Health Services and Primary Care Research Study: Comprehensive Report.

This study presents the results of a congressionally mandated, independent assessment of federally funded health services research (HSR) and primary care research (PCR) spanning the U.S. Department of Health and Human Services (HHS) and U.S. Department of Veterans Affairs (VA) from FYs 2012 to 2018. Through technical expert panels, stakeholder interviews, and a systematic environmental scan of research grants and contracts funded by HHS and the VA, the authors characterize the distinct contributions of agencies in these departments to the federal HSR and PCR enterprise. The authors also identify opportunities to improve detection and coordination of overlap in agency research portfolios, the impacts of HSR and PCR and how they cumulate across research portfolios, and gaps in research funding, methods, and dissemination. The authors offer recommendations to maximize the outcomes and value of future investments in federal HSR and PCR to better guide and serve the needs of a complex and rapidly changing U.S. health care system.

How Can Neighborhood Parks Be Used to Increase Physical Activity?

Regular physical activity is important for both physical and mental health. However, less than half of Americans currently meet federal activity guidelines. Public neighborhood parks offer accessible infrastructure that can facilitate physical activity, and most urban U.S. residents live within a mile of at least one park. Many communities and organizations have tried to encourage park use and park-based physical activity by building new facilities or adding activity centers. However, until recently, there has been little research to understand whether these or other investments are increasing the use of parks for physical activity. RAND Corporation researchers have conducted multiple studies to examine park use and assess parks' role in promoting physical activity. They found that whether residents visit their local parks and how they decide to use them can be related to a wide range of factors, including individual characteristics, such as potential park users' ages and genders; neighborhood and environmental factors, including community poverty level and residents' perceptions of park safety; and park factors, including the numbers and types of facilities and the availability of organized activities. To support these studies, researchers developed an innovative tool, System of Observing Play and Recreation in Communities (SOPARC), to assess park use and physical activity. They also conducted in-depth surveys of park users and neighborhood residents. Their efforts provide insights into how parks are currently being used and suggest ways in which parks might be enhanced to encourage more physical activity. This report describes the tool and the research findings and recommendations.

Governing Academic Medical Center Systems: Evaluating and Choosing Among Alternative Governance Approaches.

The ability of academic medical centers (AMCs) to fulfill their triple mission of patient care, medical education, and research is increasingly being threatened by rising financial pressures and resource constraints. Many AMCs are, therefore, looking to expand into academic medical systems, increasing their scale through consolidation or affiliation with other health care systems. As clinical operations grow, though, the need for effective governance becomes even more critical to ensure that the business of patient care does not compromise the rest of the triple mission. Multi-AMC systems, a model in which multiple AMCs are governed by a single body, pose a particular challenge in balancing unity with the needs of component AMCs, and therefore offer lessons for designing AMC governance approaches. This article describes the development and application of a set of criteria to evaluate governance options for one multi-AMC system-the University of California (UC) and its five AMCs. Based on a literature review and key informant interviews, the authors identified criteria for evaluating governance approaches (structures and processes), assessed current governance approaches using the criteria, identified alternative governance options, and assessed each option using the identified criteria. The assessment aided UC in streamlining governance operations to enhance their ability to respond efficiently to change and to act collectively. Although designed for UC and a multi-AMC model, the criteria may provide a systematic way for any AMC to assess the strengths and weaknesses of its governance approaches.

Preventing, Identifying, and Treating Prescription Drug Misuse Among Active-Duty Service Members.

Prescription drug misuse (PDM) is of critical concern for the military because of its potential impact on military readiness, the health and well-being of military personnel, and associated health care costs. The purpose of this study is to summarize insights gleaned from a series of activities that the RAND Corporation undertook for the Deputy Assistant Secretary of Defense for Readiness to address this important health and military readiness issue. The authors completed a review of U.S. Department of Defense policies and a comprehensive literature review of clinical guidelines and the empirical literature on the prevention and treatment of PDM and conducted individual face-to-face interviews with 66 health and behavioral health care providers at nine medical treatment facilities across three regions within the contiguous United States to identify best practices in the prevention, identification, and treatment of PDM and the extent to which those practices are known and followed. The study also presents the framework of an analytic tool that, once informed by data available to the military but not available to the authors, can assist the military in predicting future trends in PDM based on current demographics of active-duty service members and rates of injury and prescribing of prescription drugs. The findings from this work led the authors to formulate a set of key insights that they believe might improve the rapid identification and treatment of service members dealing with PDM, thereby improving future force readiness.

Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events.

This article describes the design, development, and testing of the Health Care Safety Hotline, a prototype consumer reporting system for patient safety events. The prototype was designed and developed with ongoing review by a technical expert panel and feedback obtained during a public comment period. Two health care delivery organizations in one metropolitan area collaborated with the researchers to demonstrate and evaluate the system. The prototype was deployed and elicited information from patients, family members, and caregivers through a website or an 800 phone number. The reports were considered useful and had little overlap with information received by the health care organizations through their usual risk management, customer service, and patient safety monitoring systems. However, the frequency of reporting was lower than anticipated, suggesting that further refinements, including efforts to raise awareness by actively soliciting reports from subjects, might be necessary to substantially increase the volume of useful reports. It is possible that a single technology platform could be built to meet a variety of different patient safety objectives, but it may not be possible to achieve several objectives simultaneously through a single consumer reporting system while also establishing trust with patients, caregivers, and providers.

Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans.

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the Department of Veterans Affairs (VA) current and projected health care capabilities and resources. An examination of data from a variety of sources, along with a survey of VA medical facility leaders, revealed the breadth and depth of VA resources and capabilities: fiscal resources, workforce and human resources, physical infrastructure, interorganizational relationships, and information resources. The assessment identified barriers to the effective use of these resources and capabilities. Analysis of data on access to VA care and the quality of that care showed that almost all veterans live within 40 miles of a VA health facility, but fewer have access to VA specialty care. Veterans usually receive care within 14 days of their desired appointment date, but wait times vary considerably across VA facilities. VA has long played a national leadership role in measuring the quality of health care. The assessment showed that VA health care quality was as good or better on most measures compared with other health systems, but quality performance lagged at some VA facilities. VA will require more resources and capabilities to meet a projected increase in veterans' demand for VA care over the next five years. Options for increasing capacity include accelerated hiring, full nurse practice authority, and expanded use of telehealth.

JOURNAL CLUB: Radiologists' Perceptions of Computerized Decision Support: A Focus Group Study From the Medicare Imaging Demonstration Project.

OBJECTIVE: The purpose of this study was to discern radiologists' perceptions regarding the implementation of a decision support system intervention as part of the Medicare Imaging Demonstration project and the effect of decision support on radiologists' interactions with ordering clinicians, their radiology work flow, and appropriateness of advanced imaging. SUBJECTS AND METHODS: A focus group study was conducted with a diverse sample of radiologists involved in interpreting advanced imaging studies at Medicare Imaging Demonstration project sites. A semistructured moderator guide was used, and all focus group discussions were recorded and transcribed verbatim. Qualitative data analysis software was used to code thematic content and identify representative segments of text. Participating radiologists also completed an accompanying survey designed to supplement focus group discussions. RESULTS: Twenty-six radiologists participated in four focus group discussions. The following major themes related to the radiologists' perceptions after decision support implementation were identified: no substantial change in radiologists' interactions with referring clinicians; no substantial change in radiologist work flow, including protocol-writing time; and no perceived increase in imaging appropriateness. Radiologists provided suggestions for improvements in the decision support system, including increasing the usability of clinical data captured, and expressed a desire to have greater involvement in future development and implementation efforts. CONCLUSION: Overall, radiologists from health care systems involved in the Medicare Imaging Demonstration did not perceive that decision support had a substantial effect, either positive or negative, on their professional roles and responsibilities. Radiologists expressed a desire to improve efficiencies and quality of care by having greater involvement in future efforts.

A natural experiment opportunity in two low-income urban food desert communities: research design, community engagement methods, and baseline results.

A growing body of evidence has highlighted an association between a lack of access to nutritious, affordable food (e.g., through full-service grocery stores [FSGs]), poor diet, and increased risk for obesity. In response, there has been growing interest among policy makers in encouraging the siting of supermarkets in "food deserts," that is, low-income geographic areas with low access to healthy food options. However, there is limited research to evaluate the impact of such efforts, and most studies to date have been cross-sectional. The Pittsburgh Hill/Homewood Research on Eating, Shopping, and Health (PHRESH) is a longitudinal quasi-experimental study of a dramatic change (i.e., a new FSG) in the food landscape of a low-income, predominantly Black neighborhood. The study is following a stratified random sample of households (n = 1,372), and all food venues (n = 60) in both intervention and control neighborhoods, and the most frequently reported food shopping venues outside both neighborhoods. This article describes the study design and community-based methodology, which focused simultaneously on the conduct of scientifically rigorous research and the development and maintenance of trust and buy-in from the involved neighborhoods. Early results have begun to define markers for success in creating a natural experiment, including strong community engagement. Baseline data show that the vast majority of residents already shop at a FSG and do not shop at the nearest one. Follow-up data collection will help determine whether and how a new FSG may change behaviors and may point to the need for additional interventions beyond new FSGs alone.

Medicare Imaging Demonstration Final Evaluation: Report to Congress.

Increasing use of advanced medical imaging is often cited as a key driver of cost growth in medical spending. In 2011, the Medicare Imaging Demonstration from the Centers for Medicare & Medicaid Services began testing whether exposing ordering clinicians to appropriateness guidelines for advanced imaging would reduce ordering inappropriate images. The evaluation examined trends in advanced diagnostic imaging utilization starting January 1, 2009-more than two years before the beginning of the demonstration-to November 30, 2013-two months after the close of the demonstration. Small changes in ordering patterns were noted, but decision support systems were unable to assign appropriateness ratings to many orders, thus limiting the potential effectiveness of decision support. Many opportunities to refine decision support systems have been identified.

The national response for preventing healthcare-associated infections: infrastructure development.

BACKGROUND: In 2009, the US Department of Health and Human Services (HHS) launched the Action Plan to Prevent Healthcare-associated Infections (HAIs). The Action Plan adopted national targets for reduction of specific infections, making HHS accountable for change across the healthcare system over which federal agencies have limited control. OBJECTIVES: This article examines the unique infrastructure developed through the Action Plan to support adoption of HAI prevention practices. RESEARCH DESIGN: Interviews of federal (n=32) and other stakeholders (n=38), reviews of agency documents and journal articles (n=260), and observations of interagency meetings (n=17) and multistakeholder conferences (n=17) over a 3-year evaluation period. MEASURES: We extract key progress and challenges in the development of national HAI prevention infrastructure--1 of the 4 system functions in our evaluation framework encompassing regulation, payment systems, safety culture, and dissemination and technical assistance. We then identify system properties--for example, coordination and alignment, accountability and incentives, etc.--that enabled or hindered progress within each key development. RESULTS: The Action Plan has developed a model of interagency coordination (including a dedicated "home" and culture of cooperation) at the federal level and infrastructure for stimulating change through the wider healthcare system (including transparency and financial incentives, support of state and regional HAI prevention capacity, changes in safety culture, and mechanisms for stakeholder engagement). Significant challenges to infrastructure development included many related to the same areas of progress. CONCLUSIONS: The Action Plan has built a foundation of infrastructure to expand prevention of HAIs and presents useful lessons for other large-scale improvement initiatives.

The national response for preventing healthcare-associated infections: data and monitoring.

BACKGROUND: Historically, the ability to accurately track healthcare-associated infections (HAIs) was hindered due to a lack of coordination among data sources and shortcomings in individual data sources. OBJECTIVES: This paper presents the results of the evaluation of the HAI data and the monitoring component of the Action Plan, focusing on context (goals), inputs, and processes. RESEARCH DESIGN: We used the Content-Input-Process-Product framework, together with the HAI prevention system framework, to describe the transformative processes associated with data and monitoring efforts. RESULTS: Six HAI priority conditions in the 2009 Action Plan created a focus for the selection of goals and activities. Key Action Plan decisions included a phased-in data and monitoring approach, commitment to linking the selection of priority HAIs to highly visible national 5-year prevention targets, and the development of a comprehensive HAI database inventory. Remaining challenges relate to data validation, resources, and the opportunity to integrate electronic health and laboratory records with other provider data systems. CONCLUSIONS: The Action Plan's data and monitoring program has developed a sound infrastructure that builds upon technological advances and embodies a firm commitment to prioritization, coordination and alignment, accountability and incentives, stakeholder engagement, and an awareness of the need for predictable resources. With time, and adequate resources, it is likely that the investment in data-related infrastructure during the Action Plan's initial years will reap great rewards.

The national response for preventing healthcare-associated infections: research and adoption of prevention practices.

BACKGROUND: Healthcare-associated infections (HAIs) have long been the subject of research and prevention practice. When findings show potential to significantly impact outcomes, clinicians, policymakers, safety experts, and stakeholders seek to bridge the gap between research and practice by identifying mechanisms and assigning responsibility for translating research to practice. OBJECTIVES: This paper describes progress and challenges in HAI research and prevention practices, as explained through an examination of Health and Human Services (HHS) Action Plan's goals, inputs, and implementation in each area. RESEARCH DESIGN: We used the Context-Input-Process-Product evaluation model, together with an HAI prevention system framework, to assess the transformative processes associated with HAI research and adoption of prevention practices. RESULTS: Since the introduction of the Action Plan, HHS has made substantial progress in prioritizing research projects, translating findings from those projects into practice, and designing and implementing research projects in multisite practice settings. Research has emphasized the basic science and epidemiology of HAIs, the identification of gaps in research, and implementation science. The basic, epidemiological, and implementation science communities have joined forces to better define mechanisms and responsibilities for translating HAI research into practice. Challenges include the ongoing need for better evidence about intervention effectiveness, the growing implementation burden on healthcare providers and organizations, and challenges implementing certain practices. CONCLUSIONS: Although these HAI research and prevention practice activities are complex spanning multiple system functions and properties, HHS is making progress so that the right methods for addressing complex HAI problems at the interface of patient safety and clinical practice can emerge.

The national response for preventing healthcare-associated infections: system capacity and sustainability for improvement.

BACKGROUND: Strengthening capacity across the healthcare system for improvement is critical to ensuring that past efforts and investments establish a foundation for sustaining progress in patient safety. OBJECTIVES: The objective of this analysis was to identify key system capacity issues for sustainability from evaluation of the Action Plan to prevent healthcare-associated infections, a major national initiative launched by the US Department of Health and Human Services in 2009. RESEARCH DESIGN: The analysis involves the review and synthesis of results across the components of a 3-year evaluation of the Action Plan, as described in the evaluation framework and detailed in separate analyses elsewhere in this special issue. Data collection methods included interviews with government and private stakeholders, document and literature reviews, and observations of meetings and conferences at multiple time points. MEASURES: Key developments in healthcare-associated infection prevention system capacity were extracted on the basis of "major activities" identified through multiple methods and organized into the level of progress based on perspectives of multiple stakeholders. Activities within each level were then examined and compared according to our evaluation's framework of 4 system functions and 5 system properties. RESULTS: Key system capacity and sustainability issues for the Action Plan to be addressed centered on coordination and alignment (among participating agencies, with other federal initiatives, and across levels of healthcare), infrastructure for data and accountability (including more efficient technologies and unintended consequences), cultural embedding of prevention practices, and uncertainty and variability in resources. CONCLUSIONS: Sustainability depends on improvements across system functions and properties and how they reinforce each other. Change is more robust if different system elements support and incentivize behavior in similar directions.

Approach for conducting the longitudinal program evaluation of the US Department of Health and Human Services National Action Plan to prevent healthcare-associated infections: roadmap to elimination.

BACKGROUND: In response to mounting evidence about skyrocketing morbidity, mortality, and costs associated with healthcare-associated infections (HAIs), in 2009, the US Department of Health and Human Services (HHS) issued the HHS HAI Action Plan to enhance collaboration and coordination and to strengthen the impact of national efforts to address HAIs. To optimize timely understanding of the Action Plan's approach and outcomes, as well as improve the likely success of this effort, HHS requested an independent longitudinal and formative program evaluation. OBJECTIVES: This article describes the evaluation approach to assessing HHS's progress and the challenges encountered as HHS attempted to transform the national strategy to HAI elimination. RESEARCH DESIGN: The Context-Input-Process-Product (CIPP) model, a structured-yet-flexible formative and summative evaluation tool, supported the assessment of: (1) the Context in which the Action Plan developed, (2) the Inputs and decisions made about selecting activities for implementation, (3) Processes or implementation of selected activities, and (4) Products and outcomes. MEASURES: A system framework consisting of 4 system functions and 5 system properties. RESULTS: The CIPP evaluation model provides a structure for tracking the components of the program, the relationship between components, and the way in which components change with time. The system framework allows the evaluation team to understand what the Action Plan is doing and how it aims to facilitate change in the healthcare system to address the problem of HAIs. CONCLUSIONS: With coordination and alignment becoming increasingly important among large programs within healthcare and other fields, program evaluations like this can inform the policy community about what works and why, and how future complex large-scale programs should be evaluated.

An Assessment of the Army's Tactical Human Optimization, Rapid Rehabilitation and Reconditioning Program.

In 2009, U.S. Special Operations Command provided U.S. Army Special Operations Command with funds to establish the Tactical Human Optimization, Rapid Rehabilitation and Reconditioning (THOR3) program, an investment reflecting "truth number 1" of special operations forces: "Humans are more important than hardware." The goals of THOR3 are to increase the physical and mental capabilities of Army special forces, help these soldiers recover more rapidly from injuries sustained in combat or training, and help them stay healthy and able to contribute longer. The program differs from other Army fitness programs in several important ways, including its holistic approach to improving physical and mental performance, its focus on individual and unit needs, and its reliance on a professional staff of program coordinators, strength and conditioning coaches, physical therapists, dietitians, and cognitive enhancement specialists to deliver training and rehabilitation services that are on par with those provided to professional sports teams. U.S. Army Special Operations Command asked RAND Arroyo Center to determine whether THOR3 is effectively utilizing the resources provided and to identify opportunities for improvement in the program's planning and implementation, staffing (including hiring and retention), leader development and education, facility and equipment requirements, and ability to support participating personnel.

Toward a Culture of Consequences: Performance-Based Accountability Systems for Public Services.

Performance-based accountability systems (PBASs), which link incentives to measured performance as a means of improving services to the public, have gained popularity. While PBASs can vary widely across sectors, they share three main components: goals, incentives, and measures. Research suggests that PBASs influence provider behaviors, but little is known about PBAS effectiveness at achieving performance goals or about government and agency experiences. This study examines nine PBASs that are drawn from five sectors: child care, education, health care, public health emergency preparedness, and transportation. In the right circumstances, a PBAS can be an effective strategy for improving service delivery. Optimum circumstances include having a widely shared goal, unambiguous observable measures, meaningful incentives for those with control over the relevant inputs and processes, few competing interests, and adequate resources to design, implement, and operate the PBAS. However, these conditions are rarely fully realized, so it is difficult to design and implement PBASs that are uniformly effective. PBASs represent a promising policy option for improving the quality of service-delivery activities in many contexts. The evidence supports continued experimentation with and adoption of this approach in appropriate circumstances. Even so, PBAS design and its prospects for success depend on the context in which it will operate. Also, ongoing system evaluation and monitoring are integral components of a PBAS; they inform refinements that improve system functioning over time. Empirical evidence of the effects of performance-based public management is scarce. This article also describes a framework used to evaluate a PBAS. Such a system identifies individuals or organizations that must change their behavior for the performance of an activity to improve, chooses an implicit or explicit incentive structure to motivate these organizations or individuals to change, and then chooses performance measures tailored to inform the incentive structure appropriately. The study focused on systems in the child care, education, health care, public health emergency preparedness, and transportation sectors, mainly in the United States. Analysts could use this framework to seek empirical information in other sectors and other parts of the world. Additional empirical information could help refine existing PBASs and, more broadly, improve decisions on where to initiate new PBASs, how to implement them, and then how to design, manage, and refine them over time.

The Role of Faith-Based Organizations in HIV Prevention and Care in Central America.

Faith-based organizations (FBOs) have historically played an important role in delivering health and social services in developing countries; however, little research has been done on their role in HIV prevention and care, particularly in Latin America. This article summarizes a study that describes FBO involvement in HIV/AIDS in three Central American countries hard hit by this epidemic: Belize, Guatemala, and Honduras. Summarizing the results of key informant and stakeholder interviews with health and FBO leaders and site visits to FBO-sponsored HIV/AIDS clinics, hospices, programs, and other activities, the authors describe the range of FBO activities and assess the advantages of FBO involvement in addressing HIV/AIDS, such as churches' diverse presence and extensive reach, and the challenges to such involvement, such as the unwillingness of some FBOs to discuss condom use and their lack of experience in evaluating the impact of programs. The authors conclude with a discussion of possible ways that FBOs can address the HIV epidemic, both independently and in collaboration with other organizations, such as government ministries of health.

Developing national standards for public health emergency preparedness with a limited evidence base.

OBJECTIVE: The paucity of evidence and wide variation among communities creates challenges for developing congressionally mandated national performance standards for public health preparedness. Using countermeasure dispensing as an example, we present an approach for developing standards that balances national uniformity and local flexibility, consistent with the quality of evidence available. METHODS: We used multiple methods, including a survey of community practices, mathematical modeling, and expert panel discussion. RESULTS: The article presents recommended dispensing standards, along with a general framework that can be used to analyze tradeoffs involved in developing other preparedness standards. CONCLUSIONS: Standards can be developed using existing evidence, but would be helped immensely by a stronger evidence base.

Using quality improvement methods to improve public health emergency preparedness: PREPARE for Pandemic Influenza.

Many public health departments seek to improve their capability to respond to large-scale events such as an influenza pandemic. Quality improvement (QI), a structured approach to improving performance, has not been widely applied in public health. We developed and tested a pilot QI collaborative to explore whether QI could help public health departments improve their pandemic preparedness. We demonstrated that this is a promising model for improving public health preparedness and may be useful for improving public health performance overall. Further efforts are needed, however, to encourage the robust implementation of QI in public health.

Quality improvement in public health emergency preparedness.

Quality improvement (QI) methods have been used in many industries to improve performance and outcomes. This chapter reviews key QI concepts and their application to public health emergency preparedness (PHEP). We conclude that for QI to flourish and become standard practice, changes to the status quo are necessary. In particular, public health should build its capabilities in QI, enhance implementation, and align incentives to facilitate use of QI.