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Background: Vaccine hesitancy, especially related to COVID-19 vaccinations among Veterans, may limit uptake. Behaviorally informed text-based messages have the potential to improve uptake of COVID-19 vaccinations., Objective: To evaluate the impact of two different behaviorally informed text message nudges on COVID-19 vaccine scheduling and completion, compared to standard control message., Design: Prospective, three-arm patient-level randomized quality improvement trial., Participants: Between March and May 2021, 20,523 Veterans were eligible for the initial series of COVID-19 vaccination, enrolled at two large Veterans Health Administration sites., Intervention: Arm 1 (Control): standard scheduling message; Arm 2 (Social Good): standard message plus behaviorally informed text message "When you get a vaccine now, you help protect yourself, your family, and your community"; and Arm 3 (Scarcity): standard plus behaviorally informed text message "Only a limited number of vaccine appointments are available.", Main Measures: Outcomes were vaccine scheduling and/or completion rate within 7 days of receipt of text message (primary), and within 14 days and 30 days after receipt of text message (secondary)., Key Results: Veterans had an overall rate of 19% of scheduling or receiving a vaccination in 7 days. In our adjusted intention-to-treat analysis, we found no difference between intervention social good or scarcity (aOR 0.98, 95% CI, 0.88-1.09, for both arms) compared to standard scheduling message. We found no statistical differences in our secondary outcomes., Conclusions: During the initial phases of vaccine roll-out, two behaviorally informed text messages did not increase COVID-19 vaccination rates among Veterans compared to a standard scheduling message., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Importance: During the COVID-19 pandemic, the Veterans Health Administration (VHA) expanded telehealth infrastructure. Understanding telehealth initiation and sustained engagement could inform future resource allocation for high-need populations., Objective: To describe and examine primary care use, including initiation, use, and engagement factors, of telehealth modalities (telephone, video visits, and secure messaging) from 2020 to 2022., Design, Setting, and Participants: This cohort study was conducted among 1 383 070 patients in the 75th or higher percentile for 90-day risk of hospitalization or mortality (using previously validated Care Assessment Need scores) engaged in VHA primary care from March 11, 2019, to March 10, 2022., Exposures: Patient sociodemographic characteristics (age, sex, race and ethnicity, and marital and housing status), health characteristics (chronic condition count, military service disability, serious mental illness, or substance use disorder diagnoses), geographic characteristics (driving distance to clinic and rural or urban location), and Federal Communications Commission-reported broadband speed among subgroups of patients at high risk categorized by telehealth use from 2020 to 2022., Main Outcomes and Measures: Primary care utilization by modality., Results: A total of 1 383 070 patients at high risk were engaged in VHA primary care in March 2020 (median age, 73.0 years [IQR, 65-80 years]; 92.4% male; 77.7% regular telehealth users in 2019). With the onset of the COVID-19 pandemic from March 2020 to March 2021, 92.7% of patients at high risk (1 158 804 of 1 250 438 retained in care) became regular telehealth users. The following year, most patients continued as telehealth users (83.4% [942 151 of 1 129 683 retained]), including 38.2% retention of users at high risk newly engaged in 2020. Between 2019 and 2022 among those living and engaged in VHA primary care, adjusted exploratory multinomial logit models estimated that new telehealth users in 2020 (both sustained or only transiently engaged) were more often Black non-Hispanic individuals with greater comorbidity burdens than those who never engaged in telehealth use (Black non-Hispanic with new persistent telehealth use: adjusted relative risk ratio [ARR], 1.18 [95% CI, 1.16-1.20]; Black non-Hispanic with transient telehealth use: ARR, 1.11 [95% CI, 1.08-1.13]; ≥5 chronic conditions with new persistent telehealth use: ARR, 1.92 [95% CI, 1.88-1.96]; ≥5 chronic conditions with transient telehealth use: ARR, 1.43 [95% CI, 1.40-1.46])., Conclusions and Relevance: This cohort study suggests that primary care telehealth initiation, use and sustained engagement differed among subgroups of patients at high risk throughout the COVID-19 pandemic. Those never or only transiently engaged with telehealth had lower illness burdens and were less likely to identify as members of racial or ethnic minority groups. Variation in telehealth use among subgroups of patients at high risk during this period could inform future resource allocation.

Background: The Veterans Affairs (VHA) is working to establish a population-based colorectal cancer screening program for average-risk patients using mailed fecal immunochemical testing (FIT). However, low response rates to mailed FIT may hinder success. Key features of mailed FIT programs, including the use of reminders, differ among various national programs, with limited evidence among veterans., Objective: We sought to test whether using reminders, either via telephone call or text message, was effective in improving mailed FIT response rates., Design: We conducted a prospective, randomized quality improvement trial ( ClinicalTrials.gov NCT05012007). Veterans who had not returned a FIT within 2 weeks of receiving the kit were randomized to one of three groups: (1) control (no reminder); (2) an automated telephone call reminder; or (3) an automated text message reminder., Participants: A total of 2658 veterans enrolled at VA Puget Sound Health Care System who were aged 45-75 and had an average risk of colorectal cancer., Interventions: A single automated telephone call or text message reminder prompting veterans to return the FIT kit., Main Measures: Our primary outcome was FIT return at 90 days and our secondary outcome was FIT return at 180 days., Key Results: Participant average age was 62 years, 88% were men, and 66% White. At 90 days, both the phone and text reminder interventions had higher FIT return rates compared to control (intention-to-treat results (ITT): control 28%, phone 39%, text 38%; p<0.001). At 180 days, FIT kit return remained higher in the reminder interventions (ITT: control 32%, phone 42%, text 40%; p<0.001)., Conclusions: Automated reminders increased colorectal cancer screening completion among average-risk veterans. An automated phone call or text message was equally effective. VHA facilities seeking to implement a mailed FIT program should consider using phone or text reminders, depending on available resources., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: Mailed fecal immunochemical testing (FIT) programs are increasingly utilized for population-based colorectal cancer (CRC) screening. Advanced notifications (primers) are one behavioral designed feature of many mailed FIT programs, but few have tested this feature among Veterans., Objective: To determine if an advanced notification, a primer postcard, increases completion of FIT among Veterans., Design: This is a prospective, randomized quality improvement trial to evaluate a postcard primer prior to a mailed FIT versus mailed FIT alone., Participants: A total of 2404 Veterans enrolled for care at a large VA site that were due for average-risk CRC screening., Intervention: A written postcard sent 2 weeks in advance of a mailed FIT kit that contained information on CRC screening and completing a FIT., Main Measures: Our primary outcome was FIT completion at 90 days, and our secondary outcome was FIT completion at 180 days., Key Results: Overall, unadjusted mailed FIT return rates were similar among control vs. primer arms at 90 days (27% vs. 29%, p = 0.11). Our adjusted analysis found a primer postcard did not increase FIT completion compared to mailed FIT alone (OR 1.14 (0.94, 1.37))., Conclusions: Though primers are often a standard part of mailed FIT programs, we did not find an increase in FIT completion with mailed postcard primers among Veterans. Given the overall low mailed FIT return rates, testing different ways to improve return rates is essential to improving CRC screening., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: "Low-value" healthcare is care without benefit to patients. Overly intensive glycemic control (i.e., HgbA 1 C < 7 %) can cause harm to patients at high risk of hypoglycemia, particularly among older adults with co-morbidities. It is unknown whether overly intensive glycemic control differs among patients with diabetes and at high-risk of hypoglycemia cared for by primary care nurse practitioners versus physicians., Objective: This study examined patients with diabetes at high risk of hypoglycemia receiving primary care between Jan 2010 and Jan 2012, comparing patients reassigned to nurse practitioners to those reassigned to physicians after their previous physician separated from practice in an integrated United States health system., Design: This was a retrospective cohort study. Study outcomes were collected at two years after reassignment to a new primary care provider. Outcomes were predicted probabilities of HgbA 1 C < 7 % using two-stage residual inclusion instrumental variable models, controlling for baseline confounders., Setting: Primary care clinics within the United States Veterans Health Administration., Participants: 38,543 patients with diabetes at increased risk for hypoglycemia (age ≥ 65 years with renal disease, dementia, or cognitive impairment), who had their primary care physician leave the Veterans Health Administration and who were reassigned to a new primary care provider in the following year., Results: Cohort patients were on average 76 years and 99 % men. Of these, 33,700 were reassigned to physicians and 4843 to nurse practitioners. After two years with their new provider, in adjusted models, patients reassigned to nurse practitioners had a -20.4 percentage-point [95 % CI -37.9 to -2.8] lower probability of two-year HgbA 1 C < 7 %., Conclusions: Aligned with prior studies on care quality, rates of overly intensive glycemic control may be appropriately lower among older patients with diabetes at high-risk of hypoglycemia, cared for by nurse practitioners than physicians., Tweetable Abstract: Primary care nurse practitioners deliver equivalent or better rates of low-value diabetes care for older patients, compared to physicians., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest, financial or otherwise., (Published by Elsevier Ltd.)

Background: Medication adherence impacts health outcomes. Healthcare organisations implementing system-level interventions have potential for greater spread and sustainability than individual-level interventions. Within the integrated US Veterans Health Administration, a multidisciplinary team developed and evaluated a pilot quality improvement programme to assess the feasibility of automatic mailed prescription refills for patients with diabetes and low medication adherence (assessed by medication possession ratio <80%)., Methods: Patients were randomised to usual care with self-initiated refills versus automatic mailed refills for 6 months. Process outcomes included glycaemic control measures (HgbA1C), medication possession ratios for both automatic and self-initiated (reference) refills of medications, patient satisfaction and workforce effort (pharmacist time)., Results: Overall, 199 patients were randomised to automatic refills (n=99; 40 of whom participated) versus usual care (n=100). In multivariable analysis adjusting for baseline differences, after 6 months there was no difference in the proportion of patients with follow-up HgbA1C <8% (60.8% automatic refills vs 60.5% usual care, p=0.96). In the automatic refill group, the medication possession ratio for reference medicines was significantly higher than usual care (63.9% vs 54.5%, 95% CI (for difference) 3.1% to 15.9%, p<0.01)., Conclusions: Implications and lessons from this pilot programme include potential beneficial indirect effects from automatic medication refills on patient self-initiated refills of other medications; the importance of tailoring solutions to patient subgroups and specific adherence barriers; and recognition that the rapid deployment, iteration and evaluation of the project was facilitated by a multidisciplinary team embedded within an organisational learning health system., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Intensive management programs may improve health care experiences among high-risk and complex patients. We assessed patient experience among (1) prior enrollees (n = 59) of an intensive management program (2014-2018); (2) nonenrollees (n = 356) at program sites; and (3) nonprogram site patients (n = 728), using a patient survey based on the Consumer Assessment of Healthcare Providers and Systems in 2019. Outcomes included patient ratings of patient-centered care; overall health care experience; and satisfaction with their usual outpatient care provider. In multivariate models, enrollees were more satisfied with their current provider versus nonenrollees within program sites (adjusted odds ratio 2.36; 95% confidence interval 1.15-4.85).

Importance: The effectiveness of remotely delivered, self-directed, weight loss programs in routine clinical practice is largely unknown., Objective: To test whether a self-directed, remotely administered behavioral lifestyle intervention improves weight and self-reported general health status compared with usual care., Design, Setting, and Participants: In this randomized clinical trial, 511 adults with a body mass index (BMI) of 30 or more and less than 45 (based on electronic health record [EHR] weight and height), were enrolled from 30 Veterans Health Administration (VHA) sites between February 15, 2018, and December 18, 2018 (final follow-up February 18, 2021)., Interventions: Participants were randomly assigned to the intervention group (n = 254) or the control group (n = 257). Both received usual care. Participants randomized to the intervention received Diabetes Prevention Program-based self-directed videos, handouts, and coaching messages via an online platform or US mail for 12 months., Main Outcomes and Measures: Coprimary outcomes were weight measured in primary care and recorded in the EHR and self-reported general health status using the Medical Outcomes Study 12-Item Short Form Health Survey (SF-12) physical component score (PCS; higher scores are better [range, 0-100]) at the 12-month follow-up. The between-group minimal clinically important differences are 3 kg for weight and 5 points for the SF-12 PCS. Linear mixed models used weights and SF-12 PCS measured at either time point, with participants analyzed according to randomization assignment. Statistical significance for each coprimary outcome was based on a 2-sided α level of .025., Results: Among 511 participants randomized (mean age, 57.4 [SD, 13.9] years; 231 female [45%]), 429 (84.0%) had EHR-based weights and 410 (80.2%) had SF-12 PCS data at 12 months. The unadjusted mean weight at 12 months declined from 102.7 kg to 99.8 kg in the intervention group compared with 101.9 kg to 101.0 kg in the control group (adjusted between-group mean difference, -1.93 [97.5% CI, -3.24 to -0.61]; P = .001). At 12 months, the unadjusted mean SF-12 PCS scores declined from 44.8 to 44.3 among intervention participants compared with 44.5 to 43.2 among control participants (adjusted between-group mean difference, intervention minus control, 0.69 [97.5% CI, -1.11 to 2.49]; P = .39). Cardiovascular events represented the highest percentage of serious adverse events, accounting for 25% of events in the intervention group and 35% in the control group., Conclusions and Relevance: Among adults with obesity, a remotely delivered self-directed, behavioral lifestyle intervention, compared with usual care, resulted in statistically significantly greater weight loss at 12 months, although the difference was not clinically important. There was no significant difference in self-reported general physical health status at 12 months., Trial Registration: ClinicalTrials.gov Identifier: NCT03260140.

Background: Patient-centered care reflecting patient preferences and needs is integral to high-quality care. Individualized care is important for psychosocially complex or high-risk patients with multiple chronic conditions (i.e., multimorbidity), given greater potential risks of interventions and reduced benefits. These patients are increasingly prevalent in primary care. Few studies have examined provision of patient-centered care from the clinician perspective, particularly from primary care physicians serving in integrated, patient-centered medical home settings within the US Veterans Health Administration., Objective: We sought to clarify facilitators and barriers perceived by primary care physicians in the Veterans Health Administration to delivering patient-centered care for high-risk or complex patients with multimorbidity., Design: We conducted semi-structured telephone interviews from April to July 2020 among physicians across 20 clinical sites. Findings were analyzed with deductive content analysis based on conceptual models of patient-centeredness and hierarchical factors affecting care delivery., Participants: Of 23 physicians interviewed, most were female (n = 14/23, 61%), serving in hospital-affiliated outpatient clinics (n = 14/23, 61%). Participants had a mean of 21 (SD = 11.3) years of experience., Key Results: Facilitators included the following: effective physician-patient communication to individualize care, prioritize among multiple needs, and elicit goals to improve patient engagement; access to care, enabled by interdisciplinary teams, and dictating personalized care planning; effortful but worthwhile care coordination and continuity; meeting complex needs through effective teamwork; and integrating medical and non-medical care aspects in recognition of patients' psychosocial contexts. Barriers included the following: intra- and interpersonal (e.g., perceived patient reluctance to engage in care); organizational (e.g., limited encounter time); and community or policy impediments (e.g., state decisional capacity laws) to patient-centered care., Conclusions: Physicians perceived individual physician-patient interactions were the greatest facilitators or barriers to patient-centered care. Efforts to increase primary care patient-centeredness for complex or high-risk patients with multimorbidity could focus on targeting physician-patient communication and reducing interpersonal conflict., (© 2022. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Introduction: The prevalence of patients with multimorbidity (ie, multiple chronic conditions) is increasing. Clinical decision-making guided by patients' values, health priorities and goals, and treatment preferences is particularly important in the context of interacting diseases and psychosocial needs. Physicians face challenges incorporating patient perspectives into care plans. We examined primary care physician (PCP) views on the influence of patients' values, health priorities and goals, and preferences on clinical decisions for patients with multimorbidity and increased psychosocial complexity., Methods: We conducted semi-structured telephone interviews with 23 PCPs within patient-centered medical home teams in a nationally integrated health system in the United States between May and July 2020. Data were analyzed via thematic analysis with deductive and inductive coding., Results: Three major themes emerged: 1. Patient personal values were rarely explicitly discussed in routine clinical encounters but informed more commonly discussed concepts of patient priorities, goals, and preferences; 2. Patient values, health priorities and goals, and preferences were sources of divergent views about care plans between healthcare teams, patients, and families; 3. Physicians used explicit strategies to communicate and negotiate about patient values, health priorities and goals, and preferences when developing care plans, including trust-building; devoting extra effort to individualizing care; connecting patient values to healthcare recommendations; deliberate elicitation and acknowledgement of patient concerns; providing "space" for patient perspectives; incorporating family into care planning; pairing physician to patient priorities; and collaborative teamwork., Conclusion: Primary care physicians perceive patient values, health priorities and goals, and preferences as influential during clinical decision-making for complex patients with multimorbidity. Participants used concrete strategies to negotiate alignment of these aspects when physician-patient divergence occurred. While rarely discussed directly in clinical encounters, personal values affected patient health priorities, goals, and preferences during care planning, suggesting a clinical role for more deliberate elicitation and discussion of patient values for this population., Competing Interests: The authors declare no competing conflicts of interest, financial or otherwise., (© 2022 Schuttner et al.)

In 2016, the Agency for Healthcare Research and Quality (AHRQ) recommended seven domains for training and mentoring researchers in learning health systems (LHS) science. Health equity was not included as a competency domain. This commentary from scholars in the Consortium for Applied Training to Advance the Learning health system with Scholars/Trainees (CATALyST) K12 program recommends that competency domains be extended to reflect growing demands for evidence on health inequities and interventions to alleviate them. We present real-life case studies from scholars in an LHS research training program that illustrate facilitators, challenges, and potential solutions at the program, funder, and research community-level to receiving training and mentorship in health equity-focused LHS science. We recommend actions in four areas for LHS research training programs: (a) integrate health equity throughout the current LHS domains; (b) develop training and mentoring in health equity; (c) establish program evaluation standards for consideration of health equity; and (d) bring forth relevant, extant expertise from the areas of health disparities research, community-based participatory research, and community-engaged health services research. We emphasize that LHS research must acknowledge and build on the substantial existing contributions, mainly by scholars of color, in the health equity field., Competing Interests: All authors report no conflicts of interest including relevant financial interests, activities, relationships, and affiliations related to the submitted work., (© 2022 The Authors. Learning Health Systems published by Wiley Periodicals LLC on behalf of University of Michigan.)

Background: Patients with multiple chronic conditions (multimorbidity) and additional psychosocial complexity are at higher risk of adverse outcomes. Establishing treatment or care plans for these patients must account for their disease interactions, finite self-management abilities, and even conflicting treatment recommendations from clinical practice guidelines. Despite existing insight into how primary care physicians (PCPs) approach care decisions for their patients in general, less is known about how PCPs make care planning decisions for more complex populations particularly within a medical home setting. We therefore sought to describe factors affecting physician decision-making when care planning for complex patients with multimorbidity within the team-based, patient-centered medical home setting in the integrated healthcare system of the U.S. Department of Veterans Affairs, the Veterans Health Administration (VHA)., Methods: This was a qualitative study involving semi-structured telephone interviews with PCPs working > 40% time in VHA clinics. Interviews were conducted from April to July, 2020. Content was analyzed with deductive and inductive thematic analysis., Results: 23 physicians participated in interviews; most were MDs (n = 21) and worked in hospital-affiliated clinics (n = 14) across all regions of the VHA's national clinic network. We found internal, external, and relationship-based factors, with developed subthemes describing factors affecting decision-making for complex patients with multimorbidity. Physicians described tailoring decisions to individual patients; making decisions in keeping with an underlying internal style or habit; working towards an overarching goal for care; considering impacts from patient access and resources on care plans; deciding within boundaries provided by organizational structures; collaborating on care plans with their care team; and impacts on decisions from their own emotions and relationship with patient., Conclusions: PCPs described internal, external, and relationship-based factors that affected their care planning for high-risk and complex patients with multimorbidity in the VHA. Findings offer useful strategies employed by physicians to effectively conduct care planning for complex patients in a medical home setting, such as delegation of follow-up within multidisciplinary care teams, optimizing visit time vs frequency, and deliberate investment in patient-centered relationship building to gain buy-in to care plans., (© 2022. The Author(s).)

Importance: Most clinical practice guidelines recommend stopping cancer screenings when risks exceed benefits, yet low-value screenings persist. The Veterans Health Administration focuses on improving the value and quality of care, using a patient-centered medical home model that may affect cancer screening behavior., Objective: To understand rates and factors associated with outpatient low-value cancer screenings., Design, Setting, and Participants: This cohort study assessed the receipt of low-value cancer screening and associated factors among 5 993 010 veterans. Four measures of low-value cancer screening defined by validated recommendations of practices to avoid were constructed using administrative data. Patients with cancer screenings in 2017 at Veterans Health Administration primary care clinics were included. Excluded patients had recent symptoms or historic high-risk diagnoses that may affect test appropriateness (eg, melena preceding colonoscopy). Data were analyzed from December 23, 2019, to June 21, 2021., Exposures: Receipt of cancer screening test., Main Outcomes and Measures: Low-value screenings were defined as occurring for average-risk patients outside of guideline-recommended ages or if the 1-year mortality risk estimated using a previously validated score was at least 50%. Factors evaluated in multivariable regression models included patient, clinician, and clinic characteristics and patient-centered medical home domain performance for team-based care, access, and continuity previously developed from administrative and survey data., Results: Of 5 993 010 veterans (mean [SD] age, 63.1 [16.8] years; 5 496 976 men [91.7%]; 1 027 836 non-Hispanic Black [17.2%] and 4 539 341 non-Hispanic White [75.7%] race and ethnicity) enrolled in primary care, 903 612 of 4 647 479 men of average risk (19.4%) underwent prostate cancer screening; 299 765 of 5 770 622 patients of average risk (5.2%) underwent colorectal cancer screening; 21 930 of 469 045 women of average risk (4.7%) underwent breast cancer screening; and 65 511 of 458 086 women of average risk (14.3%) underwent cervical cancer screening. Of patients screened, low-value testing was rare for 3 cancers, with receipt of a low-value test in 633 of 21 930 of women screened for breast cancer (2.9%), 630 of 65 511 of women screened for cervical cancer (1.0%), and 6790 of 299 765 of patients screened for colorectal cancer (2.3%). However, 350 705 of 4 647 479 of screened men (7.5%) received a low-value prostate cancer test. Patient race and ethnicity, sociodemographic factors, and illness burden were significantly associated with likelihood of receipt of low-value tests among screened patients. No single patient-, clinician-, or clinic-level factor explained the receipt of a low-value test across cancer screening cohorts., Conclusions and Relevance: This large cohort study found that low-value breast, cervical, and colorectal cancer screenings were rare in the Veterans Health Administration, but more than one-third of patients screened for prostate cancer were tested outside of clinical practice guidelines. Guideline-discordant care has quality implications and is not consistently explained by associated multilevel factors.

Background: The extent that organizational learning and resilience for the change process, that is, adaptive reserve (AR), is a component of building practice capacity for continuous quality improvement (QI) is unknown., Purpose: The aim of the study was to examine the association of AR and development of QI capacity., Methodology: One hundred forty-two primary care practices were evaluated at baseline and 12 months in a randomized trial to improve care quality. Practice AR was measured by staff survey along with a validated QI capacity assessment (QICA). We assessed the association of baseline QICA with baseline AR and both baseline and change in AR with change in QICA from 0 to 12 months. Effect modification by presence of QI infrastructure in parent organizations and trial arm was examined., Results: Mean QICA increased from 6.5 to 8.1 (p < .001), and mean AR increased from 71.8 to 73.9 points (p < .001). At baseline, there was a significant association between AR and QICA scores: The QICA averaged 0.34 points higher (95% CI [0.04, 0.64], p = .03) per 10-point difference in AR. There was a significant association between baseline AR and 12-month QICA-which averaged 0.30 points higher (95% CI [0.02, 0.57], p = .04) per 10 points in baseline AR. There was no association between changes in AR and the QICA from 0 to 12 months and no effect modification by trial arm or external QI infrastructure., Conclusions: Baseline AR was positively associated with both baseline and follow-up QI capacity, but there was no association between change in AR and change in the QICA, suggesting AR may be a precondition to growth in QI capacity., Practice Implications: Findings suggest that developing AR may be a valuable step prior to undertaking QI-oriented growth, with implications for sequencing of development strategies, including added gain in QI capacity development from building AR prior to engaging in transformation efforts., (Copyright © 2020 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Quality metrics are fundamental to value-based payment reforms. Because metrics are key components used to drive performance, health care organizations participating in payment reforms should consider metric reliability-a measure of true performance versus statistical "noise." This cross-sectional study examined reliability, variation from patient and clinician characteristics, and volume thresholds for 9 ambulatory quality metrics in a health system engaged in value-based payment reforms. Hierarchical mixed models were used to analyze data from 276 316 patients attributed to 4373 clinicians in 31 primary care clinics from 2015 to 2017. Reliability was lower for all metrics at the clinician level (range 6%-64%) than at the clinic level (84%-99%), with little variation related to patient or clinician characteristics. Few clinicians, but the majority of clinics, contributed sufficient volumes of patient encounters to meet a 70% reliability threshold. These findings suggest that clinic-level performance measurement may be more appropriate than individual clinician-level measurement, particularly in low-volume contexts.

Background: The patient-centered medical home (PCMH) was established in part to improve chronic disease management, yet evidence is limited for effects on patients with multimorbidity., Objective: To examine the association of Patient-Aligned Care Team (PACT) implementation, the Veterans Health Administration (VA) PCMH model, and care quality for multimorbid patients enrolled in VA primary care from 2012 to 2014., Design: Retrospective cohort., Patients: 318,764 multimorbid (> 3 chronic diseases) patients receiving care in 917 clinics., Main Measures: PCMH implementation was measured using the PACT Implementation Progress Index (PI 2 ) for clinics in 2012. The PI 2 is a validated composite measure of administrative and survey data with higher scores associated with greater care quality. Quality outcomes from 2013 to 2014 were assessed from External Peer Review Program (EPRP) metrics. Outcomes included preventative care, chronic disease management, and mental health and substance use metrics. We used generalized estimating equations to model associations adjusting for patient and clinic characteristics. We also examined associations for a subgroup with > 5 chronic diseases., Key Results: For one-third of metrics (5/15), greater implementation of PACT in 2012 was associated with higher predicted probability of meeting the quality metric in 2013-2014. This association persisted for only two metrics (diabetic glycemic control, P < 0.001; lipid control in ischemic heart disease, P = 0.02) among patients with > 5 chronic diseases., Conclusions: Multimorbid patients engaged in care from clinics with higher PCMH implementation received higher quality care across several quality domains, but this association was reduced in patients with > 5 chronic diseases.

Nearly half of Veterans have obesity, fueling chronic diseases. The Department of Veterans Affairs (VA) offers an evidence-based behavioral weight management intervention called MOVE!, mostly delivered through in-person group sessions. Few eligible Veterans participate due to factors like distance and preferences, mirroring barriers in the general population. Practical alternatives to standard in-person programs are needed to improve access and engagement. A self-directed lifestyle intervention called D-ELITE-delivered through pre-recorded videos by DVD or online streaming-previously efficacious in a general primary care population, may provide such an alternative. This pragmatic clinical trial will evaluate whether D-ELITE improves weight and general health status among Veterans with obesity, relative to VA usual care. The yearlong intervention includes one orientation by phone, supplemental lifestyle coaching primarily via technology-based messages, 12 DVD or online streaming sessions over 3 months, and continued self-directed weight management for months 4-12. Participants use MyFitnessPal.com or paper booklets for self-monitoring weight, diet, and physical activity. Follow-up assessments at 12 and 24 months are administered by mail or phone. The study hypothesis is that compared with usual care, D-ELITE will lead to greater improvements in 12-month weight loss, per VA electronic health records, and general physical health status, assessed using the self-reported SF-12 physical composite score. We will also explore D-ELITE's effects on secondary biometric (e.g., HbA1c) and intermediate (e.g., diet) outcomes, reach, and budget impact. If effective, D-ELITE will offer a potentially scalable, low-cost alternative to VA's existing weight loss interventions by mitigating barriers presented by distance and technology., Competing Interests: Declaration of Competing Interest Dr. Ma serves as a paid scientific consultant for Health Mentor, Inc. (San Jose, CA). Dr. Au in the past 3 years has received personal remuneration from: 1. Novartis - member of DMC. 2. ABIM - Pulmonary Board Exam Writing Committee. 3. American Thoracic Society – Annals of the ATS, Deputy Editor. This has not had any influence over the conceptualization or plan, nor will it influence the execution, of this study. Otherwise, the authors have no conflicts of interest to disclose., (Published by Elsevier Inc.)

Background and Objectives: Adults older than 75 years are overscreened for cancer, especially those with less than 10-year life expectancy. This study aimed to learn the effects of providing primary care providers (PCPs) with scripts for discussing stopping mammography and colorectal cancer (CRC) screening and with information on patient's 10-year life expectancy on their patients' intentions to be screened for these cancers., Research Design and Methods: Patient participants, identified via PCP appointment logs, completed a questionnaire pre- and postvisit. Primary care providers were given scripts for discussing stopping screening and information on patient's 10-year life expectancy before these visits. Primary care providers completed a questionnaire at the end of the study. Patients and PCPs were asked about discussing stopping cancer screening and patient life expectancy. Patient screening intentions (1-15 Likert scale; lower scores suggest lower intentions) were compared pre- and postvisit using the Wilcoxon signed-rank test., Results: Ninety patients older than 75 years (47% of eligible patients reached by phone) from 45 PCPs participated. Patient mean age was 80.0 years ( SD = 2.9), 43 (48%) were female, and mean life expectancy was 9.7 years ( SD = 2.4). Thirty-seven PCPs (12 community-based) completed a questionnaire. Primary care providers found the scripts helpful (32 [89%]) and thought they would use them frequently (29 [81%]). Primary care providers also found patient life expectancy information helpful (35 [97%]). However, only 8 PCPs (22%) reported feeling comfortable discussing patient life expectancy. Patients' intentions to undergo CRC screening (9.0 [ SD = 5.3] to 6.5 [ SD = 6.0], p < .0001) and mammography screening (12.9 [ SD = 3.0] to 11.7 [ SD = 4.9], p = .08) decreased from pre- to postvisit (significantly for CRC). Sixty-three percent of patients (54/86) were interested in discussing life expectancy with their PCP previsit and 56% (47/84) postvisit., Discussion and Implications: PCPs found scripts for discussing stopping cancer screening and information on patient life expectancy helpful. Possibly, as a result, their patients older than 75 years had lower intentions of being screened for CRC., Clinical Trials Registration Number: NCT03480282., (© The Author(s) 2020. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Background: Despite guidelines recommending not to continue cancer screening for adults > 75 years old, especially those with short life expectancy, primary care providers (PCPs) feel ill-prepared to discuss stopping screening with older adults., Objective: To develop scripts and strategies for PCPs to use to discuss stopping cancer screening with adults > 75., Design: Qualitative study using semi-structured interview guides to conduct individual interviews with adults > 75 years old and focus groups and/or individual interviews with PCPs., Participants: Forty-five PCPs and 30 patients > 75 years old participated from six community or academic Boston-area primary care practices., Approach: Participants were asked their thoughts on discussions around stopping cancer screening and to provide feedback on scripts that were iteratively revised for PCPs to use when discussing stopping mammography and colorectal cancer (CRC) screening., Results: Twenty-one (47%) of the 45 PCPs were community based. Nineteen (63%) of the 30 patients were female, and 13 (43%) were non-Hispanic white. PCPs reported using different approaches to discuss stopping cancer screening depending on the clinical scenario. PCPs noted it was easier to discuss stopping screening when the harms of screening clearly outweighed the benefits for a patient. In these cases, PCPs felt more comfortable being more directive. When the balance between the benefits and harms of screening was less clear, PCPs endorsed shared decision-making but found this approach more challenging because it was difficult to explain why to stop screening. While patients were generally enthusiastic about screening, they also reported not wanting to undergo tests of little value and said they would stop screening if their PCP recommended it. By the end of participant interviews, no further edits were recommended to the scripts., Conclusions: To increase PCP comfort and capability to discuss stopping cancer screening with older adults, we developed scripts and strategies that PCPs may use for discussing stopping cancer screening.

Background: Following implementation of the patient-centered medical home (PCMH) within the Department of Veterans Affairs (VA), access to primary care improved. However, understanding of how this occurred is lacking., Objective: To examine the association between organizational aspects of the PCMH model and access-related initiatives with patient perception of access to urgent, same-day, and routine care within the VA., Design: Cross-sectional PARTICIPANTS: Veterans who responded to the annual Survey of Healthcare Experiences of Patients in 2016 (N = 241,122 patients) and primary staff who responded to VA National Primary Care Provider and Staff Survey (N = 4815 staff)., Main Measures: Three outcomes of perception of access: percentage of patients responding in the highest category for same-day care (waiting ≤ 1 day), urgent care (always receiving care when needed), and routine care (always receiving checkups when desired). Predictors were staff-level report of access-related initiatives and organizational factors in the clinic. We used generalized estimating equations to model associations, adjusting for characteristics of patients and their respective clinics., Key Results: Access was significantly better in clinics where staff reviewed performance reports (+ 0.9% in the highest perception of access for urgent care, P < 0.01; + 1.2% for routine care, P < 0.001), leadership was supportive of the PCMH (+ 1.6% for urgent care, P < 0.01), and initiatives to improve access included open access (+ 0.8% to + 1.7% across all outcomes, P < 0.01) and telehealth visits (+ 1.2% to + 1.4%, P < 0.001). Perceived access was worse in clinics with moderate staff burnout (- 1.1% to - 1.4%, P < 0.001), primary care provider turnover during the past year (- 1.0% to - 1.6%, P < 0.001), or medical support assistant turnover in the past year (- 0.9% to - 1.4%, P < 0.001)., Conclusions: Perception of access was strongly associated with identifiable organizational factors and access-related initiatives within VA primary care clinics that could be adopted by other health systems.

Competing Interests: Competing interests: None declared.

Background: The patient-centered medical home (PCMH) has clinical benefits for chronic disease care, but the association with patient-reported outcomes such as health-related quality of life (HRQoL) is unexplored in patients with multimorbidity (two or more chronic diseases)., Objective: To examine if greater clinic-level PCMH implementation was associated with higher HRQoL in multimorbid adults., Design: A retrospective cohort study., Participants: Twenty-two thousand ninety-five multimorbid patients who received primary care at 944 Veterans Health Administration (VHA) clinics., Main Measures: Our exposure was the Patient Aligned Care Team Implementation Progress Index (PI 2 ) for the clinic in 2012, a previously validated composite measure of PCMH implementation. Higher PI 2 scores indicate better performance within eight PCMH domains. Outcomes were patient-reported HRQoL measured by the physical and mental component scores (PCS and MCS) from the Short Form-12 patient experiences survey in 2013-2014. Interaction of the outcomes with total hospitalizations and primary care visit count was also examined. Generalized estimating equations were used for main models after adjusting for patient and clinic characteristics., Results: The cohort average age was 68 years, mostly male (96%), and had an average of 4.4 chronic diagnoses. Compared with patients seen at the lowest scoring clinics for PCMH implementation, care in the highest scoring clinics was associated with a higher adjusted marginal mean PCS (42.3 (95% CI 41.3-43.4) versus 40.3 (95% CI 39.1-41.5), P = 0.01), but a lower MCS (35.2 (95% CI 34.4-36.1) versus 36.0 (95% CI 35.3-36.8), P = 0.17). Patients with prior hospitalizations seen in clinics with higher compared with lower PI 2 scores had a 2.7 point greater MCS (95% CI 0.6-4.8; P = 0.01)., Conclusions: Multimorbid patients seen in clinics with greater PCMH implementation reported higher physical HRQoL, but lower mental HRQoL. The association between PCMH implementation and mental HRQoL may depend on complex interactions with disease severity and prior hospitalizations.

Objectives: The Veterans Affairs (VA) Health Care System is among the largest integrated health systems in the United States. Many VA enrollees are dual users of Medicare, and little research has examined methods to most accurately predict which veterans will be mostly reliant on VA services in the future. This study examined whether machine learning methods can better predict future reliance on VA primary care compared with traditional statistical methods., Study Design: Observational study of 83,143 VA patients dually enrolled in fee-for-service Medicare using VA and Medicare administrative databases and the 2012 Survey of Healthcare Experiences of Patients., Methods: The primary outcome was a dichotomous measure denoting whether patients obtained more than 50% of all primary care visits (VA + Medicare) from VA. We compared the performance of 6 candidate models-logistic regression, elastic net regression, decision trees, random forest, gradient boosting machine, and neural network-in predicting 2013 reliance as a function of 61 patient characteristics observed in 2012. We measured performance using the cross-validated area under the receiver operating characteristic (AUROC) metric., Results: Overall, 72.9% and 74.5% of veterans were mostly VA reliant in 2012 and 2013, respectively. All models had similar average AUROCs, ranging from 0.873 to 0.892. The best-performing model used gradient boosting machine, which exhibited modestly higher AUROC and similar variance compared with standard logistic regression., Conclusions: The modest gains in performance from the best-performing model, gradient boosting machine, are unlikely to outweigh inherent drawbacks, including computational complexity and limited interpretability compared with traditional logistic regression.

Background: Healthy Hearts Northwest (H2N) is a study of external support strategies to build quality improvement (QI) capacity in primary care with a focus on cardiovascular risk factors: appropriate aspirin use, blood pressure control, and tobacco screening/cessation., Methods: To guide practice facilitator support, experts in practice transformation identified seven domains of QI capacity and mapped items from a previously validated medical home assessment tool to them. A practice facilitator (PF) met with clinicians and staff in each practice to discuss each item on the Quality Improvement Capacity Assessment (QICA) resulting in a practice-level response to each item. We examined the association between the QICA total and sub-scale scores, practice characteristics, a measure of prior experience with managing practice change, and performance on clinical quality measures (CQMs) for the three cardiovascular risk factors., Results: The QICA score was associated with prior experience managing change and moderately associated with two of the three CQMs: aspirin use (r = 0.16, p = 0.049) and blood pressure control (r = 0.18, p = 0.013). Rural practices and those with 2-5 clinicians had lower QICA scores.., Conclusions: The QICA is useful for assessing QI capacity within a practice and may serve as a guide for both facilitators and primary care practices in efforts to build this capacity and improve measures of clinical quality., Trial Registration: This trial is registered with www.clinicaltrials.gov Identifier# NCT02839382, retrospectively registered on July 21, 2016.

Background: Healthcare utilization is skewed to a subset of high-need, high-use patients, but optimal models of care are not known., Purpose: To reduce emergency room (ER) use and hospital readmissions, trainees designed an innovative model of care delivery for chronically ill, high-utilizing adult patients., Methods: Enrolled patients (N = 65) joined an interprofessional care program (nutrition, behavioral health, pharmacy, and care coordination), located in a single ambulatory clinic with extended hours., Results: Evaluated by generalized linear mixed-effects models, the primary outcome of all-cause ER visits showed a significant decreasing trend after enrollment, from an increasing odds of ER visits (OR 1.07) in the 12-months prior to the program, compared to a decreasing trend post-enrollment (OR 0.88). Implementation and completion of the program was cost neutral., Discussion and Conclusions: This pilot supports team-based ambulatory care models that address the diverse needs of chronically ill patients, with a focus on improving select health services utilization., Competing Interests: Conflict of Interest Statement: No conflicting interests or financial relationships to disclose. No other part of this article is currently being consider for, nor has been previously published at another journal.

Background: Mobile health (m-health) utilizes widespread access to mobile phone technologies to expand health services. Community health workers (CHWs) provide first-level contact with health facilities; combining CHW efforts with m-health may be an avenue for improving primary care services. As part of a primary care improvement project, a pilot CHW program was developed using a mobile phone-based application for outreach, referral, and follow-up between the clinic and community in rural Zambia., Materials and Methods: The program was implemented at six primary care sites. Computers were installed at clinics for data entry, and data were transmitted to central servers. In the field, using a mobile phone to send data and receive follow-up requests, CHWs conducted household health surveillance visits, referred individuals to clinic, and followed up clinic patients., Results: From January to April 2011, 24 CHWs surveyed 6,197 households with 33,304 inhabitants. Of 15,539 clinic visits, 1,173 (8%) had a follow-up visit indicated and transmitted via a mobile phone to designated CHWs. CHWs performed one or more follow-ups on 74% (n=871) of active requests and obtained outcomes on 63% (n=741). From all community visits combined, CHWs referred 840 individuals to a clinic., Conclusions: CHWs completed all planned aspects of surveillance and outreach, demonstrating feasibility. Components of this pilot project may aid clinical care in rural settings and have potential for epidemiologic and health system applications. Thus, m-health has the potential to improve service outreach, guide activities, and facilitate data collection in Zambia.

We evaluated the association of the number of late antiretroviral therapy (ART) refills with patient outcomes in a large public-sector human immunodeficiency virus treatment program in Lusaka, Zambia. Using pharmacy data routinely collected during 2004-2010, we calculated the number of late refills during the initial year of ART. We used multivariable Cox proportional hazard regression to examine the association between the number of late refills and death or program failure (i.e., death, loss to follow-up, or program withdrawal) >12 months after ART initiation, with and without stratification by the medication possession ratio (MPR) during the initial year of ART. Of 53,015 adults who received ART for ≥12 months (median follow-up duration, 86.1 months; interquartile range, 53.2-128.2 months), 26,847 (50.6%) had 0 late refills, 16,762 (31.6%) had 1, 6,505 (12.3%) had 2, and 2,901 (5.5%) had ≥3. Kaplan-Meier analysis revealed that ≥3 late refills was associated with a greater mortality risk than 1 and 2 late refills (p<0.001, by the log-rank test). The mortality risk was greater for patients with 2 late refills [adjusted hazard ratio (HR), 1.17; 95% confidence interval (CI), 0.99-1.38] or ≥3 late refills (adjusted HR, 1.51; 95% CI, 1.23-1.87), compared with that for patients with 0-1 late refills. Program failure was associated with ≥2 late refills. An MPR of <80% was associated with similar increases in mortality risk across late-refill strata. Monitoring late refills during the initial period of ART may help resource- and time-constrained clinics identify patients at risk for program failure.

Introduction: Zambia's under-resourced public health system will not be able to deliver on its health-related Millennium Development Goals without a substantial acceleration in mortality reduction. Reducing mortality will depend not only upon increasing access to health care but also upon improving the quality of care that is delivered. Our project proposes to improve the quality of clinical care and to improve utilization of that care, through a targeted quality improvement (QI) intervention delivered at the facility and community level., Description of Implementation: The project is being carried out 42 primary health care facilities that serve a largely rural population of more than 450,000 in Zambia's Lusaka Province. We have deployed six QI teams to implement consensus clinical protocols, forms, and systems at each site. The QI teams define new clinical quality expectations and provide tools needed to deliver on those expectations. They also monitor the care that is provided and mentor facility staff to improve care quality. We also engage community health workers to actively refer and follow up patients., Evaluation Design: Project implementation occurs over a period of four years in a stepped expansion to six randomly selected new facilities every three months. Three annual household surveys will determine population estimates of age-standardized mortality and under-5 mortality in each community before, during, and after implementation. Surveys will also provide measures of childhood vaccine coverage, pregnancy care utilization, and general adult health. Health facility surveys will assess coverage of primary health interventions and measures of health system effectiveness., Discussion: The patient-provider interaction is an important interface where the community and the health system meet. Our project aims to reduce population mortality by substantially improving this interaction. Our success will hinge upon the ability of mentoring and continuous QI to improve clinical service delivery. It will also be critical that once the quality of services improves, increasing proportions of the population will recognize their value and begin to utilize them.

Background: Although tenofovir (TDF) is a common component of antiretroviral therapy (ART), recent evidence suggests inferior outcomes when it is combined with nevirapine (NVP)., Methods: We compared outcomes among patients initiating TDF + emtricitabine or lamivudine (XTC) + NVP, TDF + XTC + efavirenz (EFV), zidovudine (ZDV) + lamuvidine (3TC) + NVP, and ZDV + 3TC + EFV. We categorized drug exposure by initial ART dispensation by a time-varying analysis that accounted for drug substitutions and by predominant exposure (>75% of drug dispensations) during an initial window period. Risks for death and program failure were estimated using Cox proportional hazard models. All regimens were compared with ZDV + 3TC + NVP., Results: Between July 2007 and November 2010, 18,866 treatment-naive adults initiated ART: 18.2% on ZDV + 3TC + NVP, 1.8% on ZDV + 3TC + EFV, 36.2% on TDF + XTC + NVP, and 43.8% on TDF + XTC + EFV. When exposure was categorized by initial prescription, patients on TDF + XTC + NVP [adjusted hazard ratio (AHR): 1.45; 95% confidence interval (CI): 1.03 to 2.06] had a higher post-90-day mortality. TDF + XTC + NVP was also associated with an elevated risk for mortality when exposure was categorized as time-varying (AHR: 1.51; 95% CI: 1.18 to 1.95) or by predominant exposure over the first 90 days (AHR: 1.91, 95% CI: 1.09 to 3.34). However, these findings were not consistently observed across sensitivity analyses or when program failure was used as a secondary outcome., Conclusion: TDF + XTC + NVP was associated with higher mortality when compared with ZDV + 3TC + NVP but not consistently across sensitivity analyses. These findings may be explained in part by inherent limitations to our retrospective approach, including residual confounding. Further research is urgently needed to compare the effectiveness of ART regimens in use in resource-constrained settings.