Veterans Affairs Primary Care Clinics Research Articles

59-OR: Improving Diabetic Kidney Disease Screening in a Veterans Affairs Primary Care Clinic

59-OR: Improving Diabetic Kidney Disease Screening in a Veterans Affairs Primary Care Clinic

Culture change and lessons learned from ten years in the VA centers of excellence in primary care education

BackgroundTeam-based care is critical to achieving health care value while maximizing patient outcomes. Few descriptions exist of graduate-level team training interventions and practice models. Experience from the multisite, decade-long Veterans Affairs (VA) Centers of Excellence in Primary Care Education provides lessons for developing internal medicine training experiences in interprofessional clinical learning environments.MethodsA review of multisite demonstration project transforming traditional silo-model training to interprofessional team-based primary care. Using iterative quality improvement approaches, sites evaluated curricula with learner, faculty and staff feedback. Learner- and patient-level outcomes and organizational culture change were examined using mixed methods, within and across sites. Participants included more than 1600 internal medicine, nurse practitioner, nursing, pharmacy, psychology, social work and physical therapy trainees. This took place in seven academic university-affiliated VA primary care clinics with patient centered medical home designResultsEach site developed innovative design and curricula using common competencies of shared decision making, sustained relationships, performance improvement and interprofessional collaboration. Educational strategies included integrated didactics, workplace collaboration and reflection. Sites shared implementation best practices and outcomes. Cross-site evaluations of the impacts of these educational strategies indicated improvements in trainee clinical knowledge, team-based approaches to care and interest in primary care careers. Improved patient outcomes were seen in the quality of chronic disease management, reduction in polypharmacy, and reduced emergency department and hospitalizations. Evaluations of the culture of training environments demonstrated incorporation and persistence of interprofessional learning and collaboration.ConclusionsAligning education and practice goals with cross-site collaboration created a robust interprofessional learning environment. Improved trainee/staff satisfaction and better patient care metrics supports use of this model to transform ambulatory care training.Trial registrationThis evaluation was categorized as an operation improvement activity by the Office of Academic Affairs based on Veterans Health Administration Handbook 1058.05, in which information generated is used for business operations and quality improvement (Title 38 Code of Federal Regulations Part 16 (38 CFR 16.102(l)). The overall project was subject to administrative oversight rather Human Subjects Institutional Review Board, as such informed consent was waived as part of the project implementation and evaluation.

The impact of screening positive for hazardous alcohol use on the diagnostic accuracy of the PTSD Checklist for DSM-5 among veterans.

The Posttraumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5) is a widely used self-report measure of PTSD symptoms that has demonstrated strong psychometric properties across settings and samples. Co-occurring hazardous alcohol use and PTSD are prevalent among veterans, and the effects of alcohol use may impact the performance of the PCL-5. However, this possibility is untested. In this study, we evaluated the PCL-5 diagnostic accuracy for veterans who did and did not screen positive for hazardous alcohol use according to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). Participants were 385 veterans recruited from Veterans Affairs primary care clinics. Results indicated that PCL-5 performance, AUC = .904, 95% CI [.870, .937], did not differ as a product of hazardous alcohol use. PCL-5 diagnostic utility was comparably high for veterans with, AUC = .904; 95% CI [.846, .962], and without, AUC = .904 95% CI [.861, .946], positive AUDIT-C screens. Although optimally efficient cutoff scores for veterans who screened positive were higher (i.e., 34-36) than for those with negative screens (i.e., 30), neither were significantly different from the overall PCL-5 cutoff score (i.e., 32), suggesting that neither veterans with nor without positive AUDIT-C screens require differential PCL-5 cutoff scores. The results do underscore the importance of using PCL-5 cutoff scores in concert with clinical judgment when establishing a provisional PTSD diagnosis and highlight the need for additional study of the impact of comorbidities on PCL-5 diagnostic accuracy and cutoff scores.

Depression care quality among patients with solid tumor cancers detected to have depression in Veterans Health Administration primary care clinics.

Patients with cancer, especially advanced cancer, experience depression at high rates. We aimed to evaluate the quality of depression care received by patients with solid tumor cancer and advanced solid tumor cancer in Veterans Affairs (VA) primary care clinics. This is a retrospective cohort study of patients seen in 82 VA primary care clinics who newly screened positive for depression on the Patient Health Questionnaire (PHQ-2). Outcomes included timely follow-up within 84 or 180 days (3+ mental health specialty, 3+ psychotherapy, or 3+ primary care visits with depression diagnosis codes) and minimum treatment within 1 year (60+ days antidepressants prescribed, 4+ mental health specialty visits, or 3+ psychotherapy visits). 608,042 individuals were seen in VA primary care clinics during this period; 49,839 patients (8.2%) had solid tumor cancer and 9,278 (1.5%) had advanced or poor-prognosis solid tumor cancer. For 686 observations of patients with cancer and new depression, rates of appropriate follow-up were 22.3% within 84 days and 38.2% within 180 days. For 73 observations of patients with advanced or poor-prognosis cancer and new depression, rates of appropriate follow-up were 21.9% within 84 days and 34.3% within 180 days. Rates of minimum treatment within 1 year were 68.4% and 64.4% for patients with cancer and patients with advanced or poor-prognosis cancer, respectively. Quality of timely depression management is low in patients with solid tumor cancers. Even in health systems with well-integrated mental health services, care gaps remain for patients with cancer and depression. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A Randomized Controlled Pilot Trial of Primary Care Treatment Integrating Motivation and Exposure Treatment (PC-TIME) in Veterans With PTSD and Harmful Alcohol Use

Individuals with posttraumatic stress disorder (PTSD) often engage in harmful alcohol use. These co-occurring conditions are associated with negative health consequences and disability. PTSD and harmful drinking are typically experienced as closely related—thus treatments that target both simultaneously are preferred by patients. Many individuals with PTSD and harmful alcohol use receive primary care services but encounter treatment barriers in engaging in specialty mental health and substance use services. A pilot randomized controlled trial of a brief integrated treatment for PTSD and harmful drinking versus primary care treatment as usual (PC-TAU) took place in three U.S. Department of Veterans Affairs (VA) primary care clinics. The intervention (primary care treatment integrating motivation and exposure [PC-TIME]) combines motivational interviewing to reduce alcohol use and brief prolonged exposure for PTSD delivered over five brief sessions. Participants (N = 63) were veterans with PTSD and harmful drinking. Multilevel growth curve modeling examined changes in drinking (average number of drinks per drinking day and percentage of heavy drinking days) and self-reported PTSD severity at baseline, 8, 14, and 20 weeks. Participants reported high satisfaction with PC-TIME and 70% (n = 23) completed treatment. As hypothesized, a significantly steeper decrease in self-reported PTSD severity and heavy drinking was evident for participants randomized to PC-TIME compared with PC-TAU. Contrary to expectations, no significant posttreatment differences in PTSD diagnoses were observed. PC-TIME participants were less likely to exceed National Institute for Alcoholism and Alcohol Abuse (NIAAA) guidelines for harmful alcohol use posttreatment compared with PC-TAU participants. PC-TIME is a promising brief, primary care-based treatment for individuals with co-occurring PTSD and harmful alcohol use. A full-scale randomized clinical trial is needed to fully test its effectiveness.

Does screening for PTSD lead to VA mental health care? Identifying the spectrum of initial VA screening actions.

Despite the active posttraumatic stress disorder (PTSD) screening program in Department of Veterans Affairs (VA) primary care clinics and the availability of empirically supported treatments for PTSD at VA, many veterans for whom screening suggests treatment may be indicated do not gain access to VA-based mental health care. To determine where we may be losing veterans to follow-up, we need to begin by identifying the initial action taken in response to a positive PTSD screen in primary care. Using VA administrative data and chart review, we identified the spectrum of initial actions taken after veterans screened positive for PTSD in VA primary care clinics nationwide between October 2017 and September 2018 (N = 41,570). We collapsed actions into those that could lead to VA-based mental health care (e.g., consult placed to a VA mental health clinic) versus not (e.g., veteran declined care), and then examined the association between these categories of actions and contextual- and individual-level variables. More than 61% of veterans with positive PTSD screens had evidence that an initial action toward VA-based mental health care was taken. Urban-dwelling and female veterans were significantly more likely to have evidence of these initial actions, whereas White and Vietnam-era veterans were significantly less likely to have this evidence. Our findings suggest that most veterans screening positive for PTSD in VA primary care clinics have evidence of initial actions taken toward VA-based mental health care; however, a substantial minority do not, making them unlikely to receive follow-up care. Findings highlight the potential benefit of targeted primary care-based access interventions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Carpal Tunnel Syndrome as a Test Case for Value Assessment During the Presurgical Period: The Impact of Structure and Processes of Care.

Few performance measures assess presurgical value (quality and utilization). Using carpal tunnel syndrome (CTS) as a case study: (1) develop a model to evaluate presurgical quality and utilization and (2) identify opportunities for value improvement. A retrospective cohort study utilizing Veterans Affairs (VA) national administrative data. Patients who were evaluated in a VA primary care clinic on at least 1 occasion for CTS and received carpal tunnel release over a 7-year period. We modeled facility-level performance on 2 outcomes: surgical delay (marker of quality) and number of presurgical encounters (utilization) for CTS, and examined association between patient, facility, and care process variables and performance. Among 41,912 Veterans undergoing carpal tunnel release at 127 VA medical centers, the median facility-level predicted probability of surgical delay was 48%, with 16 (13%) facilities having significantly less delay than the median and 13 (10%) facilities having greater delay. The median facility-level predicted number of presurgical encounters was 8.8 visits, with 22 (17%) facilities having significantly fewer encounters and 22 (17%) facilities having more. Care processes had a stronger association with both outcomes than structural variables included in the models. Processes associated with the greatest deviations in predicted delay and utilization included receipt of repeat electrodiagnostic testing, use of 2 or more nonoperative treatments, and community referral outside of VA. Using CTS as a test case, this study demonstrates the potential to assess presurgical value and identify modifiable care processes associated with presurgical delay and utilization performance.

Relationship Health and Intimate Partner Violence in Integrated Primary Care: Individual Characteristics and Preferences for Relationship Support across Risk Levels.

This study explores differences in characteristics and relationship treatment preferences across different levels of intimate partner violence (IPV) among Veterans Affairs (VA) primary care patients. In Fall 2019, we sent a mail-in survey assessing relationship healthcare needs to N = 299 Veterans randomly sampled from 20 northeastern VA primary care clinics (oversampling female and younger Veterans). We compared those reporting past year use or experience of physical/sexual aggression, threats/coercion, or injury (Severe IPV; 21%), to those only reporting yelling and screaming (Verbal Conflict; 51%), and denying any IPV (No IPV; 28%). Participants across groups desired 2-6 sessions of face-to-face support for couples' health and communication. No IPV participants were older and had preferred treatment in primary care. The Verbal Conflict and Severe IPV groups were both flagged by IPV screens and had similar interest in couple treatment and relationship evaluation. The Severe IPV group had higher rates of harms (e.g., depression, alcohol use disorder, relationship dissatisfaction, fear of partner) and higher interest in addressing safety outside of VA. Exploratory analyses suggested differences based on use vs. experience of Severe IPV. Findings highlight ways integrated primary care teams can differentiate services to address dissatisfaction and conflict while facilitating referrals for Severe IPV.

S1365 Improving Screening and Vaccination Rate for Hepatitis B in Veterans Affair Primary Care Population: A Quality Improvement Study

Introduction: According to Advisory Committee on Immunization Practices (ACIP), acute infection with Hepatitis B virus (HBV) is rising among adults 40 years and older. Hepatitis B (HepB) vaccines have long demonstrated safety and efficacy for decades, however less than a third of U.S. adults reported being vaccinated against HBV in 2018. In 2022, ACIP updated its recommendation and advised vaccinating all adults aged 19-59 and those 60 years and older with risk factors; adults 60 years and older without known risk factors may also be vaccinated. Our project aims to improve HBV screening and vaccination rate among Veterans Affairs (VA) primary care clinic patient population. Methods: Data was collected from pre-intervention (October – December 2021) and post-intervention (March – May 2022); all patients seen in clinic during these months were included. Patients were considered immune against HBV from vaccination if they have positive anti-HBsAg; and susceptible to infection if hepatitis panel negative. Interventions include educating each resident group regarding update in vaccination guideline and hepatitis panel interpretation. Reminder poster regarding HBV vaccine was placed in each clinic room. In addition, reminder for checking HepB status was developed and embedded in VA electronic medical record (EMR) system, which will show up at the end of each visit. (Figure) Results: In the pre-intervention period from October to December 2021, a total of 1242 veterans were seen in primary care clinic. 532 veterans were screened for immunity in the past with 378 veterans noted to have no immunity against hepatitis B. Out of 378 non-immune veterans, only 35 patients were vaccinated against HepB. (Table) In the post-intervention period from March to May 2022, 1174 veterans were seen. 689 veterans were screened for immunity and 402 have no immunity against HBV on hepatitis panel; 123 veterans received HepB vaccine during clinic visit, which is more than 20% increase compared to prior. Conclusion: Our data suggest that HBV vaccination rate was suboptimal among veteran population. A low-cost intervention along with the help of technology could be beneficial in integrating new vaccination guideline in VA standard of care. Our project strikes to encourage clinicians to bear the responsibility and offer the vaccine to adult patients proactively, rather than wait for patients to request for it. The goal of this project is to increase awareness of new vaccination guideline and reach for full vaccination rate among veteran population. Table 1. - Data gathered from pre-intervention and post-intervention period. Pre-Intervention (October to December 2021) Post-Intervention (March to May 2022) Total veterans seen in clinic 1242 1174 Veterans that were screened for Hepatitis B 532 out of 1242 (42.8%) 689 out of 1174 (58.7%) Screened veterans found to have no immunity against Hepatitis B 378 out of 532 (71%) 402 out of 689 (58.3%) Veterans without HepB immunity that received HepB vaccine 35 out of 378 (9%) 123 out of 402 (30.6%) Figure 1.: Example of electronic reminder that was developed and embedded in VA electronic medical record system. The reminder will show up at the end of each clinic visit, which will ask physicians to check veterans' hepatitis B status and offer vaccine if appropriate.

Abstract P014: A Pilot Study To Develop A Telehealth Program For Self-Measured Blood Pressure Education And Assessment Within A Veterans Affairs Clinic

Background: Lack of education and assessment of self-measured blood pressure (BP) monitoring quality is a barrier to its widespread implementation. Objective: To develop a pilot Veterans Affairs (VA) Telehealth Program utilizing a tool to educate and assess competencies in self-measured BP technique. Methods: This pilot study was implemented in a single VA primary care clinic. Veterans aged 18 to 85 years old with an office-based BP measurement of ≥140/90 or ≥130/80 mmHg and high cardiovascular disease risk were eligible. Enrolled Veterans completed a four-week program whereby trained registered nurses (RNs) educated Veterans on self-measured BP techniques via video conferencing. At each visit, RNs conducted an 11-part assessment tool (Figure Top) adapted from the American Medical Association measurement skills assessment for patient self-measured BP technique. Results: Forty Veterans (mean age 66 years [SD 12.6], 100% male) were referred for enrollment and twenty completed the program. Veterans demonstrated overall high scores on self-BP measurement skills assessment at each time point (Figure Top), but most frequent skills with non-adherence included: avoiding stimulant use prior to BP measurement; emptying bladder; resting quietly for 3-5 minutes; and talking or using a personal device during measurement. Mean SBP and DBP generally declined over time from a baseline mean SBP and DBP of 147.9 and 81.7 mmHg at enrollment to a mean of 140.4 and 79.9 mmHg, respectively, at program completion (Figure Bottom). Conclusions: Education and assessment of self-measured BP technique may serve as a meaningful target for future education and quality improvement efforts.

Do functional status and Medicare claims data improve the predictive accuracy of an electronic health record mortality index? Findings from a national Veterans Affairs cohort

BackgroundElectronic health record (EHR) prediction models may be easier to use in busy clinical settings since EHR data can be auto-populated into models. This study assessed whether adding functional status and/or Medicare claims data (which are often not available in EHRs) improves the accuracy of a previously developed Veterans Affairs (VA) EHR-based mortality index.MethodsThis was a retrospective cohort study of veterans aged 75 years and older enrolled in VA primary care clinics followed from January 2014 to April 2020 (n = 62,014). We randomly split participants into development (n = 49,612) and validation (n = 12,402) cohorts. The primary outcome was all-cause mortality. We performed logistic regression with backward stepwise selection to develop a 100-predictor base model using 854 EHR candidate variables, including demographics, laboratory values, medications, healthcare utilization, diagnosis codes, and vitals. We incorporated functional measures in a base + function model by adding activities of daily living (range 0-5) and instrumental activities of daily living (range 0-7) scores. Medicare data, including healthcare utilization (e.g., emergency department visits, hospitalizations) and diagnosis codes, were incorporated in a base + Medicare model. A base + function + Medicare model included all data elements. We assessed model performance with the c-statistic, reclassification metrics, fraction of new information provided, and calibration plots.ResultsIn the overall cohort, mean age was 82.6 years and 98.6% were male. At the end of follow-up, 30,263 participants (48.8%) had died. The base model c-statistic was 0.809 (95% CI 0.805-0.812) in the development cohort and 0.804 (95% CI 0.796-0.812) in the validation cohort. Validation cohort c-statistics for the base + function, base + Medicare, and base + function + Medicare models were 0.809 (95% CI 0.801-0.816), 0.811 (95% CI 0.803-0.818), and 0.814 (95% CI 0.807-0.822), respectively. Adding functional status and Medicare data resulted in similarly small improvements among other model performance measures. All models showed excellent calibration.ConclusionsIncorporation of functional status and Medicare data into a VA EHR-based mortality index led to small but likely clinically insignificant improvements in model performance.

A novel opt-in vs opt-out approach to referral-based treatment of tobacco use in Veterans Affairs (VA) primary care clinics: A provider-level randomized controlled trial protocol

To determine whether an opt-out approach is effective for referral to treatment for tobacco use, we designed a clinical reminder for nurses in a primary care setting that provides a referral for patients who smoke cigarettes. We will use a two-arm, cluster-randomized design to assign nurses at the VA New York Harbor Healthcare System to test which mode of referral (opt-in vs opt-out) is more effective. All patients will be referred to evidence-based treatment for tobacco cessation including counseling from the New York State Quitline, and VetsQuit, a text messaging-based system for tobacco cessation counseling. We will measure patient engagement with the referral both in the short and long term to determine if referral modality had an impact on tobacco cessation treatment. We will also measure nurse engagement with the referral before, during, and after the implementation of the reminder to determine whether an opt-out approach is cost effective at the health system level. At the conclusion of this project, we expect to have developed and tested an opt-out system for increasing tobacco cessation treatment for Veterans in VA primary care and to have a thorough understanding of factors associated with implementation.Trial Registration:Clinicaltrials.govIdentifierNCT03477435

Enhancing Problem-Solving Therapy With Smartphone Technology: A Pilot Randomized Controlled Trial.

Development of smartphone apps for mental health care has outpaced research on their effectiveness. This pilot study tested Moving Forward, an app designed to support problem-solving therapy (PST). Thirty-three veterans seeking mental health care in U.S. Department of Veterans Affairs primary care clinics were randomly assigned to receive six sessions of PST accompanied by either the Moving Forward app (N=17) or a workbook (N=16). Participants completed measures of anxiety, depression, stress, problem-solving style, satisfaction, and between-session practice at baseline and 6- and 12-week follow-ups. Qualitative interviews were used to elicit feedback. Participants in both groups reported high satisfaction and reductions in depression, anxiety, and stress. Veterans who used the app reported skills practice, and qualitative data indicated that patients perceived the app as valuable, with the potential to reduce barriers to care. This study provides preliminary evidence to support the ability of the Moving Forward app to augment brief psychotherapy in primary care clinics.

Protocol to improve hypertension management in a VA outpatient clinic.

This 20-week quality improvement study describes implementation of a hypertension identification and management program with use of a standardized oscillometric blood pressure (BP) measurement protocol, provider education, and audit/feedback of hypertension control in a Veterans Affairs primary care clinic. A total of 692 male Veterans ages 18-85 years with treated hypertension and at least one clinic visit in the previous year were included for analysis. Mean age was 69.7 years (standard deviation 7.6) and race and ethnicity were 42.0% White, 29.1% Black and 3.0% Hispanic. Prior to program implementation, clinic BP was measured using the auscultatory method with a manual syphgmomanometer. Baseline BP measurements demonstrated bias as determined by terminal digit preference for digits 0 and 8 in 29.5% and 25.2% of systolic (SBP) and 31.6% and 21.8% of diastolic BP measurements, respectively (p < 0.001). Post-implementation of the standardized oscillometric BP measurement protocol, digit preference was eliminated. Protocol compliance was 89.1% at 5 weeks and 92.4% at 20 weeks. Overall average SBP was significantly higher in the post-implementation period compared to average SBP in the 12-month pre-implementation period (137.4 [Standard Deviation (SD) 17.4] vs. 126.3 [SD 15.3]; P < 0.001). Uncontrolled hypertension, (BP ≥ 140/90 mmHg), increased from 17.8% at baseline to 41.8% post-implementation while provider therapeutic inertia declined from 84.5% at baseline to 55.8% after 20 weeks. This study shows that terminal digit preference is reduced with implementation of standardized oscillatory BP measurement and a quality improvement program can reduce therapeutic inertia of hypertension treatment.

Factors influencing providers' willingness to deprescribe medications

AbstractBackgroundPolypharmacy (taking ≥ five medications) is common and associated with adverse drug events, medication nonadherence, and increased mortality and healthcare costs. Primary care providers are uniquely positioned to deprescribe unnecessary medications, yet little is known about factors that influence their deprescribing decisions.ObjectivesWe sought to identify factors that influence primary care providers' recommendations to deprescribe potentially unnecessary medications.MethodsThis study represents a secondary data analysis from a national, cross‐sectional survey assessing providers' beliefs, attitudes, and experiences regarding medication deprescribing. A random sample of 2475 providers in Veterans Affairs (VA) primary care clinics were invited; 411 responded (16.6% response rate). Respondents included physicians (n = 304), nurse practitioners/physician assistants (n = 68), and clinical pharmacists (n = 39). Respondents estimated the proportion of their patients taking a potentially unnecessary medication. Of these patients, providers then identified the proportion for whom they recommended medication deprescribing (response options: &lt;20%, 20%‐39%, 40%‐59%, 60%‐79%, ≥80%). We used multivariable logistic regression to determine factors associated with recommending deprescribing to ≥80% of candidate patients.ResultsAlthough most respondents indicated having patients taking unnecessary medications, less than one‐third reported recommending deprescribing to most (≥80%) of their candidate patients. In adjusted analyses, factors significantly associated with increased likelihood of recommending deprescribing included having more patients who asked for medication information, providers' self‐rated comfort with deprescribing, and having support to monitor patients after deprescribing. When the indication for a medication was unclear, providers reported being less likely to recommend deprescribing.ConclusionMost providers indicated caring for patients taking potentially unnecessary medications, yet they did not consistently say they recommended deprescribing to these patients. Our findings suggest that requiring prescriptions to include their reason for use and models of primary care designed to strengthen interdisciplinary teamwork and communication, such as the patient‐centered medical home, could address barriers providers face to deprescribing medications.

Diagnostic Accuracy and Acceptability of the Primary Care Posttraumatic Stress Disorder Screen for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) Among US Veterans

Posttraumatic stress disorder (PTSD) is a serious mental health disorder that can be effectively treated with empirically based practices. PTSD screening is essential for identifying undetected cases and providing patients with appropriate care. To determine whether the Primary Care PTSD screen for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PC-PTSD-5) is a diagnostically accurate and acceptable measure for use in Veterans Affairs (VA) primary care clinics. This cross-sectional, diagnostic accuracy study enrolled participants from May 19, 2017, to September 26, 2018. Participants were recruited from primary care clinics across 2 VA Medical Centers. Session 1 was conducted in person, and session 2 was completed within 30 days via telephone. A consecutive sample of 1594 veterans, aged 18 years or older, who were scheduled for a primary care visit was recruited. Data analysis was performed from March 2019 to August 2020. In session 1, participants completed a battery of questionnaires. In session 2, a research assistant administered the PC-PTSD-5 to participants, and then a clinician assessor blind to PC-PTSD-5 results conducted a structured diagnostic interview for PTSD. The range of PC-PTSD-5 cut points overall and across gender was assessed, and diagnostic performance was evaluated by calculating weighted κ values. In total, 495 of 1594 veterans (31%) participated, and 396 completed all measures and were included in the analyses. Participants were demographically similar to the VA primary care population (mean [SD] age, 61.4 [15.5] years; age range, 21-93 years) and were predominantly male (333 participants [84.1%]) and White (296 of 394 participants [75.1%]). The PC-PTSD-5 had high levels of diagnostic accuracy for the overall sample (area under the receiver operating characteristic curve [AUC], 0.927; 95% CI, 0.896-0.959), men (AUC, 0.932; 95% CI, 0.894-0.969), and women (AUC, 0.899, 95% CI, 0.824-0.974). A cut point of 4 ideally balanced false negatives and false positives for the overall sample and for men. However, for women, this cut point resulted in high numbers of false negatives (6 veterans [33.3%]). A cut point of 3 fit better for women, despite increasing the number of false positives. Participants rated the PC-PTSD-5 as highly acceptable. The PC-PTSD-5 is an accurate and acceptable screening tool for use in VA primary care settings. Because performance parameters will change according to sample, clinicians should consider sample characteristics and screening purposes when selecting a cut point.

Managing access to primary care clinics using scheduling templates.

An important challenge confronting healthcare is the effective management of access to primary care. Appointment scheduling policies/templates can help strike an effective balance between the lead-time to an appointment (a.k.a. indirect waiting time, measuring the difference between a patient's desired and actual appointment dates) and waiting times at the clinic on the day of the appointment (a.k.a. direct waiting time). We propose methods for identifying effective appointment scheduling templates using a two-stage stochastic mixed-integer linear program model. The model embeds simulation for accurate evaluation of direct waiting times and uses sample average approximation method for computational efficiency. The model accounts for patients' no-show behaviors, provider availability, overbooking, demand uncertainty, and overtime constraints. The model allows the scheduling templates to be potentially updated at regular intervals while minimizing the patient expected waiting times and balancing provider utilization. Proposed methods are validated using data from the U.S. Department of Veterans Affairs (VA) primary care clinics.

145. Monthly Antibiotic Prescribing Peer Comparison Combined with In-person Education Decreases Antibiotic Prescribing for Acute Respiratory Infections

BackgroundInappropriate antibiotic prescribing is an important modifiable risk factor for antibiotic resistance. Approximately half of all antibiotics prescribed for acute respiratory infections (ARIs) in the United States may be inappropriate or unnecessary. The purpose of this quality improvement (QI) project was to evaluate the effect of three consecutive interventions on improving antibiotic prescribing for ARIs (i.e., pharyngitis, rhinosinusitis, bronchitis, common cold).MethodsThis was a pre-post analysis of an antimicrobial stewardship QI initiative to improve antibiotic prescribing for ARIs in six Veterans Affairs (VA) primary care clinics. Three distinct intervention phases occurred. Educational interventions included training on appropriate antibiotic prescribing for ARIs. During the first intervention period (8/2017-1/2019), education was presented virtually to primary care providers on a single occasion. In the second intervention period (2/2019-10/2019), in-person education with peer comparison was presented on a single occasion. In the third intervention period (11/2019-4/2020), education and prescribing feedback with peer comparison was presented once in-person followed by monthly emails of prescribing feedback with peer comparison. January 2016-July 2017 was used as a pre-intervention baseline period.The primary outcome was the antibiotic prescribing rate for all classifications of ARIs. Secondary outcomes included adherence to antibiotic prescribing guidance for pharyngitis and rhinosinusitis. Descriptive statistics and interrupted time series segmented regression were used to analyze the outcomes.ResultsMonthly antibiotic prescribing peer comparison emails in combination with in-person education was associated with a statistically significant 12.5% reduction in the rate of antibiotic prescribing for ARIs (p=0.0019). When provider education alone was used, the reduction in antibiotic prescribing was nonsignificant. ConclusionEducation alone does not significantly reduce antibiotic prescribing for ARIs, regardless of the delivery mode. In contrast, education followed by monthly prescribing feedback with peer comparison was associated with a statistically significant reduction in ARI antibiotic prescribing rates.Disclosures All Authors: No reported disclosures

Predicting Persistent Disabling Low Back Pain in Veterans Affairs Primary Care Using the STarT Back Tool

The Subgrouping for Targeted Treatment (STarT Back) is a stratified care approach to low back pain (LBP) treatment. The predictive validity of STarT Back in Veterans Affairs (VA) primary care has not been demonstrated. To examine the validity of the STarT Back tool for predicting future persistent disabling LBP in VA primary care. Cohort study. VA primary care in Washington State. Veterans seeking care for LBP in VA primary care clinics. Not applicable. The STarT Back tool was used to classify Veterans according to their baseline risk group (low vs medium vs high). The primary study outcome, persistent disabling LBP, was defined as a Roland-Morris Disability Questionnaire (RMDQ) score ≥ 7 at 6-month follow-up. Analyses examined discrimination and calibration of the baseline STarT Back risk groups for prediction of persistent disabling LBP at 6-month follow-up. Of the study sample, 9% were female and 80% reported longstanding LBP (>5 year duration). Among 538 participants, the baseline STarT Back risk groups were associated with future persistent disabling LBP at 6-month follow-up. Within each baseline STarT Back risk group, the proportions with future persistent disabling LBP at 6-month follow-up were 54% (low risk), 88% (medium risk), and 97% (high risk). The baseline STarT Back risk groups had useful discrimination (area under the curve [AUC] 0.79) for predicting future persistent disabling LBP, but the proportion of Veterans with persistent disabling LBP at 6-month follow-up was substantially higher than that observed in non-VA primary care settings. The STarT Back risk groups had useful discrimination (AUC = 0.79) for future persistent disabling LBP, but calibration was poor, underestimating the risk of persistent disabling LBP. The STarT Back tool may require updating for use in VA primary care.

WOMEN'S HEALTH

Research ObjectiveResearch suggests that about 80% of women veterans receiving care at the Department of Veterans Affairs (VA) have experienced at least one trauma in their lifetimes, including military sexual trauma or combat‐related trauma. Trauma‐sensitive communication reflects an understanding of the impact of trauma and the needs of trauma survivors during health care encounters. We explored whether provider gender sensitivity is associated with positive ratings of trauma‐sensitive communication among women veteran patients.Study DesignWe conducted cross‐sectional surveys of providers to measure provider gender sensitivity using 10 survey items adapted from the Gender Awareness Inventory‐VA. Example items included “Sometimes I wish VA primary care clinics had only male patients.” We averaged responses in 5‐point Likert scales to create a composite score, with a higher score indicating higher sensitivity. We used cross‐sectional surveys of patients to measure women veterans' perspectives of trauma‐sensitive communication: providers (1) asked about any serious problems or stresses in life (yes vs no), (2) made sure they were comfortable before any treatments or examinations (always vs otherwise), and (3) made them feel comfortable talking about emotional issues (very comfortable vs otherwise). We linked survey responses of providers to women veterans via VA primary care visit information in 2014. We used logistic regression to predict each measure of trauma‐sensitive communication, controlling for women veterans' age, race, and ethnicity, a service‐connected disability, military sexual trauma, physical and mental comorbidities, and primary care and mental health visits in 2014. All analyses were weighted for survey nonresponses.Population StudiedA total of 94 primary care providers (PCPs) (33% response rate) and 1395 women veterans (45% response rate) from 12 VA medical centers (VAMCs) completed the surveys between 2014 and 2015. After linking women veterans to PCPs, they had visited for primary care or women's health at the same 12 VAMCs in 2014, and the analyses included 804 women veterans and 58 PCPs who responded to the surveys.Principal FindingsOverall, 80.3% of women veterans reported that their PCPs asked about any serious problems or stresses in life, 79.3% reported that PCPs always made sure they were comfortable before any treatments or examinations, and 55.6% felt very comfortable talking with PCPs about emotional issues. After adjusting for covariates, higher provider gender sensitivity score was associated with more women veterans reporting that (1) PCPs asked about any serious problems or stresses in life (AOR: 1.33, 95% CI: 1.08‐1.63), (2) PCPs always made sure they were comfortable before any treatments or examinations (AOR: 1.10, 95% CI: 0.91‐1.34), and (3) they felt very comfortable talking with PCPs about emotional issues (AOR: 1.11, 95% CI: 0.93‐1.30).ConclusionsOverall, women veterans' ratings of trauma‐sensitive communication were positive. Higher provider sensitivity was associated with greater trauma‐sensitive communication.Implications for Policy or PracticeStrategies to improve provider readiness to care for women veterans and their gender sensitivity can improve trauma‐sensitive communication with women veterans.Primary Funding SourceDepartment of Veterans Affairs.