Improving Pain Care for Service Members: Administrator, Provider, and Patient Perspectives on Treatment, Policies, and Opportunities for Change.

Acute and chronic pain are common among service members, with musculoskeletal pain and injuries being the leading cause of nondeployability among active-duty service members. Given the significant implications for individual health and force readiness, providing high-quality pain care to service members is a priority of the Military Health System (MHS). Prior RAND research used administrative data to assess the quality and safety of pain care and opioid prescribing in the MHS, generated a set of quality measures that the MHS could adopt going forward, and identified strengths and opportunities for improvement in care provided to service members with pain conditions. In this study, authors document findings from interviews with MHS administrators, providers, and patients, providing valuable detail and context for those findings, along with on-the-ground perspectives on MHS pain care policies and guidance in practice. Staff and patients recommended prioritizing increases in treatment access and availability to improve pain care, and patients emphasized effective treatment and patient-centered care as the most important facilitators of high-quality pain care.

Virtual Behavioral Health for Army Soldiers: Soldier Perspectives and Patterns of Treatment.

Delivery of high-quality behavioral health (BH) care is essential to supporting the readiness of the U.S. armed forces and their families. The coronavirus disease 2019 (COVID-19) pandemic led to a dramatic expansion of virtual behavioral health (VBH) care: remote patient access to BH care using technology such as a computer or cellular phone. The U.S. Army asked RAND Arroyo Center to examine the use of VBH to inform recommendations on the role of VBH care in the future of BH care in the Military Health System. The authors analyzed administrative data on VBH and in-person BH care from prior to the pandemic through March 2022 and surveyed soldiers who received BH care to assess their perceptions of VBH care. Administrative data analyses showed that direct care providers were less likely to deliver VBH care than private-sector providers and relied heavily on audio rather than video VBH. In addition, soldiers who received VBH care typically received a mix of VBH and in-person visits. Survey respondents who used VBH care had similar perceptions of the quality of their care and more-positive views of VBH than respondents who did not use VBH care. Few respondents had declined VBH care in favor of in-person care. Using these findings, the authors make recommendations on the role of VBH care in overall BH delivered by the military.

Assessing the Quality of Outpatient Pain Care and Opioid Prescribing in the Military Health System.

Pain conditions are the leading cause of disability among active-duty service members. Given the significant implications for force readiness and service member well-being, the Military Health System (MHS) has made it a strategic priority to provide service members with the highest-quality treatment for pain conditions. RAND researchers assessed MHS outpatient care for acute and chronic pain, including opioid prescribing. The assessment involved developing a set of 14 quality measures designed to assess aspects of outpatient care for pain, including care associated with dental and ambulatory procedures, acute low back pain, chronic pain, opioid prescribing, and medication treatment for opioid use disorder. This research offers the most comprehensive examination to date of the quality and safety of pain care in the MHS and its alignment with evidence-based clinical practice guidelines. It identifies several areas of strength in pain care delivery, along with some areas for improvement, and provides recommendations to support the MHS in continuing to improve pain care for service members.

Readiness of Soldiers and Adult Family Members Who Receive Behavioral Health Care: Identifying Promising Outcome Metrics.

Behavioral health (BH) conditions-such as posttraumatic stress disorder, depression, and anxiety-are the second most common medical reasons for nondeployability in the U.S. Army. The authors of this report aimed to identify promising metrics to assess readiness among soldiers and adult family members who receive BH care. These metrics would expand the Army's outcome monitoring, which currently includes symptom improvement metrics, for patients who received BH care. The authors developed rigorous criteria to evaluate candidate readiness metrics, conducted interviews with stakeholders (Army subject-matter experts and BH providers), reviewed existing sources of data that could support the development of a readiness metric, and conducted a literature review to identify instruments that have been used to measure readiness-related domains in both military and civilian populations. The authors found that no existing data source or patient self-report instrument met criteria for implementation of a readiness metric for soldiers, but one instrument, the Walter Reed Functional Impairment Scale (WRFIS), is promising. No existing data source or patient self-report instrument met criteria for Army-wide implementation of a readiness metric for adult family members. Stakeholders reported that psychiatric symptoms, diagnosis, treatment, and impaired functioning are important indicators of lack of readiness among soldiers and adult family members. BH providers reported variability in assessing readiness and applying profiles, but behavioral experts provided suggestions for improving readiness assessment. The authors recommend that the Army conduct a pilot evaluation of a soldier readiness metric based on the WRFIS and increase standardization in applying profiles by continuing provider training.

Improving Behavioral Health Care for U.S. Army Personnel: Identifying Predictors of Treatment Outcomes.

This article identifies factors associated with changes in outcomes for soldiers who received Army behavioral health (BH) specialty care and provides recommendations to improve BH care and outcomes. RAND researchers identified three samples of soldiers who received Army BH care with diagnoses of posttraumatic stress disorder (PTSD), depression, or anxiety and whose symptoms were assessed during their care. Multivariate analyses included 141 patient and treatment variables to identify factors associated with symptom improvement. Analyses also examined patterns in how the symptoms changed over time. Analyses suggest that the Behavioral Health Data Portal, an online system that allows for collection of multiple patient- and clinician-reported measures, is widely used to track symptoms of PTSD, depression, and anxiety, but there are opportunities to expand symptom tracking. Two treatment factors-therapeutic alliance and receipt of benzodiazepines-were associated with treatment outcomes. Specifically, a stronger therapeutic relationship or alliance with providers, as reported by soldiers, was associated with improved PTSD, depression, and anxiety outcomes. Further, receipt of more than a 30-day supply of benzodiazepines was associated with poorer PTSD, depression, and anxiety outcomes. Many soldiers' trajectories of symptom change did not demonstrate improvement. Recommendations include providing feedback and guidance to providers on how to strengthen alliance with their patients, expanding tracking and feedback on benzodiazepine prescribing, and increasing provider use of measurement-based BH care.

Researching the Appropriateness of Care in the Complementary and Integrative Health Professions Part 5: Using Patient Records: Selection, Protection, and Abstraction.

OBJECTIVES: The purpose of this paper is to describe the 4-step process (consent, selection, protection, and abstraction) of acquiring a large sample of chiropractic patient records from multiple practices and subsequent data abstraction. METHODS: From April 2017 to December 2017, RAND acquired patient records from 99 chiropractic practices across the United States. The records included patients enrolled in a survey e-study (prospective sample) and a random sample of all clinic patients (retrospective sample) with chronic back or neck pain. Clinic staff were trained to collect the sample, scan, and transfer the records. We designed an online data collection tool for abstraction. Protocols were instituted to protect patient confidentiality. Doctors of chiropractic were selected and trained as abstractors, and a system was established to monitor data collection. RESULTS: In compliance with data protection protocols, 3603 patient records were scanned, including 1475 in the prospective sample and 2128 in the random sample. A total of 1716 patients (prospective sample) consented to having their records scanned, but only 1475 could be retrieved. Of records scanned, 19% were unusable owing to illegibility, no care during the period of interest, or poor scanning. The abstractor interrater reliability for appropriateness of care decisions was fair to moderate (κ .38-.48). CONCLUSION: The acquisition, handling, and abstraction of a large sample of chiropractic records was a complex task with challenges that necessitated adapting planned approaches. Of the records abstracted, many revealed incomplete provider documentation regarding the details of and rationale for care. Better documentation and more standardized record keeping would facilitate future research using patient records.

Continuity of Information Between Mental Health and Primary Care Providers After a Mental Health Consultation.

OBJECTIVE: Information sharing between mental health providers (MHPs) and primary care providers (PCPs) is important for persons with mental illnesses. The authors determined the level of information continuity between MHPs who saw a patient for a new consult and PCPs and whether continuity varied between providers with and without access to a shared electronic health record (EHR). METHODS: Data were analyzed for 141 randomly selected enrollees in six Medicare Advantage plans receiving a new outpatient mental health consultation in 2012. Medical records of MHPs and PCPs were abstracted to evaluate whether PCP records recognized the consultation, documented mental health hospitalizations and emergency department visits, and acknowledged psychotropic medications. Measures were compared between patients whose providers used and did not use mutual-access EHRs. RESULTS: For 21% of patients, the PCP record documented communication from the MHP within three months of the consultation. The PCP record showed evidence of timely communication (within seven days) for 42% of mental health hospitalizations and emergency department visits. Of 152 medications recorded by MHPs, 103 (68%) were acknowledged in the PCP record by the next visit. For patients with mutual-access EHRs, provider communication about the consultation was documented for a greater percentage of patients, compared with those without mutual-access EHRs (46% versus 11%, p<.001), as was communication about psychotropic medication (100% versus 57%, p<.001). CONCLUSIONS: This small but detailed study of patients receiving new outpatient mental health consults found poor continuity of information between MHPs and PCPs. A mutual-access EHR facilitated but did not guarantee such information sharing.

Hospital-Based Quality Measures for Pediatric Mental Health Care.

BACKGROUND AND OBJECTIVES: Patients with a primary mental health condition account for nearly 10% of pediatric hospitalizations nationally, but little is known about the quality of care provided for them in hospital settings. Our objective was to develop and test medical record-based measures used to assess quality of pediatric mental health care in the emergency department (ED) and inpatient settings. METHODS: We drafted an evidence-based set of pediatric mental health care quality measures for the ED and inpatient settings. We used the modified Delphi method to prioritize measures; 2 ED and 6 inpatient measures were operationalized and field-tested in 2 community and 3 children's hospitals. Eligible patients were 5 to 19 years old and diagnosed with psychosis, suicidality, or substance use from January 2012 to December 2013. We used bivariate and multivariate models to examine measure performance by patient characteristics and by hospital. RESULTS: Eight hundred and seventeen records were abstracted with primary diagnoses of suicidality (n = 446), psychosis (n = 321), and substance use (n = 50). Performance varied across measures. Among patients with suicidality, male patients (adjusted odds ratio: 0.27, P < .001) and African American patients (adjusted odds ratio: 0.31, P = .02) were less likely to have documentation of caregiver counseling on lethal means restriction. Among admitted suicidal patients, 27% had documentation of communication with an outside provider, with variation across hospitals (0%-38%; P < .001). There was low overall performance on screening for comorbid substance abuse in ED patients with psychosis (mean: 30.3). CONCLUSIONS: These new pediatric mental health care quality measures were used to identify sex and race disparities and substantial hospital variation. These measures may be useful for assessing and improving hospital-based pediatric mental health care quality.

Quality of Care for PTSD and Depression in the Military Health System: Final Report.

The U.S. Department of Defense (DoD) strives to maintain a physically and psychologically healthy, mission-ready force, and the care provided by the Military Health System (MHS) is critical to meeting this goal. Attention has been directed to ensuring the quality and availability of programs and services for posttraumatic stress disorder (PTSD) and depression. This study is a comprehensive assessment of the quality of care delivered by the MHS in 2013-2014 for over 38,000 active-component service members with PTSD or depression. The assessment includes performance on 30 quality measures to evaluate the receipt of recommended assessments and treatments. These measures draw on multiple data sources including administrative encounter data, medical record review data, and patient self-reported outcome monitoring data. The assessment identified strengths and areas for improvement for the MHS. In particular, the MHS excels at screening for suicide risk and substance use, but rates of appropriate follow-up for service members with suicide risk are lower. Most service members received at least some psychotherapy, but less than half of psychotherapy delivered was evidence-based. In analyses focused on Army soldiers, outcome monitoring increased notably over time, yet preliminary analyses suggest that more work is needed to ensure that services are effective in reducing symptoms. When comparing performance between 2012-2013 and 2013-2014, most measures demonstrated slight improvement, but targeted efforts will be needed to support further improvements. RAND provides recommendations for strategies to improve the quality of care delivered for these conditions.

Quality of care and patient-reported outcomes in carpal tunnel syndrome: A prospective observational study.

INTRODUCTION: Higher quality care for carpal tunnel syndrome (CTS) may be associated with better outcomes. METHODS: This prospective observational study recruited adults diagnosed with CTS from 30 occupational health centers, evaluated physicians' adherence to recommended care processes, and assessed results of the Boston Carpal Tunnel Questionnaire (BCTQ) and Short Form Health Survey version 2 (SF-12v2) at recruitment and at 18 months. RESULTS: Among 343 individuals, receiving better care (80th vs. 20th percentile for adherence) was associated with greater improvements in BCTQ Symptom Severity scores (-0.18, 95% confidence interval [CI] -0.32 to -0.05), BCTQ Functional Status scores (-0.21, 95% CI -0.34 to -0.08), and SF12-v2 Physical Component scores (1.75, 95% CI 0.33-3.16). Symptoms improved more when physicians assessed and managed activity, patients underwent necessary surgery, and employers adjusted job tasks. DISCUSSION: Efforts should be made to ensure that patients with CTS receive essential care processes including necessary surgery and activity assessment and management. Muscle Nerve 57: 896-904, 2018.

Development and Testing of the Pediatric Respiratory Illness Measurement System (PRIMES) Quality Indicators.

OBJECTIVES: To develop and test quality indicators for assessing care in pediatric hospital settings for common respiratory illnesses. PATIENTS: A sample of 2796 children discharged from the emergency department or inpatient setting at 1 of the 3 participating hospitals with a primary diagnosis of asthma, bronchiolitis, croup, or community-acquired pneumonia (CAP) between January 1, 2010, and December 31, 2011. SETTING: Three tertiary care children's hospitals in the United States. METHODS: We developed evidence-based quality indicators for asthma, bronchiolitis, croup, and CAP. Expert panel-endorsed indicators were included in the Pediatric Respiratory Illness Measurement System (PRIMES). This new set of pediatric quality measures was tested to assess feasibility of implementation and sensitivity to variations in care. Medical records data were extracted by trained abstractors. Quality measure scores (0-100 scale) were calculated by dividing the number of times indicated care was received by the number of eligible cases. Score differences within and between hospitals were determined by using the Student's t-test or analysis of variance. RESULTS: CAP and croup condition-level PRIMES scores demonstrated significant between-hospital variations (P < .001). Asthma and bronchiolitis condition-level PRIMES scores demonstrated significant within-hospital variation with emergency department scores (means [SD] 82.2(6.1)-100.0 (14.4)] exceeding inpatient scores (means [SD] 71.1 (2.0)-90.8 (1.3); P < .001). CONCLUSIONS: PRIMES is a new set of measures available for assessing the quality of hospital-based care for common pediatric respiratory illnesses.

Quality of Care for Work-Associated Carpal Tunnel Syndrome.

OBJECTIVE: To evaluate the quality of care provided to individuals with workers' compensation claims related to Carpal tunnel syndrome (CTS) and identify patient characteristics associated with receiving better care. METHODS: We recruited subjects with new claims for CTS from 30 occupational clinics affiliated with Kaiser Permanente Northern California. We applied 45 process-oriented quality measures to 477 subjects' medical records, and performed multivariate logistic regression to identify patient characteristics associated with quality. RESULTS: Overall, 81.6% of care adhered to recommended standards. Certain tasks related to assessing and managing activity were underused. Patients with classic/probable Katz diagrams, positive electrodiagnostic tests, and higher incomes received better care. However, age, sex, and race/ethnicity were not associated with quality. CONCLUSIONS: Care processes for work-associated CTS frequently adhered to quality measures. Clinical factors were more strongly associated with quality than demographic and socioeconomic ones.

Quality Measures to Assess Care Transitions for Hospitalized Children.

BACKGROUND: Transitions between sites of care are inherent to all hospitalizations, yet we lack pediatric-specific transitions-of-care quality measures. We describe the development and validation of new transitions-of-care quality measures obtained from medical record data. METHODS: After an evidence review, a multistakeholder panel prioritized quality measures by using the RAND/University of California, Los Angeles modified Delphi method. Three measures were endorsed, operationalized, and field-tested at 3 children's hospitals and 2 community hospitals: quality of hospital-to-home transition record content, timeliness of discharge communication between inpatient and outpatient providers, and ICU-to-floor transition note quality. Summary scores were calculated on a scale from 0 to 100; higher scores indicated better quality. We examined between-hospital variation in scores, associations of hospital-to-home transition quality scores with readmission and emergency department return visit rates, and associations of ICU-to-floor transition quality scores with ICU readmission and length of stay. RESULTS: A total of 927 charts from 5 hospitals were reviewed. Mean quality scores were 65.5 (SD 18.1) for the hospital-to-home transition record measure, 33.3 (SD 47.1) for the discharge communication measure, and 64.9 (SD 47.1) for the ICU-to-floor transition measure. The mean adjusted hospital-to-home transition summary score was 61.2 (SD 17.1), with significant variation in scores between hospitals (P < .001). Hospital-to-home transition quality scores were not associated with readmissions or emergency department return visits. ICU-to-floor transition note quality scores were not associated with ICU readmissions or hospital length of stay. CONCLUSIONS: These quality measures were feasible to implement in diverse settings and varied across hospitals. The development of these measures is an important step toward standardized evaluation of the quality of pediatric transitional care.

Quality of Care Provided by a Comprehensive Dementia Care Comanagement Program.

Multiple studies have shown that quality of care for dementia in primary care is poor, with physician adherence to dementia quality indicators (QIs) ranging from 18% to 42%. In response, the University of California at Los Angeles (UCLA) Health System created the UCLA Alzheimer's and Dementia Care (ADC) Program, a quality improvement program that uses a comanagement model with nurse practitioner dementia care managers (DCM) working with primary care physicians and community-based organizations to provide comprehensive dementia care. The objective was to measure the quality of dementia care that nurse practitioner DCMs provide using the Assessing Care of Vulnerable Elders (ACOVE-3) and Physician Consortium for Performance Improvement QIs. Participants included 797 community-dwelling adults with dementia referred to the UCLA ADC program over a 2-year period. UCLA is an urban academic medical center with primarily fee-for-service reimbursement. The percentage of recommended care received for 17 dementia QIs was measured. The primary outcome was aggregate quality of care for the UCLA ADC cohort, calculated as the total number of recommended care processes received divided by the total number of eligible quality indicators. Secondary outcomes included aggregate quality of care in three domains of dementia care: assessment and screening (7 QIs), treatment (6 QIs), and counseling (4 QIs). QIs were abstracted from DCM notes over a 3-month period from date of initial assessment. Individuals were eligible for 9,895 QIs, of which 92% were passed. Overall pass rates of DCMs were similar (90-96%). All counseling and assessment QIs had pass rates greater than 80%, with most exceeding 90%. Wider variation in adherence was found among QIs addressing treatments for dementia, which patient-specific criteria triggered, ranging from 27% for discontinuation of medications associated with mental status changes to 86% for discussion about acetylcholinesterase inhibitors. Comprehensive dementia care comanagement with a nurse practitioner can result in high quality of care for dementia, especially for assessment, screening, and counseling. The effect on treatment QIs is more variable but higher than previous reports of physician-provided dementia care.

The Quality of Care Provided to Women with Urinary Incontinence in 2 Clinical Settings.

PURPOSE: Our aim was to test the feasibility of a set of quality of care indicators for urinary incontinence and at the same time measure the care provided to women with urinary incontinence in 2 clinical settings. MATERIALS AND METHODS: This was a pilot test of a set of quality of care indicators. A total of 20 quality of care indicators were previously developed using the RAND Appropriateness Method. These quality of care indicators were used to measure care received for 137 women with a urinary incontinence diagnosis in a 120-physician hospital based multispecialty medical group. We also performed an abstraction of 146 patient records from primary care offices in Southern California. These charts were previously used as part of ACOVE (Assessing Care of Vulnerable Elders Project). As a post-hoc secondary analysis, the 2 populations were compared with respect to quality, as measured by compliance with the quality of care indicators. RESULTS: In the ACOVE population, 37.7% of patients with urinary incontinence underwent a pelvic examination vs 97.8% in the multispecialty medical group. Only 15.6% of cases in the multispecialty medical group and 14.2% in ACOVE (p = 0.86) had documentation that pelvic floor exercises were offered. Relatively few women with a body mass index of greater than 25 kg/m(2) were counseled about weight loss in either population (20.9% multispecialty medical group vs 26.1% ACOVE, p = 0.76). For women undergoing sling surgery, documentation of counseling about risks was lacking and only 9.3% of eligible cases (multispecialty medical group only) had documentation of the risks of mesh. CONCLUSIONS: Quality of care indicators are a feasible means to measure the care provided to women with urinary incontinence. Care varied by population studied and yet deficiencies in care were prevalent in both patient populations studied.

Quality of Care for PTSD and Depression in the Military Health System: Phase I Report.

The U.S. Department of Defense (DoD) strives to maintain a physically and psychologically healthy, mission-ready force, and the care provided by the Military Health System (MHS) is critical to meeting this goal. Given the rates of posttraumatic stress disorder (PTSD) and depression among U.S. service members, attention has been directed to ensuring the quality and availability of programs and services targeting these and other psychological health (PH) conditions. Understanding the current quality of care for PTSD and depression is an important step toward improving care across the MHS. To help determine whether service members with PTSD or depression are receiving evidence-based care and whether there are disparities in care quality by branch of service, geographic region, and service member characteristics (e.g., gender, age, pay grade, race/ethnicity, deployment history), DoD's Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) asked the RAND Corporation to conduct a review of the administrative data of service members diagnosed with PTSD or depression and to recommend areas on which the MHS could focus its efforts to continuously improve the quality of care provided to all service members. This study characterizes care for service members seen by MHS for diagnoses of PTSD and/or depression and finds that while the MHS performs well in ensuring outpatient follow-up following psychiatric hospitalization, providing sufficient psychotherapy and medication management needs to be improved. Further, quality of care for PTSD and depression varied by service branch, TRICARE region, and service member characteristics, suggesting the need to ensure that all service members receive high-quality care.

Targeting a high-risk group for fall prevention: strategies for health plans.

OBJECTIVES: Although Medicare has implemented incentives for health plans to reduce fall risk, the best way to identify older people at high risk of falling and to use screening results to target fall prevention services remains unknown. We evaluated 4 different strategies using a combination of administrative data and patient-reported information that health plans could easily obtain. STUDY DESIGN: Observational study. METHODS: We used data from 1776 patients 75 years or older in 4 community-based primary care practices who screened positive for a fear of falling and/or a history of falls. For these patients, we predicted fall-related injuries in the 24 months after the date of screening using claims/encounter data. After controlling for age and gender, we predicted the number of fall-related injuries by adding Elixhauser comorbidity count, any claim for a fall-related injury during the 12 months prior to screening, and falls screening question responses in a sequential fashion using negative binomial regression models. RESULTS: Basic patient characteristics, including age and Elixhauser comorbidity count, were strong predictors of fall-related injury. Among falls screening questions, a positive response to, "Have you fallen 2 or more times in the past year?" was the most predictive of a fall-related injury (incidence rate ratio [IRR], 1.56; 95% CI, 1.25-1.94). Prior claim for a fall-related injury also independently predicted this type of injury (IRR, 1.41; 95% CI, 1.05-1.89). The best model for predicting fall-related injuries combined all of these approaches. CONCLUSIONS: The combination of administrative data and a simple screening item can be used by health plans to target patients at high risk for future fall-related injuries.

Effect of Physician Delegation to Other Healthcare Providers on the Quality of Care for Geriatric Conditions.

The quality of care of older adults in the United States has been consistently shown to be inadequate. This gap between recommended and actual care provides an opportunity to improve the value of health care for older adults. Prior work from the Assessing Care of Vulnerable Elders (ACOVE) investigators first defined, and then sought to improve, clinical practice for common geriatric conditions. A critical component of the ACOVE intervention for practice improvement was an emphasis on the delegation of specific care processes, but the independent effect of delegation on the quality of care has not been evaluated. This study analyzed the pooled results of prior ACOVE projects from 1998 to 2010. Totaled, these studies included 4,776 individuals aged 65 and older of mixed demographic backgrounds and 16,204 ACOVE quality indicators (QIs) for three geriatric conditions: falls, urinary incontinence, and dementia. In unadjusted analyses, QI pass probabilities were 0.36 for physician-performed tasks, 0.55 for nurse practitioner (NP)-, physician assistant (PA)-, and registered nurse (RN)-performed tasks; and 0.61 for medical assistant- and licensed vocational nurse-performed tasks. In multiply adjusted models, the independent pass-probability effect of delegation to NPs, PAs, and RNs was 1.37 (P = .05). These findings suggest that delegation of selected tasks to nonphysician healthcare providers is associated with higher quality of care for these geriatric conditions in community practices and supports the value of interdisciplinary team management for common outpatient conditions in older adults.

Effect of a falls quality improvement program on serious fall-related injuries.

OBJECTIVES: To determine whether a program that improves the quality of care for falls reduces the number of episodes of care for serious fall-related injuries. DESIGN: Nonrandomized controlled trial. SETTING: Four community-based primary care practices. PARTICIPANTS: Individuals aged 75 and older who screened positive for fall risk. INTERVENTION: A multicomponent quality improvement program (Assessing Care of Vulnerable Elders Practice Redesign for Improved Medical Care for Elders) involving face-to-face clinician education about falls and decision support to prompt primary care providers to implement appropriate care, including referral to appropriate community resources, in response to individuals screening positive for fall risk. MEASUREMENTS: Episodes of care for selected fall-related injuries, based on healthcare claims. RESULTS: Of 1,791 individuals with data available for analysis, 1,187 were in the intervention group, and 604 were in the control group. Mean age was 83, and more than two-thirds of the sample were women. After adjusting for potential confounders, there were no statistically significant differences between intervention and control groups in episodes of care for fall-related injuries during the 12-month (incidence rate ratio (IRR) 1.27, 95% confidence interval (CI) = 0.93-1.73) or 24-month (IRR 1.18, 95% CI = 0.93-1.49) period after initiation of the intervention. CONCLUSION: Despite improving the care of falls, this quality improvement initiative did not result in a change in the number of episodes of care for serious fall-related injuries. Future work in community-based settings should test higher-intensity interventions to reduce fall-related injuries.

Measuring the Quality of Care for Psychological Health Conditions in the Military Health System: Candidate Quality Measures for Posttraumatic Stress Disorder and Major Depressive Disorder.

In recent years, the number of U.S. service members treated for psychological health conditions has increased substantially. In particular, at least two psychological health conditions-posttraumatic stress disorder (PTSD) and major depressive disorder (MDD)-have become more common, with prevalence estimates up to 20 percent for PTSD and 37 percent for MDD. Delivering quality care to service members with these conditions is a high-priority goal for the military health system (MHS). Meeting this goal requires understanding the extent to which the care the MHS provides is consistent with evidence-based clinical practice guidelines and its own standards for quality. To better understand these issues, RAND Corporation researchers developed a framework to identify and classify a set of measures for monitoring the quality of care provided by the MHS for PTSD and MDD. The goal of this project was to identify, develop, and describe a set of candidate quality measures to assess care for PTSD and MDD. To accomplish this goal, the authors performed two tasks: (1) developed a conceptual framework for assessing the quality of care for psychological health conditions and (2) identified a candidate set of measures for monitoring, assessing, and improving the quality of care for PTSD and MDD. This article describes their research approach and the candidate measure sets for PTSD and MDD that they identified. The current task did not include implementation planning but provides the foundation for future RAND work to pilot a subset of these measures.