SCAN-ECHO for Pain Management: Implementing a Regional Telementoring Training for Primary Care Providers.

Objective: The Specialty Care Access Network-Extension for Community Health Outcomes (SCAN-ECHO) is a video teleconferencing-based training program where primary care providers are trained by a specialty care team to provide specialty care. A multidisciplinary team of pain management specialists at the Cleveland Veterans Affairs Medical Center established such a program for pain management; a description and preliminary effectiveness assessment of this training program is presented. Design: Primary care provider participants in the Specialty Care Access Network program in pain management completed pre- and post-training questionnaires. A subset of these participants also participated in a group session semistructured interview. Subjects: Twenty-four primary care providers from Cleveland, South Texas, or Wisconsin Veterans Affairs Medical Centers who regularly attended pain management SCAN-ECHO sessions during 2011, 2012, 2013, or 2014 completed pre- and post-training questionnaires. Methods: Pre- and post-training questionnaires were conducted to measure confidence in treating and knowledge of pain management. Questionnaire responses were tested for significance using R. Qualitative data were analyzed using inductive coding and content analysis. Results: Statistically significant increases in confidence ratings and scores on knowledge questionnaires were noted from pre- to post-pain management SCAN-ECHO training. Program participants felt more knowledgeable and reported improved communication between specialty and primary care providers. Conclusions: This pilot study reveals positive outcomes in terms of primary care providers' confidence and knowledge in treating patients with chronic pain. Results suggest that involving primary care providers in a one-year academic project such as this can improve their knowledge and skills and has the potential to influence their opioid prescribing practices.

Quality improvement in heart failure: a randomized educational intervention to change provider behavior.

UNLABELLED: Whether provider education changes practice for HF has not been reported. (NHeFT)™ uses didactic and experiential training of primary care providers (PCP) to optimize treatment of HF. We randomized PCP's in the Cleveland VA clinics to training (T) vs control (C). ENDPOINTS: Primary - the number of patients with EF < 40% treated with ACEI/ARB and Beta Blocker, +/- diuretic post T vs pre T; Secondary - the number of patients with increase in ACEI/ARB or a decrease in diuretic post T vs. pre T. Of 641 patients, 216 (85 C,131 T) had EF < 40%; 188 (85%) did not meet the primary endpoint at baseline. After T, a similar proportion (64.2% C, 74.4%,T) met the endpoint at end of study (P = 0.14). The odds of a patient meeting the primary endpoint by care of a T provider, was not significantly higher than C (OR 1.496, 95% CI (0.751, 2.982)). Patients seen by T were more likely to have the diuretic dose decreased vs patients under C, without increases in ACEI or ARB (P < 0.03). Thus, a didactic program of HF plus a preceptorship changed practice modestly. Studies should address provider readiness of change and self efficacy to adhere to evidenced-based care.

Using evidence-based quality improvement methods for translating depression collaborative care research into practice.

OBJECTIVE: Translating Initiatives in Depression into Effective Solution (TIDES) aimed to translate research-based collaborative care for depression into an approach for the Veterans Health Administration (VA). SITES: Three multistate administrative regions and seven of their medium-sized primary care practices. INTERVENTION: Researchers assisted regional leaders in adapting research-based depression care models using evidence-based quality improvement (EBQI) methods. EVALUATION: We evaluated model fidelity and impacts on patients. Trained nurse depression care managers collected data on patient adherence and outcomes. RESULTS: Among 72% (128) of the 178 patients followed in primary care with depression care manager assistance during the 3-year study period, mean PHQ-9 scores dropped from 15.1 to 4.7 (p < .001). A total of 87% of patients achieved a PHQ-9 score lower than 10 (no major depression). 62% achieved a score lower than six (symptom resolution). Care managers referred 28% (50) TIDES patients to mental health specialty (MHS). In the MHS-referred group, mean PHQ-9 scores dropped from 16.4 to 9.0 (p < .001). A total of 58% of MHS-referred patients achieved a PHQ-9 score lower than 10, and 40%, a score less than 6. Over the 2 years following the initial development phase reported here, national policymakers endorsed TIDES through national directives and financial support. CONCLUSIONS: TIDES developed an evidence-based depression collaborative care prototype for a large health care organization (VA) using EBQI methods. As expected, care managers referred sicker patients to mental health specialists; these patients also improved. Overall, TIDES achieved excellent overall patient outcomes, and the program is undergoing national spread.

Gender differences in the association between antidepressant use and restless legs syndrome.

Contradictory results have been reported for the association between antidepressant use and Restless Legs Syndrome (RLS). Our aim was to clarify the relationship and examine possible gender differences. We interviewed 1,693 veterans receiving primary care from the Cleveland VA Medical Center and obtained prescription drug information from their medical records. Overall, use of an antidepressant was associated with RLS for men (RR = 1.77, CI = 1.26, 2.48) but not for women (RR = 0.79, CI = 0.43, 1.47). Analyses of individual antidepressants revealed an association between RLS and fluoxetine for women (RR = 2.47, CI = 1.33, 4.56), and associations between RLS and citalopram, (RR = 2.09, CI = 1.20, 3.64), paroxetine (RR = 1.97, CI = 1.02, 3.79), and amitriptyline (RR = 2.40, CI = 1.45, 4.00) for men. We conclude that RLS may be associated with antidepressant use, but the association varies by gender and type of antidepressant. Antidepressant use is more strongly associated with RLS in men than in women.

Organizational cost of quality improvement for depression care.

OBJECTIVE: We documented organizational costs for depression care quality improvement (QI) to develop an evidence-based, Veterans Health Administration (VA) adapted depression care model for primary care practices that performed well for patients, was sustained over time, and could be spread nationally in VA. DATA SOURCES AND STUDY SETTING: Project records and surveys from three multistate VA administrative regions and seven of their primary care practices. STUDY DESIGN: Descriptive analysis. DATA COLLECTION: We documented project time commitments and expenses for 86 clinical QI and 42 technical expert support team participants for 4 years from initial contact through care model design, Plan-Do-Study-Act cycles, and achievement of stable workloads in which models functioned as routine care. We assessed time, salary costs, and costs for conference calls, meetings, e-mails, and other activities. PRINCIPLE FINDINGS: Over an average of 27 months, all clinics began referring patients to care managers. Clinical participants spent 1,086 hours at a cost of $84,438. Technical experts spent 2,147 hours costing $197,787. Eighty-five percent of costs derived from initial regional engagement activities and care model design. CONCLUSIONS: Organizational costs of the QI process for depression care in a large health care system were significant, and should be accounted for when planning for implementation of evidence-based depression care.

Dual perinephric and prostatic abscesses from methacillin-resistant Staphylococcus aureus.

Perinephric and prostatic abscesses may present with protean symptoms and often arise from ascending urinary tract infections. Both abscesses are often caused by uropathogens, and only on rare occasions is the etiology due to methacillin-resistant Staphylococcus aureus (MRSA). Perinephric and prostatic abscesses have never been reported to occur together. We present a 56-year-old male with poorly controlled diabetes that had recently begun performing daily self-digital rectal examinations, who presented with a three day history of urinary symptoms. The patient had bilateral costovertebral angle tenderness and a boggy, tender, enlarged prostate. Blood and urine cultures showed MRSA. CT scan of the abdomen and pelvis demonstrated right perinephric abscess and prostatic abscess. This case report illustrates the potential for simultaneous perinephric and prostatic abscesses by MRSA.

Are provider self-efficacy and attitudes related to cardiovascular prevention associated with better treatment outcomes?

Cardiovascular risk factor control is inadequate in many high-risk patients. Although many provider-directed educational interventions attempt to address this issue by enhancing provider self-efficacy, a link between greater self-efficacy and better patient outcomes has not been established. Primary care providers (PCPs) in outpatient clinics of a large Veteran's Administration (VA) facility were asked to complete 4 subscales assessing self-efficacy and attitudes related to cardiovascular prevention (CVP). Using a cross-sectional study design, responses were linked with process and CVP outcomes related to blood pressure (BP) and low-density lipoprotein-cholesterol (LDL-C) control and the Framingham Risk Score (FRS), a summary measure of risk factor control, in diabetic patients observed by participating PCPs between December 1, 2004 and December 31, 2005. Multivariable, multilevel models assessed associations between these patient outcomes and provider self-efficacy and CVP-related attitudes, after accounting for patient characteristics, including baseline risk factor control, provider characteristics, and patient clustering within provider practices. Fifty-nine PCPs (86%) providing care to 1495 patients with diabetes completed the survey. Mean scores for provider efficacy and CVP-related attitudes were moderate to high. Higher self-efficacy scores were associated with initiation of medications in previously untreated individuals with inadequate BP or lipid control at baseline. Despite adequate power, however, multilevel models demonstrated neither consistent nor substantive associations between providers' self-efficacy and CVP-related attitudes and patient outcome measures. These findings underscore the need for interventions to enhance cardiovascular risk factor control that look beyond educational strategies to address a broader range of factors with potential influence on patient outcomes and the delivery of preventive care.

Developing effective collaboration between primary care and mental health providers.

OBJECTIVE: Improving care for depressed primary care (PC) patients requires system-level interventions based on chronic illness management with collaboration among primary care providers (PCPs) and mental health providers (MHPs). We describe the development of an effective collaboration system for an ongoing multisite Department of Veterans Affairs (VA) study evaluating a multifaceted program to improve management of major depression in PC practices. METHOD: Translating Initiatives for Depression into Effective Solutions (TIDES) is a research project that helps VA facilities adopt depression care improvements for PC patients with depression. A regional telephone-based depression care management program used Depression Case Managers (DCMs) supervised by MHPs to assist PCPs with patient management. The Collaborative Care Workgroup (CWG) was created to facilitate collaboration between PCPs, MHPs, and DCMs. The CWG used a 3-phase process: (1) identify barriers to better depression treatment, (2) identify target problems and solutions, and (3) institutionalize ongoing problem detection and solution through new policies and procedures. RESULTS: The CWG overcame barriers that exist between PCPs and MHPs, leading to high rates of the following: patients with depression being followed by PCPs (82%), referred PC patients with depression keeping their appointments with MHPs (88%), and PC patients with depression receiving antidepressants (76%). The CWG helped sites implement site-specific protocols for addressing patients with suicidal ideation. CONCLUSION: By applying these steps in PC practices, collaboration between PCPs and MHPs has been improved and maintained. These steps offer a guide to improving collaborative care to manage depression or other chronic disorders within PC clinics.

Insulin use in elderly diabetic patients.

The prevalence of type 2 diabetes is increasing among older adults as is their diabetes-related mortality rate. Studies suggest that tighter glucose control reduces complications in elderly patients. However, too low a glycosylated hemoglobin (HbA1c) value is associated with increased hypoglycemia. Moreover, the appropriateness of most clinical trial data and standards of care related to diabetes management in elderly patients is questionable given their heterogeneity. Having guidelines to safely achieve glycemic control in elderly patients is crucial. One of the biggest challenges in achieving tighter control is predicting when peak insulin action will occur. The clinician's options have increased with new insulin analogs that physiologically match the insulin peaks of the normal glycemic state, enabling patients to achieve the tighter diabetes control in a potentially safer way. We discuss the function of insulin in managing diabetes and how the new insulin analogs modify that state. We offer some practical considerations for individualizing treatment for elderly patients with diabetes, including how to incorporate these agents into current regimens using several methods to help match carbohydrate intake with insulin requirements. Summarizing guidelines that focus on elderly patients hopefully will help reduce crises and complications in this growing segment of the population.

Continuity of care and cardiovascular risk factor management: does care by a single clinician add to informational continuity provided by electronic medical records?

BACKGROUND: Electronic medical records allow information sharing among multiple clinicians treating the same patient, enabling informational continuity between visits. OBJECTIVE: To assess the contribution of continuity of care (COC) with a single clinician to short-term outcomes in a setting in which electronic medical records are used. STUDY DESIGN: Retrospective cohort study. METHODS: Between January 1, 2003, and October 1, 2004, we identified 3718 patients assessed for lipid and blood pressure control and a subgroup of 1448 patients with diabetes mellitus assessed for glycemic control in the primary care clinics of a large Department of Veterans Affairs healthcare facility. Continuity of care was defined as having been seen by the same clinician (physician or nurse practitioner) in the year before testing. Analytic techniques accounting for clustering of patients by providers yielded robust estimators for the association between continuity with a single clinician and control of these cardiovascular disease risk factors. RESULTS: Patients with complete COC were more likely to be men with few medical problems and visits during the study period. Controlling for these differences, we detected no association between COC and patient attainment of recommended goals for cardiovascular disease risk factor control (P < .05 for all). CONCLUSION: Continuity of care with a single clinician contributes little to cardiovascular risk factor management in a setting in which electronic medical records provide enhanced informational continuity, although its value may be greater in the management and outcomes of established diseases that require coordination of care and ongoing collaboration between clinician and patient.