Publications by authors named "Peter J Kaboli"

105 Publications

Transfer boarding delays care more in low-volume rural emergency departments: A cohort study.

J Rural Health 2021 Feb 28. Epub 2021 Feb 28.

Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, Iowa, USA.

Purpose: Emergency department (ED) crowding is increasing and is associated with adverse patient outcomes. The objective of this study was to measure the relative impact of ED boarding on timeliness of early ED care for new patient arrivals, with a focus on the differential impact in low-volume rural hospitals.

Methods: A retrospective cohort of all patients presenting to a Veterans Health Administration (VHA) ED between 2011 and 2014. The primary exposure was the number of patients in the ED at the time of ED registration, stratified by disposition (admit, discharge, or transfer) and mental health diagnosis. The primary outcome was time-to-provider evaluation, and secondary outcomes included time-to-EKG, time-to-laboratory testing, time-to-radiography, and total ED length-of-stay. Rurality was measured using the Rural-Urban Commuting Areas.

Findings: A total of 5,912,368 patients were included from all 123 VHA EDs. Adjusting for acuity, new patients had longer time-to-provider when more patients were in the ED, and patients awaiting transfer for nonmental health conditions impacted time-to-provider for new patients (16.6 min delays, 95% CI: 12.3-20.7 min) more than other patient types. Rural patients saw a greater impact of crowding on care timeliness than nonrural patients (additional 5.3 min in time-to-provider per additional patient in ED, 95% CI: 4.3-6.4), and the impact of additional patients in all categories was most pronounced in the lowest-volume EDs.

Conclusions: Patients seen in EDs with more crowding have small, but additive, delays in early elements of ED care, and transferring patients with nonmental health diagnoses from rural facilities were associated with the greatest impact.
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http://dx.doi.org/10.1111/jrh.12559DOI Listing
February 2021

The Focus They Deserve: Improving Women Veterans' Health Care Access.

Womens Health Issues 2021 Jul-Aug;31(4):399-407. Epub 2021 Feb 10.

VA Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington; Department of Health Services, University of Washington School of Public Health, Seattle, Washington.

Purpose: Veterans Health Administration (VHA) initiatives aim to provide veterans timely access to quality health care. The focus of this analysis was provider and staff perspectives on women veterans' access in the context of national efforts to improve veterans' access to care.

Methods: We completed 21 site visits at Veterans Health Administration medical facilities to evaluate the implementation of a national access initiative. Qualitative data collection included semistructured interviews (n = 127), focus groups (n = 81), and observations with local leadership, administrators, providers, and support staff across primary and specialty care services at each facility. Deductive and inductive content analysis was used to identify barriers, facilitators, and contextual factors affecting implementation of initiatives and women veterans' access.

Results: Participants identified barriers to women veterans' access and strategies used to improve access. Barriers included a limited availability of providers trained in women's health and gender-specific care services (e.g., women's specialty care), inefficient referral and coordination with community providers, and psychosocial factors (e.g., childcare). Participants also identified issues related to childcare and perceived harassment in medical facility settings as distinct access issues for women veterans. Strategies focused on increasing internal capacity to provide on-site women's comprehensive care and specialty services by streamlining provider training and credentialing, contracting providers, using telehealth, and improving access to community providers to fill gaps in women's services. Participants also highlighted efforts to improve gender-sensitive care delivery.

Conclusions: Although some issues affect all veterans, problems with community care referrals may disproportionately affect women veterans' access owing to a necessary reliance on community care for a range of gender-specific services.
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http://dx.doi.org/10.1016/j.whi.2020.12.011DOI Listing
February 2021

Association Between Rural Residence and In-Hospital and 30-Day Mortality Among Veterans Hospitalized with COPD Exacerbations.

Int J Chron Obstruct Pulmon Dis 2021;16:191-202. Epub 2021 Feb 2.

Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.

Background: We explored the relationship between rural residency and in-hospital mortality in patients hospitalized with COPD exacerbations.

Methods: We retrospectively analyzed COPD hospitalizations from 2011 to 2017 at 124 acute care Veterans Health Administration (VHA) hospitals in the US. Patient residence was classified using Rural Urban Commuting Area codes as urban, rural, or isolated rural. We stratified patient hospitalizations into quartiles by travel time from patient residence to the nearest VHA primary care provider clinic and hospital. Multivariate analyses utilized generalized estimating equations with a logit link accounting for repeated hospitalizations among patients and adjusting for patient- and hospital-level characteristics.

Results: Of 64,914 COPD hospitalizations analyzed, 43,549 (67.1%) were for urban, 18,673 (28.8%) for rural, and 2,692 (4.1%) for isolated rural veterans. In-hospital mortality was 4.9% in urban, 5.5% in rural, and 5.2% in isolated rural veterans (=0.008). Thirty-day mortality was 8.3% in urban, 9.9% in rural, and 9.2% in isolated rural veterans (<0.001). Travel time to a primary care provider and VHA hospital was not associated with in-hospital mortality among isolated rural and rural veterans. In the multivariable analysis, compared to urban veterans, isolated rural patients did not have increased mortality. Rural residence was not associated with in-hospital (OR=0.87; 95% CI=0.67-1.12, =0.28) but was associated with increased 30-day mortality (OR=1.13; 95% CI=1.04-1.22, =0.002). Transfer from another acute care hospital (OR=14.97; 95% CI=9.80-17.16, <0.001) or an unknown/other facility (OR=33.05; 95% CI=22.66-48.21, <0.001) were the strongest predictors of increased in-hospital mortality compared to patients coming from the outpatient sector. Transfer from another acute care facility was also a risk factor for 30-day mortality.

Conclusion: Potential gaps in post-discharge care of rural veterans may be responsible for the rural-urban disparities. Further research should investigate the exact mechanism that inter-hospital transfers affect mortality.
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http://dx.doi.org/10.2147/COPD.S281162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7866931PMC
June 2021

Association of Secure Messaging with Primary Care In-Person and Telephone Visits Among Veterans: a Matched Difference-in-Difference Analysis.

J Gen Intern Med 2021 04 2;36(4):946-951. Epub 2021 Feb 2.

Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, IA, USA.

Background: Secure messaging (SM) between patients and primary care teams has expanded care access but may impact other clinical encounters.

Objective: To study associations between SM use and primary care in-person and telephone visits in the Veterans Health Administration (VHA).

Design: The SM feature of VHA's patient portal, MyHealtheVet, supports asynchronous communication between patients and primary care teams. To study the impact of SM on in-person and telephone visits, two analyses were performed: (1) a retrospective pre-/post-analysis comparing changes after initiating SM use and (2) a difference-in-difference comparison among SM users and non-users 1 year before and after index SM use. Matching to non-users was by primary care team, demographics, and predicted propensity of SM use by Nosos comorbidity score and drive time to clinic.

Patients: In 2016, 154,053 Veterans initiated SM from all primary care patients (N = 5,891,893); 25,683 were propensity-matched to controls (N = 49,266) from the same primary care team not using SM.

Main Measures: Primary care provider in-person visits and telephone contacts between patients and their primary care team were assessed 1 year prior and post index SM.

Key Results: Overall, primary care in-person visits decreased 13.3% (p < 0.0001); telephone visits increased 13.5% (p < 0.0001). In the matched analysis, in-person primary care visits decreased by 16.0% (p < 0.0001) by SM users and 9.9% (p < 0.0001) among controls, resulting in a across-group decrease of 6.1% in-person visits after SM initiation. Telephone visits increased by 11.0% (p < 0.0001) for SM users and 4.5% for controls (p < 0.0001) resulting in an across-group increase of 6.5% telephone visits after SM initiation.

Conclusions: Use of SM was associated with decreased in-person visits and increased telephone visits. This may improve clinic appointment availability, while increasing time commitments for providers for non-traditional forms of access.
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http://dx.doi.org/10.1007/s11606-020-06541-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8041942PMC
April 2021

Call Center Remote Triage by Nurse Practitioners Was Associated With Fewer Subsequent Face-to-Face Healthcare Visits.

J Gen Intern Med 2021 Jan 26. Epub 2021 Jan 26.

VA Puget Sound Health Care System, Seattle, WA, USA.

Background: In 2015, the Veterans Health Administration (VHA) incorporated nurse practitioners (NPs) into remote triage call centers to supplement registered nurse (RN)-handled calls.

Objective: To assess 7-day healthcare use following telephone triage by NPs compared to RNs. We hypothesized that NP clinical decision ability may reduce follow-up healthcare.

Design: Retrospective observational comparative effectiveness study of clinical and administrative databases. NP routed calls were matched to RN calls based on chief complaint with propensity score matching and multivariate count data models, adjusting for differences in call severity and patient comorbidity.

Participants: Callers to a VHA regional call center, April 2015 to March 2019.

Main Measures: Primary care, specialty care, and emergency department (ED) visits plus hospitalizations within 7 days.

Key Results: NP-handled calls (N = 1554) were matched to RN calls (N = 48,024) for the same chief complaint. NP-handled calls, compared to RNs, had lower comorbidities, fewer hospitalizations, and less urgent complaints. Seven-day healthcare use was lower for NP compared to RN calls for specialty care (0.15 vs. 0.20 visits per person [VPP]; p < 0.001), ED (0.11 vs. 0.27 VPP; p < 0.001), and hospitalizations (0.01 vs. 0.04 VPP; p < 0.001), but not primary care (0.43 vs. 0.42 VPP; p = 0.80). In adjusted analyses, estimated avoided in-person visits per 100 calls routed to NPs were 0.7 primary care visits (95% confidence interval [CI] 0.4, 1.0), 2.6 specialty care visits (95% CI 0.0, 5.1), 5.9 ED visits (95% CI 2.7, 9.1), and 1.4 hospital stays (95% CI 0.1, 2.6). Propensity score-matched models comparing NP (N = 1533) to RN (N = 2646) calls had adjusted odds ratios for 7-day healthcare use of 0.75 (primary care), 0.75 (specialty care), and 0.73 (ED) (all p < 0.003).

Conclusion: Incorporating NPs into a call center was associated with lower in-person healthcare use in the subsequent 7 days compared to routine RN-triaged calls.
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http://dx.doi.org/10.1007/s11606-020-06536-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837076PMC
January 2021

Growth of electronic consultations in the Veterans Health Administration.

Am J Manag Care 2021 01;27(1):12-19

Division of Endocrinology, Metabolism and Diabetes, University of Colorado, Anschutz Medical Campus, 12801 E 17th Ave, Mail Stop 8106, Aurora, CO 80045. Email:

Objectives: To evaluate the growth and variation of electronic consultation, or e-consult, use in the Veterans Health Administration (VHA) across regions and specialties.

Study Design: Observational cohort study using administrative data of all veterans who received an e-consult for 41 specialties across 1269 VHA medical centers and associated clinical sites from January 1, 2012, through December 31, 2018.

Methods: Assessments included (1) the number and characteristics of all e-consults, (2) growth of e-consult use, (3) e-consults as a proportion of all consults by region and by specific specialty, (4) need for an in-person visit with the same specialty within 12 months after an e-consult, and (5) potential miles of driving saved for patients and mileage reimbursement costs avoided for VHA due to e-consult use.

Results: Over the 7-year study period, VHA providers completed 3,117,998 e-consults (5.5% of all specialty consults). e-Consults increased by 309% for all specialties. By 2018, for 16 of 41 specialties, e-consults accounted for greater than 10% of all consults. Overall, 21.5% of e-consults resulted in an in-person visit with the same specialty within 12 months. On average, each e-consult resulted in approximately 84.3 (SD, 89.9; interquartile range, 25.1-115.0) miles in driving saved, equating to potential driving reimbursement savings of $46 million.

Conclusions: Use of e-consults in the VHA grew substantially between 2012 and 2018, with variability across specialties. In-person follow-up after an e-consult was low, suggesting that e-consults may substitute for in-person visits and reduce considerable patient travel burden.
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http://dx.doi.org/10.37765/ajmc.2021.88572DOI Listing
January 2021

A simplified critical illness severity scoring system (CISSS): Development and internal validation.

J Crit Care 2021 Feb 30;61:21-28. Epub 2020 Sep 30.

Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA.

Purpose: To create a simplified critical illness severity scoring system with high prediction accuracy for 30-day mortality using only commonly available variables.

Materials And Methods: This is a retrospective cohort study of ICU admissions 2010-2015 in 306 ICUs in 117 Veterans Affairs (VA) hospitals. We randomly divided our cohort into a training dataset (75%) and a validation dataset (25%). We created a critical illness severity scoring system (CISSS) using age, comorbidities, heart rate, mean arterial blood pressure, temperature, respiratory rate, hematocrit, white blood cell count, creatinine, sodium, glucose, albumin, bilirubin, bicarbonate, use of invasive mechanical ventilation, and whether the admission was surgical or not. We validated the performance of CISSS to predict 30-day mortality internally.

Results: After excluding 31,743 re-admissions, we divided our sample (n = 534,001) into a training (n = 400,613) and a validation dataset (n = 133,388). In the training dataset, the area under the curve (AUC) of CISSS was 0.847(95%CI = 0.845-0.850). In the validation dataset, the AUC was 0.848 (95%CI = 0.844-0.852), the standardized mortality ratio (SMR) was 1.00 (95%CI = 0.98-1.02), and Brier's score for 30-day mortality was 0.058 (95%CI = 0.057-0.059). CISSS calibration was acceptable.

Conclusions: CISSS has very good performance and requires only commonly used variables that can be easily extracted by electronic health records.
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http://dx.doi.org/10.1016/j.jcrc.2020.09.029DOI Listing
February 2021

Applying a Text-Search Algorithm to Radiology Reports Can Find More Patients With Pulmonary Nodules Than Radiology Coding Alone.

Fed Pract 2020 May;37(Suppl 2):S32-S37

is a Clinical Assistant Professor of Pulmonary and Critical Care Medicine; is a Professor of Internal Medicine; and is a Professor of Internal Medicine, all at the University of Iowa Carver College of Medicine in Iowa City. is a Research Data Manager; is a Registered Nurse and Research Coordinator; and Peter Kaboli is an Associate Investigator, all in the Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System. is a Research Professor of Public Health at the Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System and the University of Washington School of Public Health in Seattle.

Introduction: Chest imaging often incidentally finds indeterminate nodules that need to be monitored to ensure early detection of lung cancers. Health care systems need effective approaches for identifying these lung nodules. We compared the diagnostic performance of 2 approaches for identifying patients with lung nodules on imaging studies (chest/abdomen): (1) relying on radiologists to code imaging studies with lung nodules; and (2) applying a text search algorithm to identify references to lung nodules in radiology reports.

Methods: We assessed all radiology studies performed between January 1, 2016 and November 30, 2016 in a single Veterans Health Administration hospital. We first identified imaging reports with a diagnostic code for a pulmonary nodule. We then applied a text search algorithm to identify imaging reports with key words associated with lung nodules. We reviewed medical records for all patients with a suspicious radiology report based on either search strategy to confirm the presence of a lung nodule. We calculated the yield and the positive predictive value (PPV) of each search strategy for finding pulmonary nodules.

Results: We identified 12,983 imaging studies with a potential lung nodule. Chart review confirmed 8,516 imaging studies with lung nodules, representing 2,912 unique patients. The text search algorithm identified all the patients with lung nodules identified by the radiology coding (n = 1,251) as well as an additional 1,661 patients. The PPV of the text search was 72% (2,912/4,071) and the PPV of the radiology code was 92% (1,251/1,363). Among the patients with nodules missed by radiology coding but identified by the text search algorithm, 130 had lung nodules > 8 mm in diameter.

Conclusions: The text search algorithm can identify additional patients with lung nodules compared to the radiology coding; however, this strategy requires substantial clinical review time to confirm nodules. Health care systems adopting nodule-tracking approaches should recognize that relying only on radiology coding might miss clinically important nodules.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7497875PMC
May 2020

Effect of a patient activation intervention on hypertension medication optimization: results from a randomized clinical trial.

Am J Manag Care 2020 09;26(9):382-387

Florida State University College of Medicine, 1115 W Call St, Tallahassee, FL 32306. Email:

Objectives: To examine the effect of a patient activation intervention with financial incentives to promote switching to a thiazide in patients with controlled hypertension using calcium channel blockers (CCBs).

Study Design: The Veterans Affairs Project to Implement Diuretics, a randomized clinical trial, was conducted at 13 Veterans Affairs primary care clinics.

Methods: Patients (n = 236) with hypertension previously controlled using CCBs were randomized to a control group (n = 90) or 1 of 3 intervention groups designed to activate patients to talk with their primary care providers about switching to thiazides: Group A (n = 53) received an activation letter, group B (n = 42) received a letter plus a financial incentive to discuss switching from a CCB to a thiazide, and group C (n = 51) received a letter, a financial incentive, and a telephone call encouraging patients to speak with their primary care providers. The primary outcome was thiazide prescribing at the index visit.

Results: At the index visit, the rate of switching to a thiazide was 1.1% in the control group and 9.4% (group A), 26.2% (group B), and 31.4% (group C) for the intervention groups (P < .0001). In adjusted analysis, patients randomized to group C were significantly more likely to switch from a CCB to thiazide at the index visit (odds ratio, 4.14; 95% CI, 1.45-11.84; P < .01).

Conclusions: This low-cost, low-intensity patient activation intervention resulted in increased rates of switching to a thiazide in those whose hypertension was controlled using another medication, suggesting that such interventions may be used to overcome medication optimization challenges, including clinical inertia.
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http://dx.doi.org/10.37765/ajmc.2020.88488DOI Listing
September 2020

Use of the Veterans' Choice Program and Attrition From Veterans Health Administration Primary Care.

Med Care 2020 12;58(12):1091-1097

VA Health Economics Resource Center, VA Palo Alto Healthcare System, Menlo Park.

Background: Concerns over timely access and waiting times for appointments in the Veterans Health Administration (VHA) spurred the push towards greater privatization. In 2014, VHA increased the provision of care from community providers through the Veterans' Choice Program (Choice).

Objectives: We examined the characteristics of patients and practices more likely to use Choice care and whether using Choice care affected patients' attrition from VHA primary care.

Study Design: We conducted a longitudinal study of VHA primary care users in the fiscal year 2015 and their attrition 2 years later. In the multivariate analysis, we examined whether attrition from VHA primary care was related to prior use of Choice care.

Subjects: A total of 1.4 million nonelderly patients diagnosed with chronic conditions.

Measures: Choice outpatient care utilization was measured in the baseline year. Attrition was measured as not receiving any VHA primary care in 2 subsequent years.

Results: In our cohort, 93,710 (7%) patients used some Choice outpatient care, and these patients were more likely to be female, White or Hispanic, to have more primary care utilization at baseline, and to have long driving distances to VHA care. Practices which sent more patients out for Choice care had lower mean scores for patient-centered medical home implementation and longer mean waiting times for appointments. In the adjusted analysis, the probability of attrition was significantly lower (-0.009) among patients who used Choice outpatient care (0.036) versus patients who did not (0.044) (P<0.001).

Conclusion: The use of community outpatient providers in the Choice program was associated with less attrition from VHA primary care.
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http://dx.doi.org/10.1097/MLR.0000000000001401DOI Listing
December 2020

Enhancing Usability of Appointment Reminders: Qualitative Interviews of Patients Receiving Care in the Veterans Health Administration.

J Gen Intern Med 2021 01 9;36(1):121-128. Epub 2020 Sep 9.

Comprehensive Access and Delivery Research and Evaluation Center, Iowa City Veterans Affairs Healthcare System, Iowa City, USA.

Background: No-shows are a persistent and costly problem in all healthcare systems. Because forgetting is a common cause of no-shows, appointment reminders are widely used. However, qualitative research examining appointment reminders and how to improve them is lacking.

Objective: To understand how patients experience appointment reminders as part of intervention development for a pragmatic trial of enhanced appointment reminders.

Design: Qualitative content analysis PARTICIPANTS: Twenty-seven patients at a single Department of Veterans Affairs hospital and its satellite clinics APPROACH: We conducted five waves of interviews using rapid qualitative analysis, in each wave continuing to ask veterans about their experience of reminders. We double-coded all interviews, used deductive and inductive content analysis to identify themes, and selected quotations that exemplified three themes (limitations, strategies, recommendations).

Key Results: Interviews showed four limitations on the usability of current appointment reminders which may contribute to no-shows: (1) excessive information within reminders; (2) frustrating telephone systems when calling in response to an appointment reminder; (3) missing or cryptic information about clinic logistics; and (4) reminder fatigue. Patients who were successful at keeping appointments often used specific strategies to optimize the usability of reminders, including (1) using a calendar; (2) heightening visibility; (3) piggybacking; and (4) combining strategies. Our recommendations to enhance reminders are as follows: (1) mix up their content and format; (2) keep them short and simple; (3) add a personal touch; (4) include specifics on clinic location and contact information; (5) time reminders based on the mode of delivery; and (6) hand over control of reminders to patients.

Conclusions: Appointment reminders are vital to prevent no-shows, but their usability is not optimized for patients. There is potential for healthcare systems to modify several aspects of the content, timing, and delivery of appointment reminders to be more effective and patient-centered.
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http://dx.doi.org/10.1007/s11606-020-06183-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7859164PMC
January 2021

Reduced In-Person and Increased Telehealth Outpatient Visits During the COVID-19 Pandemic.

Ann Intern Med 2021 01 10;174(1):129-131. Epub 2020 Aug 10.

VA New York Harbor Healthcare System and New York University School of Medicine, New York, New York (M.D.S.).

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http://dx.doi.org/10.7326/M20-3026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429994PMC
January 2021

Association of patient preferences on medication discussion in hypertension: Results from a randomized clinical trial.

Soc Sci Med 2020 10 29;262:113244. Epub 2020 Jul 29.

Center for Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA, USA; Division of General Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City, IA, USA.

Patient-centered care has received significant attention and is an integral component of high-quality healthcare. While it is often assumed that most prefer a patient-centered role orientation, such preferences exist along a continuum with some patients preferring a more provider-centered role. The present study examines patient preference data from a randomized clinical trial designed to test the efficacy of a patient activation intervention to promote thiazide prescribing for veteran patients with uncontrolled hypertension. Patient preferences for involvement in healthcare were assessed using the 9-item Sharing subscale of the Patient-Practitioner Orientation Scale (PPOS). The primary aim was to examine differences in discussion of thiazide use in the clinical encounter by those scoring high versus low on the PPOS. Five hundred ninety-five veteran patients were randomized to either one of three intervention groups or a usual care control group. The adjusted odds ratios (OR) for the three intervention groups relative to the control group indicated that thiazide discussion increased as a function of intervention intensity across both high and low PPOS groups. ORs for the most intensive intervention group were 3.72 (95% CI = 1.61-8.65, p < .01) for high PPOS patients and 6.71 (95% CI = 2.59-10.67, p < .001) for low PPOS patients. Results suggest that this patient activation intervention is effective for veteran patients representing a range of preferred involvement. Consideration of such preferences may be useful in tailoring future interventions in the healthcare context.
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http://dx.doi.org/10.1016/j.socscimed.2020.113244DOI Listing
October 2020

Rural Interfacility Emergency Department Transfers: Framework and Qualitative Analysis.

West J Emerg Med 2020 Jul 9;21(4):858-865. Epub 2020 Jul 9.

Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee.

Introduction: Interfacility transfers from rural emergency departments (EDs) are an important means of access to timely and specialized care.

Methods: Our goal was to identify and explore facilitators and barriers in transfer processes and their implications for emergency rural care and access. Semi-structured interviews with ED staff at five rural and two urban Veterans Health Administration (VHA) hospitals were recorded, transcribed, coded, and analyzed using an iterative inductive-deductive approach to identify themes and construct a conceptual framework.

Results: From 81 interviews with clinical and administrative staff between March-June 2018, four themes in the interfacility transfer process emerged: 1) patient factors; 2) system resources; and 3) processes and communication for transfers, which culminate in 4) the location decision. Current and anticipated resource limitations were highly influential in transfer processes, which were described as burdensome and diverting resources from clinical care for emergency patients. Location decision was highly influenced by complexity of the transfer process, while perceived quality at the receiving location or patient preferences were not reported in interviews as being primary drivers of location decision. Transfers were described as burdensome for patients and their families. Finally, patients with mental health conditions epitomized challenges of emergency transfers.

Conclusion: Interfacility transfers from rural EDs are multifaceted, resource-driven processes that require complex coordination. Anticipated resource needs and the transfer process itself are important determinants in the location decision, while quality of care or patient preferences were not reported as key determinants by interviewees. These findings identify potential benefits from tracking transfer boarding as an operational measure, directed feedback regarding outcomes of transferred patients, and simplified transfer processes.
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http://dx.doi.org/10.5811/westjem.2020.3.46059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7390588PMC
July 2020

Perceived Need and Potential Applications of a Telehospitalist Service in Rural Areas.

Telemed J E Health 2021 01 21;27(1):90-95. Epub 2020 Apr 21.

VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.

Rural hospitals struggle to staff inpatient services and may not have the clinical expertise to achieve optimal outcomes. Telehospitalist services could address these problems by bringing hospital medicine expertise to rural communities. Veterans Health Administration (VHA) rural hospitals need staffing alternatives to address gaps in inpatient coverage. This needs assessment identified perceived need for telehospitalist services as well as potential applications, benefits, and barriers from an administration perspective. We used a rapid qualitative assessment approach based on semistructured interviews with 15 physician administrators at 12 rural and low-complexity hospitals in VHA in 2018. We identified a range of needs that could be addressed by telehospitalist services, including direct care delivery, support for local providers, and on-demand coverage to fill staffing gaps. Potential benefits included cost reductions, improved care quality, education, and addressing feelings of insular practice. Potential barriers included provider buy-in, cost, and technological limitations. Our findings suggest that telehospitalist services could address inpatient coverage gaps, but with a range of views on how the service could be deployed. Telehospitalist services providing intermittent coverage could meet unmet clinical needs at appropriate economies of scale. Administrators were enthusiastic about applying innovative inpatient telemedicine initiatives, but perceived staff reluctance. The dynamic and multidisciplinary nature of inpatient care requires program acceptance at multiple levels, which may account for why it traditionally lags behind outpatient telemedicine. Rural hospital physician administrators perceived telehospitalist models as a viable option to address staffing needs and improve quality of care.
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http://dx.doi.org/10.1089/tmj.2020.0018DOI Listing
January 2021

Using Telehealth as a Tool for Rural Hospitals in the COVID-19 Pandemic Response.

J Rural Health 2021 01 1;37(1):161-164. Epub 2020 Jun 1.

VA Office of Rural Health, Veterans Rural Health Resource Center - Iowa City (VRHRC-IC), Iowa City VA Healthcare System, Iowa City, Iowa.

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http://dx.doi.org/10.1111/jrh.12443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7262306PMC
January 2021

Lung Cancer Staging at Diagnosis in the Veterans Health Administration: Is Rurality an Influencing Factor? A Cross-Sectional Study.

J Rural Health 2020 09 30;36(4):484-495. Epub 2020 May 30.

Veterans Rural Health Resource Center-Iowa City, Veterans Health Administration (VHA), Office of Rural Health, and the Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VHA, Iowa City, Iowa.

Purpose: To evaluate the association between rurality and lung cancer stage at diagnosis.

Methods: We conducted a cross-sectional study using Veterans Health Administration (VHA) data to identify veterans newly diagnosed with lung cancer between October 1, 2011 and September 30, 2015. We defined rurality, based on place of residence, using Rural-Urban Commuting Area (RUCA) codes with the subcategories of urban, large rural, small rural, and isolated. We used multivariable logistic regression models to determine associations between rurality and stage at diagnosis, adjusting for sociodemographic and clinical characteristics. We also analyzed data using the RUCA code for patients' assigned primary care sites and driving distances to primary care clinics and medical centers.

Findings: We identified 4,220 veterans with small cell lung cancer (SCLC) and 25,978 with non-small cell lung cancer (NSCLC). Large rural residence (compared to urban) was associated with early-stage diagnosis of NSCLC (OR = 1.12; 95% CI: 1.00-1.24) and SCLC (OR = 1.73; 95% CI: 1.18-1.55). However, the finding was significant only in the southern and western regions of the country. White race, female sex, chronic lung disease, higher comorbidity, receiving primary care, being a former tobacco user, and more recent year of diagnosis were also associated with diagnosing early-stage NSCLC. Driving distance to medical centers was inversely associated with late-stage NSCLC diagnoses, particularly for large rural areas.

Conclusions: We did not find clear associations between rurality and lung cancer stage at diagnosis. These findings highlight the complex relationship between rurality and lung cancer within VHA, suggesting access to care cannot be fully captured by current rurality codes.
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http://dx.doi.org/10.1111/jrh.12429DOI Listing
September 2020

Potentially avoidable inter-facility transfer from Veterans Health Administration emergency departments: A cohort study.

BMC Health Serv Res 2020 02 12;20(1):110. Epub 2020 Feb 12.

Center for Comprehensive Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA, USA.

Background: Inter-facility transfer is an important strategy for improving access to specialized health services, but transfers are complicated by over-triage, under-triage, travel burdens, and costs. The purpose of this study is to describe ED-based inter-facility transfer practices within the Veterans Health Administration (VHA) and to estimate the proportion of potentially avoidable transfers.

Methods: This observational cohort study included all patients treated in VHA EDs between 2012 and 2014 who were transferred to another VHA hospital. Potentially avoidable transfers were defined as patients who were either discharged from the receiving ED or admitted to the receiving hospital for ≤1 day without having an invasive procedure performed. We conducted facility- and diagnosis-level analyses to identify subgroups of patients for whom potentially avoidable transfers had increased prevalence.

Results: Of 6,173,189 ED visits during the 3-year study period, 18,852 (0.3%) were transferred from one VHA ED to another VHA facility. Rural residents were transferred three times as often as urban residents (0.6% vs. 0.2%, p < 0.001), and 22.8% of all VHA-to-VHA transfers were potentially avoidable transfers. The 3 disease categories most commonly associated with inter-facility transfer were mental health (34%), cardiac (12%), and digestive diagnoses (9%).

Conclusions: VHA inter-facility transfer is commonly performed for mental health and cardiac evaluation, particularly for patients in rural settings. The proportion that are potentially avoidable is small. Future work should focus on improving capabilities to provide specialty evaluation locally for these conditions, possibly using telehealth solutions.
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http://dx.doi.org/10.1186/s12913-020-4956-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7014752PMC
February 2020

Development of a novel metric of timely care access to primary care services.

Health Serv Res 2020 04 14;55(2):301-309. Epub 2020 Jan 14.

Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health and Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, Iowa.

Objective: To develop a model for identifying clinic performance at fulfilling next-day and walk-in requests after adjusting for patient demographics and risk.

Data Source: Using Department of Veterans Affairs (VA) administrative data from 160 VA primary care clinics from 2014 to 2017.

Study Design: Using a retrospective cohort design, we applied Bayesian hierarchical regression models to predict provision of timely care, with clinic-level random intercept and slope while adjusting for patient demographics and risk status. Timely care was defined as the provision of an appointment within 48 hours of any patient requesting the clinic's next available appointment or walking in to receive care.

Data Collection/extraction Methods: We extracted 1 841 210 timely care requests from 613 263 patients.

Principal Findings: Across 160 primary care clinics, requests for timely care were fulfilled 86 percent of the time (range 83 percent-88 percent). Our model of timely care fit the data well, with a Bayesian R of .8. Over the four years of observation, we identified 25 clinics (16 percent) that were either struggling or excelling at providing timely care.

Conclusion: Statistical models of timely care allow for identification of clinics in need of improvement after adjusting for patient demographics and risk status. VA primary care clinics fulfilled 86 percent of timely care requests.
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http://dx.doi.org/10.1111/1475-6773.13255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080389PMC
April 2020

The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS).

Am J Health Syst Pharm 2020 01;77(2):128-137

Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, and Geriatric Research, Education, and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN.

Purpose: High-quality medication reconciliation reduces medication discrepancies, but smaller hospitals serving rural patients may have difficulty implementing this because of limited resources. We sought to adapt and implement an evidence-based toolkit of best practices for medication reconciliation in smaller hospitals, evaluate the effect on unintentional medication discrepancies, and assess facilitators and barriers to implementation.

Methods: We conducted a 2-year mentored-implementation quality improvement feasibility study in 3 Veterans Affairs (VA) hospitals serving rural patients. The primary outcome was unintentional medication discrepancies per medication per patient, determined by comparing the "gold standard" preadmission medication history to the documented preadmission medication list and admission and discharge orders.

Results: In total, 797 patients were included; their average age was 68.7 years, 94.4% were male, and they were prescribed an average of 9.6 medications. Sites 2 and 3 implemented toolkit interventions, including clarifying roles among clinical personnel, educating providers on taking a best possible medication history, and hiring pharmacy professionals to obtain a best possible medication history and perform discharge medication reconciliation. Site 1 did not implement an intervention. Discrepancies improved in intervention patients compared with controls at Site 3 (adjusted incidence rate ratio [IRR], 0.55; 95% confidence interval [CI], 0.45-0.67) but increased in intervention patients compared with controls at Site 2 (adjusted IRR, 1.22; 95% CI, 1.08-1.36).

Conclusions: An evidence-based toolkit for medication reconciliation adapted to the VA setting was adopted in 2 of 3 small, rural, resource-limited hospitals, resulting in both reduced and increased unintentional medication discrepancies. We highlight facilitators and barriers to implementing evidence-based medication reconciliation in smaller hospitals.
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http://dx.doi.org/10.1093/ajhp/zxz275DOI Listing
January 2020

Perceptions of Telehospitalist Services to Address Staffing Needs in Rural and Low Complexity Hospitals in the Veterans Health Administration.

J Rural Health 2020 06 15;36(3):355-359. Epub 2019 Dec 15.

VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Healthcare System, Iowa City, Iowa.

Purpose: Rural hospitals are disproportionally affected by physician shortages and struggle to staff inpatient services. Telemedicine presents an opportunity to address staffing problems and bring the advantages of hospital medicine to rural areas.

Methods: In this study we surveyed administrators from 34 rural and low complexity hospitals in the Veterans Health Administration (VHA) to evaluate staffing needs and perceptions of a potential telehospitalist service.

Findings: Of the 25 respondent facilities (74% response rate), 96% reported vacancies that resulted in staffing difficulties within the last 3 years and 84% relied on intermittent providers to staff their inpatient services in the last year. Almost two-thirds of respondents thought that a telehospitalist service could help address their staffing needs and 72% were interested in participating in a pilot program.

Conclusions: The results of this study corroborate staffing challenges in rural hospitals within VHA and support the use of alternative staffing models like a telehospitalist service to address intermittent and long-term staffing needs.
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http://dx.doi.org/10.1111/jrh.12403DOI Listing
June 2020

Creating and disseminating a home-based cardiac rehabilitation program: experience from the Veterans Health Administration.

BMC Cardiovasc Disord 2019 11 6;19(1):242. Epub 2019 Nov 6.

The Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, USA.

Background: Cardiac rehabilitation (CR) programs provide significant benefit for people with cardiovascular disease. Despite these benefits, such services are not universally available. We designed and evaluated a national home-based CR (HBCR) program in the Veterans Health Administration (VHA). The primary aim of the study was to examine barriers and facilitators associated with site-level implementation of HBCR.

Methods: This study used a convergent parallel mixed-methods design with qualitative data to analyze the process of implementation, quantitative data to determine low and high uptake of the HBCR program, and the integration of the two to determine which facilitators and barriers were associated with adoption. Data were drawn from 16 VHA facilities, and included semi-structured interviews with multiple stakeholders, document analysis, and quantitative analysis of CR program attendance codes. Qualitative data were analyzed using the Consolidated Framework for Implementation Research codes including three years of document analysis and 22 interviews.

Results: Comparing high and low uptake programs, readiness for implementation (leadership engagement, available resources, and access to knowledge and information), planning, and engaging champions and opinion leaders were key to success. High uptake sites were more likely to seek information from the external facilitator, compared to low uptake sites. There were few adaptations to the design of the program at individual sites.

Conclusion: Consistent and supportive leadership, both clinical and administrative, are critical elements to getting HBCR programs up and running and sustaining programs over time. All sites in this study had external funding to develop their program, but high adopters both made better use of those resources and were able to leverage existing resources in the setting. These data will inform broader policy regarding use of HBCR services.
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http://dx.doi.org/10.1186/s12872-019-1224-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6833278PMC
November 2019

Sequelae of an Evidence-based Approach to Management for Access to Care in the Veterans Health Administration.

Med Care 2019 10;57 Suppl 10 Suppl 3:S213-S220

Southern California Evidence-based Practice Center, RAND, Santa Monica.

Background: Access to health care is a critical concept in the design, delivery, and evaluation of high quality care. Meaningful evaluation of access requires research evidence and the integration of perspectives of patients, providers, and administrators.

Objective: Because of high-profile access challenges, the Department of Veterans Affairs (VA) invested in research and implemented initiatives to address access management. We describe a 2-year evidence-based approach to improving access in primary care.

Methods: The approach included an Evidence Synthesis Program (ESP) report, a 22-site in-person qualitative evaluation of VA initiatives, and in-person and online stakeholder panel meetings facilitated by the RAND corporation. Subsequent work products were disseminated in a targeted strategy to increase impact on policy and practice.

Results: The ESP report summarized existing research evidence in primary care management and an evaluation of ongoing initiatives provided organizational data and novel metrics. The stakeholder panel served as a source of insights and information, as well as a knowledge dissemination vector. Work products included the ESP report, a RAND report, peer-reviewed manuscripts, presentations at key conferences, and training materials for VA Group Practice Managers. Resulting policy and practice implications are discussed.

Conclusions: The commissioning of an evidence report was the beginning of a cascade of work including exploration of unanswered questions, novel research and measurement discoveries, and policy changes and innovation. These results demonstrate what can be achieved in a learning health care system that employs evidence and expertise to address complex issues such as access management.
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http://dx.doi.org/10.1097/MLR.0000000000001177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6750154PMC
October 2019

The Effects of Telephone Visits and Rurality on Veterans Perceptions of Access to Primary Care.

J Am Board Fam Med 2019 Sep-Oct;32(5):749-751

From VISN 23 Patient Aligned Care Team Demonstration Lab, Iowa City VA Healthcare System, Iowa City, IA (ML, GS); Department of Health Sciences Research, Mayo Clinic, Rochester, MN (ML); Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System Sepulveda, CA (SS); Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA (SS); Center for Access Delivery Research & Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA (PJK, GS); Department of Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City, IA (PJK); VA Puget Sound Healthcare System, Seattle, WA (EJ, GBW, WLC); Kaiser Permanente Washington Health Research Institute, Seattle, WA (WLC); University of Iowa-Tippie College of Business, Iowa City, IA (GS).

Introduction: The objectives of this study were to examine if self-reported access to primary care is associated with actual patient wait times and use of telephone visits, and to assess whether this relationship differs by rural residence.

Methods: This study used 2016 administrative data from 994 primary care clinics within the Veterans Health Administration. Multiple-linear regression was used to examine relationships between patient perceptions of access and average actual patient wait time, use of telephone visits, and rural residence. Average panel size, clinic type, and panel severity were included as model covariates with cross-product terms for actual wait time, telephone use, and rurality to test for interactions.

Results: This study found patient perceptions of access aggregated at the clinic level to be conditional on the relationship between use of telephone visits, actual patient wait times, and rural residence. As actual wait time for routine appointments increases, Veterans served by clinics with a higher percent of rural Veterans perceive telephone visits more positively.

Discussion: These findings contribute to our understanding of factors associated with patient perceptions of access by highlighting complex interrelationships between strategies intended to improve access to care and how they can have differing impacts on perceptions among those living in rural or urban locations.
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http://dx.doi.org/10.3122/jabfm.2019.05.190047DOI Listing
September 2020

Impact of Rural Residence on Kidney Transplant Rates Among Waitlisted Candidates in the VA Transplant Programs.

Transplantation 2019 09;103(9):1945-1952

Comprehensive Access and Delivery Research Evaluation (CADRE), Iowa City VAMC, Iowa City, IA.

Background: Although proportionally more veterans live in rural areas compared to nonveterans, the impact of rurality status on kidney transplantation (KTP) access among veterans is unknown. Our objective was to study KTP rates among veterans listed for KTP and to compare the impact of rurality status on KTP rates among veterans and nonveterans.

Methods: Retrospective cohort study of adult patients waitlisted per the United Network for Organ Sharing from January 2000 to December 2014. Patient characteristics were compared using Chi-square or t tests, as appropriate, by veteran status and patient rurality. Multivariable competing-risks Cox regression was performed.

Results: The study sample included 3281 veterans receiving care in Veteran Health Administration transplant programs and 445 177 nonveterans. Veterans, compared to nonveterans, were older (57 versus 50 y; P < 0.001), more likely to be male (96% versus 60%; P < 0.001) or diabetic at waitlisting (51% versus 41%; P < 0.001), and less likely be an urban resident (79% versus 84%; P < 0.001). Among veterans, dialysis duration prior to registration was longer among urban compared to all other rurality types (810 ± 22.1 d versus 632 to 702 ± 41.6 to 77.6 d; P = 0.02). In multivariate competing risks models, there was no evidence that the hazard of transplant among veterans differs by residential rurality.

Conclusions: Among waitlisted veterans served by Veteran Health Administration transplant programs, residential rurality status does not portend longer waiting time for KTP.
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http://dx.doi.org/10.1097/TP.0000000000002624DOI Listing
September 2019

Waiting for Care in Veterans Affairs Health Care Facilities and Elsewhere.

JAMA Netw Open 2019 01 4;2(1):e187079. Epub 2019 Jan 4.

Department of Medicine, University of Washington, Seattle.

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http://dx.doi.org/10.1001/jamanetworkopen.2018.7079DOI Listing
January 2019

Efficacy of Patient Activation Interventions With or Without Financial Incentives to Promote Prescribing of Thiazides and Hypertension Control: A Randomized Clinical Trial.

JAMA Netw Open 2018 12 7;1(8):e185017. Epub 2018 Dec 7.

Center for Comprehensive Access & Delivery Research & Evaluation, Veterans Affairs Iowa City Healthcare System, Iowa City, Iowa.

Importance: Evidence-based guidelines recommend thiazide diuretics as a first-line therapy for uncomplicated hypertension; however, thiazides are underused, and hypertension remains inadequately managed.

Objective: To test the efficacy of a patient activation intervention with financial incentives to promote thiazide prescribing.

Design, Setting, And Participants: The Veterans Affairs Project to Implement Diuretics, a randomized clinical trial, was conducted at 13 Veterans Affairs primary care clinics from August 1, 2006, to July 31, 2008, with 12 months of follow-up. A total of 61 019 patients were screened to identify 2853 eligible patients who were not taking a thiazide and not at their blood pressure (BP) goal; 598 consented to participate. Statistical analysis was conducted from December 1, 2017, to September 12, 2018.

Interventions: Patients were randomized to a control group (n = 196) or 1 of 3 intervention groups designed to activate patients to talk with their primary care clinicians about thiazides and hypertension: group A (n = 143) received an activation letter, group B (n = 128) received a letter plus a financial incentive, and group C (n = 131) received a letter, financial incentive, and a telephone call encouraging patients to speak with their primary care clinicians.

Main Outcomes And Measures: Primary outcomes were thiazide prescribing and BP control. A secondary process measure was discussion between patient and primary care clinician about thiazides.

Results: Among 598 participants (588 men and 10 women), the mean (SD) age for the combined intervention groups (n = 402) was 62.9 (8.8) years, and the mean baseline BP was 148.1/83.8 mm Hg; the mean (SD) age for the control group (n = 196) was 64.1 (9.2) years, and the mean baseline BP was 151.0/83.4 mm Hg. At index visits, the unadjusted rate of thiazide prescribing was 9.7% for the control group (19 of 196) and 24.5% (35 of 143) for group A, 25.8% (33 of 128) for group B, and 32.8% (43 of 131) for group C (P < .001). Adjusted analyses demonstrated an intervention effect on thiazide prescribing at the index visit and 6-month visit, which diminished at the 12-month visit. For BP control, there was a significant intervention effect at the 12-month follow-up for group C (adjusted odds ratio, 1.73; 95% CI, 1.06-2.83; P = .04). Intervention groups exhibited improved thiazide discussion rates in a dose-response fashion: group A, 44.1% (63 of 143); group B, 56.3% (72 of 128); and group C, 68.7% (90 of 131) (P = .004).

Conclusions And Relevance: This patient activation intervention about thiazides for hypertension resulted in two-thirds of patients having discussions and nearly one-third initiating a prescription of thiazide. Adding a financial incentive and telephone call to the letter resulted in incremental improvements in both outcomes. By 12 months, improved BP control was also evident. This low-cost, low-intensity intervention resulted in high rates of discussions between patients and clinicians and subsequent thiazide treatment and may be used to promote evidence-based guidelines and overcome clinical inertia.

Trial Registration: ClinicalTrials.gov Identifier: NCT00265538.
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http://dx.doi.org/10.1001/jamanetworkopen.2018.5017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6324341PMC
December 2018

An automated computerized critical illness severity scoring system derived from APACHE III: modified APACHE.

J Crit Care 2018 12 6;48:237-242. Epub 2018 Sep 6.

Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA.

Purpose: To evaluate the performance of an automated computerized ICU severity scoring derived from the APACHE III.

Materials And Methods: Within a retrospective cohort of patients admitted to Veterans Health Administration ICUs between 2009 and 2015, we created an automated illness severity score(modified APACHE or mAPACHE), that we extracted from the electronic health records, using the same scoring as the APACHE III excluding the Glasgow Coma Scale, urine output, arterial blood gas components of APACHE III. We assessed the mAPACHE discrimination by using the area under the curve(AUC), and calibration by using the Hosmer-Lemeshow test and calculating the difference between observed and expected mortality across equal-sized risk deciles for death.

Results: The ICU and 30-day mortality was 5.07% of 7.82%, respectively (n = 490,955 patients). The AUC of mAPACHE for ICU and 30-day mortality was 0.771 and 0.786, respectively. The Hosmer-Lemeshow test was significant for both ICU and 30-day mortality (p < .001). The absolute difference between observed and expected mortality did not exceed ±1.53% across equal-sized deciles of risk for death. The AUC for ICU mortality was >0.7 in all admission diagnosis categories except in endocrine, respiratory, and sepsis. The AUC for 30-day mortality was >0.7 in every category.

Conclusion: mAPACHE has adequate performance to predict mortality.
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http://dx.doi.org/10.1016/j.jcrc.2018.09.005DOI Listing
December 2018

Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study.

BMJ Qual Saf 2018 12 20;27(12):954-964. Epub 2018 Aug 20.

Department of Medicine and Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee, USA.

Background: Unintentional discrepancies across care settings are a common form of medication error and can contribute to patient harm. Medication reconciliation can reduce discrepancies; however, effective implementation in real-world settings is challenging.

Methods: We conducted a pragmatic quality improvement (QI) study at five US hospitals, two of which included concurrent controls. The intervention consisted of local implementation of medication reconciliation best practices, utilising an evidence-based toolkit with 11 intervention components. Trained QI mentors conducted monthly site phone calls and two site visits during the intervention, which lasted from December 2011 through June 2014. The primary outcome was number of potentially harmful unintentional medication discrepancies per patient; secondary outcome was total discrepancies regardless of potential for harm. Time series analysis used multivariable Poisson regression.

Results: Across five sites, 1648 patients were sampled: 613 during baseline and 1035 during the implementation period. Overall, potentially harmful discrepancies did not decrease over time beyond baseline temporal trends, adjusted incidence rate ratio (IRR) 0.97 per month (95% CI 0.86 to 1.08), p=0.53. The intervention was associated with a reduction in total medication discrepancies, IRR 0.92 per month (95% CI 0.87 to 0.97), p=0.002. Of the four sites that implemented interventions, three had reductions in potentially harmful discrepancies. The fourth site, which implemented interventions and installed a new electronic health record (EHR), saw an increase in discrepancies, as did the fifth site, which did not implement any interventions but also installed a new EHR.

Conclusions: Mentored implementation of a multifaceted medication reconciliation QI initiative was associated with a reduction in total, but not potentially harmful, medication discrepancies. The effect of EHR implementation on medication discrepancies warrants further study.

Trial Registration Number: NCT01337063.
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http://dx.doi.org/10.1136/bmjqs-2018-008233DOI Listing
December 2018

Using Video Telehealth to Facilitate Inhaler Training in Rural Patients with Obstructive Lung Disease.

Telemed J E Health 2019 03 17;25(3):230-236. Epub 2018 Jul 17.

1 Health Services Research and Development (HSR&D), Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington.

Background: Proper inhaler technique is important for effective drug delivery and symptom control in chronic obstructive pulmonary disease (COPD) and asthma, yet not all patients receive inhaler instructions.

Introduction: Using a retrospective chart review of participants in a video telehealth inhaler training program, the study compared inhaler technique within and between monthly telehealth visits and reports associated with patient satisfaction.

Materials And Methods: Seventy-four (N = 74) rural patients prescribed ≥1 inhaler participated in three to four pharmacist telehealth inhaler training sessions using teach-to-goal (TTG) methodology. Within and between visit inhaler technique scores are compared, with descriptive statistics of pre- and postprogram survey results including program satisfaction and computer technical issues. Healthcare utilization is compared between pre- and post-training periods.

Results: Sixty-nine (93%) patients completed all three to four video telehealth inhaler training sessions. During the initial visit, patients demonstrated improvement in inhaler technique for metered dose inhalers (albuterol, budesonide/formoterol), dry powder inhalers (formoterol, mometasone, tiotropium), and soft mist inhalers (ipratropium/albuterol) (p < 0.01 for all). Improved inhaler technique was sustained at 2 months (p < 0.01). Ninety-four percent of participants were satisfied with the program. Although technical issues were common, occurring among 63% of attempted visits, most of these visits (87%) could be completed. There was no significant difference in emergency department visits and hospitalizations pre- and post-training.

Discussion: This study demonstrated high patient acceptance of video telehealth training and objective improvement in inhaler technique.

Conclusions: Video telehealth inhaler training using the TTG methodology is a promising program that improved inhaler technique and access to inhaler teaching for rural patients with COPD or asthma.
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http://dx.doi.org/10.1089/tmj.2017.0330DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6916242PMC
March 2019
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