Research Projects

VA Funded Research Projects 2007

Duffy, Inpatient Smoking Cessation:  Bringing the Program to the Smoker:  New
This study is implementing and evaluating an inpatient, nurse-administered smoking cessation program in three VA medical centers.  Patients admitted to two hospitals will receive the intervention, and patients admitted to the third hospital will receive usual care.  The intervention includes physician advice to quit, nurse counseling and educational materials (videotape and workbook), medications, and follow-up phone calls by trained volunteers.  In less than one year and ahead of schedule, 96% (210/219) of all inpatient staff nurses in the two intervention sites have been trained.  The intervention has also disseminated rapidly to units not originally targeted, including psychiatric, substance abuse, and outpatient clinics.  Facility tobacco cessation performance measures are steadily improving.  Patient enrollment and data collection are ongoing.

Heisler, Adherence and Intensification of Medications:  A Population-Based Clinical Pharmacist Implementation Study Among Hypertensive Diabetes Patients:  New
This study forms a partnership with the VA Pharmacy Benefits Management (PBM) Office and VISN 11 to evaluate a tailored clinical pharmacist-based intervention to improve medication management, adherence, and blood pressure control in VA patients with diabetes.  The intervention will use an automated algorithm to identify patients with poor blood pressure control and either poor refill adherence or insufficient medication intensification.  Clinical pharmacists, trained in motivational interviewing techniques and guided by computerized modules, will identify barriers to medication adherence and provide relevant counseling.  They will also be authorized to change and titrate medications following site-specific algorithms.  Eleven primary care teams at 3 VA sites will be randomized to either the intervention group or usual care.  Outcomes will be assessed 6-months after the end of the 12-month intervention period. 

Hopp, Evaluation of a Cardiac Nurse Practitioner Palliative Care Program:  Ongoing
This RCT will evaluate the impact of a cardiac nurse practitioner palliative care program for VA patients with advanced symptoms of chronic heart failure (CHF).  The objective of the intervention is to encourage the use of palliative care services earlier in the disease process, to provide maximum benefits from palliative-focused psychological support and symptom relief.  This study is intended to direct appropriate end-of-life care to CHF patients, who have not been a traditional focus of palliative care services.  As of 10/2/07, 84 patients have been enrolled (32 in Ann Arbor, 52 in Detroit).  Enrollment continues until February 2009.

Kales, Modifiable Determinants of Anti-Depressant Adherence among Older Veterans:  New
While depression is a significant problem in geriatric patients, poor participation in and adherence to depression treatment regimens limit the extent to which patients realize the benefits of efficacious treatments.  The primary objective of this mixed-methods study is to identify and examine factors that impede late-life antidepressant adherence.  Qualitative methods (focus groups) will be used to guide the development of a quantitative structured interview.  289 patients aged 60 years or older with depression and given a new outpatient antidepressant prescription will be recruited to participate in baseline, 4- and 12-month follow-up interviews.  Analyses will examine the effect of comorbid anxiety and other factors on antidepressant adherence and will examine the impact of non-adherence on health care outcomes.  The findings will aid in understanding late-life depression adherence behaviors essential for developing and testing interventions to increase the effectiveness of existing depression treatments for older veterans.

Kerr and Hofer, Addressing Barriers to Translation for Treatment of Hypertension:  Ongoing
This project is examining clinician, organizational and patient factors that contribute to clinical inertia in the treatment of hypertension.  The project has enrolled 1169 diabetic patients of 92 primary care providers (PCPs) in nine Midwest VA facilities.  Patients were enrolled if their lowest triage blood pressure (BP) was >= 140/90.  Patients and providers completed baseline surveys.  Additionally, providers completed a brief post-visit survey within the same clinic session in which they saw the patient.  Medical record review and clinical automated data were obtained for all patients.  For approximately 50% of study patients, providers initiated medication intensification or planned close follow-up at the time of the primary care visit.  The following factors made treatment change less likely:  repeat BP by PCP recorded as < 140/90; report by patient of home BP < 140/90; discussion at the visit of conditions unrelated to hypertension and diabetes; and discussion of medication issues at the visit.  Results suggest that factors related to clinical uncertainty around the true BP value are prominent predictors of treatment change at a visit.  Further analyses will examine factors that underlie BP uncertainty and inertia.

Kilbourne, Continuous Improvement for Veterans in Care—Mood Disorders:  Analysis/Final Report
The goal of this study was to determine which patient factors are associated with gaps in quality of care for bipolar disorder in VA patients, to inform the design of subsequent interventions.  Between July 2004 and July 2006, 435 eligible patients completed surveys.  Of the patients who completed surveys, 39.7% received adequate serum drug level for mood stabilizers, 38.8% received a thyroid function test for lithium, and the majority (71.4% - 75.9%) received complete blood counts and hepatic function tests for valproate or carbamazepine.  About half of patients prescribed atypical antipsychotics received cholesterol counts 949.6%), and 68.7% received serum glucose levels.  Analyses continue to determine which kinds of patients are at risk for poorer quality care. 

Krein and Saint, Translating Infection Prevention Evidence to Enhance Patient Safety:  Ongoing
This study is using quantitative and qualitative methods to identify factors that facilitate and impede the adoption and implementation of evidence-based infection prevention practices in VA and non-VA medical centers.  Findings from written surveys (quantitative phase) were presented in the 2006 report.  This past year the qualitative phase was completed, which included semi-structured interviews with 86 individuals at 14 hospitals and in-person visits to 6 geographically diverse hospitals.  Preliminary analyses of the qualitative data revealed four recurrent themes related to UTI prevention.  First, though preventing hospital-acquired UTI was a low priority for most hospitals, there was substantial recognition of the value of early urinary catheter removal.  Second, those sites that made UTI prevention a high priority focused on non-infectious complications and had committed champions who facilitated prevention activities.  Third, hospital-specific pilot studies were important in deciding whether or not to use devices such as antimicrobial catheters.  Finally, external forces, such as public reporting, influenced UTI surveillance and prevention activities.  Analyses focusing on practices to prevent ventilator associated pneumonia and additional qualitative analyses are underway. 

Lowery, Evaluation of a Nurse Case Management Model for Chronic Heart Failure:  Ongoing
This study is evaluating the impact of a nurse practitioner case management model compared with usual care in patients with congestive heart failure (CHF) using a quasi-experimental design.  969 patients were enrolled (458 intervention, 511 control) between 2002 and 2004.  Patients were followed for two years.  Preliminary analysis of the resource utilization data suggests that the intervention had the desired effect of reducing admissions and bed days of care in the short-term, but possibly at a cost of increased outpatient visits.  Final data analysis is underway and a final report is expected by December 2007.

McCarthy, VA Nursing Home Care for Veterans with Serious Mental Illness:  New
Little is currently known about the prevalence, characteristics, or quality of care for VA nursing home residents with serious mental illness (SMI).  This study will test whether and how nursing home structural elements and facility treatment processes influence risks of adverse outcomes for patients with and without SMI.  The study will use a retrospective cohort design, analyzing national VA administrative data from FY01-FY06, as well as surveying VA nursing home unit nurse managers.  The study is in the start-up phase. 

Piette and Heisler, Improving Insulin Therapy with Enhanced Care Management and Peer Support:  Ongoing
This RCT will evaluate use of an interactive voice response (IVR) exchange system to promote peer-to-peer communication among diabetes patients initiating or increasing insulin therapy under medical guidance.  This low-cost peer support system may improve VA diabetes patients’ self-care and treatment outcomes.  Because the intervention addresses barriers to effective disease management that are common among chronically-ill patients, the study may have broader impact on management practices for patients with other illnesses, such as depression, chronic pain, or heart failure.  The study is presently in the recruitment phase.

Valenstein, Suicide among Veterans: Using the VA Depression Registry to Inform Care:  Ongoing
The objective of this study is to inform VA policy makers and clinicians about the current suicide rates within depressed VA patients, risk factors for suicide that are germaneto thispopulation, and the impact of treatment practices on risks.  Analyses conducted this past year identified patient characteristics associated with higher rates of suicide.  Unlike the general population, suicide among depressed patients is more common among younger veterans.  Analyses also examined depression treatment quality and found that few VA patients received recommended levels of practitioner contacts for new depressive episodes.  Ongoing analyses include examining whether closer clinical monitoring is associated with reduced suicide rates, as well as estimating the costs of increasing the intensity of clinical monitoring during high-risk periods for suicide. 

Angela Fagerlin (MREP).  Dr. Fagerlin's work focuses on testing methods for educating patients about their cancer prevention and treatment options.  She has examined various methods for communicating the risks and benefits of tamoxifen and raloxifene for women contemplating chemoprevention.  Her IIR Merit Award, “Testing the impact of a plain language decision aid on prostate cancer decision making”, is waiting to receive funding and will test how 2 types of decision aids influence patient-physician decision communication and patient decision making.  Over the past year Dr. Fagerlin has published 5 papers, was a co-investigator or principal investigator on 7 grants (5 which were funded). 

Amy Kilbourne (MREP).  Dr. Kilbourne completed a study examining patient and system factors associated with quality and outcomes of care for patients with bipolar disorder.  She completed one IIR (“Continuous Improvement for Veterans in Care: Mood Disorders”) and obtained funding for three new projects:  an RCT of a behavioral intervention to reduce cardiovascular risk factors in veterans with bipolar disorder (CSRD IIR); an NIMH RCT implementing medical care management for bipolar disorder (MH74509); and a VA HSRD grant focused on organizational and integration factors influencing quality of medical and substance use disorder services for veterans with bipolar and other mental disorders (IIR 07 115).  Dr. Kilbourne received a NARSAD Young Investigator Award, and has a pending R01 focused on implementing bipolar disorder treatment models in a national sample of VA and community-based practices.  In the past year, Dr. Kilbourne published 13 articles and has 3 in press. 

John McCarthy (MREP).  Dr. McCarthy’s work has examined access and quality of care for patients with mental illness, with a particular focus on long-term care services.  He is an investigator on six funded projects, including three HSR&D funded studies.  He is principal investigator on a three-year HSR&D-funded study, “VA Nursing Home Care for Veterans with Serious Mental Illnesses” (IAD 06-055).  In 2007, he was honored as an exceptional reviewer for the journal Medical Care for the period 2005-2006.  He has had 11 publications in 2007, and he has another three publications currently in press.

Dylan Smith (MREP).  In the third year of his MREP, Dr. Smith submitted an R21 proposal to NIH (“Measuring Health Related Quality of Life in Older Adults with Chronic Illness”) and received a priority score of 126.  A decision about funding is expected in October, 2007.  This past year he has submitted 15 papers for publication in peer reviewed journals (7 as first or last author), and has had 10 papers accepted for publication (2 as first author and 2 as last author).

Michele Heisler (RCD Award).  Dr. Heisler is currently in the fourth year of her CDA.  She is PI of an HSR&D IIR examining nurse-led group visits and telephone-based peer support among veterans with diabetes and poor glycemic control (see above).  She is also PI on an NHLBI-funded intervention targeting heart failure patients.  Finally, she is PI on the HSR&D SDP, “Adherence and Intensification of Medications (AIM)” (see above).  Dr. Heisler recently published a study examining mechanisms for racial and ethnic disparities in glycemic control among adults with diabetes.  This study received extensive coverage in the English and Spanish-speaking press. 

Mark Ilgen (MREP).  Dr. Ilgen continues to study methods for improving care for veterans with both psychiatric and substance use disorders.  He recently received 2 years of funding (part of the Center of Excellence award to the Canandaigua VA Medical Center) for a project entitled, “Service utilization and suicide in veterans with substance use disorders.”  Additionally, Dr. Ilgen submitted a proposal for a study on suicide and substance use to NIDA and is in the process of completing an IIR proposal to be submitted to VA HSR&D in December 2007.  In the past year, Dr. Ilgen published 10 articles (5 as first author) and currently has 7 manuscripts submitted for review. 

Helen Kales (RCD Level 2 Award).  Dr. Kales has two federal grant projects in progress:  HSR&D IIR, “Modifiable Determinants of Antidepressant Adherence among Older Veterans” (see above); and NIMH R21, “Racial Differences in Geriatric Antidepressant Adherence”.  She also successfully competed for a third federal grant in the area of antipsychotics and mortality (NIMH R01), which began in September.  In the past year, Dr. Kales published four articles; she also has two manuscripts submitted and another two in preparation. 

Maria Silveira (RCD Award).  Dr. Silveira has completed two qualitative studies examining the provision of palliative care by primary care and oncology providers.  Her focus groups revealed that for clinicians to provide competent end-of-life care, they need better support within their clinics in the form of care coordination, information sharing, clear role delineation, and scheduling flexibility.  Palliative care experts are needed only for the most challenging cases, otherwise, they present an obstacle to continuity with primary care.  She is in the process of quantifying her findings using a national survey of physicians.  She has applied for a CDTA, and is planning an R21 to study a caregiver support system in cancer and an IIR to evaluate hospice use in VA.

Sanjay Saint (RCD Level 2 Award).  Dr. Saint is co-PI of the HSR&D IIR, “Translating Infection Prevention Evidence to Enhance Patient Safety” (see above) and is PI of an NIH-funded R21 using a linked Medicare-nursing home dataset to evaluate urinary collection practices in several states.  He recently became PI of a Blue Cross Blue Shield of Michigan Foundation grant evaluating an open disclosure policy on malpractice costs.  He had several peer-reviewed publications in the last year, including studies coming from his VA grant as well as clinical problem-solving exercises in the New England Journal of Medicine.