|
VA Funded Research Projects 2008
Kerr and Hofer, Addressing Barriers to Translation for Treatment of Hypertension: Final
This project examined clinician, organizational and patient factors that contribute to clinical inertia in
the treatment of hypertension. The project 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. 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. The most actionable
finding from this study is that rather than simply failing to act (inertia), providers are often confronted
with the inherent clinical uncertainty about patients’ “true” blood pressure values; they then
document actions to incorporate additional information (e.g., repeating measurements or eliciting
home blood pressure values). In turn, this has an enormous effect on decisions to change
treatment. Unfortunately, this response to clinical uncertainty is non-systematic, could easily
undermine performance improvement initiatives, and may be a major obstacle to optimizing the
management of hypertension and improving outcomes for high-risk populations. VHA needs to
promote more systematic approaches to the use of clinic and home blood pressure measurements
in the treatment of hypertension. Systematic approaches might include standardized protocols for
using average home BPs for decision-making about treatment change.
Krein and Saint, Translating Infection Prevention Evidence to Enhance Patient Safety: Final
This study used quantitative (surveys from 119 VA Medical Centers and 678 non-VA hospitals) and
qualitative (86 interviews at 14 hositals) 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. Results showed that VA hospitals were more likely than non-VA hospitals to use
certain practices to prevent bloodstream infections linked to central venous catheters. Specifically,
VA hospitals were more likely to report regular use of maximal sterile barrier precautions (MSB),
chlorhexidine gluconate for site antisepsis, and a combined approach including MSB, chlorhexidine
gluconate, and avoidance of routine central line changes. Compared with non-VA hospitals, VA
hospitals had higher RN staffing ratios and were more likely to have an approved residency training
program, hospital epidemiologist, and a supervisory infection-control professional certified in
infection control and epidemiology. One third of all hospitals in the study did not track catheter use
in their patients, despite the fact that as many as one third of the days in which patients have these
devices are medically unnecessary, and infections from the devices, the most common type of
infections acquired in hospitals, can be difficult to treat and can be life-threatening. Three-fourths
had no system to know how long patients had a catheter. Less than 10% used physician
reminders, a proven strategy, to check catheter use daily.
Lowery, Evaluation of a Nurse Case Management Model for Chronic Heart Failure: Final
This study evaluated 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. Excluding deaths,
sample size was 845 at 1 year following enrollment and 766 at 2 years. Using logistic regression,
control patients were 1.8 and 1.5 times more likely than intervention patients to die after one and
two years (respectively). In addition, control patients were 1.6 and 2.8 times more likely than
intervention patients to have an admission for any reason and for an admission for CHF
(respectively) within year 1. In year 2, control patients were 1.3 times as likely to have an
admission for any reason; but there were no differences between groups for CHF admissions.
Using Poisson regression to analyze bed days of care for patients with admissions, there was no
significant difference between the two groups for both years. The intervention group had
significantly more outpatient visits than the control group in both years (Poisson regression, _=0.80
year 1, 0.78 year 2). Thus, it appears that the intervention had the desired effect of reducing the
probability of deaths and admissions, but at a cost of increased outpatient visits.
Valenstein, Suicide among Veterans: Using the VA Depression Registry to Inform Care: Final
The objective of this study was to inform VA policy makers and clinicians about the current suicide
rates within depressed VA patients, risk factors for suicide that are germane to this population, and
the impact of treatment practices on risks. The study found that the predictors of suicide among
veterans in depression treatment differ from those seen in the general American population, with
younger, white, non-Hispanic men having the highest risk among veterans. Veterans with
substance abuse issues, and those who had been hospitalized for psychiatric reasons in the year
before their depression diagnosis, also had a higher suicide risk. Surprisingly, older veterans who
had been diagnosed with post-traumatic stress disorder in addition to depression had a lower
overall rate of suicide than those without a PTSD diagnosis, perhaps because they were more likely
to receive care through VA PTSD programs. Because this study confirms that suicide rates among
depressed veterans are higher than those typically seen in the general population, it reinforces the
need for the kinds of suicide prevention programs that the VA has launched in recent
years/months. The findings should also help VA doctors and others understand which veterans are
most at risk, so they can offer help sooner.
Fagerlin, Impact of a Plain Language Prostate Cancer Decision Aid on Decision Making: New
Previous research has revealed that men are often uninformed about their prostate cancer,
particularly African American men and men with less education. Thus, it is critical to develop and
test decision aids that can help all men (especially those with low literacy skills) make an informed
decision regarding their treatment. This study will test the impact of a plain language (i.e., low
reading level) decision aid on VA prostate cancer patients’ decision making experience and in their
interactions with their physician and the VA health system. It will also test if there are differences in
receipt of active treatment between men with low vs. high literacy skills.
Hawley, Evaluating a Preference-based Intervention for Increasing CRC Screening: New
A recent VA directive recommends that CRC screening among veterans should be based on their
preferences, given that there is insufficient evidence to support recommending one test. However,
the impact of such a preference-based strategy on important outcomes, including screening
adherence and cost, is unknown. The broad hypothesis of this study is that helping veterans clarify
their CRC screening preferences will lead to increased adherence. The specific aims are: (1) to
test the effectiveness of a preference-tailored (PT) versus standard information (SI) intervention for
increasing veterans’ CRC screening adherence; (2) to assess the impact of the information on
informed decision-making, knowledge and attitudes toward screening, decisional outcomes, and
intention to get screened; and (3) to conduct a cost effectiveness analysis of the PT intervention for
increasing CRC screening across the VA.
Vijan, Improving Quality Measurement Using Quality Adjusted Life Years: New
VHA has been a leader in using quality measures to provide incentives and improve quality of care,
and is expanding this with “pay-for-performance” programs. However, there is a significant need for
a composite metric of quality that can assign appropriate weights to individual measures and can
be compared across and within disease processes. This study will examine the use of qualityadjusted
life years (QALYs) as a quality measure. The specific aims are: (1) to use administrative
and profiling data to model individual level QALYs across a spectrum of VA patients, and to develop
a metric that allows a more refined measure of quality of care; (2) to examine provider and site level
variation in QALYs lost to examine its utility as a profiling tool; and (3) to examine the relative
benefits and possible weights for individual quality measures.
Piette, Enhancing Caregiver Support for Patients with Heart Failure: New
This study will evaluate a model for leveraging informal caregivers (ICGs) and structuring their role
in heart failure (HF) patients’ overall disease management. Specifically, it will examine whether the
use of health information technology (HIT) for providing monitoring and self-management support
by a care partner (CP) (defined as adult children or friends living outside the patient’s home) can
improve patient outcomes. If effective, the intervention may enable the frequent monitoring and
behavior change assistance that patients needs, allowing VA to extend its impact beyond what
current care management programs can realistically deliver.
|
