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1.  PTSD Risk and Mental Health Care Engagement in a Multi-War Era Community Sample of Women Veterans 
ABSTRACT
BACKGROUND
Post-traumatic stress disorder (PTSD) is common in women veterans (WVs), and associated with significant co-morbidity. Effective treatment is available; however, PTSD is often unrecognized.
OBJECTIVES
Identify PTSD prevalence and mental healthcare (MHC) use in a representative national WV sample.
DESIGN AND PARTICIPANTS
Cross-sectional, population-based 2008–2009 national survey of 3,611 WVs, weighted to the population.
MAIN MEASURES
We screened for PTSD using a validated instrument, and also assessed demographic characteristics, health characteristics, and MHC use in the prior 12 months. Among those screening positive, we conducted multivariate logistic regression to identify independent predictors of MHC use.
KEY RESULTS
Overall, 13.0 % (95 % confidence interval [CI] 9.8–16.2) of WVs screened PTSD-positive. Veterans Health Administration (VA) healthcare was used by 31.1 % of PTSD-positives and 11.4 % of PTSD-negatives (p < 0.001). Among those screening positive, 48.7 % (95 % CI 35.9–61.6) used MHC services (66.3 % of VA-users, 40.8 % of VA-nonusers; p < 0.001). Having a diagnosis of depression (OR = 8.6; 95 % CI 1.5–48.9) and VA healthcare use (OR = 2.7; 95 % CI 1.1–7.0) predicted MHC use, whereas lacking a regular provider for health care (OR = 0.2; 95 % CI 0.1–0.4) and household income below the federal poverty level (OR = 0.2; 95 % CI 0.1–0.5) predicted nonuse.
CONCLUSIONS
More than one in eight WVs screened positive for PTSD. Though a majority of VA-users received MHC, low income predicted nonuse. Only a minority of VA-nonusers received MHC. The majority of WVs use non-VA healthcare providers, who may be unaware of their veteran status and PTSD risk. VA outreach to educate VA-nonusers and their healthcare providers about WVs’ PTSD risk and available evidence-based VA treatment options is one approach to extend the reach of VA MHC. Research to characterize barriers to VA MHC use for VA-nonusers and low income VA-users is warranted to better understand low service utilization, and to inform program development to engage more WVs in needed MHC.
doi:10.1007/s11606-012-2303-2
PMCID: PMC3682036  PMID: 23435765
post-traumatic stress disorder; women; veterans; mental health services; utilization; Veterans hospitals
2.  Wide Clinic-Level Variation in Adherence to Oral Diabetes Medications in the VA 
ABSTRACT
BACKGROUND
While there has been extensive research into patient-specific predictors of medication adherence and patient-specific interventions to improve adherence, there has been little examination of variation in clinic-level medication adherence.
OBJECTIVE
We examined the clinic-level variation of oral hypoglycemic agent (OHA) medication adherence among patients with diabetes treated in the Department of Veterans Affairs (VA) primary care clinics. We hypothesized that there would be systematic variation in clinic-level adherence measures, and that adherence within organizationally-affiliated clinics, such as those sharing local management and support, would be more highly correlated than adherence between unaffiliated clinics.
DESIGN
Retrospective cohort study.
SETTING
VA hospital and VA community-based primary care clinics in the contiguous 48 states.
PATIENTS
444,418 patients with diabetes treated with OHAs and seen in 158 hospital-based clinics and 401 affiliated community primary care clinics during fiscal years 2006 and 2007.
MAIN MEASURES
Refill-based medication adherence to OHA.
KEY RESULTS
Adjusting for patient characteristics, the proportion of patients adherent to OHAs ranged from 57 % to 81 % across clinics. Adherence between organizationally affiliated clinics was high (Pearson Correlation = 0.82), and adherence between unaffiliated clinics was low (Pearson Correlation = 0.04).
CONCLUSION
The proportion of patients adherent to OHAs varied widely across VA primary care clinics. Clinic-level adherence was highly correlated to other clinics in the same organizational unit. Further research should identify which factors common to affiliated clinics influence medication adherence.
doi:10.1007/s11606-012-2331-y
PMCID: PMC3631064  PMID: 23371383
pharmacoepidemiology; health services research; diabetes; veterans; primary care
4.  Determinants of Readiness for Primary Care-Mental Health Integration (PC-MHI) in the VA Health Care System 
ABSTRACT
BACKGROUND
Depression management can be challenging for primary care (PC) settings. While several evidence-based models exist for depression care, little is known about the relationships between PC practice characteristics, model characteristics, and the practice’s choices regarding model adoption.
OBJECTIVE
We examined three Veterans Affairs (VA)-endorsed depression care models and tested the relationships between theoretically-anchored measures of organizational readiness and implementation of the models in VA PC clinics.
DESIGN
1) Qualitative assessment of the three VA-endorsed depression care models, 2) Cross-sectional survey of leaders from 225 VA medium-to-large PC practices, both in 2007.
MAIN MEASURES
We assessed PC readiness factors related to resource adequacy, motivation for change, staff attributes, and organizational climate. As outcomes, we measured implementation of one of the VA-endorsed models: collocation, Translating Initiatives in Depression into Effective Solutions (TIDES), and Behavioral Health Lab (BHL). We performed bivariate and, when possible, multivariate analyses of readiness factors for each model.
KEY RESULTS
Collocation is a relatively simple arrangement with a mental health specialist physically located in PC. TIDES and BHL are more complex; they use standardized assessments and care management based on evidence-based collaborative care principles, but with different organizational requirements. By 2007, 107 (47.5 %) clinics had implemented collocation, 39 (17.3 %) TIDES, and 17 (7.6 %) BHL. Having established quality improvement processes (OR 2.30, [1.36, 3.87], p = 0.002) or a depression clinician champion (OR 2.36, [1.14, 4.88], p = 0.02) was associated with collocation. Being located in a VA regional network that endorsed TIDES (OR 8.42, [3.69, 19.26], p < 0.001) was associated with TIDES implementation. The presence of psychologists or psychiatrists on PC staff, greater financial sufficiency, or greater spatial sufficiency was associated with BHL implementation.
CONCLUSIONS
Both readiness factors and characteristics of depression care models influence model adoption. Greater model simplicity may make collocation attractive within local quality improvement efforts. Dissemination through regional networks may be effective for more complex models such as TIDES.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2217-z) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-012-2217-z
PMCID: PMC3579970  PMID: 23054917
primary care; mental health; depression; collaborative care; implementation; readiness
5.  Sexual Victimization, Health Status, and VA Healthcare Utilization Among Lesbian and Bisexual OEF/OIF Veterans 
Journal of General Internal Medicine  2013;28(Suppl 2):604-608.
ABSTRACT
Background
Many lesbian and bisexual (LB) women veterans may have been targets of victimization in the military based on their gender and presumed sexual orientation, and yet little is known regarding the health or mental health of LB veterans, nor the degree to which they feel comfortable receiving care in the VA.
Objective
The purpose of this study was to examine the prevalence of mental health and gender-specific conditions, VA healthcare satisfaction and trauma exposure among LB veterans receiving VA care compared with heterosexually-identified women veterans receiving.
Design
Prospective cohort study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) women veterans at two large VA facilities.
Participants
Three hundred and sixty five women veterans that completed a baseline survey. Thirty-five veterans (9.6 %) identified as gay or lesbian (4.7 %), or bisexual (4.9 %).
Main Measures
Measures included sexual orientation, military sexual trauma, mental and gender-specific health diagnoses, and VA healthcare utilization and satisfaction.
Key Results
LB OEF/OIF veterans were significantly more likely to have experienced both military and childhood sexual trauma than heterosexual women (MST: 31 % vs. 13 %, p < .001; childhood sexual trauma: 60 % vs. 36 %, p = .01), to be hazardous drinkers (32 % vs. 16 %, p = .03) and rate their current mental health as worse than before deployment (35 % vs. 16 %, p < .001).
Conclusions
Many LB veterans have experienced sexual victimization, both within the military and as children, and struggle with substance abuse and poor mental health. Health care providers working with female Veterans should be aware of high rates of military sexual trauma and childhood abuse and refer women to appropriate VA treatment and support groups for sequelae of these experiences. Future research should focus on expanding this study to include a larger and more diverse sample of lesbian, gay, bisexual, and transgender veterans receiving care at VA facilities across the country.
doi:10.1007/s11606-013-2357-9
PMCID: PMC3695265  PMID: 23807072
lesbian; health services research; Veterans; women
6.  Women Veterans’ Healthcare Delivery Preferences and Use by Military Service Era: Findings from the National Survey of Women Veterans 
Journal of General Internal Medicine  2013;28(Suppl 2):571-576.
ABSTRACT
BACKGROUND
The number of women Veterans (WVs) utilizing the Veterans Health Administration (VA) has doubled over the past decade, heightening the importance of understanding their healthcare delivery preferences and utilization patterns. Other studies have identified healthcare issues and behaviors of WVs in specific military service eras (e.g., Vietnam), but delivery preferences and utilization have not been examined within and across eras on a population basis.
OBJECTIVE
To identify healthcare delivery preferences and healthcare use of WVs by military service era to inform program design and patient-centeredness.
DESIGN AND PARTICIPANTS
Cross-sectional 2008–2009 survey of a nationally representative sample of 3,611 WVs, weighted to the population.
MAIN MEASURES
Healthcare delivery preferences measured as importance of selected healthcare features; types of healthcare services and number of visits used; use of VA or non-VA; all by military service era.
KEY RESULTS
Military service era differences were present in types of healthcare used, with World War II and Korea era WVs using more specialty care, and Vietnam era-to-present WVs using more women’s health and mental health care. Operations Enduring Freedom, Iraqi Freedom, New Dawn (OEF/OIF/OND) WVs made more healthcare visits than WVs of earlier military eras. The greatest healthcare delivery concerns were location convenience for Vietnam and earlier WVs, and cost for Gulf War 1 and OEF/OIF/OND WVs. Co-located gynecology with general healthcare was also rated important by a sizable proportion of WVs from all military service eras.
CONCLUSIONS
Our findings point to the importance of ensuring access to specialty services closer to home for WVs, which may require technology-supported care. Younger WVs’ higher mental health care use reinforces the need for integration and coordination of primary care, reproductive health and mental health care.
doi:10.1007/s11606-012-2323-y
PMCID: PMC3695266  PMID: 23807067
women Veterans; VA healthcare; health services need; health services utilization; health care preferences
7.  An Inventory of VHA Emergency Departments’ Resources and Processes for Caring for Women 
Journal of General Internal Medicine  2013;28(Suppl 2):583-590.
ABSTRACT
BACKGROUND
More women are using Veterans’ Health Administration (VHA) Emergency Departments (EDs), yet VHA ED capacities to meet the needs of women are unknown.
OBJECTIVE
We assessed VHA ED resources and processes for conditions specific to, or more common in, women Veterans.
DESIGN/SUBJECTS
Cross-sectional questionnaire of the census of VHA ED directors
MAIN MEASURES
Resources and processes in place for gynecologic, obstetric, sexual assault and mental health care, as well as patient privacy features, stratified by ED characteristics.
KEY RESULTS
All 120 VHA EDs completed the questionnaire. Approximately nine out of ten EDs reported having gynecologic examination tables within their EDs, 24/7 access to specula, and Gonorrhea/Chlamydia DNA probes. All EDs reported 24/7 access to pregnancy testing. Fewer than two-fifths of EDs reported having radiologist review of pelvic ultrasound images available 24/7; one-third reported having emergent consultations from gynecologists available 24/7. Written transfer policies specific to gynecologic and obstetric emergencies were reported as available in fewer than half of EDs. Most EDs reported having emergency contraception 24/7; however, only approximately half reported having Rho(D) Immunoglobulin available 24/7. Templated triage notes and standing orders relevant to gynecologic conditions were reported as uncommon. Consistent with VHA policy, most EDs reported obtaining care for victims of sexual assault by transferring them to another institution. Most EDs reported having some access to private medical and mental health rooms. Resources and processes were found to be more available in EDs with more encounters by women, more ED staffed beds, and that were located in more complex facilities in metropolitan areas.
CONCLUSIONS
Although most VHA EDs have resources and processes needed for delivering emergency care to women Veterans, some gaps exist. Studies in non-VA EDs are required for comparison. Creative solutions are needed to ensure that women presenting to VHA EDs receive efficient, timely, and consistently high-quality care.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2327-7) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-012-2327-7
PMCID: PMC3695270  PMID: 23807069
veterans’ health; women’s health; emergency medicine; organization of care
8.  VA Location and Structural Factors Associated with On-Site Availability of Reproductive Health Services 
Journal of General Internal Medicine  2013;28(Suppl 2):591-597.
ABSTRACT
INTRODUCTION
With the increasing number of women Veterans enrolling in the Veterans Health Administration (VA), there is growing demand for reproductive health services. Little is known regarding the on-site availability of reproductive health services at VA and how this varies by site location and type.
OBJECTIVE
To describe the on-site availability of hormonal contraception, intrauterine device (IUD) placement, infertility evaluation or treatment, and prenatal care by site location and type; the characteristics of sites providing these services; and to determine whether, within this context, site location and type is associated with on-site availability of these reproductive health services.
METHODS
We used data from the 2007 Veterans Health Administration Survey of Women Veterans Health Programs and Practices, a national census of VA sites serving 300 or more women Veterans assessing practice structure and provision of care for women. Hierarchical models were used to test whether site location and type (metropolitan hospital-based clinic, non-metropolitan hospital-based clinic, metropolitan community-based outpatient clinic [CBOC]) were associated with availability of IUD placement and infertility evaluation/treatment. Non-metropolitan CBOCs were excluded from this analysis (n = 2).
RESULTS
Of 193 sites, 182 (94 %) offered on-site hormonal contraception, 97 (50 %) offered on-site IUD placement, 57 (30 %) offered on-site infertility evaluation/treatment, and 11 (6 %) offered on-site prenatal care. After adjustment, compared with metropolitan hospital based-clinics, metropolitan CBOCs were less likely to offer on-site IUD placement (OR 0.33; 95 % CI 0.14, 0.74).
CONCLUSION
Compared with metropolitan hospital-based clinics, metropolitan CBOCs offer fewer specialized reproductive health services on-site. Additional research is needed regarding delivery of specialized reproductive health care services for women Veterans in CBOCs and clinics in non-metropolitan areas.
doi:10.1007/s11606-012-2289-9
PMCID: PMC3695272  PMID: 23807070
women veterans; reproductive health; reproductive health services; Department of Veterans Affairs
10.  Racial/Ethnic Differences in Cardiovascular Risk Factors Among Women Veterans 
Journal of General Internal Medicine  2013;28(Suppl 2):524-528.
ABSTRACT
BACKGROUND
Heart disease is the leading cause of death for women in the United States, accounting for 24.5 % of all deaths among women. Earlier research has demonstrated racial/ethnic differences in prevalence of cardiovascular (CVD) risk factors.
OBJECTIVE
To empirically examine the prevalence of CVD risk factors among a national sample of women Veterans by race/ethnicity, providing the first portrait of women Veterans’ cardiovascular care needs.
DESIGN AND PARTICIPANTS
Cross-sectional, national population-based telephone survey of 3,611 women Veterans.
MEASUREMENTS
Women Veterans were queried about presence of diabetes, hypertension, obesity, tobacco use and physical activity. Four racial/ethnic categories were created: Hispanic, Non-Hispanic White (White), Non-Hispanic Black (Black), and Other. Logistic regressions were conducted for each risk factor to test for racial/ethnic differences, controlling for age (under 40 vs. 40 and over).
KEY RESULTS
Racial/ethnic differences in CVD risk factors persisted after adjusting for age. Black women Veterans were more likely to report a diagnosis of diabetes (OR: 2.58, 95 % CI: 1.07, 6.21) or hypertension (OR: 2.31, 95 % CI: 1.10, 4.83) and be obese (OR: 2.06, 95 % CI: 1.05, 3.91) than White women Veterans. Hispanic women Veterans were more likely than White women Veterans to report diabetes (OR: 4.20, 95 % CI: 1.15, 15.39) and daily smoking (OR: 3.38, 95 % CI: 1.01, 11.30), but less likely to report a hypertension diagnosis (OR 0.21, 95% CI: 0.07, 0.64) or to be obese (OR: 0.39, 95 % CI: 0.18, 0.81).
CONCLUSIONS
Among women Veterans, CVD risks vary by race/ethnicity. Black women Veterans consistently face higher CVD risk compared to White women Veterans, while results are mixed for Hispanic women Veterans.
doi:10.1007/s11606-012-2309-9
PMCID: PMC3695277  PMID: 23807060
cardiovascular disease; risk factors; race; ethnicity; women veterans
11.  Medical Center Characteristics Associated with PSA Screening in Elderly Veterans with Limited Life Expectancy 
ABSTRACT
BACKGROUND
Although guidelines recommend against prostate-specific antigen (PSA) screening in elderly men with limited life expectancy, screening is common.
OBJECTIVE
We sought to identify medical center characteristics associated with screening in this population.
DESIGN/PARTICIPANTS
We conducted a prospective study of 622,262 screen-eligible men aged 70+ seen at 104 VA medical centers in 2003.
MAIN MEASURES
Primary outcome was the percentage of men at each center who received PSA screening in 2003, based on VA data and Medicare claims. Men were stratified into life expectancy groups ranging from favorable (age 70–79 with Charlson score = 0) to limited (age 85+ with Charlson score ≥1 or age 70+ with Charlson score ≥4). Medical center characteristics were obtained from the 1999–2000 VA Survey of Primary Care Practices and publicly available VA data sources.
KEY RESULTS
Among 123,223 (20%) men with limited life expectancy, 45% received PSA screening in 2003. Across 104 VAs, the PSA screening rate among men with limited life expectancy ranged from 25-79% (median 43%). Higher screening was associated with the following center characteristics: no academic affiliation (50% vs. 43%, adjusted RR = 1.14, 95% CI 1.04–1.25), a ratio of midlevel providers to physicians ≥3:4 (55% vs. 45%, adjusted RR = 1.20, 95% CI 1.09–1.32) and location in the South (49% vs. 39% in the West, adjusted RR = 1.25, 95% CI 1.12–1.40). Use of incentives and high scores on performance measures were not independently associated with screening. Within centers, the percentages of men screened with limited and favorable life expectancies were highly correlated (r = 0.90).
CONCLUSIONS
Substantial practice variation exists for PSA screening in older men with limited life expectancy across VAs. The high center-specific correlation of screening among men with limited and favorable life expectancies indicates that PSA screening is poorly targeted according to life expectancy.
doi:10.1007/s11606-011-1945-9
PMCID: PMC3358397  PMID: 22180196
PSA screening; regional variation; elderly; life expectancy
12.  Targeting Primary Care Referrals to Smoking Cessation Clinics Does Not Improve Quit Rates: Implementing Evidence-Based Interventions into Practice 
Health Services Research  2008;43(5 Pt 1):1637-1661.
Objective
To evaluate the impact of a locally adapted evidence-based quality improvement (EBQI) approach to implementation of smoking cessation guidelines into routine practice.
Data Sources/Study Setting
We used patient questionnaires, practice surveys, and administrative data in Veterans Health Administration (VA) primary care practices across five southwestern states.
Study Design
In a group-randomized trial of 18 VA facilities, matched on size and academic affiliation, we evaluated intervention practices’ abilities to implement evidence-based smoking cessation care following structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback, and monitoring. Control practices received mailed guidelines and VA audit-feedback reports as usual care.
Data Collection
To represent the population of primary care-based smokers, we randomly sampled and screened 36,445 patients to identify and enroll eligible smokers at baseline (n = 1,941) and follow-up at 12 months (n = 1,080). We used computer-assisted telephone interviewing to collect smoking behavior, nicotine dependence, readiness to change, health status, and patient sociodemographics. We used practice surveys to measure structure and process changes, and administrative data to assess population utilization patterns.
Principal Findings
Intervention practices adopted multifaceted EBQI plans, but had difficulty implementing them, ultimately focusing on smoking cessation clinic referral strategies. While attendance rates increased (p<.0001), we found no intervention effect on smoking cessation.
Conclusions
EBQI stimulated practices to increase smoking cessation clinic referrals and try other less evidence-based interventions that did not translate into improved quit rates at a population level.
doi:10.1111/j.1475-6773.2008.00865.x
PMCID: PMC2653889  PMID: 18522670
Smoking cessation; quality of health care; veterans
13.  Implementation and Spread of Interventions Into the Multilevel Context of Routine Practice and Policy: Implications for the Cancer Care Continuum 
The promise of widespread implementation of efficacious interventions across the cancer continuum into routine practice and policy has yet to be realized. Multilevel influences, such as communities and families surrounding patients or health-care policies and organizations surrounding provider teams, may determine whether effective interventions are successfully implemented. Greater recognition of the importance of these influences in advancing (or hindering) the impact of single-level interventions has motivated the design and testing of multilevel interventions designed to address them. However, implementing research evidence from single- or multilevel interventions into sustainable routine practice and policy presents substantive challenges. Furthermore, relatively few multilevel interventions have been conducted along the cancer care continuum, and fewer still have been implemented, disseminated, or sustained in practice. The purpose of this chapter is, therefore, to illustrate and examine the concepts underlying the implementation and spread of multilevel interventions into routine practice and policy. We accomplish this goal by using a series of cancer and noncancer examples that have been successfully implemented and, in some cases, spread widely. Key concepts across these examples include the importance of phased implementation, recognizing the need for pilot testing, explicit engagement of key stakeholders within and between each intervention level; visible and consistent leadership and organizational support, including financial and human resources; better understanding of the policy context, fiscal climate, and incentives underlying implementation; explication of handoffs from researchers to accountable individuals within and across levels; ample integration of multilevel theories guiding implementation and evaluation; and strategies for long-term monitoring and sustainability.
doi:10.1093/jncimonographs/lgs004
PMCID: PMC3482959  PMID: 22623601
14.  Yield of Practice-Based Depression Screening In VA Primary Care Settings 
Background
Many patients who should be treated for depression are missed without effective routine screening in primary care (PC) settings. Yearly depression screening by PC staff is mandated in the VA, yet little is known about the expected yield from such screening when administered on a practice-wide basis.
Objective
We characterized the yield of practice-based screening in diverse PC settings, as well as the care needs of those assessed as having depression.
Design
Baseline enrollees in a group randomized trial of implementation of collaborative care for depression.
Participants
Randomly sampled patients with a scheduled PC appointment in ten VA primary care clinics spanning five states.
Measurements
PHQ-2 screening followed by the full PHQ-9 for screen positives, with standardized sociodemographic and health status questions.
Results
Practice-based screening of 10,929 patients yielded 20.1% positive screens, 60% of whom were assessed as having probable major depression based on the PHQ-9 (11.8% of all screens) (n = 1,313). In total, 761 patients with probable major depression completed the baseline assessment. Comorbid mental illnesses (e.g., anxiety, PTSD) were highly prevalent. Medical comorbidities were substantial, including chronic lung disease, pneumonia, diabetes, heart attack, heart failure, cancer and stroke. Nearly one-third of the depressed PC patients reported recent suicidal ideation (based on the PHQ-9). Sexual dysfunction was also common (73.3%), being both longstanding (95.1% with onset >6 months) and frequently undiscussed and untreated (46.7% discussed with any health care provider in past 6 months).
Conclusions
Practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. The substantial level of comorbid physical and mental illness among PC patients precludes solo management by either PC or mental health (MH) specialists. PC practice- and provider-level guideline adherence is problematic without systems-level solutions supporting adequate MH assessment, PC treatment and, when needed, appropriate MH referral.
doi:10.1007/s11606-011-1904-5
PMCID: PMC3286554  PMID: 21975821
depression; screening; primary care; health care delivery; veterans
15.  Primary Care Practice Organization Influences Colorectal Cancer Screening Performance 
Health Services Research  2007;42(3 Pt 1):1130-1149.
Objective
To identify primary care practice characteristics associated with colorectal cancer (CRC) screening performance, controlling for patient-level factors.
Data Sources/Study Setting
Primary care director survey (1999–2000) of 155 VA primary care clinics linked with 38,818 eligible patients' sociodemographics, utilization, and CRC screening experience using centralized administrative and chart-review data (2001).
Study Design
Practices were characterized by degrees of centralization (e.g., authority over operations, staffing, outside-practice influence); resources (e.g., sufficiency of nonphysician staffing, space, clinical support arrangements); and complexity (e.g., facility size, academic status, managed care penetration), adjusting for patient-level covariates and contextual factors.
Data Collection/Extraction Methods
Chart-based evidence of CRC screening through direct colonoscopy, sigmoidoscopy, or consecutive fecal occult blood tests, eliminating cases with documented histories of CRC, polyps, or inflammatory bowel disease.
Principal Findings
After adjusting for sociodemographic characteristics and health care utilization, patients were significantly more likely to be screened for CRC if their primary care practices had greater autonomy over the internal structure of care delivery (p<.04), more clinical support arrangements (p < .03), and smaller size (p < .001).
Conclusions
Deficits in primary care clinical support arrangements and local autonomy over operational management and referral procedures are associated with significantly lower CRC screening performance. Competition with hospital resource demands may impinge on the degree of internal organization of their affiliated primary care practices.
doi:10.1111/j.1475-6773.2006.00643.x
PMCID: PMC1955248  PMID: 17489907
Primary health care; colorectal cancer; prevention; quality of health care; veterans
16.  Does the presence of a pharmacist in primary care clinics improve diabetes medication adherence? 
Background
Although oral hypoglycemic agents (OHAs) are an essential element of therapy for the management of type 2 diabetes, OHA adherence is often suboptimal. Pharmacists are increasingly being integrated into primary care as part of the move towards a patient-centered medical home and may have a positive influence on medication use. We examined whether the presence of pharmacists in primary care clinics was associated with higher OHA adherence.
Methods
This retrospective cohort study analyzed 280,603 diabetes patients in 196 primary care clinics within the Veterans Affairs healthcare system. Pharmacists presence, number of pharmacist full-time equivalents (FTEs), and the degree to which pharmacy services are perceived as a bottleneck in each clinic were obtained from the 2007 VA Clinical Practice Organizational Survey—Primary Care Director Module. Patient-level adherence to OHAs using medication possession ratios (MPRs) were constructed using refill data from administrative pharmacy databases after adjusting for patient characteristics. Clinic-level OHA adherence was measured as the proportion of patients with MPR >= 80%. We analyzed associations between pharmacy measures and clinic-level adherence using linear regression.
Results
We found no significant association between pharmacist presence and clinic-level OHA adherence. However, adherence was lower in clinics where pharmacy services were perceived as a bottleneck.
Conclusions
Pharmacist presence, regardless of the amount of FTE, was not associated with OHA medication adherence in primary care clinics. The exact role of pharmacists in clinics needs closer examination in order to determine how to most effectively use these resources to improve patient-centered outcomes including medication adherence.
doi:10.1186/1472-6963-12-391
PMCID: PMC3537712  PMID: 23148570
Pharmacist; Medication adherence; Diabetes mellitus; Oral hypoglycemic agent; Patient-centered medical home
17.  Access to Care for Women Veterans: Delayed Healthcare and Unmet Need 
Journal of General Internal Medicine  2011;26(Suppl 2):655-661.
ABSTRACT
BACKGROUND
Timely access to healthcare is essential to ensuring optimal health outcomes, and not surprisingly, is at the heart of healthcare reform efforts. While the Veterans Health Administration (VA) has made improved access a priority, women veterans still underutilize VA healthcare relative to men. Eliminating access disparities requires a better understanding of the barriers to care that women veterans’ experience.
OBJECTIVE
We examined the association of general and veteran-specific barriers on access to healthcare among women veterans.
DESIGN AND PARTICIPANTS
Cross-sectional, population-based national telephone survey of 3,611 women veterans.
MAIN MEASURE
Delayed healthcare or unmet healthcare need in the prior 12 months.
KEY RESULTS
Of women veterans, 19% had delayed healthcare or unmet need, with higher rates in younger age groups (36%, 29%, 16%, 7%, respectively, in 18–34, 35–49, 50–64, and 65-plus age groups; p < 0.001). Among those delaying or going without care, barriers that varied by age group were: unaffordable healthcare (63% of 18–34 versus 12% of 65-plus age groups); inability to take off from work (39% of those <50); and transportation difficulties (36% of 65-plus). Controlling for age, race/ethnicity, regular source of care, and health status, being uninsured (OR = 6.5; confidence interval [CI] 3.0–14.0), knowledge gaps about VA care (OR = 2.1; 95% CI 1.1–4.0), perception that VA providers are not gender-sensitive (OR = 2.4; CI 1.2–4.7), and military sexual assault history (OR = 2.1; CI 1.1–4.0) predicted delaying or foregoing care, whereas VA use and enrollment priority did not.
CONCLUSIONS
Both general and veteran-specific factors impact women veterans’ access to needed services. Many of the identified access barriers are potentially modifiable through expanded VA healthcare and social services. Health reform efforts should address these barriers for VA nonusers. Efforts are also warranted to improve women veterans’ knowledge of availability and affordability of VA healthcare, and to enhance the gender-sensitivity of this care.
doi:10.1007/s11606-011-1772-z
PMCID: PMC3191223  PMID: 21989618
access to care; women veterans; VA healthcare; health services need; health services utilization
18.  Variations in Nurse Practitioner Use in Veterans Affairs Primary Care Practices 
Health Services Research  2004;39(4 Pt 1):887-904.
Background
Increasingly, primary care practices include nurse practitioners (NPs) in their staffing mix to contain costs and expand primary care. To achieve these aims in U.S. Department of Veterans Affairs medical centers (VAMCs), national policy endorsed involvement of NPs as primary care (PC) providers.
Objectives
To evaluate the degree to which VAMCs incorporated NPs into PC practices between 1996 and 1999, and to identify the internal and external practice environment features associated with NP use.
Study Design
We surveyed 131 PC directors of all VAMCs in 1996 and 1999 to ascertain the staffing and characteristics of the PC practice and parent organization (e.g., academic affiliation, level of physician staffing, use of managed care arrangements), and drew on previously published studies and HRSA State Health Workforce Profiles to characterize each practice's regional health care environment (e.g., geographic region, state NP practice laws, state managed care penetration). Using multivariate linear regression, we evaluate the contribution of these environmental and organizational factors on the number of NPs/10,000 PC patients in 1999, controlling for the rate of NP use in 1996.
Principal Findings
From 1996–1999, NP use increased from 75 percent to 90 percent in VA PC practices. The mean number of NPs per practice increased by about 60 percent (2.0 versus 3.2; p<.001), while the rate of NPs/10,000 PC patients trended upward (2.2 versus 2.7; p=.09). Staffing of other primary care clinicians (e.g., physicians and physician assistants per practice) remained stable, while the NP-per-physician rate increased (0.2 versus 0.4; p<.001). After multivariate adjustment, greater reliance on managed-care-oriented provider education programs (p=.02), the presence of NP training programs (p=.05), and more specialty-trained physicians/10,000 PC patients (p=.09) were associated with greater NP involvement in primary care.
Conclusions
Staffing models in VA PC practices have, in fact, changed, with NPs having a greater presence. However, we found substantial practice-based variations in their use, suggesting that more research is needed to better understand how they have been integrated into practice and what impact their involvement has had on the VA's ability to achieve its restructuring goals.
doi:10.1111/j.1475-6773.2004.00263.x
PMCID: PMC1361043  PMID: 15230933
Nurse practitioner; primary care staffing; practice characteristics; environmental characteristics
19.  UROLOGIC DISEASE BURDEN IN THE UNITED STATES: VETERAN USERS OF VA HEALTH CARE 
Urology  2008;72(1):37-41.
Objectives
To determine the disease burden, measured by resource utilization, of four urologic conditions among veteran users of VA health care services and to assess variations by selected socio-demographic characteristics.
Methods
We applied expert-derived diagnosis clusters to establish four patient cohorts from a population of U.S. veterans age 18 and older with at least 1 outpatient visit in a VA health care facility in Fiscal year 2001 (n=3,691,519): (1) benign prostatic hyperplasia/lower urinary tract symptoms (BPH/LUTS), (2) kidney stones (KS), (3) urinary tract infections (UTI), and (4) urinary incontinence (UI). We identified patients with qualifying diagnosis codes associated with outpatient visits in the national VA Outpatient Clinic file thereby generating case counts for each diagnostic category.
Results
Among veteran users of VA health care services, when defined as the primary reason for the visit, the prevalence of BPH/LUTS was 4,811 per 100,000 veterans (4.8%); the prevalence of KS was 597 per 100,000 (0.6%); the prevalence of UTI was 4,265 and 1,719 per 100,000 female and male veterans, respectively (4.3% and 1.7%); and the prevalence of UI was 2,161 and 515 per 100,000 female and male veterans, respectively (2.2% and 0.5%). Prevalence of these conditions when ascertained by capturing diagnoses appearing as secondary reasons for a physician visit was much higher.
Conclusions
Although we expected the prevalence of urologic conditions to be high among veterans who use the VA system for care, we found the burden of urologic disease among veterans to be comparable to other national data sets. Prevalence estimates based on primary diagnosis, rather than secondary or “any” diagnosis, significantly underestimated the disease burden among veterans.
doi:10.1016/j.urology.2007.11.163
PMCID: PMC3361891  PMID: 18342928
20.  Implementing collaborative care for depression treatment in primary care: A cluster randomized evaluation of a quality improvement practice redesign 
Background
Meta-analyses show collaborative care models (CCMs) with nurse care management are effective for improving primary care for depression. This study aimed to develop CCM approaches that could be sustained and spread within Veterans Affairs (VA). Evidence-based quality improvement (EBQI) uses QI approaches within a research/clinical partnership to redesign care. The study used EBQI methods for CCM redesign, tested the effectiveness of the locally adapted model as implemented, and assessed the contextual factors shaping intervention effectiveness.
Methods
The study intervention is EBQI as applied to CCM implementation. The study uses a cluster randomized design as a formative evaluation tool to test and improve the effectiveness of the redesign process, with seven intervention and three non-intervention VA primary care practices in five different states. The primary study outcome is patient antidepressant use. The context evaluation is descriptive and uses subgroup analysis. The primary context evaluation measure is naturalistic primary care clinician (PCC) predilection to adopt CCM.
For the randomized evaluation, trained telephone research interviewers enrolled consecutive primary care patients with major depression in the evaluation, referred enrolled patients in intervention practices to the implemented CCM, and re-surveyed at seven months.
Results
Interviewers enrolled 288 CCM site and 258 non-CCM site patients. Enrolled intervention site patients were more likely to receive appropriate antidepressant care (66% versus 43%, p = 0.01), but showed no significant difference in symptom improvement compared to usual care. In terms of context, only 40% of enrolled patients received complete care management per protocol. PCC predilection to adopt CCM had substantial effects on patient participation, with patients belonging to early adopter clinicians completing adequate care manager follow-up significantly more often than patients of clinicians with low predilection to adopt CCM (74% versus 48%%, p = 0.003).
Conclusions
Depression CCM designed and implemented by primary care practices using EBQI improved antidepressant initiation. Combining QI methods with a randomized evaluation proved challenging, but enabled new insights into the process of translating research-based CCM into practice. Future research on the effects of PCC attitudes and skills on CCM results, as well as on enhancing the link between improved antidepressant use and symptom outcomes, is needed.
Trial Registration
ClinicalTrials.gov: NCT00105820
doi:10.1186/1748-5908-6-121
PMCID: PMC3219630  PMID: 22032247
21.  The Burden of Illness in the First Year Home: Do Male and Female VA Users Differ in Health Conditions and Healthcare Utilization 
Background
We sought to describe gender differences in medical and mental health conditions and health care utilization among veterans who used Veterans Health Administration (VA) services in the first year after combat in Iraq and Afghanistan.
Methods
This is an observational study, using VA administrative and clinical data bases, of 163,812 Operation Enduring Freedom/Operation Iraqi Freedom veterans who had enrolled in VA and who had at least one visit within 1 year of last deployment.
Results
Female veterans were slightly younger (mean age, 30 years vs. 32 for men; p <.0001), twice as likely to be African American (30% vs. 15%; p <.0001), and less likely to be married (32% vs. 49%; p < .0001). Women had more visits to primary care (2.6 vs. 2.0; p < .001) and mental health (4.0 vs. 3.6; p < .001) clinics and higher use of community care outside the VA (14% vs. 10%; p < .001). After adjustment for significant demographic differences, women were more likely to have musculoskeletal and skin disorders, mild depression, major depression, and adjustment disorders, whereas men were more likely to have ear disorders and posttraumatic stress disorder. Thirteen percent of women sought care for gynecologic examination, 10% for contraceptive counseling, and 7% for menstrual disorders.
Conclusion
Female veterans had similar rates of physical conditions, but higher rates of some mental health disorders and additionally, used the VA for reproductive health needs. They also had slightly greater rates of health care service use. These findings highlight the complexity of female Veteran health care and support the development of enhanced comprehensive women’s health services within the VA.
doi:10.1016/j.whi.2010.08.001
PMCID: PMC3138124  PMID: 21185994
22.  The Impact of Integrated HIV Care on Patient Health Outcomes 
Medical care  2009;47(5):560-567.
Background
Control of viral replication through combination antiretroviral therapy (cART) improves patient health outcomes. Yet many HIV-infected patients have co-morbidities that pose social and clinical barriers to achieving viral suppression. Integration of subspecialty services into HIV primary care may overcome such barriers.
Objective
Evaluate effect of Integrated HIV Care on suppression of HIV replication.
Research Design
A retrospective cohort study of HIV patients from five Veterans Affairs healthcare facilities 2000–2006.
Subjects
Patients with >3 months of follow-up, sufficient baseline HIV severity, on cART.
Measures
We measured and ranked Integrated Care at the facilities. These rankings were applied to patient visits to form an index of Integrated HIV Care utilization. We evaluated effect of Integrated HIV Care utilization on likelihood of achieving viral suppression while on cART, controlling for demographic and clinical factors using survival analysis.
Results
The 1,018 HIV-infected patients eligible for analysis had substantial barriers to responding to cART: 93% had co-morbidities with mean 3.2 co-morbidities per patient (S.D.=2.0); 52% achieved viral suppression in median 231 days (S.D.=411.6). Patients visiting clinics which offered hepatitis, psychiatric, psychological and social services in addition to HIV primary care were 3.1 times more likely to achieve viral suppression than patients visiting clinics which offered only HIV primary care (Hazard ratio=3.1, p<.001).
Conclusions
Patients who visited Integrated HIV Care clinics were more likely to achieve viral suppression while on cART. Future research should investigate which elements of Integrated Care are most associated with viral control and what role provider experience plays in this association.
doi:10.1097/MLR.0b013e31819432a0
PMCID: PMC3108041  PMID: 19318998
23.  Use of Radical Cystectomy for Patients With Invasive Bladder Cancer 
Background
Evidence-based guidelines recommend radical cystectomy for patients with muscle-invasive bladder cancer. However, many patients receive alternate therapies, such as chemotherapy or radiation. We examined factors that are associated with the use of radical cystectomy for invasive bladder cancer and compared the survival outcomes of patients with invasive bladder cancer by the treatment they received.
Methods
From linked Surveillance, Epidemiology, and End Results–Medicare data, we identified a cohort of 3262 Medicare beneficiaries aged 66 years or older at diagnosis with stage II muscle-invasive bladder cancer from January 1, 1992, through December 31, 2002. We examined the use of radical cystectomy with multilevel multivariable models and survival after diagnosis with the use of instrumental variable analyses. All statistical tests were two-sided.
Results
A total of 21% of the study subjects underwent radical cystectomy. Older age at diagnosis and higher comorbidity were associated with decreased odds of receiving cystectomy (for those ≥80 vs 66–69 years old, odds ratio [OR] = 0.10, 95% confidence interval [CI] = 0.07 to 0.14; for Charlson comorbidity index of 3 vs 0–1, OR = 0.25, 95% CI = 0.14 to 0.45). Long travel distance to an available surgeon was associated with decreased odds of receiving cystectomy (for >50 vs 0–4 miles travel distance to an available surgeon, OR = 0.60, 95% CI = 0.37 to 0.98). Overall survival was better for those who underwent cystectomy compared with those who underwent alternative treatments (for chemotherapy and/or radiation vs cystectomy, hazard ratio of death = 1.5, 95% CI = 1.3 to 1.8; for surveillance vs cystectomy, hazard ratio of death = 1.9, 95% CI = 1.6 to 2.3; 5-year adjusted survival: 42.2% [95% CI = 39.1% to 45.4%] for cystectomy; 20.7% [95% CI = 18.7% to 22.8%] for chemotherapy and/or radiation; 14.5% [95% CI = 13.0% to 16.2%] for surveillance).
Conclusions
Guideline-recommended care with radical cystectomy is underused for patients with muscle-invasive bladder cancer. Many bladder cancer patients whose survival outcomes might benefit with surgery are receiving alternative less salubrious treatments.
doi:10.1093/jnci/djq121
PMCID: PMC3245689  PMID: 20400716
24.  'To take care of the patients': Qualitative analysis of Veterans Health Administration personnel experiences with a clinical informatics system 
Background
The Veterans Health Administration (VA) has invested significant resources in designing and implementing a comprehensive electronic health record (EHR) that supports clinical priorities. EHRs in general have been difficult to implement, with unclear cost-effectiveness. We describe VA clinical personnel interactions with and evaluations of the EHR.
Methods
As part of an evaluation of a quality improvement initiative, we interviewed 72 VA clinicians and managers using a semi-structured interview format. We conducted a qualitative analysis of interview transcripts, examining themes relating to participants' interactions with and evaluations of the VA EHR.
Results
Participants described their perceptions of the positive and negative effects of the EHR on their clinical workflow. Although they appreciated the speed and ease of documentation that the EHR afforded, they were concerned about the time cost of using the technology and the technology's potential for detracting from interpersonal interactions.
Conclusions
VA personnel value EHRs' contributions to supporting communication, education, and documentation. However, participants are concerned about EHRs' potential interference with other important aspects of healthcare, such as time for clinical care and interpersonal communication with patients and colleagues. We propose that initial implementation of an EHR is one step in an iterative process of ongoing quality improvement.
doi:10.1186/1748-5908-5-63
PMCID: PMC2931450  PMID: 20727182
25.  Does Gender Influence Immunization Status for Influenza and Pneumonia Among Older Veterans? 
Background
While adult immunization rates in the Department of Veterans Affairs (VA) remain higher than national rates in the United States, little is known about immunizations among one of the fastest growing populations of new VA users – women.
Objectives
We compared the prevalence of influenza and pneumococcal immunization rates by gender in a national sample of older veterans in the VA system.
Design and Setting
We used a retrospective, cross-sectional sample of older veterans (age 65+) in the VA healthcare system eligible for immunization in Fiscal Years 2000-2003. We performed generalized estimating equations to analyze combined chart review and administrative data to determine effect of gender on receipt of each immunization.
Participants
Current veteran VA users age 65 and older (N=48,424 patient records).
Measurements
Receipt of influenza immunization and receipt of pneumococcal immunization.
Results
Unadjusted immunization rates were higher for men compared to women for influenza (73% vs. 69%) and pneumococcal vaccine (87% vs. 83%). Adjusting for demographics, clinical co-morbidities, utilization and region, we found that women had a significantly lower odds of both influenza (OR 0.85, 95% CI 0.79, 0.92) and pneumococcal immunization (OR 0.77, 95% CI 0.71, 0.84).
Conclusion
Older women veterans have lower rates of immunization compared to older men veterans in VA settings. While VA remains above community levels for immunization, older women veterans will benefit from targeted efforts to increase immunization prevalence.
doi:10.1111/j.1532-5415.2009.02316.x
PMCID: PMC2785130  PMID: 19515114
immunizations; preventive health services; women; veterans; elderly

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