The effects of crew resource management on teamwork and safety climate at Veterans Health Administration facilities.

Communication failure is a significant source of adverse events in health care and a leading root cause of sentinel events reported to the Joint Commission. The Veterans Health Administration National Center for Patient Safety established Clinical Team Training (CTT) as a comprehensive program to enhance patient safety and to improve communication and teamwork among health care professionals. CTT is based on techniques used in aviation's Crew Resource Management (CRM) training. The aviation industry has reached a significant safety record in large part related to the culture change generated by CRM and sustained by its recurrent implementation. This article focuses on the improvement of communication, teamwork, and patient safety by utilizing a standardized, CRM-based, interprofessional, immersive training in diverse clinical areas. The Teamwork and Safety Climate Questionnaire was used to evaluate safety climate before and after CTT. The scores for all of the 27 questions on the questionnaire showed an increase from baseline to 12 months, and 11 of those increases were statistically significant. A recurrent training is recommended to maintain the positive outcomes. CTT enhances patient safety and reduces risk of patient harm by improving teamwork and facilitating clear, concise, specific and timely communication among health care professionals.

Access to Subspecialty Care And Survival Among Patients With Liver Disease.

OBJECTIVES: Access to subspecialty care may be difficult for patients with liver disease, but it is unknown whether access influences outcomes among this population. Our objectives were to determine rates and predictors of access to ambulatory gastrointestinal (GI) subspecialty care for patients with liver disease and to determine whether access to subspecialty GI care is associated with better survival. METHODS: We studied 28,861 patients within the Veterans Administration VISN 11 Liver Disease cohort who had an ICD-9-CM diagnosis code for liver disease from 1 January 2000 through 30 May 2011. Access was defined as a completed outpatient clinic visit with a gastroenterologist or hepatologist at any time after diagnosis. Multivariable logistic regression was used to determine predictors of access to a GI subspecialist. Survival curves were compared between those who did and those who did not see a specialist, with propensity score adjustment to account for other covariates that may affect access. RESULTS: Overall, 10,710 patients (37%) had a completed GI visit. On multivariable regression, older patients (odds ratio (OR) 0.98, P<0.001), those with more comorbidities (OR 0.98, P=0.01), and those living farther from a tertiary-care center (OR 0.998/mi, P<0.001) were less likely to be seen in clinic. Patients who were more likely to be seen included those who had hepatitis C (OR 1.5, P<0.001) or cirrhosis (OR 3.5, P<0.001) diagnoses prior to their initial visit. Patients with an ambulatory GI visit at any time after diagnosis were less likely to die at 5 years when compared with propensity-score-matched controls (hazard ratio 0.81, P<0.001). CONCLUSIONS: Access to ambulatory GI care was associated with improved 5-year survival for patients with liver disease. Innovative care coordination techniques may prove beneficial in extending access to care to liver disease patients.

Employee attitudes about moving toward a smoke-free campus at a Veterans Affairs hospital.

BACKGROUND: Although Veterans Affairs (VA) hospitals have been smoke-free inside of buildings since 1991, smoke-free campuses have not been initiated. The purpose of this article is to describe staff attitudes regarding making the VA hospital a smoke-free campus except for the mandated smoking shelters. METHODS: In 2008, a cross-sectional, anonymous survey was conducted with a convenience sample of employees at a Midwestern VA (N = 397). RESULTS: Descriptive statistics showed that the vast number of employees were in support of a smoke-free campus (76%), relocating the smoking shelters (62%), and offering employees assistance to quit smoking (71%). Multivariate analyses showed that those who were nonsmokers, older, women, and higher educated were the greatest supporters of policies to support a smoke-free environment (p < .05). Write-in comments were generally favorable but also revealed employee resistance related to freedom, personal choice, and potential loss in productivity as smokers go further away from the building to smoke. CONCLUSIONS: VA hospitals have unique challenges in implementing smoke-free campus policies.

Early mortality and years of potential life lost among Veterans Affairs patients with depression.

OBJECTIVE: Substantial literature documents excess and early mortality among individuals with serious mental illness, but there are relatively few data about mortality and depression. METHODS: During fiscal year 2007, data from the U.S. Department of Veterans Affairs and the National Death Index were used to calculate mean age of death and years of potential life lost (YPLL) associated with 13 causes of death among veterans with (N=701,659) or without (N=4,245,193) depression. RESULTS: Compared with nondepressed patients, depressed patients died younger (71.1 versus 75.9) and had more YPLL (13.4 versus 10.2) as a result of both natural and unnatural causes. Depending on the cause of death, depressed patients died between 2.5 and 8.7 years earlier and had 1.5 to 6.1 YPLL compared with nondepressed patients. CONCLUSIONS: These findings have important implications for clinical practice, given that improved quality of care may be needed to reduce early mortality among depressed VA patients.

Eight-year trends of cardiometabolic morbidity and mortality in patients with schizophrenia.

OBJECTIVE: We examined cardiometabolic disease and mortality over 8 years among individuals with and without schizophrenia. METHOD: We compared 65,362 patients in the Veteran Affairs (VA) health system with schizophrenia to 65,362 VA patients without serious mental illness (non-SMI) matched on age, service access year and location. The annual prevalence of diagnosed cardiovascular disease, diabetes, dyslipidemia, hypertension, obesity, and all-cause and cause-specific mortality was compared for fiscal years 2000-2007. Mean years of potential life lost (YPLLs) were calculated annually. RESULTS: The cohort was mostly male (88%) with a mean age of 54 years. Cardiometabolic disease prevalence increased in both groups, with non-SMI patients having higher disease prevalence in most years. Annual between-group differences ranged from <1% to 6%. Annual mortality was stable over time for schizophrenia (3.1%) and non-SMI patients (2.6%). Annual mean YPLLs increased from 12.8 to 15.4 in schizophrenia and from 11.8 to 14.0 for non-SMI groups. CONCLUSIONS: VA patients with and without schizophrenia show increasing but similar prevalence rates of cardiometabolic diseases. YPLLs were high in both groups and only slightly higher among patients with schizophrenia. The findings highlight the complex population served by the VA while suggesting a smaller mortality impact from schizophrenia than previously reported.

Design and rationale of a randomized controlled trial to reduce cardiovascular disease risk for patients with bipolar disorder.

BACKGROUND: Persons with bipolar disorder (BD) experience a disproportionate burden of medical comorbidity, notably cardiovascular disease (CVD), contributing to decreased function and premature mortality. We describe the design, rationale, and baseline findings for the Self-Management Addressing Heart Risk Trial (SMAHRT), a randomized controlled effectiveness trial of an intervention (Life Goals Collaborative Care; LGCC) designed to reduce CVD risk factors and improve physical and mental health outcomes in patients with BD. METHODS: Patients with BD and at least one CVD risk factor were recruited from a VA healthcare system and randomized to either LGCC or usual care (UC). LGCC participants attended four weekly, group-based self-management sessions followed by monthly individual contacts supportive of health behavior change and ongoing medical care management. In contrast, UC participants received monthly wellness newsletters. Physiological and questionnaire assessments measured changes in CVD outcomes and quality of life (QOL) over 24 months. RESULTS: Out of the 180 eligible patients, 134 patients were enrolled (74%) and 118 started the study protocols. At baseline (mean age=54, 17% female, 5% African American) participants had a high burden of clinical risk with nearly 70% reporting at least three CVD risk factors including, smoking (41%) and physical inactivity (57%). Mean mental and physical HRQOL scores were 1.5 SD below SF-12 population averages. CONCLUSION: SMAHRT participants experienced substantial CVD morbidity and risk factors, poor symptom control, and decreased QOL. LGCC is the first integrated intervention for BD designed to mitigate suboptimal health outcomes by combining behavioral medicine and care management strategies.

Evaluation of a nurse practitioner disease management model for chronic heart failure: a multi-site implementation study.

While disease management appears to be effective in selected, small groups of CHF patients from randomized controlled trials, its effectiveness in a broader CHF patient population is not known. This prospective, quasi-experimental study compared patient outcomes under a nurse practitioner-led disease management model (intervention group) with outcomes under usual care (control group) in both primary and tertiary medical centers. The study included 969 veterans (458 intervention, 511 control) treated for CHF at six VA medical centers. Intervention patients had significantly fewer (p<0.05) CHF and all-cause admissions at one-year follow-up, and lower mortality at both one- and two-year follow-up. These data provide support for the potential effectiveness of the intervention, and suggest that the evidence from RCTs of disease management models for CHF can be translated into clinical practice, even without the benefits of a selected patient population and dedicated resources often found in RCTs.

Quality of general medical care among patients with serious mental illness: does colocation of services matter?

OBJECTIVE: This study was conducted to determine whether patients with serious mental illness receiving care in Veterans Affairs (VA) mental health programs with colocated general medical clinics were more likely to receive adequate medical care than patients in programs without colocated clinics based on a nationally representative sample. METHODS: The study included all VA patients with diagnoses of serious mental illness in fiscal year (FY) 2006-2007 who were also part of the VA's External Peer Review Program (EPRP) FY 2007 random sample and who received care from VA facilities (N=107 facilities) with organizational data from the VA Mental Health Program Survey (N=7,514). EPRP included patient-level chart review quality indicators for common processes of care (foot and retinal examinations for diabetes complications; screens for colorectal health, breast cancer, and alcohol misuse; and tobacco counseling) and outcomes (hypertension, diabetes blood sugar, and lipid control). RESULTS: Ten out of 107 (10%) mental health programs had colocated medical clinics. After adjustment for organizational and patient-level factors, analyses showed that patients from colocated clinics compared with those without colocation were more likely to receive foot exams (OR=1.87, p<.05), colorectal cancer screenings (OR=1.54, p<.01), and alcohol misuse screenings (OR=2.92, p<.01). They were also more likely to have good blood pressure control (<140/90 mmHg; OR=1.32, p<.05) but less likely to have glycosylated hemoglobin <9% (OR=.69, p<.05). CONCLUSIONS: Colocation of medical care was associated with better quality of care for four of nine indicators. Additional strategies, particularly those focused on improving diabetes control and other chronic medical outcomes, might be warranted for patients with serious mental illness.

Ratings of patient-provider communication among veterans: serious mental illnesses, substance use disorders, and the moderating role of trust.

Many individuals with a mental illness are not satisfied with their communication with their primary provider. The present study examined the relationship of serious mental illness (SMI), substance use disorder (SUD), and trust for the provider with provider communication. The sample included Veterans Administration (VA) patients throughout the United States who either had a SMI diagnosis (schizophrenia or bipolar disorder) or were in a random sample of non-SMI patients (total N=8,089). Latent class (LC) modeling identified three classes of provider communication ratings in the sample: very good, good, and poor. In LC regression, poor trust for the provider was associated with a decrease in the likelihood of being in the "very good" or "good" compared to the "poor" provider communication ratings group, and the decrease was significantly greater for VA patients with a SMI or SUD diagnosis than those without. Training providers on creating trust is particularly important for those who serve patients with SMI and SUD diagnoses.

The relationship between religious involvement and clinical status of patients with bipolar disorder.

OBJECTIVE: Religion and spirituality are important coping strategies in depression but have been rarely studied within the context of bipolar disorder. The present study assessed the association between different forms of religious involvement and the clinical status of individuals treated for bipolar disorder. METHODS: A cross-sectional observation study of follow-up data from a large cohort study of patients receiving care for bipolar disorder (n = 334) at an urban Veterans Affairs mental health clinic was conducted. Bivariate and multivariate analyses were performed to assess the association between public (frequency of church attendance), private (frequency of prayer/meditation), as well as subjective forms (influence of beliefs on life) of religious involvement and mixed, manic, depressed, and euthymic states when demographic, anxiety, alcohol abuse, and health indicators were controlled. RESULTS: Multivariate analyses found significant associations between higher rates of prayer/meditation and participants in a mixed state [odds ratio (OR) = 1.29; 95% confidence interval (CI) = 1.10-1.52, chi square = 9.42, df = 14, p < 0.05], as well as lower rates of prayer/meditation and participants who were euthymic (OR = 0.84; 95% CI = 0.72-0.99, chi square = 4.60, df = 14, p < 0.05). Depression and mania were not associated with religious involvement. CONCLUSIONS: Compared to patients with bipolar disorder in depressed, manic, or euthymic states, patients in mixed states have more active private religious lives. Providers should assess the religious activities of individuals with bipolar disorder in mixed states and how they may complement/deter ongoing treatment. Future longitudinal studies linking bipolar states, religious activities, and treatment-seeking behaviors are needed.

Quality of care for cardiometabolic disease: associations with mental disorder and rurality.

BACKGROUND: This study examines quality of cardiometabolic care among veterans receiving care in the Veterans Affairs (VA) health system. We assess whether quality of care disparities by mental disorder status are magnified for individuals living in rural areas. RESEARCH DESIGN: We identified all patients in a 2005 national Veterans Administration cardiometabolic quality of care chart review. The intersection of this cohort and VA registries, that include patients with and without mental disorder, permitted identification of chart review patients with and without mental disorder. Using residential ZIP code, patients were assigned to rural-urban commuting area codes. We used logistic regression adjusting for age, demographics, comorbidities, and income. MEASURES: We assessed association between rural residence and 9 cardiometabolic care quality indicators including care processes and intermediate outcomes. RESULTS: Compared with those without mental disorder, patients with mental disorder were less likely to receive diabetes sensory foot exams (OR: 0.82; 95% CI: 0.72-0.94), retinal exams (OR: 0.82; 95% CI: 0.73-0.93), and renal tests (OR: 0.79; CI: 0.74-0.90). Rural residence was associated with no differences in quality measures. Primary care visit volume was associated with significantly greater likelihood of obtaining diabetic retinal examination and renal testing, but did not explain disparities among patients with mental disorder. CONCLUSIONS: Mental disorder is associated with lesser attainment of quality cardiometabolic care. In this integrated VA care system, rurality and visit volume did not explain this disparity. Other explanations for disparities must be explored to improve the health and health care of this population.

"No-shows": who fails to follow up with initial behavioral health treatment?

OBJECTIVE: We sought to determine what demographic and clinical factors are associated with receipt of initial mental health treatment. STUDY DESIGN AND METHODS: A total of 1177 patients completed structured clinical interviews (Michigan Screening for Treatment and Research Triage) when they called to authorize mental health benefits. Measures included age, sex, alcohol use, drug use, anxiety, depression, medical history, behavioral health treatment history, psychosocial stressors, functioning, and suicidality. Multivariate analyses determined the association between these variables and a behavioral health claim within 90 days of the interview. RESULTS: Among those completing interviews, 85% attended initial mental health treatment. Factors significantly associated with increased odds of treatment initiation were good self-rated health (odds ratio [OR] = 1.70; 95% confidence interval [CI] = 1.15, 2.50), support of family or friends (OR = 1.71; 95% CI = 1.11, 2.65), previous outpatient mental health visits (OR = 1.56; 95% CI = 1.11, 2.19), and recent alcohol use (OR = 1.41; 95% CI = 1.00, 1.97). Factors associated with decreased odds of treatment initiation were recent period of total disability (OR = 0.62; 95% CI = 0.45, 0.87), any previous suicide attempt (OR = 0.56; 95% CI = 0.36, 0.87), 6 or more physician visits for medical reasons this year (OR = 0.64; 95% CI = 0.44, 0.92), and legal problems (OR = 0.31; 95% CI = 0.16, 0.61). In multivariate analyses, family support, history of medical visits, and recent alcohol use were no longer significant predictors. CONCLUSIONS: Most individuals in this insured population who completed an initial telephone assessment had an initial behavioral health claim. However, patients with greater health or social service needs were at higher risk for not obtaining treatment, suggesting the need for greater outreach and attention by providers and insurers.

Clinical and demographic factors associated with homelessness and incarceration among VA patients with bipolar disorder.

OBJECTIVES: We assessed the association between homelessness and incarceration in Veterans Affairs patients with bipolar disorder. METHODS: We used logistic regression to model each participant's risk of incarceration or homelessness after we controlled for known risk factors. RESULTS: Of 435 participants, 12% reported recent homelessness (within the past month), and 55% reported lifetime homelessness. Recent and lifetime incarceration rates were 2% and 55%, respectively. In multivariate models, current medication adherence (based on a 5-point scale) was independently associated with a lower risk of lifetime homelessness (odds ratio [OR] = 0.80 per point, range 0-4; 95% confidence interval [CI] = 0.66, 0.96), and lifetime incarceration increased the risk of lifetime homelessness (OR = 4.4; 95% CI = 2.8, 6.9). Recent homelessness was associated with recent incarceration (OR = 26.4; 95% CI = 5.2, 133.4). Lifetime incarceration was associated with current substance use (OR = 2.6; 95% CI = 2.7, 6.7) after control for lifetime homelessness (OR = 4.2; 95% CI = 2.7, 6.7). CONCLUSIONS: Recent and lifetime incarceration and homelessness were strongly associated with each other. Potentially avoidable or treatable correlates included current medication nonadherence and substance use. Programs that better coordinate psychiatric and drug treatment with housing programs may reduce the cycle of incarceration, homelessness, and treatment disruption within this vulnerable patient population.

A collaborative therapeutic relationship and risk of suicidal ideation in patients with bipolar disorder.

BACKGROUND: A diagnosis of Bipolar Disorder (BD) is among the strongest known risk factors for suicide. The present study examines the relative impact of current mood state (depressed, manic or mixed) and patient perceptions of the therapeutic relationship on suicidal ideation in veterans with BD. METHODS: We conducted analyses of the baseline data from a naturalistic cohort study of veterans receiving care for BD (N=432) at a large urban VA mental health clinic. Logistic regression was used to examine the relative impact of patient- and treatment-related factors on suicidal ideation within the two weeks prior to recruitment. RESULTS: Over 49% (213/432) of veterans receiving current outpatient treatment for BD reported at least some suicidal ideation within the two weeks prior to recruitment. After accounting for current mood state and other identified risk factors, even minimal increases (i.e., per point increase on a 0-60 rating scale) in the extent to which the therapeutic relationship is perceived as collaborative (OR=0.97; p<.01) were associated with a reduction in risk of suicidal ideation. LIMITATIONS: This study is cross sectional and relies exclusively on patient self-report. CONCLUSIONS: Mental health treatment providers should be aware of the high rate of suicidal ideation in patients with BD. Successful management of suicidal ideation likely involves a focus on improving symptoms as well as establishing a collaborative therapeutic relationship.

Health-related quality of life and utilities among patients with depression in the Department of Veterans Affairs.

OBJECTIVE: This study establishes veteran-specific utility measures for patients with and those without depression. METHODS: A cross-sectional study was conducted of 87,797 Veterans Affairs (VA) patients who had completed the 12-Item Short-Form Health Survey (SF-12) portion of the VA's Large Health Survey of Veteran Enrollees administered in 1999 (58,442 veterans had an ICD-9 diagnosis of depression and 29,355 did not have such a diagnosis). RESULTS: All demographic and clinical comparisons were statistically significant between the two groups. Compared with veterans without depression, those with depression had lower mental component scores and physical component scores, indicating worse health. Utilities, an indication of health state, were lower for veterans with depression, indicating worse health. CONCLUSIONS: This is the first national study of utilities among veterans with and those without depression. Future research should investigate how treatment interventions may affect utilities and develop broader cost-effectiveness models of VA depression care.

Using pharmacy data on partial adherence to inform clinical care of patients with serious mental illness.

OBJECTIVE: Low adherence to antipsychotic medications is a risk factor for poor outcomes for people with serious mental illness. Pharmacy data might be used by health systems to identify partially adherent patients for interventions. This study assessed whether using pharmacy data is an accurate screening method for identifying at-risk patients. METHODS: Administrative data were used to identify 1,712 veterans as having schizophrenia or a schizoaffective or bipolar disorder and who had 12-month antipsychotic medication possession ratios (MPRs) of less than .80. Patients' charts were reviewed for alternative explanations for low rates of filling prescriptions for antipsychotic medication. RESULTS: Of 1,712 patients whose pharmacy data indicated partial adherence (MPRs less than .80), 17% (N=297) may have been adherent. Patients with bipolar disorder had higher odds of receiving a false-positive designation (adjusted odds ratio of 1.8, 95% confidence interval of 1.31-2.39). CONCLUSIONS: MPRs constructed from pharmacy data can be a useful first screen for identifying patients who need assistance with medication adherence.

Rates of clinical depression diagnosis, functional impairment, and nursing home placement in coexisting dementia and depression.

OBJECTIVE: Depression is commonly found as a coexisting condition in dementia. An earlier retrospective study by the authors found that patients with coexisting dementia and depression (CDD) were high utilizers of inpatient and nursing home care. The current prospective study was designed to investigate specific factors that might contribute to outcomes such as nursing home placement by examining the detection and course of CDD subjects as compared with subjects with either disorder alone. METHODS: Eighty-two subjects (N=29 with CDD, N=27 with Depression Alone, and N=26 with Dementia Alone) were recruited and reassessed at 3, 6, and 12 months after baseline assessment. RESULTS: Lower rates of depression detection by treating (non-study) physicians were found in CDD subjects. Only 35% of the CDD group were correctly diagnosed and receiving adequate treatment for their depression. Although the CDD group did not differ in baseline dementia stage or cognitive functioning as compared with the dementia-only group, they had significantly higher levels of functional impairment. CDD subjects used nursing home care at significantly higher rates; nursing home placement correlated significantly with baseline severity of functional impairment and mood measures, but not with other factors, including dementia stage and medical burden. CONCLUSIONS: Undetected, untreated, or inadequately treated depression may result in higher rates of nursing home placement in patients with dementia by increasing their functional disability. Aggressive outpatient treatment of depression could improve the course of coexisting dementia and depression.

Race, gender, and psychiatrists' diagnosis and treatment of major depression among elderly patients.

OBJECTIVE: This study examined psychiatrists' contributions to racial and gender disparities in diagnosis and treatment among elderly persons. METHODS: Psychiatrists who volunteered to participate in the study were randomly assigned to one of four video vignettes depicting an elderly patient with late-life depression. The vignettes differed only in terms of the race of the actor portraying the patient (white or African American) and gender. The study participants were 329 psychiatrists who attended the 2002 annual meeting of the American Psychiatric Association. RESULTS: Eighty-one percent of the psychiatrists assigned the elderly patient a diagnosis of major depression. Patients' race and gender was not associated with significant differences in the diagnoses of major depression, assessment of most patient characteristics, or recommendations for managing the disorder. However, psychiatrists' characteristics, particularly the location of the medical school at which the psychiatrist was trained (United States versus international), were significantly associated with a number of variables. CONCLUSIONS: Given standardized symptom pictures, psychiatrists are no less likely to diagnose or treat depression among African-American elderly patients than among other patients, which suggests that bias based simply on race is not a likely explanation for racial differences in diagnosis and treatments found in earlier clinical studies. The impact of psychiatrists' having trained at international medical schools on diagnosis, treatment, and judgment of several patient attributes may indicate the need for targeted educational initiatives for aging and cultural competency.

Variation in outcomes in Veterans Affairs intensive care units with a computerized severity measure.

OBJECTIVE: To quantify the variability in risk-adjusted mortality and length of stay of Veterans Affairs intensive care units using a computer-based severity of illness measure. DESIGN: Retrospective cohort study. SETTING: A stratified random sample of 34 intensive care units in 17 Veterans Affairs hospitals. PARTICIPANTS: A consecutive sample of 29,377 first intensive care unit admissions from February 1996 through July 1997. INTERVENTIONS: Standardized mortality ratio (observed/expected deaths) and observed minus expected length of stay (OMELOS) with 95% confidence intervals were estimated for each unit using a hierarchical logistic (standardized mortality ratio) or linear (OMELOS) regression model with Markov Chain Monte Carlo simulation. We adjusted for patient characteristics including age, admission diagnosis, comorbid disease, physiology at admission (from laboratory data), and transfer status. MEASUREMENTS AND MAIN RESULTS: Mortality across the intensive care units for the 12,088 surgical and 17,289 medical cases averaged 11% (range, 2-30%). Length of stay in the intensive care units averaged 4.0 days (range, mean unit length of stay 3.0-5.9). Standardized mortality ratio of the intensive care units varied from 0.62 to 1.27; the standardized mortality ratio and 95% confidence interval were <1 for four intensive care units and >1.0 for seven intensive care units. OMELOS of the intensive care units ranged from -0.89 to 1.34 days. In a random slope hierarchical model, variation in standardized mortality ratio among intensive care units was similar across the range of severity, whereas variation in length of stay increased with severity. Standardized mortality ratio was not associated with OMELOS (Pearson's r = .13). CONCLUSIONS: We identified intensive care units whose indicators for mortality and length of stay differ substantially using a conservative statistical approach with a severity adjustment model based on data available in computerized clinical databases. Computerized risk adjustment employing routinely available data may facilitate research on the utility of intensive care unit profiling and analysis of natural experiments to understand process and outcome links and quality efforts.