Veterans Affairs Primary Care Clinics Research Articles

Does Greater Continuity of Veterans Administration Primary Care Reduce Emergency Department Visits and Hospitalization in Older Veterans?

ObjectivesTo evaluate the association between longitudinal continuity of primary care and use of emergency department (ED) and inpatient care in older veterans.DesignRetrospective cohort study.SettingDepartment of Veterans Affairs (VA) primary care clinics in 15 regional health networks, ED and inpatient facilities.ParticipantsMedicare‐eligible veterans aged 65 and older with three or more VA primary care visits during fiscal year 2007–08 (baseline period) (N = 243,881).MeasurementsTwo measures of longitudinal continuity were estimated using merged VA–Centers for Medicare and Medicaid Services administrative data: Usual Provider of Continuity (UPC) and Modified Modified Continuity Index (MMCI). Negative binomial and multivariable logistic regression models were used to predict ED use and inpatient hospitalization during fiscal year 2009, controlling for sociodemographic characteristics, medical and psychiatric comorbidity, and baseline use of health services.ResultsThe incidence rate ratio (IRR) of ED visits was greater in patients with high (IRR = 1.05, 95% confidence interval (CI) = 1.02–1.07), intermediate (IRR = 1.04, 95% CI = 1.02–1.07), and low (IRR = 1.06, 95% CI = 1.03–1.09) UPC than in those with very high UPC (0.9–1.0). Patients with high (odds ratio (OR) = 1.04, 95% CI = 1.01–1.07), intermediate (OR = 1.03, 95% CI = 1.00–1.06), and low (OR = 1.04, 95% CI = 1.01–1.07) UPC were also more likely to be hospitalized during follow‐up. Results were similar for MMCI continuity scores.ConclusionEven slightly lower primary care provider (PCP) continuity was associated with modestly greater ED use and inpatient hospitalization in older veterans. Additional efforts should be made to schedule older adults with their assigned PCP whenever possible.

Screen of Drug Use: Diagnostic Accuracy of a New Brief Tool for Primary Care.

Illicit drug use is prevalent, and primary care provides an ideal setting in which to screen for drug use disorders (DUDs) and negative consequences of drug use (NCDU). Comprehensive reviews have concluded that existing drug use screening instruments are not appropriate for routine use in primary care. To develop and validate a screening instrument for drug use. We revised items drawn from existing screening instruments and conducted signal detection analyses to develop the new instrument. We approached 3173 patients at 2 primary care clinics in a US Department of Veterans Affairs health care system from February 1, 2012, through April 30, 2014. A total of 1300 (41.0%) patients consented to the study, of whom 1283 adults were eligible (mean [SD] age, 62.2 [12.6] years). In the last 12 months, 241 (18.8%) participants reported using illicit drugs or prescription medication for a nonmedical purpose, and 189 (14.7%) reported 1 or more NCDU. A total of 133 (10.4%) patients met DSM-IV criteria for a DUD. The sample was randomly divided first to develop the measure and then to validate it. The Mini-International Diagnostic Interview was used as the criterion for DUDs, and the Inventory of Drug Use Consequences was used as the criterion for NCDU. The screening instrument has 2 questions. The first is, "How many days in the past 12 months have you used drugs other than alcohol?" Patients meet that criterion with a response of 7 or more days. The second question asks, "How many days in the past 12 months have you used drugs more than you meant to?" A response of 2 or more days meets that criterion. The screening instrument was 100% sensitive and 93.73% specific for DUDs (643 patients); when replicated in the second half of the sample (640 patients), it was 92.31% sensitive and 92.87% specific. The screening instrument was 93.18% sensitive and 96.03% specific for NCDU (643 patients); when replicated in the second half of the sample (640 patients), it was 83.17% sensitive and 96.85% specific. The 2-item screen of drug use has excellent statistical properties and is a brief screening instrument for DUDs and problems suitable for busy US Department of Veterans Affairs primary care clinics.

Impact of an educational intervention on provider knowledge, attitudes, and comfort level regarding counseling women ages 40-49 about breast cancer screening.

BackgroundMammography screening for women under the age of 50 is controversial. Groups such as the US Preventive Services Task Force recommend counseling women 40–49 years of age about mammography risks and benefits in order to incorporate the individual patient’s values in decisions regarding screening. We assessed the impact of a brief educational intervention on the knowledge and attitudes of clinicians regarding breast cancer screening.MethodsThe educational intervention included a review of the risks and benefits of screening, individual risk assessment, and counseling methods. Sessions were led by a physician expert in breast cancer screening. Participants were physicians and nurses in 13 US Department of Veterans Affairs primary care clinics in Alabama. Outcomes were as follows: 1) knowledge assessment of mammogram screening recommendations; 2) counseling practices on the risks and benefits of screening; and 3) comfort level with counseling about screening. Outcomes were assessed by survey before and after the intervention.ResultsAfter the intervention, significant changes in attitudes about breast cancer screening were seen. There was a decrease in the percentage of participants who reported that they would screen all women ages 40–49 years (82% before the intervention, 9% afterward). There was an increase in the percentage of participants who reported that they would wait until the patient was 50 years old before beginning to screen (12% before the intervention, 38% afterward). More participants (5% before, 53% after; P<0.001) said that they would discuss the patient’s preferences. Attitudes favoring discussion of screening benefits increased, though not significantly, from 94% to 99% (P=0.076). Attitudes favoring discussion of screening risks increased from 34% to 90% (P<0.001). The comfort level with discussing benefits increased from a mean of 3.8 to a mean of 4.5 (P<0.001); the comfort level with discussing screening risks increased from 2.7 to 4.3 (P<0.001); and the comfort level with discussing cancer risks and screening preferences with patients increased from 3.2 to 4.3 (P<0.001). (The comfort levels measurements were assessed by using a Likert scale, for which 1= not comfortable and 5= very comfortable.)ConclusionMost clinicians in the US Department of Veterans Affairs ambulatory practices in Alabama reported that they routinely discuss mammography benefits but not potential harms with patients. An educational intervention detailing recommendations and counseling methods affected the knowledge and attitudes about breast cancer screening. Participants expressed greater likelihood of discussing screening options in the future.

Outcomes of a partnered facilitation strategy to implement primary care-mental health.

Implementing new programs and practices is challenging, even when they are mandated. Implementation Facilitation (IF) strategies that focus on partnering with sites show promise for addressing these challenges. Our aim was to evaluate the effectiveness of an external/internal IF strategy within the context of a Department of Veterans Affairs (VA) mandate of Primary Care-Mental Health Integration (PC-MHI). This was a quasi-experimental, Hybrid Type III study. Generalized estimating equations assessed differences across sites. Patients and providers at seven VA primary care clinics receiving the IF intervention and national support and seven matched comparison clinics receiving national support only participated in the study. We used a highly partnered IF strategy incorporating evidence-based implementation interventions. We evaluated the IF strategy using VA administrative data and RE-AIM framework measures for two 6-month periods. Evaluation of RE-AIM measures from the first 6-month period indicated that PC patients at IF clinics had nine times the odds (OR=8.93, p<0.001) of also being seen in PC-MHI (Reach) compared to patients at non-IF clinics. PC providers at IF clinics had seven times the odds (OR=7.12, p=0.029) of referring patients to PC-MHI (Adoption) than providers at non-IF clinics, and a greater proportion of providers' patients at IF clinics were referred to PC-MHI (Adoption) compared to non-IF clinics (β=0.027, p<0.001). Compared to PC patients at non-IF sites, patients at IF clinics did not have lower odds (OR=1.34, p=0.232) of being referred for first-time mental health specialty clinic visits (Effectiveness), or higher odds (OR=1.90, p=0.350) of receiving same-day access (Implementation). Assessment of program sustainability (Maintenance) was conducted by repeating this analysis for a second 6-month time period. Maintenance analyses results were similar to the earlier period. The addition of a highly partnered IF strategy to national level support resulted in greater Reach and Adoption of the mandated PC-MHI initiative, thereby increasing patient access to VA mental health care.

Association between Women Veterans' Experiences with VA Outpatient Health Care and Designation as a Women's Health Provider in Primary Care Clinics

BackgroundWomen veterans comprise a small percentage of Department of Veterans Affairs (VA) health care users. Prior research on women veterans' experiences with primary care has focused on VA site differences and not individual provider characteristics. In 2010, the VA established policy requiring the provision of comprehensive women's health care by designated women's health providers (DWHPs). Little is known about the quality of health care delivered by DWHPs and women veterans' experience with care from these providers. MethodsSecondary data were obtained from the VA Survey of Healthcare Experience of Patients (SHEP) using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient-centered medical home (PCMH) survey from March 2012 through February 2013, a survey designed to measure patient experience with care and the DWHPs Assessment of Workforce Capacity that discerns between DWHPs versus non-DWHPs. FindingsOf the 28,994 surveys mailed to women veterans, 24,789 were seen by primary care providers and 8,151 women responded to the survey (response rate, 32%). A total of 3,147 providers were evaluated by the SHEP-CAHPS-PCMH survey (40%; n = 1,267 were DWHPs). In a multivariable model, patients seen by DWHPs (relative risk, 1.02; 95% CI, 1.01–1.04) reported higher overall experiences with care compared with patients seen by non-DWHPs. ConclusionsThe main finding is that women veterans' overall experiences with outpatient health care are slightly better for those receiving care from DWHPs compared with those receiving care from non-DWHPs. Our findings have important policy implications for how to continue to improve women veterans' experiences. Our work provides support to increase access to DWHPs at VA primary care clinics.

Predictors of Stage of Adoption for Colorectal Cancer Screening Among African American Primary Care Patients

Compared with other racial groups, African Americans have the highest colorectal cancer (CRC) incidence and mortality rates coupled with lower screening rates. Our study examined the predictors of stage of adoption for fecal occult blood testing (FOBT) and colonoscopy among African American primary care patients who were nonadherent to published screening guidelines. Baseline data (N = 815) in a randomized clinical trial were analyzed. Participants were categorized into precontemplation, contemplation, and preparation stages for FOBT and colonoscopy. Predictor variables were demographics, clinical variables, CRC health beliefs and knowledge, and social support. Hierarchical modeling was to identify significant predictors of stage of adoption. Older, male, Veterans Affairs participants and those with higher perceived self-efficacy, family/friend encouragement, and a provider recommendation had higher odds of being at a more advanced stage of adoption for FOBT. Patients with a history of cancer and higher perceived barriers had higher odds of being at an earlier stage of adoption for FOBT. Predictors of more advanced stage of adoption for colonoscopy included higher perceived benefits, higher perceived self-efficacy, family/friend encouragement, and a provider recommendation for colonoscopy. Higher income (>30 000 vs <15 000) was predictive of earlier stage of adoption for colonoscopy. Enhancing self-efficacy, encouragement from family and friends, and provider recommendations are important components of interventions to promote CRC screening. Nurses can use knowledge of the characteristics associated with stage of adoption to educate and motivate their African American primary care patients to complete CRC screening tests.

A five-year self-sustainability analysis of nurse-administered HIV rapid testing in Veterans Affairs primary care

In 2008, nurse-administered HIV oral rapid testing (RT) was introduced at the Veterans Affairs Primary Care Clinic in Downtown Los Angeles. Analysis at five years revealed variable yet increasing rates of HIV RT at that facility despite the fact that no post-launch support was provided by the implementation team. Qualitative interviews among stakeholders conducted at five years revealed the pre-existing implementation practices endemic to this clinic that facilitated this unprecedented success (e.g. history of positive quality improvement implementations, leadership support, clinician involvement at each step of the process to facilitate empowerment, ownership and feasible customisation of the implementation, cohesive communication among clinicians and leadership, training, efficient supply pathway, progressive performance feedback and ongoing encouragement).

Relationship Quality and Patient-Assessed Quality of Care in VA Primary Care Clinics: Development and Validation of the Work Relationships Scale

Efforts to better understand the impact of clinic member relationships on care quality in primary care clinics have been limited by the absence of a validated instrument to assess these relationships. The purpose of this study was to develop and validate a scale assessing relationships within primary care clinics. The Work Relationships Scale (WRS) was developed and administered as part of a survey of learning and relationships among 17 Department of Veterans Affairs (VA) primary care clinics. A Rasch partial-credit model and principal components analysis were used to evaluate item performance, select the final items for inclusion, and establish unidimensionality for the WRS. The WRS was then validated against semistructured clinic member interviews and VA Survey of Healthcare Experiences of Patients (SHEP) data. Four hundred fifty-seven clinicians and staff completed the clinic survey, and 247 participated in semistructured interviews. WRS scores were significantly associated with clinic-level reporting for 2 SHEP variables: overall rating of personal doctor/nurse (r(2) =0.43, P <.01) and overall rating of health care (r(2)= 0.25, P <.05). Interview data describing relationship characteristics were consistent with variability in WRS scores across low-scoring and high-scoring clinics. The WRS shows promising validity as a measure assessing the quality of relationships in primary care settings; moreover, primary care clinics with lower WRS scores received poorer patient quality ratings for both individual clinicians and overall health care. Relationships play an important role in shaping care delivery and should be assessed as part of efforts to improve patient care within primary care settings.

Health-Related Outcomes Associated with Patterns of Risk Factors in Primary Care Patients

It is important to find ways to identify prevalent co-occurring health risk factors to help facilitate treatment programming. One method is to use electronic medical record (EMR) data. Funderburk et al. (J Behav Med 31:525-535, 2008) used such data and latent class analysis to identify three classes of individuals based on standard health screens administered in Veterans Affairs primary care clinics. The present study extended these results by examining the health-related outcomes for each of these identified classes. Follow-up data were collected from a subgroup of the original sample (N=4,132). Analyses showed that class assignment predicted number of diagnoses associated with the diseases that the health screens target and number of primary care behavioral health, and emergency room encounters. The findings illustrate one way an EMR can be used to identify clusters of individuals presenting with multiple health risk factors and where the healthcare system comes in contact with them.

Capsule Commentary on Oslin et al., A Randomized Clinical Trial of Alcohol Care Management Delivered in Department of Veterans Affairs Primary Care Clinics Versus Specialty Addiction Treatment

Alcohol use disorders (AUDs) are highly prevalent conditions that largely go untreated. Because of this unmet treatment need, the question of whether and for whom alcohol treatment can be successfully delivered in primary care is important. While AUD screening and provision of brief intervention and/or treatment referral as appropriate is encouraged in primary care settings, brief intervention may not be efficacious for patients with heavy alcohol use or dependence,1 and referrals often have low rates of acceptance. This trial by Oslin and colleagues2 suggests that providing more intensive interventions in primary care settings is an alternative to brief intervention and referral. Patients (n = 163) with alcohol dependence were randomized to receive primary care-based Alcohol Care Management (ACM) vs. outpatient addiction specialty care (SC) at three Veterans Affairs (VA) medical centers. Patients randomized to ACM, which consisted of once weekly psychosocial support and encouraged use of oral naltrexone, were much more likely to be engaged in treatment (OR = 5.36, 95 % CI = 2.99, 9.59) and much less likely to drink heavily (OR = 2.16, 95 % CI = 1.27, 3.66) over a 26-weeks course relative to those randomized to SC. Overall abstinence did not differ between conditions.

A Randomized Clinical Trial of Alcohol Care Management Delivered in Department of Veterans Affairs Primary Care Clinics Versus Specialty Addiction Treatment

Alcohol use disorder is one of the leading causes of disability worldwide. Despite the availability of efficacious treatments, few individuals with an alcohol use disorder are actively engaged in treatment. Available evidence suggests that primary care may play a crucial role in the identification of patients with an alcohol use disorder, delivery of interventions, and the success of treatment. The principal aims of this study were to test the effectiveness of a primary care-based Alcohol Care Management (ACM) program for alcohol use disorder and treatment engagement in veterans. The design of the study was a 26-week single-blind randomized clinical trial. The study was conducted in the primary care practices at three VA medical centers. Participants were randomly assigned to treatment in ACM or standard treatment in a specialty outpatient addiction treatment program. One hundred and sixty-three alcohol-dependent veterans were randomized. ACM focused on the use of pharmacotherapy and psychosocial support. ACM was delivered in-person or by telephone within the primary care clinic. Engagement in treatment and heavy alcohol consumption. The ACM condition had a significantly higher proportion of participants engaged in treatment over the 26weeks [OR = 5.36, 95% CI = (2.99, 9.59)]. The percentage of heavy drinking days were significantly lower in the ACM condition [OR = 2.16, 95% CI = (1.27, 3.66)], while overall abstinence did not differ between groups. Results demonstrate that treatment for an alcohol use disorder can be delivered effectively within primary care, leading to greater rates of engagement in treatment and greater reductions in heavy drinking.

Are VA Primary Care Providers Aware of HIV Testing Recommendations for Veterans? Findings at an Urban VA Primary Care Clinic

Given the prevalence of human immunodeficiency virus (HIV) in veterans and that nearly 90% of veterans have not been HIV tested, the Veterans Affairs (VA) has recommended routine HIV testing of all veterans.The objective of this study carried out at an urban VA primary care clinic was to assess provider knowledge of recent U.S. Centers for Disease Control and Prevention (CDC) and VA HIV testing recommendations and policies. Fifty-six primary care providers completed a survey. Nearly 40% of providers were unaware of the CDC recommendation to test all persons ages 13 to 64 in health care settings or the VA policy to test veterans of all ages. Over 75% of providers were unaware of the latest requirements for pre- and posttest counseling, and many were unaware of the latest consent process requirements. Educating VA providers about recent HIV testing recommendations and policies may improve the low HIV testing prevalence in the VA.

Wide Clinic-Level Variation in Adherence to Oral Diabetes Medications in the VA

While there has been extensive research into patient-specific predictors of medication adherence and patient-specific interventions to improve adherence, there has been little examination of variation in clinic-level medication adherence. We examined the clinic-level variation of oral hypoglycemic agent (OHA) medication adherence among patients with diabetes treated in the Department of Veterans Affairs (VA) primary care clinics. We hypothesized that there would be systematic variation in clinic-level adherence measures, and that adherence within organizationally-affiliated clinics, such as those sharing local management and support, would be more highly correlated than adherence between unaffiliated clinics. Retrospective cohort study. VA hospital and VA community-based primary care clinics in the contiguous 48 states. 444,418 patients with diabetes treated with OHAs and seen in 158 hospital-based clinics and 401 affiliated community primary care clinics during fiscal years 2006 and 2007. Refill-based medication adherence to OHA. Adjusting for patient characteristics, the proportion of patients adherent to OHAs ranged from 57 % to 81 % across clinics. Adherence between organizationally affiliated clinics was high (Pearson Correlation = 0.82), and adherence between unaffiliated clinics was low (Pearson Correlation = 0.04). The proportion of patients adherent to OHAs varied widely across VA primary care clinics. Clinic-level adherence was highly correlated to other clinics in the same organizational unit. Further research should identify which factors common to affiliated clinics influence medication adherence.

Association between sense of coherence and health-related quality of life among primary care patients with chronic musculoskeletal pain

BackgroundSense of Coherence (SOC) is a measure of an individual’s capacity to use various coping mechanisms and resources when faced with a stressor. Chronic pain is one of the most prevalent and disabling conditions in clinical practice. This study examines the extent to which a strong SOC is associated with less pain and better health related quality of life (HRQoL) among patients with chronic pain.MethodsWe analyzed data from the Stepped Care to Optimize Pain care Effectiveness (SCOPE) trial which enrolled 250 patients with persistent (3 months or longer) musculoskeletal pain who were receiving care in an United States Department of Veterans Affairs (VA) primary care clinic. The abbreviated three-item SOC scale was used to measure personal coping capability. Participants were categorized into Strong SOC (score 0–1) and Weak SOC (score 2–6). The Brief Pain Inventory (BPI) was used to assess the severity and disability associated with pain. Additionally, pain self-efficacy (ASES) and catastrophizing (CSQ) were assessed. HRQoL was assessed with the 36-item Short-Form Health Survey (SF-36) social functioning, vitality, and general health subscales. Multiple linear regression models were performed to examine whether SOC was independently associated with pain-specific and HRQoL outcomes, after adjusting for sociodemographic and socioeconomic characteristics, medical comorbidities and major depression.ResultsOf the 250 study patients, 61% had a strong SOC whereas 39% had a weak SOC. Multivariable linear regression analysis showed that a strong SOC was significantly associated with better general health, vitality, social functioning and pain self-efficacy as well as less pain catastrophizing. These significant findings were partially attenuated, but remained statistically significant, after controlling for major depression. SOC was not significantly associated with pain severity or pain disability.ConclusionsA strong SOC is associated with better HRQoL and self-efficacy as well as less catastrophizing in patients with chronic pain. SOC may be an important coping mechanism (strategy) for patients with chronic musculoskeletal pain.Trial registrationClinicaltrials.gov Identifier: NCT00926588.

Determinants of Readiness for Primary Care-Mental Health Integration (PC-MHI) in the VA Health Care System

Depression management can be challenging for primary care (PC) settings. While several evidence-based models exist for depression care, little is known about the relationships between PC practice characteristics, model characteristics, and the practice's choices regarding model adoption. We examined three Veterans Affairs (VA)-endorsed depression care models and tested the relationships between theoretically-anchored measures of organizational readiness and implementation of the models in VA PC clinics. 1) Qualitative assessment of the three VA-endorsed depression care models, 2) Cross-sectional survey of leaders from 225 VA medium-to-large PC practices, both in 2007. We assessed PC readiness factors related to resource adequacy, motivation for change, staff attributes, and organizational climate. As outcomes, we measured implementation of one of the VA-endorsed models: collocation, Translating Initiatives in Depression into Effective Solutions (TIDES), and Behavioral Health Lab (BHL). We performed bivariate and, when possible, multivariate analyses of readiness factors for each model. Collocation is a relatively simple arrangement with a mental health specialist physically located in PC. TIDES and BHL are more complex; they use standardized assessments and care management based on evidence-based collaborative care principles, but with different organizational requirements. By 2007, 107 (47.5%) clinics had implemented collocation, 39 (17.3%) TIDES, and 17 (7.6%) BHL. Having established quality improvement processes (OR 2.30, [1.36, 3.87], p = 0.002) or a depression clinician champion (OR 2.36, [1.14, 4.88], p = 0.02) was associated with collocation. Being located in a VA regional network that endorsed TIDES (OR 8.42, [3.69, 19.26], p < 0.001) was associated with TIDES implementation. The presence of psychologists or psychiatrists on PC staff, greater financial sufficiency, or greater spatial sufficiency was associated with BHL implementation. Both readiness factors and characteristics of depression care models influence model adoption. Greater model simplicity may make collocation attractive within local quality improvement efforts. Dissemination through regional networks may be effective for more complex models such as TIDES.

Screening for Cognitive Impairment: Comparing the Performance of Four Instruments in Primary Care

To determine whether brief cognitive screening tests perform as well as a longer screening test in diagnosis of cognitive impairment, no dementia (CIND) or dementia. A cross-sectional comparison of cognitive screening tests to an independent criterion standard evaluation using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. Performance of the cognitive screening tests for identifying dementia, and separately for identifying dementia or CIND, was characterized using sensitivity, specificity, likelihood ratios, and diagnostic odds ratios. Three Department of Veterans Affairs primary care clinics. Of 826 independently living veterans aged 65 and older without a prior diagnosis of dementia, 639 participated and 630 were assigned a research diagnosis. Screening tests included the modified Mini-Mental State Examination (3MS; average time to administer, 17 minutes) and three brief instruments: the Memory Impairment Screen (MIS; 4 minutes), the Mini-Cog (3 minutes), and a novel two-item functional memory screen (MF-2; 1.5 minutes). Participants were aged 74.8 on average and were mostly white or black. They were mostly male (92.9%) and had been prescribed a mean of 7.7 medications for chronic conditions. The prevalence of dementia and CIND was 3.3% and 39.2%, respectively. Sensitivity and specificity for dementia were 86% and 79% for the 3MS, 76% and 73% for the Mini-Cog, 43% and 93% for the MIS, and 38% and 87% for the MF-2, respectively. In individuals without a prior diagnosis of cognitive impairment, the prevalence of dementia was low, but the prevalence of CIND was high. The 3MS and Mini-Cog had reasonable performance characteristics for detecting dementia, but a definitive diagnosis requires additional evaluation.

A Qualitative Evaluation of Knowledge of and Attitudes toward VA Smoking Cessation Services

AbstractIntroduction:The aim of this study was to assess Veterans' and primary care clinic staff's knowledge about, and experiences with, tobacco cessation services available through their Department of Veterans Affairs (VA) medical facility.Methods:Qualitative, semi-structured, in-depth interviews and surveys were conducted with 7 patients and 12 providers/clinic staff members at three VA primary care clinics serving large numbers of rural Veterans. Interviews were transcribed and coded for the- matic content.Results:Five primary themes emerged: (1) lack of knowledge about available cessation services, (2) smoking cessation services provided to patients, (3) perceived barriers to cessation and the provision of treatment, (4) patient receptiveness to treatment and primary care provider involvement, (5) recommended strategies for improving smoking cessation services.Discussion:Our findings suggest there is a considerable lack of knowledge regarding available tobacco cessation services in VA primary care clinics serving rural Veterans. While many patients expressed the opinion that VA was providing adequate care for nicotine dependence, they also identified important barriers to cessation and offered opinions regarding what more could be done to help them to quit smoking. Clinicians/staff also provided insight into barriers they encounter in the delivery of cessation services. Future work should focus on attempting to address these barriers.

Cost-effectiveness of an intensive telephone-based intervention for smoking cessation

We calculated the incremental cost per quit of a telephone care intervention versus usual care using the provider's perspective. The study population was 819 smokers at five US Veterans Affairs (VA) primary care clinics. They enrolled in the clinical trial between June 2001 and December 2002. After 12 months the participants were assessed for short- and long-term abstinence over the previous six months. VA records were used to extract the cost of VA services over 12 months, and the cost of care purchased by the VA from others. Intervention costs were derived through micro-costing. On average, the intervention cost $142 per person, excluding medications. The average cost of all VA-funded medical care during the study period was $8959 in the telephone-care arm and $7939 in the usual care arm (P = 0.37). Under a standard intent-to-treat analysis the average cost per quit was $11,408 and thus the intervention was cost-effective by conventional standards.

Factor Structure of the PTSD Checklist in a Sample of OEF/OIF Veterans Presenting to Primary Care: Specific and Nonspecific Aspects of Dysphoria.

Although DSM-IV-TR diagnostic criteria for posttraumatic stress disorder (PTSD) include three primary symptom clusters, recent evidence from confirmatory factor analyses suggest that the latent structure of PTSD is better represented by four factors, which will likely be reflected in the upcoming DSM-5. Given this likely transition from three to four clusters, the present study sought to examine specific and non-specific aspects of dysphoria in the factor structure of PTSD symptoms in a sample of OEF/OIF combat veterans presenting to a Veterans Affairs primary care clinic. PTSD symptoms were assessed using the PCL-M (Weathers et al. 1993). Results from confirmatory factor analyses suggested that a dysphoria factor involving a number of non-specific distress symptoms may be an important part of the PTSD symptom profile. After controlling for variance due to general psychological distress, we further found that factor loadings on the dysphoria factor were attenuated but continued to significantly load onto the factor, suggesting that dysphoria may be a specific part of the PTSD symptom constellation.

Clinical Effectiveness of Using an Integrated Model to Treat Depressive Symptoms in Veterans Affairs Primary Care Clinics and Its Impact on Health Care Utilization

To determine if veterans treated in an integrated mental health program within a Veterans Affairs (VA) primary care clinic sustained long-term improvement in depressive symptoms and changed their use of health care. In this pilot program, 72 veterans were offered short-term treatment for depressive symptoms by a colocated psychiatrist who was integrated into a VA primary care team (October 1, 1997, through September 30, 1999). Patients were assessed initially and at their final session using the Hamilton Depression Rating Scale. Veterans who completed treatment were referred back to their primary care provider or to specialty mental health services. Patients were contacted and invited to be reevaluated 3 to 5 years later using the same measure (December 1, 2001, through November 30, 2002). Health care utilization data were collected for 1 year preintervention and 2 years postintervention. Outcomes for treatment completers were compared to outcomes for those who declined or dropped out of treatment. Of 48 patients who agreed to participate in the study, 27 completed treatment and showed a significant decline in symptoms from pretreatment to follow-up (P = .008) compared to 16 noncompleters, as well as a moderate-to-large between-group effect size (d = 0.78) and trends for higher remission and response rates. Completers ranked significantly higher in the number of antidepressant prescriptions filled before (P = .002) and after treatment (P = .001) and in the number of medical visits postintervention (year 1: P = .021; year 2: P = .023), without an associated cost increase. Colocated mental health care integrated into VA primary care is associated with sustained improvement of depressive symptoms in a heterogeneous patient population with a high incidence of psychiatric comorbidities. This finding compares favorably with the results of earlier controlled clinical trials and suggests a potential effect on health care utilization.