Patient Experience Outcomes Research Articles

Characteristics and Long Term Follow up of Men Who Suffer Ischemic Priapism Secondary to Recreational Use of Intracavernosal Injectable Medications

To better understand patient experience, risk factors, culture, and ED outcomes surrounding recreational ICI use that led to ischemic priapism. After IRB approval, men presenting for ischemic priapism secondary to recreational ICI use from January 2010 to December 2018 were contacted by mail and then via telephone. Standardized questions were asked of all study participants on the topics of erectile function (IIEF-5), sexual practices, and at-risk behavior at the time of priapism. Qualitative data analysis was performed using grounded theory methodology. 14 men age 24-59 were successfully recruited. All men described themselves as men having sex with men (MSM) and one (7.1%) as having both male and female sexual partners. Average follow up IIEF-5 among participants was 13 (SD 4.0). Eleven men (78.6 %) described illicit drug use at the time of priapism. Qualitative data analysis yielded several preliminary themes: concomitant drug use, naivety, peer pressure, and delay in seeking treatment. Men frequently reported illicit drug use in group sex scenarios and ICI use under pressure to perform sexually or to counteract effects of illicit substances. Recreational ICI in this cohort was part of a lifestyle of risky behavior. Methamphetamine use and group sex encounters strongly motivate recreational ICI use. Substance abuse centers may offer an entry point into this population for counseling and primary prevention.

University COVID -19 Surveillance Testing Center: Challenges and Opportunities for Schools of Nursing.

As the impact of the COVID-19 pandemic became clear, it was evident that higher education schools and Universities, including schools of nursing were facing enormous challenges to create a safe environment for educational instruction to continue. Clinical education in particular was affected as clinical sites were increasingly unable to accommodate student clinical rotations due to crushing volumes and overwhelming care needs of COVID patients. This article outlines the innovative efforts of one university that set up a robust surveillance testing program that required and provided weekly COVID-19 testing of all students, faculty and staff that were on-campus. The testing center is nurse led and nurse managed, providing a clinical experience for over 50 nursing students each semester, allowing them to accrue community clinical hours so that they can progress through their nursing program. Clinical quality and patient experience outcomes are shared, and lessons learned described.

Exploring patients\u2019 pharmacy stories: an analysis of online feedback

Background Studies have demonstrated the potential for patient feedback to inform quality care as well as a direct relationship between patient experience and clinical outcomes. Over recent years, there has been increasing use of online patient feedback platforms, however, there has been little study of the content of patient feedback relating to pharmacy and pharmacy services. Objective This study explores the content of online feedback provided by patients from across the UK in relation to their experiences of their interaction with pharmacy staff and pharmacy services. Main outcome measure Content of online patient feedback relating to pharmacy. Method Patient stories published on Care Opinion, a national online patient feedback platform, for a one-year period were searched for all content relating to patients’ pharmacy experiences. A thematic and sentiment analysis was conducted on 237 patient stories. Results Patient stories related to supply, staff attitudes, services, accessibility, systems, and errors. Patient sentiment depended on pharmacy setting, but staff attitudes, services, and accessibility were generally positive across all settings. Waiting time was the most common complaint in both hospital and community pharmacies with stories relaying experiences of slow discharge, stock shortages and poor communication and collaboration between pharmacies and GP surgeries. Conclusions Online patient feedback highlighted factors important to patients when interacting with pharmacies and their staff. Medication supply was the primary topic of patient stories with waiting times and stock shortages being clear areas for improvement; however, accessibility, pharmacy services and advice were key strengths of the profession. Further research is needed to understand how online patient feedback can be used effectively to inform improvements in pharmacy services.

The need for a standardized conceptual term to describe invalidation of patient symptoms.

In this paper, I comment on a growing literature documenting that many patients perceive their symptoms have been dismissed, ignored, not taken seriously, not believed, etc. (i.e. invalidated) by healthcare providers. I provide a narrative review of research reporting on this patient-provider phenomenon, invalidation of patient symptoms, in various illness contexts in order to highlight the variability concerning how scholars have been referring to the seemingly same phenomenon. Next, I discuss the challenges this variability poses for scholarship, including how it precludes the ability to build on our understanding of how it contributes to the patient experience and related health outcomes. I conclude with recommendations for future research.

A Novel Methodology to Estimate the Need for Proton Beam Therapy

Purpose: Currently, Canada is the only G8 country without a proton beam therapy (PBT) facility in operation or under construction. Based on experience from other G8 countries with PBT facilities, it has been estimated that approximately 5-16% of all cancer patients who receive radiation treatment with curative intent should be considered for PBT. To begin planning for a PBT facility in Ontario, a more robust and localized estimate of the need for PBT is required. Methods: An expert panel was assembled to develop an estimate of the need for PBT services. A step-wise approach was taken to: 1) identify clinical indications for PBT; 2) obtain volume estimates for curative photon therapy for select practice site groups and patient subpopulations (pediatric, adolescent young adult and adult); 3) develop and apply clinical algorithms to estimate the proportion of each indication that should be considered for PBT. Data was gathered from program level reporting and published literature. Expert opinion and consensus further informed decision-making. Results: 13 practice site groups for which PBT could have potential clinical benefit were identified: benign neoplasms, breast, central nervous system, endocrine, gastrointestinal, genitourinary, gynecological, hematology, head and neck, lung, other cancers, sarcoma, and skin. The largest variation in practice site estimates across subpopulations were found in endocrine, breast, gastrointestinal, sarcoma, and skin. Applying expert panel proportion estimates to curative radiation treatment volumes gathered from program level reporting for the respective practice groups and subpopulations (n=27,500), the estimated provincial need for PBT is 1,542 (5.6%) patients per year, with a lower bound of 364 (1.32%) and an upper bound of 4,246 (15.44%). Conclusions: An Ontario PBT facility has the potential to provide equitable access to comprehensive cancer care; decreasing long-term toxicities, improving patient experience and health outcomes. With limited published data in the Canadian context of an estimated need for Proton Beam Therapy, the methodology described provides a more robust estimate of the need for PBT. This methodology can be applied across other jurisdictions to assist with PBT planning exercises.

Associations between patient experience and clinical outcomes in substance use disorder clinics: Findings from the veterans outcomes assessment survey

BackgroundPatient-centeredness is a cornerstone of substance use disorder (SUD) treatment. Patient-experience measures are potential tools for the routine assessment of patient-centered SUD care and may be valuable measures to inform quality monitoring improvement efforts. Little research exists on the predictive validity of patient-experience measures in SUD care. PurposeWe report on findings from the Veterans Outcome Assessment (VOA) survey that provides information on Veterans Health Administration SUD specialty care at treatment initiation and approximately 3-months post-initiation. MethodsThe VOA includes patient-reported outcomes across multiple domains, including the Brief Addiction Monitor (BAM-R), the Short-Form-12 (SF-12) and the Experience of Care and Health Outcome Survey (ECHO), and provides patient reports of the quality of provider communication and overall quality of SUD care. ResultsNearly 40% of veterans in SUD care gave the highest possible ratings for communication and quality at both baseline and follow-up. Ratings of communication at 3-months were associated with treatment discontinuation and both ratings of communication and quality at 3-months and were independently associated with SUD symptoms and with mental well-being at 3-months. ConclusionsThis study provides preliminary support for the inclusion of patient experience measures, particularly ratings of provider communication, as part of routine assessment in SUD care. However, further work on the validity of ratings of provider communication using additional methodologies is likely important before piloting the inclusion of such measures in routine assessment, such as in measurement base care.

Are Online Patient Reviews Associated With Health Care Outcomes? A Systematic Review of the Literature

Although online patient reviews (OPRs) are ubiquitous, there has been debate about whether OPRs are associated with measures of health care outcomes. The majority of patients search for online information about a hospital or provider before scheduling an encounter, therefore, the extent to which OPRs are valid information is important. We conducted a systematic review of the literature to examine the extent to which OPRs are associated with measures of patient experience, clinical quality, and other outcomes. We searched Medline, CINAHL, Web of Science, and PsycInfo, which yielded 32 studies. There were consistent positive correlations between OPRs and patient experience at both the organization and individual provider levels of analysis. However, associations between OPRs and quality measures were mixed. Organizational level OPRs may be more reliable than individual provider OPRs. In addition, the strength of association could be affected by the type of encounter setting, specialty, and specific measures.

Why Measure Patient Experience in Physical Therapy?

BackgroundPatient experience is an important component of quality and patient centered health care not fully explored in physical therapy.Main bodyThis article addresses (1) concept of patient experience, (2) importance of capturing the patient experience, (3) measures to capture patient experience and whether these measures exhibit psychometrically sound measurement properties, (4) relationship between patient experience and clinical effectiveness outcomes, and (5) clinical applications of patient experience measures in the outpatient physical therapy setting, including suggestions for future studies.Short conclusionEmploying patient experience measures into physical therapy practice may be an important key to improve clinical effectiveness outcomes and provide excellent patient-centered care delivery. An area of continued research should be focused on demonstrating the generalizability and measurement properties of patient reported experience measures for the musculoskeletal outpatient physical therapy population focusing first on the most common musculoskeletal conditions such as cervical, low back, and shoulder pain.

The influence of COVID-19 visitation restrictions on patient experience and safety outcomes: A critical role for subjective advocates

With the emergence of the coronavirus (COVID-19) pandemic in the United States in early 2020, hospitals across the country made the difficult decision to alter visitation policies, by either limiting visitations or restricting visitations altogether by closing access to family, friends and care partners in an effort to reduce further spread of the virus. While there is foundational research on the impact of family and care partner presence on the experience of patients and patient safety outcomes, the actions driven by the pandemic allowed for a real-time comparison of the impact of family or care partner presence or lack thereof. Patient and family engagement has long been a part of patient experience scholarship where the role of family members and care partners as patient advocates and a presence of support has been reinforced. Scholarship and practice have also encouraged movement from restricted visiting hours to having open visitation based on findings that, in addition to better patient outcomes, there is a benefit in nurse job satisfaction and communication when visitations are unrestricted. The purpose of this study is to examine the degree to which hospital visitation restrictions in U.S. hospitals during the COVID-19 pandemic help to explain changes in patient experience and patient safety outcomes. To examine this relationship, patient experience and safety outcomes of a national sample of hospitals (n=32) during the pandemic is compared to previous corresponding performance. The results indicate that hospital performance was negatively impacted on average during the pandemic for hospitals in the sample. However, differences in hospital performance during the pandemic were driven by hospitals that disallowed patient visitations. Hospitals with closed visitations saw most pronounced deficits in their performance with regard to patient ratings of medical staff responsiveness, fall rates and sepsis rates. Performance in hospitals that either remained unrestricted or partially limited their visitations was not appreciably different from pre-pandemic performance, and in some cases performance even improved marginally. The findings of this study indicate that the policy to allow for visitors, or subjective advocates, individuals with a vested interest in the well-being of the patient, is beneficial not only for the patient, but also in sustaining high quality of care. Recommendations are given for how hospitals might achieve improved quality and safety outcomes even in instances when organizations believe visitation needs to be disallowed or restricted. The results of this study suggest those decisions should be made with great care and in only the most extreme circumstances.

Integration of Lean Visual Management Tools Into Quality Improvement Practices in the Hospital Setting.

Lean management tools have proven effective in achieving high reliability in health care. Unstructured leader rounds, decentralized prevention bundle repositories, and unfavorable patient experience outcomes prompted leaders on a thoracic and cardiovascular surgery unit to find other methods to address these issues and positively impact outcomes. Nurse sensitive indicator prevention bundles, root cause analysis tools, and best practices were used to develop Kamishibai Cards (K-Cards) for each measure targeted. K-Cards were implemented to standardize processes, engage patients in their care, and promote staff identification of barriers and solutions. Nurse-sensitive indicators and patient experience metrics were positively impacted by Kamishibai Rounding. K-Cards promote a state of continuous improvement, which supports sustainability of evidence-based practice and best practices that were implemented. K-Cards use high-reliability principles to standardize nursing practice to promote quality outcomes.

Mallet fractures: a prospective comparison of treatment outcomes

Background: The optimal management of mallet fractures is controversial. Currently, published evidence does not clearly define the role of surgery in managing these fractures or identify when splinting alone is suitable.Methods: An observational, prospective cohort study was undertaken between 2012 and 2015 evaluating patient experience, and radiological and functional outcomes following mallet fractures managed with splinting alone or surgery combined with post-operative splinting. This study was registered with our local research facility and ethical approval was granted by the New Zealand Northern B Health and Disability Ethics Committee Health and Disability Ethics Committee (HDEC) #13/NTB/202. All patients provided formal written consent. Results: A total of 109 adult patients with 113 mallet fractures were enrolled in the study and 85 patients with 89 fractures completed follow-up. Mean follow-up was 190 days. Fractures initially associated with subluxation of the distal interphalangeal (DIP) joint treated with splinting alone were five times more likely to fail to meet a minimum standard of success than those fixed with surgery. When the fracture fragment occupies between one and two thirds of the joint surface, even in the absence of initial DIP joint subluxation, 13/35 (37%) joints subluxed during splint treatment. Conclusion: This study aids clinicians by highlighting where splinting is likely to fail and providing a means of identifying injuries in which surgery must be considered

Patient characteristics, treatment patterns, and clinical outcomes among patients with previously treated recurrent or metastatic cervical cancer: A community oncology-based analysis

ObjectiveThere is no standard systemic treatment for recurrent or metastatic cervical cancer (r/mCC) after failure of first-line (1L) therapy. This study characterizes the patient experience, treatment patterns, and clinical outcomes of patients who initiated second-line (2L) therapy for r/mCC in a US community oncology setting. MethodsThis is an observational study of cervical cancer patients who failed 1L systemic treatment for r/mCC and initiated 2L systemic therapy between 2014 and 2019 within the US Oncology Network (USON). USON's electronic health records were used to identify eligible patients and abstract data. Overall survival (OS), time to treatment discontinuation (TTD), and time to first subsequent treatment (TFST) were estimated using Kaplan–Meier methods. ResultsA total of 130 patients were identified (mean age 53 years). Over 60% of patients had Eastern Cooperative Oncology Group score of 0–1. Cytotoxic monotherapy was the most frequently prescribed regimen (N = 60, 46%) in 2L, followed by combination therapies (N = 45, 35%), pembrolizumab monotherapy (N = 19, 15%), and bevacizumab monotherapy (N = 6, 5%). Median OS was 9.1 months (95% CI: 7.2–12.2) after initiation of 2L therapy. Median TTD was 2.8 months (95% CI: 2.5–3.3), and median TFST was 4.9 months (95% CI: 4.2–5.7). No significant difference in outcomes was found when stratified by 2L treatments. ConclusionsThe observed heterogeneity in 2L r/mCC therapy suggests no clear standard-of-care in this setting. Additionally, short duration of OS observed was consistent across 2L regimens. New, effective treatment options in this setting are needed.

Comparison of an Artificial Intelligence–Enabled Patient Decision Aid vs Educational Material on Decision Quality, Shared Decision-Making, Patient Experience, and Functional Outcomes in Adults With Knee Osteoarthritis

Decision aids can help inform appropriate selection of total knee replacement (TKR) for advanced knee osteoarthritis (OA). However, few decision aids combine patient education, preference assessment, and artificial intelligence (AI) using patient-reported outcome measurement data to generate personalized estimations of outcomes to augment shared decision-making (SDM). To assess the effect of an AI-enabled patient decision aid that includes education, preference assessment, and personalized outcome estimations (using patient-reported outcome measurements) on decision quality, patient experience, functional outcomes, and process-level outcomes among individuals with advanced knee OA considering TKR in comparison with education only. This randomized clinical trial at a single US academic orthopedic practice included 129 new adult patients presenting for OA-related knee pain from March 2019 to January 2020. Data were analyzed from April to May 2020. Patients were randomized into a group that received a decision aid including patient education, preference assessment, and personalized outcome estimations (intervention group) or a group receiving educational material only (control group) alongside usual care. The primary outcome was decision quality, measured using the Knee OA Decision Quality Instrument (K-DQI). Secondary outcomes were collaborative decision-making (assessed using the CollaboRATE survey), patient satisfaction with consultation (using a numerical rating scale), Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS JR) score, consultation time, TKR rate, and treatment concordance. A total of 69 patients in the intervention group (46 [67%] women) and 60 patients in the control group (37 [62%] women) were included in the analysis. The intervention group showed better decisional quality (K-DQI mean difference, 20.0%; SE, 3.02; 95% CI, 14.2%-26.1%; P < .001), collaborative decision-making (CollaboRATE, 8 of 69 [12%] vs 28 of 60 [47%] patients below median; P < .001), satisfaction (numerical rating scale, 9 of 65 [14%] vs 19 of 58 [33%] patients below median; P = .01), and improved functional outcomes at 4 to 6 months (mean [SE] KOOS JR, 4.9 [2.24] points higher in intervention group; 95% CI, 0.8-9.0 points; P = .02). The intervention did not significantly affect consultation time (mean [SE] difference, 2.23 [2.18] minutes; P = .31), TKR rates (16 of 69 [23%] vs 7 of 60 [12%] patients; P = .11), or treatment concordance (58 of 69 [84%] vs 44 of 60 [73%] patients; P = .19). In this randomized clinical trial, an AI-enabled decision aid significantly improved decision quality, level of SDM, satisfaction, and physical limitations without significantly impacting consultation times, TKR rates, or treatment concordance in patients with knee OA considering TKR. Decision aids using a personalized, data-driven approach can enhance SDM in the management of knee OA. ClinicalTrials.gov Identifier: NCT03956004.

Soft tissue grafting with the tunnel technique in the mandibular anterior: Myths and realities.

To address the myths and realities of soft tissue grafting with the tunnel technique in the mandibular anterior region. Myths associated with use of the tunnel technique for soft tissue grafting in the mandibular anterior region are identified and examined. Explanations for the misunderstandings are presented and documented with case examples and evidence from scientific studies. Six myths are described and the realities are presented. This report demonstrates that the tunnel technique can be successfully used in the mandibular anterior region in the presence of anatomic features thought to favor the use of more invasive surgical methods. Soft tissue grafting in the mandibular anterior region has complicating anatomical features including a strong frenal attachment, shallow vestibule and thin tissue. These features may be successfully managed with a free gingival graft, but that procedure results in an uncomfortable experience for the patient. The tunnel technique, especially when combined with an acellular dermal matrix, dramatically improves the patient experience and esthetic outcome without compromising the clinical outcome.

Editorial: Visualizing user experience and stories: From customer journeys to patient experience mapping

Patient journey mapping represents a visual approach to documenting and analysing the experiences and stories of patients as they move through healthcare systems. Journey maps can also diagrammatically illustrate how patients interact with other stakeholders, systems and organizations throughout their journey. In this special issue a variety of innovative and scientific approaches to mapping the patient journey are described. The methods range from development of journey maps based on observation and interviews, to developing maps based on results of evidence-based literature reviews as well as from case studies. The outputs of the mapping may include an improved understanding of patient experiences, issues and problems encountered as well as the identification of opportunities for improving the healthcare process, patient experience and health outcomes. In this issue a range of health-related applications are described in order to illustrate the potential of the approach for improving complex domains such as healthcare.

"They were all together … discussing the best options for me": Integrating specialist diabetes care with primary care in Australia.

Over one-third of diabetes-related encounters with healthcare providers in Australia fail to meet clinical guidelines. Evidence is mounting that care provision within an integrated framework may facilitate greater adherence to clinical guidelines and improved outcomes for patients. The Diabetes Alliance Program was implemented across a large healthcare district to enhance diabetes care capacity at the primary care level through intensive case-conferencing involving the primary care team, patients and visiting specialist team, whole practice performance review and regular diabetes education for practitioners. Here, we provide an in-depth patient assessment of the case-conferencing process and impact on diabetes management. Two practices with high pre-intervention HbA1c monitoring and three practices with low HbA1c monitoring provided the sampling frame. Patients were selected according to their score on the Patient Activation MeasureTM to achieve maximum variation, with up to two patients with high scores and three with low scores, selected from each practice. Patients were sampled until data saturation was achieved and then subjected to thematic content analysis (n=19). Patients mostly described the model of care as a positive experience, reporting a boost in confidence in diabetes self-management (particularly around nutrition). The program was also seen to be helpful in providing an opportunity to refocus when "life gets in the way". Other valued aspects of the program included the holistic approach to healthcare, reduced travel time, familiarity in environment and clinical care, top-down knowledge transfer as well as mutual learning by the patient and their primary care team. Despite this, difficulties in coping with diabetes and adherence to treatment recommendations remained for a minority of patients. Integrating specialist teams within primary care has the ability to provide efficient healthcare delivery, better patient experience and health outcomes. Investment in such approaches will be critical to navigating healthcare provision in order to meet the demands of an ageing population.

The association between patient experience and healthcare outcomes using SEER-CAHPS patient experience and outcomes among cancer survivors

ObjectiveTo understand the relationship between patient experience, as measured by scores on the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey, and clinical and financial outcomes among older cancer survivors. Materials and MethodsWe analyzed the records of all Fee-for-Service (FFS) Medicare beneficiaries 66 years and older who completed one CAHPS survey from 2001 to 2004 or 2007–2013 with one of the five following cancer types: breast, bladder, colorectal, lung, or prostate; and completed a CAHPS survey within 5 years of cancer diagnosis date. We conducted a multivariate analysis, controlling for clinical and demographic variables, to evaluate the association between excellent CAHPS scores and the following clinical and financial outcomes: mortality, emergency department visits, and total healthcare expenditures. ResultsA total of 7395 individuals were present in our cohort, with 57% being male and 85.7% non-Hispanic White. Breakdown of the cohort by cancer site is as follows: prostate (40.4%), breast (28.6%), colorectal (14.0%), lung (9.4%), and bladder (7.6%). When looking at the relationship between CAHPS scores and clinical outcomes, there was no significant difference between excellent and non-excellent CAHPS score respondents in all three of the clinical outcomes studied. Furthermore, there was no association between ED utilization and patient experience scores when stratifying by cancer site and race/ethnicity among this cohort. ConclusionIn this cohort, a highly rated patient experience, as measured by responses on the CAHPS survey, is not associated with improved clinical outcomes among older cancer survivors.

Contemporaneous evaluation of patient experience, surgical strategy, and seizure outcomes in patients undergoing stereoelectroencephalography or subdural electrode monitoring.

Intracranial electrographic localization of the seizure onset zone (SOZ) can guide surgical approaches for medically refractory epilepsy patients, especially when the presurgical workup is discordant or functional cortical mapping is required. Minimally invasive stereotactic placement of depth electrodes, stereoelectroencephalography (SEEG), has garnered increasing use, but limited data exist to evaluate its postoperative outcomes in the context of the contemporaneous availability of both SEEG and subdural electrode (SDE) monitoring. We aimed to assess the patient experience, surgical intervention, and seizure outcomes associated with these two epileptic focus mapping techniques during a period of rapid adoption of neuromodulatory and ablative epilepsy treatments. We retrospectively reviewed 66 consecutive adult intracranial electrode monitoring cases at our institution between 2014 and 2017. Monitoring was performed with either SEEG (n=47) or SDEs (n=19). Both groups had high rates of SOZ identification (SEEG 91.5%, SDE 88.2%, P=.69). The majority of patients achieved Engel class I (SEEG 29.3%, SDE 35.3%) or II outcomes (SEEG 31.7%, SDE 29.4%) after epilepsy surgery, with no significant difference between groups (P=.79). SEEG patients reported lower median pain scores (P=.03) and required less narcotic pain medication (median = 94.5 vs 594.6 milligram morphine equivalents, P=.0003). Both groups had low rates of symptomatic hemorrhage (SEEG 0%, SDE 5.3%, P=.11). On multivariate logistic regression, undergoing resection or ablation (vs responsive neurostimulation/vagus nerve stimulation) was the only significant independent predictor of a favorable outcome (adjusted odds ratio = 25.4, 95% confidence interval = 3.48-185.7, P=.001). Although both SEEG and SDE monitoring result in favorable seizure control, SEEG has the advantage of superior pain control, decreased narcotic usage, and lack of routine need for intensive care unit stay. Despite a heterogenous collection of epileptic semiologies, seizure outcome was associated with the therapeutic surgical modality and not the intracranial monitoring technique. The potential for an improved postoperative experience makes SEEG a promising method for intracranial electrode monitoring.

Associations between patient experience and clinical outcomes in general mental health clinics: Findings from the veterans outcomes assessment survey

For mental health, evidence linking the patients’ experiences of care with treatment outcomes is limited. We report findings from the Veterans Outcome Assessment (VOA) survey of Veterans beginning treatment in Veterans Health Administration (VHA) mental health programs with follow-up after approximately 3 months. In addition to assessments of symptoms and functioning, it includes key components of the Experience of Care and Health Outcomes (ECHO) survey including patient reports of communication with clinicians and of the overall quality of mental health care. For Veterans treated in VHA general mental health clinics, significant associations between ratings of communication and quality at baseline, and both retention in treatment and patient-reported outcomes assessed at follow-up demonstrate that better patient experience predicts more favorable outcomes. Further research is necessary to determine whether including them in measurement-based care could improve outcomes by facilitating the early identification of problems in providing care.

The Economics and Effectiveness of Advanced Practice Providers Are Decidedly Local Phenomena.

The growth and promulgation of Advanced Practice Providers (APPs) across the entire spectrum of healthcare delivery has been profound, and APPs are increasingly common members of emergency department (ED) care teams. Emergency APP workforce growth is outpacing that of emergency physicians with little to suggest that this trend will subside. The evolution of the deployment of APPs in emergency care has been dramatic; initially, emergency APPs were deployed to lower acuity patients or environments-minor injury and illness and in conjunction with an emergency physician-hence the now antiquated description of APPs as "physician extenders."