Organization Complexity and Primary Care Providers' Perceptions of Quality Improvement Culture Within the Veterans Health Administration

Organizational and Implementation Factors Associated with Cirrhosis Care in the Veterans Health Administration

BACKGROUND

The Veterans Health Administration provides care to more than 100,000 Veterans with cirrhosis.

AIMS

This implementation evaluation aimed to understand organizational resources and barriers associated with cirrhosis care.

METHODS

Clinicians across 145 Department of Veterans Affairs (VA) medical centers (VAMCs) were surveyed in 2022 about implementing guideline-concordant cirrhosis care. VA Corporate Data Warehouse data were used to assess VAMC performance on two national cirrhosis quality measures: HCC surveillance and esophageal variceal surveillance or treatment (EVST). Organizational factors associated with higher performance were identified using linear regression models.

RESULTS

Responding VAMCs (n = 124, 86%) ranged in resource availability, perceived barriers, and care processes. In multivariable models, factors independently associated with HCC surveillance included on-site interventional radiology and identifying patients overdue for surveillance using a national cirrhosis population management tool ("dashboard"). EVST was significantly associated with dashboard use and on-site gastroenterology services. For larger VAMCs, the average HCC surveillance rate was similar between VAMCs using vs. not using the dashboard (47% vs. 41%), while for smaller and less resourced VAMCs, dashboard use resulted in a 13% rate difference (46% vs. 33%). Likewise, higher EVST rates were more strongly associated with dashboard use in smaller (55% vs. 50%) compared to larger (57% vs. 55%) VAMCs.

CONCLUSIONS

Resources, barriers, and care processes varied across diverse VAMCs. Smaller VAMCs without specialty care achieved HCC and EVST surveillance rates nearly as high as more complex and resourced VAMCs if they used a population management tool to identify the patients due for cirrhosis care.

Understanding clinician connections to inform efforts to promote high-quality inflammatory bowel disease care

BACKGROUND

Highly connected individuals disseminate information effectively within their social network. To apply this concept to inflammatory bowel disease (IBD) care and lay the foundation for network interventions to disseminate high-quality treatment, we assessed the need for improving the IBD practices of highly connected clinicians. We aimed to examine whether highly connected clinicians who treat IBD patients were more likely to provide high-quality treatment than less connected clinicians.

METHODS

We used network analysis to examine connections among clinicians who shared patients with IBD in the Veterans Health Administration between 2015-2018. We created a network comprised of clinicians connected by shared patients. We quantified clinician connections using degree centrality (number of clinicians with whom a clinician shares patients), closeness centrality (reach via shared contacts to other clinicians), and betweenness centrality (degree to which a clinician connects clinicians not otherwise connected). Using weighted linear regression, we examined associations between each measure of connection and two IBD quality indicators: low prolonged steroids use, and high steroid-sparing therapy use.

RESULTS

We identified 62,971 patients with IBD and linked them to 1,655 gastroenterologists and 7,852 primary care providers. Clinicians with more connections (degree) were more likely to exhibit high-quality treatment (less prolonged steroids beta -0.0268, 95%CI -0.0427, -0.0110, more steroid-sparing therapy beta 0.0967, 95%CI 0.0128, 0.1805). Clinicians who connect otherwise unconnected clinicians (betweenness) displayed more prolonged steroids use (beta 0.0003, 95%CI 0.0001, 0.0006). The presence of variation is more relevant than its magnitude.

CONCLUSIONS

Clinicians with a high number of connections provided more high-quality IBD treatments than less connected clinicians, and may be well-positioned for interventions to disseminate high-quality IBD care. However, clinicians who connect clinicians who are otherwise unconnected are more likely to display low-quality IBD treatment. Efforts to improve their quality are needed prior to leveraging their position to disseminate high-quality care.

Initiating Low-Value Inhaled Corticosteroids in an Inception Cohort with Chronic Obstructive Pulmonary Disease

Rationale: Decreasing medication overuse represents an opportunity to avoid harm and costs in the era of value-based purchasing. Studies of inhaled corticosteroids (ICS) overuse in chronic obstructive pulmonary disease (COPD) have examined prevalent use. Understanding initiation of low-value ICS among complex patients with COPD may help shape deadoption efforts.Objectives: Examine ICS initiation among a cohort with low exacerbation risk COPD and test for associations with markers of patient and health system complexity.Methods: Between 2012 and 2016, we identified veterans with COPD from 21 centers. Our primary outcome was first prescription of ICS. We used the care assessment needs (CAN) score to assess patient-level complexity as the primary exposure. We used a time-to-event model with time-varying exposures over 1-year follow-up. We tested for effect modification using selected measures of health system complexity.Results: We identified 8,497 patients with COPD without an indication for ICS and did not have baseline use (inception cohort). Follow-up time was four quarters. Patient complexity by a continuous CAN score was associated with new dispensing of ICS (hazard ratio = 1.17 per 10-unit change; 95% confidence interval = 1.13-1.21). This association demonstrated a dose-response when examining quartiles of CAN score. Markers of health system complexity did not modify the association between patient complexity and first use of low-value ICS.Conclusions: Patient complexity may represent a symptom burden that clinicians are attempting to mitigate by initiating ICS. Lack of effect modification by health system complexity may reflect the paucity of structural support and low prioritization for COPD care.

Using Lean-Facilitation to Improve Quality of Hepatitis C Testing in Primary Care

BACKGROUND

Lean management has been successfully employed in healthcare to improve outcomes and efficiencies. Facilitation is increasingly being used to support evidence-based practice uptake in healthcare. However, while both Lean and Facilitation are used in healthcare quality improvement, limited research has explored their integration and the sustainability of their combined effects.

OBJECTIVE

To improve hepatitis C virus (HCV) screening rates among persons born between 1945 and 1965 through the design and evaluation of a multi-modal Lean-Facilitation intervention (LFI) for Department of Veterans Affairs primary care community clinics.

DESIGN

We conducted a mixed methods quasi-experimental evaluation in eight clinics, guided by the integrated Promoting Action on Research Implementation in Health Services framework.

PARTICIPANTS

We engaged regional and local leadership (N = 9), implemented our LFI with clinicians and staff (N = 68), and conducted summative interviews with participants (N = 13).

INTERVENTION

The LFI included six implementation strategies: (1) external facilitation, (2) stakeholder engagement, (3) champion activation, (4) rapid process improvement sessions, (5) Plan-Do-Study-Act cycles, and (6) audit-feedback.

MEASURES

The primary outcome was rate of new HCV screening among previously untested patients with a primary care visit. Using interrupted time series, we analyzed intervention and time effects on HCV testing rates, and administered organizational readiness surveys, conducted summative qualitative interviews, and tracked facilitation events.

RESULTS

The LFI was associated with significant, immediate, and sustained increases in HCV testing. No change was detected at matched comparison clinics. Staff accepted the LFI and the philosophy of "bottom-up" solution development yet had mixed feedback on its appropriateness and feasibility. Enablers of implementation and early sustainment included lower satisfaction with baseline HCV testing processes and staff culture, while later sustainment was related to implementation climate support, measurement, and evaluation.

CONCLUSIONS

High-reach and relatively low effort, but persistent intervention led to significant improvement in guideline-concordant HCV testing rates which were sustained.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02936648.

Factors Associated With Patient Ratings of Timeliness of Primary Care Appointments

As access is the lowest rated dimension in surveys of outpatient experience, we sought to identify patient, practice, and provider factors associated with positive ratings of timeliness of primary care appointments. A cross-sectional study with multivariable, multilevel logistic regression was performed using survey responses from 236 695 individuals receiving care in the Veterans Health Administration (VA). Top box ratings (response of "always") for whether the patient reported receiving an appointment as soon as they needed in primary care for routine care and for care needed right away were the main outcomes. Independent variables capturing patient, practice, and provider factors were obtained from survey responses and VA databases. Degree of continuity with primary care provider and duration of relationship were strongly associated with higher ratings. Shorter primary care appointment wait times for both new and returning patients were associated with higher ratings. Independent wait times for mental health and specialty appointments had no effect. Older age, better self-reported physical and mental health, lower disease complexity, and rural residence were patient factors associated with higher ratings while gender, race, ethnicity, and education had little effect. Measures of continuity with primary care provider as well as appointment wait times have strong association with positive patient ratings of appointment timeliness. Patients treated in Veterans Affairs clinics may value continuity with their primary care provider over longer times. Initiatives to improve access could focus on improving continuity and ensuring efforts to improve access do not impact continuity.

Impact of a Resident-Centered Interprofessional Quality Improvement Intervention on Acute Care Length of Stay

Competency in interprofessional quality improvement and performance measurement is required by the Accreditation Council for Graduate Medical Education. We implemented an interprofessional quality improvement project to support trainee involvement in systems-level improvement to reduce hospital length of stay and engage trainees in efforts to improve the validity and reliability of clinical documentation contributing to risk-adjusted performance measures. The intervention had three components: daily interprofessional disposition huddles to discuss discharge needs, medical documentation curriculum to improve clinical data accuracy, and scheduled coding huddles to provide real-time feedback on documentation. Outcome measures included an unadjusted and risk-adjusted measure of hospital length of stay. Case severity index (CSI) served as a process measure. Statistical process control charts were used to measure change over time. The mean unadjusted length of stay decreased from 5.84 to 4.98 days. Both the unadjusted and the risk-adjusted length of stay measures exceeded the lower control limit of the statistical control chart. The CSI increased and exceeded the upper control limit of the statistical control chart. Improvements were sustained in the year following implementation. The intervention offers a model for academic institutions to satisfy new Common Program Requirements by engaging trainees in performance measurement and interprofessional improvement efforts.

Medical Record Documentation of Goals-of-Care Discussions Among Older Veterans With Incident Kidney Failure

RATIONALE & OBJECTIVE

Elicitation and documentation of patient preferences is at the core of shared decision making and is particularly important among patients with high anticipated mortality. The extent to which older patients with incident kidney failure undertake such discussions with their providers is unknown and its characterization was the focus of this study.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

A random sample of veterans 67 years and older with incident kidney failure receiving care from the US Veterans Health Administration between 2005 and 2010.

EXPOSURES

Demographic and facility characteristics, as well as predicted 6-month mortality risk after dialysis initiation and documentation of resuscitation preferences.

OUTCOMES

Documented discussions of dialysis treatment and supportive care.

ANALYTICAL APPROACH

We reviewed medical records over the 2 years before incident kidney failure and up to 1 year afterward to ascertain the frequency and timing of documented discussions about dialysis treatment, supportive care, and resuscitation. Logistic regression was used to identify factors associated with these documented discussions.

RESULTS

The cohort of 821 veterans had a mean age of 80.9±7.2 years, and 37.2% had a predicted 6-month mortality risk>20% with dialysis. Documented discussions addressing dialysis treatment and resuscitation were present in 55.6% and 77.1% of patients, respectively. Those addressing supportive care were present in 32.4%. The frequency of documentation varied by mortality risk and whether the patient ultimately started dialysis. In adjusted analyses, the frequency and pattern of documentation were more strongly associated with geographic location and receipt of outpatient nephrology care than with patient demographic or clinical characteristics.

LIMITATIONS

Documentation may not fully reflect the quality and content of discussions, and generalizability to nonveteran patients is limited.

CONCLUSIONS

Among older veterans with incident kidney failure, discussions of dialysis treatment are decoupled from other aspects of advance care planning and are suboptimally documented, even among patients at high risk for mortality.

Center Predictors of Long-Term Benzodiazepine Use in Chronic Obstructive Pulmonary Disease and Post-traumatic Stress Disorder

Rationale: Symptoms of insomnia and anxiety are common among patients with chronic obstructive pulmonary disease (COPD), especially among patients with comorbid mental health disorders such as post-traumatic stress disorder (PTSD). Benzodiazepines provide temporary relief of these symptoms, but guidelines discourage routine use of benzodiazepines because of the serious risks posed by these medications. A more thorough understanding of guideline-discordant benzodiazepine use will be critical to reduce potentially inappropriate prescribing and its associated risks.Objectives: Examine the national prevalence, variability, and center correlates of long-term benzodiazepine prescriptions for patients with COPD and comorbid PTSD.Methods: We identified patients with COPD and PTSD between 2010 and 2012 who received care within the Department of Veterans Affairs. We used a mixed-effects logistic regression model to assess center predictors of long-term benzodiazepine prescriptions (≥90 d), while accounting for patient characteristics.Results: Of 43,979 patients diagnosed with COPD and PTSD at 129 centers, 24.4% were prescribed benzodiazepines long term, with use varying from 9.5% to 49.4% by medical center. Patients with long-term prescriptions were more likely to be white (90.1% vs. 80.7%) and have other mental health comorbidities, including generalized anxiety disorder (31.3% vs. 16.5%). Accounting for patient mix and characteristics, long-term benzodiazepine use was associated with lower patient-reported access to mental health care (odds ratio, 0.54; 95% confidence interval, 0.37-0.80).Conclusions: Long-term benzodiazepine prescribing is common among patients at high risk for complications, although this practice varies substantially from center to center. Poor access to mental health care is a potential driver of this guideline inconsistent use.

Total duration of antimicrobial therapy in veterans hospitalized with uncomplicated pneumonia: Results of a national medication utilization evaluation

OBJECTIVE

Practice guidelines recommend the shortest duration of antimicrobial therapy appropriate to treat uncomplicated pneumonia be prescribed to reduce the emergence of resistant pathogens. A national evaluation was conducted to assess the duration of therapy for pneumonia.

DESIGN

Retrospective medication utilization evaluation.

SETTING

Thirty Veterans Affairs medical centers.

PATIENTS

Inpatients discharged with a diagnosis of pneumonia.

MEASUREMENTS

A manual review of electronic medical records of inpatients discharged with uncomplicated community-acquired pneumonia (CAP) or healthcare-associated pneumonia (HCAP) was conducted. Appropriate CAP therapy duration was defined as at least 5 days, and up to 3 additional days beginning the first day the patient achieved clinical stability criteria; the appropriate HCAP therapy duration was defined as 8 days. The duration of antimicrobial therapy for intravenous (IV) and oral (PO) inpatient administration, PO therapy dispensed upon discharge, Clostridium difficile infection (CDI), hospital readmission, and death rates were measured.

RESULTS

Of 3881 pneumonia admissions, 1739 met inclusion criteria (CAP [n = 1195]; HCAP [n = 544]). Overall, 13.9% of patients (CAP [6.9%], HCAP [29.0%]) received therapy duration consistent with guideline recommendations. The median (interquartile range) days of therapy were 4 days (3-6 days), 1 day (0-3 days), and 6 days (4-8 days) for inpatient IV, inpatient PO, and outpatient PO antimicrobials, respectively. CDI was rare but more common in patients who received therapy duration consistent with guidelines. Therapy duration was not associated with the readmission or mortality rate.

CONCLUSIONS

Antimicrobials were commonly prescribed for a longer duration than guidelines recommend. The majority of excessive therapy was completed upon discharge, identifying the need for strategies to curtail unnecessary use postdischarge. Journal of Hospital Medicine 2015;11:832-839. © 2015 Society of Hospital Medicine.

Antimicrobial de-escalation of treatment for healthcare-associated pneumonia within the Veterans Healthcare Administration

OBJECTIVES

The objective of this study was to measure quantitatively antimicrobial de-escalation utilizing electronic medication administration data based on the spectrum of activity for antimicrobial therapy (i.e. spectrum score) to identify variables associated with de-escalation in a nationwide healthcare system.

METHODS

A retrospective cohort study of patients hospitalized for healthcare-associated pneumonia was conducted in Veterans Affairs Medical Centers (n = 119). Patients hospitalized for healthcare-associated pneumonia on acute-care wards between 5 and 14 days who received antimicrobials for ≥ 3 days during calendar years 2008-11 were evaluated. The spectrum score method was applied at the patient level to measure de-escalation on day 4 of hospitalization. De-escalation was expressed in aggregate and facility-level proportions. Logistic regression was used to assess variables associated with de-escalation. ORs with 95% CIs were reported.

RESULTS

Among 9319 patients, the de-escalation proportion was 28.3% (95% CI 27.4-29.2), which varied 6-fold across facilities [median (IQR) facility-level de-escalation proportion 29.1% (95% CI 21.7-35.6)]. Variables associated with de-escalation included initial broad-spectrum therapy (OR 1.5, 95% CI 1.4-1.5 for each 10% increase in spectrum), collection of respiratory tract cultures (OR 1.1, 95% CI 1.0-1.2) and care in higher complexity facilities (OR 1.3, 95% CI 1.1-1.6). Respiratory tract cultures were collected from 35.3% (95% CI 32.7-37.7) of patients.

CONCLUSIONS

De-escalation of antimicrobial therapy was limited and varied substantially across facilities. De-escalation was associated with respiratory tract culture collection and treatment in a high complexity-level facility.

Denominator doesn't matter: standardizing healthcare-associated infection rates by bed days or device days

OBJECTIVE

To examine the impact on infection rates and hospital rank for catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP) using device days and bed days as the denominator

DESIGN

Retrospective survey from October 2010 to July 2013 SETTING: Veterans Health Administration medical centers providing acute medical and surgical care

PATIENTS

Patients admitted to 120 Veterans Health Administration medical centers reporting healthcare-associated infections

METHODS

We examined the importance of using device days and bed days as the denominator between infection rates and hospital rank for CAUTI, CLABSI, and VAP for each medical center. The relationship between device days and bed days as the denominator was assessed using a Pearson correlation, and changes in infection rates and device utilization were evaluated by an analysis of variance.

RESULTS

A total of 7.9 million bed days were included. From 2011 to 2013, CAUTI decreased whether measured by device days (2.32 to 1.64, P=.001) or bed days (4.21 to 3.02, P=.006). CLABSI decreased when measured by bed days (1.67 to 1.19, P=.04). VAP rates and device utilization ratios for CAUTI, CLABSI, and VAP were not statistically different across time. Infection rates calculated with device days were strongly correlated with infection rates calculated with bed days (r=0.79-0.94, P<.001). Hospital relative performance measured by ordered rank was also strongly correlated for both denominators (r=0.82-0.96, P<.001).

CONCLUSIONS

These findings suggest that device days and bed days are equally effective adjustment metrics for comparing healthcare-associated infection rates between hospitals in the setting of stable device utilization.