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Objectives: The Department of Veterans Affairs (VA) is transitioning from its legacy electronic health record (EHR) to a new commercial EHR in a nationwide, rolling-wave transition. We evaluated clinician and staff experiences to identify strategies to improve future EHR rollouts., Materials and Methods: We completed a convergent mixed-methods formative evaluation collecting survey and interview data to measure and describe clinician and staff experiences. Survey responses were analyzed using descriptive statistics; interview transcripts were coded using a combination of a priori and emergent codes followed by qualitative content analysis. Qualitative and quantitative findings were compared to provide a more comprehensive understanding of participant experience. Employees of specialty and primary care teams at the first nationwide EHR transition site agreed to participate in our study. We distributed surveys at 1-month pre-transition, 2 months post-transition, and 10 months post-transition to each of the 68 identified team members and completed longitudinal interviews with 30 of these individuals totaling 122 semi-structured interviews., Results: Interview participants reported profoundly disruptive experiences during the EHR transition that persisted at 1-year post implementation. Survey responses indicated training difficulties throughout the transition, and sharp declines ( P  ≤ .05) between pre- and post-go-live measures of EHR usability and increase in EHR burden that were perceived to be due in part to system inefficiencies, discordant positive messaging that initially ignored user challenges, and inadequate support for and attention to ongoing EHR issues. Participants described persistent high levels of stress associated with these disruptions., Discussion: Our findings highlight strategies to improve employee experiences during EHR transitions: (1) working with Oracle Cerner to resolve known issues and improve usability; (2) role-based training with opportunities for self-directed learning; (3) peer-led support systems and timely feedback on issues; (4) messaging that responds to challenges and successes; and (5) continuous efforts to support staff with issues and address clinician and staff stress and burnout., Conclusion: Our findings provide relevant strategies to navigate future EHR transitions while supporting clinical teams., Competing Interests: None declared., (Published by Oxford University Press on behalf of the American Medical Informatics Association 2024.)

Background: The use of research tools developed and validated in one cultural and linguistic context to another often faces challenges. One major challenge is poor performance of the tool in the new context. This potentially impact the legitimacy of health policy research conducted with informal adaptations of existing tools which have not been subjected to formal validation. Best practices exist to guide researchers in adapting and validating research tools effectively. We present here, as an extended example, our validation of the SHEMESH questionnaire ('Organizational Readiness to Change Assessment'; In Hebrew: 'SHE'elon Muchanut Ergunit le'SHinuy'), a Hebrew-language version of the Organizational Readiness to Change Assessment (ORCA). SHEMESH is tailored to support implementation science projects, whose aim is to promote a more rapid and complete adoption of evidence-based health policies and practices., Methods: The SHEMESH included originally eleven questions from the Evidence (item 1-4) and Context (items 5-11) domains. We validated SHEMESH through the following steps: 1. Professional translation to Hebrew and discussion of the translation by multidisciplinary committee; 2. Back-translation into English by a different translator to detect discrepancies; 3. Eleven cognitive interviews with psychiatric emergency department physicians and nurses; and 4. Pilot testing and psychometric analyses, including Cronbach's alpha for subscales and factor analyses., Results: Following translation and cognitive interviews, SHEMESH was administered to 222 psychiatrists and nurses. Pearson correlation showed significant and strong correlations of items 1-4 to the Evidence construct and items 6-11 to the Context construct. Item 5 did not correlate with the other items, and therefore was removed from the other psychometric procedures and eventually from the SHEMESH. Factor analysis with the remaining 10 items yielded two factors, which together explained a total of 69.7% of variance. Cronbach's Alpha scores for the two subscales were high (Evidence, 0.887, and Context, 0.852)., Conclusions: This multi-step validation process of the SHEMESH questionnaire may serve as a comprehensive guideline for others who are willing to adapt research tools that were developed in other languages. Practically, SHEMESH has been validated for use in implementation science research projects in Israel., (© 2023. The Author(s).)

Objective: Assess factors contributing to variation in the use of new and evolving diagnostic and interventional procedures for percutaneous coronary intervention (PCI)., Background: Evidence-based practices for PCI have the potential to improve outcomes but are variably adopted. Finding possible drivers of PCI procedure-use variability is key for efforts aimed at establishing more uniform practice., Methods: Veterans Affairs Clinical Assessment, Reporting, and Tracking Program data were used to estimate a proportion of variation attributable to hospital-, operator-, and patient-level factors across (a) radial arterial access, (b) intravascular imaging/optical coherence tomography, and (c) atherectomy for PCI. We used random-effects models with hospital, operator, and patient random effects. Overlap between levels generated cumulative variability estimates greater than 100%., Results: A total of 445 operators performed 95,391 PCI procedures across 73 hospitals from 2011 to 2018. The rates of all procedures increased over this time. 24.45% of variability in the use of radial access was attributable to the hospital, 53.04% to the operator, and 57.83% to patient-level characteristics. 9.06% of the variability in intravascular imaging use was attributable to the hospital, 43.92% to the operator, and 21.20% to the patient. Lastly, 20.16% of the variability in use of atherectomy was attributed to the hospital, 34.63% to the operator, and 57.50% to the patient., Conclusions: The use of radial access, intracoronary imaging, and atherectomy is influenced by patient, operator, and hospital factors, but patient and operator-level effects predominate. Efforts to increase the use of evidence-based practices for PCI should consider interventions at these levels., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2023 Diana Naranjo et al.)

Background: Patient enrollment levels at Veterans Health Administration (VHA) facilities change based on Veteran demand for care, potentially affecting demands on staff. Effects on burnout in the primary care workforce associated with increases or decreases in enrollment are unknown., Objective: Estimate associations between patient enrollment and burnout., Design: In this serial cross-sectional study, VHA patient enrollment and workforce data from 2014 to 2018 were linked to burnout estimates for 138 VHA facilities. The VHA's annual All Employee Survey provided burnout estimates., Participants: A total of 82,421 responses to the 2014-2018 All Employee Surveys by primary care providers (PCPs), including physicians, nurse practitioners, and physician assistants; nurses; clinical associates; and administrative clerks were included. Respondents identified as patient-aligned care team members., Main Measures: Independent variables were (1) the ratio of enrollment to PCPs at VHA facilities and (2) the year-over-year change in enrollment per PCP. Burnout was measured as the annual proportion of staff at VHA facilities who reported emotional exhaustion and/or depersonalization. Each primary care role was analyzed independently., Key Results: Overall enrollment decreased from 1553 enrollees per PCP in 2014 to 1442 enrollees per PCP in 2018 across VHA facilities. Forty-three facilities experienced increased enrollment (mean of 1524 enrollees/PCP in 2014 to 1668 in 2018) and 95 facilities experienced decreased enrollment (mean of 1566 enrollees/PCP in 2014 to 1339 in 2018). Burnout decreased for all primary care roles. PCP burnout was highest, decreasing from a facility-level mean of 51.7% in 2014 to 43.8% in 2018. Enrollment was not significantly associated with burnout for any role except nurses, for whom a 1% year-over-year increase in enrollment was associated with a 0.2 percentage point increase in burnout (95% CI: 0.1 to 0.3)., Conclusions: Studies assessing changes in organizational-level predictors are rare in burnout research. Patient enrollment predicted burnout only among nurses in primary care., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Objectives: Electronic health record (EHR) inbox notifications can be burdensome for primary care providers (PCPs), potentially contributing to burnout. We estimated the association between changes in the quantities of EHR inbox notifications and PCP burnout., Study Design: In this observational study, we tested the association between the percent change in daily inbox notification volumes and PCP burnout after an initiative to reduce low-value notifications at the Veterans Health Administration (VHA)., Methods: The VHA initiative resulted in increases and decreases in notification volumes for PCPs. For each facility, the proportion of PCPs reporting burnout was estimated using VHA All Employee Survey responses before and after the initiative in 2016 and 2018, respectively. Survey responses were aggregated for 6459 PCPs (physicians, nurse practitioners, and physician assistants) at 138 VHA facilities. Fixed effects regression models estimated the association of small and large increases and small and large decreases in notifications on burnout., Results: Daily inbox notifications per PCP decreased by a mean (SD) of 5.9% (30.1%) across study facilities, from a mean (SD) of 128 (52) notifications to 114 (44) notifications after the initiative. Fifty-one percent of facilities experienced reductions in notifications, 30% experienced no change, and 20% experienced increased notifications. PCP burnout was not significantly associated with any level of increase or decrease in notifications., Conclusions: Changes in notification volumes alone did not predict PCP burnout. Future research to reduce burnout might still address EHR notification volumes, but as part of a broader set of strategies that consider the other stressors that PCPs experience.

Introduction: A substantial proportion of individuals with low cardiovascular risk receive inappropriate statin prescription for primary prevention of cardiovascular disease (CVD) instead of the evidence-based recommendations to promote healthy lifestyle behaviors. This study reports on the structured process performed to design targeted de-implementation strategies to reduce inappropriate prescription of statins and to increase healthy lifestyle promotion in low cardiovascular risk patients in Primary Care (PC)., Methods: A formative study was conducted based on the Theoretical Domains Framework and the Behavior Change Wheel (BCW). It comprised semi-structured interviews with PC professionals to define the problem in behavioral terms; focus groups with Family Physicians and patients to identify the determinants (barriers and facilitators) of inappropriate statin prescription and of healthy lifestyle promotion practice; mapping of behavioral change interventions operationalized as de-implementation strategies for addressing identified determinants; and consensus techniques for prioritization of strategies based on perceived effectiveness, feasibility and acceptability., Results: Identified key determinants of statin prescription and healthy lifestyle promotion were: the lack of time and clinical inertia, external resources, patients' preferences and characteristics, limitation of available clinical tools and guidelines, social pressures, fears about negative consequences of not treating, and lack of skills and training of professionals. Fourteen potential de-implementation strategies were mapped to the identified determinants and the following were prioritized: 1) non-reflective decision assistance strategies based on reminders and decision support tools for helping clinical decision-making; 2) decision information strategies based on the principles of knowledge dissemination (e.g., corporative diffusion of evidence-based Clinical Practice Guidelines and Pathways for CVD primary prevention); 3) reflective decision-making restructuring strategies (i.e., audit and feedback provided along with intention formation interventions)., Conclusions: This study supports the usefulness of the BCW to guide the design and development of de-implementation strategies targeting the determinants of clinicians' decision-making processes to favor the abandonment of low-value practices and the uptake of those recommended for CVD primary prevention in low-risk patients. Further research to evaluate the feasibility and effectiveness of selected strategies is warranted., Clinical Trial Registration: Sanchez A. De-implementation of Low-value Pharmacological Prescriptions (De-imFAR). ClinicalTrials.gov, Identifier: NCT04022850. Registered July 17, 2019. In: ClinicalTrials.gov. Bethesda (MD): U.S. National Library of Medicine (NLM). Available from: https://www.clinicaltrials.gov/ct2/show/NCT04022850., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Sanchez, Elizondo-Alzola, Pijoan, Mediavilla, Pablo, Sainz de Rozas, Lekue, Gonzalez-Larragan, Llarena, Larrañaga, Helfrich and Grandes.)

Importance: Medications for addiction treatment (MAT) are inconsistently offered in HIV clinics., Objective: To evaluate the impact of implementation facilitation (hereafter referred to as "facilitation"), a multicomponent implementation strategy, on increasing provision of MAT for opioid use disorder (MOUD), alcohol use disorder (MAUD), and tobacco use disorder (MTUD)., Design, Setting, and Participants: Conducted from July 26, 2016, through July 25, 2020, the Working with HIV Clinics to adopt Addiction Treatment using Implementation Facilitation (WHAT-IF?) study used an unblinded, stepped wedge design to sequentially assign each of 4 HIV clinics in the northeastern US to cross over from control (ie, baseline practices) to facilitation (ie, intervention) and then evaluation and maintenance periods every 6 months. Participants were adult patients with opioid, alcohol, or tobacco use disorder. Data analysis was performed from August 2020 to September 2022., Interventions: Multicomponent facilitation., Main Outcomes and Measures: Outcomes, assessed using electronic health record data, were provision of MAT among patients with opioid, alcohol, or tobacco use disorder during the evaluation (primary outcome) and maintenance periods compared with the control period., Results: Among 3647 patients, the mean (SD) age was 49 (12) years, 1814 (50%) were Black, 781 (22%) were Hispanic, and 1407 (39%) were female; 121 (3%) had opioid use disorder, 126 (3%) had alcohol use disorder, and 420 (12%) had tobacco use disorder. Compared with the control period, there was no increase in provision of MOUD with facilitation during the evaluation period (243 patients [27%; 95% CI, 22%-32%] vs 135 patients [28%; 95% CI, 22%-35%]; P = .59) or maintenance period (198 patients [29%; 95% CI, 22%-36%]; P = .48). The change in provision of MAUD from the control period to the evaluation period was not statistically significant (251 patients [8%; 95% CI, 5%-12%] vs 112 patients [13%; 95% CI, 8%-21%]; P = .11); however, the difference increased and became significant during the maintenance period (180 patients [17%; 95% CI, 12%-24%]; P = .009). There were significant increases in provision of MTUD with facilitation during both the evaluation (810 patients [33%; 95% CI, 30%-36%] vs 471 patients [40%; 95% CI, 36%-45%]; P = .005) and maintenance (643 patients [38%; 95% CI, 34%-41%]; P = .047) periods., Conclusions and Relevance: In this randomized clinical trial, facilitation led to increased provision of MTUD, delayed improvements in MAUD, and no improvements in MOUD in HIV clinics. Enhanced strategies, potentially including clinic and patient incentives, especially for MOUD, may be needed to further increase provision of MAT in HIV clinics., Trial Registration: ClinicalTrials.gov Identifier: NCT02907944.

Introduction: Clinical-community linkages (CCLs) can improve health, but few instruments exist to evaluate these partnerships. To address this gap, we develop and test the Clinical-Community Linkage Self-Assessment Survey (CCL Self-Assessment)., Materials and Methods: We built on an existing framework and conducted a literature review to guide the design of our survey, and obtained feedback from academic, clinical, and community-based experts. To pretest the instrument, we conducted 10 think-aloud interviews with community-based health-promotion organizations. We performed feasibility testing with 38 staff from 20 community organizations, followed by criterion-validity testing., Results: The 15-item final instrument includes five domains: Nature of the Relationship, Communication, Referral Process, Feedback Loop, and Timeliness. Expert feedback included keeping the CCL Self-Assessment brief and actionable. Think-aloud interviews produced a range of revisions related to item wording, instructions, brevity, and formatting. Feasibility testing showed high response rate and ease of administration. Sites scoring high on the CCL Self-Assessment also scored high on the criterion measure., Discussion: We demonstrate feasibility, as well as face, content, construct, and criterion validity. Initial results suggest the CCL Self-Assessment survey may be used by community organizations to identify strengths and weaknesses of their linkages. Next steps include additional statistical validation and testing to determine how the CCL Self-Assessment survey works in the field as well as providing specific tools to improve linkages., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Fishleder, Harris, Petrescu-Prahova, Kohn and Helfrich.)

Background: Prior studies of radial access for cardiac catheterization have focused on early adopters of the technique, and some have described a risk/treatment paradox of low radial access use among high bleeding risk patients. This study aimed to determine (1) trends in radial access use over time, (2) if increasing use of radial access is driven by new invasive and interventional cardiologists (operators) or existing operators changing their practice, and (3) if increasing radial rates are associated with lower bleeding rates and elimination of the risk/treatment paradox., Methods: In this cross-sectional study using data from the Clinical Assessment, Reporting, and Tracking Program, we calculated radial access rates and risk-adjusted postprocedural bleeding rates of patients undergoing diagnostic angiography or percutaneous coronary intervention (PCI) between 2011 and 2018 in Veterans Affairs hospitals. We used separate bleeding risk models for diagnostic angiography and PCI and assessed temporal trends with the Kendall Tau-b test., Results: Among 253 179 diagnostic angiograms and 93 614 PCIs, radial access rates increased over time for both diagnostic (17.5%-60.4%; P <0.01)) and PCI procedures (14.0%-51.8%; P <0.01). Existing operators and new operators increased their use at similar rates, but new operators entered practice with higher baseline rates. Nearly all operators used radial access at least once in 2018. Overall adjusted rates of bleeding declined, a trend that was significant for diagnostic angiography (2.4%-1.4%, P =0.02) but not PCI (3.4%-2.5%, P =0.20). Femoral access patients had a higher predicted risk for bleeding., Conclusions: A steady rise in radial access for diagnostic angiography and PCI was driven by increasing use among existing operators and high use by new operators. While this was associated with decreasing bleeding rates, a risk/treatment paradox for access site selection persists; patients at higher bleeding risk were still more likely to receive femoral access.

Objective: Burnout, or job-related stress, affects more than half of all US physicians, with primary care physicians (PCPs) experiencing some of the highest rates in medicine. Our study analyzes national survey data to identify and prioritize workplace climate predictors of burnout among PCPs within a large integrated health system., Design: Observational study of annual survey data from the Veterans Health Administration (VHA) All Employee Survey (AES) for 2013-2017. AES response rate ranged from 56 to 60% during the study period. Independent and dependent variables were measured from separate random samples. In total, 8,456 individual-level responses among PCPs at 110 VHA practice sites were aggregated at the facility level by reporting year. We used the semi-automated LASSO procedure to identify workplace climate measures that were more influential in predicting burnout and assessed relative importance using the Shapely value decomposition., Participants: VHA employees that self-identify as PCPs., Main Measures: Dependent variables included two dichotomous measures of burnout: emotional exhaustion and depersonalization. Independent measures included 30 survey measures related to dimensions of workplace climate (e.g., workload, leadership, satisfaction)., Results: We identified seven influential workplace climate predictors of emotional exhaustion and nine predictors of depersonalization. With few exceptions, higher agreement/satisfaction scores for predictors were associated with a lower likelihood of burnout. The majority of explained variation in emotional exhaustion was attributable to perceptions of workload (32.6%), organization satisfaction (28.2%), and organization support (19.4%). The majority of explained variation in depersonalization was attributable to workload (25.3%), organization satisfaction (22.9%), and connection to VHA mission (20.7%)., Conclusion: Identifying the relative importance of workplace climate is important for the allocation of health organization resources to mitigate and prevent burnout within the PCP workplace. In a context of limited resources, efforts to reduce perceived workload and improve organization satisfaction may represent the biggest leverage points for health organizations to address physician burnout., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Background: The transradial approach (TRA) to cardiac catheterization is safer than the traditional transfemoral approach (TFA), with similar clinical effectiveness. However, adoption of TRA remains low, representing less than 50% of catheterization procedures in 2015. Peer coaching is one approach to facilitate implementation; however, the costs of this strategy for cardiac procedures such as TRA are unclear., Methods: We conducted an activity-based costing analysis (ABC) of a multi-center, hybrid type III implementation trial of a coaching intervention designed to increase the use of TRA. We identified the key activities of the intervention and determined the personnel, resources, and time needed to complete each activity. The personnel cost per hour and the activity duration were then used to estimate the cost of each activity and the total variable cost of the implementation. Fixed costs related to designing and running the implementation were calculated separately. All costs are reported in 2019 constant US dollars., Results: The total cost of the coaching intervention implementation was $374,863. Of the total cost, $367,752 were variable costs due to travel, preparatory work, in-person coaching, post-intervention evaluation, and administrative time. We estimated fixed costs of $7112. The mean marginal cost of implementing the intervention at only one additional medical center was $52,536., Conclusions: We provide granular cost estimates of a conceptually rooted implementation strategy designed to increase the uptake of TRA for cardiac catheterization. We estimate that implementation costs stemming from the coaching approach would be offset after the conversion of approximately 409 to 1363 catheterizations from TFA to TRA. Our estimates provide benchmarks of the expected costs of implementing evidence-based, but expertise-intensive, cardiac procedures., Trial Registration: ISRCTN, ISRCTN66341299 . Registered 7 July 2020-retrospectively registered., (© 2021. 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: Implementation researchers recognize the influential role of organizational factors and, thus, seek to assess these factors using quantitative measurement instruments. However, researchers are hindered by instruments that measure similar constructs but rely on different nomenclature and/or definitions. The Consolidated Framework for Implementation Research (CFIR) provides a taxonomy of constructs derived from prior frameworks and empirical studies of implementation-related constructs. The CFIR includes constructs based on the original Promoting Action on Research Implementation in Health Services (PARiHS) framework which highlights the key roles of strength of evidence for a specific evidence-based intervention (EBI), favorability of organizational context for change, and capacities to facilitate implementation of the EBI. Although the CFIR is among the most frequently used implementation frameworks, it does not include quantitative measures. The Organizational Resource and Context Assessment (ORCA) is a quantitative measurement instrument that was developed based on PARiHS, assessing its three domains. Factors within these three domains are conceptually similar to constructs in the CFIR but do not match directly. The aim of this work was to map ORCA survey items to CFIR constructs to enable direct comparisons and syntheses of findings across studies using the CFIR and/or ORCA., Methods: Two distinct, independent research teams, each used rigorous constant comparative techniques with deliberation and consensus to map individual items from the ORCA to the five domains and 39 constructs of CFIR., Results: ORCA items were mapped primarily to three of five CFIR domains: Inner Setting, Process, and Intervention Characteristics. The two research teams agreed on 88% of mappings at the higher domain level; at the lower construct level, their mappings aligned for 62.2% of the ORCA items., Conclusions: Mapping results reveal that the ORCA focuses measurement prominently on Inner Setting, Process, and Intervention Characteristics. This mapping guide can help improve consistency in measurement and reporting, enabling more efficient comparison and synthesis of findings that use either the ORCA instrument or the CFIR framework. The guide helps advance implementation science utilizing mixed methods by providing CFIR users with quantitative measures for selected constructs and enables ORCA users to map their findings to CFIR constructs.

Introduction: Despite evidence of possible patient harm and substantial costs, medication overuse is persistent. Patient reaction is one potential barrier to deprescribing, but little research has assessed this in specific instances of medication discontinuation. We sought to understand Veteran and provider experience when de-implementing guideline-discordant use of inhaled corticosteroids (ICS) in those with mild-to-moderate chronic obstructive pulmonary disease (COPD)., Methods: We conducted a mixed-methods analysis in a provider-randomized quality improvement project testing a proactive electronic-consultation from pulmonologists recommending ICS discontinuation when appropriate. PCPs at two Veterans Health Administration healthcare systems were included. We completed interviews with 16 unexposed providers and 6 intervention-exposed providers. We interviewed 9 patients within 3 months after their PCP proposed ICS discontinuation. We conducted inductive and deductive content analysis of qualitative data to explore an emergent theme of patient reaction. Forty-eight PCPs returned surveys (24 exposed and 24 unexposed, response rate: 35%)., Results: The unexposed providers anticipated their patients might resist ICS discontinuation because it seems counterintuitive to stop something that is working, patient's fear of worsening symptoms, or if the prescription was initiated by another provider. Intervention-exposed providers reported similar experiences in post-intervention interviews. Unexposed providers anticipated that patients may accept ICS discontinuation, citing tactical use of patient-centered care strategies. This was echoed by intervention-exposed providers who had successfully discontinued an ICS. Veterans reported acceding to their providers out of trust or deference to their advanced training, even after describing an ICS as a 'security blanket'. Our survey findings supported the subthemes from our interviews. Among providers who proposed discontinuation of an ICS, 76% reported that they were able to discontinue it or switch to another more appropriate medication., Conclusions: While PCPs anticipated that patients would resist discontinuing an ICS, interviews with patient and intervention-exposed PCPs along with surveys suggest that patients were receptive to this change., Competing Interests: The authors have declared that no competing interests exist.

Background: De-implementation or abandonment of ineffective or low-value healthcare is becoming a priority research field globally due to the growing empirical evidence of the high prevalence of such care and its impact in terms of patient safety and social inefficiency. Little is known, however, about the factors, barriers, and facilitators involved or about interventions that are effective in promoting and accelerating the de-implementation of low-value healthcare. The De-imFAR study seeks to carry out a structured, evidence-based, and theory-informed process involving the main stakeholders (clinicians, managers, patients, and researchers) for the design, deployment, and assessment of de-implementation strategies for reducing low-value pharmacological prescribing., Methods: A phase I formative study using a systematic and comprehensive framework based on theory and evidence for the design of implementation strategies-specifically, the Behavior Change Wheel (BCW)-will be conducted to design and model de-implementation strategies to favor reductions in low-value pharmacological prescribing of statins in primary prevention of cardiovascular disease (CVD) by main stakeholders (clinicians, managers, patients, and researchers) in a collegiate way. Subsequently, a phase II comparative hybrid trial will be conducted to assess the feasibility and potential effectiveness of at least one active de-implementation strategy to reduce low-value pharmacological prescribing of statins in primary prevention of CVD compared to the usual procedures for dissemination of clinical practice guidelines ("what-not-to-do" recommendations). A mixed-methods evaluation will be used: quantitative for the results of the implementation at the professional level (e.g., adoption, reach and implementation or execution of the recommended clinical practice); and qualitative to determine the feasibility and perceived impact of the de-implementation strategies from the clinicians' perspective, and patients' experiences related to the clinical care received., Discussion: The DE-imFAR study aims to generate valid scientific knowledge about the design and development of de-implementation strategies using theory- and evidence-based methodologies suggested by implementation science. It will explore the effectiveness of these strategies and their acceptability among clinicians, policymakers, and patients. Its ultimate goal is to maximize the quality and efficiency of our health system by abandoning low-value pharmacological prescribing., Trial Registration: Clinicaltrials.gov identifier: NCT04022850. Registered 17 July 2019.

Background: Chronic obstructive pulmonary disease (COPD) is among the most common medical diagnoses among Veterans. More than 50% of Veterans diagnosed with mild-to-moderate COPD are prescribed inhaled corticosteroids despite recommendations for use restricted to patients with frequent exacerbations., Objective: We explored primary care providers' experiences prescribing inhaled corticosteroids among patients with mild-to-moderate COPD as part of a quality improvement initiative., Design: We used a sequential mixed-methods evaluation approach to understand factors influencing primary care providers' inhaled corticosteroid prescribing for patients with mild-to-moderate COPD. Participants were recruited to participate in qualitative interviews and structured surveys., Participants: We used a purposive sample of primary care providers from 13 primary care clinics affiliated with two urban Veteran Health Administration healthcare systems., Main Measures: Interviews were transcribed and analyzed using content analysis. Qualitative findings informed a subsequent survey. Surveys were administered through REDCap and analyzed descriptively. Key qualitative and quantitative findings were compared., Key Results: Participants reported they were unaware of current evidence and recommendations for prescribing inhaled corticosteroids; for example, 46% of providers reported they were unaware of risks of pneumonia. Providers reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. We also found primary care providers may be reluctant to change inherited prescriptions, even if they thought inhaled corticosteroid therapy might not be appropriate., Conclusions: Inhaled corticosteroid prescribing in this patient population is partly due to primary care providers' lack of knowledge about the potential harms and availability of alternative therapies. Our findings suggest that efforts to expand access by increasing the number of prescribing providers a patient potentially sees could make it more difficult to de-implement harmful prescriptions. Our findings also corroborate prior findings that awareness of current evidence-based guidelines is likely an important part of medical overuse.

Objectives. To determine whether (1) participating in HealthLinks , and (2) adding wellness committees to HealthLinks increases worksites' evidence-based intervention (EBI) implementation. Methods. We developed HealthLinks to disseminate EBIs to small, low-wage worksites. From 2014 to 2017, we conducted a site-randomized trial in King County, Washington, with 68 small worksites (20-200 employees). We assigned worksites to 1 of 3 arms: HealthLinks , HealthLinks plus wellness committee ( HealthLinks+ ), or delayed control. At baseline, 15 months, and 24 months, we assessed worksites' EBI implementation on a 0% to 100% scale and employees' perceived support for their health behaviors. Results. Postintervention EBI scores in both intervention arms ( HealthLinks and HealthLinks+ ) were significantly higher than in the control arm at 15 months (51%, 51%, and 23%, respectively) and at 24 months (33%, 37%, and 24%, respectively; P  < .001). Employees in the intervention arms perceived greater support for their health at 15 and 24 months than did employees in control worksites. Conclusions. HealthLinks is an effective strategy for disseminating EBIs to small worksites in low-wage industries. Public Health Implications. Future research should focus on scaling up HealthLinks , improving EBI maintenance, and measuring impact of these on health behavior.

Despite higher health care needs, older adults often have limited and fixed income. Approximately a quarter of them report not filling or delaying prescription medications due to cost (cost-related prescription delay, CRPD). To ascertain the association between CRPD and satisfaction with health care, secondary analysis of the 2012 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare Advantage Survey was performed.Regression models quantified the association between CRPD and rating of personal doctor, specialist, and overall health care. Models were adjusted for demographic, health-related, and socioeconomic characteristics. 274,996 Medicare Advantage enrollees were mailed the CAHPS survey, of which 101,910 (36.8%) returned a survey that had responses to all the items we analyzed. CRPD was assessed by self-report of delay in filling prescriptions due to cost. Health care ratings were on a 0-10 scale. A score ≤ 5 was considered a poor rating of care.In unadjusted models, CRPD more than doubled the relative risk (RR) for poor ratings of personal doctor (RR 2.34), specialist (RR 2.14), and overall health care (RR 2.40). Adjusting for demographics and health status slightly reduced the RRs to 1.9, but adjusting for low-income subsidy and lack of insurance for medications did not make a difference.CRPD is independently associated with poor ratings of medical care, regardless of health, financial or insurance status. Providers might reduce patients' financial stress and improve patient satisfaction by explicitly discussing prescription cost and incorporating patient priorities when recommending treatments.

Ensuring equitable access to quality health care historically has focused on gaps in care, where patients fail to receive the high-value care that will benefit them, something termed underuse. But providing high-quality health care sometimes requires reducing low-value care that delivers no benefit or where known harms outweigh expected benefits. These situations represent health care overuse. The process involved in reducing low-value care is known as de-implementation. In this article, we argue that de-implementation is critical for advancing equity for several reasons. First, medical overuse is associated with patient race, ethnicity, and socioeconomic status. In some cases, the result is even double jeopardy, where racial and ethnic minorities are at higher risk of both overuse and underuse. In these cases, more traditional efforts focused exclusively on underuse ignore half of the problem. Second, overuse of preventive care and screening is often greater for more socioeconomically advantaged patients. Within insured populations, this means more socioeconomically disadvantaged patients subsidize overuse. Finally, racial and ethnic minorities may have different experiences of overuse than Whites in the United States. This may make efforts to de-implement overuse particularly fraught. We therefore provide several actions for closing current research gaps, including: adding subgroup analyses in studies of medical overuse; specifying and measuring potential mechanisms related to equity (eg, double jeopardy vs thermostat models of overuse); and testing de-implementation strategies that may mitigate bias., Competing Interests: Competing Interests: None declared.

Introduction: Organizational readiness to change may be a key determinant of implementation success and a mediator of the effectiveness of implementation interventions. If organizational readiness can be reliably and validly assessed at the outset of a change initiative, it could be used to assess the effectiveness of implementation-support activities by measuring changes in readiness factors over time., Methods: We analyzed two waves of readiness-to-change survey data collected as part of a three-arm, randomized controlled trial to implement evidence-based health promotion practices in small worksites in low-wage industries. We measured five readiness factors: context (favorable broader conditions); change valence (valuing health promotion); information assessment (demands and resources to implement health promotion); change commitment (an intention to implement health promotion); and change efficacy (a belief in shared ability to implement health promotion). We expected commitment and efficacy to increase at intervention sites along with their self-reported effort to implement health promotion practices, termed wellness-program effort. We compared means between baseline and 15 months, and between intervention and control sites. We used linear regression to test whether intervention and control sites differed in their change-readiness scores over time., Results: Only context and change commitment met reliability thresholds. Change commitment declined significantly for both control (-0.39) and interventions sites (-0.29) from baseline to 15 months, while context did not change for either. Only wellness program effort at 15 months, but not at baseline, differed significantly between control and intervention sites (1.20 controls, 2.02 intervention). Regression analyses resulted in two significant differences between intervention and control sites in changes from baseline to 15 months: (1) intervention sites exhibited significantly smaller change in context scores relative to control sites over time and (2) intervention sites exhibited significantly higher changes in wellness program effort relative to control sites., Discussion: Contrary to our hypothesis, change commitment declined significantly at both Healthlinks and control sites, even as wellness-program effort increased significantly at HealthLinks sites. Regression to the mean may explain the decline in change commitment. Future research needs to assess whether baseline commitment is an independent predictor of wellness-program effort or an effect modifier of the HealthLinks intervention.

Background and Objectives: Many barriers exist to older adult participation in physical activity, despite known benefits. Referrals from physical therapists (PTs) through clinical-community linkages offer novel, promising opportunities to increase older adult engagement in appropriate community-based physical activity programs. We assessed the capacity of PTs to participate in such linkages., Research Design and Methods: We collected qualitative data using semistructured phone interviews ( n = 30) with PTs across 14 states. We conducted thematic analysis using a priori themes based on the 2008 Bridging Model of Etz and colleagues: capacity to assess patient risk, ability to provide brief counseling, capacity and ability to refer, and awareness of community resources., Results: Risk assessment and counseling were already part of routine practice for our respondents, but counseling could be further facilitated if PTs had more skills to engage less-motivated patients. PTs expressed a desire to refer their patients to community programs; however, barriers to referrals included lack of knowledge of and trust in community programs, and limited infrastructure for communicating with potential partners., Discussion and Implications: PTs have the capacity to develop patient referral linkages with community-based physical activity programs. PT session length and content facilitates patient risk assessment and behavioral counseling. Integrating motivational techniques can help PTs engage less-motivated patients in physical activity. Systemic improvements should include innovations in communication infrastructure, identifying clinic-level champions, and in-person outreach initiated by organizations that deliver community physical activity programs.

Background: The patient-centered medical home (PCMH) is a primary care delivery model predicated on shared responsibility for patient care among members of an interprofessional team. Effective task sharing may reduce burnout among primary care providers (PCPs). However, little is known about the extent to which PCPs share these responsibilities, and which, if any, of the primary care tasks performed independently by the PCPs (vs. shared with the team) are particularly associated with PCP burnout. A better understanding of the relationship between these tasks and their effects on PCP burnout may help guide focused efforts aimed at reducing burnout., Objective: To investigate (1) the extent to which PCPs share responsibility for 14 discrete primary care tasks with other team members, and (2) which, if any, of the primary care tasks performed by the PCPs (without reliance on team members) are associated with PCP burnout., Design: Secondary data analysis of Veterans Health Administration (VHA) survey data from two time periods., Participants: 327 providers from 23 VA primary care practices within one VHA regional network., Main Measures: The dependent variable was PCP report of burnout. Independent variables included PCP report of the extent to which they performed 14 discrete primary care tasks without reliance on team members; team functioning; and PCP-, clinic-, and system-level variables., Key Results: In adjusted models, PCP reports of intervening on patient lifestyle factors and educating patients about disease-specific self-care activities, without reliance on their teams, were significantly associated with burnout (intervening on lifestyle: b = 4.11, 95% CI = 0.39, 7.83, p = 0.03; educating patients: b = 3.83, 95% CI = 0.33, 7.32, p = 0.03)., Conclusions: Performing behavioral counseling and self-management education tasks without relying on other team members for assistance was associated with PCP burnout. Expanding the roles of nurses and other healthcare professionals to assume responsibility for these tasks may ease PCP burden and reduce burnout.

Purpose: Appropriate delegation of clinical tasks from primary care providers (PCPs) to other team members may reduce employee burnout in primary care. However, (1) the extent to which delegation occurs within multidisciplinary teams, (2) factors associated with greater delegation, and (3) whether delegation is associated with burnout are all unknown., Methods: We performed a national cross-sectional survey of Veterans Affairs (VA) PCP-nurse dyads in Department of VA primary care clinics, 4 years into the VA's patient-centered medical home initiative. PCPs reported the extent to which they relied on other team members to complete 15 common primary care tasks; paired nurses reported how much they were relied on to complete the same tasks. A composite score of task delegation/reliance was developed by taking the average of the responses to the 15 questions. We performed multivariable regression to explore predictors of task delegation and burnout., Results: Among 777 PCP-nurse dyads, PCPs reported delegating tasks less than nurses reported being relied on (PCP mean ± standard deviation composite delegation score, 2.97± 0.64 [range, 1-4]; nurse composite reliance score, 3.26 ± 0.50 [range, 1-4]). Approximately 48% of PCPs and 35% of nurses reported burnout. PCPs who reported more task delegation reported less burnout (odds ratio [OR], 0.62 per unit of delegation; 95% confidence interval [CI], 0.49-0.78), whereas nurses who reported being relied on more reported more burnout (OR, 1.83 per unit of reliance; 95% CI, 1.33-2.5)., Conclusions: Task delegation was associated with less burnout for PCPs, whereas task reliance was associated with greater burnout for nurses. Strategies to improve work life in primary care by increasing PCP task delegation must consider the impact on nurses., Competing Interests: Conflict of interest: none declared., (© Copyright 2018 by the American Board of Family Medicine.)

Background: Work-related burnout is common in primary care and is associated with worse patient safety, patient satisfaction, and employee mental health. Workload, staffing stability, and team completeness may be drivers of burnout. However, few studies have assessed these associations at the team level, and fewer still include members of the team beyond physicians., Objective: To study the associations of burnout among primary care providers (PCPs), nurse care managers, clinical associates (MAs, LPNs), and administrative clerks with the staffing and workload on their teams., Design: We conducted an individual-level cross-sectional analysis of survey and administrative data in 2014., Participants: Primary care personnel at VA clinics responding to a national survey., Main Measures: Burnout was measured with a validated single-item survey measure dichotomized to indicate the presence of burnout. The independent variables were survey measures of team staffing (having a fully staffed team, serving on multiple teams, and turnover on the team), and workload both from survey items (working extended hours), and administrative data (patient panel overcapacity and average panel comorbidity)., Key Results: There were 4610 respondents (estimated response rate of 20.9%). The overall prevalence of burnout was 41%. In adjusted analyses, the strongest associations with burnout were having a fully staffed team (odds ratio [OR] = 0.55, 95% CI 0.47-0.65), having turnover on the team (OR = 1.67, 95% CI 1.43-1.94), and having patient panel overcapacity (OR = 1.19, 95% CI 1.01-1.40). The observed burnout prevalence was 30.1% lower (28.5% vs. 58.6%) for respondents working on fully staffed teams with no turnover and caring for a panel within capacity, relative to respondents in the inverse condition., Conclusions: Complete team staffing, turnover among team members, and panel overcapacity had strong, cumulative associations with burnout. Further research is needed to understand whether improvements in these factors would lower burnout.

Objective: Investigations of Appropriate Use Criteria (AUC) education have shown a mixed effect on changing provider behaviour. At our facility, rarely appropriate myocardial perfusion imaging (MPI) differs by specialty; awareness of AUC is low. Our objective is to investigate if specialty-specific, multimodality education could reduce rarely appropriate MPI., Methods: We designed education focused on the rarely appropriate MPI ordered most often by each specialty. We tracked appropriateness of MPI in three cohorts: pre, post (immediately after) and late-post (4 months after) intervention., Results: A total of 889 MPI were evaluated (n=287 pre, n=313 post, n=289 late-post), 95.3% were men. Chest pain was the most common symptom (n=530, 59.6%), while 14.1% (n=125) had no symptoms. Rarely appropriate testing decreased from 4.9% to 1.3% and remained at 1.4% in the late-post cohort (p<0.0001). In logistic regression, lack of symptoms (OR 31.3, 95% CI 10.3 to 94.8, p≤0.0001) and being in the post or late-post cohorts (OR 0.27, 95% CI 0.11 to 0.68, p=0.006) were associated with rarely appropriate MPI. Preoperative MPI in patients with good exercise capacity was a common rarely appropriate indication. Ischaemia was not observed among patients with rarely appropriate indication for MPI., Conclusions: In certain clinical settings, education may be an effective approach for deimplementing rarely appropriate MPI. The effect of education may be enhanced when focused on improving patient care, delivered by a peer, and needs assessment indicates low awareness of guidelines. Lack of symptoms and preoperative MPI continue to be the predominant rarely appropriate MPI ordered., Competing Interests: Competing interests: None declared.

Background: The patient-centered medical home (PCMH) is a team-based, comprehensive model of primary care. When effectively implemented, PCMH is associated with higher patient satisfaction, lower staff burnout, and lower hospitalization for ambulatory care-sensitive conditions. However, less is known about what factors contribute to (or hinder) PCMH implementation. We explored the associations of specific facilitators and barriers reported by primary care employees with a previously validated, clinic-level measure of PCMH implementation, the Patient Aligned Care Team Implementation Progress Index (Pi(2))., Methods: We used a 2012 survey of primary care employees in the Veterans Health Administration to perform cross-sectional, respondent-level multinomial regressions. The dependent variable was the Pi(2) categorized as high implementation (top decile, 54 clinics, 235 respondents), medium implementation (middle eight deciles, 547 clinics, 4537 respondents), and low implementation (lowest decile, 42 clinics, 297 respondents) among primary care clinics. The independent variables were ordinal survey items rating 19 barriers to patient-centered care and 10 facilitators of PCMH implementation. For facilitators, we explored clinic Pi(2) score decile both as a function of respondent-reported availability of facilitators and of rating of facilitator helpfulness., Results: The availability of five facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile: teamlet huddles (OR = 3.91), measurement tools (OR = 3.47), regular team meetings (OR = 2.88), information systems (OR = 2.42), and disease registries (OR = 2.01). The helpfulness of four facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile. Six barriers were associated with significantly higher odds of a respondent's clinic's Pi(2) scores being in the lowest versus highest decile, with the strongest associations for the difficulty recruiting and retaining providers (OR = 2.37) and non-provider clinicians (OR = 2.17). Results for medium versus low Pi(2) score clinics were similar, with fewer, smaller significant associations, all in the expected direction., Conclusions: A number of specific barriers and facilitators were associated with PCMH implementation, notably recruitment and retention of clinicians, team huddles, and local education. These findings can guide future research, and may help healthcare policy makers and leaders decide where to focus attention and limited resources.

Objectives: In 2011, the Veterans Health Administration (VHA) implemented electronic consults (e-consults) as an alternative to in-person specialty visits to improve access and reduce travel for veterans. We conducted an evaluation to understand variation in the use of the new e-consult mechanism and the causes of variable implementation, guided by the Consolidated Framework for Implementation Research (CFIR)., Study Design: Qualitative case studies of 3 high- and 5 low-implementation e-consult pilot sites. Participants included e-consult site leaders, primary care providers, specialists, and support staff identified using a modified snowball sample., Methods: We used a 3-step approach, with a structured survey of e-consult site leaders to identify key constructs, based on the CFIR. We then conducted open-ended interviews, focused on key constructs, with all participants. Finally, we produced structured, site-level ratings of CFIR constructs and compared them between high- and low-implementation sites., Results: Site leaders identified 14 initial constructs. We conducted 37 interviews, from which 4 CFIR constructs distinguished high implementation e-consult sites: compatibility, networks and communications, training, and access to knowledge and information. For example, illustrating compatibility, a specialist at a high-implementation site reported that the site changed the order of consult options so that all specialties listed e-consults first to maintain consistency. High-implementation sites also exhibited greater agreement on constructs., Conclusions: By using the CFIR to analyze results, we facilitate future synthesis with other findings, and we better identify common patterns of implementation determinants common across settings.

As VHA expands the use of e-consults, this study suggests that they often are more timely than are face-to-face consultations., Competing Interests: Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.

Background: Burnout affects nearly half of all U.S. nurses and physicians, and has been linked to poor outcomes such as worse patient safety. The most common measure of burnout is the well-validated Maslach Burnout Inventory (MBI). However, the MBI is proprietary and carries licensing fees, posing challenges to routine or repeated assessment., Objective: To compare a non-proprietary, single-item burnout measure to a single item from the MBI Emotional Exhaustion (MBI:EE) subscale that has been validated as a standalone burnout measure., Design: Cross-sectional online survey., Participants: A sample of primary care providers (PCPs), registered nurses, clinical associates (e.g., licensed practical nurses (LPNs), medical technicians), and administrative clerks in the Veterans Health Administration surveyed in 2012., Main Methods: We compared a validated one-item version of the MBI:EE and a non-proprietary single-item burnout measure used in the Physician Work Life Study. We calculated kappa statistics, sensitivity and specificity, positive predictive (PPV) and negative predictive values (NPV), and area under the receiver operator curve (AUC). We conducted analyses stratified by occupation to determine the stability of the correlation between the two measures., Key Results: We analyzed responses from 5,404 participants, including 1,769 providers and 1,380 registered nurses. The prevalence of burnout was 36.7% as measured on the single MBI:EE item and 38.5% as measured on the non-proprietary single-item measure. Relative to the MBI:EE, the non-proprietary single-item measure had a correlation of 0.79, sensitivity of 83.2%, specificity of 87.4%, and AUC of 0.93 (se = 0.004). Results were similar when stratified by respondent occupation., Conclusions: A non-proprietary single-item measure served as a reliable substitute for the MBI:EE across occupations. Because it is non-proprietary and easy to interpret, it has logistical advantages over the one-item MBI.

Background: Like other transformative healthcare initiatives, patient-centered medical home (PCMH) implementation requires substantial investments of time and resources. Even though PCMH and PCMH-like models are being implemented by multiple provider practices and health systems, little is known about what facilitates their implementation. The purpose of this study was to assess which PCMH-implementation resources are most widely used, by whom, and which resources primary care personnel find most helpful., Methods: This study is an analysis of data from a cross-sectional survey of primary care personnel in the Veterans Health Administration in 2012, in which respondents were asked to rate whether they were aware of and accessed PCMH-implementation resources, and to rate their helpfulness. Logistic regression was used to produce odds ratios for the outcomes (1) resource use and (2) resource helpfulness. Respondents were nested within clinics, nested, in turn, within 135 parent hospitals., Results: Teamlet huddles were the most widely accessed (80.4% accessed) and most helpful (90.4% rated helpful) resource; quality-improvement methods to conduct small tests of change were the least frequently accessed (42.4% accessed) resource though two-thirds (66.7%) of users reported as helpful. Supervisors were significantly more likely (ORs, 1.46 to 1.86) to use resources than non-supervisors but were less likely to rate the majority (8 out of 10) of resources as "somewhat/very helpful" than non-supervisors (ORs, 0.72 to 0.84). Longer-tenured employees tended to rate resources as more helpful., Conclusions: These findings are the first in the PCMH literature that we are aware of that systematically assesses primary care staff's access to and the helpfulness of PCMH implementation resources. Supervisors generally reported greater access to resources, relative to non-supervisors, but rated resources as less helpful, suggesting that information about them may not have been optimally disseminated. Knowing what resources primary care staff use and find helpful can inform administrators' and policymakers' investments in PCMH-implementation resources. The implications of our model extend beyond just PCMH implementation but also to considerations when providing implementation resources for other complex quality-improvement initiatives.

Background: Older persons account for the majority of hospitalizations in the United States.1 Identifying risk factors for hospitalization among elders, especially potentially preventable hospitalization, may suggest opportunities to improve primary care. Certain factors-for example, living alone-may increase the risk for hospitalization, and their effect may be greater among persons with dementia and the old-old (aged 85+)., Objectives: To determine the association of living alone and risk for hospitalization, and see if the observed effect is greater among persons with dementia or the old-old., Design: Retrospective longitudinal cohort study., Participants: 2,636 participants in the Adult Changes in Thought (ACT) study, a longitudinal cohort study of dementia incidence. Participants were adults aged 65+ enrolled in an integrated health care system who completed biennial follow-up visits to assess for dementia and living situation., Main Measures: Hospitalization for all causes and for ambulatory care sensitive conditions (ACSCs) were identified using automated data., Key Results: At baseline, the mean age of participants was 75.5 years, 59 % were female and 36 % lived alone. Follow-up time averaged 8.4 years (SD 3.5), yielding 10,431 approximately 2-year periods for analysis. Living alone was positively associated with being aged 85+, female, and having lower reported social support and better physical function, and negatively associated with having dementia. In a regression model adjusted for age, sex, comorbidity burden, physical function and length of follow-up, living alone was not associated with all-cause (OR = 0.93; 95 % CI 0.84, 1.03) or ambulatory care sensitive condition (ACSC) hospitalization (OR = 0.88; 95 % CI 0.73, 1.07). Among participants aged 85+, living alone was associated with a lower risk for all-cause (OR = 0.76; 95 % CI 0.61, 0.94), but not ACSC hospitalization. Dementia did not modify any observed associations., Conclusion: Living alone in later life did not increase hospitalization risk, and in this population may be a marker of healthy aging in the old-old.

Background: A high proportion of the US primary care workforce reports burnout, which is associated with negative consequences for clinicians and patients. Many protective factors from burnout are characteristics of patient-centered medical home (PCMH) models, though even positive organizational transformation is often stressful. The existing literature on the effects of PCMH on burnout is limited, with most findings based on small-scale demonstration projects with data collected only among physicians, and the results are mixed., Objective: To determine if components of PCMH related to team-based care were associated with lower burnout among primary care team members participating in a national medical home transformation, the VA Patient Aligned Care Team (PACT)., Design: Web-based, cross-sectional survey and administrative data from May 2012., Participants: A total of 4,539 VA primary care personnel from 588 VA primary care clinics., Main Measures: The dependent variable was burnout, and the independent variables were measures of team-based care: team functioning, time spent in huddles, team staffing, delegation of clinical responsibilities, working to top of competency, and collective self-efficacy. We also included administrative measures of workload and patient comorbidity., Key Results: Overall, 39 % of respondents reported burnout. Participatory decision making (OR 0.65, 95 % CI 0.57, 0.74) and having a fully staffed PACT (OR 0.79, 95 % CI 0.68, 0.93) were associated with lower burnout, while being assigned to a PACT (OR 1.46, 95 % CI 1.11, 1.93), spending time on work someone with less training could do (OR 1.29, 95 % CI 1.07, 1.57) and a stressful, fast-moving work environment (OR 4.33, 95 % CI 3.78, 4.96) were associated with higher burnout. Longer tenure and occupation were also correlated with burnout., Conclusions: Lower burnout may be achieved by medical home models that are appropriately staffed, emphasize participatory decision making, and increase the proportion of time team members spend working to the top of their competency level.

The Department of Veterans Affairs (VA) has been at the vanguard of information technology (IT) and use of comprehensive electronic health records. Despite the widespread use of health IT in the VA, there are still a variety of key questions that need to be answered in order to maximize the utility of IT to improve patient access to quality services. This paper summarizes the potential of IT to enhance healthcare access, key gaps in current evidence linking IT and access, and methodologic challenges for related research. We also highlight four key issues to be addressed when implementing and evaluating the impact of IT interventions on improving access to quality care: 1) Understanding broader needs/perceptions of the Veteran population and their caregivers regarding use of IT to access healthcare services and related information. 2) Understanding individual provider/clinician needs/perceptions regarding use of IT for patient access to healthcare. 3) System/Organizational issues within the VA and other organizations related to the use of IT to improve access. 4) IT integration and information flow with non-VA entities. While the VA is used as an example, the issues are salient for healthcare systems that are beginning to take advantage of IT solutions.

Background: Based on a critical synthesis of literature on use of the Promoting Action on Research Implementation in Health Services (PARIHS) framework, revisions and a companion Guide were developed by a group of researchers independent of the original PARIHS team. The purpose of the Guide is to enhance and optimize efforts of researchers using PARIHS in implementation trials and evaluations., Methods: Authors used a planned, structured process to organize and synthesize critiques, discussions, and potential recommendations for refinements of the PARIHS framework arising from a systematic review. Using a templated form, each author independently recorded key components for each reviewed paper; that is, study definitions, perceived strengths/limitations of PARIHS, other observations regarding key issues and recommendations regarding needed refinements. After reaching consensus on these key components, the authors summarized the information and developed the Guide., Results: A number of revisions, perceived as consistent with the PARIHS framework's general nature and intent, are proposed. The related Guide is composed of a set of reference tools, provided in Additional files. Its core content is built upon the basic elements of PARIHS and current implementation science., Conclusions: We invite researchers using PARIHS for targeted evidence-based practice (EBP) implementations with a strong task-orientation to use this Guide as a companion and to apply the revised framework prospectively and comprehensively. Researchers also are encouraged to evaluate its use relative to perceived strengths and issues. Such evaluations and critical reflections regarding PARIHS and our Guide could thereby promote the framework's continued evolution.

Background: There is widespread interest in measuring organizational readiness to implement evidence-based practices in clinical care. However, there are a number of challenges to validating organizational measures, including inferential bias arising from the halo effect and method bias - two threats to validity that, while well-documented by organizational scholars, are often ignored in health services research. We describe a protocol to comprehensively assess the psychometric properties of a previously developed survey, the Organizational Readiness to Change Assessment., Objectives: Our objective is to conduct a comprehensive assessment of the psychometric properties of the Organizational Readiness to Change Assessment incorporating methods specifically to address threats from halo effect and method bias., Methods and Design: We will conduct three sets of analyses using longitudinal, secondary data from four partner projects, each testing interventions to improve the implementation of an evidence-based clinical practice. Partner projects field the Organizational Readiness to Change Assessment at baseline (n = 208 respondents; 53 facilities), and prospectively assesses the degree to which the evidence-based practice is implemented. We will conduct predictive and concurrent validities using hierarchical linear modeling and multivariate regression, respectively. For predictive validity, the outcome is the change from baseline to follow-up in the use of the evidence-based practice. We will use intra-class correlations derived from hierarchical linear models to assess inter-rater reliability. Two partner projects will also field measures of job satisfaction for convergent and discriminant validity analyses, and will field Organizational Readiness to Change Assessment measures at follow-up for concurrent validity (n = 158 respondents; 33 facilities). Convergent and discriminant validities will test associations between organizational readiness and different aspects of job satisfaction: satisfaction with leadership, which should be highly correlated with readiness, versus satisfaction with salary, which should be less correlated with readiness. Content validity will be assessed using an expert panel and modified Delphi technique., Discussion: We propose a comprehensive protocol for validating a survey instrument for assessing organizational readiness to change that specifically addresses key threats of bias related to halo effect, method bias and questions of construct validity that often go unexplored in research using measures of organizational constructs.

Background: The Promoting Action on Research Implementation in Health Services framework, or PARIHS, is a conceptual framework that posits key, interacting elements that influence successful implementation of evidence-based practices. It has been widely cited and used as the basis for empirical work; however, there has not yet been a literature review to examine how the framework has been used in implementation projects and research. The purpose of the present article was to critically review and synthesize the literature on PARIHS to understand how it has been used and operationalized, and to highlight its strengths and limitations., Methods: We conducted a qualitative, critical synthesis of peer-reviewed PARIHS literature published through March 2009. We synthesized findings through a three-step process using semi-structured data abstraction tools and group consensus., Results: Twenty-four articles met our inclusion criteria: six core concept articles from original PARIHS authors, and eighteen empirical articles ranging from case reports to quantitative studies. Empirical articles generally used PARIHS as an organizing framework for analyses. No studies used PARIHS prospectively to design implementation strategies, and there was generally a lack of detail about how variables were measured or mapped, or how conclusions were derived. Several studies used findings to comment on the framework in ways that could help refine or validate it. The primary issue identified with the framework was a need for greater conceptual clarity regarding the definition of sub-elements and the nature of dynamic relationships. Strengths identified included its flexibility, intuitive appeal, explicit acknowledgement of the outcome of 'successful implementation,' and a more expansive view of what can and should constitute 'evidence.', Conclusions: While we found studies reporting empirical support for PARIHS, the single greatest need for this and other implementation models is rigorous, prospective use of the framework to guide implementation projects. There is also need to better explain derived findings and how interventions or measures are mapped to specific PARIHS elements; greater conceptual discrimination among sub-elements may be necessary first. In general, it may be time for the implementation science community to develop consensus guidelines for reporting the use and usefulness of theoretical frameworks within implementation studies.

One important factor influencing the successful implementation of system-wide change is initial readiness. Readiness is defined as the degree to which those involved are individually and collectively primed, motivated, and technically capable of executing the change. We present a conceptual framework that highlights three broad areas to be considered if health-care professionals are to comprehensively evaluate readiness that includes psychological factors (i.e., characteristics of those being asked to change), structural factors (i.e., circumstances under which the change is occurring) as well as the level of analysis (i.e., individual and organizational levels). We also describe more specific dimensions within each of these broad categories that have both empirical and theoretical support, presenting several valid and reliable survey instruments that measure key dimensions of readiness quantitatively.

The VA Cardiovascular Assessment, Reporting, and Tracking (CART) system is a customized electronic medical record system which provides standardized report generation for cardiac catheterization procedures, serves as a national data repository, and is the centerpiece of a national quality improvement program. Like many health information technology projects, CART implementation did not proceed without some barriers and resistance. We describe the nationwide implementation of CART at the 77 VA hospitals which perform cardiac catheterizations in three phases: (1) strategic collaborations; (2) installation; and (3) adoption. Throughout implementation, success required a careful balance of technical, clinical, and organizational factors. We offer strategies developed through CART implementation which are broadly applicable to technology projects aimed at improving the quality, reliability, and efficiency of health care.

Background: Mortality from acute myocardial infarction (AMI) is declining worldwide. We sought to determine if mortality in the Veterans Health Administration (VHA) has also been declining., Methods: We calculated 30-day mortality rates between 2004 and 2006 using data from the VHA External Peer Review Program (EPRP), which entails detailed abstraction of records of all patients with AMI. To compare trends within VHA with other systems of care, we estimated relative mortality rates between 2000 and 2005 for all males 65 years and older with a primary diagnosis of AMI using administrative data from the VHA Patient Treatment File and the Medicare Provider Analysis and Review (MedPAR) files., Results: Using EPRP data on 11,609 patients, we observed a statistically significant decline in adjusted 30-day mortality following AMI in VHA from 16.3% in 2004 to 13.9% in 2006, a relative decrease of 15% and a decrease in the odds of dying of 10% per year (p = .011). Similar declines were found for in-hospital and 90-day mortality.Based on administrative data on 27,494 VHA patients age 65 years and older and 789,400 Medicare patients, 30-day mortality following AMI declined from 16.0% during 2000-2001 to 15.7% during 2004-June 2005 in VHA and from 16.7% to 15.5% in private sector hospitals. After adjusting for patient characteristics and hospital effects, the overall relative odds of death were similar for VHA and Medicare (odds ratio 1.02, 95% C.I. 0.96-1.08)., Conclusion: Mortality following AMI within VHA has declined significantly since 2003 at a rate that parallels that in Medicare-funded hospitals.

Background: The Promoting Action on Research Implementation in Health Services, or PARIHS, framework is a theoretical framework widely promoted as a guide to implement evidence-based clinical practices. However, it has as yet no pool of validated measurement instruments that operationalize the constructs defined in the framework. The present article introduces an Organizational Readiness to Change Assessment instrument (ORCA), organized according to the core elements and sub-elements of the PARIHS framework, and reports on initial validation., Methods: We conducted scale reliability and factor analyses on cross-sectional, secondary data from three quality improvement projects (n = 80) conducted in the Veterans Health Administration. In each project, identical 77-item ORCA instruments were administered to one or more staff from each facility involved in quality improvement projects. Items were organized into 19 subscales and three primary scales corresponding to the core elements of the PARIHS framework: (1) Strength and extent of evidence for the clinical practice changes represented by the QI program, assessed with four subscales, (2) Quality of the organizational context for the QI program, assessed with six subscales, and (3) Capacity for internal facilitation of the QI program, assessed with nine subscales., Results: Cronbach's alpha for scale reliability were 0.74, 0.85 and 0.95 for the evidence, context and facilitation scales, respectively. The evidence scale and its three constituent subscales failed to meet the conventional threshold of 0.80 for reliability, and three individual items were eliminated from evidence subscales following reliability testing. In exploratory factor analysis, three factors were retained. Seven of the nine facilitation subscales loaded onto the first factor; five of the six context subscales loaded onto the second factor; and the three evidence subscales loaded on the third factor. Two subscales failed to load significantly on any factor. One measured resources in general (from the context scale), and one clinical champion role (from the facilitation scale)., Conclusion: We find general support for the reliability and factor structure of the ORCA. However, there was poor reliability among measures of evidence, and factor analysis results for measures of general resources and clinical champion role did not conform to the PARIHS framework. Additional validation is needed, including criterion validation.

Objective: Identify and describe interventions to reduce time to reperfusion for patients with ST-segment elevation myocardial infarction (STEMI)., Data Source: Key word searches of five research databases: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Web of Science, and Cochrane Clinical Trials Registry., Interventions: We included controlled and uncontrolled studies of interventions to reduce time to reperfusion. One researcher reviewed abstracts and 2 reviewed full text articles. Articles were subsequently abstracted into structured data tables, which included study design, setting, intervention, and outcome variables. We inductively developed intervention categories from the articles. A second researcher reviewed data abstraction for accuracy., Measurements and Main Results: We identified 666 articles, 42 of which met inclusion criteria. We identified 11 intervention categories and classified them as either process specific (e.g., emergency department administration of thrombolytic therapy, activation of the catheterization laboratory by emergency department personnel) or system level (e.g., continuous quality improvement, critical pathways). A majority of studies (59%) were single-site pre/post design, and nearly half (47%) had sample sizes less than 100 patients. Thirty-two studies (76%) reported significantly lower door to reperfusion times associated with an intervention, 12 (29%) of which met or exceeded guideline recommended times. Relative decreases in times to reperfusion ranged from 15 to 82% for door to needle and 13-64% for door to balloon., Conclusions: We identified an array of process and system-based quality improvement interventions associated with significant improvements in door to reperfusion time. However, weak study designs and inadequate information about implementation limit the usefulness of this literature.

Background: The Competing Values Framework (CVF) has been widely used in health services research to assess organizational culture as a predictor of quality improvement implementation, employee and patient satisfaction, and team functioning, among other outcomes. CVF instruments generally are presented as well-validated with reliable aggregated subscales. However, only one study in the health sector has been conducted for the express purpose of validation, and that study population was limited to hospital managers from a single geographic locale., Methods: We used exploratory and confirmatory factor analyses to examine the underlying structure of data from a CVF instrument. We analyzed cross-sectional data from a work environment survey conducted in the Veterans Health Administration (VHA). The study population comprised all staff in non-supervisory positions. The survey included 14 items adapted from a popular CVF instrument, which measures organizational culture according to four subscales: hierarchical, entrepreneurial, team, and rational., Results: Data from 71,776 non-supervisory employees (approximate response rate 51%) from 168 VHA facilities were used in this analysis. Internal consistency of the subscales was moderate to strong (alpha = 0.68 to 0.85). However, the entrepreneurial, team, and rational subscales had higher correlations across subscales than within, indicating poor divergent properties. Exploratory factor analysis revealed two factors, comprising the ten items from the entrepreneurial, team, and rational subscales loading on the first factor, and two items from the hierarchical subscale loading on the second factor, along with one item from the rational subscale that cross-loaded on both factors. Results from confirmatory factor analysis suggested that the two-subscale solution provides a more parsimonious fit to the data as compared to the original four-subscale model., Conclusion: This study suggests that there may be problems applying conventional CVF subscales to non-supervisors, and underscores the importance of assessing psychometric properties of instruments in each new context and population to which they are applied. It also further highlights the challenges management scholars face in assessing organizational culture in a reliable and comparable way. More research is needed to determine if the emergent two-subscale solution is a valid or meaningful alternative and whether these findings generalize beyond VHA.