Affairs Tennessee Valley Healthcare Research Articles

Implementation and evaluation of interprofessional overdose review team recommendations following intentional or accidental overdose events.

Drug overdose death rates in the United States remain high despite efforts to mitigate this risk. Many communities and hospitals across the country have implemented overdose review teams, including local overdose fatality review teams or postoverdose intervention programs, to address the opioid crisis. The goal of most of these teams is to identify missed opportunities or patient-specific interventions to prevent future opioid overdose fatalities. Few overdose review teams review a combination of both fatal and nonfatal overdose events. The Veterans Affairs Tennessee Valley Healthcare System implemented a novel overdose review team (ORT) that collaboratively reviews all overdose incidents regardless of fatality, intent, or substance involved. This practice description characterizes reported facility overdose events and patient-specific risk-mitigation strategies recommended by the ORT, highlights the implementation rate and time to implementation of ORT recommendations, and discusses potential areas for process improvement. This practice highlights the potential impact of a pharmacist-led, interdisciplinary ORT following accidental or intentional overdose events involving any substance or medication. Key patient-specific interventions implemented following ORT recommendations included overdose prevention education and naloxone distribution, prescribing of medications for opioid use disorder and/or alcohol use disorder, reducing medication supply to limit lethal means access, and facilitation of mental health and/or substance use disorder specialty appointments. Further research to evaluate clinical outcomes related to specific ORT interventions should be considered.

1223. Utilizing Multiple Antimicrobial Stewardship Metrics to Trend Vancomycin Use in an Implementation Study

Abstract Background Inpatient IV vancomycin use is often inappropriately prolonged. Methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR) nares swabs have shown high negative predictive values for many infections and can guide appropriate vancomycin de-escalation. Antibiotic stewardship programs (ASPs) often monitor vancomycin use in days of therapy (DoT) per 1000 patient days present (PDP). This measure can be affected, especially for smaller facilities, by changes in bed capacity and prolonged stays and thus may not accurately reflect vancomycin use. We evaluated whether alternative metrics of vancomycin use would show different impacts during a multi-step ASP intervention to reduce inappropriate vancomycin use at Veterans Affairs Tennessee Valley Healthcare System. Figure 1 Run chart of vancomycin DoT/1000 PDP at the Tennessee Valley Healthcare System (TVHS) in two years prior to intervention. Methods In September 2021, the ASP, with multiple stakeholders, initiated use of MRSA nasal swabs to inform vancomycin de-escalation. From 7/2022 to 3/2023, we performed iterative Plan-Do-Study-Act intervention cycles including educating medicine and surgical divisions on MRSA swab result interpretation, educating nurses on timely swab collection, replacing MRSA culture swabs with PCR swabs, and adding MRSA swab orders to vancomycin order sets. In April 2022, in addition to DoT/1000 PDP, we began measuring mean, median, and mode DoT per vancomycin course initiated by start week. Results Despite multiple interventions beginning July 2022, vancomycin use in DoT/1000 PDP increased to a peak of 106 DoT/1000 PDP in September 2022. In that same period, median and mode DoT per vancomycin initiation remained steady at 2 days and 1 day, respectively. Figure 2 Run chart of vancomycin DoT/1000 PDP at the TVHS from April 2022 to March 2023. Specific ASP interventions are annotated on the dates they occur. Figure 3 Run chart of mean, median, and mode days of vancomycin therapy per vancomycin course initiated at the TVHS from April 2022 to March 2023. Specific ASP interventions are annotated on the dates they occur. Conclusion DoT/1000 PDP may not be the best metric to evaluate efforts to reduce inappropriate vancomycin use. By tracking mean, median, and mode of DoT per individual vancomycin course, we determined that most providers already practice rapid de-escalation, minimizing patient vancomycin exposure. This method also allows us to quickly detect changes in prescribing patterns and determine whether interventions were warranted. More evaluation of antibiotic use metric appropriateness based on desired outcome is needed in ASPs. Disclosures Milner Staub, MD, MPH, Gilead: Stocks/Bonds|Johnson & Johnson: Stocks/Bonds

Veteran Satisfaction for Upper Respiratory-Tract Infection (URI) Visits Is Not Associated with Antibiotic Receipt But Is Associated with Antibiotic Expectation

Background: Antibiotics are not recommended but are often prescribed for upper respiratory-tract infections (URIs). Prescribers cite patient expectation as a driver of inappropriate antibiotic prescribing; prior literature has demonstrated higher satisfaction scores in patients who receive antibiotics compared to those who do not. We assessed whether veteran satisfaction at URI visits was associated with antibiotic receipt or with reported expectation for antibiotics. Methods: We surveyed veterans with documented URI encounters in the Veterans’ Affairs Tennessee Valley Healthcare System between January 1, 2018, and December 31, 2019. Patients not evaluated in person, with documented dementia, or who died prior to the study start date were excluded. Veterans were asked to recall their URI visit and to complete the Patient Safety Questionnaire (PSQ)-18 (Rand Corporation) and questions assessing antibiotic expectations. The PSQ-18, an 18-item survey that assesses patient satisfaction, uses a 5-point Likert scale (ie, strongly disagree, disagree, uncertain, agree, strongly agree), yielding a composite score of 18–90. Higher scores represent more satisfaction with care. Demographic and visit-specific information were extracted via chart review. We used multivariable linear regression to assess differences in composite PSQ-18 satisfaction scores between those who did and did not receive an antibiotic, adjusted for patient and visit characteristics, and to assess differences in satisfaction scores for those who did and did not report expecting antibiotics, adjusted for antibiotic receipt. Results: We identified 1,435 patients seen for URI at 17 sites. After exclusions, 1,343 veterans were eligible for chart abstraction. After excluding 42 responders who responded after study close or returned blank surveys, the final analytic cohort included 432 (32.2%) of 1,343 responders; 225 (52.1%) received an antibiotic and 207 (47.9%) did not. Mean total satisfaction for veterans who received an antibiotic was 67.8 (SD, ±9.4) compared to 66.7 (SD, ±9.7) for those who did not (Figure 1). Increased total satisfaction was not significantly associated with antibiotic receipt (0.65; 95% CI, −2.0 to 3.3). Most veterans (72.0%) disagreed that visit satisfaction depended on antibiotic receipt. However, only 30.8% reported that they would not expect an antibiotic for URI visits. A significant reduction in total satisfaction (−4.1; 95% CI, −6.3 to −1.9) was associated with expecting compared to not expecting an antibiotic. Conclusions: Our findings suggest that prescribing an antibiotic is not associated with increased veteran satisfaction for URI visits but is associated with expecting an antibiotic. Future work will evaluate methods to change veteran antibiotic expectations.Funding: NoDisclosures: None

1130. Optimizing Use of COVID-19 Personal Protective Equipment among Resident Physicians at a Veterans Affairs Hospital

BackgroundCorrect personal protective equipment (PPE) use is key to prevent infection. Observations on a single unit at the Veterans Affairs (VA) Tennessee Valley Healthcare System (TVHS) prior to COVID-19 (October 2019-February 2020) showed low rates of correct PPE use among healthcare workers (HCWs) (Figure 1). In response to the COVID-19 epidemic, the VA implemented new PPE protocols. Based on our initial observations, we were concerned that incorrect use of PPE may increase the risk of COVID-19 exposure among HCWs. Resident physicians, who work at many sites, may be at high-risk for incorrect PPE use due to rapid turnover and limited site-specific PPE training. We aimed to assess and improve COVID-19 PPE use among internal medicine residents rotating at the VA TVHS.Figure 1: Pre-COVID-19 Observations of Adherence to Contact Precaution Protocols at the Veterans Affairs Tennessee Valley Healthcare System MethodsWe used the plan, do, study, act (PDSA) model. Prior to starting VA rotations, residents were emailed PPE education to review. We implemented a 1-hour video conference PPE protocol review at rotation start followed by in-person PPE use evaluations for residents performed by infectious diseases fellows on day 2 and day 5-6 post-review to provide just-in-time educational intervention. Errors at each PPE don/doff step were tracked. Correct PPE use data from both observations were compared using McNemar’s test. Baseline and post-implementation resident surveys assessed PPE use knowledge and comfort.ResultsPre-implementation survey response rate was 72% (21/29); 19/21(91%) reported knowing which PPE to use and 16/21(76%) reported knowing how to safely don/doff PPE. Twenty of 29 (69%) residents completed both observations. Errors decreased by 55% (p=0.0045) from 17/20 (85%) to 6/20 (30%) between initial and follow up observations. Errors in hand hygiene, inclusion of all donning/doffing steps, and PPE reuse decreased, but PPE don/doff order errors increased (Figure 2). Post-project survey response rate was 16/29 (55%). All 16 reported knowing which PPE to use and how to safely don/doff PPE, and 11/16 (69%) residents felt both online and in-person interventions were helpful.Figure 2: COVID-19 PPE Errors and Correction Types by Observation ConclusionCorrect COVID-19 PPE use is essential to protect HCWs and patients. Just-in-time education intervention for PPE training may yield higher correct use compared to pre-recorded or online training.Disclosures All Authors: No reported disclosures

COVID-19 and Venous Thromboembolism Pharmacologic Thromboprophylaxis.

Coagulopathy has emerged as a hallmark issue of the coronavirus 2019 (COVID-19). Medical facilities are faced with the challenge of developing institutional thromboprophylaxis protocols; however, due to the novelty of the disease, there is a dearth of high-quality, prospective evidence for decision making. The US National Institutes of Health along with 4 leading societies in the fields of thrombosis and hemostasis have published guidance based on expert consensus that helps provide a framework for local policy development. While there is agreement in a few areas, there are notable and sometimes considerable differences in recommendations that facilities should discuss when developing local guidance. This document aims to streamline and simplify the available guidance so health care providers can readily identify consensus and divergence of COVID-19 thromboprophylaxis recommendations. Additionally, the authors provide and briefly highlight the COVID-19 thromboprophylaxis protocol of the US Department of Veterans Affairs Tennessee Valley Healthcare System in Nashville and Murfreesboro to serve as an example of a guideline-directed approach for order-set development.

Evaluation of a novel discharge reminder tool on pneumococcal vaccination in hospitalized elderly veterans

Study ObjectiveThe Advisory Committee on Immunization Practices (ACIP) recommendations for pneumococcal vaccinations include updates on appropriate spacing between the 13‐valent conjugate vaccine (PCV13) and the 23‐valent polysaccharide vaccine (PPSV23). The schedule may confuse providers leading to either vaccine omission or inappropriate vaccination. Numerous facilities have implemented inpatient reminder tools with limited success rates; however, the complexity of vaccine selection is not eliminated with this reminder approach nor does it provide education to the provider on ACIP recommendations. The Veterans Affairs Tennessee Valley Healthcare System implemented a tool to provide patient specific guidance and education on ACIP‐appropriate vaccine selection embedded within a required discharge note called the discharge instruction inpatient note (DIPN). This study evaluates its impact on pneumococcal vaccination rates in hospitalized veterans 65 years of age and older.DesignThis was a single center, retrospective, observational analysis of pneumococcal vaccine utilization during the three‐month periods surrounding DIPN implementation.PatientsA total of 540 patients aged 65 and older hospitalized in the Nashville campus of the Veterans Affairs Tennessee Valley Healthcare System.Measurements/Main ResultsPneumococcal vaccine utilization increased following DIPN implementation, with a total of 9 doses administered in the pre‐DIPN group compared with 41 in the post‐DIPN group (3.3% vs 15.2%, P < 0.0001). Among pneumococcal vaccine naïve patients, vaccination at discharge increased from 1.4% to 25% following implementation (P = 0.0003). However, all 20 of the PPSV23 vaccines administered post‐DIPN implementation were found to be inappropriate when compared with ACIP recommendations.ConclusionImplementation of a vaccine reminder tool embedded within the DIPN significantly increased the inpatient use of pneumococcal vaccines in a large VA facility with high baseline vaccination rates. Given the number of inappropriate vaccines administered, focused efforts on provider education in conjunction with implementation of reminder tools are warranted to encourage appropriate vaccine usage.

ACCP Virtual Poster Symposium

<scp>ACCP</scp> Virtual Poster Symposium

Validation of the Home Hearing Test™.

The Home Hearing Test™ (HHT) is an automated pure-tone threshold test that obtains an air-conduction audiogram at five test frequencies. It was developed to provide increased access to hearing testing and support home telehealth programs. The study was conducted as part of an audiology telehealth trial based at the U.S. Department of Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN. Air-conduction audiograms obtained by the HHT were compared to results obtained in the clinic. Prospective, repeated measures. Twenty-eight participants, aged 44-88 yr (mean = 65) were recruited from the Nashville U.S. Department of Veterans Affairs audiology clinic. Participants were required to have a Windows personal computer in the home and were self-reported to be comfortable with using computers. Two participants had normal hearing and 26 had hearing loss of various severities and configurations. Audiograms were obtained in the audiology clinic by experienced audiologists following standard clinical protocols. Participants were provided with a kit for installing HHT on their home computers. The HHT air-conduction audiogram is obtained with Automated Method for Testing Auditory Sensitivity (AMTAS(®)), described in previous publications. Threshold pairs (clinic versus HHT) were analyzed by determining distributions of threshold differences and absolute differences. These were compared to distributions of differences between manual threshold pairs obtained by two audiologists and AMTAS(®) versus manual threshold pairs obtained under laboratory conditions. Threshold differences (clinic versus HHT) were slightly larger than differences between thresholds obtained by two audiologists and AMTAS(®) versus manual threshold differences obtained under laboratory conditions. The differences were not statistically significant. HHT air-conduction audiograms agree well with audiograms obtained in the clinic. HHT is well suited to home telehealth applications and personal use.

3D Printing of Bone-Templated Scaffolds

SJ Fernando1, JA Sterling2,3, SA Guelcher1 1Vanderbilt University Medical Center, Department of Chemical and Biomolecular Engineering, 2 Veterans' Affairs Tennessee Valley Healthcare System, Nashville, 3Vanderbilt University, Department of Clinical Pharmacology Statement of Purpose: Biomimetic 3D tissue engineered systems have been proposed for investigating molecular mechanisms of disease progression and for screening drugs [1]. We have utilized 3D printing technology to investigate how the mechanical and topological properties of the bone microenvironment influence both cellular interactions and tumor progression in bone. Trabecular curvature, pore size, and pore shape have also been reported to affect the rate of new bone formation. Cells sense and respond to radii of curvature larger than themselves, and the rate of new bone formation increases with the curvature of the surface [2]. The Structure Model Index (SMI) parameter characterizes the structure of trabecular bone, with 0 representing plate-like (e.g., 2D) structures and 3 representing rod-like structures.[3] The trabecular structure largely varies between values of 0 and 3, rather than being predominantly plates or rods. Vertebral trabeculae have an SMI typically closer to a rod-like structure (SMI=3), whereas femoral trabeculae have structure closer to plates (SMI=0). We reason that 3D scaffolds replicating the mechanical and topological properties of bone at different anatomic sites will enable the development of 3D cell culture models for investigating the spatio-temporal dynamics of both bone cellular physiology and cancer progression [1]. We have developed a fabrication process in which wax templates of trabecular bone are prepared by a 3D inkjet printer and subsequently filled with reactive polyurethanes to create scaffolds with elastic modulus and SMI comparable to human bone. Methods: Human cadaver samples from the proximal tibia, proximal femur, and lumbar vertebrae were obtained from the Program in Advanced Anatomy and Simulated Skills Program at Vanderbilt. Isolated tissue samples were imaged using uCT technology from Scanco Inc. Using Scanco software the scans were converted into STL images, a format representative of the surface of bone uCT images, which specifically captures the trabecular architecture. These images were inverted using the same software to create a representation of the trabecular spacing (Tb.Sp.) The STL images of Tb.SP were then uploaded into the Solidscape Studio 3Z Printer for fabrication. The resulting wax molds were filled with a reactive two-component polyurethane (PUR) composed of lysine diisocyanate (LDI), a poly(e-caprolactone-coglycolide) triol (Mw=300 or 3000 g/mol), and iron(III) acetylacetonate (FeAA) catalyst. The polyol (900 Da) was prepared from glycerol starter and backbone comprising 70wt% ɛ-caprolactone, 20wt% glycolide, and 10wt% D,L-lactide. The mixture was cured overnight under vacuum at 80° C. The cured polyurethane structure was extracted from the wax mold using acetone solution to dissolve the wax (sulphonamide derivatives, polyester resin, and benzoate derivatives,) and dried under vacuum overnight. The resulting structures were imaged by SEM and uCT. Nanoindentation was performed on 2D films and on the 3D biomimetic PUR scaffolds. Rat bone marrow-derived stromal cells and monocytes, as well as bone-metastatic MDA-MB-231 breast cancer cells were incubated with the scaffolds under standard cell culture conditions.

Human Factors Engineering in Patient Safety

Human Factors Engineering in Patient Safety

Management of Senescent Gynecomastia in the Veterans Health Administration

Senescent gynecomastia is common in Veterans Health Administration patients because of clinical characteristics in the population, mainly obesity and the use of numerous etiologic drugs. To assess management of the disease, we studied patients treated between January 1, 2003 and December 31, 2007, in the Veterans Affairs-Tennessee Valley Healthcare System. Four hundred and fifty-four cases of senescent gynecomastia were retrieved from 670 charts addressing breast complaints (positive predictive value = 68%). Average patient age was 68.5 years. Mean body mass index was 29.7. Ninety-two percent of patients were using multiple medications associated with gynecomastia. Medications were considered at least partially etiologic in 79.3% of cases. Medical conditions caused gynecomastia in 13.7%. Over 50% of patients underwent diagnostic imaging studies. One-fifth of patients were tested for etiologic endocrine tumors. Yield on this testing was 1.1% (1/93). Ninety-four percent of patients were managed nonoperatively. Case management in the Tennessee Valley Healthcare System was generally correct, though there was excessive use of imaging, invasive diagnostic procedures, and endocrine assessment. Senescent gynecomastia, a benign disease, can usually be diagnosed by history and physical examination, requires little diagnostic testing, and should be treated nonoperatively.

Retroperitoneal Repair of Abdominal Aortic Aneurysms Offers Postoperative Benefits to Male Patients in the Veterans Affairs Health System

Transperitoneal (TP) and retroperitoneal (RP) approaches have equal efficacy in elective open abdominal aortic aneurysm (AAA) repair. The effect of open operative approach on patient-specific outcomes after AAA repair was tested. Consecutive patients undergoing open AAA repair at the Veterans Affairs Tennessee Valley Healthcare System between January 2000 and August 2008 were retrospectively reviewed. Analysis was performed to examine the effects of demographic and clinical covariates on postoperative outcomes. A total of 106 patients were identified: 54 with TP approach and 52 with RP approach. Demographics and preoperative comorbidities were equivalent (p > or = 0.10), with the exception of chronic obstructive pulmonary disease which was more prevalent in the TP group (61 vs. 40%). Operative times were longer in the TP group (4.6 vs. 3.5 hours; p < 0.01); however, significantly more TP patients had reconstruction with a bifurcated graft (72 vs. 2%; p < 0.01). Postoperative nasogastric tube decompression times were shorter in the RP group (1 vs. 3 days; p < 0.01), and RP approach led to a quicker return to preoperative diet (4 vs. 6 days; p = 0.05). Patients undergoing RP repair developed fewer incisional hernias (2 vs. 15%; p = 0.03). RP approach to AAA repair offers patients faster return of bowel function and is associated with fewer incisional hernias.

Physician-assisted death

Vanderbilt University Medical Center, Geriatric Research Education Clinical Center (GRECC) for Veteran's Affairs Tennessee Valley Healthcare System, Nashville, TN

Quality Improvement Initiatives Improve Hypertension Care Among Veterans

We implemented a quality improvement initiative to improve hypertension care at Veterans Affairs-Tennessee Valley Healthcare System. We implemented multiple interventions among 2 teaching hospitals, 5 community-based outpatient clinics, and 4 contract clinic sites. Goals of the program were to (1) improve measurement and documentation of blood pressure (BP), (2) initiate outpatient patient education, (3) emphasize VA/Department of Defense hypertension treatment algorithms to providers, (4) emphasize external peer review program performance goals, and (5) initiate feedback of each clinic's performance. The primary outcome was the proportion of patients seen each week with a diagnosis of hypertension who had their last available BP in control (< or =140/90 mm Hg). Observation time was 40 weeks (14 weeks preintervention, 8 weeks intervention implementation, and 18 weeks postintervention), during which there were 55 586 unique clinic visits for hypertension. After intervention deployment, there was an absolute improvement of 4.2% in BP control (preintervention 61.5% [12 245/19 908] versus postintervention 65.7% [15 809/24 059], P<0.0001). Teaching hospital A had an absolute improvement of 1.4% (63.4% [3544/5591] versus 64.8% [4581/7073], P=0.108). Teaching hospital B showed a 0.8% absolute improvement in BP control (59.7% [2577/4315] versus 60.5% [3416/5650], P=0.456). The community-based outpatient clinics had a combined absolute improvement of 8.6% (60.2% [5252/8728] versus 68.8% [6895/10025], P<0.0001). The contract clinics had a combined improvement of 1.5% (68.4% [872/1274] versus 69.9% [917/1311], P=0.409). Results were sustained 1 year after intervention. After implementing small, focused, and inexpensive interventions, BP control improved 4.2%, thereby improving the quality of hypertension care.

Clinical Nurse Leader Impact on Clinical Microsystems Outcomes

The clinical nurse leader (CNL) role is being rapidly implemented in healthcare settings. A major component of the CNL role is to provide a leader at the center of the microsystem to promote quality outcomes. To examine the impact of CNLs at the Department of Veterans Affairs Tennessee Valley Healthcare System, outcomes from 5 diverse microsystems were evaluated before and after CNL implementation using electronic scheduling system reports, patient medical records, and quality improvement reports. Statistically significant improvements were found in all 5 of the indicators evaluated. The authors discuss the implications of improvement for clinical, satisfaction, and financial performance.

Comparison of the Morel Emotional Numbing Test for PostTraumatic Stress Disorder to the Word Memory Test in Neuropsychological Evaluations

The most commonly feigned cognitive and psychiatric disorders for survivors of traumatic injury are memory dysfunction and posttraumatic stress disorder (PTSD). The position of the National Academy of Neuropsychology is that symptom validity tests (SVTs) should be part of any comprehensive neuropsychological evaluation. In this article the Morel Emotional Numbing Test for Posttraumatic Stress Disorder (MENT), a SVT for PTSD, was compared to a SVT for memory, the Word Memory Test (WMT). Available archival data on 216 consecutive referrals for neuropsychological evaluations at the Veterans Affairs Tennessee Valley Healthcare System were reviewed. Of the total records reviewed, 37 patients had been administered both the MENT and the WMT. The clinically recommended cutoff on the WMT was used as the main criterion to classify patients into two groups: simulating impairment or credible. The results indicated that the simulating impairment group had significantly more errors on the MENT than the credible group did (p < .0001). The criterion-related characteristics of the MENT in assessing response bias in relation to the WMT were confirmed. Clinical and research implications of the utilization of the MENT are discussed in this study.

Improving Blood Pressure Control through Provider Education, Provider Alerts, and Patient Education

Inadequate blood pressure control is a persistent gap in quality care. To evaluate provider and patient interventions to improve blood pressure control. Cluster randomized, controlled trial. 2 hospital-based and 8 community-based clinics in the Veterans Affairs Tennessee Valley Healthcare System. 1341 veterans with essential hypertension cared for by 182 providers. Eligible patients had 2 or more blood pressure measurements greater than 140/90 mm Hg in a 6-month period and were taking a single antihypertensive agent. Providers who cared for eligible patients were randomly assigned to receive an e-mail with a Web-based link to the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) guidelines (provider education); provider education and a patient-specific hypertension computerized alert (provider education and alert); or provider education, hypertension alert, and patient education, in which patients were sent a letter advocating drug adherence, lifestyle modification, and conversations with providers (patient education). Proportion of patients with a systolic blood pressure less than 140 mm Hg at 6 months; intensification of antihypertensive medication. Mean baseline blood pressure was 157/83 mm Hg with no differences between groups (P = 0.105). Six-month follow-up data were available for 975 patients (73%). Patients of providers who were randomly assigned to the patient education group had better blood pressure control (138/75 mm Hg) than those in the provider education and alert or provider education alone groups (146/76 mm Hg and 145/78 mm Hg, respectively). More patients in the patient education group had a systolic blood pressure of 140 mm Hg or less compared with those in the provider education or provider education and alert groups (adjusted relative risk for the patient education group compared with the provider education alone group, 1.31 [95% CI, 1.06 to 1.62]; P = 0.012). Follow-up blood pressure measurements were missing for 27% of study patients. The study could not detect a mechanism by which patient education improved blood pressure control. A multifactorial intervention including patient education improved blood pressure control compared with provider education alone.

A three-part intervention to change the use of hormone replacement therapy in response to new evidence.

Slow adaptation of new information by providers may result in suboptimal care. To evaluate changes in prescriptions for combination hormone replacement therapy (HRT) after a multicomponent intervention to deliver new information to patients and providers. Quasi-experimental study with multiple baselines. Veterans Affairs Tennessee Valley Healthcare System (VA-TVHS). Female veterans age 50 to 79 years who had a prescription filled at the VA-TVHS for combination HRT between 1 January 2002 and 1 July 2002. Discontinuation of HRT. A 3-part intervention consisted of 1) notifying patients who were using combination HRT of the results of the Women's Health Initiative study (patient education component), 2) sending all providers an e-mail with the Women's Health Initiative study results (provider education component), and 3) placing an electronic alert in each eligible patient's chart (provider care component). The alert asked providers to reevaluate the need for combination HRT. The intervention was implemented at different VA-TVHS sites in a stepwise fashion to differentiate intervention effect from media effect. Study follow-up continued through 31 December 2002. The total rate of discontinuation of combination HRT was 70.3% in 2002. The proportion of discontinuation from time of media release until intervention was 23.3%. After initiation of the intervention, an additional 43% of the original cohort discontinued use of HRT; this percentage represents a 59% relative decrease in HRT use among patients. After adjustment for time, the discontinuation rate per day was 4.9 times higher after the multifacted intervention than after the media release (95% CI, 1.8 to 13.1). A true control group is lacking. A multifaceted approach in an integrated health care system with standardized methods of communication is an effective way to implement patient-centered, effective, and timely care with changing medical knowledge.