Longitudinal Analysis of Quality of Diabetes Care and Relational Climate in Primary Care

Association Between Availability of Women's Health Services and Women Veterans' Care Experiences

INTRODUCTION

Few studies have focused on determinants of women's ratings of care experiences in primary care. We assessed associations between availability of women's health services and women veterans' ratings of care experiences.

METHODS

In a cross-sectional analysis, we linked Fiscal Year 2017 (October 1, 2016, to September 30, 2017) survey data from 126 Veterans Health Administration (VA) primary care leaders to 4,254 women veterans' ratings of care from VA's Survey of Health care Experiences of Patients-Patient Centered Medical Home (2017). The dependent variables were ratings of optimal access (appointments, information), care coordination, comprehensiveness (behavioral health assessment), patient-provider communication, and primary care provider. Key independent variables were number of women's health services 1) routinely available all weekday hours (compared with some hours or not available) and 2) available in VA general primary care vs. other arrangements. In multilevel logistic regression models, we adjusted for patient-, facility-, and area-level characteristics.

RESULTS

A greater number of women's health services routinely available in VA primary care was associated with a higher likelihood of optimal ratings of care coordination (adjusted odds ratio [AOR], 1.06; 95% confidence interval [CI], 1.01-1.10), provider communication (AOR, 1.08; 95% CI, 1.002-1.16), and primary care provider (AOR, 1.07; 95% CI, 1.02-1.13). A greater number of services available in VA primary care was associated with a lower likelihood of optimal ratings for access (AOR, 0.94; 95% CI, 0.88-0.99).

CONCLUSION

For the most part, routine availability of women's health services in VA primary care clinics enhanced women's health care experiences. These empirical findings offer health care leaders evidence-based approaches for improving women's care experiences.

Multilevel analysis exploring the relative importance of workplace resources in explaining nurses' workload perceptions: Are we setting the right focus?

BACKGROUND

Nurses' workload has become increasingly recognized as an important determinant of nurse turnover and shortage and has been also associated with poorer quality of care. Despite strong evidence that heavy workloads have negative consequences, we still lack a comprehensive understanding of the workplace characteristics that contribute most to improving nurses' workload, the relative importance of each in doing so, or indeed the workplace characteristics and other factors that drive nurses' perceptions of their workload.

PURPOSE

The aim of this study was to examine workplace resources as antecedents of nurses' perceptions of their workload and to investigate their relative importance in explaining workload perceptions. We considered workplace resources related to staffing, professional relationships, and technology.

METHODOLOGY

The study sample comprised nurse-reported and administrative data from U.S. Veterans Health Administration hospitals between 2014 and 2017. Our multilevel analyses are based on data from 20,330 nurses working in 273 work groups at 123 hospitals. We developed and empirically tested a theoretical model using multilevel mixed-effects linear regression. The relative importance of workplace resources was assessed by dominance analysis.

RESULTS

Staffing levels, relational climate, and information technology were significantly associated with nurses' workload perceptions. Dominance analysis indicated that relational resources are the most important measure in explaining nurses' workload perceptions.

PRACTICE IMPLICATIONS

This is the first study to examine the relative importance of workplace resources in explaining nurses' perceptions of their workload. Our results suggest that much might be gained by investing in interventions to boost relational resources. In turn, these findings could lead to more targeted, effective, and resource efficient interventions to improve nurses' workload.

Organizational culture and climate as moderators of enhanced outreach for persons with serious mental illness: results from a cluster-randomized trial of adaptive implementation strategies

Background

Organizational culture and climate are considered key factors in implementation efforts but have not been examined as moderators of implementation strategy comparative effectiveness. We investigated organizational culture and climate as moderators of comparative effectiveness of two sequences of implementation strategies (Immediate vs. Delayed Enhanced Replicating Effective Programs [REP]) combining Standard REP and REP enhanced with facilitation on implementation of an outreach program for Veterans with serious mental illness lost to care at Veterans Health Administration (VA) facilities nationwide.

Methods

This study is a secondary analysis of the cluster-randomized Re-Engage implementation trial that assigned 3075 patients at 89 VA facilities to either the Immediate or Delayed Enhanced REP sequences. We hypothesized that sites with stronger entrepreneurial culture, task, or relational climate would benefit more from Enhanced REP than Standard REP. Veteran- and site-level data from the Re-Engage trial were combined with site-aggregated measures of entrepreneurial culture and task and relational climate from the 2012 VA All Employee Survey. Longitudinal mixed-effects logistic models examined whether the comparative effectiveness of the Immediate vs. Delayed Enhanced REP sequences were moderated by culture or climate measures at 6 and 12 months post-randomization. Three Veteran-level outcomes related to the engagement with the VA system were assessed: updated documentation, attempted contact by coordinator, and completed contact.

Results

For updated documentation and attempted contact, Veterans at sites with higher entrepreneurial culture and task climate scores benefitted more from Enhanced REP compared to Standard REP than Veterans at sites with lower scores. Few culture or climate moderation effects were detected for the comparative effectiveness of the full sequences of implementation strategies.

Conclusions

Implementation strategy effectiveness is highly intertwined with contextual factors, and implementation practitioners may use knowledge of contextual moderation to tailor strategy deployment. We found that facilitation strategies provided with Enhanced REP were more effective at improving uptake of a mental health outreach program at sites with stronger entrepreneurial culture and task climate; Veterans at sites with lower levels of these measures saw more similar improvement under Standard and Enhanced REP. Within resource-constrained systems, practitioners may choose to target more intensive implementation strategies to sites that will most benefit from them.

Trial registration

ISRCTN: ISRCTN21059161. Date registered: April 11, 2013.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0787-9) contains supplementary material, which is available to authorized users.

Transfer from paediatric to adult care for young adults with Type 2 diabetes: the SEARCH for Diabetes in Youth Study

AIM

To describe factors associated with transfer from paediatric to adult care and poor glycaemic control among young adults with Type 2 diabetes, using the SEARCH for Diabetes in Youth study.

METHODS

Young adults with Type 2 diabetes were included if they had a baseline SEARCH visit while in paediatric care at < 18 years and ≥ 1 follow-up SEARCH visit thereafter at 18-25 years. At each visit, HbA1c , BMI, self-reported demographic and healthcare provider data were collected. Associations of demographic factors with transfer of care and poor glycaemic control (HbA1c ≥ 75 mmol/mol; 9.0%) were explored with multivariable logistic regression.

RESULTS

182 young adults with Type 2 diabetes (36% male, 75% minority, 87% with obesity) were included. Most (n = 102, 56%) reported transfer to adult care at follow-up; a substantial proportion (n = 28, 15%) reported no care and 29% did not transfer. Duration of diabetes [odds ratio (OR) 1.4, 95% confidence interval (95% CI) 1.1, 1.8] and age at diagnosis (OR 1.8, 95% CI 1.4, 2.4) predicted leaving paediatric care. Transfer to adult or no care was associated with a higher likelihood of poor glycaemic control at follow-up (adult: OR 4.5, 95% CI 1.8, 11.2; none: OR 4.6, 95% CI 1.4, 14.6), independent of sex, age, race/ethnicity or baseline HbA1c level.

CONCLUSIONS

Young adults with Type 2 diabetes exhibit worsening glycaemic control and loss to follow-up during the transfer from paediatric to adult care. Our study highlights the need for development of tailored clinical programmes and healthcare system policies to support the growing population of young adults with youth-onset Type 2 diabetes.

Relational Climate and Health Care Costs: Evidence From Diabetes Care

Quality of care worries and rising costs have resulted in a widespread interest in enhancing the efficiency of health care delivery. One area of increasing interest is in promoting teamwork as a way of coordinating efforts to reduce costs and improve quality, and identifying the characteristics of the work environment that support teamwork. Relational climate is a measure of the work environment that captures shared employee perceptions of teamwork, conflict resolution, and diversity acceptance. Previous research has found a positive association between relational climate and quality of care, yet its relationship with costs remains unexplored. We examined the influence of primary care relational climate on health care costs incurred by diabetic patients at the U.S. Department of Veterans Affairs between 2008 and 2012. We found that better relational climate is significantly related to lower costs. Clinics with the strongest relational climate saved $334 in outpatient costs per patient compared with facilities with the weakest score in 2010. The total outpatient cost saving if all clinics achieved the top 5% relational climate score was $20 million. Relational climate may contribute to lower costs by enhancing diabetic treatment work processes, especially in outpatient settings.