Effectiveness of an Evidence-Based Quality Improvement Approach to Cultural Competence Training: The Veterans Affairs' "Caring for Women Veterans" Program

Impact of Evidence-Based Quality Improvement on Tailoring VA's Patient-Centered Medical Home Model to Women Veterans' Needs

BACKGROUND

Women Veterans' numerical minority, high rates of military sexual trauma, and gender-specific healthcare needs have complicated implementation of comprehensive primary care (PC) under VA's patient-centered medical home model, Patient Aligned Care Teams (PACT).

OBJECTIVE

We deployed an evidence-based quality improvement (EBQI) approach to tailor PACT to meet women Veterans' needs and studied its effects on women's health (WH) care readiness, team-based care, and burnout.

DESIGN

We evaluated EBQI effectiveness in a cluster randomized trial with unbalanced random allocation of 12 VAMCs (8 EBQI vs. 4 control). Clinicians/staff completed web-based surveys at baseline (2014) and 24 months (2016). We adjusted for individual-level covariates (e.g., years at VA) and weighted for non-response in difference-in-difference analyses for readiness and team-based care overall and by teamlet type (mixed-gender PC-PACTs vs. women-only WH-PACTs), as well as post-only burnout comparisons.

PARTICIPANTS

We surveyed all clinicians/staff in general PC and WH clinics.

INTERVENTION

EBQI involved structured engagement of multilevel, multidisciplinary stakeholders at network, VAMC, and clinic levels toward network-specific QI roadmaps. The research team provided QI training, formative feedback, and external practice facilitation, and support for cross-site collaboration calls to VAMC-level QI teams, which developed roadmap-linked projects adapted to local contexts.

MAIN MEASURES

WH care readiness (confidence providing WH care, self-efficacy implementing PACT for women, barriers to providing care for women, gender sensitivity); team-based care (change-readiness, communication, decision-making, PACT-related QI, functioning); burnout.

KEY RESULTS

Overall, EBQI had mixed effects which varied substantively by type of PACT. In PC-PACTs, EBQI increased self-efficacy implementing PACT for women and gender sensitivity, even as it lowered confidence. In contrast, in WH-PACTs, EBQI improved change-readiness, team-based communication, and functioning, and was associated with lower burnout.

CONCLUSIONS

EBQI effectiveness varied, with WH-PACTs experiencing broader benefits and PC-PACTs improving basic WH care readiness. Lower confidence delivering WH care by PC-PACT members warrants further study.

TRIAL REGISTRATION

The data in this paper represent results from a cluster randomized controlled trial registered in ClinicalTrials.gov (NCT02039856).

Enhancing Primary Care and Mental Health Integration for Women Veterans with Complex Healthcare Needs Using Evidence-Based Quality Improvement

BACKGROUND

Women Veterans with co-morbid medical and mental health conditions face persistent barriers accessing high-quality health care. Evidence-based quality improvement (EBQI) offers a systematic approach to implementing new care models that can address care gaps for women Veterans.

OBJECTIVE

This study examines factors associated with the successful deployment of EBQI within integrated health systems to improve primary care for women Veterans with complex mental health needs.

DESIGN

Following a 12-site (8 EBQI, 4 control) cluster randomized study to evaluate EBQI effectiveness, we conducted an in-depth case study analysis of one women's health clinic that used EBQI to improve integrated primary care-mental health services for women Veterans.

PARTICIPANTS

Our study sample included providers, program managers, and clinic staff at a women Veteran's health clinic that, at the time of the study, had one Primary Care and Mental Health Integration team and one women's health primary care provider serving 800 women. We analyzed interviews conducted 12 months, 24 months, and 4 years post-implementation and call summaries between the clinic and support team.

MAIN MEASURES

We conducted qualitative thematic analysis of interview and call summary data to identify EBQI elements, clinic characteristics, and reported challenges and successes within project development and execution.

KEY RESULTS

The clinic harnessed core EBQI elements (multi-level stakeholder engagement, data-driven progress-monitoring, PDSA cycles, sharing results) to accomplish pre-defined project goals, strengthen inter-disciplinary partnerships, and bolster team confidence. Clinic characteristics that facilitated implementation success included prior QI experience and an organizational culture responsive to innovation, while lack of pre-existing guidelines and limited access to centralized databases posed implementation challenges.

CONCLUSIONS

Successful practice transformation emerges through the interaction of evidence-based methods and site-specific characteristics. Examining how clinic characteristics support or impede EBQI adaptation can facilitate efforts to improve care within integrated health systems.

Implementing a Multi-Disciplinary, Evidence-Based Resilience Intervention for Moral Injury Syndrome: Systemic Barriers and Facilitators

Moral injury syndrome (MIS) is a mental health (MH) problem that substantially affects resilience; the presence of MIS reduces responsiveness to psychotherapy and increases suicide risk. Evidence-based treatment for MIS is available; however, it often goes untreated. This project uses principles of the Consolidated Framework for Implementation Research (CFIR) to assess barriers and facilitators to the implementation of Building Spiritual Strength (BSS), a multi-disciplinary treatment for MIS. Interviews were conducted with chaplains and mental health providers who had completed BSS facilitator training at six sites in the VA. Data were analyzed using the Hamilton Rapid Turnaround method. Findings included multiple facilitators to the implementation of BSS, including its accessibility and appeal to VA chaplains; leadership by VA chaplains trained in the intervention; and effective collaboration between the chaplains and mental health providers. Barriers to the implementation of BSS included challenges in engaging mental health providers and incorporating them as group leaders, veterans' lack of familiarity with the group format of BSS, and the impact of the COVID-19 pandemic. Results highlight the need for increased trust and collaboration between VA chaplains and mental health providers in the implementation of BSS and treatment of MIS.

Attitudes and beliefs about sleep health among a racially and ethnically diverse sample of overweight/obese adults

OBJECTIVES

To identify and compare how sleep-related attitudes and beliefs vary among racially and ethnically diverse adults with risk factors for cardio-metabolic disease.

METHODS

This exploratory qualitative study used online focus group discussions (N = 4 groups among 17 individuals) to collect information about sleep attitudes, beliefs, and practices following participation in the Mindfulness Intervention to Improve Sleep and Reduce Diabetes Risk Among a Diverse Sample in Atlanta (MINDS) study. A rapid analyses approach was used to identify shared themes related to attitudes and beliefs about sleep health and sleep practices across participants.

RESULTS

Participants on average were 31years old, 88% female, and identified as Black/African American (52.9%), White (17.7%), Asian (11.8%), and Hispanic (17.7%). Three themes related to attitudes and beliefs about sleep health were identified: prioritization of sleep to improve one's overall health, re-evaluating sleep needs, and interpersonal barriers to sleep. For Black/African American participants prioritizing sleep was coupled with a want to minimize stress as a long-term health promotion strategy, whereas individuals of other races/ethnicities were more focused on the immediate benefits of getting sufficient sleep. Individuals had reappraised their sleep needs and worked to improve their sleep hygiene accordingly, yet still experienced barriers to sleep. The most common barrier to sleep was sharing a sleep environment with someone who had conflicting sleep routines and practices.

CONCLUSION

The results of this study suggest perceived benefits of and barriers to sleep vary by race/ethnicity, thus future interventions should be culturally tailored to enhance effectiveness.

Feasibility, appropriateness, and acceptability of a mobile mindfulness meditation intervention to improve sleep quality among a racially/ethnically diverse population

OBJECTIVES

To evaluate the acceptability, appropriateness, and feasibility of using a mindfulness meditation mobile application to improve sleep quality among a diverse group of adults.

METHODS

This explanatory qualitative study used online focus group discussions (N = 4 groups with 17 individuals) to collect information about user experiences with a mindfulness meditation mobile application (Headspace) among participants enrolled in the MINDS study. A rapid analyses approach was used to descriptively compare motivators of app use, barriers and facilitators to app use, and perceived tailoring needs across participants.

RESULTS

Participants on average were 30 years old, 88% female, and identified as Black/African American (52.9%), White (29.4%), Asian (11.8%), and Hispanic (17.6%). All participants felt the app was acceptable and appreciated the ability to personalize their app experience. Individuals with ≥50% intervention adherence (daily use for 30 days) reported being motivated to use the app because it helped them to fall asleep faster, while the remainder of participants used the app to relax throughout the day and faced external barriers to app use (eg, lack of time) and difficulty with app navigation. Only those participants who used the app exclusively in the evenings reported falling asleep faster and staying asleep. Suggestions for tailoring the app differed by race and age. Only Black/African American participants preferred using an instructor based on their race and gender.

CONCLUSION

Using a mobile meditation app to enhance sleep quality is acceptable and feasible, but additional tailoring for Black/African American individuals may improve uptake in this population.

Analyzing fast and slow: Combining traditional and rapid qualitative analysis to meet multiple objectives of a complex transnational study

Much of the methodological literature on rapid qualitative analysis describes processes used by a relatively small number of researchers focusing on one study site and using rapid analysis to replace a traditional analytical approach. In this paper, we describe the experiences of a transnational research consortium integrating both rapid and traditional qualitative analysis approaches to develop social theory while also informing program design. Research was conducted by the Innovations for Choice and Autonomy (ICAN) consortium, which seeks to understand how self-injection of the contraceptive subcutaneous depot medroxyprogesterone acetate (DMPA-SC) can be implemented in a way that best meets women's needs, as defined by women themselves. Consortium members are based in Kenya, Uganda, Malawi, Nigeria, and the United States. Data for the ICAN study was collected in all four countries in sub-Saharan Africa. In order to both illuminate social phenomena across study sites and inform the program design component of the study, researchers developed tools meant to gather both in-depth information about women's contraceptive decision-making and data targeted specifically to program design during the formative qualitative phase of the study. Using these two bodies of data, researchers then simultaneously conducted both a traditional qualitative and rapid analysis to meet multiple study objectives. To complete the traditional analysis, researchers coded interview transcripts and kept analytical memos, while also drawing on data collected by tools developed for the rapid analysis. Rapid analysis consisted of simultaneously collecting data and reviewing notes developed specifically for this analysis. We conclude that integrating traditional and rapid qualitative analysis enabled us to meet the needs of a complex transnational study with the added benefit of grounding our program design work in more robust primary data than normally is available for studies using a human-centered design approach to intervention development. However, the realities of conducting a multi-faceted study across multiple countries and contexts made truly "rapid" analysis challenging.

Evidence-Based Quality Improvement: a Scoping Review of the Literature

BACKGROUND

Quality improvement (QI) initiatives often reflect approaches based on anecdotal evidence, but it is unclear how initiatives can best incorporate scientific literature and methods into the QI process. Review of studies of QI initiatives that aim to systematically incorporate evidence review (termed evidence-based quality improvement (EBQI)) may provide a basis for further methodological development.

METHODS

In this scoping review (registration: https://osf.io/hr5bj ) of EBQI, we searched the databases PubMed, CINAHL, and SCOPUS. The review addressed three central questions: How is EBQI defined? How is evidence used to inform evidence-informed QI initiatives? What is the effectiveness of EBQI?

RESULTS

We identified 211 publications meeting inclusion criteria. In total, 170 publications explicitly used the term "EBQI." Published definitions emphasized relying on evidence throughout the QI process. We reviewed a subset of 67 evaluations of QI initiatives in primary care, including both studies that used the term "EBQI" with those that described an evidence-based initiative without using EBQI terminology. The most frequently reported EBQI components included use of evidence to identify previously tested effective QI interventions; engaging stakeholders; iterative intervention development; partnering with frontline clinicians; and data-driven evaluation of the QI intervention. Effectiveness estimates were positive but varied in size in ten studies that provided data on patient health outcomes.

CONCLUSIONS

EBQI is a promising strategy for integrating relevant prior scientific findings and methods systematically in the QI process, from the initial developmental phase of the IQ initiative through to its evaluation. Future QI researchers and practitioners can use these findings as the basis for further development of QI initiatives.

HIV care experiences and health priorities during the first wave of COVID-19: clients' perspectives - a qualitative study in Lusaka, Zambia

BACKGROUND

The novel COVID-19 pandemic threatened to disrupt access to human immunodeficiency (HIV) treatment for persons living with HIV (PLHIV), two-thirds of whom live in sub-Saharan Africa. To inform a health system response supportive of continuity of care, we sought to understand clients' HIV care experiences and health priorities during the first wave of COVID-19 outbreak in Lusaka, Zambia.

METHODS

Leveraging a study cohort of those who completed periodic SMS surveys on HIV care, we purposefully sampled 25 PLHIV after first confirmed COVID-19 case was reported in Zambia on 18^th March 2020. We phone-interviewed participants, iteratively refining interview guide to capture emergent themes on COVID-19 awareness, health facility interactions, and social circumstances, which we analyzed using matrix analysis.

RESULTS

All participants were aware of COVID-19, and HIV care experiences and health priorities of clients were affected by associated changes at health system, household, and individual level. The health system instituted early clinic visits to provide 6-months of antiretroviral therapy (ART) for stable patients and 3-months for unstable patients to reduce clinic visits and wait times. Most patients welcomed this long-desired extended appointment spacing. Some reported feeling respected and engaged when health care workers telephoned requesting their early clinic visit. However, others felt discouraged by an absence of physical distancing during their clinic visit due to 'severe acute respiratory syndrome coronavirus 2' (SARS-CoV-2) infection concerns. Several expressed a lack of clarity regarding next viral load monitoring date and means for receiving results. Patients suggested regular patient-facility communication by telephone and SMS. Patients emphasized that COVID-19 restrictions led to loss of employment and household income, exacerbating poverty and difficulties in taking ART. At individual level, most participants felt motivated to stay healthy during COVID-19 by ART adherence and regular laboratory monitoring.

CONCLUSIONS

Clients' HIV care and health priorities during the first wave of COVID-19 in Lusaka province were varied with a combination of positive and negative experiences that occurred especially at health system and individual levels, while at household level, the experiences were all negative. More research is needed to understand how patients practice resiliency in the widespread context of socio-economic instability. Governments and patients must work together to find local, health systems solutions to support ART adherence and monitoring. Additionally, the health system should consider how to build on changes for long-term HIV management and service delivery.

Contraceptive care service provision via telehealth early in the COVID-19 pandemic at rural and urban federally qualified health centers in 2 southeastern states

PURPOSE

To investigate telehealth use for contraceptive service provision among rural and urban federally qualified health centers (FQHCs) in Alabama (AL) and South Carolina (SC) during the initial months of the COVID-19 pandemic.

METHODS

This is a mixed-methods study using data from the FQHC Contraceptive Care Survey and key informant interviews with FQHC staff in AL and SC conducted in 2020. Differences between rural and urban clinics in telehealth use for contraceptive service provision were assessed with a chi-square test of independence. Interviews were audio recorded, transcribed, and coded to identify facilitators and barriers to telehealth.

FINDINGS

Telehealth for contraceptive care increased during the early months of the pandemic relative to prepandemic. Fewer rural clinics than urban clinics provided telehealth for contraceptive counseling (16.3% vs 50.6%) (P = .0002), emergency contraception (0.0% vs 16.1%) (P = .004), and sexually transmitted infection care (16.3% vs 34.6%) (P = .031). Key facilitators of telehealth were reimbursement policy, electronic infrastructure and technology, and funding for technology. Barriers included challenges with funding for telehealth, limited electronic infrastructure, and reduced staffing capacity.

CONCLUSIONS

Differences in telehealth service provision for contraceptive care between rural and urban FQHCs highlight the need for supportive strategies to increase access to care for low-income rural populations, particularly in AL and SC. It is essential for public and private entities to support the implementation and continuation of telehealth among rural clinics, particularly, investing in widespread and clinic-level electronic infrastructure and technology for telehealth, such as broadband and electronic health record systems compatible with telehealth technology.

Interventions for Women Veterans with Mental Health Care Needs: Findings from a Scoping Review

Experts have prioritized research on women veterans' mental health and the delivery of gender-sensitive care. The purpose of this study was to conduct a scoping review of the literature to summarize interventions for women veterans with mental health care needs designed in the Department of Veterans Affairs (VA). We identified 1,073 articles; eight were eligible for full review and represented seven unique interventions. Four studies focused on individual-level interventions; three studies focused on interpersonal-level interventions. Some attributes of gender-sensitive care included modifying the treatment environment and offering same gender clinicians. In designing interventions, clinicians and researchers can: (a) create interprofessional teams which include nurses, (b) use participatory methods to improve study designs, (c) assess participants' barriers to care prior to designing interventions, (d) incorporate and evaluate attributes of gender-sensitive care, and (e) utilize and clearly delineate how theory guides research. With improved intervention research, clinicians and researchers can support women veterans with mental health care needs.

Telehealth for Contraceptive Care During the Initial Months of the COVID-19 Pandemic at Local Health Departments in 2 US States: A Mixed-Methods Approach

OBJECTIVES

This study examined implementation of telehealth for contraceptive care among health departments (HDs) in 2 Southern US states with centralized/largely centralized governance structures during the early phase of the COVID-19 pandemic. Sustaining access to contraceptive care for underserved communities during public health emergencies is critical. Identifying facilitators and barriers to adaptive service provision helps inform state-level decision making and has implications for public health policy and practice, particularly in states with centralized HD governance.

DESIGN

Mixed-methods study including a survey of HD clinic administrators and key informant interviews with clinic- and system-level staff in 2 states conducted in 2020.

SETTING

Health department clinics in 2 Southern US states.

PARTICIPANTS

Clinic administrators (survey) and clinic- and system-level respondents (key informant interviews). Participation in the research was voluntary and de-identified.

MAIN OUTCOME MEASURES

(1) Telehealth implementation for contraceptive care assessed by survey and measured by the percentage of clinics reporting telehealth service provision during the pandemic; and (2) facilitators and barriers to telehealth implementation for contraceptive care assessed by key informant interviews. For survey data, bivariate differences between the states in telehealth implementation for contraceptive care were assessed using χ2 and Fisher exact tests. Interview transcripts were coded, with emphasis on interrater reliability and consensus coding, and analyzed for emerging themes.

RESULTS

A majority of HD clinics in both states (60% in state 1 and 81% in state 2) reported a decrease in contraceptive care patient volume during March-June 2020 compared with the average volume in 2019. More HD clinics in state 1 than in state 2 implemented telehealth for contraceptive services, including contraceptive counseling, initial and refill hormonal contraception, emergency contraception and sexually transmitted infection care, and reported facilitators of telehealth. Medicaid reimbursement was a predominant facilitator of telehealth, whereas lack of implementation policies and procedures and reduced staffing capacity were predominant barriers. Electronic infrastructure and technology also played a role.

CONCLUSIONS

Implementation of telehealth for contraceptive services varied between state HD agencies in the early phase of the pandemic. Medicaid reimbursement policy and directives from HD agency leadership are key to telehealth service provision among HDs in centralized states.

Discontinuity of Women Veterans' Care in Patient-Centered Medical Homes: Does Workforce Gender Sensitivity Matter?

BACKGROUND

Prior research has found that 25% of women veterans who are new to the Department of Veterans Affairs (VA) health care system discontinue services within 3 years of initial use. Although it has been suggested that providing more gender-sensitive care might improve women veterans' health care experiences, no study has yet documented an empirical relationship between clinic and provider factors associated with the provision of gender-sensitive care and women veterans' care discontinuity.

METHODS

Surveys of primary care providers (n = 82) and staff members (n = 108) from 12 VA medical centers were linked to administrative data for women veteran patients with at least one primary care visit in 2014 and 2015 (n = 9,958). Patient care discontinuity was operationalized as having no additional primary care visit within 3 years after the patient's baseline visit. Key indicators of gender-sensitive comprehensive primary care included type of medical home (women's health-focused vs. general primary care), workforce gender sensitivity, team functioning, perceived quality of provider/staff communication, leadership support for medical home implementation, and other structural components of care delivery (e.g., chaperone availability). We used logistic regression to assess the association between these indicators and women's care discontinuity, measuring discontinuity for both new and continuing VA users and controlling for patient characteristics.

RESULTS

Eleven percent of women patients discontinued primary care within 3 years. Poor workforce gender sensitivity (lowest quartile vs. top three quartiles) was significantly associated with higher odds of discontinuity (odds ratio, 1.26; 95% confidence interval, 1.01-1.57); other indicators were not associated with discontinuity.

CONCLUSIONS

This study is the first to document a relationship between workforce gender sensitivity and women veterans' care continuity. This finding underscores the need for additional attention to enhancing workforce gender sensitivity in VA.

Assessing fidelity to evidence-based quality improvement as an implementation strategy for patient-centered medical home transformation in the Veterans Health Administration

Background

Effective implementation strategies might facilitate patient-centered medical home (PCMH) uptake and spread by targeting barriers to change. Evidence-based quality improvement (EBQI) is a multi-faceted implementation strategy that is based on a clinical-researcher partnership. It promotes organizational change by fostering innovation and the spread of those innovations that are successful. Previous studies demonstrated that EBQI accelerated PCMH adoption within Veterans Health Administration primary care practices, compared with standard PCMH implementation. Research to date has not documented fidelity to the EBQI implementation strategy, limiting usefulness of prior research findings. This paper develops and assesses clinical participants’ fidelity to three core EBQI elements for PCMH (EBQI-PCMH), explores the relationship between fidelity and successful QI project completion and spread (the outcome of EBQI-PCMH), and assesses the role of the clinical-researcher partnership in achieving EBQI-PCMH fidelity.

Methods

Nine primary care practice sites and seven across-sites, topic-focused workgroups participated (2010–2014). Core EBQI elements included leadership-frontlines priority-setting for QI, ongoing access to technical expertise, coaching, and mentoring in QI methods (through a QI collaborative), and data/evidence use to inform QI. We used explicit criteria to measure and assess EBQI-PCMH fidelity across clinical participants. We mapped fidelity to evaluation data on implementation and spread of successful QI projects/products. To assess the clinical-researcher partnership role in EBQI-PCMH, we analyzed 73 key stakeholder interviews using thematic analysis.

Results

Seven of 9 sites and 3 of 7 workgroups achieved high or medium fidelity to leadership-frontlines priority-setting. Fidelity was mixed for ongoing technical expertise and data/evidence use. Longer duration in EBQI-PCMH and higher fidelity to priority-setting and ongoing technical expertise appear correlated with successful QI project completion and spread. According to key stakeholders, partnership with researchers, as well as bi-directional communication between leaders and QI teams and project management/data support were critical to achieving EBQI-PCMH fidelity.

Conclusions

This study advances implementation theory and research by developing measures for and assessing fidelity to core EBQI elements in relationship to completion and spread of QI innovation projects or tools for addressing PCMH challenges. These results help close the gap between EBQI elements, their intended outcome, and the finding that EBQI-PCMH resulted in accelerated adoption of PCMH.

Understanding Gender Sensitivity of the Health Care Workforce at the Veterans Health Administration

BACKGROUND

Gender sensitivity of providers and staff has assumed increasing importance in closing historical gender disparities in health care quality and outcomes. The Department of Veterans Affairs (VA) has implemented several initiatives intended to improve gender sensitivity of its health care workforce. The current study examines practice- and individual-level characteristics associated with gender sensitivity of primary care providers (PCPs) and staff.

METHODS

We surveyed PCPs and staff (nurses, medical assistants, and clerks) at 12 VA medical centers (VAMCs) (n = 256 of 649; response rate, 39%). Gender sensitivity was measured using a 10-item scale adapted from the Gender Awareness Inventory-VA. We used weighted multivariate regression with maximum likelihood estimation to identify individual- and practice-level characteristics associated with gender sensitivity of PCPs and staff.

RESULTS

PCPs and staff had similar gender sensitivity but differed in most characteristics associated with that gender sensitivity. Among PCPs, women's health training and positive communication with others in the clinic were associated with greater gender sensitivity. For staff, prior work experience caring for women, working in Women's Health Patient-Aligned Care Teams, and rural location were associated with greater gender sensitivity, whereas more years of VA service was associated with lower gender sensitivity. Working at VA medical centers with a higher volume of women veteran patients was associated with greater gender sensitivity for both PCPs and staff.

CONCLUSIONS

Women's health training and experience in working with other women's health professionals are strongly correlated with greater gender sensitivity in the clinical workforce.

Obesity and Health Care Experiences among Women and Men Veterans

BACKGROUND

Obesity is highly stigmatized, especially for women, and therefore may negatively affect health care experiences. Past findings on the relationship between obesity and health care experiences are mixed, perhaps because few studies examine relationships by gender and obesity class. Our objective was to evaluate whether women and men with more severe obesity report worse health care experiences related to Veterans Health Administration (VA) care.

METHODS

Health care experiences (self-management support, mental health assessments, office staff courtesy, communication with providers) and overall provider ratings were assessed with the 2014 VA Survey of Health Care Experiences of Patients. Using multiple regression analyses (n = 13,462 women, n = 268,180 men), we assessed associations among obesity classes, health care experiences, and overall provider ratings, adjusting for sociodemographic, health, and primary care use characteristics.

RESULTS

The greatest differences in health care experiences between patients with and without obesity were in self-management support experiences, which were more favorable among women and men of all obesity classes. There were gender differences in associations between obesity and mental health assessments: for men, but not women, those in any obesity class gave higher ratings than those without obesity. For most other health care experiences and provider ratings, men with obesity reported slightly less favorable experiences than those without. There was no consistent pattern for women.

CONCLUSIONS

It is promising that VA patients with obesity report more self-management support, given the behavior change required for weight management. Lower health care experience and provider ratings among men with obesity suggest a need to further investigate possible obesity-related stigma in VA primary care.

Innovations in Mixed Methods Evaluations

Mixed methods research-i.e., research that draws on both qualitative and quantitative methods in varying configurations-is well suited to address the increasing complexity of public health problems and their solutions. This review focuses specifically on innovations in mixed methods evaluations of intervention, program or policy (i.e., practice) effectiveness, and implementation. The article begins with an overview of the structure, function, and process of different mixed methods designs and then provides illustrations of their use in effectiveness studies, implementation studies, and combined effectiveness-implementation hybrid studies. The article then examines four specific innovations: procedures for transforming (or "quantitizing") qualitative data, application of rapid assessment and analysis procedures in the context of mixed methods studies, development of measures to assess implementation outcomes, and strategies for conducting both random and purposive sampling, particularly in implementation-focused evaluation research. The article concludes with an assessment of challenges to integrating qualitative and quantitative data in evaluation research.

Selection of Higher Risk Pregnancies into Veterans Health Administration Programs: Discoveries from Linked Department of Veterans Affairs and California Birth Data

OBJECTIVE

To describe variation in payer and outcomes in Veterans' births.

DATA/SETTING

Secondary data analyses of deliveries in California, 2000-2012.

STUDY DESIGN

We performed a retrospective, population-based study of all live births to Veterans (confirmed via U.S. Department of Veterans Affairs (VA) enrollment records), to identify payer and variations in outcomes among: (1) Veterans using VA coverage and (2) Veteran vs. all other births. We calculated odds ratios (aOR) adjusted for age, race, ethnicity, education, and obstetric demographics.

METHODS

We anonymously linked VA administrative data for all female VA enrollees with California birth records.

PRINCIPAL FINDINGS

From 2000 to 2012, we identified 17,495 births to Veterans. VA covered 8.6 percent (1,508), Medicaid 17.3 percent, and Private insurance 47.6 percent. Veterans who relied on VA health coverage had more preeclampsia (aOR 1.4, CI 1.0-1.8) and more cesarean births (aOR 1.2, CI 1.0-1.3), and, despite similar prematurity, trended toward more neonatal intensive care (NICU) admissions (aOR 1.2, CI 1.0-1.4) compared to Veterans using other (non-Medicaid) coverage. Overall, Veterans' birth outcomes (all-payer) mirrored California's birth outcomes, with the exception of excess NICU care (aOR 1.15, CI 1.1-1.2).

CONCLUSIONS

VA covers a higher risk fraction of Veterans' births, justifying maternal care coordination and attention to the maternal-fetal impacts of Veterans' comorbidities.

Characteristics and Health Care Preferences Associated with Cardiovascular Disease Risk among Women Veterans

BACKGROUND

Women veterans are at increased risk for cardiovascular disease (CVD), but little is known about comorbidities and healthcare preferences associated with CVD risk in this population.

METHODS

We describe the prevalence of CVD-relevant health behaviors, mental health symptoms, and health care use characteristics and preferences among participants of the National Survey of Women Veterans (conducted 2008-2009).

FINDINGS

Fifty-four percent of respondents were at risk for CVD (defined as a diagnosis of hypertension, diabetes, current tobacco use, or obesity without CVD). In unadjusted analysis, ORs for being at risk for CVD were greater among those interested in gender-specific clinical settings (OR, 2.0; 95% CI, 1.2-3.4) and gender-specific weight loss programs (OR, 1.8; 95% CI, 1.1-2.9). ORs were also greater for women who were physically inactive (OR, 1.9; 95% CI, 1.1-3.3), with current symptoms of depression (OR, 2.5; 95% CI, 1.1-6.1), anxiety (OR, 2.1; 95% CI, 1.2-3.6), and posttraumatic stress disorder (OR, 2.4; 95% CI, 1.2-4.8). Adjusting for age, race/ethnicity, marital status, education level, employment, and source of health care use, the ORs for CVD risk were higher for women with current posttraumatic stress disorder symptoms (2.5; 95% CI, 1.1-5.3) and gender-specific health care preferences (2.0; 95% CI, 1.1-3.4), and gender-specific weight loss programs (1.9; 95% CI, 1.1-3.2).

CONCLUSIONS

Risk for CVD was common and preferences for gender-specific care and posttraumatic stress disorder were associated with being at risk for CVD. Women's health clinics may be a good location for targeted CVD prevention interventions for women veterans both in and outside the Veterans Health Administration.

Practice-based research networks add value to evidence-based quality improvement

Background

Evidence-Based Quality Improvement (EBQI) is a systematic, multilevel approach to implementing research evidence into clinical settings. Little is known about EBQI effectiveness in the context of Practice-Based Research Networks (PBRNs), which are themselves designed to foster practice-based change. We evaluated EBQI implementation in a PBRN setting to determine the extent to which the PBRN infrastructure added value.

METHODS

We conducted a four-site cluster randomized trial of an EBQI approach to tailoring an evidence-based gender awareness curriculum in the VA Women’s Health PBRN (WH-PBRN). After curriculum implementation, site teams identified impacts of the WH-PBRN context on EBQI processes using qualitative methods, including a formal review of project call minutes, post-project debriefing calls, and structured site team input. WH-PBRN site feedback was mapped to the Replicating Effective Programs implementation phases: pre-condition, pre-implementation, implementation, and maintenance/evolution.

RESULTS

The pre-condition phase benefited from the existing WH-PBRN research-clinician relationships to facilitate stakeholder engagement and build project buy-in at local sites. During pre-implementation, differences across WH-PBRN sites offered variations in local tailoring of EBQI elements. The WH-PBRN Coordinating Center helped resolve process complexities stemming from local resource differences and the sharing of mid-project adaptations during implementation. Local efforts were amplified in the maintenance phase by WH-PBRN dissemination of findings.

Conclusions

The PBRN strengthened multi-site EBQI activities across all implementation phases.

Implications

PBRNs contribute to the uptake of evidence into everyday practice, and may serve as an important component of the future implementation of evidence-based initiatives. Level of evidence: V.

Cluster randomized trial of a multilevel evidence-based quality improvement approach to tailoring VA Patient Aligned Care Teams to the needs of women Veterans

BACKGROUND

The Veterans Health Administration (VA) has undertaken a major initiative to transform care through implementation of Patient Aligned Care Teams (PACTs). Based on the patient-centered medical home (PCMH) concept, PACT aims to improve access, continuity, coordination, and comprehensiveness using team-based care that is patient-driven and patient-centered. However, how VA should adapt PACT to meet the needs of special populations, such as women Veterans (WVs), was not considered in initial implementation guidance. WVs' numerical minority in VA healthcare settings (approximately 7-8 % of users) creates logistical challenges to delivering gender-sensitive comprehensive care. The main goal of this study is to test an evidence-based quality improvement approach (EBQI) to tailoring PACT to meet the needs of WVs, incorporating comprehensive primary care services and gender-specific care in gender-sensitive environments, thereby accelerating achievement of PACT tenets for women (Women's Health (WH)-PACT).

METHODS/DESIGN

EBQI is a systematic approach to developing a multilevel research-clinical partnership that engages senior organizational leaders and local quality improvement (QI) teams in adapting and implementing new care models in the context of prior evidence and local practice conditions, with researchers providing technical support, formative feedback, and practice facilitation. In a 12-site cluster randomized trial, we will evaluate WH-PACT model achievement using patient, provider, staff, and practice surveys, in addition to analyses of secondary administrative and chart-based data. We will explore impacts of receipt of WH-PACT care on quality of chronic disease care and prevention, health status, patient satisfaction and experience of care, provider experience, utilization, and costs. Using mixed methods, we will assess pre-post practice contexts; document EBQI activities undertaken in participating facilities and their relationship to provider/staff and team actions/attitudes; document WH-PACT implementation; and examine barriers/facilitators to EBQI-supported WH-PACT implementation through a combination of semi-structured interviews and monthly formative progress narratives and administrative data.

DISCUSSION

Lack of gender-sensitive comprehensive care has demonstrated consequences for the technical quality and ratings of care among WVs and may contribute to decisions to continue use or seek care elsewhere under the US Affordable Care Act. We hypothesize that tailoring PACT implementation through EBQI may improve the experience and quality of care at many levels.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02039856.