Introduction

To improve the health of overweight and obese veterans, the Department of Veterans Affairs (VA) developed the MOVE! Weight Management Program for Veterans. The aim of this evaluation was to assess its reach and effectiveness.

Methods

We extracted data on program involvement, demographics, medical conditions, and outcomes from VA administrative databases in 4 Western states. Eligibility criteria for MOVE! were being younger than 70 years and having a body mass index (BMI, in kg/m2) of at least 30.0, or 25.0 to 29.9 with an obesity-related condition. To evaluate reach, we estimated the percentage of eligible veterans who participated in the program and their representativeness. To evaluate effectiveness, we estimated changes in weight and BMI using multivariable linear regression.

Results

Less than 5% of eligible veterans participated, of whom half had only a single encounter. Likelihood of participation was greater in women, those with a higher BMI, and those with more primary care visits, sleep apnea, or a mental health condition. Likelihood of participation was lower among those who were younger than 55 (vs 55-64), widowed, current smokers, and residing farther from the medical center (≥30 vs <30 miles). At 6- and 12-month follow-up, participants lost an average of 1.3 lb (95% confidence interval [CI], −2.6 to −0.02 lb) and 0.9 lb (95% CI, −2.0 to 0.1 lb) more than nonparticipants, after covariate adjustment. More intensive treatment (≥6 encounters) was associated with greater weight loss at 12 months (−3.7 lb; 95% CI, −5.1 to −2.3 lb).

Conclusion

Few eligible patients participated in the program during the study period, and overall estimates of effectiveness were low.

BACKGROUND

The VHA is the largest integrated US health system and is increasingly moving care into the communities where veterans reside. Veterans who utilize the VA for their care have worse health status than the general population. However, there is limited evidence about the association of neighborhood environment and health outcomes among veterans.

OBJECTIVES

The primary aim of this study is to assess the relative contribution of neighborhood environment, health system, and individual characteristics to health status and mortality of veterans.

METHODS

Information on personal socio-economic indicators, existing medical conditions and health status were obtained from baseline data from a multi-site, randomized trial of primary care patients (n = 15,889). The physical component scale (PCS) and mental component scale (MCS) summarized health status. Census tracts were used as proxies for neighborhoods. A summary score based on census tract data characterized the neighborhood socio-economic environment and walkability. Data were analyzed with multilevel hierarchical models. Analyses of health status were cross-sectional. Mortality analyses were longitudinal as participants were followed for an average of 722.5 days to ascertain vital status.

RESULTS

Neighborhood SES was associated with PCS and MCS scores, controlling for individual socio-economic status, self-reported co-morbid disease, smoking status, and health care access. In the lowest versus highest quartiles of neighborhood SES, adjusted PCS scores were 34.4 vs. 35.4 (p < 0.05) and adjusted MCS scores were 46.2 versus 47.0 (p < 0.05). PCS score was also significantly associated with neighborhood walkability (p < 0.05). Mortality was lower for veterans living in neighborhoods with the highest decile neighborhood SES (HR 0.78, highest vs. lowest decile 95% CI 0.63, 0.97).

CONCLUSIONS

Veterans living in lower SES neighborhoods have poorer health status and a higher risk of mortality, independent of individual characteristics and health care access. Neighborhood walkability was associated with higher PCS scores.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-011-1710-0) contains supplementary material, which is available to authorized users.

Background

High-quality systems have adopted a comprehensive approach to preventive care instead of diagnosis or procedure driven care. The current emphasis on prescribing medications to prevent complications of coronary artery disease (CAD) at discharge following an acute coronary syndrome (ACS) may exclude high-risk patients who are hospitalized with conditions other than ACS.

Methods

Among a sample of patients with CAD treated at Veterans Affairs medical centers between January, 2005 and November, 2006, we investigated whether recent non-ACS hospitalization was associated with prescriptions of preventive medications as compared with patients recently hospitalized with ACS.

Results

Of 13,211 patients with CAD, 58% received aspirin, 70% β-blocker, 60% angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB), and 65% lipid-lowering therapy. Twenty-five percent of eligible patients were receiving all four medications. Having been hospitalized for a non-ACS event in the prior 6 months did not substantially affect the adjusted proportion on preventive medications. In contrast, among patients hospitalized for ACS in the prior 6 months, the adjusted proportion prescribed aspirin was 21% higher (p < 0.001), β-blocker was 14% higher (p < 0.001), ACE-I or ARB was 9% higher (p < 0.001), lipid therapy was 12% higher (p < 0.001), and prescribed all four medications was 18% higher (p < 0.001) than among patients hospitalized for ACS more than 2 years earlier.

Conclusions

Being hospitalized for a non-ACS condition did not appear to influence preventive medication use among patients with CAD and represents a missed opportunity to improve patient care. The same protocols employed to improve use of preventive medications in patients discharged for ACS might be extended to CAD patients discharged for other conditions as well.

Background

The Centers for Medicare and Medicaid Services publicly-reports hospital-specific risk-standardized, 30-day, all-cause, mortality rates (RSMRs) for all hospitalizations among fee-for-service Medicare beneficiaries for acute myocardial infarction (AMI), heart failure (HF), and pneumonia at non-Federal hospitals.

Objective

To examine the performance of the statistical models used by CMS among veterans at least 65 years of age hospitalized for AMI, HF, and pneumonia in Veterans Health Administration (VHA) hospitals.

Research Design

Cross-sectional analysis of VHA administrative claims data between October 1, 2006 and September 30, 2009.

Subjects

13,046 veterans hospitalized for AMI among 123 VHA hospitals; 26,379 veterans hospitalized for HF among 124 VHA hospitals; and 31,126 veterans hospitalized for pneumonia among 124 VHA hospitals.

Measures

Hospital-specific RSMR for AMI, HF, and pneumonia hospitalizations calculated using hierarchical generalized linear models.

Results

Median number of AMI hospitalizations per VHA hospital was 87. Average AMI RSMR was 14.3% (95% Confidence Interval (CI), 13.9%-14.6%) with modest heterogeneity among VHA hospitals (RSMR range: 8.4%-20.3%). The c-statistic for the AMI RSMR statistical model was 0.79. Median number of HF hospitalizations was 188. Average HF RSMR was 10.1% (95% CI, 9.9%-10.4%) with modest heterogeneity (RSMR range: 6.1%-14.9%). The c-statistic for the HF RSMR statistical model was 0.73. Median number of pneumonia hospitalizations was 221.5 Average pneumonia RSMR was 13.0% (95% CI, 12.7%-13.3%) with modest heterogeneity (RSMR range: 9.0%-18.4%). The c-statistic for the pneumonia RSMR statistical model was 0.72.

Conclusions

The statistical models used by CMS to estimate RSMRs for AMI, HF, and pneumonia hospitalizations at non-Federal hospitals demonstrate similar discrimination when applied to VHA hospitals.

Objective

This study aimed to examine factors other than estrogen deficiency influencing the development and persistence of vaginal dryness, itching, and painful sexual intercourse after menopause.

Methods

We analyzed data from a 2-year, population-based cohort of 1,017 postmenopausal women aged 55 to 75 years. Vaginal symptoms were assessed by interviewer-administered questionnaire, and vaginal swabs were performed to assess vaginal pH and microbial flora at baseline, 12 months, and 24 months. Generalized estimating equations were used to identify characteristics associated with symptoms.

Results

Half of the women (n = 471) reported problematic vaginal dryness, a third (n = 316) reported itching, and 40% of sexually active women (n = 166) reported painful intercourse at baseline. Of women not taking estrogen, half of those reporting baseline symptoms were symptomatic after 24 months. Vaginal dryness was associated with younger age (odds ratio [OR], 0.81; 95% CI, 0.69–0.94, per 5-y increase), nonwhite race (ie, African American, Hispanic, Asian or Pacific Islander, or American Indian [OR, 1.53; 95% CI, 1.04–2.27]), diabetes (OR, 1.51; 95% CI, 1.07–2.12), lower 36-item Short-Form Health Survey physical functioning scores (OR, 0.90; 95% CI, 0.85–0.97, per 10-point increase), lower body mass index (OR, 0.81; 95% CI, 0.71–0.93, per 5 kg/m2 increase), recent sexual activity (OR, 1.14; 95% CI, 1.08–1.21), and vaginal colonization with enterococci (OR, 1.25; 95% CI, 1.04–1.51). Vaginal itching was also associated with lower physical functioning scores (OR, 0.86; 95% CI, 0.80–0.92, per 10-point increase). Risk factors for painful intercourse included younger age (OR, 0.72; 95% CI, 0.56–0.93, per 5-y increase), diabetes (OR, 3.48; 95% CI, 1.93–6.27), lower body mass index (OR, 0.76; 95%CI, 0.61–0.95, per 5 kg/m2 increase), and higher vaginal pH (OR, 1.10; 95% CI, 1.00–1.21, per 0.5 units).

Conclusions

Vaginal symptoms affect a large proportion of postmenopausal women, particularly those with diabetes and those with lower body mass index, but may resolve for up to half of women without estrogen therapy.

The VA Cardiovascular Assessment, Reporting, and Tracking (CART) system is a customized electronic medical record system which provides standardized report generation for cardiac catheterization procedures, serves as a national data repository, and is the centerpiece of a national quality improvement program. Like many health information technology projects, CART implementation did not proceed without some barriers and resistance. We describe the nationwide implementation of CART at the 77 VA hospitals which perform cardiac catheterizations in three phases: (1) strategic collaborations; (2) installation; and (3) adoption. Throughout implementation, success required a careful balance of technical, clinical, and organizational factors. We offer strategies developed through CART implementation which are broadly applicable to technology projects aimed at improving the quality, reliability, and efficiency of health care.

OBJECTIVE—To compare the ability of generic comorbidity and risk adjustment measures, a diabetes-specific measure, and a self-reported functional status measure to explain variation in health care expenditures for individuals with diabetes.

RESEARCH DESIGN AND METHODS—This study included a retrospective cohort of 3,092 diabetic veterans participating in a multisite trial. Two comorbidity measures, four risk adjusters, a functional status measure, a diabetes complication count, and baseline expenditures were constructed from administrative and survey data. Outpatient, inpatient, and total expenditure models were estimated using ordinary least squares regression. Adjusted R2 statistics and predictive ratios were compared across measures to assess overall explanatory power and explanatory power of low- and high-cost subgroups.

RESULTS—Administrative data–based risk adjusters performed better than the comorbidity, functional status, and diabetes-specific measures in all expenditure models. The diagnostic cost groups (DCGs) measure had the greatest predictive power overall and for the low- and high-cost subgroups, while the diabetes-specific measure had the lowest predictive power. A model with DCGs and the diabetes-specific measure modestly improved predictive power.

CONCLUSIONS—Existing generic measures can be useful for diabetes-specific research and policy applications, but more predictive diabetes-specific measures are needed.

Background

Mortality from acute myocardial infarction (AMI) is declining worldwide. We sought to determine if mortality in the Veterans Health Administration (VHA) has also been declining.

Methods

We calculated 30-day mortality rates between 2004 and 2006 using data from the VHA External Peer Review Program (EPRP), which entails detailed abstraction of records of all patients with AMI. To compare trends within VHA with other systems of care, we estimated relative mortality rates between 2000 and 2005 for all males 65 years and older with a primary diagnosis of AMI using administrative data from the VHA Patient Treatment File and the Medicare Provider Analysis and Review (MedPAR) files.

Results

Using EPRP data on 11,609 patients, we observed a statistically significant decline in adjusted 30-day mortality following AMI in VHA from 16.3% in 2004 to 13.9% in 2006, a relative decrease of 15% and a decrease in the odds of dying of 10% per year (p = .011). Similar declines were found for in-hospital and 90-day mortality.

Based on administrative data on 27,494 VHA patients age 65 years and older and 789,400 Medicare patients, 30-day mortality following AMI declined from 16.0% during 2000-2001 to 15.7% during 2004-June 2005 in VHA and from 16.7% to 15.5% in private sector hospitals. After adjusting for patient characteristics and hospital effects, the overall relative odds of death were similar for VHA and Medicare (odds ratio 1.02, 95% C.I. 0.96-1.08).

Conclusion

Mortality following AMI within VHA has declined significantly since 2003 at a rate that parallels that in Medicare-funded hospitals.

Objective

Identify and describe interventions to reduce time to reperfusion for patients with ST-segment elevation myocardial infarction (STEMI).

Data Source

Key word searches of five research databases: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Web of Science, and Cochrane Clinical Trials Registry.

Interventions

We included controlled and uncontrolled studies of interventions to reduce time to reperfusion. One researcher reviewed abstracts and 2 reviewed full text articles. Articles were subsequently abstracted into structured data tables, which included study design, setting, intervention, and outcome variables. We inductively developed intervention categories from the articles. A second researcher reviewed data abstraction for accuracy.

Measurements and Main Results

We identified 666 articles, 42 of which met inclusion criteria. We identified 11 intervention categories and classified them as either process specific (e.g., emergency department administration of thrombolytic therapy, activation of the catheterization laboratory by emergency department personnel) or system level (e.g., continuous quality improvement, critical pathways). A majority of studies (59%) were single-site pre/post design, and nearly half (47%) had sample sizes less than 100 patients. Thirty-two studies (76%) reported significantly lower door to reperfusion times associated with an intervention, 12 (29%) of which met or exceeded guideline recommended times. Relative decreases in times to reperfusion ranged from 15 to 82% for door to needle and 13–64% for door to balloon.

Conclusions

We identified an array of process and system-based quality improvement interventions associated with significant improvements in door to reperfusion time. However, weak study designs and inadequate information about implementation limit the usefulness of this literature.

Electronic supplementary materials

The online version of this article (doi:10.1007/s11606-008-0563-7) contains supplementary material, which is available to authorized users.

ABSTRACT

Background

Sexual intercourse increases the risk of symptomatic urinary tract infections (UTI) in young women, but its role among post-menopausal women is unclear.

Objective

To determine whether recent sexual intercourse, as documented by daily diaries, is associated with an increased risk of symptomatic UTI in post-menopausal women.

Design

A 2-year prospective cohort study conducted from 1998 to 2002.

Participants

One thousand and seventeen randomly selected post-menopausal women enrolled at Group Health Cooperative (GHC), a Washington State HMO.

Measurements and Main Results

Women were asked to enter daily diary information on vaginal intercourse, medication use, and genito-urinary symptoms. The outcome of interest, symptomatic UTI, was defined as a positive urine culture ≥105 CFU/mL of a uropathogen and the presence of ≥2 acute urinary symptoms. Nine hundred thirteen women returned diaries and were included in this study. Seventy-eight women experienced 108 symptomatic UTIs, and 361 (40%) reported sexual intercourse in their diaries. There was an increased hazard for UTI 2 calendar days after the reporting of sexual intercourse in the diaries (adjusted hazard ratio [HR], 3.42, 95% CI 1.49–7.80), while there was no evidence for an increased hazard associated with intercourse at other times. When the UTI criterion was relaxed from ≥105 CFU/mL to ≥104 CFU/mL, adding 9 UTI events to the analysis, the HR for UTI 2 days after intercourse changed slightly to 3.26 (95% CI 1.43–7.43).

Conclusions

Our data suggest that, as with younger women, recent sexual intercourse is strongly associated with incident UTI in generally healthy post-menopausal women.

Background

In the United States, relatively little is known about cause of death in individuals who die prior to or after hospital discharge for acute coronary syndromes (ACS). The purpose of this report was to compare baseline patient characteristics according to whether the underlying cause of death was cardiac or non-cardiac.

Methods

We linked cause of death information from Washington State death records to the Department of Veterans Affairs (VA) External Peer Review Program ACS registry. From 524 individuals who were hospitalized for ACS in veterans hospitals located in Washington State or Oregon, we identified 136 individuals who according to VA death records died during the years 2003 to 2005. Of these, 117 (86%) were found in Washington State death records. Sociodemographic variables, as well as underlying and secondary causes of death, were obtained from Washington State death records provided by the Washington State Department of Health. Clinical variables, including medical histories, presentation on admission, and in-hospital death were extracted from the VA ACS registry.

Results

Somewhat surprisingly, only 52% of veterans died of cardiac causes when only the underlying cause of death was used. However, when secondary causes of death were added to the definition, the proportion that died of cardiac causes increased to 81%. Patient characteristics were similar in the two groups, although small numbers limited the ability to detect statistically significant differences.

Conclusion

These preliminary findings suggest that it is important to consider secondary causes as well as the underlying one when classifying deaths as cardiac or non-cardiac.

Background

Severe mental illness (SMI) has been associated with more medical co-morbidity and less cardiovascular procedure use for older patients with myocardial infarction. However, it is unknown whether SMI is associated with increased long term mortality risk among patients presenting with acute coronary syndromes (ACS). We tested the hypothesis that SMI is associated with higher one-year mortality following ACS hospitalization.

Methods

All ACS patients (n = 14,194) presenting to Veterans Health Administration (VHA) hospitals between October 2003 and September 2005 were included. Survival analysis evaluated the association between SMI and one-year all-cause mortality, adjusting for demographics, co-morbidities, in-hospital treatment, and discharge medications.

Results

Overall, 18.4 % of ACS patients had SMI. Patients with SMI were more likely female, younger, Caucasian race, have a history of alcohol abuse, liver disease, dementia, hypertension and more likely to be a current smoker; however, prior cardiac history was similar between the 2 groups. There were no significant differences in cardiac procedure use, including coronary angiogram (38.7% vs. 40.3%, p = 0.14) or coronary revascularization (31.0% vs. 32.3%, p = 0.19), and discharge medications between those with and without SMI. One-year mortality was lower for patients with SMI (15.8% vs. 19.1%, p < 0.001). However, in multivariable analysis, there were no significant differences in mortality (HR 0.91; 95% CI 0.81–1.02) between patients with and without SMI.

Conclusion

Among ACS patients in the VHA, SMI is prevalent, affecting almost 1 in 5 patients. However, patients with SMI were as likely to undergo coronary revascularization and be prescribed evidence-based medications at hospital discharge, and were not at elevated risk of adverse 1-year outcomes compared to patients without SMI.

Objective

We compared single- and multi-item measures of general self-rated health (GSRH) to predict mortality and clinical events a large population of veteran patients.

Data Source/Study Setting

We analyzed prospective cohort data collected from 21,732 patients as part of the Veterans Affairs Ambulatory Care Quality Improvement Project (ACQUIP), a randomized controlled trial investigating quality-of-care interventions.

Study Design

We created an age-adjusted, logistic regression model for each predictor and outcome combination, and estimated the odds of events by response category of the GSRH question and compared the discriminative ability of the predictors by developing receiver operator characteristic curves and comparing the associated area under the curve (AUC)/c-statistic for the single- and multi-item measures.

Data Collection/Extraction Methods

All patients were sent a baseline assessment that included a multi-item measure of general health, the 36-item Medical Outcomes Study Short Form (SF-36), and an inventory of comorbid conditions. We compared the predictive and discriminative ability of the GSRH to the SF-36 physical component score (PCS), the mental component score (MCS), and the Seattle index of comorbidity (SIC). The GSRH is an item included in the SF-36, with the wording: “In general, would you say your health is: Excellent, Very Good, Good, Fair, Poor?”

Principal Findings

The GSRH, PCS, and SIC had comparable AUC for predicting mortality (AUC 0.74, 0.73, and 0.73, respectively); hospitalization (AUC 0.63, 0.64, and 0.60, respectively); and high outpatient use (AUC 0.61, 0.61, and 0.60, respectively). The MCS had statistically poorer discriminatory performance for mortality and hospitalization than any other other predictors (p<.001).

Conclusions

The GSRH response categories can be used to stratify patients with varying risks for adverse outcomes. Patients reporting “poor” health are at significantly greater odds of dying or requiring health care resources compared with their peers. The GSRH, collectable at the point of care, is comparable with longer instruments.

Objective

To evaluate the performance of different prospective risk adjustment models of outpatient, inpatient, and total expenditures of veterans who regularly use Veterans Affairs (VA) primary care.

Data Sources

We utilized administrative, survey and expenditure data on 14,449 VA patients enrolled in a randomized trial that gave providers regular patient health assessments.

Study Design

This cohort study compared five administrative data-based, two self-report risk adjusters, and base year expenditures in prospective models.

Data Extraction Methods

VA outpatient care and nonacute inpatient care expenditures were based on unit expenditures and utilization, while VA expenditures for acute inpatient care were calculated from a Medicare-based inpatient cost function. Risk adjusters for this sample were constructed from diagnosis, medication and self-report data collected during a clinical trial. Model performance was compared using adjusted R2 and predictive ratios.

Principal Findings

In all expenditure models, administrative-based measures performed better than self-reported measures, which performed better than age and gender. The Diagnosis Cost Groups (DCG) model explained total expenditure variation (R2=7.2 percent) better than other models. Prior outpatient expenditures predicted outpatient expenditures best by far (R2=42 percent). Models with multiple measures improved overall prediction, reduced over-prediction of low expenditure quintiles, and reduced under-prediction in the highest quintile of expenditures.

Conclusions

Prediction of VA total expenditures was poor because expenditure variation reflected utilization variation, but not patient severity. Base year expenditures were the best predictor of outpatient expenditures and nearly the best for total expenditures. Models that combined two or more risk adjusters predicted expenditures better than single-measure models, but are more difficult and expensive to apply.

Background

It is uncertain whether black white differences in the use of percutaneous coronary intervention (PCI) persist in the era of drug eluting stents. The purpose of this study is to determine if black veterans with acute myocardial infarction (AMI) are less likely to receive PCI than their white counterparts.

Methods

This study included 680 black and 3529 white veterans who were admitted to Veterans Health Administration (VHA) medical centers between July 2003 and August 2004. Information for this study was collected as part of the VHA External Peer Review Program for quality monitoring and improvement for a variety of medical conditions and procedures, including AMI. In addition, Department of Veterans Affairs workload files were used to determine PCI utilization after hospital discharge. Standard statistical methods including the Chi-square, 2 sample t-test, and logistic regression with a cluster correction for medical center were used to assess the association between race and the use of PCI ≤ 30 days from admission.

Results

Black patients were younger, more often had diabetes mellitus, renal disease, or dementia and less often had lipid disorders, previous coronary artery bypass surgery, or chronic obstructive pulmonary disease than their white counterparts. Equal proportions of blacks and whites underwent cardiac catheterization ≤ 30 days after admission, but the former were less likely to undergo PCI (32% vs. 40%, p < 0.0001). This difference persisted after multivariate adjustment, although measures of the extent of coronary artery disease were not available.

Conclusion

Given the equivalent use of cardiac catheterization, it is possible that less extensive or minimal coronary artery disease in black patients could account for the observed difference.

OBJECTIVE

To determine the extent to which chronic illness and disease severity affect patient satisfaction with their primary care provider in general internal medicine clinics.

DESIGN

Cross-sectional mailed questionnaire study.

SETTING

Primary care clinics at 7 Veterans Affairs medical centers.

PATIENTS/PARTICIPANTS

Of 62,487 patients participating in the Ambulatory Care Quality Improvement Project, 35,383 (57%) returned an initial screening questionnaire and were subsequently sent a satisfaction questionnaire. Patients (N=21,689; 61%) who returned the Seattle Outpatient Satisfaction Survey (SOSQ) were included in the final analysis, representing 34% of the original sample.

MEASUREMENTS AND MAIN RESULTS

The organizational score of the SOSQ measures satisfaction with health care services in the internal medicine clinic, and the humanistic scale measures patient satisfaction with the communication skills and humanistic qualities of the primary care physician. For ischemic heart disease (IHD), chronic obstructive pulmonary disease (COPD), and diabetes, patient ability to cope with their disease was more strongly associated with patient satisfaction than disease severity. Among IHD patients, improvement in ability to cope emotionally with their angina was associated with higher SOSQ organizational scores (standardized β=0.18; P<.001) but self-reported physical limitation due to angina was not (β=0.01; P=.65). Similarly, in COPD, improved ability to cope with dyspnea was associated with greater organizational scores (β=0.11; P<.001) but physical function was not (β=−0.03; P=.27). For diabetes, increased education was associated with improved organizational scores (β=0.31; P<.001) but improvement in symptom burden was not (β=0.03; P=.14). Similar results were seen with prediction of SOSQ humanistic scores.

CONCLUSIONS

Patient education and ability to cope with chronic conditions are more strongly associated with satisfaction with their primary care provider than disease severity. Further improvements in patient education and self-management may lead to improved satisfaction and quality of care.

OBJECTIVE

The patient-clinician relationship is a central feature of primary care, and recent developments in the delivery of health care have tended to limit continuity of care. The objective of this study was to evaluate the extent to which continuity of care and other factors are related to patient satisfaction.

DESIGN

Cross-sectional, mailed questionnaire study.

SETTING

Primary care clinics at 7 Veterans Affairs medical centers.

PATIENTS/PARTICIPANTS

Patients (N=21,689) participating in the Ambulatory Care Quality Improvement Project who returned the baseline Seattle Outpatient Satisfaction Questionnaire (SOSQ).

MEASUREMENTS AND MAIN RESULTS

We evaluated the association between self-reported continuity and satisfaction, after adjusting for characteristics of patients, clinics, and providers. The humanistic scale of the SOSQ measures patient satisfaction with communication skills and humanistic qualities of providers, whereas the organizational scale measures satisfaction with delivery of health care services. The mean adjusted humanistic score for patients who reported always seeing the same provider was 17.3 (95% confidence interval [CI], 15.5 to 19.1) points higher than for those who rarely saw the same provider. Similarly, the mean adjusted organizational score was 16.3 (95% CI, 14.5 to 18.1) points higher for patients who always saw the same provider compared to rarely. Demographic factors, socioeconomic status, health status, clinic site, and patient utilization of services were all associated with both the adjusted humanistic and organizational scores of the SOSQ.

CONCLUSIONS

Self-reported continuity of care is strongly associated with higher patient satisfaction. This suggests that improving continuity of care may improve patient satisfaction with providers as well as with their health care organization.

The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The task force believes that the chaos and dysfunction that characterize today's medical care, and the challenges facing general internal medicine, should spur innovation. These are our recommendations: while remaining true to its core values and competencies, general internal medicine should stay both broad and deep—ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care their teams give, embrace changes in information systems, and aim to provide most of the care their patients require. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency, and provide comprehensive, ongoing care. General internal medicine residency training should be reformed to provide both broad and deep medical knowledge, as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification (CAQ) in special generalist fields. Research will expand to include practice and operations management, developing more effective shared decision making and transparent medical records, and promoting the close personal connection that both doctors and patients want. We believe these changes constitute a paradigm shift that can benefit patients and the public and reenergize general internal medicine.

OBJECTIVE

Without clinical input on what constitutes a significant change, health-related quality of life (HRQoL) measures are less likely to be adopted by clinicians for use in daily practice. Although standards can be determined empirically by within-person change studies based on patient self-reports, these anchor-based methods incorporate only the patients' perspectives of important HRQoL change, and do not reflect an informed clinical evaluation. The objective of this study was to establish clinically important difference standards from the physician's perspective for use of 2 HRQoL measures among patients with chronic obstructive pulmonary disease (COPD).

DESIGN

We assembled a 9-person expert panel of North American physicians familiar with the use of the Chronic Respiratory Questionnaire (CRQ), a disease-specific HRQoL measure, or the generic Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36, Version 2.0) among patients with COPD.

RESULTS

Using 2 rounds of the Delphi process, 1 in-person meeting, and an iterative improvement process for circulating and correcting the final report, the expert panel established small, moderate, and large clinically important change levels for the CRQ and SF-36.

CONCLUSIONS

For this expert physician panel, levels for detecting clinically important differences on the CRQ were equal to or slightly higher than previous studies based on patient-reported differences. Clinically important differences on the SF-36, Version 2.0, were noticeably larger than previous estimates based on cross-sectional differences between clinically defined patient groups.

OBJECTIVE

To compare collaborative care for treatment of depression in primary care with consult-liaison (CL) care. In collaborative care, a mental health team provided a treatment plan to the primary care provider, telephoned patients to support adherence to the plan, reviewed treatment results, and suggested modifications to the provider. In CL care, study clinicians informed the primary care provider of the diagnosis and facilitated referrals to psychiatry residents practicing in the primary care clinic.

DESIGN

Patients were randomly assigned to treatment model by clinic firm.

SETTING

VA primary care clinic.

PARTICIPANTS

One hundred sixty-eight collaborative care and 186 CL patients who met criteria for major depression and/or dysthymia.

MEASUREMENTS

Hopkins Symptom Checklist (SCL-20), Short Form (SF)-36, Sheehan Disability Scale.

MAIN RESULTS

Collaborative care produced greater improvement than CL in depressive symptomatology from baseline to 3 months (SCL-20 change scores), but at 9 months there was no significant difference. The intervention increased the proportion of patients receiving prescriptions and cognitive behavioral therapy. Collaborative care produced significantly greater improvement on the Sheehan at 3 months. A greater proportion of collaborative care patients exhibited an improvement in SF-36 Mental Component Score of 5 points or more from baseline to 9 months.

CONCLUSIONS

Collaborative care resulted in more rapid improvement in depression symptomatology, and a more rapid and sustained improvement in mental health status compared to the more standard model. Mounting evidence indicates that collaboration between primary care providers and mental health specialists can improve depression treatment and supports the necessary changes in clinic structure and incentives.

OBJECTIVE

This study describes primary care discussions with patients who screened positive for at-risk drinking. In addition, discussions about alcohol use from 2 clinic firms, one with a provider-prompting intervention, are compared.

DESIGN

Cross-sectional analyses of audiotaped appointments collected over 6 months.

PARTICIPANTS AND SETTING

Male patients in a VA general medicine clinic were eligible if they screened positive for at-risk drinking and had a general medicine appointment with a consenting provider during the study period. Participating patients (N = 47) and providers (N = 17) were enrolled in 1 of 2 firms in the clinic (Intervention or Control) and were blinded to the study focus.

INTERVENTION

Intervention providers received patient-specific results of positive alcohol-screening tests at each visit.

MEASURES AND MAIN RESULTS

Of 68 visits taped, 39 (57.4%) included any mention of alcohol. Patient and provider utterances during discussions about alcohol use were coded using Motivational Interviewing Skills Codes. Providers contributed 58% of utterances during alcohol-related discussions with most coded as questions (24%), information giving (23%), or facilitation (34%). Advice, reflective listening, and supportive or affirming statements occurred infrequently (5%, 3%, and 5%, of provider utterances respectively). Providers offered alcohol-related advice during 21% of visits. Sixteen percent of patient utterances reflected “resistance” to change and 12% reflected readiness to change. On average, Intervention providers were more likely to discuss alcohol use than Control providers (82.4% vs 39.6% of visits; P = .026).

CONCLUSIONS

During discussions about alcohol, general medicine providers asked questions and offered information, but usually did not give explicit alcohol-related advice. Discussions about alcohol occurred more often when providers were prompted.

Objective: To improve and simplify electronic order entry in an existing electronic patient record, the authors developed an alternative system for entering orders, which is based on a command- interface using robust and simple natural-language techniques.

Design: The authors conducted a randomized evaluation of the new entry pathway, measuring time to complete a standard set of orders, and users' satisfaction measured by questionnaire. A group of 16 physician volunteers from the staff of the Department of Veterans Affairs Puget Sound Health Care System–Seattle Division participated in the evaluation.

Results: Thirteen of the 16 physicians (81%) were able to enter medical orders more quickly using the natural-language–based entry system than the standard graphical user interface that uses menus and dialogs (mean time spared, 16.06 ± 4.52 minutes; P=0.029). Compared with the graphical user interface, the command-–based pathway was perceived as easier to learn (P<0.01), was considered easier to use and faster (P<0.01), and was rated better overall (P<0.05).

Conclusion: Physicians found the command- interface easier to learn and faster to use than the usual menu-driven system. The major advantage of the system is that it combines an intuitive graphical user interface with the power and speed of a natural-language analyzer.

OBJECTIVE

In 1996, the Health Care Financing Administration (HCFA) introduced new evaluation and management (E&M) guidelines mandating more intensive supervision and documentation by attending physicians. We assessed the effects of the guidelines on inpatient teaching.

DESIGN

Pretest-posttest, nonequivalent control group design.

SETTING

A university hospital and an affiliated county hospital where the guidelines were implemented and an affiliated VA medical center where they were not.

PARTICIPANTS

Sixty-one full-time faculty who had attended on the general medical wards for at least 1 month for 2 of 3 consecutive years prior to July 1996 and for at least 1 month during the 18 following months.

MEASUREMENTS AND MAIN RESULTS

We evaluated standardized, confidential evaluations of attending physicians that are routinely completed by residents and students after clinical rotations at all three sites. Comparing 863 evaluations completed before July 1, 1996 and 497 completed after that date, there were no significant differences at any of the hospitals on any items assessed. There were also no differences between the university and county hospitals as compared with the VA. Eighty-seven percent of 39 university and county attending physicians returned a survey about their perceptions of inpatient teaching activities before and after July 1, 1996. They reported highly significant increases in time devoted to attending responsibilities but diminished time spent on teaching activities.

CONCLUSIONS

Physicians reported a dramatic increase in overall time spent attending but a decrease in time spent teaching following implementation of the revised E&M guidelines. Yet, evaluations of their teaching effectiveness did not change.

Accurately recognizing the learning goals of trainees should enhance teachers' effectiveness. We sought to determine how commonly such recognition occurs and whether it improves residents' satisfaction with the teaching interaction. In a cross-sectional survey of 97 internal medicine residents and 42 ambulatory clinic preceptors in five ambulatory care clinics in Washington and Oregon, we systematically sampled 236 dyadic teaching interactions. Each dyad participant independently indicated the residents' perceived learning needs from a standardized list. Overall, the preceptors' recognition of the residents' learning needs, as measured by percentage of agreement between preceptors and residents on the learning topics, was modest (κ 0.21, p = .02). The percentage of agreement for all topics was 43%, ranging from 8% to 66%. Greater time pressures were associated with lower agreement (38% vs 56% for the highest and lowest strata of resident-reported time pressure; 15% vs 43% for highest and lowest strata of preceptor-reported time pressure). Agreement increased as the number of sessions the pair had worked together increased (62% for pairs with >20 vs 17% for pairs with 0 previous sessions). Satisfaction with teaching encounters was high (4.5 on a 5-point scale) and unrelated to the degree of agreement (p = .92). These findings suggest that faculty development programs should emphasize precepting skills in recognizing residents' perceived learning needs and that resident clinics should be redesigned to maximize preceptor-resident continuity and minimize time pressure.