Salva N. Balbale

Through Their Eyes: Lessons Learned Using Participatory Methods in Health Care Quality Improvement Projects

In this methodological article, we examine participatory methods in depth to demonstrate how these methods can be adopted for quality improvement (QI) projects in health care. We draw on existing literature and our QI initiatives in the Department of Veterans Affairs to discuss the application of photovoice and guided tours in QI efforts. We highlight lessons learned and several benefits of using participatory methods in this area. Using participatory methods, evaluators can engage patients, providers, and other stakeholders as partners to enhance care. Participant involvement helps yield actionable data that can be translated into improved care practices. Use of these methods also helps generate key insights to inform improvements that truly resonate with stakeholders. Using participatory methods is a valuable strategy to harness participant engagement and drive improvements that address individual needs. In applying these innovative methodologies, evaluators can transcend traditional approaches to uniquely support evaluations and improvements in health care.

Health Care Employee Perceptions of Patient-Centered Care

Given the importance of health care employees in the delivery of patient-centered care, understanding their unique perspectives is essential for quality improvement. The purpose of this study was to use photovoice to evaluate perceptions and experiences around patient-centered care among U.S. Veterans Affairs (VA) health care employees. We asked participants to take photographs of salient features in their environment related to patient-centered care. We used the photographs to facilitate dialogue during follow-up interviews. Twelve VA health care employees across two VA sites participated in the project. Although most participants felt satisfied with their work environment and experiences at the VA, they identified several areas for improvement. These included a need for more employee health and wellness initiatives and a need for enhanced opportunities for training and professional growth. Application of photovoice enabled us to learn about employees’ unique perspectives around patient-centered care while engaging them in an evaluation of care delivery.

Community-associated Clostridium difficile infection among veterans with spinal cord injury and disorder

The impact of community-associated Clostridium difficile infection (CA-CDI) on patients with spinal cord injuries and disorders (SCI/Ds) is not fully understood. We examined CA-CDI cases among veterans with SCI/D, comparing them with community-onset, healthcare facility-associated (CO-HCFA) cases. Generally, patients with CA-CDI had less comorbidity, less severe CDI, and lower likelihood of antibiotic exposure.

Evaluation and Treatment of Mild Traumatic Brain Injury Through the Implementation of Clinical Video Telehealth: Provider Perspectives From the Veterans Health Administration

Substantial numbers of U.S. military veterans who served in recent conflicts experience mild traumatic brain injury. Data suggest that as many as 25% of veterans do not have a comprehensive traumatic brain injury evaluation to determine a diagnosis and develop a plan to treat symptoms. Technologies like clinical video telehealth offer a potential means to overcome travel distance and other barriers that can impact veteran receipt of a comprehensive traumatic brain injury evaluation after a positive screening; however, little is known about implementing clinical video telehealth in this context.

Sociotechnical Perspective on Implementing Clinical Video Telehealth for Veterans with Spinal Cord Injuries and Disorders

BACKGROUND Real-time videoconferencing technology such as clinical video telehealth (CVT) offers a means to reach patient populations who face limited access to healthcare. The Veterans Health Administration has invested in CVT to improve care access for U.S. military veterans with spinal cord injuries and disorders (SCI/D); however, no studies have assessed the factors that influence implementation of this technology in clinical practice for individuals with SCI/D. INTRODUCTION Guided by a sociotechnical perspective, the purpose of this study was to identify factors that influence implementation of CVT for veterans with SCI/D. MATERIALS AND METHODS We conducted semistructured telephone interviews with 40 healthcare providers who use CVT to deliver services to veterans with SCI/D. RESULTS Factors related to workflow and communication were widely reported as implementation barriers. Coordinating logistics for CVT appointments was challenging, and effective communication between CVT team members across facilities was considered crucial. Providers also cited factors related to technical infrastructure, people, and organizational features, including the need for appropriate equipment, space, personnel, and support for using CVT equipment. DISCUSSION The implementation of CVT in the care of veterans with SCI/D was influenced by an interrelated set of social and technical factors. Key among them were social factors related to people, workflow, and communication, given that CVT supports healthcare teams interacting remotely in real time. CONCLUSIONS CVT implementation requires teams working together to negotiate a complex, distributed process across multiple sites. Such complexity places a premium on teamwork and communication among healthcare teams before, during, and after a CVT encounter.

Strategies to Identify and Reduce Opioid Misuse Among Patients with Gastrointestinal Disorders: A Systematic Scoping Review

BackgroundScoping reviews are preliminary assessments intended to characterize the extent and nature of emerging research evidence, identify literature gaps, and offer directions for future research. We conducted a systematic scoping review to describe published scientific literature on strategies to identify and reduce opioid misuse among patients with gastrointestinal (GI) symptoms and disorders.MethodsWe performed structured keyword searches to identify manuscripts published through June 2016 in the PubMed MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science databases to extract original research articles that described healthcare practices, tools, or interventions to identify and reduce opioid misuse among GI patients. The Chronic Care Model (CCM) was used to classify the strategies presented.ResultsTwelve articles met the inclusion criteria. A majority of studies used quasi-experimental or retrospective cohort study designs. Most studies addressed the CCM’s clinical information systems element. Seven studies involved identification of opioid misuse through prescription drug monitoring and opioid misuse screening tools. Four studies discussed reductions in opioid use by harnessing drug monitoring data and individual care plans, and implementing self-management and opioid detoxification interventions. One study described drug monitoring and an audit-and-feedback intervention to both identify and reduce opioid misuse. Greatest reductions in opioid misuse were observed when drug monitoring, self-management, or audit-and-feedback interventions were used.ConclusionPrescription drug monitoring and self-management interventions may be promising strategies to identify and reduce opioid misuse in GI care. Rigorous, empirical research is needed to evaluate the longer-term impact of these strategies.

Experience and Utility of Using the Participatory Research Method, Photovoice, in Individuals with Spinal Cord Injury

Background: There is a need to engage persons with spinal cord injuries/disorders (SCI/D) in research methodologies beyond traditional approaches. This provides an opportunity for individuals to convey their perspectives in a variety of ways. Photovoice empowers people to share their perspectives through photographs and narrative; this is well-suited for individuals who are less comfortable speaking up when other methods are used, such as focus groups. Objective: To examine photovoice methodology in US Veterans with SCI/D to describe their experiences with and the utility of photovoice. We also provide a sample of content (qualitative data) to illustrate how individuals with SCI/D conceptualized function and factors important to them. Methods: Photovoice, a qualitative participatory research method, was used to collect photographs from Veterans with SCI/D, which was followed by personal narratives describing the meaning of their photos. Results: Participants (N = 9) were 64 years old, on average, and 75% had paraplegia. Participants discussed the challenges with taking photographs, but they enjoyed participating, appreciated inclusion, and hoped the information they provided would help others with disabilities. Conclusion: These findings suggest that despite challenges and ethical barriers, individuals with SCI/D are interested in, highly capable of, and should be given the opportunity to be included in studies like this that empower participants to share their views using novel ways of expression. These findings demonstrate the desirability, feasibility, and utility of using photovoice in individuals with SCI/D. This method may be used to understand factors impacting health and well-being and can be made available to individuals with SCI/D to minimize inequalities in research opportunities.

Barriers and strategies for coordinating care among veterans with traumatic brain injury: a mixed methods study of VA polytrauma care team members

ABSTRACT Background: Veterans who experience traumatic brain injury (TBI) may have long-term needs placing a premium on well-coordinated care. This study aimed to (1) identify barriers to care coordination for Veterans with TBI; and (2) describe strategies used by VA polytrauma care team members to coordinate care for Veterans with TBI. Methods: We utilised a mixed method design, including an online survey of VA polytrauma care team members (N = 236) and subsequent semi-structured interviews (N = 25). Analysis of the survey data was descriptive; interview data was analysed using constant comparative techniques. Results: The most common system-related barriers 25 for access to military records (64%) and insufficient time (58%). The most common patient-related barriers were missed appointments/no shows (87%) and the mental health issues (74%). Strategies reported on the survey to promote coordination reflected the centrality of teamwork and communication, and included promoting multidisciplinary team collaboration (32%) and holding 30 regular meetings (23%). Interview findings were consistent, emphasising the effective functioning of multidisciplinary clinics. Conclusion: Polytrauma care team members encounter barriers to care coordination for Veterans with TBI, and have developed strategies in response. Information sharing, provider workload, communication, and patient engagement will be critical to address in future efforts to enhance care coordination in this context.

Tu1096 Perceptions of Patient-Centered Care Among Veterans With Gastroesophageal Reflux Disease on Proton Pump Inhibitor Therapy

Background. Limited data exist describing patient-centered care (PCC) outcomes among patients with gastroesophageal reflux disease (GERD) on proton pump inhibitor (PPI) therapy. The study purpose was to use a patient-reported outcome measure to explore perceptions of care among patients with GERD on PPI therapy. Methods. The Center for Evaluation of Practices and Experiences of Patient Centered Care (CEPEP) is a VA funded project to evaluate various PCC outcomes, using mailed validated surveys to Veterans with chronic conditions seen across 8 nationally representative VA centers. We analyzed the Patient Assessment of Care for Chronic Conditions (PACIC) in a subset of Veterans diagnosed with GERD and prescribed PPI therapy. The PACIC assesses patient views of the chronic care received and is organized into five subscales that address elements of patient-centered care as perceived by patients (Patient Activation, Delivery System Design/Decision Support, Goal Setting, Problem Solving/Contextual Counseling, and Follow-up/Coordination). Overall summary and subscale scores range from 1-5; higher scores indicate higher subjective ratings of health care received. We used descriptive statistics to describe patient characteristics and assess if PPI dosing (standard vs high dose) or duration of therapy (short term = 6 mo) was associated with perception of care received. Results. Veteran patients with GERD on PPI (n=501) were mostly male (94.6%), white/non-Hispanic (70.6%), and, on average, 68 years of age. 67.5% of respondents reported having 3 or more chronic conditions. Nearly all respondents (99.8%) reported having one or more recent outpatient visits; 24.8% reported one or more recent ER visits. 53.1% had high total daily dose initial PPI prescriptions; 46.9% had standard total daily dose initial prescriptions. A majority of respondents (87.6%) reported long-term PPI use. The mean PACIC summary score for the entire sample was 3.01 (SD=1.16). 39.0% of respondents achieved an overall PACIC summary score of 3.5 or higher. Respondents achieved highest scores overall in the Delivery System Design/Decision Support (3.36, SD=1.19) and Patient Activation subscales (3.23, SD=1.26); lowest scores were achieved in the Follow-up/Coordination subscale (2.56, SD=1.26) and the Goal Setting/Tailoring subscale (2.97, SD=1.27).Mean subscale score for Problem Solving/ Contextual Counseling was 3.21, SD=1.35. There were no differences in PACIC scores by PPI dose or duration of therapy. Conclusions. Veterans with GERD on PPI therapy were generally activated in their care and perceived care to be supportive in enhancing their own understanding of care. However, further efforts are needed to explore if PCC outcomes are associated with GERD symptom control, particularly in areas of follow-up support, tailored goal setting and coordination of care.