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This pilot study explored the feasibility and acceptability of PARTNER-MH, which aimed to engage racially diverse Veterans in mental health services, facilitate their active participation in care, and improve their communication with providers. Fifty participants were randomized to the intervention or a waitlist control group. For primary outcomes, we assessed the feasibility of the study design and PARTNER-MH’s feasibility and acceptability. For secondary outcomes, we explored preliminary effects on patient engagement, patient activation, shared decision-making, and health-related outcomes. The study had a recruitment rate of 68%, enrollment rate of 91%, and a follow-up retention rate of 72%. For intervention feasibility and acceptability, fidelity scores were satisfactory and improved over time, session attendance was modest with 33% of participants completing ≥6 sessions, and 89% of participants were satisfied with the intervention. For secondary outcomes, patients in the intervention arm showed significant improvement on self-reported mental health and depression, compared with those in the control group at both 6- and 9-month follow-ups. However, there were no significant differences between study arms on the other measures. Pilot results provide support for future testing of PARTNER-MH in a larger trial, although modifications are needed to increase session attendance and follow-up retention rate. Clinical Trial information: The study was preregistered at Clinical Trials.gov. The study Trial registration number is ClinicalTrials.gov NCT04515771.

Objective:To describe the relative frequency, demographics, comorbidities, and healthcare utilization of veterans who receive migraine care at the Veteran’s Health Administration (VHA) and to evaluate differences by gender.Methods:This study extracted data from VHA administrative sources. Veterans diagnosed with migraine by a healthcare provider between fiscal year 2008-2019 were included. Demographics and military exposures were extracted at cohort entry. Comorbidities were extracted within 18 months of the first migraine diagnosis. Health care utilization and headache comorbidities were extracted across the study period. Differences between men and women were evaluated using chi-square tests and student t-tests.Results:More than half a million (n = 567,121) veterans were diagnosed with migraine during the 12-year study period, accounting for 5.3% of the 10.8 million veterans served in the VHA; in the most recent year of the study period (2019), the annual incidence and one-year period prevalence of medically diagnosed migraine was 2.7% and 13.0% for women, and 0.7% and 2.5% for men. In the total cohort diagnosed with migraine, 27.8% were women and 72.2% men. Among those with diagnosed migraine, a higher proportion of men vs. women also had a TBI diagnosis (3.9% vs. 1.1%; p < 0.001). A higher proportion of women vs. men reported military sexual trauma (35.5% vs. 3.5%; p < 0.001). Participants with diagnosed migraine had an average of 1.44 (SD 1.73) annual encounters for headache. Primary care was the most common headache care setting (88.1%); almost one-fifth of veterans with diagnosed migraine sought care in the ED at least once during the study period. Common comorbidities were overweight/obesity (80.3%), non-headache pain disorders (61.7%), and mental health disorders (48.8%).Conclusions:Migraine is commonly treated in the VHA setting, but likely under ascertained. Most people treated for migraine in the VHA are men. Pain comorbidities and psychiatric disorders are common. Future research should identify methods to improve diagnosis and treatment and to reduce use of the emergency department.

The reach of home-based clinical programs for medically complex, older adults can be limited by geographic scope. Implementing telehealth versions can expand reach but create constraints for comprehensive assessments and technological barriers for users. We describe challenges and lessons learned during the pre-implementation period for the randomized trial of a hybrid video -modality of the Geriatrics Resources for Assessment and Care for Elders (GRACE) Program at the Indianapolis Veterans Health Care System. In TeleGRACE, a health technician makes home visits to facilitate clinical activities (e.g., medication reconciliation) using telehealth technology for a clinical team (social worker, nurse practitioner) who conduct the visits remotely. Data used in this one-year pre-implementation evaluation included: periodic reflections with the clinical and evaluation staff, planning and interdisciplinary team meeting fieldnotes, and interviews with clinical team members. Data were summarized by selected constructs from the Consolidated Framework for Implementation Research; implementation challenges and problem solving were identified. Pre-implementation challenges occurred in: assuring assessment devices worked correctly for and were trusted by staff (e.g., connectivity, virtual stethoscope), technician fit with existing GRACE team, ensuring technician welfare (e.g., COVID-19 exposure, guns in the home), caseload balance amid staffing shortages, travel logistics, and sampling to adequately power the trial. Building on an existing strong team dynamic and a culture of feedback for quality improvement, challenges were addressed through pilot-testing, monitoring for barriers and impacts, and group reflecting conversations. Adaptations to the initial plan resulted in a more focused and targeted implementation effort to test the model and its effectiveness.

Background: Mental healthcare disparities are persistent and have increased in recent years. Compared to their White counterparts, racial and ethnic minority groups have less access to mental healthcare. Minority groups also have lower engagement in mental health treatment and are more likely to experience ineffective patient-provider communication, which contribute to negative mental healthcare experiences and poor mental health outcomes. Interventions that embrace recovery-oriented practices to support patient engagement and empower patients to participate in their mental healthcare and treatment decisions may help to reduce mental healthcare disparities. Designed to achieve this goal, PARTNER-MH is a peer-led, patient navigation intervention that aims to engage minority patients in mental health treatment, support them to take a greater role in their care, and facilitate their participation in treatment shared decision-making. Methods: This pilot study evaluates the feasibility and acceptability of PARTNER-MH in a VHA mental health setting using a mixed-methods, randomized controlled trial study design. PARTNER-MH is tested under real-world conditions, using certified VHA peer support specialists (peers), selected via usual VHA hiring practices and assigned to the mental health service. The peers provide PARTNER-MH and usual peer support services. The study compares the impact of PARTNER-MH versus a wait-list control group on patient activation, patient engagement, and shared decision-making, as well as other patient-level outcomes. PARTNER-MH also examines organizational factors that could impact its future implementation in VHA settings. Results: Participants (N=50) were veterans who were mostly male (62%), self-identified as non-Hispanic Black (70%), with a median age in the 45-54 group. Most had at least some college education, and 32% completed 4 or more years of college. Randomization produced comparable groups in terms of characteristics and outcome measures at baseline, except for gender. Discussion and Conclusion: Rather than simply documenting health disparities among vulnerable populations, PARTNER-MH offers opportunities to evaluate a tailored, culturally-sensitive system-based intervention to improve patient engagement and patient-provider communication in mental healthcare for racial and ethnic minorities. IRB Protocol #1708628270Trial registration: ClinicalTrials.gov, NCT04515771. Registered 14 August 2020, https://clinicaltrials.gov/ct2/show/NCT04515771

Background Mental health care disparities are persistent and have increased in recent years. Compared with their White counterparts, members of racially and ethnically minoritized groups have less access to mental health care. Minoritized groups also have lower engagement in mental health treatment and are more likely to experience ineffective patient-provider communication, which contribute to negative mental health care experiences and poor mental health outcomes. Interventions that embrace recovery-oriented practices to support patient engagement and empower patients to participate in their mental health care and treatment decisions may help reduce mental health care disparities. Designed to achieve this goal, the Proactive, Recovery-Oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare (PARTNER-MH) is a peer-led patient navigation intervention that aims to engage minoritized patients in mental health treatment, support them to play a greater role in their care, and facilitate their participation in shared treatment decision-making. Objective The primary aim of this study is to assess the feasibility and acceptability of PARTNER-MH delivered to patients over 6 months. The second aim is to evaluate the preliminary effects of PARTNER-MH on patient activation, patient engagement, and shared decision-making. The third aim is to examine patient-perceived barriers to and facilitators of engagement in PARTNER-MH as well as contextual factors that may inhibit or promote the integration, sustainability, and scalability of PARTNER-MH using the Consolidated Framework for Implementation Research. Methods This pilot study evaluates the feasibility and acceptability of PARTNER-MH in a Veterans Health Administration (VHA) mental health setting using a mixed methods, randomized controlled trial study design. PARTNER-MH is tested under real-world conditions using certified VHA peer specialists (peers) selected through usual VHA hiring practices and assigned to the mental health service line. Peers provide PARTNER-MH and usual peer support services. The study compares the impact of PARTNER-MH versus a wait-list control group on patient activation, patient engagement, and shared decision-making as well as other patient-level outcomes. PARTNER-MH also examines organizational factors that could impact its future implementation in VHA settings. Results Participants (N=50) were Veterans who were mostly male (n=31, 62%) and self-identified as non-Hispanic (n=44, 88%) and Black (n=35, 70%) with a median age of 45 to 54 years. Most had at least some college education, and 32% (16/50) had completed ≥4 years of college. Randomization produced comparable groups in terms of characteristics and outcome measures at baseline, except for sex. Conclusions Rather than simply documenting health disparities among vulnerable populations, PARTNER-MH offers opportunities to evaluate a tailored, culturally sensitive, system-based intervention to improve patient engagement and patient-provider communication in mental health care for racially and ethnically minoritized individuals. Trial Registration ClinicalTrials.gov NCT04515771; https://clinicaltrials.gov/ct2/show/NCT04515771 International Registered Report Identifier (IRRID) DERR1-10.2196/37712

Background: Use of MRI with diffusion weighted imaging (DWI) can identify infarcts in 30-50% of patients with transient neurovascular symptoms. Previous guidelines have indicated that MRI-DWI is the preferred imaging modality for patients with TIA symptoms. We assessed the frequency of MRI utilization and predictors of MRI performance in a national integrated health system. Methods: A review of TIA and minor stroke patients evaluated at Veterans Affairs Hospitals (fiscal year 2011) was conducted. Administrative data was reviewed with regard to demographic factors, past medical history, use of diagnostic imaging within two days of presentation, and in hospital care variables. Detailed chart abstraction was performed in a patient subset of large volume hospitals to assess clinical variables. Results: 8427 patients with TIA or minor stroke were included in the administrative data cohort. Overall, 6817 patients (80.9%) had cranial imaging (either CT or MRI) within two days of presentation, with 3420 (50.2%) having CT without MRI and 3397 (49.8%) having MRI. 3.6% of patients with CT only had a pacemaker. Specific variables that were associated with CT performance (rather than MRI) in the administrative data cohort included the following: age>80 years, prior stroke, atrial fibrillation, dementia, and congestive heart failure (p6 hours (74% had MRI vs. 26% had CT only, p=0.0009) were associated with MRI performance. Conclusions: Within a large national health system, about 40% of patients with TIA or minor stroke had MRI performed within two days. Performance of MRI appears to be influenced by several variables, including age, nature of the symptoms, prior stroke, and neurological consultation in the ED. These data suggest that there has been partial acceptance of the previous guideline which endorsed MRI for patients with TIA.

We conducted an evaluation of the implementation of a Veteran Secondary Stroke Prevention Program at two VA medical center sites. We prospectively recruited patients hospitalized for stroke/TIA and randomized to either an intervention or a control group. Each site locally tailored the intervention. The program targeted stroke self-management and risk factors or a placebo telephone call program that mimicked the intervention schedule. The self-management program followed a standardized manual (control call simply asked how the patient was doing), and interviews were conducted at baseline during hospital visit, 3 and 6 months. To address veteran preferences, both sites implemented the ASA Sharegiver peer support program to subjects in the intervention.We assessed stroke health-related quality of life with the SS-QOL and depression with the PHQ9. Results: The final sample included 174 veteran patients with an acute stroke/TIA and were randomized to receive either a VSPP (n=87) or a control program (n=87) stratified by stroke/TIA and by receipt of inpatient rehabilitation to control for stroke severity. A random subject effect was used to correlate observations from the same subject. Subgroup analyses were run with subgroups defined as diagnosed TIA or Stroke at acute event. On the SSQoL overall score and the Language subscale, those with a TIA in the intervention group reported an improved score while those in the control group reported a declined score at 3 mos. For those with Stroke in the intervention group, improvements in the Energy subscale were reported compared to declines in the control group at 3 months. For those with TIA in the intervention reported less depression than those in the control group and this effect was maintained at 6 months. Self-efficacy increased among those with stroke in the intervention group while decreased among the control group; although not significant. Our results indicate the feasibility of delivering a local, secondary stroke prevention program. We report better stroke specific quality of life at 3 months among stroke/TIA survivors and less depression among those with TIA 6 months after the intervention suggesting that a post stroke program may enhance recovery. Funded by Veterans Health Administration HSRD IAB 05-297-2

We targeted both providers and patients for medication and lifestyle modification to reduce secondary stroke risk factors after stroke. The specific aim of this study was to: Conduct a quasi-experimental feasibility test of implementing the adapted VA stroke prevention program (VSPP) at two VA sites to evaluate the impact on medication adherence. Program sessions targeted stroke risk factor management. The key stroke risk factors of interest were: 1) hypertension, 2) diabetes, 3) hypercholesterolemia. Medication possession ratios based upon patient medication refills were calculated to evaluate medication compliance for the randomized subjects using PBM data pre (6 months prior to the acute event) and post (6 months after the event). Based upon the literature standard of 80% compliance, we used this rate to dichotomize and model the data using logistics regression. Results: The final sample included 174 veteran patients with an acute stroke/TIA who were randomized to receive either the intervention (n=87) or a control program (n=87). In the intervention group, the odds of compliance to diabetes meds post stroke were significantly larger than the odds of compliance prior to the stroke (odds ratio=3.45 (1.08, 10.96) p

Objectives: In 2009, the VHA reported inpatient stroke quality indicators based on chart abstractions of fiscal year (FY) 2007 data at all VA medical centers (VAMCs). Prior to a randomized trial of a Systems Redesign-based intervention, we re-measured VA stroke quality indicators (QIs) from 2009 data in 11 of the largest volume VAMCs. The purpose of this analysis is to examine whether any significant changes occurred in inpatient stroke care in these sites between 2007 and 2009. Methods: Data for 10 Joint Commission (JC) inpatient stroke QIs were obtained by experienced external VA chart abstractors via review of FY 2007 electronic medical records. We abstracted 2009 data at 11 sites as baseline data for a quality improvement randomized study. We calculated eligibility and passing rates for ten inpatient stroke QIs defined similarly to the 10 JC indicators from the FY 2007 study. We compared patient demographics, clinical variables, and passing rates for each QI between the FY 2007 and CY 2009 data at the 11 sites using Student’s t-test and Chi-square tests. Results: Comparing 2007 (N =750) to 2009 (N =817) data, mean age (66.3, 66.6), % male (97%, 96%), and % Black (34%, 33%) were similar but mean NIH Stroke Scale score was increased in 2009 (4.2, 5.9, p < 0.001). Three QIs were unchanged over time: DVT prophylaxis, anticoagulation for atrial fibrillation, and antithrombotic at discharge (Table). Performance on four indicators was significantly improved: dysphagia screening (16%, 45%), receipt of rehabilitation consultation (62%, 89%), stroke education (17%, 31%), and receipt of tPA (17%, 47%). Performance on three indicators was significantly reduced: antithrombotic by hospital day two (98%, 87%), cholesterol lowering medication at discharge (90%, 72%), and receipt of smoking cessation counseling (100%, 89%). Conclusions: Prior to VHA national quality improvement efforts, both positive and negative shifts in performance occurred for common inpatient stroke QIs. Future work should examine whether focusing efforts on one aspect of stroke care can lead to reduction in quality in other areas, and on whether consistent reporting of these QIs can promote maintenance of high quality stroke care across a large national healthcare system.

Objective: Clinical champions may serve as important facilitators of clinical quality improvement. We sought to understand how stroke clinical champions communicate within and between clinical services among providers of acute stroke care which spans clinical services. Methods: We conducted semi-structured, in-person baseline interviews with clinical providers of acute stroke care services and related administrators and service managers across 11 VA Medical Centers across the US. We consented the responders and audiotaped the interviews. Closed ended question responses were entered into a database and open ended question responses were transcribed and qualitatively coded. For qualitative data, we assigned at least two coders per transcript for analysis. A priori, we operationalized key constructs of stroke quality improvement and utilized these constructs as an initial coding scheme. Additionally, we coded emerging themes from the qualitative responses using Nvivo software. Coders met regularly to review and consolidate when possible the emergent themes. Results: We completed 104 interviews of which the respondents included the following service lines: neurology, emergency department, inpatient care, education, social work, quality improvement, rehabilitation. Qualitative analyses indicated that 5 of the 12 facilities had unanimously identified stroke clinical champions. These sites reported more frequent communications within neurology service and stronger communications across service lines. Respondents external to the neurology service line were more likely to identify the presence of a stroke clinical champion at VA facilities that had established acute stroke care processes across the medical center compared to facilities where no systematic acute stroke care processes currently existed. Conclusions: A stroke clinical champion may be associated with the establishment of systematic clinical processes that span interdisciplinary services within an organization. The coordination of such interdisciplinary care and the brokering of interdisciplinary relationships may need a clinical champion to foster. Impact: Understanding the development of a stroke clinical champion is crucial for organizations that seek to improve their clinical processes.

Depression and pain are common comorbid conditions that have reciprocal adverse effects on disability and treatment outcomes. The objective of this article is to describe a study that tests the effectiveness of a stepped-care approach using a combined medication-behavioral intervention.Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) is an NIMH-sponsored randomized clinical trial nested within a prospective cohort study. A total of 250 patients with clinically significant depression (PHQ-9 scoresor =10) and musculoskeletal pain of the lower back or legs (hip or knee) and 250 nondepressed patients with similar pain are enrolled, with baseline and serial follow-up assessments to be conducted over 12 months. The depressed patients are randomized to either a stepped-care intervention group or a usual-care control group. Stepped-care patients receive 12 weeks of optimized antidepressant management (Step 1) followed by six sessions of a pain self-management (PSM) program over the next 12 weeks (Step 2), all delivered by a nurse care manager who is supervised by a physician specialist. Approximately two thirds of the care manager contacts are by telephone.The target sample of 500 subjects has been successfully enrolled, and randomization of the depressed patients has resulted in balanced groups of patients with moderately severe pain and depression. Mean SCL-20 depression severity in the clinical trial group is 1.9, with most meeting DSM-IV criteria for major depression (76.3%) and the rest having dysthymia only (18.4%) or minor depression (5.3%). Pain is about equally distributed between lower back (53%) and hip or knee (47%). A rational algorithmic approach to antidepressant selection and dosing, as well as an overview of the PSM program, is provided.When completed, SCAMP will test whether optimized antidepressant management improves outcomes in patients with comorbid depression and pain and whether PSM produces additional benefits. The findings will be important for both primary care and mental health clinicians confronted by the prevalent depression-pain dyad.