Interventions to improve veterans' access to care: a systematic review of the literature

The accessibility of pharmacist prescribing and impacts on medicines access: A systematic review

BACKGROUND

Pharmacist prescribing has been introduced in several countries as a strategy to improve access to health care and medicines. However, the direct impacts of pharmacist prescribing on medicines access, and the overall accessibility of pharmacist prescribing services, are not well known.

OBJECTIVES

This systematic review aimed to assess the direct impacts of pharmacist prescribing on medicines access, and the accessibility of pharmacist prescribing services, in community and primary care settings.

METHODS

PubMed, Embase, and CINAHL were searched for studies published in English between 01 January 2003 to 15 June 2023. Both quantitative and qualitative primary studies were included if they described pharmacist prescribing in a primary care setting. Outcomes included findings related to access to medicines as a result of pharmacist prescribing (primary outcome), and access to pharmacist prescribing services overall (secondary outcome). Narrative synthesis of outcomes was undertaken.

RESULTS

A total of 47 studies were included from four countries (United States, United Kingdom, Canada, New Zealand). Thirteen studies provided evidence that pharmacist prescribing may improve medicines access in several ways, including: increasing the proportion of eligible people receiving medicines, increasing the number of overall dispensed prescriptions, or reducing time to receipt of treatment. The remainder of the included studies reported on the accessibility of pharmacist prescribing services. Published studies highlight that pharmacist prescribers practicing in community settings are generally accessible, with pharmacist prescribers viewed by patients as easy and convenient to consult. There was limited evidence about the affordability of pharmacy prescribing services, and a number of potential equity issues were observed, including reduced access to pharmacist prescribers in more socioeconomically disadvantaged areas and those with greater proportions of populations at risk of health inequities, such as culturally and linguistically diverse communities.

CONCLUSIONS

This systematic review found that pharmacist prescribing services were both highly accessible and beneficial in improving access to medicines. However, measures of medicines access varied, and few studies included direct measures of medicines access as an outcome of pharmacist prescribing, highlighting a need for future studies to incorporate direct measures of medicines access when assessing the impact of pharmacist prescribing services.

The role of depression and anxiety symptom severity in remotely delivered mental health care

This study examined differences in mental health characteristics of Veterans who received VA Video Connect (VVC) or audio-only care during initial phases of the COVID-19 pandemic. A cohort of Veterans with primary diagnoses of depressive or anxiety disorders (diagnosed between March 2019 and February 2020) was identified, and data were obtained for Veterans who engaged in virtual care from April to December 2020. Two groups were created: Veterans receiving audio-only care (n = 161,071) and Veterans receiving two or more VVC visits (n = 84,505). Multiple logistic regression models examined symptom severity in the year before COVID as a predictor of treatment modality during COVID. Chi-square tests examined associations between modality and the number of assessments. Symptom severity as evaluated by the nine-item Patient Health Questionnaire and Generalized Anxiety Disorder-7 significantly predicted modality of encounters during the pandemic such that those who had moderate or severe symptoms prior to COVID-19 were more likely than those with low or no symptoms to have two or more VVC encounters during the pandemic. Of those who received VVC, 55.62% had no Patient Health Questionnaire-9 assessments compared to 68.96% of those who received audio-only. In the VVC group, 70.36% had no Generalized Anxiety Disorder-7 assessments compared to 81.02% in the audio-only group. Taken together, these findings suggest that VVC, when compared to audio-only, was used during the pandemic to reach Veterans with more severe mental health symptomatology and to engage in administration of measurement-based care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Engaging Operational Partners Is Critical for Successful Implementation of Research Products: a Coincidence Analysis of Access-Related Projects in the Veterans Affairs Healthcare System

BACKGROUND/OBJECTIVE

The Veterans Health Administration (VHA) has prioritized timely access to care and has invested substantially in research aimed at optimizing veteran access. However, implementing research into practice remains challenging. Here, we assessed the implementation status of recent VHA access-related research projects and explored factors associated with successful implementation.

DESIGN

We conducted a portfolio review of recent VHA-funded or supported projects (1/2015-7/2020) focused on healthcare access ("Access Portfolio"). We then identified projects with implementable research deliverables by excluding those that (1) were non-research/operational projects; (2) were only recently completed (i.e., completed on or after 1/1/2020, meaning that they were unlikely to have had time to be implemented); and (3) did not propose an implementable deliverable. An electronic survey assessed each project's implementation status and elicited barriers/facilitators to implementing deliverables. Results were analyzed using novel Coincidence Analysis (CNA) methods.

PARTICIPANTS/KEY RESULTS

Among 286 Access Portfolio projects, 36 projects led by 32 investigators across 20 VHA facilities were included. Twenty-nine respondents completed the survey for 32 projects (response rate = 88.9%). Twenty-eight percent of projects reported fully implementing project deliverables, 34% reported partially implementing deliverables, and 37% reported not implementing any deliverables (i.e., resulting tool/intervention not implemented into practice). Of 14 possible barriers/facilitators assessed in the survey, two were identified through CNA as "difference-makers" to partial or full implementation of project deliverables: (1) engagement with national VHA operational leadership; (2) support and commitment from local site operational leadership.

CONCLUSIONS

These findings empirically highlight the importance of operational leadership engagement for successful implementation of research deliverables. Efforts to strengthen communication and engagement between the research community and VHA local/national operational leaders should be expanded to ensure VHA's investment in research leads to meaningful improvements in veterans' care. The Veterans Health Administration (VHA) has prioritized timely access to care and has invested substantially in research aimed at optimizing veteran access. However, implementing research findings into clinical practice remains challenging, both within and outside VHA. Here, we assessed the implementation status of recent VHA access-related research projects and explored factors associated with successful implementation. Only two factors were identified as "difference-makers" to adoption of project findings into practice: (1) engagement with national VHA leadership or (2) support and commitment from local site leadership. These findings highlight the importance of leadership engagement for successful implementation of research findings. Efforts to strengthen communication and engagement between the research community and VHA local/national leaders should be expanded to ensure VHA's investment in research leads to meaningful improvements in veterans' care.

Mapping Rural and Urban Veterans' Spatial Access to Primary Care Following the MISSION Act

BACKGROUND

The 2018 MISSION Act sought to improve Veterans' access to primary care by allowing Veterans living more than 30 min from VA care to utilize non-VA clinics. The impact of this legislation may vary for rural compared to urban Veterans.

OBJECTIVE

Assess the extent to which the 2018 MISSION Act facilitates spatial access to primary care for Veterans living in rural versus urban Oregon.

DESIGN

We identified locations of all VA and non-VA primary care clinics in Oregon then calculated 30-min drive-time catchment areas from census tract centroids to the nearest clinics. We compared measures of spatial access to primary care for Veterans in rural, micropolitan, and urban areas.

PARTICIPANTS

American Community Survey data representing Oregon adults.

MAIN MEASURES

Two measures of spatial access focusing on the number of clinics (supply), and an access index based on the two-step floating catchment area method (2SFCA) which accounts for number of clinics (supply) and population size (demand).

KEY RESULTS

Compared to only 13.0% of rural Veterans, 83.6% of urban Veterans lived within 30 min' drive time of VA primary care. Given the MISSION Act's eligibility criteria, 81.6% of rural Veterans and ~ 97% of urban and micropolitan Veterans had spatial access to primary care. When accounting for both supply and demand, rural areas had significantly higher access scores (p < 0.05) compared to urban areas.

CONCLUSIONS

Using MISSION Act guidelines for Veteran access to primary care, rural compared to urban Veterans had less spatial access based on clinic number (supply), but more access when considering clinic number and population size (supply and demand). Geographic Information System (GIS) spatial techniques may help to assess changes in access to care. However, these methods do not incorporate all dimensions of access and work is needed to understand whether utilization and quality of care is improved.

Engaging Stakeholders in Identifying Access Research Priorities for the Department of Veterans Affairs

BACKGROUND

The Veterans Access Research Consortium (VARC), a Department of Veterans Affairs (VA) Consortium of Research focused on access to healthcare, has been funded by VA's Health Services Research and Development Service (HSR&D) to develop a research roadmap for healthcare access. The goal of the roadmap is to identify operationally aligned research questions that are most likely to lead to meaningful improvements in Veterans' healthcare access.

OBJECTIVES

To describe the process of soliciting diverse stakeholder perspectives about key priorities on which VA's HSR&D access agenda should focus and identify the results of that process.

METHODS

We used a modified Delphi approach to engage researchers and VA operational partners in a process to develop recommendations regarding the access-related research questions VA should prioritize. We then collaborated with three Veteran Engagement Groups (VEGs) across the country to solicit Veterans' reactions to the Delphi results and their perspectives about access-related issues affecting access to VA health care.

RESULTS

The Delphi panel consisted of 22 research and operational experts, both internal and external to VA. The Delphi process resulted in five research questions identified by the panelists as highest priority for VA to pursue, each representing one of the following domains: (1) measurement of access, (2) barriers to access, (3) equity and subpopulations, (4) effective interventions to improve access, and (5) consequences of poor/better access. Veterans' perspectives focused primarily on the barriers to access domain. Veterans indicated several barriers that might be addressed through research or operational initiatives, including poor communication about services, weak connections to and partnerships with local community care facilities, and poor provision of telehealth resources and education.

CONCLUSIONS

Engaging multiple methods to solicit stakeholder perspectives enables more nuanced understanding of access-related priorities for VA. Future research should consider utilizing such an approach to identify additional research and/or operational priorities.

Initial concurrent and convergent validity of the Perceived Access Inventory (PAI) for mental health services

Access to high-quality health care, including mental health care, remains a high priority for the Department of Veterans Affairs and civilian health care systems. Increased access to mental health care is associated with improved outcomes, including decreased suicidal behavior. Multiple policy changes and interventions are being developed and implemented to improve access to mental health care. The Perceived Access Inventory (PAI) is a patient-centered questionnaire developed to understand the veteran perspective about access to mental health services. The PAI is a self-report measure that includes 43 items across 5 domains: Logistics (6 items), Culture (4 items), Digital (9 items), Systems of Care (13 items), and Experiences of Care (11 items). This article is a preliminary examination of the concurrent and convergent validity of the PAI with respect to the Hoge Perceived Barriers to Seeking Mental Health Services scale (concurrent) and the Client Satisfaction Questionnaire (CSQ; convergent). Telephone interviews were conducted with veterans from 3 geographic regions. Eligibility criteria included screening positive for posttraumatic stress disorder, alcohol use disorder, or depression in the past 12 months. Data from 92 veterans were analyzed using correlation matrices. PAI scores were significantly correlated with the Hoge total score (concurrent validity) and CSQ scores (convergent validity). The PAI items with the strongest correlation with CSQ were in the Systems of Care domain and the weakest were in the Logistics domain. Future efforts will evaluate validity using larger data sets and utilize the PAI to develop and test interventions to improve access to care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Accelerating Implementation of Virtual Care in an Integrated Health Care System: Future Research and Operations Priorities

BACKGROUND

Virtual care is critical to Veterans Health Administration (VHA) efforts to expand veterans' access to care. Health care policies such as the Veterans Access, Choice, and Accountability (CHOICE) Act and the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act impact how the VHA provides care. Research on ways to refine virtual care delivery models to meet the needs of veterans, clinicians, and VHA stakeholders is needed.

OBJECTIVE

Given the importance of virtual approaches for increasing access to high-quality VHA care, in December 2019, we convened a Think Tank, Accelerating Implementation of Virtual Care in VHA Practice, to consider challenges to virtual care research and practice across the VHA, discuss novel approaches to using and evaluating virtual care, assess perspectives on virtual care, and develop priorities to enhance virtual care in the VHA.

METHODS

We used a participatory approach to develop potential priorities for virtual care research and activities at the VHA. We refined these priorities through force-ranked prioritization and group discussion, and developed solutions for selected priorities.

RESULTS

Think Tank attendees (n = 18) consisted of VHA stakeholders, including operations partners (e.g., Office of Rural Health, Office of Nursing Services, Health Services Research and Development), clinicians (e.g., physicians, nurses, psychologists, physician assistants), and health services researchers. We identified an initial list of fifteen potential priorities and narrowed these down to four. The four priorities were (1) scaling evidence-based practices, (2) centralizing virtual care, (3) creating high-value care within the VHA with virtual care, and (4) identifying appropriate patients for virtual care.

CONCLUSION

Our Think Tank took an important step in setting a partnered research agenda to optimize the use of virtual care within the VHA. We brought together research and operations stakeholders and identified possibilities, partnerships, and potential solutions for virtual care.

Did Access to Care Improve Since Passage of the Veterans Choice Act?: Differences Between Rural and Urban Veterans

BACKGROUND

The 2014 Veterans Choice Program aimed to improve care access for Veterans through expanded availability of community care (CC). Increased access to CC could particularly benefit rural Veterans, who often face obstacles in obtaining medical care at the Veterans Health Administration (VHA). However, whether Veterans Choice Program improved timely access to care for this vulnerable population is understudied.

OBJECTIVES

To examine wait times among rural and urban Veterans for 5 outpatient specialty care services representing the top requests for CC services among rural Veterans.

RESEARCH DESIGN

Retrospective study using VHA and CC outpatient consult data from VHA's Corporate Data Warehouse in Fiscal Year (FY) 2015 (October 1, 2014 to September 30, 2015) and FY2018 (October 1, 2017 to September 30, 2018).

SUBJECTS

All Veterans who received a new patient consult for physical therapy, cardiology, optometry, orthopedics, and/or dental services in VHA and/or CC.

MEASURES

Wait time, care setting (VHA/CC), rural/urban status, sociodemographics, and comorbidities.

RESULTS

Our sample included 1,112,876 Veterans. Between FY2015 and FY2018, mean wait times decreased for all services for both rural and urban Veterans; declines were greatest in VHA (eg, mean optometry wait times for rural Veterans in VHA vs. CC declined 8.3 vs. 6.4 d, respectively, P<0.0001). By FY2018, for both rural and urban Veterans, CC mean wait times for most services were longer than VHA wait times.

CONCLUSIONS

Timely care access for all Veterans improved between FY15 and FY18, particularly in VHA. As expansion of CC continues under the MISSION Act, more research is needed to evaluate quality of care across VHA and CC and what role, if any, wait times play.

Impact of Attitudes and Rurality on Veterans' Use of Veterans Health Administration Mental Health Services

OBJECTIVE

Veterans, especially those residing in rural areas, continue to underutilize mental health care. This longitudinal study assessed attitudes relevant to seeking mental health care services from the Veterans Health Administration (VHA) over 12 months, adjusting for residence.

METHODS

A questionnaire addressing attitudes, sociodemographic factors, residence, place identity, perceived health status and needs, and structural barriers was administered by telephone to 752 veterans with previous VHA service use. Service use data were obtained from a VHA database.

RESULTS

In adjusted models, four attitudes were significantly associated with underuse of VHA mental health care (no use vs. any use; no use vs. nonsustained use vs. sustained use). Higher levels of mistrust of others (adjusted odds ratio [AOR]=1.06, p=0.046), emotional stoicism (AOR=1.08, p=0.003), belief in the self-resolving nature of mental health problems (AOR=1.91, p=0.015), and belief in the efficacy of religious counseling for such problems (AOR=1.09, p=0.022) were associated with no subsequent service use versus any use. Place identity (suburban), older age, and greater need were associated with greater odds of VHA use. For the comparison of no use versus sustained use, women had lower odds of no use (AOR=0.49, p<0.001); similarly, women had lower odds of nonsustained use versus sustained use (AOR=0.45, p<0.001).

CONCLUSIONS

The association of potentially modifiable attitudes with underuse of VHA mental health services suggests that attitudes offer useful targets for efforts to increase mental health care use. That these attitudes were influential regardless of residence suggests that programs addressing attitudinal barriers can be broadly targeted.

Propensity score matching for multilevel spatial data: accounting for geographic confounding in health disparity studies

BACKGROUND

Diabetes is a public health burden that disproportionately affects military veterans and racial minorities. Studies of racial disparities are inherently observational, and thus may require the use of methods such as Propensity Score Analysis (PSA). While traditional PSA accounts for patient-level factors, this may not be sufficient when patients are clustered at the geographic level and thus important confounders, whether observed or unobserved, vary by geographic location.

METHODS

We employ a spatial propensity score matching method to account for "geographic confounding", which occurs when the confounding factors, whether observed or unobserved, vary by geographic region. We augment the propensity score and outcome models with spatial random effects, which are assigned scaled Besag-York-Mollié priors to address spatial clustering and improve inferences by borrowing information across neighboring geographic regions. We apply this approach to a study exploring racial disparities in diabetes specialty care between non-Hispanic black and non-Hispanic white veterans. We construct multiple global estimates of the risk difference in diabetes care: a crude unadjusted estimate, an estimate based solely on patient-level matching, and an estimate that incorporates both patient and spatial information.

RESULTS

In simulation we show that in the presence of an unmeasured geographic confounder, ignoring spatial heterogeneity results in increased relative bias and mean squared error, whereas incorporating spatial random effects improves inferences. In our study of racial disparities in diabetes specialty care, the crude unadjusted estimate suggests that specialty care is more prevalent among non-Hispanic blacks, while patient-level matching indicates that it is less prevalent. Hierarchical spatial matching supports the latter conclusion, with a further increase in the magnitude of the disparity.

CONCLUSIONS

These results highlight the importance of accounting for spatial heterogeneity in propensity score analysis, and suggest the need for clinical care and management strategies that are culturally sensitive and racially inclusive.

Does Community Outsourcing Improve Timeliness of Care for Veterans With Obstructive Sleep Apnea?

BACKGROUND

Providing timely access to care has been a long-standing priority for the Veterans Affairs Healthcare System. Recent strategies to reduce long wait times have focused on purchasing community care by a fee-for-service model. Whether outsourcing Veterans Affairs (VA) specialty care to the community improves access is unclear.

OBJECTIVES

We compared time from referral to treatment among Veterans whose care was provided by VA versus community care purchased by the VA, using obstructive sleep apnea as an example condition.

METHODS

This was a retrospective cohort study of Northern California Veterans seeking sleep apnea care through the San Francisco VA Healthcare System between 2012 and 2018. We used multivariable linear regression with propensity score matching to investigate the relationship between time to care delivery and care setting (VA provided vs. VA-purchased community care). A total of 1347 Northern California Veterans who completed sleep apnea testing within the VA and 88 Veterans who completed sleep apnea testing in the community had complete data for analysis.

RESULTS

Among Northern California Veterans with obstructive sleep apnea, outsourcing of care to the community was associated with longer time from referral to therapy (mean±SD, 129.6±82.8 d with VA care vs. 252.0±158.8 d with community care, P<0.001) and greater loss to follow-up.

CONCLUSIONS

These findings suggest that purchasing community care may lead to care fragmentation and not improve wait times nor improve access to subspecialty care for Veterans.

Time and Organizational Cost for Facilitating Implementation of Primary Care Mental Health Integration

BACKGROUND

Integrating mental health services into primary care settings is complex and challenging. Although facilitation strategies have successfully supported implementation of primary care mental health integration and other complex innovations, we know little about the time required or its cost.

OBJECTIVE

To examine the time and organizational cost of facilitating implementation of primary care mental health integration.

DESIGN

Descriptive analysis.

PARTICIPANTS

One expert external facilitator and two internal regional facilitators who helped healthcare system stakeholders, e.g., leaders, managers, clinicians, and non-clinical staff, implement primary care mental health integration at eight clinics.

INTERVENTION

Implementation facilitation tailored to the needs and resources of the setting and its stakeholders.

MAIN MEASURES

We documented facilitators' and stakeholders' time and types of activities using a structured spreadsheet collected from facilitators on a weekly basis. We obtained travel costs and salary information. We conducted descriptive analysis of time data and estimated organizational cost.

KEY RESULTS

The external facilitator devoted 263 h (0.09 FTE), including travel, across all 8 clinics over 28 months. Internal facilitator time varied across networks (1792 h versus 1169 h), as well as clinics. Stakeholder participation time was similar across networks (1280.6 versus 1363.4 person hours) but the number of stakeholders varied (133 versus 199 stakeholders). The organizational cost of providing implementation facilitation also varied across networks ($263,490 versus $258,127). Stakeholder participation accounted for 35% of the cost of facilitation activities in one network and 47% of the cost in the other.

CONCLUSIONS

Although facilitation can improve implementation of primary care mental health integration, it requires substantial organizational investments that may vary by site and implementation effort. Furthermore, the cost of using an external expert to transfer facilitation skills and build capacity for implementation efforts appears to be minimal.

Remote Temperature Monitoring of the Diabetic Foot: From Research to Practice

INTRODUCTION

Diabetic foot ulcers (DFUs) are devastating, common, and costly. The mortality of veterans following a DFU is sobering with ulceration recognized as a significant marker of disease severity. Given the dramatic impact of diabetic foot complications to the veteran and the US health care system, the US Department of Veterans Affairs (VA) has long recognized the importance of preventive care for those at risk. Telemedicine has been suggested as a modality to reach veterans at high risk of chronic wound formation.

OBSERVATIONS

The purpose of this review is to: (1) present the evidence supporting once-daily remote temperature monitoring (RTM), a telemedicine approach critical to improving both veteran access to care and diabetic foot outcomes; (2) summarize a 2017 study published by VA providers who have advanced clinical understanding of RTM; (3) present previously unpublished data from this study comparing high-risk VA and non-VA cohorts, highlighting the opportunity for additional focus on DFU prevention within the VA; and (4) report on recent VA use of a RTM technology based on this research, emphasizing lessons learned and best practices.

CONCLUSIONS

There is a significant opportunity to shift diabetic foot care from treatment to prevention, improving veteran outcomes and reducing resource utilization. RTM is an evidence-based, recommended, but underused telemedicine solution that can catalyze this needed paradigm shift.

Provider Perspectives on Integrating Sensor-Captured Patient-Generated Data in Mental Health Care

The increasing ubiquity of health sensing technology holds promise to enable patients and health care providers to make more informed decisions based on continuously-captured data. The use of sensor-captured patient-generated data (sPGD) has been gaining greater prominence in the assessment of physical health, but we have little understanding of the role that sPGD can play in mental health. To better understand the use of sPGD in mental health, we interviewed care providers in an intensive treatment program (ITP) for veterans with post-traumatic stress disorder. In this program, patients were given Fitbits for their own voluntary use. Providers identified a number of potential benefits from patients' Fitbit use, such as patient empowerment and opportunities to reinforce therapeutic progress through collaborative data review and interpretation. However, despite the promise of sensor data as offering an "objective" view into patients' health behavior and symptoms, the relationships between sPGD and therapeutic progress are often ambiguous. Given substantial subjectivity involved in interpreting data from commercial wearables in the context of mental health treatment, providers emphasized potential risks to their patients and were uncertain how to adjust their practice to effectively guide collaborative use of the FitBit and its sPGD. We discuss the implications of these findings for designing systems to leverage sPGD in mental health care.

Patient-Reported Access in the Patient-Centered Medical Home and Avoidable Hospitalizations: an Observational Analysis of the Veterans Health Administration

BACKGROUND

The Patient-Centered Medical Home (PCMH) has emphasized timely access to primary care, often by using non-traditional modes of delivery, such as care in person after-hours or by phone during or after normal hours. Limited data exists on whether improving patient-reported access with these service types reduces hospitalization.

OBJECTIVE

To examine the association of patient-reported access to primary care within the Veteran Health Administration (VHA) via five service types and hospitalizations for ambulatory care sensitive conditions (ACSCs).

DESIGN

Retrospective cohort study, using multivariable logistic regression adjusting for patient demographics, comorbidity, characteristics of patients' area of residence, and clinic-level random effects.

PARTICIPANTS

A total of 69,710 VHA primary care patients who responded to the 2012 Survey of Healthcare Experiences of Patients (SHEP), PCMH module.

MAIN MEASURES

Survey questions captured patients' ability to obtain care from VHA for five service types: routine care, immediate care, after-hours care, care by phone during regular office hours, and care by phone after normal hours. Outcomes included binary measures of hospitalization for overall, acute, and chronic ACSCs in 2013, identified in VHA administrative data and Medicare fee-for-service claims.

KEY RESULTS

Patients who reported "always" able to obtain after-hours care compared to "never" were less likely to be hospitalized for chronic ACSCs (OR 0.62, 95% CI 0.44-0.89, p = 0.009). Patients reporting "usually" getting care by phone during regular hours were more likely have a hospitalization for chronic ACSC (OR 1.49, 95% CI 1.03-2.17, p = 0.034). Experiences with routine care, immediate care, and care by phone after-hours demonstrated no significant association with hospitalization for ACSCs.

CONCLUSIONS

Improving patients' ability to obtain after-hours care was associated with fewer hospitalizations for chronic ACSCs, while access to care by phone during regular hours was associated with more hospitalizations. Health systems should consider the benefits, including reduced hospitalizations for chronic ACSCs, against the costs of implementing each of these PCMH services.

Association Between Mental Health Staffing Level and Primary Care-Mental Health Integration Level on Provision of Depression Care in Veteran's Affairs Medical Facilities

We examined the association of mental health staffing and the utilization of primary care/mental health integration (PCMHI) with facility-level variations in adequacy of psychotherapy and antidepressants received by Veterans with new, recurrent, and chronic depression. Greater likelihood of adequate psychotherapy was associated with increased (1) PCMHI utilization by recurrent depression patients (AOR 1.02; 95% CI 1.00, 1.03); and (2) staffing for recurrent (AOR 1.03; 95% CI 1.01, 1.06) and chronic (AOR 1.02; 95% CI 1.00, 1.03) depression patients (p < 0.05). No effects were found for antidepressants. Mental health staffing and PCMHI utilization explained only a small amount of the variance in the adequacy of depression care.

Improving primary care Access in Context and Theory (I-ACT trial): a theory-informed randomised cluster feasibility trial using a realist perspective

Background

Primary care access can be challenging for older, rural, socio-economically disadvantaged populations. Here we report the I-ACT cluster feasibility trial which aims to assess the feasibility of trial design and context-sensitive intervention to improve primary care access for this group and so expand existing theory.

Methods

Four general practices were recruited; three randomised to intervention and one to usual care. Intervention practices received £1500, a support manual and four meetings to develop local, innovative solutions to improve the booking system and transport.

Patients aged over 64 years old and without household car access were recruited to complete questionnaires when booking an appointment or attending the surgery. Outcome measures at 6 months included: self-reported ease of booking an appointment and transport; health care use; patient activation; capability; and quality of life. A process evaluation involved observations and interviews with staff and participants.

Results

Thirty-four patients were recruited (26 female, eight male, mean age 81.6 years for the intervention group and 79.4 for usual care) of 1143 invited (3% response rate). Most were ineligible because of car access. Twenty-nine participants belonged to intervention practices and five to usual care. Practice-level data was available for all participants, but participant self-reported data was unavailable for three. Fifty-six appointment questionnaires were received based on 150 appointments (37.3%).

Practices successfully designed and implemented the following context-sensitive interventions: Practice A: a stacked telephone system and promoting community transport; Practice B: signposting to community transport, appointment flexibility, mobility scooter charging point and promoting the role of receptionists; and Practice C: local taxi firm partnership and training receptionists. Practices found the process acceptable because it gave freedom, time and resource to be innovative or provided an opportunity to implement existing ideas. Data collection methods were acceptable to participants, but some found it difficult remembering to complete booking and appointment questionnaires. Expanded theory highlighted important mechanisms, such as reassurance, confidence, trust and flexibility.

Conclusions

Recruiting older participants without access to a car proved challenging. Retention of participants and practices was good but only about a third of appointment questionnaires were returned. This study design may facilitate a shift from one-size-fits-all interventions to more context-sensitive interventions.

Trial registration

ISRCTN18321951, Registered on 6 March 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3299-2) contains supplementary material, which is available to authorized users.

The Role of Integrated Primary Care in Increasing Access to Effective Psychotherapies in the Veterans Health Administration

American military veterans have higher rates of psychiatric disorders, and timely access to high-quality mental health treatment in the Veterans Health Administration (VHA) is a persistent challenge. Integrated primary care (IPC) is one of many strategies implemented by VHA to increase access to care. IPC, including collaborative care and primary care behavioral health services, successfully increases access to initial behavioral health services in primary care (e.g., brief psychotherapies, pharmacotherapy) and continued engagement in specialty mental health services. IPC components that drive increased access include population-based care, response to patient preferences, and team-based care. The state of the evidence for IPC interventions for common behavioral health concerns in primary care (depression, anxiety, posttraumatic stress disorder, alcohol use, tobacco use, and insomnia) is reviewed, with areas for future research and implementation discussed, including how technology can assist IPC services and the importance of incorporating evidence-based psychotherapies into IPC.

Evaluating patterns and predictors of symptom change during a three-week intensive outpatient treatment for veterans with PTSD

BACKGROUND

Intensive delivery of evidence-based treatment for posttraumatic stress disorder (PTSD) is becoming increasingly popular for overcoming barriers to treatment for veterans. Understanding how and for whom these intensive treatments work is critical for optimizing their dissemination. The goals of the current study were to evaluate patterns of PTSD and depression symptom change over the course of a 3-week cohort-based intensive outpatient program (IOP) for veterans with PTSD, examine changes in posttraumatic cognitions as a predictor of treatment response, and determine whether patterns of treatment outcome or predictors of treatment outcome differed by sex and cohort type (combat versus military sexual trauma [MST]).

METHOD

One-hundred ninety-one veterans (19 cohorts: 12 combat-PTSD cohorts, 7 MST-PTSD cohorts) completed a 3-week intensive outpatient program for PTSD comprised of daily group and individual Cognitive Processing Therapy (CPT), mindfulness, yoga, and psychoeducation. Measures of PTSD symptoms, depression symptoms, and posttraumatic cognitions were collected before the intervention, after the intervention, and approximately every other day during the intervention.

RESULTS

Pre-post analyses for completers (N = 176; 92.1% of sample) revealed large reductions in PTSD (d = 1.12 for past month symptoms and d = 1.40 for past week symptoms) and depression symptoms (d = 1.04 for past 2 weeks). Combat cohorts saw a greater reduction in PTSD symptoms over time relative to MST cohorts. Reduction in posttraumatic cognitions over time significantly predicted decreases in PTSD and depression symptom scores, which remained robust to adjustment for autocorrelation.

CONCLUSION

Intensive treatment programs are a promising approach for delivering evidence-based interventions to produce rapid treatment response and high rates of retention. Reductions in posttraumatic cognitions appear to be an important predictor of response to intensive treatment. Further research is needed to explore differences in intensive treatment response for veterans with combat exposure versus MST.

Development of the Perceived Access Inventory: A patient-centered measure of access to mental health care

According to recent Congressional testimony by the Secretary for Veterans Affairs (VA), improving the timeliness of services is one of five current priorities for VA. A comprehensive access measure, grounded in veterans' experience, is essential to support VA's efforts to improve access. In this article, the authors describe the process they used to develop the Perceived Access Inventory (PAI), a veteran-centered measure of perceived access to mental health services. They used a multiphase, mixed-methods approach to develop the PAI. Each phase built on and was informed by preceding phases. In Phase 1, the authors conducted 80 individual, semistructured, qualitative interviews with veterans from 3 geographic regions to elicit the barriers and facilitators they experienced in seeking mental health care. In Phase 2, they generated a preliminary set of 77 PAI items based on Phase 1 qualitative data. In Phase 3, an external expert panel rated the preliminary PAI items in terms of relevance and importance, and provided feedback on format and response options. Thirty-nine PAI items resulted from Phase 3. In Phase 4, veterans gave feedback on the readability and understandability of the PAI items generated in Phase 3. Following completion of these 4 developmental phases, the PAI included 43 items addressing 5 domains: logistics (five items), culture (three items), digital (nine items), systems of care (13 items), and experiences of care (13 items). Future work will evaluate concurrent and predictive validity, test/retest reliability, sensitivity to change, and the need for further item reduction. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Robotic assistance in the coordination of patient care

We conducted a study to investigate trust in and dependence upon robotic decision support among nurses and doctors on a labor and delivery floor. There is evidence that suggestions provided by embodied agents engender inappropriate degrees of trust and reliance among humans. This concern represents a critical barrier that must be addressed before fielding intelligent hospital service robots that take initiative to coordinate patient care. We conducted our experiment with nurses and physicians, and evaluated the subjects’ levels of trust in and dependence upon high- and low-quality recommendations issued by robotic versus computer-based decision support. The decision support, generated through action-driven learning from expert demonstration, produced high-quality recommendations that were accepted by nurses and physicians at a compliance rate of 90%. Rates of Type I and Type II errors were comparable between robotic and computer-based decision support. Furthermore, embodiment appeared to benefit performance, as indicated by a higher degree of appropriate dependence after the quality of recommendations changed over the course of the experiment. These results support the notion that a robotic assistant may be able to safely and effectively assist with patient care. Finally, we conducted a pilot demonstration in which a robot-assisted resource nurses on a labor and delivery floor at a tertiary care center.

Veterans' Perspectives on Fitbit Use in Treatment for Post-Traumatic Stress Disorder: An Interview Study

BACKGROUND

The increase in availability of patient data through consumer health wearable devices and mobile phone sensors provides opportunities for mental health treatment beyond traditional self-report measurements. Previous studies have suggested that wearables can be effectively used to benefit the physical health of people with mental health issues, but little research has explored the integration of wearable devices into mental health care. As such, early research is still necessary to address factors that might impact integration including patients' motivations to use wearables and their subsequent data.

OBJECTIVE

The aim of this study was to gain an understanding of patients' motivations to use or not to use wearables devices during an intensive treatment program for post-traumatic stress disorder (PTSD). During this treatment, they received a complementary Fitbit. We investigated the following research questions: How did the veterans in the intensive treatment program use their Fitbit? What are contributing motivators for the use and nonuse of the Fitbit?

METHODS

We conducted semistructured interviews with 13 veterans who completed an intensive treatment program for PTSD. We transcribed and analyzed interviews using thematic analysis.

RESULTS

We identified three major motivations for veterans to use the Fitbit during their time in the program: increase self-awareness, support social interactions, and give back to other veterans. We also identified three major reasons certain features of the Fitbit were not used: lack of clarity around the purpose of the Fitbit, lack of meaning in the Fitbit data, and challenges in the veteran-provider relationship.

CONCLUSIONS

To integrate wearable data into mental health treatment programs, it is important to understand the patient's perspectives and motivations in using wearables. We also discuss how the military culture and PTSD may have contributed to our participants' behaviors and attitudes toward Fitbit usage. We conclude with possible approaches for integrating patient-generated data into mental health treatment settings that may address the challenges we identified.

"Availability of healthcare providers for rural veterans eligible for purchased care under the veterans choice act"

BACKGROUND

Military Veterans in the United States are more likely than the general population to live in rural areas, and often have limited geographic access to Veterans Health Administration (VHA) facilities. In an effort to improve access for Veterans living far from VHA facilities, the recently-enacted Veterans Choice Act directed VHA to purchase care from non-VHA providers for Veterans who live more than 40 miles from the nearest VHA facility. To explore potential impacts of these reforms on Veterans and healthcare providers, we identified VHA-users who were eligible for purchased care based on distance to VHA facilities, and quantified the availability of various types of non-VHA healthcare providers in counties where these Veterans lived.

METHODS

We combined 2013 administrative data on VHA-users with county-level data on rurality, non-VHA provider availability, population, household income, and population health status.

RESULTS

Most (77.9%) of the 416,338 VHA-users who were eligible for purchased care based on distance lived in rural counties. Approximately 16% of these Veterans lived in primary care shortage areas, while the majority (70.2%) lived in mental health care shortage areas. Most lived in counties that lacked specialized health care providers (e.g. cardiologists, pulmonologists, and neurologists). Counterintuitively, VHA played a greater role in delivering healthcare for the overall adult population in counties that were farther from VHA facilities (30.7 VHA-users / 1000 adults in counties over 40 miles from VHA facilities, vs. 22.4 VHA-users / 1000 adults in counties within 20 miles of VHA facilities, p < 0.01).

CONCLUSIONS

Initiatives to purchase care for Veterans living more than 40 miles from VHA facilities may not significantly improve their access to care, as these areas are underserved by non-VHA providers. Non-VHA providers in the predominantly rural areas more than 40 miles from VHA facilities may be asked to assume care for relatively large numbers of Veterans, because VHA has recently cared for a greater proportion of the population in these areas, and these Veterans are now eligible for purchased care.

Veterans' experiences initiating VA-based mental health care

Military veterans who could benefit from mental health services often do not access them. Research has revealed a range of barriers associated with initiating United States Department of Veterans Affairs (VA) care, including those specific to accessing mental health care (e.g., fear of stigmatization). More work is needed to streamline access to VA mental health-care services for veterans. In the current study, we interviewed 80 veterans from 9 clinics across the United States about initiation of VA mental health care to identify barriers to access. Results suggested that five predominant factors influenced veterans' decisions to initiate care: (a) awareness of VA mental health services; (b) fear of negative consequences of seeking care; (c) personal beliefs about mental health treatment; (d) input from family and friends; and (e) motivation for treatment. Veterans also spoke about the pathways they used to access this care. The four most commonly reported pathways included (a) physical health-care appointments; (b) the service connection disability system; (c) non-VA care; and (d) being mandated to care. Taken together, these data lend themselves to a model that describes both modifiers of, and pathways to, VA mental health care. The model suggests that interventions aimed at the identified pathways, in concert with efforts designed to reduce barriers, may increase initiation of VA mental health-care services by veterans. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Going direct to the consumer: Examining treatment preferences for veterans with insomnia, PTSD, and depression

Inclusion of consumer preferences to disseminate evidence-based psychosocial treatment (EBPT) is crucial to effectively bridge the science-to-practice quality chasm. We examined this treatment gap for insomnia, posttraumatic stress disorder (PTSD), depression, and comorbid symptoms in a sample of 622 young adult veterans through preference in symptom focus, treatment modality, and related gender differences among those screening positive for each problem. Data were collected from veteran drinkers recruited through targeted Facebook advertisements as part of a brief online alcohol intervention. Analyses demonstrated that veterans reported greater willingness to seek insomnia-focused treatment over PTSD- or depression-focused care. Notably, even when participants screened negative for insomnia, they preferred sleep-focused care to PTSD- or depression-focused care. Although one in five veterans with a positive screen would not consider care, veterans screening for both insomnia and PTSD who would consider care had a preference for in-person counseling, and those screening for both insomnia and depression had similar preferences for in-person and mobile app-based/computer self-help treatment. Marginal gender differences were found. Incorporating direct-to-consumer methods into research can help educate stakeholders about methods to expand EBPT access. Though traditional in-person counseling was often preferred, openness to app-based/computer interventions offers alternative methods to provide veterans with EBPTs.

The effect of telehealth, telephone support or usual care on quality of life, mortality and healthcare utilization in elderly high-risk patients with multiple chronic conditions. A prospective study

BACKGROUND AND OBJECTIVE

To assess the effect of home based telehealth or structured telephone support interventions with respect to usual care on quality of life, mortality and healthcare utilization in elderly high-risk multiple chronic condition patients.

PATIENTS AND METHODS

472 elderly high-risk patients with plurimorbidity in the region of Valencia (Spain) were recruited between June 2012 and May 2013, and followed for 12 months from recruitment. Patients were allocated to either: (a) a structured telephone intervention, a nurse-led case management program with telephone follow up every 15 days; (b) telehealth, which adds technology for remote self-management and the exchange of clinical data; or (c) usual care. Main outcome measures was quality of life measured by the EuroQol (EQ-5D) instrument, cognitive impairment, functional status, mortality and healthcare resource use. Inadequate randomization process led us to used propensity scores for adjusted analyses to control for imbalances between groups at baseline.

RESULTS

EQ-5D score was significantly higher in the telehealth group compared to usual care (diff: 0.19, 0.08-0.30), but was not different to telephone support (diff: 0.04, -0.05 to 0.14). In adjusted analyses, inclusion in the telehealth group was associated with an additional 0.18 points in the EQ-5D score compared to usual care at 12 months (p<0.001), and with a gain of 0.13 points for the telephone support group (p<0.001). No differences in mortality or utilization were found, except for a borderline significant increase in General Practitioner visits.

CONCLUSIONS

Telehealth was associated with better quality of life. Important limitations of the study and similarity of effects to telephone intervention call for careful endorsement of telemedicine. Clinicaltrials.gov (identifier: NCT02447562).

Access to primary care for socio-economically disadvantaged older people in rural areas: A qualitative study

Objective

We aim to explore the barriers to accessing primary care for socio-economically disadvantaged older people in rural areas.

Methods

Using a community recruitment strategy, fifteen people over 65 years, living in a rural area, and receiving financial support were recruited for semi-structured interviews. Four focus groups were held with rural health professionals. Interviews and focus groups were audio-recorded and transcribed. Thematic analysis was used to identify barriers to primary care access.

Findings

Older people’s experience can be understood within the context of a patient perceived set of unwritten rules or social contract–an individual is careful not to bother the doctor in return for additional goodwill when they become unwell. However, most found it difficult to access primary care due to engaged telephone lines, availability of appointments, interactions with receptionists; breaching their perceived social contract. This left some feeling unwelcome, worthless or marginalised, especially those with high expectations of the social contract or limited resources, skills and/or desire to adapt to service changes.

Health professionals’ described how rising demands and expectations coupled with service constraints had necessitated service development, such as fewer home visits, more telephone consultations, triaging calls and modifying the appointment system.

Conclusion

Multiple barriers to accessing primary care exist for this group. As primary care is re-organised to reduce costs, commissioners and practitioners must not lose sight of the perceived social contract and models of care that form the basis of how many older people interact with the service.

Differences in Perceptions of and Practices Regarding Treatment of Alcohol Use Disorders Among VA Primary Care Providers in Urban and Rural Clinics

BACKGROUND

Effective behavioral and pharmacological treatments are available and recommended for patients with alcohol use disorders (AUD) but rarely received. Barriers to receipt and provision of evidence-based AUD treatments delivered by specialists may be greatest in rural areas.

METHODS

A targeted subanalysis of qualitative interview data collected from primary care providers at 5 Veterans Affairs clinics was conducted to identify differences in provider perceptions and practices regarding AUD treatment across urban and rural clinics. Key contacts were used to recruit 24 providers from 3 "urban" clinics at medical centers and 2 "rural" community-based outpatient clinics. Providers completed 30-minute semistructured interviews, which were recorded, transcribed, and analyzed using inductive content analysis.

RESULTS

Thirteen urban and 11 rural providers participated. Urban and rural providers differed regarding referral practices and in perceptions of availability and utility of specialty addictions treatment. Urban providers described referral to specialty treatment as standard practice, while rural providers reported substantial barriers to specialty care access and infrequent specialty care referral. Urban providers viewed specialty addictions treatment as accessible and comprehensive, and perceived addictions providers as "experts" and collaborators, whereas rural providers perceived inadequate support from the health care system for AUD treatment. Urban providers desired greater integration with specialty addictions care while rural providers wanted access to local addictions treatment resources.

CONCLUSIONS

Providers in rural settings view referral to specialty addictions treatment as impractical and resources inadequate to treat AUD. Additional work is needed to understand the unique needs of rural clinics and decrease barriers to AUD treatment.

Survey Instruments to Assess Patient Experiences With Access and Coordination Across Health Care Settings: Available and Needed Measures

BACKGROUND

Improving access can increase the providers a patient sees, and cause coordination challenges. For initiatives that increase care across health care settings, measuring patient experiences with access and care coordination will be crucial.

OBJECTIVES

Map existing survey measures of patient experiences with access and care coordination expected to be relevant to patients accessing care across settings. Preliminarily examine whether aspects of access and care coordination important to patients are represented by existing measures.

RESEARCH DESIGN

Structured literature review of domains and existing survey measures related to access and care coordination across settings. Survey measures, and preliminary themes from semistructured interviews of 10 patients offered VA-purchased Community Care, were mapped to identified domains.

RESULTS

We identified 31 existing survey instruments with 279 items representing 6 access and 5 care coordination domains relevant to cross-system care. Domains frequently assessed by existing measures included follow-up coordination, primary care access, cross-setting coordination, and continuity. Preliminary issues identified in interviews, but not commonly assessed by existing measures included: (1) acceptability of distance to care site given patient's clinical situation; (2) burden on patients to access and coordinate care and billing; (3) provider familiarity with Veteran culture and VA processes.

CONCLUSIONS

Existing survey instruments assess many aspects of patient experiences with access and care coordination in cross-system care. Systems assessing cross-system care should consider whether patient surveys accurately reflect the level of patients' concerns with burden to access and coordinate care, and adequately reflect the impact of clinical severity and cultural familiarity on patient preferences.

Substance Use Disorder Treatment Services for Women in the Veterans Health Administration

PURPOSE

The present study used national Veterans Health Administration (VHA) facility-level data to examine the extent of women's specialty substance use disorder (SUD) treatment programming in the VHA. In addition, the study compared facilities with women's specialty SUD programming with facilities without to determine whether having this programming was associated with serving other special patient populations, treatment staffing, and breadth of service provision.

METHODS

The study used data from the VHA Program Evaluation and Resource Center's Drug and Alcohol Program Survey, conducted in 2015 (100% response rate among VHA specialty SUD treatment programs). Program responses were calculated at the facility level (n = 140 VHA facilities).

MAIN FINDINGS

The majority of VHA facilities (85%) provided women veterans with SUD-specific individual psychotherapy. However, only 30% of facilities provided SUD-specific groups for women only, and only 14% provided SUD-posttraumatic stress disorder groups for women only in specialty SUD treatment. VHA facilities with greater numbers of specialty SUD treatment staff members, a greater breadth of staff roles, and a broader scope of treatment services, activities, and practices were more likely to provide women-only groups.

CONCLUSIONS

Because the number of women veterans in specialty SUD treatment is likely to continue to grow, these data serve as a benchmark against which future administrations of the Drug and Alcohol Program Survey will document the extent to which VHA services are responsive to their needs.

U.S. Veteran Health Care Utilization Increases after Caregivers' Use of National Caregiver Telephone Support Line

The U.S. Department of Veterans Affairs (VA) established the national Caregiver Support Line (CSL) in February 2011. The CSL is operated by licensed master's degree social workers who provide caregivers of veterans with information about caregiver benefits and services, counseling, and referrals to a caregiver support coordinator at the nearest VA medical center. The authors compared differences in veteran health care utilization patterns in the six months before and after a caregiver call to the CSL, hypothesizing that veterans with caregivers using the CSL had improved access to health care services and improved access increased utilization of health care. A pre- and posttest design was used. CSL calls that resulted in referrals to VA health care services or to local VA caregiver support coordinators were included in the sample. Data were extracted from the CSL database and matched to veteran care utilization data using veteran medical record data. Veteran inpatient stays for general medicine, hospice, respite, and long-term care significantly increased after the CSL call, but other inpatient stays (surgery, neurology) did not. Outpatient services for home health, respite, and mental health all significantly increased. Caregivers' use of the national CSL may help facilitate access for veterans to needed care services.

Moving From Discovery to System-Wide Change: The Role of Research in a Learning Health Care System: Experience from Three Decades of Health Systems Research in the Veterans Health Administration

The Veterans Health Administration is unique, functioning as an integrated health care system that provides care to more than six million veterans annually and as a home to an established scientific enterprise that conducts more than $1 billion of research each year. The presence of research, spanning the continuum from basic health services to translational research, has helped the Department of Veterans Affairs (VA) realize the potential of a learning health care system and has contributed to significant improvements in clinical quality over the past two decades. It has also illustrated distinct pathways by which research influences clinical care and policy and has provided lessons on challenges in translating research into practice on a national scale. These lessons are increasingly relevant to other health care systems, as the issues confronting the VA—the need to provide timely access, coordination of care, and consistent high quality across a diverse system—mirror those of the larger US health care system.

Comparing VA and Non-VA Quality of Care: A Systematic Review

BACKGROUND

The Veterans Affairs (VA) health care system aims to provide high-quality medical care to veterans in the USA, but the quality of VA care has recently drawn the concern of Congress. The objective of this study was to systematically review published evidence examining the quality of care provided at VA health care facilities compared to quality of care in other facilities and systems.

METHODS

Building on the search strategy and results of a prior systematic review, we searched MEDLINE (from January 1, 2005, to January 1, 2015) to identify relevant articles on the quality of care at VA facilities compared to non-VA facilities. Articles from the prior systematic review published from 2005 and onward were also included and re-abstracted. Studies were classified, analyzed, and summarized by the Institute of Medicine's quality dimensions.

RESULTS

Sixty-nine articles were identified (including 31 articles from the prior systematic review and 38 new articles) that address one or more Institute of Medicine quality dimensions: safety (34 articles), effectiveness (24 articles), efficiency (9 articles), patient-centeredness (5 articles), equity (4 articles), and timeliness (1 article). Studies of safety and effectiveness indicated generally better or equal performance, with some exceptions. Too few articles related to timeliness, equity, efficiency, and patient-centeredness were found from which to reliably draw conclusions about VA care related to these dimensions.

DISCUSSION

The VA often (but not always) performs better than or similarly to other systems of care with regard to the safety and effectiveness of care. Additional studies of quality of care in the VA are needed on all aspects of quality, but particularly with regard to timeliness, equity, efficiency, and patient-centeredness.

A comparison of MOVE! versus TeleMOVE programs for weight loss in Veterans with obesity

BACKGROUND

Obesity is a leading contributor to disability. Treatment approaches incorporating telehealth technologies are becoming increasingly popular in treating obesity, but their benefits relative to established behavioural weight loss therapies are poorly understood. The objective of this study was to compare a new telehealth treatment (TeleMOVE) to an established behavioural treatment (MOVE!) among Veterans with obesity.

METHODS

This was an observational study of Veterans in the TeleMOVE or MOVE! programs between October, 2011 and March, 2013. A total of 699 Veterans enrolled in these programs from 2011-2013. A secondary focus was on Veterans that were ≥90% adherent to their treatment. From this group, 72 (33.1%) TeleMOVE and 141 (29.3%) MOVE! participants met adherence criteria. The primary outcome criterion was changes in body weight.

RESULTS

Both programs were associated with significant weight reductions, with MOVE! participants showing significantly less weight loss relative to those in TeleMOVE (MOVE! mean weight loss=4.5[7.1]lb/2.0[3.2]kg; 1.8% mean weight loss; 12.0% achieving ≥5% weight loss; TeleMOVE mean weight loss=8.6[9.9]lb/3.9[4.5]kg; 3.6% mean weight loss; 26.6% achieving ≥5% weight loss, p's<.01). Among highly adherent participants, patients in TeleMOVE versus MOVE! lost significantly more weight (TeleMOVE=11.1[9.9]lb/5.0[4.5]kg versus MOVE!=5.7[7.1]lb/2.6[3.2]kg; t=4.6, p<.001) and were significantly more likely to achieve clinically significant weight loss (% with ≥5% weight loss were 43.1% versus 13.5%, respectively, p<.001).

CONCLUSIONS

In this observational study, TeleMOVE was at least as effective for weight loss as the more established multidisciplinary MOVE!

PROGRAM

Platelet monoamine oxidase type B, MAOB intron 13 and MAOA-uVNTR polymorphism and symptoms of post-traumatic stress disorder

Post-traumatic stress disorder (PTSD), a disorder that develops following exposure to traumatic experience(s), is frequently associated with agitation, aggressive behavior and psychotic symptoms. Monoamine oxidase (MAO) degrades different biogenic amines and regulates mood, emotions and behavior, and has a role in the pathophysiology of various neuropsychiatric disorders. The aim of the study was to investigate the association between different symptoms occurring in PTSD [PTSD symptom severity assessed by the Clinician Administered PTSD Scale (CAPS), agitation and selected psychotic symptoms assessed by the Positive and Negative Syndrome Scale (PANSS)] and platelet MAO-B activity and/or genetic variants of MAOB rs1799836 and MAOA-uVNTR polymorphisms in 249 Croatian male veterans with PTSD. Our study revealed slightly higher platelet MAO-B activity in veterans with PTSD with more severe PTSD symptoms and in veterans with agitation, and significantly higher platelet MAO-B activity in veterans with more pronounced psychotic symptoms compared to veterans with less pronounced psychotic symptoms. Platelet MAO-B activity was associated with smoking but not with age. Genetic variants of MAOB rs1799836 and MAOA-uVNTR were not associated with agitation and selected psychotic symptoms in veterans with PTSD. A marginally significant association was found between MAOB rs1799836 polymorphism and severity of PTSD symptoms, but it was not confirmed since carriers of G or A allele of MAOB rs1799836 did not differ in their total CAPS scores. These findings suggest an association of platelet MAO-B activity, but a lack of association of MAOB rs1799836 and MAOA-uVNTR, with selected psychotic symptoms in ethnically homogenous veterans with PTSD.

E-consult implementation: lessons learned using consolidated framework for implementation research

OBJECTIVES

In 2011, the Veterans Health Administration (VHA) implemented electronic consults (e-consults) as an alternative to in-person specialty visits to improve access and reduce travel for veterans. We conducted an evaluation to understand variation in the use of the new e-consult mechanism and the causes of variable implementation, guided by the Consolidated Framework for Implementation Research (CFIR).

STUDY DESIGN

Qualitative case studies of 3 high- and 5 low-implementation e-consult pilot sites. Participants included e-consult site leaders, primary care providers, specialists, and support staff identified using a modified snowball sample.

METHODS

We used a 3-step approach, with a structured survey of e-consult site leaders to identify key constructs, based on the CFIR. We then conducted open-ended interviews, focused on key constructs, with all participants. Finally, we produced structured, site-level ratings of CFIR constructs and compared them between high- and low-implementation sites.

RESULTS

Site leaders identified 14 initial constructs. We conducted 37 interviews, from which 4 CFIR constructs distinguished high implementation e-consult sites: compatibility, networks and communications, training, and access to knowledge and information. For example, illustrating compatibility, a specialist at a high-implementation site reported that the site changed the order of consult options so that all specialties listed e-consults first to maintain consistency. High-implementation sites also exhibited greater agreement on constructs.

CONCLUSIONS

By using the CFIR to analyze results, we facilitate future synthesis with other findings, and we better identify common patterns of implementation determinants common across settings.

Improving access to high-quality primary care for socioeconomically disadvantaged older people in rural areas: a mixed method study protocol

INTRODUCTION

The UK has an ageing population, especially in rural areas, where deprivation is high among older people. Previous research has identified this group as at high risk of poor access to healthcare. The aim of this study is to generate a theory of how socioeconomically disadvantaged older people from rural areas access primary care, to develop an intervention based on this theory and test it in a feasibility trial.

METHODS AND ANALYSIS

On the basis of the MRC Framework for Developing and Evaluating Complex Interventions, three methods will be used to generate the theory. First, a realist review will elucidate the patient pathway based on existing literature. Second, an analysis of the English Longitudinal Study of Ageing will be completed using structural equation modelling. Third, 15 semistructured interviews will be undertaken with patients and four focus groups with health professionals. A triangulation protocol will be used to allow each of these methods to inform and be informed by each other, and to integrate data into one overall realist theory. Based on this theory, an intervention will be developed in discussion with stakeholders to ensure that the intervention is feasible and practical. The intervention will be tested within a feasibility trial, the design of which will depend on the intervention. Lessons from the feasibility trial will be used to refine the intervention and gather the information needed for a definitive trial.

ETHICS AND DISSEMINATION

Ethics approval from the regional ethics committee has been granted for the focus groups with health professionals and interviews with patients. Ethics approval will be sought for the feasibility trial after the intervention has been designed. Findings will be disseminated to the key stakeholders involved in intervention development, to researchers, clinicians and health planners through peer-reviewed journal articles and conference publications, and locally through a dissemination event.

A systematic review of barriers to optimal outpatient specialist services for individuals with prevalent chronic diseases: what are the unique and common barriers experienced by patients in high income countries?

Health utilization and need assessment data suggest there is considerable variation in access to outpatient specialist care. However, it is unclear if the types of barriers experienced are specific to chronic disease groups or experienced universally. This systematic review provides a detailed summary of common and unique barriers experienced by chronic disease groups when accessing and receiving care, and a synthesized list of possible health service initiatives to improve equitable delivery of optimal care in high-income countries. Quantitative articles describing barriers to specialist outpatient services were retrieved from CINAHL, MEDLINE, Embase, and PyscINFO. To be eligible for review, studies: were published from 2002 to May 2014; included samples with cancer, diabetes mellitus, osteoporosis, arthritis, ischaemic heart disease, stroke, asthma, chronic pulmonary disorder (COPD) or depression; and, were conducted in high-income countries. Using a previously validated model of access (Penchansky and Thomas' model of fit), barriers were grouped according to five overarching domains and defined in more detail using 33 medical subject headings. Results from reviewed articles, including the scope and frequency of reported barriers, are conceptualized using thematic analysis and framed as possible health service initiatives. A total of 3181 unique records were screened for eligibility, of which 74 studies were included in final analysis. The largest proportion of studies reported acceptability barriers (75.7 %), of which demographic disparities (44.6 %) were reported across all diseases. Other frequently reported barriers included inadequate need assessment (25.7 %), information provision (32.4 %), or health communication (20 %). Unique barriers were identified for oncology, mental health, and COPD samples. Based on the scope, frequency and measurement of reported barriers, eight key themes with associated implications for health services are presented. Examples include: common accommodation and accessibility barriers caused on service organization or physical structure, such as parking and appointment scheduling; common barriers created by poor coordination of care within the healthcare team; and unique barriers resulting from inadequate need assessment and referral practices. Consideration of barriers, across and within chronic diseases, suggests a number of specific initiatives are likely to improve the delivery of patient-centered care and increase equity in access to high-quality health services.

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.

Behavioral health coaching for rural veterans with diabetes and depression: a patient randomized effectiveness implementation trial

BACKGROUND

Depression and diabetes cause significant burden for patients and the healthcare system and, when co-occurring, result in poorer self-care behaviors and worse glycemic control than for either condition alone. However, the clinical management of these comorbid conditions is complicated by a host of patient, provider, and system-level barriers that are especially problematic for patients in rural locations. Patient-centered medical homes provide an opportunity to integrate mental and physical health care to address the multifaceted needs of complex comorbid conditions. Presently, there is a need to not only develop robust clinical interventions for complex medically ill patients but also to find feasible ways to embed these interventions into the frontlines of existing primary care practices.

METHODS/DESIGN

This randomized controlled trial uses a hybrid effectiveness-implementation design to evaluate the Healthy Outcomes through Patient Empowerment (HOPE) intervention, which seeks to simultaneously address diabetes and depression for rural veterans in Southeast Texas. A total of 242 Veterans with uncontrolled diabetes and comorbid symptoms of depression will be recruited and randomized to either the HOPE intervention or to a usual-care arm. Participants will be evaluated on a host of diabetes and depression-related measures at baseline and 6- and 12-month follow-up. The trial has two primary goals: 1) to examine the effectiveness of the intervention on both physical (diabetes) and emotional health (depression) outcomes and 2) to simultaneously pilot test a multifaceted implementation strategy designed to increase fidelity and utilization of the intervention by coaches interfacing within the primary care setting.

DISCUSSION

This ongoing blended effectiveness-implementation design holds the potential to advance the science and practice of caring for complex medically ill patients within the constraints of a busy patient-centered medical home.

TRIAL REGISTRATION

Behavioral Activation Therapy for Rural Veterans with Diabetes and Depression: NCT01572389.

Predictors of anger treatment outcomes

OBJECTIVE

This study investigated predictors of therapeutic outcomes for veterans who received treatment for dysregulated anger.

METHOD

Data are from a randomized controlled trial investigating the effectiveness of video teleconferencing compared to in-person delivery of anger management therapy (AMT) among 125 military veterans. Multilevel modeling was used to assess 2 types of predictors (demographic characteristics and mental health factors) of changes in anger symptoms after treatment.

RESULTS

Results showed that while veterans benefited similarly from treatment across modalities, veterans who received two or more additional mental health services and who had longer commutes to care showed the greatest improvement on a composite measure of self-reported anger symptoms.

CONCLUSION

Results highlight that veterans with a range of psychosocial and mental health characteristics benefited from AMT, while those receiving the most additional concurrent mental health services had better outcomes.

Quality of prostate cancer care among rural men in the Veterans Health Administration

BACKGROUND

Patient travel distances, coupled with variation in facility-level resources, create barriers for prostate cancer care in the Veterans Health Administration integrated delivery system. For these reasons, the authors investigated the degree to which these barriers impact the quality of prostate cancer care.

METHODS

The Veterans Affairs Central Cancer Registry was used to identify all men who were diagnosed with prostate cancer in 2008. Patient residence was characterized using Rural Urban Commuting Area codes. The authors then examined whether rural residence, compared with urban residence, was associated with less access to cancer-related resources and worse quality of care for 5 prostate cancer quality measures.

RESULTS

Approximately 25% of the 11,368 patients who were diagnosed with prostate cancer in 2008 lived in either a rural area or a large town. Rural patients tended to be white (62% urban vs 86% rural) and married (47% urban vs 63% rural), and they tended to have slightly higher incomes (all P<.01) but similar tumor grade (P=.23) and stage (P=.12) compared with urban patients. Rural patients were significantly less likely to be treated at facilities with comprehensive cancer resources, although they received a similar or better quality of care for 4 of the 5 prostate cancer quality measures. The time to prostate cancer treatment was similar (rural patients vs urban patients, 96.6 days vs 105.7 days).

CONCLUSIONS

Rural patients with prostate cancer had less access to comprehensive oncology resources, although they received a similar quality of care, compared with their urban counterparts in the Veterans Health Administration integrated delivery system. A better understanding of the degree to which facility factors contribute to the quality of cancer care may assist other organizations involved in rural health care delivery.

Antidepressant Medication Use Among Patients with Depression: Comparison between Usual Care and Collaborative Care Using Care Managers

Depression poses a significant economic and health burden, yet it remains underdiagnosed and inadequately treated. The STAR*D trial funded by the National Institute of Mental Health showed that more than one antidepressant medication is often necessary to achieve disease remission among patients seen in both psychiatric and primary care settings. The collaborative care model (CCM), using care managers, has been shown to be effective in numerous studies in achieving sustained outcomes in depression management compared to usual care. This model was adopted in a statewide depression treatment improvement initiative among primary care clinics in Minnesota, which was launched in March 2008. In this study, records of patients who were enrolled in CCM from March 2008 until March 2009 were reviewed and compared to those under usual care. Patients who were followed under the CCM had a significantly greater number of antidepressant medication utilizations when compared to those under usual care. After 6 months, mean PHQ-9 score of patients under CCM was statistically lower than those in usual care. There was no significant difference in both mean PHQ-9 scores at 6 months and antidepressant utilization between the 2 groups among patients aged 65 years and older.

Evaluating the promise of health IT to enhance/expand the reach of mental health services

OBJECTIVE

A growing number of health information technologies (HIT) are being developed and tested to address mental health conditions. HIT includes Internet and smartphone programs or apps, text messaging protocols and telepsychiatry. We reviewed the promise and evidence that HIT can expand access to mental health care and reduce disparities in use of services across groups in need.

CONCLUSIONS

Limited reach of mental health services is a pervasive problem in the United States, and solving it will require innovations that enable us to extend our clinical reach into underserved populations without significantly expanding our workforce. In theory, HIT can extend access to mental health care in several ways: by enhancing the reach to priority populations, addressing system capacity issues, supporting training, improving clinical decision making, lowering the "consumer's threshold" for treatment, delivering preventive mental health services, speeding innovation and adoption and reducing cost barriers to treatment. At present, evidence is limited, and research is needed, focusing on consumer engagement strategies, the benefits and harms of HIT for the therapeutic relationship and the comparative effectiveness of various HIT alternatives.