Intimate Partner Violence Among Female OEF/OIF/OND Veterans Who Were Evaluated for Traumatic Brain Injury in the Veterans Health Administration: A Preliminary Investigation.

Many female veterans have deployed to Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND), and some experience traumatic brain injury (TBI). Although TBI is increasingly recognized as an important health issue for female OEF/OIF/OND veterans, there is little attention to stressful experiences that may exacerbate health problems or hinder recovery among veterans who may have experienced TBI. Lifetime intimate partner violence (IPV) is common among general samples of female veterans. Given the negative implications of IPV on women's health, it is important to understand whether there is a relationship between lifetime IPV and health functioning among female veterans who have experienced possible TBI. This study provides an exploration of lifetime IPV and its associations with physical and mental health, as well as community reintegration, among female OEF/OIF/OND veterans who have been evaluated for TBI. The sample comprised 127 female veterans who participated in a larger study that examined reintegration among OEF/OIF/OND veterans who received a TBI evaluation in the Veterans Heath Administration (VHA) and completed an assessment of lifetime IPV. Primary and secondary data sources included survey responses (e.g., health symptoms and reintegration) and VHA administrative data (e.g., health diagnoses). Results indicated that nearly two thirds (63.0%) of women who completed a TBI evaluation reported lifetime IPV, though clinician-confirmed TBI was not associated with IPV. Women who experienced IPV, compared with those who did not, reported higher levels of neurobehavioral symptoms and were significantly more likely to have diagnoses of back pain (48.6% vs. 30.0%, respectively) and substance abuse (12.2% vs. 0%, respectively). Notwithstanding, women with and without lifetime IPV reported similar levels of reintegration. Findings provide evidence that lifetime IPV may be common among female OEF/OIF/OND veterans who are evaluated for TBI, and that IPV is associated with several treatable health problems among this population.

Space-Time Cluster Analysis to Detect Innovative Clinical Practices: A Case Study of Aripiprazole in the Department of Veterans Affairs.

OBJECTIVE: To identify space-time clusters of changes in prescribing aripiprazole for bipolar disorder among providers in the VA. DATA SOURCES: VA administrative data from 2002 to 2010 were used to identify prescriptions of aripiprazole for bipolar disorder. Prescriber characteristics were obtained using the Personnel and Accounting Integrated Database. STUDY DESIGN: We conducted a retrospective space-time cluster analysis using the space-time permutation statistic. DATA EXTRACTION METHODS: All VA service users with a diagnosis of bipolar disorder were included in the patient population. Individuals with any schizophrenia spectrum diagnoses were excluded. We also identified all clinicians who wrote a prescription for any bipolar disorder medication. PRINCIPAL FINDINGS: The study population included 32,630 prescribers. Of these, 8,643 wrote qualifying prescriptions. We identified three clusters of aripiprazole prescribing centered in Massachusetts, Ohio, and the Pacific Northwest. Clusters were associated with prescribing by VA-employed (vs. contracted) prescribers. Nurses with prescribing privileges were more likely to make a prescription for aripiprazole in cluster locations compared with psychiatrists. Primary care physicians were less likely. CONCLUSIONS: Early prescribing of aripiprazole for bipolar disorder clustered geographically and was associated with prescriber subgroups. These methods support prospective surveillance of practice changes and identification of associated health system characteristics.

Team Process Variation Across Diabetes Quality of Care Trajectories.

Conceptual frameworks in health care do not address mechanisms whereby teamwork processes affect quality of care. We seek to fill this gap by applying a framework of teamwork processes to compare different patterns of primary care performance over time. We thematically analyzed 114 primary care staff interviews across 17 primary care clinics. We purposefully selected clinics using diabetes quality of care over 3 years using four categories: consistently high, improving, worsening, and consistently low. Analyses compared participant responses within and between performance categories. Differences were observed among performance categories for action processes (monitoring progress and coordination), transition processes (goal specification and strategy formulation), and interpersonal processes (conflict management and affect management). Analyses also revealed emergent concepts related to psychological and organizational context that were reported to affect team processes. This study is a first step toward a comprehensive model of how teamwork processes might affect quality of care.

Strengthening organizations to implement evidence-based clinical practices.

OBJECTIVES: Despite recognition that implementation of evidence-based clinical practices (EBPs) usually depends on the structure and processes of the larger health care organizational context, the dynamics of implementation are not well understood. This project's aim was to deepen that understanding by implementing and evaluating an organizational model hypothesized to strengthen the ability of health care organizations to facilitate EBPs. CONCEPTUAL MODEL: The model posits that implementation of EBPs will be enhanced through the presence of three interacting components: active leadership commitment to quality, robust clinical process redesign incorporating EBPs into routine operations, and use of management structures and processes to support and align redesign. STUDY DESIGN: In a mixed-methods longitudinal comparative case study design, seven medical centers in one network in the Department of Veterans Affairs participated in an intervention to implement the organizational model over 3 years. The network was selected randomly from three interested in using the model. The target EBP was hand-hygiene compliance. Measures included ratings of implementation fidelity, observed hand-hygiene compliance, and factors affecting model implementation drawn from interviews. FINDINGS: Analyses support the hypothesis that greater fidelity to the organizational model was associated with higher compliance with hand-hygiene guidelines. High-fidelity sites showed larger effect sizes for improvement in hand-hygiene compliance than lower-fidelity sites. Adherence to the organizational model was in turn affected by factors in three categories: urgency to improve, organizational environment, and improvement climate. IMPLICATIONS: Implementation of EBPs, particularly those that cut across multiple processes of care, is a complex process with many possibilities for failure. The results provide the basis for a refined understanding of relationships among components of the organizational model and factors in the organizational context affecting them. This understanding suggests practical lessons for future implementation efforts and contributes to theoretical understanding of the dynamics of the implementation of EBPs.

Provider attitudes toward pay-for-performance programs: development and validation of a measurement instrument.

OBJECTIVE: To develop an instrument for assessing physician attitudes toward quality incentive programs, and to assess its reliability and validity. DATA SOURCES: Study involved primary data collection. A 40-item paper and pencil survey of primary care physicians in Rochester, New York, and Massachusetts was conducted between May 2004 and December 2004. Seven-hundred and ninety-eight completed questionnaires were received, representing a response rate of 32 percent (798/2,497). STUDY DESIGN: Based on an extensive review of the literature and discussions with experts in the field, we developed a conceptual framework representing the features of pay-for-performance (P4P) programs hypothesized to affect physician behavior in that context. A draft questionnaire was developed based on that conceptual model and pilot tested in three groups of physicians. The questionnaire was modified based on the physician feedback, and the revised version was distributed to 2,497 primary care physicians affiliated with two of the seven sites participating in Rewarding Results, a national evaluation of quality target and financial incentive programs. DATA COLLECTION: Respondents were randomly divided into a derivation and a validation sample. Exploratory factor analysis was applied to the responses of the derivation sample. Those results were used to create scales in the validation sample, and these were then subjected to multitrait analysis (MTA). One scale representing physicians' perception of the impact of P4P on their clinical practice was regressed on the other scales as a test of construct validity. PRINCIPAL FINDINGS: Seven constructs were identified and demonstrated substantial convergent and discriminant validity in the MTA: awareness and understanding, clinical relevance, cooperation, unintended consequences, control, financial salience, and impact. Internal consistency reliabilities (Cronbach's alpha coefficients) ranged from 0.50 to 0.80. A statistically significant 25 percent of the variation in perceived impact was accounted for by physician perceptions of the other six characteristics of P4P programs. CONCLUSIONS: It is possible to identify and measure the key salient features of P4P programs using a valid and reliable 26-item survey. This instrument may now be used in further studies to better understand the impact of P4P programs on physician behavior.