Purchased Behavioral Health Care Received by Military Health System Beneficiaries in Civilian Medical Facilities, 2000-2014.

Introduction: Behavioral health conditions are a significant concern for the U.S. military and the Military Health System (MHS) because of decreased military readiness and increased health care utilization. Although MHS beneficiaries receive direct care in military treatment facilities, a disproportionate majority of behavioral health treatment is purchased care received in civilian facilities. Yet, limited evidence exists about purchased behavioral health care received by MHS beneficiaries. This longitudinal study (1) estimated the prevalence of purchased behavioral health care and (2) identified patient and visit characteristics predicting receipt of purchased behavioral health care in acute care facilities from 2000 to 2014. Materials and Methods: Medical claims with Major Diagnostic Code 19 (mental disorders/diseases) or 20 (alcohol/drug disorders) as primary diagnoses and TRICARE as the primary/secondary payer were analyzed for MHS beneficiaries (n = 17,943) receiving behavioral health care in civilian acute care facilities from January 1, 2000, to December 31, 2014. The primary dependent variable, receipt of purchased behavioral health care, was modeled for select mental health and substance use disorders from 2000 to 2014 using generalized estimating equations. Patient characteristics included time, age, sex, and race/ethnicity. Visit types included inpatient hospitalization and emergency department (ED). Time was measured in days and visits were assumed to be correlated over time. Behavioral health care was described by both frequency of patients and visit type. The University of South Carolina Institutional Review Board approved this study. Results: From 2000 to 2014, purchased care visits increased significantly for post-traumatic stress disorder, adjustment, anxiety, mood, bipolar, tobacco use, opioid/combination opioid dependence, nondependent cocaine abuse, psychosocial problems, and suicidal ideation among MHS beneficiaries. The majority of care was received for mental health disorders (78.8%) and care was most often received in EDs (56%). Most commonly treated diagnoses included mood, tobacco use, and alcohol use disorders. ED visits were associated with being treated for anxiety (excluding post-traumatic stress disorder; Adjusted odds ratio [AOR]: 9.14 [95% confidence interval (CI): 8.26, 10.12]), alcohol use disorders (AOR = 1.67 [95% CI: 1.53, 1.83]), tobacco use (AOR = 1.16 [95% CI: 1.06, 1.26]), nondependent cocaine abuse (AOR = 5.47 [95% CI: 3.28, 9.12]), nondependent mixed/unspecified drug abuse (AOR = 7.30 [95% CI: 5.11, 10.44]), and psychosis (AOR = 1.38 [95% CI: 1.20, 1.58]). Compared with adults age 60 yr and older, adolescents (ages 12-17 yr), and adults under age 60 yr were more likely to be treated for suicidal ideation, adjustment, mood, bipolar, post-traumatic stress disorder, nondependent cocaine, and mixed/unspecified drug abuse. Adults under age 60 yr also had increased odds of being treated for tobacco use disorders, alcohol use disorders, and opioid/combination opioid dependence compared with adults age 60 yr and older. Conclusions: Over the past 15 yr, purchased behavioral health care received by MHS beneficiaries in acute care facilities increased significantly. MHS beneficiaries received the majority of purchased behavioral health care for mental health disorders and were treated most often in the ED. Receiving behavioral health care in civilian EDs raises questions about access to outpatient behavioral health care and patient-centered care coordination between civilian and military facilities. Given the influx of new Veterans Health Administration users from the MHS, findings have implications for military, veteran, and civilian facilities providing behavioral health care to military and veteran populations.

Perceptions of U.S. Veterans Affairs and community healthcare providers regarding cross-system care for heart failure.

OBJECTIVES: This study explores perceptions of US Veterans Affairs (VA) and non-VA healthcare providers caring for Veterans with heart failure (HF) regarding Veteran knowledge and motivations for dual use, provider roles in recommending and coordinating dual use, systems barriers and facilitators, and suggestions for improving cross-system care. METHODS: Twenty VA and 11 non-VA providers participated in semi-structured interviews, which were analyzed using parallel qualitative content and discourse analysis. RESULTS: VA and non-VA providers described variable HF knowledge and self-management among Veterans, and both groups described the need for improved education addressing medication adherence, self-care, and management of acute symptoms. Both groups described highly limited roles for providers in shaping choices surrounding dual use. VA and non-VA providers had significantly different perceptions regarding the availability, quality, and effectiveness of VA HF services. Multiple non-VA providers expressed frustration with and difficulty in contacting VA providers, accessing records, and making referrals into the VA system. Suggestions for improved care focused on patient education and care coordination. DISCUSSION: Dual healthcare system use for Veterans is increasingly common. Similarities and contrasts in perceptions of VA and non-VA providers are instructive and should be incorporated into future policy and program initiatives.

Effect of Long-Term Periodontal Care on Hemoglobin A1c in Type 2 Diabetes.

This was a prospective cohort study evaluating 126,805 individuals with diabetes and periodontal disease receiving care at all Veterans Administration medical centers and clinics in the United States from 2005 through 2012. The exposures were periodontal treatment at baseline (PT0) and at follow-up (PT2). The outcomes were change in HbA1c following initial treatment (ΔHbA1c1) and follow-up treatment (ΔHbA1c2), and diabetes control was defined as HbA1c at <7% and <9% following initial and follow-up treatment, respectively. Marginal structural models were used to account for potential confounding and selection bias. The objective was to evaluate the impact of long-term treatment of periodontal disease on glycemic control among individuals with type 2 diabetes. Participants were 64 y old on average, 97% were men, and 71% were white. At baseline, the average diabetes duration was 4 y, 12% of participants were receiving insulin, and 60% had HbA1c <7%. After an average 1.7 y of follow-up, the mean HbA1c increased from 7.03% to 7.21%. About 29.4% of participants attended their periodontal maintenance visit following baseline. Periodontal treatment at baseline and follow-up reduced HbA1c by -0.02% and -0.074%, respectively. Treatment at follow-up increased the likelihood of individuals achieving diabetes control by 5% and 3% at the HbA1c <7% and HbA1c <9% thresholds, respectively, and was observed even among never smokers. HbA1c reduction after periodontal treatment at follow-up was greater (ΔHbA1c2 = -0.25%) among individuals with higher baseline HbA1c. Long-term periodontal care provided in a clinical setting improved long-term glycemic control among individuals with type 2 diabetes and periodontal disease.

Intervention to improve care at life's end in inpatient settings: the BEACON trial.

BACKGROUND: Widespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings. OBJECTIVE: To evaluate the effectiveness of a multi-modal intervention strategy to improve processes of end-of-life care in inpatient settings. DESIGN: Implementation trial with an intervention staggered across hospitals using a multiple-baseline, stepped wedge design. PARTICIPANTS: Six Veterans Affairs Medical Centers (VAMCs). INTERVENTION: Staff training was targeted to all hospital providers and focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set and paper-based educational tools. MAIN MEASURES: Several processes of care were identified as quality endpoints for end-of-life care (last 7 days) and abstracted from electronic medical records of veterans who died before or after intervention (n = 6,066). Primary endpoints were proportion with an order for opioid pain medication at time of death, do-not-resuscitate order, location of death, nasogastric tube, intravenous line infusing, and physical restraints. Secondary endpoints were administration of opioids, order/administration of antipsychotics, benzodiazepines, and scopolamine (for death rattle); sublingual administration; advance directives; palliative care consultations; and pastoral care services. Generalized estimating equations were conducted adjusting for longitudinal trends. KEY RESULTS: Significant intervention effects were observed for orders for opioid pain medication (OR: 1.39), antipsychotic medications (OR: 1.98), benzodiazepines (OR: 1.39), death rattle medications (OR: 2.77), sublingual administration (OR: 4.12), nasogastric tubes (OR: 0.71), and advance directives (OR: 1.47). Intervention effects were not significant for location of death, do-not-resuscitate orders, intravenous lines, or restraints. CONCLUSIONS: This broadly targeted intervention strategy led to modest but statistically significant changes in several processes of care, indicating its potential for widespread dissemination to improve end-of-life care for thousands of patients who die each year in inpatient settings.

Smoking as a risk factor for prostate cancer: a meta-analysis of 24 prospective cohort studies.

OBJECTIVES: We evaluated the relationship between smoking and adenocarcinoma of the prostate. METHODS: We pooled data from 24 cohort studies enrolling 21 579 prostate cancer case participants for a general variance-based meta-analysis. Summary relative risks (RRs) and 95% confidence intervals (CIs) were calculated separately for mortality and incidence studies. We tested the robustness of effect measures and evaluated statistical heterogeneity with sensitivity analyses. RESULTS: In the pooled data, current smokers had no increased risk of incident prostate cancer (RR = 1.04; 95% CI = 0.87, 1.24), but in data stratified by amount smoked they had statistically significant elevated risk (cigarettes per day or years: RR = 1.22; 95% CI = 1.01, 1.46; pack years of smoking: RR = 1.11; 95% CI = 1.01, 1.22). Former smokers had an increased risk (RR = 1.09; 95% CI = 1.02, 1.16). Current smokers had an increased risk of fatal prostate cancer (RR = 1.14; 95% CI = 1.06, 1.19). The heaviest smokers had a 24% to 30% greater risk of death from prostate cancer than did nonsmokers. CONCLUSIONS: Observational cohort studies show an association of smoking with prostate cancer incidence and mortality. Ill-defined exposure categories in many cohort studies suggest that pooled data underestimate risk.

The Clinical Nurse Leader: impact on practice outcomes in the Veterans Health Administration.

The Clinical Nurse Leader (CNL) role was designed to meet an identified need for expert clinical leadership at the point of care. The Veterans Health Administration (VHA) became early adopters of the CNL role, foreseeing the value of this pivotal clinical leader at the point of care to meet the complex health care needs of America's veterans and shape health care delivery. Impact data were collected and assimilated from seven Veterans Administration Medical Centers to support how CNLs impact the delivery of quality and safe patient care and how practice changes could be sustained. Data collection and analyses resulted in many lessons learned. The new CNL role was implemented in a variety of settings in the VHA system. Integration of the CNL role in all areas of practice in every care setting has the promise of streamlining coordination of care for veterans across all spectrums in the provision of care.

Measurement of cell proliferation by labeling of DNA with stable isotope-labeled glucose: studies in vitro, in animals, and in humans.

A method for measuring DNA synthesis and, thus, cell proliferation, in vivo is presented. The technique consists of administering [6,6-2H2]Glc or [U-13C]Glc, isolating genomic DNA, hydrolyzing enzymatically to free deoxyribonucleosides, and derivatizing for GC-MS analysis of dA or dG isotopic enrichments, or both. Comparison of dA or dG to extracellular Glc enrichment (with a correction for intracellular dilution) reveals the fraction of newly synthesized DNA, by application of the precursor-product relationship. Thus, the technique differs from the widely used [3H]thymidine or BrdUrd techniques in that the de novo nucleotide synthesis pathway, rather than the nucleoside salvage pathway, is used to label DNA; the deoxyribose rather than the base moiety is labeled; purine rather than pyrimidine deoxyribonucleosides are analyzed; and stable isotopes rather than radioisotopes are used. The method is applied here in vitro to the growth of HepG2 and H9 cells in culture; in animals to proliferation of intestinal epithelium, thymus, and liver; and in humans to granulocyte turnover in blood. In all instances, measured cell proliferation kinetics were consistent with expected or independently measured kinetics. The method has several advantages over previously available techniques for measuring cell turnover, involves no radioactivity or potentially toxic metabolites, and is suitable for use in humans. The availability of a reliable and safe method for measuring cell proliferation in humans opens up a number of fundamental questions to direct experimental testing, including basic problems related to cancer, AIDS, and other pathologic states.

Relationships between stages of change in cigarette smokers and healthy lifestyle behaviors in a population of young military personnel during forced smoking abstinence.

This study evaluated the relationships between stages of change and related health behaviors in a population of smokers forced to quit smoking. Participants were 10,136 Air Force recruits who were in basic military training (BMT) and who were not allowed to smoke because of a ban on smoking during BMT. Participants were surveyed about their smoking history, their motivation and readiness to remain smoke free after BMT, and their behavior on 5 target health areas. Results indicated that smoking history best predicted stage of change. Though there were few gender differences, several ethnic differences emerged. These results suggest that, although stages of change involve both a cognitive and behavioral component, removing the behavioral component (smoking) through a smoking ban does not reduce the construct validity of the transtheoretical model.

Oncology case management linking structure and process with clinical and financial outcomes.

Case management programs have emerged in a variety of models. Current literature about the structure and process of case management programs has not always clearly described linkages with outcomes. Therefore, the purpose of this article is to describe a case management program, apply the model with oncology patients, and then to clarify the structure and process that the authors believe are correlated strongly with both clinical and financial indicators of quality. Planning for the case management program involved interdisciplinary inpatient staff and personnel from the ambulatory oncology clinics. After program implementation, data on patients with a diagnosis of chemotherapy without acute leukemia (DRG 410) were collected throughout 1 year (March 1995-February 1996). Results indicated a reduction in length of stay and side effects of chemotherapy linked to the improvement in process. The primary recommendation to nurse managers who are considering a case management program is to carefully decide on a structure and process that can be formalized before the program is implemented.

Job satisfaction correlates among Palestinian nurses in the West Bank.

The recruitment and retention of highly qualified nurses present ongoing challenges to nursing service administrators throughout the world. Retention of nurses has been closely linked both to job satisfaction and selected demographic factors. Administrators must be aware of these demographic factors due to their importance to employees. The primary purpose of this study was to examine demographic correlates of job satisfiers and dissatisfiers among nurses in the West Bank of Palestine. Both the McCloskey/Mueller Satisfaction Scale (MMSS) and a single overall job satisfaction item were used to survey the entire population (n = 330) of nurses employed in 20 acute care hospitals. Significant relationships were found between job satisfaction and the demographic characteristics of marital status, distance traveled to work, number of years the nurse worked as an RN, and extended family responsibilities. This study of job satisfaction among nurses in a geographic location not previously studied provides nursing leaders in the West Bank with important information as they seek to retain and recruit nurses. The findings support the use of the MMSS in non-US countries and cultures. However, an argument is presented for further refinement of the instrument and the underlying conceptual framework of the instrument.

Toward an international measure of job satisfaction.

The purpose of this study was to assess the validity of the McCloskey/Mueller Satisfaction Scale (MMSS) in the West Bank, a dissimilar society and culture from the United States, where the instrument was developed. A second purpose was to measure the correlation between the MMSS total score and a single-item measure of job satisfaction. In contrast to the 31-item scale with eight factors of Mueller and McCloskey, four factors emerged in the current study: Interaction, Extrinsic Rewards, Control Over Work Environment, and Professional Participation. The resulting model is more similar to the original 1974 McCloskey conceptual framework than the 1990 eight-factor model.

Agitation: measurement, management, and intervention research.

Strategies for controlling and managing agitation of patients in long-term care populations has been identified as a research priority. Unfortunately, there is a paucity of literature on empirically tested therapeutic interventions for agitation. This manuscript summarizes the literature related to the measurement, management, and interventions for agitation and identifies a nursing research agenda for conducting research in this area. Nonpharmacological and nonrestraint interventions are highlighted and categorized by (1) alterations in care given, (2) environmental adaptations, and (3) behavioral approaches. Future research areas identified by the authors focus on additional types of environmental, interpersonal, and behavioral interventions as well as theoretical predictors of agitation; the influence and role of nursing personnel and caregiver; and the legal and ethical issues involved in caring for patients who manifest agitation.

Collaborative discharge planning: nursing and social services.

Discharge planning impacts hospital costs and patient outcomes. The purpose of this study was to determine the effects of a structured discharge planning program using collaboration between the CNS and the social worker. The quasi-experimental study used a sample of 64 elderly patients. The experimental group (n = 29) had discharge planning directed through collaboration by a CNS and a social worker. After discharge, patients were contacted by telephone about satisfaction and services received. Charts were reviewed for information about length of stay, readmission, and documentation. Data analysis revealed that patients involved in collaborative planning were more satisfied, had a shorter length of stay, had fewer readmissions, and received a higher rate of indicated postdischarge services. Documentation was not significantly affected, except in the area of patient teaching, which was lower in the experimental group. Based on these findings, the collaborative model offers nurse administrators a way to improve outcomes for patients and the organization.

A precepted leadership course based on Bandura's social learning theory.

Transition from student to registered nurse (RN) has long been cited as a difficult time for new graduates entering health care. Bandura's (1977) theory of social learning guided a revision of a nursing leadership course required of baccalaureate student nurses (BSNs) in their final semester. The preceptorship allowed students to work closely with and to practice modeled behaviors of RNs and then receive feedback and reinforcement from both the preceptor and the supervising faculty member. Students were thus prepared to function better in the reality of the practice setting. Positive outcomes were experienced by students, BSN preceptors, faculty, and nurse administrators.

Role modeling: an educational strategy to promote effective cancer pain management.

Successful pain management is a crucial element in the nursing care of the patient with cancer. Among the many problems underlying poorly managed pain, one prominent concern is healthcare professionals' lack of current knowledge. Although educational programs are an established method of increasing knowledge, specific programming strategies may have a more significant impact on knowledge retention. This quasiexperimental study used role modeling as an educational method to improve knowledge retention. A purposive sample of 20 RNs participated in an educational program in which a lecture-only format was used for the control group and a lecture format plus a role-modeling component was used for the experimental group. An oncology pain management assessment tool was administered in a pretest/post-test design with repeated measures. A one-tailed t-test for gain scores was used to test the hypothesis. Mean change scores between groups were similar. Future studies are needed to further analyze the impact of role modeling on similarly matched, but larger, groups.

Characteristics of effective discharge planning programs for the frail elderly.

Changes in the health-care system since Prospective Payment began have directly affected the postdischarge needs of the frail elderly. Effective discharge planning programs are critical to meet the posthospital needs of this population. Effective discharge planning is believed to be associated with an increase in patient health status and satisfaction. Both can be met when plans for posthospital services are made in an organized program. Admission assessment and follow-up programs were identified as two characteristics necessary in a formally structured discharge planning program for effective care of frail elders.

Expanding the clinical specialist's role through outreach.

Reimbursement changes within the health care system have continued to challenge nurse administrators to generate innovative strategies for cost-efficient and effective services. This has resulted in restructured delivery systems for patient care and newly developed services in nursing. A consultation/outreach program was developed to support the clinical nurse specialists (CNS) in their delivery of quality care and to provide services to surrounding rural hospitals while producing revenue for the department of nursing. For the hospital described, the institutional visibility has increased, new revenue has been generated, and the referral base for potential clients has been expanded.

Canine heartworm disease: a review and pilot study.

Canine heartworm disease is a mosquito vectored illness resulting from parasitization by the filariid worm Dirofilaria immitis. While presenting some danger to humans, the filariid has its greatest impact on the canine population. In recent years the disease has become established throughout much of the United States, perhaps as the result of diffusion from a suspected hearth in the southeastern coastal plain. While its distribution is known in general terms, much research remains to be done to assess the pattern of distribution as well as the impact of D. immitis on canine populations and their human owners for many locales. The present study provides a review of the literature on the parasite; on its distribution, particularly in the United States; and on the ecology of canine heartworm disease. A pilot study is presented which emphasizes the problems encountered in establishing a data base for observations on the disease at the local level.

Keeping the program in-house.

The Scott and White Medical Institution identified a need to provide management development to its first-line, middle, and upper management personnel. What kind of program would have institution-wide appeal, application, controlled implementation, and maintenance, and at the same time could be delivered for a reasonable cost and enhance communication? Scott and White found the answer through an in-house, multi-level development program that utilizes available managers as speakers. From the beginning, managers throughout the institution became involved in the development of the program. Their early involvement ensured ease of implementation, appropriate program content, and evaluation. This effective management development program is an excellent model for a medical group seeking to further develop its team of managers.