Central Arkansas Veterans Healthcare System Research Articles

Determining feasibility of incorporating consumer engagement into implementation activities: study protocol of a hybrid effectiveness-implementation type II pilot

IntroductionImplementation researchers could draw from participatory research to engage patients (consumers of healthcare) in implementation processes and possibly reduce healthcare disparities. There is a little consumer involvement in healthcare implementation,...

An Interdisciplinary Approach to Educating Medical Students About Dementia Assessment and Treatment Planning.

Many general practitioners consider dementia care beyond their clinical domain and feel that dementia assessment and treatment should be addressed by specialists, such as geriatricians, geriatric psychiatrists, or neurologists. An urgent need exists to educate all medical trainees in dementia care, regardless of their specialization interests. We developed a multicomponent, experiential, brief curriculum using team-based learning to expose senior medical students who rotated through the US Department of Veterans Affairs Memory Disorders Clinic at the Central Arkansas Veterans Healthcare System in Little Rock to an interdisciplinary assessment of dementia. The curriculum included didactics, clinical experience, and team-based learning. In pre- and postevaluation, students rated their perception of the role of interdisciplinary team members in assessing and managing dementia, their personal abilities to assess cognition, behavioral problems, caregiver burden, and their perception of the impact of behavioral problems on dementia care. Dementia knowledge gaps were prevalent in this cohort of senior medical students. Providing interdisciplinary geriatric educational experience improved students perception of their ability to assess for dementia and their recognition of the roles of interdisciplinary team members. Plans are in place to continue and expand the program to other complex geriatric syndromes.

VA Video Connect for Clinical Care in Older Adults in a Rural State During the COVID-19 Pandemic: Cross-Sectional Study.

BackgroundThe COVID-19 pandemic has accelerated the need for telehealth at home. Although the Department of Veterans Affairs is a leading provider of telehealth, disparities may exist in reaching older veterans living in rural areas. VA Video Connect (VVC) is a video conferencing app that enables veterans to connect with their health care provider via a secure and private session.ObjectiveThe aim of this study was to examine the capability and willingness of older veterans to participate in a VVC visit during the COVID-19 pandemic.MethodsA cross-sectional study was conducted on older veterans (N=118) at the Central Arkansas Veterans Healthcare System. Participants were interviewed over the phone and responses to the following items were recorded: availability of internet, email, and an electronic device with a camera; veterans’ willingness to complete an appointment via a VVC visit; and availability of assistance from a caregiver for those who were unable to participate in a VVC visit alone.ResultsParticipants’ mean age was 72.6 (SD 8.3) years, 92% (n=108) were male, 69% (n=81) were Caucasian, 30% (n=35) were African Americans, and 36% (n=42) lived in a rural location. The majority reported having access to the internet (n=93, 77%) and email service (n=83, 70%), but only 56% (n=67) had a camera-equipped device. Overall, 53% (n=63) were willing and capable of participating in a VVC visit. The availability of internet access was significantly lower in rural compared to nonrural participants (P=.045) and in those with or less than a high school education compared to those who pursued higher education (P=.02). Willingness to participate in the VVC visit was significantly lower in rural compared to nonrural participants (P=.03). Of the participants who reported they were able and willing to partake in a VVC visit (n=54), 65% (n=35) opted for VVC and 35% (n=19) preferred a phone visit. In total, 77% (n=27) of the scheduled VVC visits were successful.ConclusionsDespite advances in technology, and willingness on the part of health care systems, there are some lingering issues with capability and willingness to participate in video telehealth visits, particularly among older adults residing in rural areas.

Year in Review: Applying Top Research to the Practice of PALTC Medicine

Year in Review: Applying Top Research to the Practice of PALTC Medicine

Improving Workflow Efficiency in Interventional Radiology

Late starts result in late finishes which creates inefficient workflow. The purpose of this quality-improvement project was to improve workflow efficiency in interventional radiology (IR) at the Central Arkansas Veterans Healthcare System. Six articles reviewed for this project demonstrated underlying problems with workflow efficiency in procedural areas that should be addressed. Interventions including checklists, facilitators, reminder e-mails to staff, requiring staff to come in earlier, and reporting arrival times of staff to supervisors helped improve on-time starts and workflow efficiency. A preimplementation and postimplementation retrospective chart review was used to evaluate this project. Random samples of 200 charts were reviewed before and after implementation, to establish the percentage of on-time starts. All patient satisfaction surveys received during the 4 months were reviewed for response to the item “My procedure began at the time it was scheduled.” Percentage of on-time starts and percentage of patients scoring “agree” or “strongly agree” on the satisfaction survey were compared before and after implementation. On-time starts increased from 29% and 24% in the 2 months before implementation to 34% and 40% in the 2 months after implementation. The item scored on the satisfaction survey increased from 73% and 83% before implementation and to 93% and 100% after implementation. In conclusion, a comprehensive checklist and increased physician reminders of first-case starts sent via e-mail helped to improve on-time starts in IR and increase patient satisfaction.

Heart Rate Variability and Cognitive Bias Feedback Interventions to Prevent Post-deployment PTSD: Results from a Randomized Controlled Trial.

There is a long history of pre-deployment PTSD prevention efforts in the military and effective pre-deployment strategies to prevent post-deployment PTSD are still needed. This randomized controlled trial included three arms: heart rate variability biofeedback (HRVB), cognitive bias modification for interpretation (CBM-I), and control. The hypothesis was that pre-deployment resilience training would result in lower post-deployment PTSD symptoms compared with control. Army National Guard soldiers (n = 342) were enrolled in the Warriors Achieving Resilience (WAR) study and analyzed. The outcome was PTSD symptom severity using the PTSD Checklist - Military version (PCL) measured at pre-deployment, 3- and 12-month post-deployment. Due to the repeated measures for each participant and cluster randomization at the company level, generalized linear mixed models were used for the analysis. This study was approved by the Army Human Research Protection Office, Central Arkansas Veterans Healthcare System Institutional Review Board (IRB), and Southeast Louisiana Veterans Health Care System IRB. Overall, there was no significant intervention effect. However, there were significant intervention effects for subgroups of soldiers. For example, at 3-months post-deployment, the HRVB arm had significantly lower PCL scores than the control arm for soldiers with no previous combat zone exposure who were age 30 and older and for soldiers with previous combat zone exposure who were 45 and older (unadjusted effect size -0.97 and -1.03, respectively). A significant difference between the CBM-I and control arms was found for soldiers without previous combat zone exposure between ages 23 and 42 (unadjusted effect size -0.41). Similarly, at 12-months post-deployment, the HRVB arm had significantly lower PCL scores in older soldiers. Pre-deployment resilience training was acceptable and feasible and resulted in lower post-deployment PTSD symptom scores in subgroups of older soldiers compared with controls. Strengths of the study included cluster randomization at the company level, use of iPod device to deliver the resilience intervention throughout the deployment cycle, and minimal disruption of pre-deployment training by using self-paced resilience training. Weaknesses included self-report app use, study personnel not able to contact soldiers during deployment, and in general a low level of PTSD symptom severity throughout the study. In future studies, it would important for the study team and/or military personnel implementing the resilience training to be in frequent contact with participants to ensure proper use of the resilience training apps.

New medication review method cuts veterans' Rx load, saves millions.

Clinical pharmacists in collaboration with primary care providers at Central Arkansas Veterans Healthcare System (CAVHS) have methodically “deprescribed” more than 20,000 medication regimens in 2 years, lessening patients’ pill burden and enabling the organization to reallocate resources,

Impact of the Implementation of Project Re-Engineered Discharge for Heart Failure patients at a Veterans Affairs Hospital at the Central Arkansas Veterans Healthcare System.

Background: Hospitalizations due to chronic diseases such as heart failure (HF) continue to increase worldwide. Fragmentation of care while transitioning from one care setting to another is an important factor contributing to hospitalizations. Fragmented discharge tools have been implemented; however, the impact of a comprehensive interdisciplinary discharge tool has not been previously studied. Objective: The goal of this study is to assess the impact of the implementation of Project Re-Engineered Discharge (RED) on the incidence of hospital readmissions, all-cause mortality, primary care physician follow-up rate, and cost savings for patients with HF. Methods: This was a single-center, retrospective, cohort study of patients admitted with HF exacerbation at the Central Arkansas Veterans Healthcare System (CAVHS). A random sample of 100 patients admitted prior to implementation of Project RED and 50 patients after Project RED intervention were included in the study. The primary end point was 30-day hospital readmission for HF exacerbation. The co-secondary end points were all-cause mortality, cost savings, and rate of primary care physician appointments scheduled as well as attended per postdischarge recommendations. Results: The 30-day hospital readmission rate was 28% in the pre-Project RED group, and it was 18% in the post-Project RED group (P = .18). The all-cause mortality was significantly lower in the post-Project RED group as compared with the pre-Project RED group (18% vs 41%, P = .04). More patients in the post-Project RED group attended an outpatient primary care appointment as recommended per postdischarge instructions (40% vs 19%, P = .006). In addition, with the decrease in hospital 30-day readmission rate in the post-Project RED group, there was a cost savings of $1453 per patient visit for HF exacerbation. Conclusions: Coordination of care using a discharge tool like Project RED should be utilized in institutions to improve patient outcomes as well as patient safety while decrease the overall health care cost.

Addressing Opioid-Associated Constipation Using Quality Oncology Practice Initiative Scores and Plan-Do-Study-Act Cycles.

Using the Quality Oncology Practice Initiative, an affiliate program of ASCO, we outlined opioid-associated constipation (OAC) as a subject in need of quality improvement (QI) in our fellowship program at the University of Arkansas for Medical Sciences and Central Arkansas Veterans Healthcare System. We initiated a fellow-led QI project to advance the quality of patient care and provide a valuable avenue for QI training of young physicians. Fellows organized meetings with all stakeholders, addressed the scope of the problem, and devised strategies for OAC management. Monthly meetings were organized using Plan-Do-Study-Act principles. Mandatory check boxes were inserted into our electronic medical record templates to remind all physicians to identify patients on opioid medications and assess and address OAC. Final chart audit and patient satisfaction surveys were performed 6 months after project initiation. Assessment of OAC improved from 52% at baseline to 92% ( P < .003). This improvement corresponded with high patient satisfaction scores, with 90% of surveyed patients reporting adequate management of their constipation. In this QI initiative, we showed that participation in ASCO's Quality Oncology Practice Initiative helps identify areas in need of QI, and such fellow-led QI projects can serve as models for QI training of young physicians.

Improving Communication on Intent of Chemotherapy Using QOPI Scores and PDSA Cycles.

Using the standardized ASCO Quality Oncology Practice Initiative (QOPI) guidelines for assessing quality cancer care, we identified communication about intent of chemotherapy as an area needing improvement in our program at the University of Arkansas for Medical Sciences (UAMS) and the Central Arkansas Veterans Healthcare System (CAVHS). We organized training in communications on intent of treatment (palliative vs curative) and added optional checkboxes to our electronic templates for progress notes. Afterwards, we conducted a retrospective review of electronic medical records of initially often randomly selected patient charts. The first 10 patient charts after 1month of implementation showed intent of treatment in 80% of charts compared to 74% at baseline. We then changed checkboxes from mandatory to optional and reviewed 30 randomly selected patient charts. Intent of treatment was documented in 96.7% of cases compared to 74% at baseline. We also assessed patient satisfaction through surveys distributed in clinic. Patient satisfaction scores were close to 100% for receiving clear information, understanding the reason for which they were receiving chemotherapy, and willingness of oncologists to listen carefully, to take time to answer questions, to explain things clearly, and to spend adequate time with them. In this study, we showed that training in communication of intent of chemotherapy and use of checkboxes in progress note templates could improve competency in communication of intent of therapy in cancer patients.

Metabolic Monitoring Falls Short for Dementia Patients

Metabolic Monitoring Falls Short for Dementia Patients

Perspectives of family and veterans on family programs to support reintegration of returning veterans with posttraumatic stress disorder.

Combat deployment and reintegration are challenging for service members and their families. Although family involvement in mental health care is increasing in the U.S. Department of Veterans Affairs (VA) system, little is known about family members' preferences for services. This study elicited the perspectives of returning Afghanistan and Iraq war veterans with posttraumatic stress disorder and their families regarding family involvement in veterans' mental health care. Semistructured qualitative interviews were conducted with 47 veterans receiving care for posttraumatic stress disorder at the Central Arkansas Veterans Healthcare System or Oklahoma City VA Medical Center and 36 veteran-designated family members. Interviews addressed perceived needs related to veterans' readjustment to civilian life, interest in family involvement in joint veteran/family programs, and desired family program content. Interview data were analyzed using content analysis and constant comparison. Both groups strongly supported inclusion of family members in programs to facilitate veterans' postdeployment readjustment and reintegration into civilian life. Both desired program content focused on information, practical skills, support, and gaining perspective on the other's experience. Although family and veteran perspectives were similar, family members placed greater emphasis on parenting-related issues and the kinds of support they and their children needed during and after deployment. To our knowledge, this is the first published report on preferences regarding VA postdeployment reintegration support that incorporates the perspectives of returning male and female veterans and those of their families. Findings will help VA and community providers working with returning veterans tailor services to the needs and preferences of this important-to-engage population.

IFN-γ Release Assay Conversions and Reversions. Challenges with Serial Testing in U.S. Health Care Workers

IFN-γ release assays (IGRAs) including the QuantiFERON-TB gold in-tube test (QFT-GIT) are increasingly used in place of the tuberculin skin test (TST) in surveillance programs for Mycobacterium tuberculosis infection in the United States. However, data on conversions, reversions, and predictive value of QFT in such programs for health care workers (HCWs) are limited. The purpose of this study is to assess long-term reproducibility and conversion and reversion rates of QFT-GIT among HCWs who underwent serial testing at a tertiary care center in the United States. Retrospective chart review of HCWs at the Central Arkansas Veterans Healthcare System (CAVHS) who underwent serial testing with QFT-GIT as a part of their employee screening between November 1, 2008 and January 31, 2011. A total of 2,303 HCWs had at least 2 QFT-GITs 1 year apart. The initial QFT-GIT was positive for 69 and 2 were indeterminate. Of these 69 HCWs, 31 (45%) reverted on repeat testing, and 25 of 31 (80.6%) HCWs who reverted had a negative look-back TST. Of the 2,232 HCWs with an initial negative QFT-GIT, 71 (3.2%) converted on repeat testing. A third QFT-GIT assay was performed in 41 of the 71 converters and 90% (37 of 41) reverted back to negative. Only two HCWs had TST and QFT-GIT conversion. Poor IGRA reproducibility and a low predictive value of QFT-GIT conversions indicate that QFT-GIT with current interpretation criteria should not be used for serial screening of U.S. HCWs. Negative TSTs have higher reproducibility than QFT-GIT for serial testing of HCWs in low tuberculosis incidence settings.

Conversations with pioneers in the bone field: Stavros C Manolagas

Editors’ Note: This is the second in a new series of interviews with investigators who have made groundbreaking contributions to understanding bone health and disease. See the first interview, with T. John Martin, here http://www.nature.com/ bonekey/knowledgeenvironment/2013/130424/bonekey201373/ full/bonekey201373.html. Stavros C. Manolagas, MD, PhD, is The Thomas E. Andreoli, MD, MACP Clinical Scholar Chair in Internal Medicine at the University of Arkansas for Medical Sciences (UAMS) in Little Rock, Arkansas, USA. He is also a Distinguished Professor of Medicine; Director, Division of Endocrinology and Metabolism; Director, the UAMS/VA Center for Osteoporosis and Metabolic Bone Diseases; and Vice Chair for Research, in the Department of Internal Medicine at UAMS. He is also Chief, Endocrinology Section at Central Arkansas Veterans Healthcare System. Professor Manolagas has spent a distinguished career studying the effects of steroid hormones on bone, making seminal contributions to understanding the cellular and molecular mechanisms by which estrogens, androgens and glucocorticoids influence the skeleton. In particular, his work has driven a paradigm shift toward thinking about osteoporosis as a disease of aging, rather than solely as a condition of estrogen deficiency. Professor Manolagas spoke recently with Neil Andrews, BoneKEy Features Editor, to discuss the genesis of his interest in steroid hormone action on bone, what drove his thinking away from an estrogen-centric view of osteoporosis and toward an age-related perspective on the disease, and what research questions he is pursuing now. An edited version of their conversation appears below. BoneKEy: How did you become interested in studying the effects of steroid hormones on bone? Stavros Manolagas: After my clinical training at the University of Athens, I was given an opportunity to do PhD work at the University of Manchester in England. My mentor then, David Anderson, had just returned from the United States, where he had learned methods for measuring multiple adrenal steroids simultaneously. David was collaborating with Robert Lindsay, who at the time was a Senior Registrar at The Royal Infirmary in Glasgow, Scotland. Robert had just reported, in studies using photon absorptiometry to measure bone density, that women who had their ovaries removed could be divided into two groups: those who lost bone quickly and those who lost bone slowly. The clinical part of my PhD thesis tested the hypothesis that adrenal steroids contributed to the variation in bone loss that follows loss of estrogens. We published that research from my PhD work in Lancet. For the basic research part of my thesis that would complement the clinical component, the plan was that I would study receptors for glucocorticosteroids and estrogens in bone. Citation: IBMS BoneKEy 10, Article number: 405 (2013) | doi:10.1038/bonekey.2013.139 & 2013 International Bone & Mineral Society All rights reserved 1940-8692/13 www.nature.com/bonekey

Osteocyte supply of RANKL meets bone remodeling demand

During bone remodeling, osteoclasts first remove old bone during the process of bone resorption, whereas osteoblasts then synthesize new bone during the process of bone formation. For decades, the conventional wisdom in the bone biology field has been that osteoblasts, or osteoblast progenitors, control osteoclastogenesis that is required for the initiation of bone resorption. In Osteocyte Control of Bone Remodeling (http://www.nature.com/bonekey/webinars/index. html?key=webinar15), a recent IBMS BoneKEy webinar, presenter Dr Charles O’Brien made the case that a different cell type—the osteocyte—controls osteoclast formation during bone remodeling via its production of the cytokine receptor activator of nuclear factor-kB ligand (RANKL). Focusing on research he and his colleagues published last year in Nature Medicine, 1 Dr O’Brien, a professor of medicine at the University of Arkansas for Medical Sciences and a VA research scientist at Central Arkansas Veterans Healthcare System in Little Rock, AR, USA, described the path that led them to the osteocyte; paving the way was a series of mouse experiments in which the researchers deleted RANKL in cell populations at different stages of differentiation, including mesenchymal progenitors, chondrocytes, osteoblast precursors, osteoblasts and osteocytes. That work reveals that osteocytes, and not osteoblasts or their progenitors, are indeed the major source of RANKL during bone remodeling. These observations represent a paradigm shift in the way the bone field thinks about bone remodeling, and continues the trend that thrusts the osteocyte, bone’s most abundant but underappreciated cell type, from its tomb-like lacunae into the limelight.

Empowering Staff Nurses through Unit-Level Shared Governance: The Nurse Executive's Role for Success

The nurse executive has a significant role, through active participation and leadership, in implementing and sustaining unit-level shared governance (ULSG). Additionally, the nurse executive's participation promotes the enculturation of the shared decision-making process for the front-line staff. At Central Arkansas Veterans Healthcare System (CAVHS), the implementation of ULSG increased nurse satisfaction and retention by empowering staff nurses to be involved in decision making, which impacted their practice environment and the organization's health care mission.

Patient Satisfaction as a Function of In-House Versus Contract Staffing Models in Veterans Affairs Community-Based Outpatient Clinics

As part of decision support for Central Arkansas Veterans Healthcare System, this research evaluated patient satisfaction differences associated with contract versus Veterans Affairs (VA) staffing of community-based outpatient clinics (CBOCs). The research question was as follows: What differences exist between contract versus VA-staffed outpatient clinics in the areas of patient perceptions of access, continuity of care, courtesy, education and information, emotional support, overall coordination, visit coordination, and patient preferences? The quarterly Survey of Healthcare Experiences of Patients provided satisfaction data necessary for this study. Results of Bonferonni-corrected z-tests of proportions indicated that the VA-staffed CBOCs had statistically higher scores for continuity of care, education and information, emotional support, overall coordination, and patient preferences. No statistically significant difference emerged for patient perception of access, courtesy, and visit coordination. The lack of finding associated with visit coordination coupled with the statistically significant difference for overall coordination suggests that coordination for non-VA-staffed CBOCs erodes after the patient encounter. In toto, patients reported higher satisfaction with in-house staffing solutions versus contractor solutions. The authors recommend additional cost-utility research to identify which of the two models, VA-staffed or non-VA-staffed, best meets the needs of all stakeholders.

Learn While You Wait: An Experience of a Novel, Interactive VHA e-Notebook Education Program for Multiple Myeloma, Final Results

Abstract 4759We evaluated a novel e-notebook -based education program for patients with multiple myeloma. The program was developed by the Myeloma Initiative in the Veteran’s Administration (MIVA) consortium to educate patients about myeloma while they wait for clinic appointments or procedures. The goals of this study were to assess the feasibility of the program in a busy clinic setting, patients ‘knowledge after the program and patients' acceptance of the e-notebook format. Study subjects were patients with multiple myeloma being treated at the Central Arkansas Veterans Healthcare System McClellan Hospital. Eligibility criteria were diagnosis of multiple myeloma and ability to follow instructions in the program and complete a paper questionnaire. Study subjects evaluated the module while awaiting their clinic visit and then completed a survey consisting of ten multiple-choice questions designed to measure the goals of the study. The scope of the questions were: patients’ primary source of medical education, patients’ perceived benefit of the education program in improving their understanding of their disease (three questions), patients’ preferences in regard to educational formats (three questions), and multiple myeloma knowledge (three questions).Fifteen consecutive patients were enrolled in the study. Patient flow was not adversely affected by use of the module in the waiting room and the program was well accepted by the patients. Most patients in our study (93%) considered their primary source of medical information about their disease to be their oncologist, followed by internet resources (20%). Most patients (93%) stated that the education program helped them better understand the information provided by their oncologists and better understand multiple myeloma treatment options. Twelve patients (60%) answered that the program motivated them to learn more about myeloma. Fourteen patients (93%) recommended that this program be expanded to spouses or family members, and twelve patients (80%) advocated creating a video format of the program for repeat viewing. Nine patients (60%) stated they plan to view the content again at a later time. Of all multiple myeloma knowledge questions, 76% were answered correctly and 60% of the patients who answered correctly attributed their answers to information they learned in the education program.We conclude that this e-notebook -based multiple myeloma education program is well accepted and can be adopted in a busy clinic. It is an effective and motivating tool for patient education in adjunct with physician efforts. It can be a productive utilization of waiting room time and has the potential for further applications. Disclosures:No relevant conflicts of interest to declare.

Men in Therapy: New Approaches for Effective Treatment

Men in Therapy: New Approaches for Effective Treatment

Learn While You Wait: An Experience of a Novel, Interactive VHA e-Notebook Education Program for Multiple Myeloma

AbstractAbstract 4743We evaluated a novel e-notebook -based education program for patients with multiple myeloma. The program was developed by the Myeloma Initiative in the Veteran's Administration (MIVA) consortium to educate patients while they wait for clinic appointments or procedures. The goals of this study were to assess feasibility of the program in a busy clinic setting, patients' gain in knowledge from the program, patients' acceptance of the e-notebook format, and potential use of program in other populations and in different formats. Study subjects were patients with multiple myeloma being treated at the Central Arkansas Veterans Healthcare System McClellan Hospital. Eligibility criteria were diagnosis of multiple myeloma, ability to follow instructions in the program and complete a paper questionnaire. Study subjects underwent the program while awaiting their oncology visit and then completed a survey consisting of ten multiple-choice questions designed to measure the goals of the study. The scope of the questions were: patients' perceived benefit of the education program in improving their understanding of their disease (three questions), patients' primary source of medical education, patients' preferences in regard to educational formats (three questions), and multiple myeloma knowledge (three questions). Program use did not adversely affect patient flow in our busy oncology clinic, and was well accepted by the patients. Eight patients were enrolled in the study. All patients considered their oncologist to be their primary source of information about their disease. All patients stated that the education program helped them better understand the information provided by their oncologists and better understand multiple myeloma treatment options. Five patients (63%) answered that the program motivated them to learn more about myeloma. Seven patients (88%) recommended that this program be expanded to spouses or family members, and seven patients (88%) advocated creating a video format of the program for repeat viewing. Five patients (63%) stated they plan to view the content again at a later time. Of all multiple myeloma knowledge questions, 71% were answered correctly and 50% of the patients attributed their correct answers to information they learned in the education program. We conclude that this e-notebook -based multiple myeloma education program is well accepted, can be adopted in a busy clinic and has the potential for further applications. It is an effective and motivating tool for patient education in adjunct with physician efforts. It can be a productive utilization of waiting room time. Disclosures:No relevant conflicts of interest to declare.