BACKGROUND: Use of participatory research methods is increasing in research trials. Once partnerships are established with end-users, there is less guidance about processes research teams can use to successfully incorporate end-user feedback. The current study describes the use of a brief reflections process to systematically examine and evaluate the impact of end-user feedback on study conduct.
METHODS: The Comparative Effectiveness of Trauma-Focused and Non-Trauma- Focused Treatment Strategies for PTSD among those with Co-Occurring SUD (COMPASS) study was a randomized controlled trial to determine the effectiveness of trauma-focused psychotherapy versus non-trauma-focused psychotherapy for Veterans with co-occurring posttraumatic stress disorder and substance use disorder who were entering substance use treatment within the Department of Veterans Affairs. We developed and paired a process of \"brief reflections\" with our end-user engagement methods as part of a supplemental evaluation of the COMPASS study engagement plan. Brief reflections were 30-minute semi-structured discussions with the COMPASS Team following meetings with three study engagement panels about feedback received regarding study issues. To evaluate the impact of panel feedback, 16 reflections were audio-recorded, transcribed, rapidly analyzed, and integrated with other study data sources.
RESULTS: Brief reflections revealed that the engagement panels made recommended changes in eight areas: enhancing recruitment; study assessment completion; creating uniformity across Study Coordinators; building Study Coordinator connection to Veteran participants; mismatch between study procedures and clinical practice; therapist skill with patients with active substance use; therapist burnout; and dissemination of study findings. Some recommendations positively impact study conduct while others had mixed impact. Reflections were iterative and led to emergent processes that included revisiting previously discussed topics, cross-pollination of ideas across panels, and sparking solutions amongst the Team when the panels did not make any recommendations or recommendations were not feasible.
CONCLUSIONS: When paired with end-user engagement methods, brief reflections can facilitate systematic examination of end-user input, particularly when the engagement strategy is robust. Reflections offer a forum of accountability for researchers to give careful thought to end-user recommendations and make timely improvements to the study conduct. Reflections can also facilitate evaluation of these recommendations and reveal end-user-driven strategies that can effectively improve study conduct.
BACKGROUND: ClinicalTrials.gov (NCT04581434) on October 9, 2020; https://clinicaltrials.gov/ct2/show/study/NCT04581434?term=NCT04581434&draw=2&rank=1 .

BACKGROUND: To evaluate the effectiveness of delivering feedback reports to increase completion of LST notes among VA Home Based Primary Care (HBPC) teams. The Life Sustaining Treatment Decisions Initiative (LSTDI) was implemented throughout the Veterans Health Administration (VHA) in the United States in 2017 to ensure that seriously ill Veterans have care goals and LST decisions elicited and documented.
METHODS: We distributed monthly feedback reports summarizing LST template completion rates to 13 HBPC intervention sites between October 2018 and February 2020 as the sole implementation strategy. We used principal component analyses to match intervention to 26 comparison sites and used interrupted time series/segmented regression analyses to evaluate the differences in LST template completion rates between intervention and comparison sites. Data were extracted from national databases for VA HBPC in addition to interviews and surveys in a mixed methods process evaluation.
RESULTS: LST template completion rose from 6.3 to 41.9% across both intervention and comparison HBPC teams between March 1, 2018, and February 26, 2020. There were no statistically significant differences for intervention sites that received feedback reports.
CONCLUSIONS: Feedback reports did not increase documentation of LST preferences for Veterans at intervention compared with comparison sites. Observed increases in completion rates across intervention and comparison sites can likely be attributed to implementation strategies used nationally as part of the national roll-out of the LSTDI. Our results suggest that feedback reports alone were not an effective implementation strategy to augment national implementation strategies in HBPC teams.

BACKGROUND: Electronic health record (EHR) transitions are known to be highly disruptive, can drastically impact clinician and staff experiences, and may influence patients\' experiences using the electronic patient portal. Clinicians and staff can gain insights into patient experiences and be influenced by what they see and hear from patients. Through the lens of an emergency preparedness framework, we examined clinician and staff reactions to and perceptions of their patients\' experiences with the portal during an EHR transition at the Department of Veterans Affairs (VA).
METHODS: This qualitative case study was situated within a larger multi-methods evaluation of the EHR transition. We conducted a total of 122 interviews with 30 clinicians and staff across disciplines at the initial VA EHR transition site before, immediately after, and up to 12 months after go-live (September 2020-November 2021). Interview transcripts were coded using a priori and emergent codes. The coded text segments relevant to patient experience and clinician interactions with patients were extracted and analyzed to identify themes. For each theme, recommendations were defined based on each stage of an emergency preparedness framework (mitigate, prepare, respond, recover).
RESULTS: In post-go-live interviews participants expressed concerns about the reliability of communicating with their patients via secure messaging within the new EHR portal. Participants felt ill-equipped to field patients\' questions and frustrations navigating the new portal. Participants learned that patients experienced difficulties learning to use and accessing the portal; when unsuccessful, some had difficulties obtaining medication refills via the portal and used the call center as an alternative. However, long telephone wait times provoked patients to walk into the clinic for care, often frustrated and without an appointment. Patients needing increased in-person attention heightened participants\' daily workload and their concern for patients\' well-being. Recommendations for each theme fit within a stage of the emergency preparedness framework.
CONCLUSIONS: Application of an emergency preparedness framework to EHR transitions could help address the concerns raised by the participants, (1) mitigating disruptions by identifying at-risk patients before the transition, (2) preparing end-users by disseminating patient-centered informational resources, (3) responding by building capacity for disrupted services, and (4) recovering by monitoring integrity of the new portal function.

OBJECTIVE: Sleep disorders are wide-ranging in their causes and impacts on other physical and mental health conditions. Thus, sleep disorders could benefit from a multidisciplinary approach to assessment and treatment. An integrated care model is often recommended but is costly to implement. We sought to understand how, in the absence of an established organizational structure for integrated sleep care, providers from different clinics work together to provide care for sleep disorders.
METHODS: A qualitative case study at one U.S. Department of Veterans Affairs (VA) medical center. We used a purposeful nested sampling strategy, combining maximum variation sampling and snowball sampling to recruit key staff involved in sleep care.
RESULTS: We interviewed providers (N = 10) from sleep medicine, primary care, and mental health services. Providers identified the ubiquity of sleep disorders and a concomitant need for multidisciplinary care. However, they described limited opportunities for multidisciplinary interactions and consequently a negative impact on clinical care. Providers described fragmentation in two areas: among sleep specialists and between sleep specialists and other referring and managing providers.
CONCLUSIONS: A range of interventions, based on setting and resources, could improve care coordination both among sleep specialists and between sleep and nonsleep providers. While integrated sleep specialist clinics could reduce care fragmentation, they may not directly impact coordination with referring providers, like primary care and general mental health, who are essential in managing chronic conditions. Future work should continue to explore improving care coordination for sleep problems to ensure patients receive high-quality, timely, patient-centered care.

Studies have raised concerns about possible inequities in the U.S. Department of Veterans Affairs (VA)\'s awards of disability for posttraumatic stress disorder (PTSD) to women. However, the diagnoses and opinions made by disability examiners have not been studied. A sample of 270 initial PTSD examination reports and corresponding VA decisions were studied. Compared to men, women veterans were as likely to be diagnosed with a service-related mental disorder, χ2(1, N = 270) = 2.31, p = .129, odds ratio (OR) = 1.79, 95% CI [0.84, 3.80], and be granted service-connection, χ2(1, N = 270) = 0.49, p = .483, OR = 1.28, 95% CI [0.65, 2.51]. Women veterans were considered to have more psychiatric symptoms, Z = -2.05, p = .041, r = .16, and more psychiatric impairment, Z = -2.48, p = .013, r = .20, but the percentage of disability awarded by the VA did not differ, χ2(1, N = 270) = 0.49, p = .483; OR = 1.28, 95% CI [0.65, 2.51]. Secondary analyses implicate the role of military sexual trauma and premilitary trauma in explaining sex differences in symptoms and impairment. The findings indicate that neither opinions by examiners nor corresponding decisions by the VA regarding service connection reflect a negative bias toward women veterans. Results indicate that unbiased examinations lead to equitable VA claims decisions for women veterans. Future studies of the VA PTSD disability program nationally, including examination procedures and VA policies and implementation, will promote equity for women veterans in the PTSD claims process.

UNASSIGNED: Representative surgical case sampling, rather than universal review, is used by US Department of Veterans Affairs (VA) and private-sector national surgical quality improvement (QI) programs to assess program performance and to inform local QI and performance improvement efforts. However, it is unclear whether case sampling is robust for identifying hospitals with safety or quality concerns.
UNASSIGNED: To evaluate whether the sampling strategy used by several national surgical QI programs provides hospitals with data that are representative of their overall quality and safety, as measured by 30-day mortality.
UNASSIGNED: This comparative effectiveness study was a national, hospital-level analysis of data from adult patients (aged ≥18 years) who underwent noncardiac surgery at a VA hospital between January 1, 2016, and September 30, 2020. Data were obtained from the VA Surgical Quality Improvement Program (representative sample) and the VA Corporate Data Warehouse surgical domain (100% of surgical cases). Data analysis was performed from July 1 to December 21, 2022.
UNASSIGNED: The primary outcome was postoperative 30-day mortality. Quarterly, risk-adjusted, 30-day mortality observed-to-expected (O-E) ratios were calculated separately for each hospital using the sample and universal review cohorts. Outlier hospitals (ie, those with higher-than-expected mortality) were identified using an O-E ratio significantly greater than 1.0.
UNASSIGNED: In this study of data from 113 US Department of Veterans Affairs hospitals, the sample cohort comprised 502 953 surgical cases and the universal review cohort comprised 1 703 140. The majority of patients in both the representative sample and the universal sample were men (90.2% vs 91.1%) and were White (74.7% vs 74.5%). Overall, 30-day mortality was 0.8% and 0.6% for the sample and universal review cohorts, respectively (P < .001). Over 2145 quarters of data, hospitals were identified as an outlier in 11.7% of quarters with sampling and in 13.2% with universal review. Average hospital quarterly 30-day mortality rates were 0.4%, 0.8%, and 0.9% for outlier hospitals identified using the sample only, universal review only, and concurrent identification in both data sources, respectively. For nonsampled cases, average hospital quarterly 30-day mortality rates were 1.0% at outlier hospitals and 0.5% at nonoutliers. Among outlier hospital quarters in the sample, 47.4% were concurrently identified with universal review. For those identified with universal review, 42.1% were concurrently identified using the sample.
UNASSIGNED: In this national, hospital-level study, sampling strategies employed by national surgical QI programs identified less than half of hospitals with higher-than-expected perioperative mortality. These findings suggest that sampling may not adequately represent overall surgical program performance or provide stakeholders with the data necessary to inform QI efforts.

BACKGROUND: Provision of team-based primary care (PC) is associated with improved care quality, but limited empirical evidence guides practices on how to optimize team functioning. We examined how evidence-based quality improvement (EBQI) was used to change PC team processes. EBQI activities were supported by research-clinical partnerships and included multilevel stakeholder engagement, external facilitation, technical support, formative feedback, QI training, local QI development and across-site collaboration to share proven practices.
METHODS: We used a comparative case study in two VA medical centers (Sites A and B) that engaged in EBQI between 2014 and 2016. We analyzed multiple qualitative data sources: baseline and follow-up interviews with key stakeholders and provider team (\"teamlet\") members (n = 64), and EBQI meeting notes, reports, and supporting materials.
RESULTS: Site A\'s QI project entailed engaging in structured daily huddles using a huddle checklist and developing a protocol clarifying team member roles and responsibilities; Site B initiated weekly virtual team meetings that spanned two practice locations. Respondents from both sites perceived these projects as improving team structure and staffing, team communications, role clarity, staff voice and personhood, accountability, and ultimately, overall team functioning over time.
CONCLUSIONS: EBQI enabled local QI teams and other stakeholders to develop and implement innovations to improve PC team processes and characteristics in ways that improved teamlet members\' perceptions of team functioning.
CONCLUSIONS: EBQI\'s multi-level approach may empower staff and facilitate innovation by and within teams, making it an effective implementation strategy for addressing unique practice-based challenges and supporting improvements in team functioning across varied clinical settings.
METHODS: VI.

暂无摘要。

OBJECTIVE: Case management in Veterans Affairs (VA) depends on leadership skills such as effective communication, excellent resource management, self-governance, patient advocacy, and a distinctly professional attitude. VA registered nurses (RNs) and social workers (SWs) also provide case management services, a role and service, which is pivotal to veteran satisfaction and effective health care coordination.The leader-follower framework (LF2) was used to assess and compare the responses of RNs, SWs, and case managers (CMs) on the annual VA All Employee Survey (AES) to provide insight regarding VA case management performance, which has influenced veteran satisfaction.
METHODS: VA CMs work in a variety of clinical settings, which, in recent years, includes the use of telehealth modalities because of COVID-19. VA CMs remain flexible working in environments where and when veterans require their services while promoting safe, effective, and equitable health care services.
CONCLUSIONS: RNs and SWs indicated greater agreement and satisfaction scores in 2019 compared with 2018 on questions related to the leadership element of character and questions regarding mutual respect between VA senior leaders and the respondents. In contrast, RNs and SWs indicated less agreement and satisfaction scores on questions related to the leadership elements of competence, context, communication, personal, interpersonal, team, organizational, and greater burnout in 2019 than in 2018. RN response scores in 2018 and 2019 were greater and burnout scores were less than SWs. Additionally, the one-way analysis of variance indicated no difference for RNs and SWs who were performing the duties of a CM.
CONCLUSIONS: The responses of RNs indicated greater satisfaction and less burnout than SWs and were consistent whether RNs and SWs were in case management roles or not. These are important findings and concerning trends warranting further discussion and research.