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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.)

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: 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.)

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.

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.

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.