Veterans Health Administration Researchers Research Articles

Conducting health services research during the COVID-19 pandemic: experiences from the veterans health administration

BackgroundHealth services researchers within the Veterans Health Administration (VA) seek to improve the delivery of care to the Veteran population, whose medical needs often differ from the general population. The COVID-19 pandemic and restricted access to medical centers and offices forced VA researchers and staff to transition to remote work. This study aimed to characterize the work experience of health service researchers during the COVID-19 pandemic.MethodsA REDCap survey developed from the management literature was distributed in July 2020 to 800 HSR&D researchers and staff affiliated with VA Centers of Innovation. We requested recipients to forward the survey to VA colleagues. Descriptive analyses and logistic regression modeling were conducted on multiple choice and Likert scaled items. Manifest content analysis was conducted on open-text responses.ResultsResponses were received from 473 researchers and staff from 37 VA Medical Centers. About half (48%; n = 228) of VA HSR&D researchers and staff who responded to the survey experienced some interference with their research due to the COVID-19 pandemic, yet 55% (n = 260) reported their programs of research did not slow or stop. Clinician investigators reported significantly greater odds of interference than non-clinician investigators and support staff. The most common barriers to working remotely were loss of face-to-face interactions with colleagues (56%; n = 263) and absence of daily routines (25%; n = 118). Strategies teams used to address COVID-19 related remote work challenges included videoconferencing (79%; n = 375), virtual get-togethers (48%; n = 225), altered timelines (42%; n = 199), daily email updates (30%; n = 143) and virtual team huddles (16%; n = 74). Pre-pandemic VA information technology structures along with systems created to support multidisciplinary research teams working across a national healthcare system maintained and enhanced staff engagement and well-being.ConclusionsThis study identifies how the VA structures and systems put in place prior to the COVID-19 pandemic to support a dispersed workforce enabled the continuation of vital scientific research, staff engagement and well-being during a global pandemic. These findings can inform remote work policies and practices for researchers during the current and future crises.

Research Priorities to Support Women Veterans' Reproductive Health and Health Care Within a Learning Health Care System.

Research Priorities to Support Women Veterans' Reproductive Health and Health Care Within a Learning Health Care System.

Veterans Health Administration research in aging: Opportunities for high impact across the academic career.

The authors have no conflicts of interest to disclose.

Experiences of researchers fulfilling VHA’s “fourth mission” during the COVID-19 pandemic.

11059 Background: As the largest integrated healthcare system in the US, the Veterans Health Administration (VHA) is chartered “to serve as the primary backup for any health care services needed...in the event of war or national emergency” according to a 1982 Congressional Act. This mission was invoked during the COVID 19 pandemic to divert clinical and research resources, resulting in dramatic changes in the activities of investigators and research staff. This study uses established behavioral change frameworks to examine the experience of VHA cancer researchers during the pandemic. Methods: We conducted a mixed methods study on the effects of the pandemic on VHA researchers. We used an electronic questionnaire composed of Likert scale statements and open-ended questions, which was constructed using the 14 domains of the Theoretical Domains Framework (TDF) and the Capability, Opportunity, and Motivation (COM-B) model for behavior change. Likert scale statements were quantified and content analysis was performed on open ended responses. Results: The questionnaire was distributed electronically to 118 researchers participating in national VHA collaborations, with 42 responses (36%). Several significant themes and findings emerged. Only 36% of respondents did not feel that their research focus changed during the pandemic. (TDF: professional role and identity maps to COM-B Motivation). And 81% of respondents reported a diverse range of research interests (COM-B: M). Only 11 of 42 respondents (26%) reported prior experience with infectious disease research (TDF: skills maps to COM-B: C), and 31 of 42 (74%) agreed that they gained new research skills during the pandemic (COM-B: C). When asked to describe support structures helpful during the pandemic, 29% mentioned local supervisors, mentors and research staff (COM-B: C, M), 15% cited larger VHA organizations (COM-B: C) and 18% mentioned remote work abilities or telehealth (COM-B: O). Lack of timely communication from supervisors and remote work, particularly for individuals with caregiving responsibilities, were seen as limiting factors for research during the pandemic (COM-B: O). Although 83% of respondents agreed that they will be prepared to respond to future crises after COVID (COM-B: C), fewer than half (40%) of respondents felt professionally rewarded for pursuing research related to COVID, with 50% feeling neutral (COM-B: M). Conclusions: This study demonstrated the tremendous effects of the COVID 19 pandemic on research activities of VHA investigators. We identified perceptions of insufficient recognition and lack of professional advancement related to pandemic era research. Improving the structure of remote work and team communication represent high yield areas for improvement. It is essential to understand barriers and facilitators of crisis redeployment in the VHA, to make the transition effective and fulfilling for those carrying out the mission.

Evaluating the Impacts of Patient Engagement on Health Services Research Teams: Lessons from the Veteran Consulting Network

BackgroundDespite increasing commitment to patient engagement in research, evaluation of the impact of these efforts on research processes, products, and teams is limited.ObjectiveTo explore the impacts of engaging patients as consultants to research studies by examining the experiences, impacts, and lessons learned from a program facilitating patient engagement at a Veterans Health Administration research center.DesignWe developed a logic model to articulate the activities being implemented to support patient engagement and their anticipated outcomes. Then, we conducted qualitative, semi-structured interviews with participants in the local Veteran Consulting Network to qualitatively explore these outcomes.ParticipantsTwelve researchers and eleven Veteran patients with experience working on at least one grant or funded study.ApproachInterview transcripts were inductively coded using a consensus-based approach. Findings were synthesized using framework analysis and mapped back onto our logic model of expected patient engagement impacts.Key ResultsPatient engagement improved the perceived quality and relevance of research studies as patient consultants challenged researchers’ assumptions about patient populations and clinical contexts and gave feedback that helped improve the feasibility of proposed grants, readability of study materials, comprehensiveness of study assessments, and cultural sensitivity and relevance of interventions. Patient engagement also had personal benefits to researchers and patients. Researchers reported improved communication skills and higher job satisfaction. Patients reported a sense of purpose and satisfaction from their work with greater awareness of and appreciation for research.ConclusionsEngaging patients in research can have multiple benefits to the people and work involved. Our evaluation process can serve as a template for other organizations to plan for and assess the impact of their own patient engagement programs. Creating logic models and updating them based on feedback from program users make engagement goals explicit, help verify expected mechanisms to achieve impact, and facilitate organizational learning.

Dynamic waitlisted design for evaluating a randomized trial of evidence-based quality improvement of comprehensive women\u2019s health care implementation in low-performing VA facilities

BackgroundWomen’s Health Services (WHS) in the Veterans Health Administration (VA) has long partnered with VA researchers to evaluate how VA care is organized for women veterans. This partnership has yielded substantial evidence of (1) variations in women veterans’ access to comprehensive healthcare services that contribute to disparities in quality and patient experience and (2) the positive impacts of gender-specific care models for women veterans’ quality and satisfaction. In an effort to provide support specifically to sites that were low-performing in women’s health, WHS and the VA Quality Enhancement Research Initiative co-funded an effort to roll out and evaluate evidence-based quality improvement (EBQI), an implementation strategy with demonstrated effectiveness in a prior cluster randomized trial in women’s health clinics.MethodsWe will identify 21 low-performing VA facilities through a combination of practice data, VA quality metrics (by gender), and other indicators. In partnership with WHS, an EBQI contractor will deliver the EBQI “package”—local consensus development and priority setting using stakeholder panels, multilevel stakeholder engagement, practice facilitation, local EBQI team training, and formative feedback—to participating sites. We propose a dynamic wait-listed design to evaluate the WHS plans for seven EBQI launches per year over 3 years. The goal is to evaluate (1) barriers and facilitators to achieving delivery of comprehensive women’s health care in low-performing VA facilities; (2) effectiveness of EBQI in supporting low-performing VA facilities to achieve improved practice features (e.g., level of comprehensive services available, care coordination arrangements, Patient Aligned Care Team (PACT) features implemented, environment of care improvements), provider/staff attitudes (e.g., improved gender awareness, women’s health knowledge and practice), quality of care, and patient experience; and (3) contextual factors, local implementation processes, and organizational changes over time.DiscussionAccess to comprehensive women’s health care reduces fragmentation of care, improves patient satisfaction, and results in better patient outcomes. We hypothesize that EBQI implementation will result in changes in leadership awareness and buy-in, multilevel engagement in problem-solving, an enhanced culture of quality improvement, structural changes in care, improved provider/staff attitudes, and better quality and patient experience.Trial registrationClinicalTrials.gov, NCT03238417. Registered 3 August 2017. Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT03238417

Developing an Algorithm for Combining Race and Ethnicity Data Sources in the Veterans Health Administration.

Racial/ethnic disparities exist in the Veterans Health Administration (VHA), despite financial barriers to care being largely mitigated and Veterans Administration's (VA) organizational commitment to health equity. Accurately identifying minority veterans is critical to monitoring progress toward equity as the VHA treats an increasingly racially and ethnically diverse veteran population. Although the VHA's completeness of race and ethnicity data is generally better than its public sector and private counterparts, the accuracy of the race and ethnicity in the various databases available to VHA is variable, as is the accuracy in identifying specific minority groups. The purpose of this article was to develop an algorithm for constructing race and ethnicity variables from data sources available to VHA researchers, to present demographic differences cross the data sources, and to apply the algorithm to one study year. We used existing VHA survey data from the Survey of Healthcare Experiences of Patients (SHEP) and three commonly used administrative databases from 2003 to 2015: the VA Corporate Data Warehouse (CDW), VA Defense Identity Repository (VADIR), and Medicare. Using measures of agreement such as sensitivity, specificity, positive and negative predictive values, and Cohen kappa, we compared self-reported race and ethnicity from the SHEP and each of the other data sources. Based on these results, we propose an algorithm for combining data on race and ethnicity from these datasets. We included VHA patients who completed a SHEP and had race/ethnicity recorded in CDW, VADIR, and/or Medicare. Agreement between SHEP and other sources was high for Whites and Blacks and substantially lower for other minority groups. The CDW demonstrated better agreement than VADIR or Medicare. We developed an algorithm of data source precedence in the VHA that improves the accuracy of the identification of historically under-identified minorities: (1) SHEP, (2) CDW, (3) Department of Defense's VADIR, and (4) Medicare.

Building Sustainable Models of Veteran-Engaged Health Services Research

Engaging veterans in research has gained momentum in the Veterans Health Administration (VHA) in recent years. Engagement ensures that health services research is more relevant and tailored to the unique needs of veteran populations. VHA research centers promote engagement through the development of veteran engagement groups (VEGs). Members engage with researchers in organized meetings to review research proposals or projects, and provide individual feedback to improve veteran-centricity. This article shares important lessons learned in implementing VEGs locally from the liaisons who serve as a bridge between researchers and the veterans involved in these groups. Five steps in the VEG formation process are discussed: (1) regulatory considerations (e.g., compliance issues, ethics); (2) recruitment of VEG members (e.g., group size, demographic characteristics); (3) structure and governance (e.g., meeting logistics, participation, and privacy/confidentiality); (4) orientation and training (e.g., orienting veterans and researchers to the engagement process); and (5) evaluation and feedback (e.g., the effectiveness of engagement and tracking the incorporation of veteran feedback in the research). While all VEGs go through identical steps in the formation process, local implementation varies contextually by research center location. To illustrate the diversity in the formation methods, we present a series of case studies throughout this article: Denver, Colorado; Portland, Oregon; Hines, Illinois; West Haven, Connecticut; Iowa City, Iowa; and Houston, Texas. Normalization of veteran engagement in VHA health services research will require a cultural shift to one that embraces veterans’ perspectives and results in a more collaborative partnership between VHA leadership, researchers, and veterans.

Determining Best Practices for Management of Bacteriuria in Spinal Cord Injury: Protocol for a Mixed-Methods Study.

BackgroundBacteriuria, either asymptomatic (ASB) or symptomatic, urinary tract infection (UTI), is common in persons with spinal cord injury (SCI). Current Veterans Health Administration (VHA) guidelines recommend a screening urinalysis and urine culture for every veteran with SCI during annual evaluation, even when asymptomatic, which is contrary to other national guidelines. Our preliminary data suggest that a positive urine culture (even without signs or symptoms of infection) drives antibiotic use.ObjectiveThrough a series of innovative studies utilizing mixed methods, administrative databases, and focus groups, we will gain further knowledge about the attitudes driving current urine testing practices during the annual exam, as well as quantitative data on the clinical outcomes of these practices.MethodsAim 1 will identify patient, provider, and facility factors driving bacteriuria testing and subsequent antibiotic use after the SCI annual evaluation through qualitative interviews and quantitative surveys. Aim 2 will use national VHA databases to identify the predictors of urine testing and subsequent antibiotic use during the annual examination and compare the clinical outcomes of those who received antibiotics with those who did not. Aim 3 will use the information gathered from the previous 2 aims to develop the Test Smart, Treat Smart intervention, a combination of patient and provider education and resources that will help stakeholders have informed conversations about urine testing and antibiotic use; feasibility will be tested at a single site.ResultsThis protocol received institutional review board and VHA Research and Development approval in July 2017, and Veterans Affairs Health Services Research and Development funding started on November 2017. As of submission of this manuscript, 10/15 (67%) of the target goal of provider interviews were complete, and 77/100 (77%) of the goal of surveys. With regard to patients, 5/15 (33%) of the target goal of interviews were complete, and 20/100 (20%) of the target goal of surveys had been completed. Preliminary analyses are ongoing; the study team plans to present these results in April 2019. Database analyses for aim 2 will begin in January 2019.ConclusionsThe negative consequences of antibiotic overuse and antibiotic resistance are well-documented and have national and even global implications. This study will develop an intervention aimed to educate stakeholders on evidence-based management of ASB and UTI and guide antibiotic stewardship in this high-risk population. The next step will be to refine the intervention and test its feasibility and effectiveness at multiple sites as well as reform policy for management of this common but burdensome condition.International Registered Report Identifier (IRRID)DERR1-10.2196/12272

Development of a veteran engagement toolkit for researchers.

Engaging patients in the planning, implementation and dissemination of research can increase the credibility and relevance of results and lead to higher quality, more patient-centered care. Veterans have unique experiences and healthcare needs, making their input on research related to their care particularly important. However, existing veteran engagement resources primarily focus on veterans who receive care through the Veterans Health Administration (VA). This excludes those veterans - the majority - who do not use the VA for healthcare. To address this gap, we developed a veteran engagement toolkit that was informed by the work of both VA and non-VA researchers across the USA. The resulting toolkit provides guidance on essential engagement activities relevant to researchers in a variety of settings.Conclusion:Investigators wishing to engage the veteran community may benefit from the experience and lessons summarized in this veteran-informed toolkit, in addition to resources directed at informing community engagement more generally.

Clinical Policy Recommendations from the VHA State-of-the-Art Conference on Non-Pharmacological Approaches to Chronic Musculoskeletal Pain.

As a large national healthcare system, Veterans Health Administration (VHA) is ideally suited to build on its work to date and develop a safe, evidence-based, and comprehensive approach to the care of chronic musculoskeletal pain conditions that de-emphasizes opioid use and emphasizes non-pharmacological strategies. The VHA Office of Health Services Research and Development (HSR&D) held a state-of-the-art (SOTA) conference titled "Non-pharmacological Approaches to Chronic Musculoskeletal Pain Management" in November 2016. Goals of the conference were (1) to establish consensus on the current state of evidence regarding non-pharmacological approaches to chronic musculoskeletal pain to inform VHA policy in this area and (2) to begin to identify priorities for the future VHA research agenda. Workgroups were established and asked to reach consensus recommendations on clinical and research priorities for the following treatment strategies: psychological/behavioral therapies, exercise/movement therapies, manual therapies, and models for delivering multimodal pain care. Participants in the SOTA identified nine non-pharmacological therapies with sufficient evidence to be implemented across the VHA system as part of pain care. Participants further recommended that effective integration of these non-pharmacological approaches across the VHA and especially into VHA primary care, pain care, and mental health settings should be a priority, and that these treatments should be offered early in the course of pain treatment and delivered in a team-based, multimodal treatment setting concurrently with active self-care and self-management approaches. In addition, we recommend that VHA leadership and policy makers systematically address the barriers to implementation of these approaches by expanding opportunities for clinician and veteran education on the effectiveness of these strategies; supporting and funding further research to determine optimal dosage, duration, sequencing, combination, and frequency of treatment; emphasizing multimodal care with rigorous evaluation grounded in team-based approaches to test integrated models of delivery and stepped-care approaches; and working to address socioeconomic and cultural barriers to veterans' access to non-pharmacological approaches.

Pain research using Veterans Health Administration electronic and administrative data sources.

Health services researchers are using Veterans Health Administration (VHA) electronic health record (EHR) data sources to examine the prevalence, treatment, and outcomes of pain among Veterans in VHA care. Little guidance currently exists on using these data; thus, findings may vary depending on the methods, data sources, and definitions used. We sought to identify current practices in order to provide guidance to future pain researchers. We conducted an anonymous survey of VHA-affiliated researchers participating in a monthly national pain research teleconference. Thirty-two researchers (89%) responded: 75% conducted pain-focused research, 78% used pain intensity numeric rating screening scale (NRS) scores to identify pain, 41% used International Classification of Diseases-9th Revision codes, and 57% distinguished between chronic and acute pain using either NRS scores or pharmacy data. The NRS and pharmacy data were rated as the most valid pain data sources. Of respondents, 48% reported the EHR data sources were adequate for pain research, while 45% had published peer-reviewed articles based on the data. Despite limitations, VHA researchers are increasingly using EHR data for pain research, and several common methods were identified. More information on the performance characteristics of these data sources and definitions is needed.

A partnered research initiative to accelerate implementation of comprehensive care for women veterans: the VA women's health CREATE.

A partnered research initiative to accelerate implementation of comprehensive care for women veterans: the VA women's health CREATE.

Health services research is translational: lessons learned from VHA-funded research on cancer screening in older adults

Health services research is translational: lessons learned from VHA-funded research on cancer screening in older adults

Transformation of VHA health data into clinically useful information to provide quality veteran care

The Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States, caring for nearly 6 million of the nation's 23 million veterans annually. VHA provides a full range of primary care, mental health, medical specialty, surgical, and rehabilitative services to enrolled veterans. It employs over 240,000 staff (including 65,000 health professionals) and manages over 1,400 sites of care (medical centers, outpatient clinics, nursing homes, and counseling centers). The critical need for a comprehensive electronic medical record system is demonstrated by the observation that approximately 130 million outpatient encounters, 600,000 hospitalizations, over 400 million laboratory tests and radiological procedures, and 170 million prescription fills are provided annually. In addition, nearly 1 billion clinically related free-text notes are recorded annually, representing a small fraction of the total electronic data collected over the past two decades. VHA's effective use of health information technology for patient care and healthcare administration, combined with expert data analyses by VHA researchers and managers, has been an important contributing factor to the success of VHA quality improvement efforts and its ability to advance evidence-based care [1-5]. Researchers have a long history of using the VHA's vast data resources to better understand the VHA's and the nation's healthcare system on individual patient, regional, and population levels. For example, recent publications have utilized VHA databases to address issues as diverse as the impact of resident duty hour reform on surgical and procedural patient safety indicators [6], the influence of obesity on quality of care [7], the impact of clopidogrel and proton pump inhibitor treatment on outcome of acute coronary syndrome [8], the impact of increasing medication copayments on medication adherence [9], and the proportion of patients at least 65 years of age hospitalized for pneumonia who are subsequently diagnosed with pulmonary malignancy [10]. The results of VHA data-based publications are often relevant to non-VHA practices and healthcare organizations. The research value of VHA databases depends on not only the quality and accessibility of the underlying data but also an understanding of the clinical and administrative processes that produce data, of how best to use data to measure important constructs, and of limitations inherent in using administrative and clinical data for research objectives. VHA researchers have greatly enhanced the value of VHA health information technology by the skilled use of data and analytic techniques to provide answers to important research questions. VHA researchers, by conducting systematic data evaluations, energize efforts to address data quality and clinical coding and thereby contribute to system-level improvements. Going forward, data quality evaluations inform efforts to improve the usefulness of VHA data for both research and management purposes. The results of formal analyses of data quality and completeness are disseminated through journal publications, web-based seminars on data quality that are subsequently archived in a readily retrievable format, and education of staff in the use and interpretation of data and analytic tools. Further, to facilitate access and analysis, VHA is implementing structured documentation using emerging clinical data standards to complement or replace unstructured text-based medical notes and reports, centralizing the most important clinical and administrative data sets, and evaluating the feasibility of using natural language processing to abstract clinically relevant concepts from its extensive free-text data. The success of the VHA healthcare system depends importantly on the transformation of data into information. …

Could ‘Smart’ Pillbox Solve Medication Adherence Problem?

Could ‘Smart’ Pillbox Solve Medication Adherence Problem?

Research on pain and pain management in Veterans Health Administration: Promoting improved pain care for veterans through science and scholarship

In late 1998, the Veterans Health Administration (VHA), one of the largest healthcare delivery systems in the United States, enacted its National Pain Management Strategy designed to provide a systemwide standard of care to reduce suffering from preventable pain. This overarching goal of the Strategy has elevated pain management to a top priority within the VHA and sparked innovation in planning and providing high-quality pain care to the >54 million veterans receiving healthcare at its facilities nationwide. An explicit component of the Strategy is a focus on pain-relevant research. As evidence of the success of the Strategy in this regard, the number of pain-relevant investigator-initiated research projects that the VHA Office of Research and Development (ORD) has funded increased from about 10 in fiscal year 2000 to 47 in the most recent fiscal year. For further promotion of networking among investigators, increased investigator-initiated and collaborative research, and VHA research priorities, a Pain Research Working Group has been developed. At present, membership in this group consists of over 50 Department of Veterans Affairs (VA) and non-VA investigators. Face-to-face meetings and semimonthly conference calls among members have led to the development of several more focused groups of investigators who share interests in research on specific targeted areas. Cluster groups have currently developed in the areas of diversity; assessment of pain in persons with cognitive impairments; pain and psychiatric comorbidities; pain and polytrauma; and pain, opioid therapy, and substance abuse. Each of these groups has already developed specific projects such as conducting systematic reviews of the relevant theoretical, clinical, and empirical literatures and developing a research agenda. Publication of this special issue of the Journal of Rehabilitation Research and Development was identified as an important outlet for dissemination of the findings and recommendations of these pain research cluster groups. Articles in this special issue focus on a broad range of VA investigative research. The multiple disciplines and perspectives of the contributors reflect the multidisciplinary and multidimensional nature of the field of pain management. The contributions include several scholarly reviews of particularly timely and important topics for the VHA. These reviews and conceptual articles are complemented by several original research reports that promise to significantly contribute to the existing evidence in key areas of investigation that are also particularly relevant to veteran care. Also important to note is that this special issue focuses on clinical or applied research with relatively direct implications for enhancing pain care. As my colleagues, Christine Elnitsky and Martha Bryan, and I emphasize in the accompanying guest editorial, basic laboratory science research represents an important and growing component of the VHA ORD pain-relevant research portfolio. A quick scan of the issues' contributions reveals several interesting observations that may help clarify some of the central clinical issues confronting the field of pain management. Of particular note is the apparent focus on pain and psychiatric and medical comorbidities. Articles by Matthew Bair, Jillian Shipherd, Cheryl Villano, and their colleagues focus on depression and posttraumatic stress disorder (PTSD) as particularly high-frequency psychiatric comorbidities that have drawn considerable attention among both VA and non-VA investigators. These investigators are interested in understanding not only the epidemiology of these disorders but possible mechanisms that may account for their apparent coprevalence. Of particular note, Shipherd and her colleagues provided some of the first evidence, albeit from retrospective chart review, to suggest that PTSD treatment may positively affect pain severity. Three additional articles report on medical comorbidities that are also particularly relevant to veteran care. …

Racial/Ethnic Differences in Diabetes Care for Older Veterans

Veterans Health Administration (VHA) databases are used extensively to study racial/ethnic disparities; however, these databases may not capture all care received by VHA patients. We examined the extent to which accounting for non-VHA care changed conclusions about racial/ethnic disparities for VHA patients with diabetes. Using a cross-sectional observational study, we analyzed a national sample of noninstitutionalized Hispanic (n = 5931), black (n = 24,670), and white (n = 149,222) VHA patients with diabetes who were at least 65 years of age for receipt of annual HbA1c testing, low-density lipoprotein (LDL) cholesterol testing, or eye examination from VHA and Medicare administrative files. In VHA alone data, adjusting for patient characteristics, Hispanic and black patients were as likely as white patients to receive HbA1c testing (odds ratio 1.06 [95% confidence interval 0.99-1.13] and 1.04 [1.00-1.07], respectively), and more likely to receive eye examinations (1.31 [1.24-1.38] and 1.33 [1.29-1.37], respectively). Hispanic patients were equally likely (1.01 [0.95-1.07]) and black patients were less likely (0.81 [0.79-0.84]) to receive LDL testing versus white patients. In VHA plus Medicare data, Hispanic and black patients were less likely than white patients to receive HbA1c (0.76 [0.71-0.82] and 0.83 [0.80-0.87], respectively) and LDL testing (0.84 [0.79-0.90] and 0.70 [0.68-0.72], respectively), and equally likely to receive eye examinations (0.91 [0.86-0.96]) and 0.98 [0.95-1.01]), respectively). Accounting for VHA facility had little effect on results. Restricting to VHA data masks racial/ethnic disparities in care of VHA patients. VHA researchers must be aware and supplement VHA data with other sources whenever possible.

A State-of-the-Art Conference on Implementing Evidence in Health Care.

In the late summer of 2004, the Veterans Health Administration (VHA) convened an invitational symposium, one in a series of state-of-the-art (SOTA) conferences. VHA's SOTAs are high-level “think tank” sessions with a defined agenda focusing on a specific health care topic. The theme of this SOTA conference was “Implementing the Evidence: Transforming Practices, Systems, and Organizations.” About 100 individuals from across North America, not just from within VHA, gathered for 2 days in the Nation's capital. These were the perceived thought leaders in the implementation sciences, enriched by a few influential “movers” within the largest single health care system in the United States (the VHA). To maximize the yield of the 2 days of SOTA conference brainstorming, VHA commissioned papers to be circulated in draft form before the SOTA, with the intent of priming the pump for discussions organized into specific work groups. This issue of the Journal presents these commissioned papers, revised after the conference, selected and refined through peer review, and augmented by additional manuscripts from SOTA participants and their collaborators who responded to a thematic solicitation.