A Web-Based, Population-Based Cirrhosis Identification and Management System for Improving Cirrhosis Care: Qualitative Formative Evaluation.

BACKGROUND: Cirrhosis, or scarring of the liver, is a debilitating condition that affects millions of US adults. Early identification, linkage to care, and retention of care are critical for preventing severe complications and death from cirrhosis. OBJECTIVE: The purpose of this study is to conduct a preimplementation formative evaluation to identify factors that could impact implementation of the Population-Based Cirrhosis Identification and Management System (P-CIMS) in clinics serving patients with cirrhosis. P-CIMS is a web-based informatics tool designed to facilitate patient outreach and cirrhosis care management. METHODS: Semistructured interviews were conducted between January and May 2016 with frontline providers in liver disease and primary care clinics at 3 Veterans Health Administration medical centers. A total of 10 providers were interviewed, including 8 physicians and midlevel providers from liver-related specialty clinics and 2 primary care providers who managed patients with cirrhosis. The Consolidated Framework for Implementation Research guided the development of the interview guides. Inductive consensus coding and content analysis were used to analyze transcribed interviews and abstracted coded passages, elucidated themes, and insights. RESULTS: The following themes and subthemes emerged from the analyses: outer setting: needs and resources for patients with cirrhosis; inner setting: readiness for implementation (subthemes: lack of resources, lack of leadership support), and implementation climate (subtheme: competing priorities); characteristics of individuals: role within clinic; knowledge and beliefs about P-CIMS (subtheme: perceived and realized benefits; useful features; suggestions for improvement); and perceptions of current practices in managing cirrhosis cases (subthemes: preimplementation process for identifying and linking patients to cirrhosis care; structural and social barriers to follow-up). Overall, P-CIMS was viewed as a powerful tool for improving linkage and retention, but its integration in the clinical workflow required leadership support, time, and staffing. Providers also cited the need for more intuitive interface elements to enhance usability. CONCLUSIONS: P-CIMS shows promise as a powerful tool for identifying, linking, and retaining care in patients living with cirrhosis. The current evaluation identified several improvements and advantages of P-CIMS over current care processes and provides lessons for others implementing similar population-based identification and management tools in populations with chronic disease.

Engaging patients and caregivers to establish priorities for the management of diabetic foot ulcers.

OBJECTIVE: Effective diabetic foot ulcer (DFU) care has been stymied by a lack of input from patients and caregivers, reducing treatment adherence and overall quality of care. Our objectives were to capture the patient and caregiver perspectives on experiencing a DFU and to improve prioritization of patient-centered outcomes. METHODS: A DFU-related stakeholder group was formed at an urban tertiary care center. Seven group meetings were held across 4 months, each lasting ∼1 hour. The meeting facilitator used semistructured questions to guide each discussion. The topics assessed the challenges of the current DFU care system and identified the outcomes most important to stakeholders. The meetings were audio recorded and transcribed. Directed and conventional content analyses were used to identify key themes. RESULTS: Six patients with diabetes (five with an active DFU), 3 family caregivers, and 1 Wound Clinic staff member participated in the stakeholder group meetings. The mean patient age was 61 years, four (67%) were women, five (83%) were either African American or Hispanic, and the mean hemoglobin A1c was 8.3%. Of the five patients with a DFU, three had previously required lower extremity endovascular treatment and four had undergone at least one minor foot amputation. Overall, stakeholders described how poor communication between medical personnel and patients made the DFU experience difficult. They felt overwhelmed by the complexity of DFU care and were persistently frustrated by inconsistent medical recommendations. Limited resources further exacerbated their frustrations and barriers to care. To improve DFU management, the stakeholders suggested a centralized healthcare delivery pathway with timely access to a coordinated, multidisciplinary DFU team. The clinical outcomes most valued by stakeholders were (1) avoiding amputation and (2) maintaining or improving health-related quality of life, which included independent mobility, pain control, and mental health. From these themes, we developed a conceptual model to inform DFU care pathways. CONCLUSIONS: Current DFU management lacks adequate care coordination. Multidisciplinary approaches tailored to the self-identified needs of patients and caregivers could improve adherence. Future DFU-related comparative effectiveness studies will benefit from direct stakeholder engagement and are required to evaluate the efficacy of incorporating patient-centered goals into the design of a multidisciplinary DFU care delivery system.

Factors Affecting Adoption of Coordinated Anxiety Learning and Management (CALM) in Veterans' Affairs Community-Based Outpatient Clinics.

PURPOSE: Many US military veterans experience anxiety, depression, and trauma-related disorders. A major goal of the Veterans Health Administration (VHA) has been to increase access to evidence-based psychotherapies (EBPs) such as cognitive-behavioral therapy to address veterans' substantial health burden. However, despite widespread implementation of EBPs throughout the VHA, smaller clinics that often serve rural veterans face barriers to delivering these interventions. The Veterans Affairs Coordinated Anxiety Learning and Management (VA CALM) program aims to empower providers in rural areas with varying levels of training and experience in delivering EBPs to provide high-quality cognitive-behavioral therapy for anxiety, depression, and trauma-related disorders. The goal of this study was to better understand, through qualitative interviews, VHA community-based outpatient clinic providers' perspectives on implementing VA CALM. METHODS: Qualitative interviews with providers (N = 22) were conducted to understand implementation of VA CALM. Template analysis was used to organize and summarize responses. FINDINGS: Providers noted several facilitators for implementing VA CALM in rural community clinics, including its perceived effectiveness, broad applicability, and structure. Barriers to implementation included scheduling problems and patient-related barriers. CONCLUSIONS: Incorporating providers' perspectives on factors that affect implementing cognitive-behavioral therapy in this setting may inform future efforts to disseminate-implement EBPs in smaller, more remote VHA clinics.

Integrated Model for Patient-Centered Advanced Liver Disease Care.

Advanced liver disease (AdvLD) is a high-risk common condition with a progressive, highly morbid, and often fatal course. Despite effective treatments, there are substantial shortfalls in access to and use of evidence-based supportive and palliative care for AdvLD. Although patient-centered, chronic illness models that integrate early supportive and palliative care with curative treatments hold promise, there are several knowledge gaps that hinder development of an integrated model for AdvLD. We review these evidence gaps. We also describe a conceptual framework for a patient-centered approach that explicates key elements needed to improve integrated care. An integrated model of AdvLD would allow clinicians, patients, and caregivers to work collaboratively to identify treatments and other healthcare that best align with patients' priorities.

Increasing the impact of randomized controlled trials: an example of a hybrid effectiveness-implementation design in psychotherapy research.

Randomized controlled trials (RCTs) are the gold standard for clinical research. However, significant delays between completion of RCTs and adoption of evidence-based practices into clinical settings remain. Engagement of stakeholders and implementation-focused outcomes to augment traditional RCTs hold the potential to increase the impact of RCT outcomes for clinical practice and more rapidly lead to the adoption of evidence-based practices in clinical settings. The purpose of this study is to discuss hybrid effectiveness-implementation designs and use a project example to highlight important methodological considerations to enhance the impact of RCTs. A hybrid effectiveness-implementation study assessed the effectiveness and implementation potential of brief cognitive behavioral therapy (bCBT) for rural Veterans. A patient-randomized trial (bCBT vs. enhanced usual care) explored the impact on depression symptoms. Implementation elements included engagement of stakeholders and a multifaceted provider training and support program to increase bCBT use by providers in Veterans Health Administration (VA) community-based outpatient clinics. Implementation outcomes included the number of providers who adopted bCBT, provider fidelity, and delivery outcomes (e.g., use of measurement-based care, treatment engagement, and completion). Hybrid designs offer opportunities to improve the alignment between research and practice, potentially improving dissemination of evidence-based interventions and reducing known delays in the translation from research to practice. Expansion of traditional RCTs through collaborative stakeholder contributions and stakeholder/consumer-informed implementation approaches is critical to improve adoption postproject. Although hybrid designs offer significant benefits related to generalizability and adoption, these approaches involve complex procedures and processes and often come at the cost of reduced internal study controls.

Personalized Implementation of Video Telehealth.

This article describes the Personalized Implementation for Video Telehealth strategy to increase adoption of video telehealth to home (VTH) across a large, urban Veterans Health Administration medical center and applications for broader use in non-VHA settings. The authors fully integrated VTH into existing mental health clinics, resulting in (1) a significant increase in the number of patients receiving VTH, (2) a significant increase in the number of VTH visits relative to median national improvement, (3) a greater number of unique specialty mental health clinics offering VTH in Houston, and (4) a greater number of community clinics active in delivering VTH.

The use of structured data elements to identify ASCVD patients with statin-associated side effects: Insights from the Department of Veterans Affairs.

BACKGROUND: Accurate identification of patients with statin-associated side effects (SASEs) is critical for health care systems to institute strategies to improve guideline-concordant statin use. OBJECTIVE: The objective of this study was to determine whether adverse drug reaction (ADR) entry by clinicians in the electronic medical record can accurately identify SASEs. METHODS: We identified 1,248,214 atherosclerotic cardiovascular disease (ASCVD) patients seeking care in the Department of Veterans Affairs. Using an ADR data repository, we identified SASEs in 15 major symptom categories. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were assessed using a chart review of 256 ASCVD patients with identified SASEs, who were not on high-intensity statin therapy. RESULTS: We identified 171,189 patients (13.71%) with documented SASEs over a 15-year period (9.9%, 2.7%, and 1.1% to 1, 2, or >2 statins, respectively). Statin use, high-intensity statin use, low-density lipoprotein cholesterol, and non-high-density lipoprotein cholesterol levels were 72%, 28.1%, 99 mg/dL, and 129 mg/dL among those with vs 81%, 31.1%, 84 mg/dL, and 111 mg/dL among those without SASEs. Progressively lower statin and high-intensity statin use, and higher low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol levels were noted among those with SASEs to 1, 2, or >2 statins. Two-thirds of SASEs were related to muscle symptoms. Sensitivity, specificity, PPV, NPV compared with manual chart review were 63.4%, 100%, 100%, and 85.3%, respectively. CONCLUSION: A strategy of using ADR entry in the electronic medical record is feasible to identify SASEs with modest sensitivity and NPV but high specificity and PPV. Health care systems can use this strategy to identify ASCVD patients with SASEs and operationalize efforts to improve guideline-concordant lipid-lowering therapy use in such patients. The sensitivity of this approach can be further enhanced by the use of unstructured text data.

Mental Health of Transgender Veterans of the Iraq and Afghanistan Conflicts Who Experienced Military Sexual Trauma.

Little is known about military sexual trauma (MST) in transgender veterans. To address this gap, we examined archival data regarding transgender veterans from the Iraq and Afghanistan conflicts. There were 332 transgender veterans treated at the Veterans Health Administration between 2000 and 2013 (78 men, 254 women; mean age 33.86 years), with most being non-Hispanic White. Transgender status and mental health conditions were identified using the International Classification of Diseases, 9th Revision (ICD-9; World Health Organization, 1980) codes and chart review. Men and women were analyzed separately, using contingency tables and χ2 testing for categorical variables and t tests for continuous variables. Likelihood of having a mental health condition and MST were examined using logistic regression. Among the 15% of participants who experienced MST, MST was associated with the likelihood of posttraumatic stress disorder, adjusted OR = 6.09, 95% confidence interval (CI) [1.22, 30.44] and personality disorder, OR = 3.86, 95% CI [1.05, 14.22] for men and with depressive, OR = 3.33, 95% CI [1.12, 9.93], bipolar, OR = 2.87, 95% CI [1.12, 7.44], posttraumatic stress, OR = 2.42, [1.11, 5.24], and personality disorder, OR = 4.61, 95% CI [2.02, 10.52] for women. Implications include that medical forms should include gender identity and biological gender and that MST treatment should be culturally competent.

Health Values and Treatment Goals of Older, Multimorbid Adults Facing Life-Threatening Illness.

OBJECTIVES: To identify a taxonomy of health-related values that frame goals of care of older, multimorbid adults who recently faced cancer diagnosis and treatment. DESIGN: Qualitative analysis of data from a longitudinal cohort study of multimorbid cancer survivors. SETTING: Cancer registries from regional Department of Veterans Affairs networks in New England and southeast Texas. PARTICIPANTS: Multimorbid adults who completed interviews 12 months after diagnosis of head and neck, colorectal, gastric, or esophageal cancer and after cancer treatment (N = 146). MEASUREMENTS: An interdisciplinary team conducted thematic analyses of participants' intuitive responses to two questions: Now that you have had cancer and may face ongoing decisions about medical care in the future, what would you want your family, friends, and doctors to know about you, in terms of what is most important to you in your life? If your cancer were to recur, is there anything you'd want to be sure your loved ones knew about you and your goals of care? RESULTS: Analysis revealed five distinct health-related values that guide how multimorbid cancer survivors conceptualize specific health care goals and medical decisions: self-sufficiency, life enjoyment, connectedness and legacy, balancing quality and length of life, and engagement in care. Participants typically endorsed more than one value as important. CONCLUSION: Older multimorbid adults who recently faced life-threatening cancer endorsed a multidimensional taxonomy of health-related values. These health-related values guide how they frame their goals for care and treatment preferences. Eliciting individuals' sense of their values during clinical encounters may improve their experiences with health care and more effectively align treatments with goals of care.

Valued life abilities among veteran cancer survivors.

BACKGROUND: When patients have multiple chronic illnesses, it is not feasible to provide disease-based care when treatments for one condition adversely affect another. Instead, health-care delivery requires a broader person-centred treatment plan based on collaborative, patient-oriented values and goals. OBJECTIVE: We examined the individual variability, thematic content, and sociodemographic correlates of valued life abilities and activities among multimorbid veterans diagnosed with life-altering cancer. SETTING AND PARTICIPANTS: Participants were 144 veterans in the 'Vet-Cares' study who completed a health-care values and goals scale 12 months after diagnosis of head and neck, gastro-oesophageal, or colorectal cancer. They had mean age of 65 years and one quarter identified as Hispanic and/or African American. DESIGN: At twelve months post-diagnosis, participants rated 16 life abilities/activities in their importance to quality of life on a 10-point Likert scale, during an in-person interview. Scale themes were validated via exploratory factor analysis and examining associations with sociodemographic variables. RESULTS: Participants rated most life abilities/activities as extremely important. Variability in responses was sufficient to identify three underlying values themes in exploratory factor analysis: self-sufficiency, enjoyment/comfort, and connection to family, friends and spirituality. Veterans with a spouse/partner rated self-sufficiency as less important. African American veterans rated connection as more important than did White veterans. CONCLUSIONS: It is feasible yet challenging to ask older, multimorbid patients to rate relative importance of values associated with life abilities/activities. Themes related to self-sufficiency, enjoyment/comfort in daily life and connection are salient and logically consistent with sociodemographic traits. Future studies should explore their role in goal-directed health care.

Implementation of video telehealth to improve access to evidence-based psychotherapy for posttraumatic stress disorder.

BACKGROUND: Increasing access to psychotherapy for posttraumatic stress disorder (PTSD) is a primary focus of the Department of Veterans Affairs (VA) healthcare system. Delivery of treatment via video telehealth can expand availability of treatment and be equally effective as in-person treatment. Despite VA efforts, barriers to establishing telehealth services remain, including both provider acceptance and organizational obstacles. Thus, development of specific strategies is needed to implement video telehealth services in complex healthcare systems, like the VA. MATERIALS AND METHODS: This project was guided by the Promoting Action on Research Implementation in Health Services framework and used external facilitation to increase access to psychotherapy via video telehealth. The project was conducted at five VA Medical Centers and their associated community clinics across six states in the South Central United States. RESULTS: Over a 21-month period, 27 video telehealth clinics were established to provide greater access to evidence-based psychotherapies for PTSD. Examination of change scores showed that participating sites averaged a 3.2-fold increase in unique patients and a 6.5-fold increase in psychotherapy sessions via video telehealth for PTSD. Differences between participating and nonparticipating sites in both unique patients and encounters were significant (p=0.041 and p=0.009, respectively). Two groups emerged, separated by degree of engagement in the facilitation intervention. Facilitation was perceived as useful by providers. CONCLUSIONS: To our knowledge, this is the first prospective study of external facilitation as an implementation strategy for telehealth. Our findings suggest that external facilitation is an effective and acceptable strategy to support providers as they establish clinics and make complex practice changes, such as implementing video telehealth to deliver psychotherapy.

Cancer survivor rehabilitation and recovery: protocol for the Veterans Cancer Rehabilitation Study (Vet-CaRes).

BACKGROUND: Cancer survivors are a rapidly growing and aging population in the U.S., but there are many challenges associated with the survivorship experience such as functional disabilities and psychosocial distress. When viewed next to the general population, Veterans are especially at risk for these challenges as they are older and have a high incidence of co-morbid conditions. While the Institute of Medicine (IOM) has called for further cancer survivorship research to address these challenges, we still know little about this experience from the perspective of aging Veterans. METHODS/DESIGN: We conducted a longitudinal, mixed-methods study over the course of three and a half years at the Boston and Houston VA Medical Centers. We recruited 170 Veterans diagnosed with head and neck, colorectal and esophageal/gastric cancers that were identified from the VA tumor registry. Veterans completed three in-depth interviews, conducted at 6, 12 and 18 months after pathology confirmation, measuring the physical, social and psychological factors related to cancer survivorship. The longitudinal design allowed us to assess any changes in cancer related disability and distress over time. DISCUSSION: Weekly teleconference study team meetings were a key aspect to the research process. Issues related to recruitment, data management and analysis, and the dissemination of research results was discussed. Interviewers presented detailed case reports of completed interviews that allowed us to refine our interview protocols. We also discussed issues relevant to the Veteran population of which we were previously unaware and some of the challenges of the research process itself. This novel study produced a robust data set that documents the functional and psychosocial cancer survivorship experiences of aging Veterans. The longitudinal design will help us more fully understand the recovery patterns for this specific population, and identify the unique needs and gaps in health services.