decrease in ED visits were significant though less intense for H-PACT enrollees versus nonenrolled (−0.29, P<0.001). H-PACT enrollees demonstrated a significant increase in the proportion of ED care visits that were not preventable/avoidable in the 6 months after enrollment, but had stable rates of primary care, mental health, social work, and substance abuse visits over the 12 months. Conclusions: Primary care treatment engagement can reduce ED visits and increase appropriate use of ED services in VHA for Veterans experiencing homelessness, especially in the highest ED utilizers.

Use of Veterans Affairs and Medicaid Services for Dually Enrolled Veterans

OBJECTIVES To examine how dual coverage for nonelderly, low-income veterans by Veterans Affairs (VA) and Medicaid affects their demand for care. DATA SOURCES Veterans Affairs utilization data and Medicaid Analytic Extract Files. STUDY DESIGN A retrospective, longitudinal study of VA users prior to and following enrollment in Medicaid 2006-2010. DATA COLLECTION/EXTRACTION METHODS Veterans Affairs reliance, or proportion of care provided by VA, was estimated with beta-binomial models, adjusting for patient and state Medicaid program factors. PRINCIPAL FINDINGS In a cohort of 19,890 nonelderly veterans, VA utilization levels were similar before and after enrolling in Medicaid. VA outpatient reliance was 0.65, and VA inpatient reliance was 0.53 after Medicaid enrollment. Factors significantly associated with greater VA reliance included sociodemographic factors, having a service-connected disability, comorbidity, and higher state Medicaid reimbursement. Factors significantly associated with less VA reliance included months enrolled in Medicaid, managed care enrollment, Medicaid eligibility type, longer drive time to VA care, greater Medicaid eligibility generosity, and better Medicaid quality. CONCLUSION Veterans Affairs utilization following new Medicaid enrollment remained relatively unchanged, and the VA continued to provide the large majority of care for dually enrolled veterans. There was variation among patients as Medicaid eligibility and other program factors influenced their use of Medicaid services.

Predictive validity of a quality measure for intensive substance use disorder treatment

ABSTRACT Background: Measures of substance use disorder (SUD) treatment quality are essential tools for performance improvement. The Veterans Health Administration (VHA) developed a measure of access to and engagement in intensive outpatient programs (IOPs) for SUD. However, predictive validity, or associations between this measure and treatment outcomes, has not been examined. Methods: Data on veterans with SUD came from 3 samples: the Outcomes Monitoring Project (N = 5436), a national evaluation of VHA mental health services (N = 339,887), and patients receiving detoxification services (N = 23,572). Propensity score–weighted mixed-effects regressions modeled associations between receiving at least 1 week of IOP treatment and patient outcomes, controlling for facility-level performance and a random effect for facility. Results: Propensity score weighting reduced or eliminated observable baseline differences between patient groups. Patients who accessed IOPs versus those who did not reported significantly reduced alcohol- and drug-related symptom severity, with significantly fewer past-month days drinking alcohol (b = 1.83, P < .001) and fewer past-month days intoxicated (b = 1.55, P < .001). Patients who received IOP after detoxification services had higher 6-month utilization of SUD outpatient visits (b = 2.09, P < .001), more subsequent detoxification episodes (b = 0.25, P < .001), and lower odds of 2-year mortality (odds ratio [OR] = 0.68, 95% confidence interval [CI]: 0.61–0.75; P < .001). Conclusions: Receiving at least 1 week of SUD treatment in an IOP was associated with higher follow-up utilization, improved health outcomes, and reduced mortality. These associations lend support to the predictive validity of VHAs IOP quality measure. Future research should focus on measure feasibility and validity outside of VHA, and whether predictive validity is maintained once this quality measure is tied to performance incentives.

Linking the Legislative Process to the Consequences of Realigning California’s Public Mental Health System

In 1991, California transferred significant responsibility, resources, and accountability for public mental health from the state to its 58 counties. Using purposeful sampling, we conducted in-depth interviews with ten senior state and county leaders to gain insights into the relatively uncharted area of their understanding of this legislation’s intent, development, and long-term consequences. While realignment secured funding for the system and provided incentives and flexibility for counties to move toward providing more community-based care, the decision to base realignment allocations on counties’ historical spending along with minimal payments to address differences helped to institutionalize spending disparities. Results of this study can inform how we develop and implement decentralization policies.