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1.  Barriers to physical activity and healthy eating in young breast cancer survivors: modifiable risk factors and associations with body mass index 
Physical activity (PA) and healthy eating (HE) are important behaviors to encourage in breast cancer survivors (BCS). We examined associations between various factors and barriers to PA (BPA) and barriers to HE (BHE), as well as relationships between barriers and body mass index (BMI) in younger BCS.
Self-reported data from 162 BCS (mean age 48 years) were used. BPA were assessed with a 21-item scale and BHE with a 19-item scale. Participants were classified as high or low on each scale. Sociodemographic, medical, and psychosocial characteristics were compared by high/low barriers. Correlates of continuous BPA and BHE were assessed as were associations between BHE, BPA and BMI.
61% of participants were characterized as having low BHE and low BPA; 12% were high for both. High BHE/High BPA participants had the least favorable scores for depression, perceived stress, social support, fatigue, bladder control, and weight problems. Factors associated with BHE were lower education, higher perceived stress, and more severe weight problems. Factors associated with BPA were more severe bladder control problems and lower physical well-being. Higher BHE and BPA were significantly and uniquely associated with higher BMI, controlling for covariates.
Several biopsychosocial factors (e.g., depression, stress, fatigue) characterize young BCS who experience barriers to both HE and PA. The correlates of BHE and BPA are distinct. Both BHE and BPA are associated with BMI. These results should be considered in designing interventions for younger women with breast cancer.
PMCID: PMC4318837  PMID: 24177756
breast cancer; survivorship; diet; physical activity; obesity
2.  Publishing Protocols for Partnered Research 
Journal of General Internal Medicine  2014;29(Suppl 4):820-824.
Published scientific protocols are advocated as a means of controlling bias in research reporting. Indeed, many journals require a study protocol with manuscript submission. However, publishing protocols of partnered research (PPR) can be challenging in light of the research model’s dynamic nature, especially as no current reporting standards exist. Nevertheless, as these protocols become more prevalent, a priori documentation of methods in partnered research studies becomes increasingly important. Using as illustration a suite of studies aimed at improving coordination and communication in the primary care setting, we sought to identify challenges in publishing PPR relative to traditional designs, present alternative solutions to PPR publication, and propose an initial checklist of content to be included in protocols of partnered research. Challenges to publishing PPR include reporting details of research components intended to be co-created with operational partners, changes to sampling and entry strategy, and alignment of scientific and operational goals. Proposed solutions include emulating reporting standards of qualitative research, participatory action research, and adaptive trial designs, as well as embracing technological tools that facilitate publishing adaptive protocols, with version histories that are able to be updated as major protocol changes occur. Finally, we present a proposed checklist of reporting elements for partnered research protocols.
PMCID: PMC4239292  PMID: 25355092
Partnership research; Reporting standards; Research protocols
3.  Barriers to Non-HDL Cholesterol Goal Attainment by Providers 
The American journal of medicine  2011;124(9):876-80.e2.
Despite improvements in low-density lipoprotein cholesterol goal attainment, non–high-density lipoprotein cholesterol (non-HDL-C) goal attainment remains poor. This study assessed providers’ knowledge of, attitude toward, and practice regarding non-HDL-C.
Based on a conceptual model, we designed a questionnaire which was administered to internal medicine, family practice, cardiology, and endocrinology providers attending continuous medical education conferences. Responses were compared to those of providers attending a clinical lipidology conference.
Response rate was 33.3% (354/1,063). Among providers attending nonlipidology conferences, only 26% knew that non-HDL-C was a secondary treatment target, 34% knew non-HDL-C treatment goals, 56% could calculate non-HDL-C levels, and 66% knew that non-HDL-C levels could be calculated from a standard lipid panel. Compared with providers attending the lipidology conference, the other providers were less likely (p≤0.01) to have read the Adult Treatment Panel III (ATP III) guidelines (46% vs. 98%) or to use non-HDL-C (36% vs. 91%). No differences were found between primary care and specialty providers. Lack of familiarity with ATP III guidelines (34%) and of knowledge regarding non-HDL-C importance (21%) and calculation (22.7%) were the most common barriers identified.
Major gaps remain in providers’ awareness regarding non-HDL-C definition, calculation, and goals. System-level interventions are needed across specialties to address these gaps.
PMCID: PMC4180871  PMID: 21854896
guideline adherence; non-HDL cholesterol; Adult Treatment Panel III guidelines; provider knowledge; treatment practice
4.  How Variability in the IRB Review Process Impacts Minimal-Risk Multisite Health Services Research 
Annals of internal medicine  2012;156(10):728-735.
The Department of Health and Human Services recently called for public comment on human subjects research protections.
(1) To assess variability in reviews across Institutional Review Boards (IRBs) for a multisite minimal risk trial of financial incentives for evidence-based hypertension care. (2) To quantify the impact of review determinations on site participation, budget, and timeline.
A natural experiment occurring from multiple IRBs reviewing the same protocol for a multicenter trial (May 2005–October 2007).
25 Veterans Affairs Medical Centers (VAMCs).
Number of submissions, time to approval, and costs were evaluated. We compared patient complexity, academic affiliation, size, and location (urban/rural) between participating and non-participating VAMCs.
Of 25 eligible VAMCs, 6 did not meet requirements for IRB review, and 2 declined participation. Of 17 applications, 14 were approved. This process required 115 submissions, lasted 27 months, and cost close to $170,000 in staff salaries. One IRB’s concern about incentivizing a particular medication recommended by national guidelines prompted a change in our design to broaden our inclusion criteria beyond uncomplicated hypertension. The change required amending the protocol at 14 sites to preserve internal validity. The IRBs that approved the protocol classified it as “minimal risk”. The 12 sites that ultimately participated in the trial were more likely to be urban, academically affiliated, and care for more complex patients, limiting the external validity of the trial’s findings.
Because data came from a single multisite trial in the VA, which uses a two-stage review process, generalizability is limited.
Complying with IRB requirements for this minimal risk study required substantial resources and threatened the study’s internal and external validity. The current review of regulatory requirements may address some of the problems.
Primary Funding Sources
Veterans Affairs Health Services Research & Development and National Institutes of Health, National Heart, Lung, and Blood Institute
PMCID: PMC4174365  PMID: 22586010
5.  Impact of Clinical Complexity on the Quality of Diabetes Care 
To assess the impact of clinical complexity on three dimensions of diabetes care.
Study Design
We identified 35,872 diabetic patients receiving care at 7 Veterans Affairs facilities between July 2007 and June 2008 using administrative and clinical data. We examined control at index and appropriate care (among uncontrolled patients) within 90 days, for blood pressure (<130/80 mm Hg), hemoglobin A1c (<7%), and low-density lipoprotein cholesterol (<100 mg/dL). We used ordered logistic regression to examine the impact of complexity, defined by comorbidities count and illness burden, on control at index and a combined measure of quality (control at index or appropriate follow-up care) for all 3 measures.
6,260 (17.5%) patients were controlled at index for all 3 quality indicators. Patients with ≥3 comorbidities (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.67–2.26) and illness burden ≥2.00, (OR, 1.22; 95% CI, 1.13–1.32), were more likely than the least complex patients to be controlled for all 3 measures. Patients with ≥3 comorbidities, (OR, 2.30; 95% CI, 2.07–2.54) and illness burden ≥2.00, (OR, 1.25; 95% CI, 1.18–1.33), were also more likely than the least complex patients to meet the combined quality indicator for all 3 measures.
Patients with greatest complexity received higher quality diabetes care compared to less complex patients, regardless of the definition chosen. Although providers may appropriately target complex patients for aggressive control, deficits in guideline achievement among all diabetic patients highlight the challenges of caring for chronically ill patients and the importance of structuring primary care to promote higher quality, patient-centered care.
PMCID: PMC4170831  PMID: 23009301
clinical complexity; quality of care; diabetes
6.  Financial Incentives and Physician Commitment to Guideline-Recommended Hypertension Management: A Mixed Methods Approach 
The American journal of managed care  2012;18(10):e378-e391.
To examine the impact of financial incentives on physician goal commitment to guideline-recommended hypertension care.
Study design
Clinic-level cluster-randomized controlled trial with four arms: control, individual-, group-, or combined incentives. Intervention arm participants received performance-based incentives every four months for five periods. All participants received guideline education at baseline and audit and feedback every four months.
83 full-time primary care physicians at 12 VA Medical Centers completed web-based survey responses to Hollenbeck’s goal commitment scale every four months and telephone interviews at months 8 and 16.
Physician goal commitment did not vary over time or across arms. Participants reported patient non-adherence and consistent follow-up as perceived barriers and facilitators to successful hypertension care, suggesting providers may perceive hypertension management as more of a patient responsibility (external locus of control).
Financial incentives may constitute an insufficiently strong intervention to influence goal commitment when providers attribute performance to external forces beyond their control.
PMCID: PMC4169298  PMID: 23145846
Goal commitment; financial incentives; Pay-for-performance; mixed methods; physicians
7.  Effects of Individual Physician-Level and Practice-Level Financial Incentives on Hypertension Care: A Cluster Randomized Trial 
Pay for performance is intended to align incentives to promote high quality care, but results have been contradictory.
To test the effect of explicit financial incentives to reward guideline-recommended hypertension care.
Design, Setting, and Participants
Cluster randomized controlled trial of 12 Veterans Affairs hospital-based outpatient clinics with five performance periods and a 12-month washout. We enrolled 83 primary care physicians and 42 non-physician personnel (e.g., nurses, pharmacists) working with physicians to deliver hypertension care.
Clinics randomized to one of four groups: physician-level (individual) incentives; practice-level incentives; individual- plus practice-level incentives (combined); or none. Intervention participants received up to five payments every four months; all participants could access feedback reports.
Main outcome measures
For each four-month period, the number of hypertensive patients among a random sample who achieved guideline-recommended blood pressure thresholds or received an appropriate response to uncontrolled blood pressure; and/or been prescribed guideline-recommended medications and the number who developed hypotension.
Mean (standard deviation) total payments over the study were $4,270 ($459), $2,672 ($153), and $1,648 ($248) for the combined, individual, and practice-level interventions, respectively. The adjusted change over the study in patients meeting the combined blood pressure/appropriate response measure was 8.84 percentage points (95% confidence interval [CI], 4.20–11.80) for the individual-level, 3.70 (95% CI, 0.24–7.68) for the practice-level, 5.54 (95% CI, 1.92–9.52) for the combined, and 0.47 (95% CI, −3.12–4.04) for the control groups. For medications, the change was 9.07 (95% CI, 4.52–13.44), 4.98 (95% CI, 0.64–10.08), 7.26 (95% CI, 2.92–12.48), and 4.35 (95% CI, −0.28–9.28) percentage points, respectively. The adjusted estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36 percentage points (95% CI, 2.40–13.00; P=.005). Use of guideline-recommended medications did not significantly change compared to controls, nor did the incidence of hypotension. The effect of the incentive was not sustained after a washout.
Conclusions and Relevance
Individual financial incentives, but not practice-level or combined incentives, resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the incentives resulted in greater use of guideline-recommended medications or increased incidence of hypotension compared to controls. Further research is needed to understand the factors that contributed to our findings.
Trial registration
PMCID: PMC4165573  PMID: 24026599
8.  Psychotherapy in the Veterans Health Administration: Missed Opportunities? 
Psychological services  2008;5(4):320-331.
Informed by data on the dose-response effect, the authors assessed use of psychotherapy in the Veterans Health Administration (VA). The authors identified 410,923 patients with newly diagnosed depression, anxiety, or posttraumatic stress disorder using VA databases (October 2003 through September 2004). Psychotherapy encounters were identified by Current Procedural Terminology codes for the 12 months following patients’ initial diagnosis. Psychotherapy was examined for session exposure received within the 12-month follow-up period and time (in days) between diagnosis and treatment. Of the cohort, 22% received at least one session of psychotherapy; 7.9% received four or more sessions; 4.2% received eight or more sessions; and 2.4% received 13 or more sessions. Delays between initial mental health diagnosis and initiation of care averaged 57 days. Patient variables including age, marital status, income, travel distance, psychiatric diagnosis, and medical-illness burden were significantly related to receipt of psychotherapy. Treatment delays and general underuse of psychotherapy services are potential missed opportunities for higher-quality psychotherapeutic care in integrated health care settings.
PMCID: PMC4145407  PMID: 25177213
psychotherapy; mental health; depression; anxiety; posttraumatic stress disorder
9.  The Safety Attitudes Questionnaire as a Tool for Benchmarking Safety Culture in the NICU 
NICU safety culture, as measured by the Safety Attitudes Questionnaire (SAQ), varies widely. Associations with clinical outcomes in the adult ICU setting make the SAQ an attractive tool for comparing clinical performance between hospitals. Little information is available on the use of the SAQ for this purpose in the NICU setting.
To determine whether the dimensions of safety culture measured by the SAQ give consistent results when used as a NICU performance measure.
Cross-sectional survey of caregivers in twelve NICUs, using the six scales of the SAQ: teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management, and working conditions. NICUs were ranked by quantifying their contribution to overall risk-adjusted variation across the scales. Spearman Rank Correlation coefficients were used to test for consistency in scale performance. We then examined whether performance in the top four NICUs in one scale predicted top four performance in others.
There were 547 respondents in twelve NICUs. Of fifteen NICU-level correlations in performance ranking, two were greater than 0.7, seven were between 0.4 and 0.69, the six remaining were less than 0.4. We found a trend towards significance in comparing the distribution of performance in the top four NICUs across domains with a binomial distribution p = .051, indicating generally consistent performance across dimensions of safety culture.
A culture of safety permeates many aspects of patient care and organizational functioning. The SAQ may be a useful tool for comparative performance assessments among NICUs.
PMCID: PMC4030665  PMID: 22337935
Infant; newborn; quality of care; benchmarking; safety culture
10.  Do Practicing Clinicians Agree with Expert Ratings of Neonatal Intensive Care Unit Quality Measures? 
To assess the level of agreement when selecting quality measures for inclusion in a composite index of neonatal intensive care quality (Baby-MONITOR) between two panels: one comprised of academic researchers (Delphi) and another comprised of academic and clinical neonatologists (Clinician).
In a modified Delphi process, a panel rated twenty eight quality measures. We assessed clinician agreement with the Delphi panel by surveying a sample of forty eight neonatal intensive care practitioners. We asked the clinician group to indicate their level of agreement with the Delphi panel for each measure using a five- point scale (much too high, slightly too high, reasonable, slightly too low, and much too low). In addition, we asked clinicians to select measures for inclusion in the Baby-MONITOR based on a yes or no vote and a pre-specified two-thirds majority for inclusion.
Twenty three (47.9%) of the clinicians responded to the survey. We found high levels of agreement between the Delphi and clinician panels, particularly across measures selected for the Baby-MONITOR. Clinicians selected the same nine measures for inclusion in the composite as the Delphi panel. For these nine measures, 74% of clinicians indicated that the Delphi panel rating was ‘reasonable’.
Practicing clinicians agree with an expert panel on the measures that should be included in the Baby-MONITOR, enhancing face validity.
PMCID: PMC3963391  PMID: 22241483
infant; newborn; quality of health care; measurement; composite indicator
11.  A procedure for obtaining Impact of Cancer Version 2 scores using Version 1 responses 
Psychometric scales often change over time, complicating comparison of scores across different versions. The Impact of Cancer (IOC) scale was developed to measure quality of life of long-term cancer survivors. We sought to develop a method for scoring the earlier version, IOCv1, to obtain scores comparable to IOCv2, which is the recommended version.
Data from 1828 cancer survivors who had completed a questionnaire including all IOCv1 and IOCv2 items were randomly split into training, validation and test sets. The training and validation sets were used to develop and validate linear regression models for predicting each IOCv2 item missing from IOCv1. The models were then applied to the test set to obtain pseudo-IOCv2 scores, which were compared to observed scores to assess predictive performance of the models in independent data.
Observed and pseudo-IOCv2 scale scores were highly correlated in the test sample and had mean differences near zero. The models performed especially well in predicting summary scale scores, with correlations exceeding 0.98.
The approach facilitates comparison across samples of survivors surveyed using different versions of the IOC and may be useful to other investigators trying to compare participants surveyed using different versions of the same instrument.
PMCID: PMC3369006  PMID: 22302619
impact of cancer; oncology; psychometric scales; quality of life; cancer survivorship
12.  Variations in Definitions of Mortality Have Little Influence on NICU Performance Ratings 
The Journal of pediatrics  2012;162(1):50-5.e2.
To measure the influence of varying mortality time frames on performance rankings among regional NICUs in a large state.
Study design
We carried out cross-sectional data analysis of VLBW infants cared for at 24 level 3 NICUs. We tested the effect of four definitions of mortality: (1) deaths between admission and end of birth hospitalization or up to 366 days; (2) deaths between 12 hours of age and end of birth hospitalization or up to 366 days; (3) deaths between admission and 28 days; and (4) deaths between 12 hours of age and 28 days. NICUs were ranked by quantifying their deviation from risk-adjusted expected mortality and splitting them into three tiers: top six, bottom six, and in-between.
There was wide inter-institutional variation in risk-adjusted mortality for each definition (observed minus expected Z-score range, -6.08 to 3.75). However, mortality-rate-based NICU rankings, and their classification into performance tiers, were very similar for all institutions for each of our time frames. Among all four definitions, NICU rank correlations were high (>0.91). Few NICUs changed relative to a neighboring tier with changes in definitions, and none changed by more than one tier.
The time frame used to ascertain mortality had little effect on comparative NICU performance.
PMCID: PMC3782108  PMID: 22854328
Infant; newborn; quality of care; performance measurement; mortality
13.  Neonatal Intensive Care Unit Safety Culture Varies Widely 
Archives of disease in childhood. Fetal and neonatal edition  2011;97(2):10.1136/archdischild-2011-300635.
Variation in health care delivery and outcomes in NICUs may be partly explained by differences in safety culture.
To describe NICU caregiver assessments of safety culture, explore the variability within and between NICUs on safety culture domains, and test for association with caregiver characteristics.
We surveyed NICU caregivers in a convenience sample of 12 hospitals from a single health care system, using the Safety Attitudes Questionnaire (SAQ). The six scales of the SAQ include teamwork climate, safety climate, job satisfaction, stress recognition, perception of management, and working conditions. For each NICU we calculated scale means, standard deviations and percent positives (percent agreement).
We found substantial variation in safety culture domains among participating NICUs. A composite mean score across the six safety culture domains ranged from 56.3 to 77.8 on a 100-point scale and NICUs in the top four NICUs were significantly different from the bottom four (p < .001). Across the six domains, respondent assessments varied widely, but were least positive on perceptions of management (3–80% positive; mean 33.3%) and stress recognition (18–61% positive; mean 41.3%). Comparisons of SAQ scale scores between NICUs and a previously published cohort of adult ICUs generally revealed higher scores for NICUs. Physicians composite scores were 8.2 (p = .04) and 9.5 (p =.02) points higher than nurses and ancillary personnel.
Significant variation and scope for improvement in safety culture exists among this sample of NICUs. The NICU variation was similar to variation in adult ICUs, but NICU scores were generally higher than adult ICU scores. Future studies should validate whether safety culture as measured with the SAQ correlates with clinical and operational outcomes in the NICU setting.
PMCID: PMC3845658  PMID: 21930691
Infant; newborn; quality of care; patient safety; safety culture
14.  Assessing the Impact of Cancer: Development of a new instrument for long-term survivors 
Psycho-oncology  2006;15(5):407-421.
To develop and evaluate a new instrument that measures aspects of long-term survivorship not measured by existing tools.
In qualitative interviews, 47 long-term cancer survivors (LTS) detailed ways that cancer has impacted their lives. Content analysis resulted in the creation of 325 candidate items for inclusion in a new Impact of Cancer (IOC) instrument. Following expert review, item reduction and pilot testing, 81 items were administered with other established health status and quality of life (QOL) instruments to 193 LTS of breast, prostate, colorectal cancers and lymphoma. Internal consistency reliability and validity of newly-derived scales was assessed.
Factor analysis of items using a priori QOL domains resulted in the derivation of ten new and specific subscales: health awareness, body changes, health worries, positive and negative self-evaluation, positive and negative life outlook, social life interferences, relationships, and meaning of cancer. Internal consistency measurements for these subscales ranged from 0.67 to 0.89. Expected associations within and among the IOC subscales and standardized measures of health status and QOL were observed, as were some unexpected findings.
Psychometric analysis indicated that this initial version of the Impact of Cancer instrument measures distinct and relevant constructs for LTS. Future work is necessary to confirm the factor structure, responsiveness and further validation of the instrument.
PMCID: PMC3731126  PMID: 16097041
Cancer survivors; Instrument development; Psychometric testing; Quality of life
15.  Exploring Situational Awareness in Diagnostic Errors in Primary Care 
BMJ quality & safety  2011;21(1):30-38.
Diagnostic errors in primary care are harmful but poorly studied. To facilitate understanding of diagnostic errors in real-world primary care settings using electronic health records (EHRs), this study explored the use of the Situational Awareness (SA) framework from aviation human factors research.
A mixed-methods study was conducted involving reviews of EHR data followed by semi-structured interviews of selected providers from two institutions in the US. The study population included 380 consecutive patients with colorectal and lung cancers diagnosed between February 2008 and January 2009. Using a pre-tested data collection instrument, trained physicians identified diagnostic errors, defined as lack of timely action on one or more established indications for diagnostic work-up for lung and colorectal cancers. Twenty-six providers involved in cases with and without errors were interviewed. Interviews probed for providers' lack of SA and how this may have influenced the diagnostic process.
Of 254 cases meeting inclusion criteria, errors were found in 30 (32.6%) of 92 lung cancer cases and 56 (33.5%) of 167 colorectal cancer cases. Analysis of interviews related to error cases revealed evidence of lack of one of four levels of SA applicable to primary care practice: information perception, information comprehension, forecasting future events, and choosing appropriate action based on the first three levels. In cases without error, the application of the SA framework provided insight into processes involved in attention management.
A framework of SA can help analyze and understand diagnostic errors in primary care settings that use EHRs.
PMCID: PMC3692739  PMID: 21890757
diagnostic error; decision-making; patient safety; primary care; medical errors; human factors; cancer; electronic health records; diagnostic delays
16.  The Impact of Comorbidity Type on Measures of Quality for Diabetes Care 
Medical Care  2011;49(6):605-610.
Studies provide conflicting results about the impact of comorbid conditions on the quality of chronic illness care. We assessed the effect of comorbidity type (concordant, discordant, or both) on the receipt of guideline-recommended care among patients with diabetes.
Research Design
Patients were assigned to 1 of 4 condition groups: diabetes-concordant (hypertension, ischemic heart disease, hyperlipidemia), and/or -discordant (arthritis, depression, chronic obstructive pulmonary disease) conditions, or neither. We evaluated hemoglobin (Hb) A1c, blood pressure, and low-density lipoprotein cholesterol (LDL-C) readings at index and measured overall good quality of diabetes care, including a 6-month follow-up interval. We assessed the effect of condition group on overall good quality of care with logistic regression and generalized ordered logistic regression.
We assigned 35,872 patients to the diabetes comorbid condition groups, ranging from 2.0% in the discordant-only group to 58.0% in the concordant-only group. Patients with both types of conditions were more likely than those with no comorbidities to receive overall good quality for glycemic [odds ratio (OR), 2.13; 95% confidence interval (CI), 1.86-2.41], blood pressure (OR, 1.62; 95% CI, 1.40-1.84) and LDL-C (OR, 3.57; 95% CI, 3.08-4.05) control within 6 months of an index visit. They were also more likely to receive overall good quality for all 3 quality measures combined (OR, 2.17; 95% CI, 1.96-2.39).
Patients with the greatest clinical complexity were more likely than less complex patients to receive high quality diabetes care, suggesting that increased complexity does not necessarily predispose chronically ill patients to receiving poorer care. However, caution should be used in treating certain patient groups, such as the elderly, for whom adherence to multiple condition-specific guidelines may lack benefit or cause harm.
PMCID: PMC3366691  PMID: 21422952
diabetes mellitus; quality of health care; comorbidity
17.  Relationship between Clinical Conditions and Use of Veterans Affairs Health Care among Medicare-Enrolled Veterans 
Health Services Research  2010;45(3):762-791.
To determine how reliance on Veterans Affairs (VA) for medical care among veterans enrolled in Medicare is affected by medical conditions, access, and patient characteristics.
Data Sources/Study Setting
Department of Veterans Affairs.
Study Design
We examined reliance on the VA for inpatient, outpatient, and overall medical care among all VA users in fiscal years 2003 and 2004 who were also enrolled in Medicare. We calculated the marginal effects of patient factors on VA reliance using fractional logistic regression; we also analyzed overall VA reliance separately for under-65 and age-65+ groups. The primary focus of this analysis was the relationship between aggregated condition categories (ACCs), which represent medical conditions, and reliance on the VA.
Principal Findings
Mean VA reliance was significantly higher in the under-65 population than in the age-65+ group (0.800 versus 0.531). Lower differential distance to the VA, and higher VA-determined priority for health care, predicted higher VA reliance. Most individual ACCs were negatively associated with VA reliance, though substance abuse and mental health disorders were significantly associated with increased reliance on VA care. Conditions of the eyes and ears/nose/throat had positive marginal effect on VA reliance for the under 65, while diabetes was positive for age 65+. Among inpatients, veterans with ACCs for mental health conditions, eye conditions, amputations, or infectious and parasitic conditions had higher likelihood of a VA hospitalization than inpatients without these conditions.
Many dually enrolled Veterans use both Medicare and VA health care. Age, accessibility, and priority level for VA services have a clear relationship with VA reliance. Because dual use is common, coordination of care among health care settings for such patients should be a policy priority.
PMCID: PMC2875759  PMID: 20403056
Access to health care; veterans; Medicare; health services research; health services
18.  Follow-up Actions on Electronic Referral Communicationin a Multispecialty Outpatient Setting 
Electronic health records (EHR) enable transmission and tracking of referrals between primary-care practitioners (PCPs) and subspecialists. We used an EHR to examine follow-up actions on electronic referral communication in a large multispecialty VA facility.
We retrieved outpatient referrals to five subspecialties between October 2006 and December 2007, and queried the EHR to determine their status: completed, discontinued (returned to PCP), or unresolved (no action taken by subspecialist). All unresolved referrals, and random samples of discontinued and completed referrals were reviewed to determine whether subspecialists took follow-up actions (i.e., schedule appointments anytime in the future) within 30 days of referral-receipt. For referrals without timely follow-up, we determined whether inaction was supported by any predetermined justifiable reasons or associated with certain referral characteristics. We also reviewed if PCPs took the required action on returned information.
Of 61,931 referrals, 22,535 were discontinued (36.4%), and 474 were unresolved (0.8%). We selected 412 discontinued referrals randomly for review. Of these, 52% lacked follow-up actions within 30 days. Appropriate justifications for inaction were documented in 69.8% (150/215) of those without action and included lack of prerequisite testing by the PCP and subspecialist opinion that no intervention was required despite referral. We estimated that at 30 days, 6.3% of all referrals were associated with an unexplained lack of follow-up actions by subspecialists. Conversely, 7.4% of discontinued referrals returned to PCPs were associated with an unexplained lack of follow-up.
Although the EHR facilitates transmission of valuable information at the PCP-subspecialist interface, unexplained communication breakdowns in the referral process persist in a subset of cases.
PMCID: PMC3024094  PMID: 20848235
referrals; primary care; sub-specialty care; electronic health records; patient safety; health information technology; communication; diagnostic errors; patient follow-up
19.  The impact of cancer and quality of life for post-treatment non-Hodgkin lymphoma survivors 
Psycho-oncology  2010;19(12):1259-1267.
Recent work suggests that perceptions of the impact of cancer on survivors’ lives are associated with physical and mental health and quality of life (QOL) outcomes. This study examines the association between the Impact of Cancer version 2 scales (IOCv2) and these outcomes in a large sample of survivors of adult non-Hodgkin lymphoma (NHL).
Participants completed a mailed survey to assess physical and mental health (SF-36), cancer-specific quality of life (FACT-G) and perceived impact of cancer (IOCv2). Hierarchical multiple regression models, in which demographic, clinical, psychosocial and IOCv2 measures were added sequentially, were employed to evaluate their contribution to explaining variance in SF-36 and FACT-G scores.
A total of 652 post-treatment NHL survivors participated. Survivors with comorbidities and negative appraisals of life threat and treatment intensity reported worse physical and mental health and QOL (all P<.05). After controlling for demographic and clinical characteristics, younger respondents reported better physical but worse mental health and QOL (all P<.01). Lower IOCv2 Negative Impact (all P<.001) and higher Positive Impact (all P<.05) scores were associated with better physical and mental health and QOL after controlling for demographic, clinical and psychosocial characteristics.
Findings suggest that perceptions of cancer’s impact on survivors’ lives may influence or be influenced by health status and functioning and QOL. Longitudinal research is needed to establish causality, which could lead to the development of interventions targeting survivors’ impact of cancer concerns, and ultimately to the enhancement of overall health and QOL.
PMCID: PMC2889206  PMID: 20099255
Quality of life; health status; non-Hodgkin lymphoma; psychosocial oncology; cancer survivors
20.  Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: study protocol 
Despite compelling evidence of the benefits of treatment and well-accepted guidelines for treatment, hypertension is controlled in less than one-half of United States citizens.
This randomized controlled trial tests whether explicit financial incentives promote the translation of guideline-recommended care for hypertension into clinical practice and improve blood pressure (BP) control in the primary care setting. Using constrained randomization, we assigned 12 Veterans Affairs hospital outpatient clinics to four study arms: physician-level incentive; group-level incentive; combination of physician and group incentives; and no incentives (control). All participants at the hospital (cluster) were assigned to the same study arm. We enrolled 83 full-time primary care physicians and 42 non-physician personnel. The intervention consisted of an educational session about guideline-recommended care for hypertension, five audit and feedback reports, and five disbursements of incentive payments. Incentive payments rewarded participants for chart-documented use of guideline-recommended antihypertensive medications, BP control, and appropriate responses to uncontrolled BP during a prior four-month performance period over the 20-month intervention. To identify potential unintended consequences of the incentives, the study team interviewed study participants, as well as non-participant primary care personnel and leadership at study sites. Chart reviews included data collection on quality measures not related to hypertension. To evaluate the persistence of the effect of the incentives, the study design includes a washout period.
We briefly describe the rationale for the interventions being studied, as well as the major design choices. Rigorous research designs such as the one described here are necessary to determine whether performance-based payment arrangements such as financial incentives result in meaningful quality improvements.
Trial Registration
PMCID: PMC3197549  PMID: 21967830
21.  Reducing Referral Delays in Colorectal Cancer Diagnosis: Is It about How You Ask? 
Delays in colorectal cancer (CRC) diagnosis related to colonoscopy referrals are not well studied. We tested whether certain details of information transmitted through computerized provider order entry (CPOE)-based referrals affected timeliness of diagnostic colonoscopy for patients with newly diagnosed colorectal cancer (CRC).
We studied a 6-year cohort of all newly diagnosed patients with CRC at a large tertiary care Veterans Affairs hospital and its affiliated multispecialty clinics. Referring providers included primary care clinicians, resident trainees, and other specialists. From the colonoscopy referral preceding CRC diagnosis, we determined request date, type and frequency of diagnostic clues provided (symptoms, signs, test results), notation of urgency, and documented evidence of verbal contact between referring provider and consultant to expedite referral. We compared distributions of proportions of diagnostic clues between patients with > 60 and ≤ 60 day lag and examined predictors of lag time.
Of 367 electronic referrals identified with a median lag of 57 days, 178 (48.5%) had lag > 60 days. Referrals associated with longer lag times included those with “positive fecal occult blood test” (92 days, P<0.0001), “hematochezia” (75 days, P=0.02), “history of polyps” (221 days, P=0.0006), and when “screening” (versus specific symptoms) was given as reason for diagnostic colonoscopy (203 days, P=0.002). Independent predictors of shorter wait times included 3 diagnostic clues, notation of urgency, and documentation of verbal contact.
Attention to certain details of diagnostic information provided to consultants through CPOE-based referrals may help reduce delays in CRC diagnosis.
PMCID: PMC2965264  PMID: 20584706
delayed cancer diagnosis; colorectal cancer; colonoscopy referrals; computerized order entry; electronic medical records; primary care
22.  Patient-to-Nurse Ratios and Outcomes of Moderately Preterm Infants 
Pediatrics  2010;125(2):320-326.
Moderately preterm infants (30–34 6/7 weeks’ gestational age) represent the largest population of NICU residents. Whether their clinical outcomes are associated with differences in NICU nurse-staffing arrangements has not been assessed. The objective of this study was to test the influence of patient-to-nurse ratios (PNRs) on outcomes of care provided to moderately preterm infants.
Using data from a prospective, multicenter, observational cohort study of 850 moderately preterm infants from 10 NICUs in California and Massachusetts, we tested for associations between PNR and several important clinical outcomes by using multivariate random-effects models. To correct for the influence of NICU size, we dichotomized the sample into those with an average daily census of <20 or ≥20 infants.
Overall, we found few clinically significant associations between PNR and clinical outcomes of care. Mean PNRs were higher in large compared with small NICUs (2.7 vs 2.1; P < .001). In bivariate analyses, an increase in PNR was associated with a slightly higher daily weight gain (5 g/day), greater gestational age at discharge, any intraventricular hemorrhage, and severe retinopathy of prematurity. After controlling for case mix, NICU size, and site of care, an additional patient per nurse was associated with a decrease in daily weight gain by 24%. Other variables were no longer independently associated with PNR.
In this population of moderately preterm infants, the PNR was associated with a decrease in daily weight gain, but was not associated with other measures of quality. In contrast with findings in the adult intensive care literature, measured clinical outcomes were similar across the range of nurse-staffing arrangements among participating NICUs. We conclude that the PNR is not useful for profiling hospitals’ quality of care delivery to moderately preterm infants.
PMCID: PMC3151172  PMID: 20064868
infant; newborn; health services research; nurse-staffing; outcomes
23.  Implementing Pay-for-Performance in the Neonatal Intensive Care Unit 
Pediatrics  2007;119(5):975-982.
Pay-for-performance initiatives in medicine are proliferating rapidly. Neonatal intensive care is a likely target for these efforts because of the high cost, available databases, and relative strength of evidence for at least some measures of quality. Pay-for-performance may improve patient care but requires valid measurements of quality to ensure that financial incentives truly support superior performance. Given the existing uncertainty with respect to both the effectiveness of pay-for-performance and the state of quality measurement science, experimentation with pay-for-performance initiatives should proceed with caution and in controlled settings. In this article, we describe approaches to measuring quality and implementing pay-for-performance in the NICU setting.
PMCID: PMC3151255  PMID: 17473099
pay-for-performance programs; quality improvement
24.  Method to Develop Health Care Peer Groups for Quality and Financial Comparisons Across Hospitals 
Health Services Research  2009;44(2 Pt 1):577-592.
To develop and explore the characteristics of a novel “nearest neighbor” methodology for creating peer groups for health care facilities.
Data Sources
Data were obtained from the Department of Veterans Affairs (VA) databases.
Statistical Methods and Findings
Peer groups are developed by first calculating the multidimensional Euclidean distance between each of 133 VA medical centers based on 16 facility characteristics. Each medical center then serves as the center for its own peer group, and the nearest neighbor facilities in terms of Euclidean distance comprise the peer facilities. We explore the attributes and characteristics of the nearest neighbor peer groupings. In addition, we construct standard cluster analysis-derived peer groups and compare the characteristics of groupings from the two methodologies.
The novel peer group methodology presented here results in groups where each medical center is at the center of its own peer group. Possible advantages over other peer group methodologies are that facilities are never on the “edge” of a group and group size—and thus group dispersion—is determined by the researcher. Peer groups with these characteristics may be more appealing to some researchers and administrators than standard cluster analysis and may thus strengthen organizational buy-in for financial and quality comparisons.
PMCID: PMC2677055  PMID: 19178585
Peer groups; cluster analysis; nearest neighbor; Euclidean distance; quality of care comparisons
25.  Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? 
The American journal of medicine  2010;123(3):238-244.
Follow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examined whether automated notifications of abnormal laboratory results (alerts) in an integrated electronic medical record resulted in timely follow-up actions.
We studied four alerts: hemoglobin A1c (HbA1c) ≥15%, positive hepatitis C antibody (HCV), prostate specific antigen (PSA) ≥15 ng/mL, and thyroid stimulating hormone (TSH) ≥ 15 mIU/L. An alert tracking system determined whether the alert was acknowledged (i.e. provider clicked on and opened the message) within two weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions (e.g. patient contact, treatment etc.). Multivariable logistic regression models analyzed predictors for lack of timely follow-up.
Between May 2008 and December 2008, 78,158 tests (HbA1c, HCV, TSH and PSA) were performed, of which 1163 (1.48%) were transmitted as alerts; 10.2% of these (119/1163) were unacknowledged. Timely follow-up was lacking in 79 (6.8%) and was statistically not different for acknowledged and unacknowledged alerts (6.4% vs. 10.1%; p =.13). Two-hundred two alerts (17.4% of 1163) arose from unnecessarily ordered (redundant) tests. Alerts for a new versus known diagnosis were more likely to lack timely follow-up (OR: 7.35; 95% CI: 4.16-12.97) whereas alerts related to redundant tests were less likely to lack timely follow-up (OR: 0.24; 95% CI: 0.07-0.84).
Safety concerns related to timely patient follow-up remain despite automated notification of non-life threatening abnormal laboratory results in the outpatient setting.
PMCID: PMC2878665  PMID: 20193832
diagnostic errors; abnormal diagnostic test results; electronic medical records; patient follow-up; patient safety; health information technology; communication; primary care

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