Evaluation Of Veterans Research Articles

Acceptability of a complex team-based quality improvement intervention for transient ischemic attack: a mixed-methods study

BackgroundThe Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was a complex quality improvement (QI) intervention targeting transient ischemic attack (TIA) evidence-based care. The aim of this study was to evaluate program acceptability among the QI teams and factors associated with degrees of acceptability.MethodsQI teams from six Veterans Administration facilities participated in active implementation for a one-year period. We employed a mixed methods study to evaluate program acceptability. Multiple data sources were collected over implementation phases and triangulated for this evaluation. First, we conducted 30 onsite, semi-structured interviews during active implementation with 35 participants at 6 months; 27 interviews with 28 participants at 12 months; and 19 participants during program sustainment. Second, we conducted debriefing meetings after onsite visits and monthly virtual collaborative calls. All interviews and debriefings were audiotaped, transcribed, and de-identified. De-identified files were qualitatively coded and analyzed for common themes and acceptability patterns. We conducted mixed-methods matrix analyses comparing acceptability by satisfaction ratings and by the Theoretical Framework of Acceptability (TFA).ResultsOverall, the QI teams reported the PREVENT program was acceptable. The clinical champions reported high acceptability of the PREVENT program. At pre-implementation phase, reviewing quality data, team brainstorming solutions and development of action plans were rated as most useful during the team kickoff meetings. Program acceptability perceptions varied over time across active implementation and after teams accomplished actions plans and moved into sustainment. We observed team acceptability growth over a year of active implementation in concert with the QI team’s self-efficacy to improve quality of care. Guided by the TFA, the QI teams’ acceptability was represented by the respective seven components of the multifaceted acceptability construct.ConclusionsProgram acceptability varied by time, by champion role on QI team, by team self-efficacy, and by perceived effectiveness to improve quality of care aligned with the TFA. A complex quality improvement program that fostered flexibility in local adaptation and supported users with access to data, resources, and implementation strategies was deemed acceptable and appropriate by front-line clinicians implementing practice changes in a large, national healthcare organization.Trial registrationclinicaltrials.gov: NCT02769338.

Leveraging Telehealth to improve access to care: a qualitative evaluation of Veterans\u2019 experience with the VA TeleSleep program

BackgroundObstructive sleep apnea is common among rural Veterans, however, access to diagnostic sleep testing, sleep specialists, and treatment devices is limited. To improve access to sleep care, the Veterans Health Administration (VA) implemented a national sleep telemedicine program. The TeleSleep program components included: 1) virtual clinical encounters; 2) home sleep apnea testing; and 3) web application for Veterans and providers to remotely monitor symptoms, sleep quality and use of positive airway pressure (PAP) therapy. This study aimed to identify factors impacting Veteran’s participation, satisfaction and experience with the TeleSleep program as part of a quality improvement initiative.MethodsSemi-structured interview questions elicited patient perspectives and preferences regarding accessing and engaging with TeleSleep care. Rapid qualitative and matrix analysis methods for health services research were used to organize and describe the qualitative data.ResultsThirty Veterans with obstructive sleep apnea (OSA) recruited from 6 VA telehealth “hubs” participated in interviews. Veterans reported positive experiences with sleep telemedicine, including improvements in sleep quality, other health conditions, and quality of life. Access to care improved as a result of decreased travel burden and ability of both clinicians and Veterans to remotely monitor and track personal sleep data. Overall experiences with telehealth technology were positive. Veterans indicated a strong preference for VA over non-VA community-based sleep care. Patient recommendations for change included improving scheduling, continuity and timeliness of communication, and the equipment refill process.ConclusionsThe VA TeleSleep program improved patient experiences across multiple aspects of care including a reduction in travel burden, increased access to clinicians and remote monitoring, and patient-reported health and quality of life outcomes, though some communication and continuity challenges remain. Implementing telehealth services may also improve the experiences of patients served by other subspecialties or healthcare systems.

Abstract WP347: The Effectiveness and Implementation of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) Quality Improvement Program: An Exampleofa Learning Healthcare System in Action

Objectives: Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) trial evaluated the implementation of a quality improvement (QI) program aligned with Learning Healthcare System principles to improve TIA care. Methods: A facility-based, stepped-wedge trial was conducted at six diverse sites. The intervention included five components: clinical programs, data feedback, professional education, electronic health record tools, and QI support. Implementation strategies included: team activation via audit and feedback, goal setting, reflecting and evaluating, and planning; external facilitation; and building a community of practice. The primary effectiveness outcome was the Without Fail rate (WFR); proportion of TIA patients who received all processes of care for which they were eligible among: brain imaging, carotid artery imaging, neurology consultation, hypertension control, anticoagulation for atrial fibrillation, antithrombotics, high/moderate potency statins. The primary implementation outcomes were the number of improvement activities completed and the Group Organization (GO) scores for providing and improving care (scale of 1-10). Results: The 6 PREVENT facilities cared for N=162 control period TIA patients and N=191 intervention period TIA patients. The mean facility WFR increased from 36.7% (baseline) to 53.9% (active implementation); p=0.002 (adjusted for temporal trend, hospital admission). The mean number of improvement activities completed during the 1-year implementation period was 26 (range 11-39). The mean facility GO scores increased: providing care, 1.2 to 6.5; improving care, 1.0 to 6.7. Conclusions: PREVENT advances three aspects of a learning healthcare system: Learning from Data (teams interacted with their facility’s performance data to explore hypotheses, plan QI activities, and evaluate change over time); Learning from Each Other (teams participated in monthly virtual collaborative conferences), and Sharing Best Practices (teams shared tools and protocols).

Abstract WP333: The Impact of External Facilitation on Implementation: Findings From the Protocol-Guided Rapid Evaluation of Veterans PREVENT Quality Improvement Program

Background and Aims: In the Veterans Administration, we found an absence of acute TIA care protocols and broad clinician uncertainty. To address these gaps, the PREVENT program was implemented in a stepped-wedge trial involving 6 medical facilities. To promote local adaptation, we employed external facilitation (EF) delivered by nurse as a key implementation strategy. The specific aim of this evaluation was to examine the effect of EF strategy on PREVENT implementation. Methods: We adapted an EF tracking template to prospectively monitor facilitation type, dose and temporality. We defined 17 apriori facilitation EF activity codes based upon the PREVENT protocol, and Consolidated Framework for Implementation Research (CFIR). We evaluated the EF activities delivered at each site over a 1 year and how the EF dose corresponded to the number of implementation activities completed and the level of team cohesion (beginning, developing, basic, intermediate, advanced) for providing and improving TIA care. Results: A total of 1209 EF activities delivered were delivered to QI teams and most frequently to the clinical champions; with a mean number of 242 EF activities per facility (range 182-295). Facility-level clinical champions were most likely to participate in EF activities compared to other team members. The most common EF activities delivered were: education (mean=34.3); planning (mean=27.8); overcoming barriers (mean=22.2) and ongoing quality process monitoring (mean=32.3). Teams with high initial team cohesion, &gt intermediate level, used EF early in the implementation process while teams that gradually developed cohesion over time, developing to basic levels of team cohesion, utilized EF later. QI teams with greater success in implementation activities had far more implementation activities completed (IA= 29-39) than EF activities related to barriers (B=18-28). However, QI teams with the least success in implementation activities (IA=11-25) had similar levels of EF activities related to barriers or higher (B=18-25). Conclusions: EF impacts real-world implementation by facilitating team education; planning; navigating the barriers; and enhancing the champions' skills. Early team cohesion was related to greater implementation success.

Psychological characteristics of war veterans after the war in Bosnia and Herzegovina.

Aim To determine psychological characteristics of war veterans after the war in Bosnia and Herzegovina (B&H). Methods The study included 207 war veterans with war experience in B&H. Evaluation of veterans was conducted by the Harvard Trauma Questionnaire (HTQ)-B&H version, Emotion Profile Index (EPI), Life Style Questionnaire (Life Style index - LSI). Results Veterans who show symptoms of posttraumatic stress disorder (PTSD) had more traumatic experiences and higher level of traumatization than veterans who did not show PTSD symptoms (p=0.000). Low level of reproduction, incorporation, lack of control, self-defence and exploratory and acceptable responses (p=0.000), lack of control (p=0.025) and deprivation (p=0.013) were shown on the emotional profile by war veterans suffering from post-traumatic stress disorder. Negation, intellectualization and compensation were coping strategies for traumatic experiences and symptoms of PTSD, used by war veterans. Conclusion War veterans with post-traumatic stress disorder experienced more traumatic experiences and show more severe symptoms of post-traumatic stress disorder. In the emotional profile, there was a lower level of emotional states, and coping strategies with posttraumatic stress disorder were negating, intellectualization and compensation. The treatment of post-traumatic stress disorder is becoming a conspicuous public health problem.

Evaluation of Veterans' Suicide Risk With the Use of Linguistic Detection Methods.

Many people who die from suicide received recent medical care prior to their death. Suicide risk assessment tools for health care settings focus on a variety of clinical and demographic factors but generally do not examine the text of notes written by clinicians about patients who later die from suicide. This study examined whether clinicians' notes indicated increased use of distancing language during the year preceding patients' suicide. The linguistic content of clinicians' notes for outpatients of U.S. Department of Veterans Affairs (VA) medical centers was examined in the year preceding suicide of 63 veterans. Approximately half of the veterans had received mental health services. They were matched based on mental health service use with living VA outpatients. Linguistics software was used to construct quantitative theme-based categories related to distancing language and to examine temporal trends via keyword analysis. Analysis of clinical notes for outpatients who died from suicide and those who did not revealed a significant difference in clinicians' distancing language. Multiple keywords emerged that also were related to distancing language, and their relative frequency increased in the time approaching the suicide. Linguistic analysis is a promising approach to identify use of distancing language by clinicians, which appears to be a marker of suicide risk. This pilot work indicates that additional analysis and validation with larger cohorts are warranted.