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Reducing the prevalence of acute kidney injury (AKI) is an important patient safety objective set forth by the National Quality Forum. Despite international guidelines to prevent AKI, there continues to be an inconsistent uptake of these interventions by cardiac teams across practice settings. The IMPROVE-AKI study was designed to test the effectiveness and implementation of AKI preventive strategies delivered through team-based coaching activities. Qualitative methods were used to identify factors that shaped sites' implementation of AKI prevention strategies. Semi-structured interviews were conducted with staff in a range of roles within the cardiac catheterization laboratories, including nurses, laboratory managers, and interventional cardiologists (N = 50) at multiple time points over the course of the study. Interview transcripts were qualitatively coded, and aggregated code reports were reviewed to construct main themes through memoing. In this paper, we report insights from semi-structured interviews regarding workflow, organizational culture, and leadership factors that impacted implementation of AKI prevention strategies. [ABSTRACT FROM AUTHOR]

This qualitative study explored the impact of COVID-19 on older rural-dwelling veterans and their caregivers enrolled in home-based primary care (HBPC) through the Birmingham VA Health Care System (BVAHCS). Phone interviews were conducted with 16 veterans and/or their caregivers and rapid qualitative analysis of interview notes was performed. Average age of veterans was 77 (range = 69–97) and 93.7% were white males. Despite a significant number of co-morbidities, 68.8% reported minimal adverse impacts of COVID-19 on overall physical and mental health. Like many healthcare teams, the inter-disciplinary VA HBPC team incorporated Telehealth during COVID-19. Telehealth utilization varied among the 16 participants, with 50% using telehealth independently, 37.5% needing assistance, and 12% lacking access. Our findings are consistent with prior research that identifies resilient characteristics as potentially protective in this high-risk older veteran population during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Background: Cancer recurrence after treatment is a concern for patients and oncologists alike. The movement towards treatment optimization, with trials testing less than the current standard of care (SoC), complicates this experience. Our objective was to assess oncologists' psychological response to patient recurrence on optimization‐focused trials and identify factors that influence those experiences. Methods: Clinical oncologists participated in a semi‐structured interview regarding patient enrollment in treatment optimization trials. We identified factors that influence the degree of psychological response that the oncologist may feel after patient recurrence. Residual agreement analysis was used to identify whether differences in reported psychological response was associated with alternative emphases on identified factors. Results: Thirty‐six oncologists identified 20 factors spanning five major themes that affected their psychological response to patient recurrence. All oncologists expressed willingness to enroll patients in treatment optimization clinical trials; however, half indicated that they were more likely to experience a negative psychological response after a treatment optimization trial than after a traditional intensification trial, and a quarter reported that patient recurrence on an optimization trial would impact their recommendations for future trial enrollment. Oncologists who reported more negative psychological responses to patient recurrence after participation in an optimization trial were more likely to emphasize introspective factors, while those who reported no difference in response emphasized patient‐ and process‐focused factors. Conclusions: Although most oncologists recognize the importance of treatment optimization trials, a significant proportion indicated a greater potential for psychological distress following patient recurrence in such trials and offered insight into how trial design and the process of patient enrollment can be improved to minimize those negative psychological responses. [ABSTRACT FROM AUTHOR]

PURPOSE As outcomes improve in early-stage breast cancer, clinical trials are undergoing a paradigm shift from intensification trials (more therapy) to improve survival to optimization trials, which assess the potential for using less toxic therapy while preserving survival outcomes. However, little is known about physician perspectives in community and academic settings about possible barriers and facilitators that could affect accrual to optimization clinical trials and the generalizability of future findings. METHODS We conducted a qualitative study with semistructured interviews of medical oncologists from different academic and community practices to assess their perspectives on optimization trials. Interviews were audiorecorded and transcribed. Three independent coders used a content analysis approach to analyze transcripts using NVivo. Major themes and exemplary quotes were extracted. RESULTS All 39 physicians reported that they would enroll patients in optimization clinical trials. Oncologists highlighted specific reasons to consider optimization trials. These included quality-of-life improvement by reducing toxicity, reduction in financial toxicity, fertility preservation, ability to avoid chemotherapy, minimization of overtreatment in patients with comorbid conditions, personalized treatment, opportunities to test novel therapies, and leveraging the availability of targeted therapies. Oncologists also identified accrual barriers, such as tumor-specific biology, individual (host) factors, prognostic markers of risk, access to therapies, provider experience, and system constraints. They voiced recommendations regarding preliminary data, trial design, and tools to support enrollment in optimization trials. CONCLUSION Although oncologists are generally willing to enroll patients on optimization clinical trials, barriers affect their acceptance. A scientific focus on overcoming these barriers is needed to support future enrollment on trials tailoring therapy on the basis of risk and potential benefit to allow true personalization of treatment. [ABSTRACT FROM AUTHOR]

Background Historically, clinical trials involved adding novel agents to standard of care to improve survival. There has been a shift to an individualized approach with testing less intense treatment, particularly in breast cancer where risk of recurrence is low. Little is known about physician perspectives on delivering less intense treatment for patients who are not well represented in clinical trials. Methods Open-ended, individual qualitative interviews with medical oncologists explored their perspectives on trials that test less intense treatment for patients with cancer, with a focus on breast cancer. Interviews were audio-recorded and transcribed. Four independent coders utilized a content analysis approach to analyze transcripts using NVivo. Major themes and exemplary quotes were extracted. Results Of the 39 participating physicians, 61.5% felt comfortable extrapolating, 30.8% were hesitant, and 7.7% would not feel comfortable extrapolating trial outcomes to underrepresented populations. Facilitators of comfort included the sentiment that "biology is biology" (such that the cancer characteristics were what mattered), the strength of the evidence, inclusion of subset analysis on underrepresented populations, and prior experience making decisions with limited data. Barriers to extrapolation included potential harm over the patient's lifetime, concerns about groups that had minimal participants, application to younger patients, and extending findings to diverse populations. Universally, broader inclusion in trials testing lowering chemotherapy was desired. Conclusions The majority (92%) of physicians reported that they would de-implement treatment for patients poorly represented in clinical trials testing less treatment, while expressing concerns about applicability to specific subpopulations. Further work is needed to increase clinical trial representation of diverse populations to safely and effectively optimize treatment for patients with cancer. Trial registration NCT03248258 [ABSTRACT FROM AUTHOR]

Disability prevention and preservation of independence is crucial for successful aging of older adults. To date, relatively little is known regarding disparities in independent aging in a disadvantaged older adult population despite widely recognized health disparities reported in other populations and disciplines. In the U.S., the Southeastern region also known as "the Deep South", is an economically and culturally unique region ravaged by pervasive health disparities – thus it is critical to evaluate barriers to independent aging in this region along with strategies to overcome these barriers. The objective of this narrative review is to highlight unique barriers to independent aging in the Deep South and to acknowledge gaps and potential strategies and opportunities to fill these gaps. We have synthesized findings of literature retrieved from searches of computerized databases and authoritative texts. Ultimately, this review aims to facilitate discussion and future research that will help to address the unique challenges to the preservation of independence among older adults in the Deep South region. [ABSTRACT FROM AUTHOR]

PURPOSE For many patients with cancer, the frequency of surveillance after primary treatment depends on the risk for cancer recurrence or progression. Lack of risk-aligned surveillance means too many unnecessary surveillance procedures for low-risk patients and not enough for high-risk patients. Using bladder cancer as an example, we examined whether practice determinants differ between Department of Veterans Affairs sites where risk-aligned surveillance was more (risk-aligned sites) or less common (need improvement sites). METHODS We used our prior quantitative data to identify two risk-aligned sites and four need improvement sites. We performed semistructured interviews with 40 Veterans Affairs staff guided by the Tailored Implementation for Chronic Diseases framework that were deductively coded. We integrated quantitative data (risk-aligned site v need improvement site) and qualitative data from interviews, cross-tabulating salient determinants by site type. RESULTS There were 14 participants from risk-aligned sites and 26 participants from need improvement sites. Irrespective of site type, we found a lack of knowledge on guideline recommendations. Additional salient determinants at need improvement sites were a lack of resources ("the next available without overbooking is probably seven to eight weeks out") and an absence of routines to incorporate risk-aligned surveillance ("I have my own guidelines that I've been using for 35 years"). CONCLUSION Knowledge, resources, and lack of routines were salient barriers to risk-aligned bladder cancer surveillance. Implementation strategies addressing knowledge and resources can likely contribute to more riskaligned surveillance. In addition, reminders for providers to incorporate risk into their surveillance plans may improve their routines. [ABSTRACT FROM AUTHOR]

Background: Pressure injury prevention is a persistent concern in nursing. The Veterans Health Administration implemented a creative approach with successful outcomes across the United States. Problem: Pressure injury prevention is a measure of nursing quality of care and a high priority in the Veterans Health Administration. Methods: A 12-month Virtual Breakthrough Series Collaborative utilizing coaching and group calls was conducted to assist long-term and acute care teams with preventing pressure injuries. Interventions: Interventions from the Veterans Health Administration Skin Bundle were implemented, including pressure-relieving surfaces, novel turning techniques, specialized dressings, and emollients to prevent skin breakdown. Results: The aggregated pressure injury rate for all teams decreased from Prework to the Action phase from 1.0 to 0.8 per 1000 bed days of care (P = .01). The aggregated pressure injury rates for long-term care units decreased from Prework to Continuous Improvement from 0.8 to 0.4 per 1000 bed days of care (P = .021). Conclusion: The Virtual Breakthrough Series helped reduce pressure injuries. [ABSTRACT FROM AUTHOR]

PURPOSE Many patients living with bladder cancer do not undergo surveillance that is aligned with their risk for recurrence or progression, which exposes them to unnecessary risk and burden of procedures. To implement risk-aligned surveillance as recommended by multiple guidelines, we need to understand patient-, provider-, and system-level factors contributing to the delivery of risk-aligned surveillance. In this study, we sought to systematically assess patient-level factors. PARTICIPANTS AND METHODS Guided by the Tailored Implementation for Chronic Diseases framework, we conducted semistructured interviews with 22 patients with bladder cancer undergoing surveillance cystoscopy procedures at three facilities within the Department of Veterans Affairs. Patients were sampled using quantitative data on bladder cancer risk category (low v high) and on surveillance category (aligned v not aligned with cancer risk). Interview transcripts were analyzed using a priori codes from the Tailored Implementation for Chronic Diseases framework. Quantitative and qualitative data were integrated by cross-tabulating determinants across risk and surveillance categories. RESULTS Participants included seven low-risk and 15 high-risk patients; 10 underwent risk-aligned surveillance and 12 did not. In mixed-methods analyses, perception of risk appropriately differed by risk but not by surveillance category. Participants understood the recommended surveillance schedule according to their risk category. Participants emphatically expressed that adhering to providers’ recommendations is prudent; intentions to adhere did not vary across risk and surveillance categories. CONCLUSION Participants intended to adhere to providers’ recommendations and strongly endorsed the importance of adherence. These findings suggest implementation strategies to improve risk-aligned surveillance may be most effective when targeting provider- and system-level factors rather than patient-level factors. [ABSTRACT FROM AUTHOR]

Aims: To reduce preventable falls and fall related injuries in State Veterans Homes (SVHs), we conducted a virtual breakthrough series (VBTS) quality improvement collaborative. Methods: Participating teams attended educational calls, received coaching, and submitted reports on process changes. Outcomes for the project included fall rates (total number of falls divided by the total number of census days reported) and fall injury rates (total number of falls with any injury divided by the total number of census days reported). Outcomes were tracked 6 months before, during, and after the project and compared using a Poisson regression model. Results: Twenty-six SVHs participated and implemented 27 unique interventions. The most commonly implemented interventions included post fall huddles, staff education, and intentional rounding. There was significant improvement in the fall related injury rate (injuries per 100 census days), decreasing from 7.4 before, to 6.6 during (p = 0.009) and 5.6 after (p = 0.005) the VBTS. The minor injury rate (minor injuries per 100 census days) decreased significantly from 6.4 during the VBTS to 5.8 (p = 0.000) after the VBTS. There was no statistically significant decrease in total fall rates or major injury rates. Conclusion: Lessons learned may be of interest to other SVH facilities seeking to improve their falls prevention program. [ABSTRACT FROM AUTHOR]

Evidence-based interventions often need to be adapted to maximize their implementation potential in low-to middle-income countries. A single-arm feasibility study was conducted to determine the feasibility and acceptability of a telephone-delivered, nurse-led, symptom management intervention for adults undergoing chemotherapy in Honduras. Over the course of 6 months, nurses engaged 25 patients undergoing chemotherapy in the intervention. Each participant received an average of 16.2 attempts to contact them for telephone sessions (SD = 8.0, range = 2-28). Collectively, the participants discussed 24 different types of symptoms. The most commonly discussed symptoms were pain (12%), nausea (7%), and constipation (5%). Qualitative and quantitative data were used to identify treatment manual modifications (i.e., adding content about different symptoms and addressing scheduling of treatment) and workplace modifications (i.e., dedicated nurse time and space) that are needed to optimize implementation of the intervention. [ABSTRACT FROM AUTHOR]

This article reports on improved processes and outcomes from a virtual breakthrough series quality improvement collaborative to reduce preventable falls and fall-related injuries in 23 State Veterans Homes. Participating teams implemented 24 interventions (process changes); the most common was the postfall huddle. Teams reduced falls and fall-related injuries. This project highlights the importance of leadership support, interdisciplinary team involvement, and collaboration as essential components of fall prevention work. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to evaluate health outcomes of a state-supported implementation in community mental health settings of an evidence-based lifestyle intervention for overweight and obese adults with serious mental illness.Methods: Weight and fitness outcomes were evaluated for 122 overweight or obese adults with serious mental illness in four community mental health centers (CMHCs) that were participating in a phased statewide implementation of the In SHAPE lifestyle intervention. Six- and 12-month outcomes were compared between two CMHCs that implemented In SHAPE in the first 12 months and two CMHCs with similar characteristics that implemented In SHAPE in a subsequent phase in the statewide implementation 12 months later.Results: Participants in the two In SHAPE sites (N=63 participants) lost significantly more weight (p=.003) and showed greater improvement in fitness (p=.011) compared with participants at the two usual care control sites (N=59 participants). At six months, nearly half (49%) of In SHAPE participants and at 12 months more than half (60%) of In SHAPE participants showed clinically significant cardiovascular risk reduction defined as ≥5% weight loss or improved fitness (>50 m [164 feet] increase on the six-minute walk test). The difference between the In SHAPE and control groups was not statistically significant.Conclusions: This natural experiment demonstrated promising public health benefits of a practical implementation of health promotion programming for overweight and obese adults with serious mental illness and offers a potential model for reducing risk of early mortality among individuals served by state-funded mental health centers nationwide. [ABSTRACT FROM AUTHOR]

Background: Given that patient safety measures are increasingly used for public reporting and pay-for performance, it is important for stakeholders to understand how to use these measures for improvement. The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are one particularly visible set of measures that are now used primarily for public reporting and pay-for-performance among both private sector and Veterans Health Administration (VA) hospitals. This trend generates a strong need for stakeholders to understand how to interpret and use the PSIs for quality improvement (QI). The goal of this study was to develop an educational program and tailor it to stakeholders' needs. In this paper, we share what we learned from this program development process.Methods: Our study population included key VA stakeholders involved in reviewing performance reports and prioritizing and initiating quality/safety initiatives. A pre-program formative evaluation through telephone interviews and web-based surveys assessed stakeholders' educational needs/interests. Findings from the formative evaluation led to development and implementation of a cyberseminar-based program, which we tailored to stakeholders' needs/interests. A post-program survey evaluated program participants' perceptions about the PSI educational program.Results: Interview data confirmed that the concepts we had developed for the interviews could be used for the survey. Survey results informed us on what program delivery mode and content topics were of high interest. Six cyberseminars were developed-three of which focused on two content areas that were noted of greatest interest: learning how to use PSIs for monitoring trends and understanding how to interpret PSIs. We also used snapshots of VA PSI reports so that participants could directly apply learnings. Although initial interest in the program was high, actual attendance was low. However, post-program survey results indicated that perceptions about the program were positive.Conclusions: Conducting a formative evaluation was a highly important process in program development. The useful information that we collected through the interviews and surveys allowed us to tailor the program to stakeholders' needs and interests. Our experiences, particularly with the formative evaluation process, yielded valuable lessons that can guide others when developing and implementing similar educational programs. [ABSTRACT FROM AUTHOR]

Objective:Despite national guidelines recommending early concurrent palliative care for individuals newly diagnosed with metastatic cancer, few community cancer centers, especially those in underserved rural areas do so. We are implementing an early concurrent palliative care model, ENABLE (Educate, Nurture, Advise, Before Life Ends) in four, rural-serving community cancer centers. Our objective was to develop a “toolkit” to assist community cancer centers that wish to integrate early palliative care for patients with newly diagnosed advanced cancer and their family caregivers.Method:Guided by the RE-AIM (Reach, Effectiveness–Adoption, Implementation, Maintenance) framework, we undertook an instrument-development process based on the literature, expert and site stakeholder review and feedback, and pilot testing during site visits.Results:We developed four instruments to measure ENABLE implementation: (1) the ENABLE RE-AIM Self-Assessment Tool to assess reach, adoption, implementation, and maintenance; (2) the ENABLE General Organizational Index to assess institutional implementation; (3) an Implementation Costs Tool; and (4) an Oncology Clinicians' Perceptions of Early Concurrent Oncology Palliative Care survey.Significance of results:We developed four measures to determine early palliative care implementation. These measures have been pilot-tested, and will be integrated into a comprehensive “toolkit” to assist community cancer centers to measure implementation outcomes. We describe the lessons learned and recommend strategies for promoting long-term program sustainability. [ABSTRACT FROM PUBLISHER]

Objective: Despite national guidelines recommending early concurrent palliative care for individuals newly diagnosed with metastatic cancer, few community cancer centers, especially those in underserved rural areas do so. We are implementing an early concurrent palliative care model, ENABLE (Educate, Nurture, Advise, Before Life Ends) in four, rural-serving community cancer centers. Our objective was to develop a "toolkit" to assist community cancer centers that wish to integrate early palliative care for patients with newly diagnosed advanced cancer and their family caregivers.Method: Guided by the RE-AIM (Reach, Effectiveness-Adoption, Implementation, Maintenance) framework, we undertook an instrument-development process based on the literature, expert and site stakeholder review and feedback, and pilot testing during site visits.Results: We developed four instruments to measure ENABLE implementation: (1) the ENABLE RE-AIM Self-Assessment Tool to assess reach, adoption, implementation, and maintenance; (2) the ENABLE General Organizational Index to assess institutional implementation; (3) an Implementation Costs Tool; and (4) an Oncology Clinicians' Perceptions of Early Concurrent Oncology Palliative Care survey.Significance Of Results: We developed four measures to determine early palliative care implementation. These measures have been pilot-tested, and will be integrated into a comprehensive "toolkit" to assist community cancer centers to measure implementation outcomes. We describe the lessons learned and recommend strategies for promoting long-term program sustainability. [ABSTRACT FROM AUTHOR]

Introduction: Guidelines recommend that substance use disorder (SUD) treatment be available in primary care-mental health integrated clinics, which offer mental and behavioral health assessment and treatment in the primary care setting. Despite this recommendation it is unclear what barriers and facilitators exist to SUD treatment being provided in that setting. This work sought to understand current SUD services in such integrated clinics, explore other services may that be appropriate, and identify barriers to such services.Methods: We conducted qualitative interviews with 23 staff members from integrated clinics at 6 Veterans Affairs medical centers. We transcribed interviews and performed thematic analysis to identify emergent themes.Results: We identified seven themes affecting staff experience and ability to provide SUD services in the integrated clinic: clinical effectiveness, clinical requirements, regulatory requirements, program goals, proximity of the integrated clinic and SUD services, training on substance use disorder, and role specialization.Conclusions: VA primary care-mental health integrated clinic staff members do not currently view SUD treatment as the focus of their work, but are open to offering SUD treatment including brief psychological interventions or medication. Several barriers to providing SUD treatment were identified, including the need for additional staff training around appropriate interventions for the integrated clinic setting, additional staffing and space, and a structured implementation strategy to promote the use of SUD treatments. [ABSTRACT FROM AUTHOR]

Objective: The U.S. Department of Veterans Affairs (VA) has engaged in substantial efforts to promote the use of evidence-based psychotherapies for posttraumatic stress disorder (PTSD). The authors evaluated the effectiveness of these efforts. Methods: This study used a cross-sectional, mixed-methods evaluation of treatment provided by the VA at specialty PTSD clinics in New England during the first six months of fiscal year 2010. Natural language processing algorithms were applied to clinical notes to determine utilization of evidence-based psychotherapy (prolonged exposure therapy and cognitive-processing therapy) among patients who were newly diagnosed as having PTSD. Data regarding efforts to implement evidence-based psychotherapy and other clinic characteristics were obtained through qualitative interviews with clinical and administrative staff (N=30), and the Promoting Action on Research Implementation in Health Services framework was used to identify clinic factors associated with use of evidence-based psychotherapy. Results: Six percent of patients (N=1,924) received any sessions of an evidence-based psychotherapy for PTSD (median=five sessions). Several clinic factors were associated with an increased rate of implementation, including prior experience with use of the treatments, customization of training, and prolonged contact with the implementation and training team. Facilitation with broad training goals and clinics with highly organized systems of care were negatively associated with implementation. Conclusions: Few patients with PTSD received evidence-based psychotherapy for PTSD during their first six months of treatment at a VA specialty PTSD clinic. The implementation framework poorly predicted factors associated with uptake of evidence-based psychotherapy. These results suggest that additional research is needed to understand implementation of evidence-based therapy in mental health settings. [ABSTRACT FROM AUTHOR]

Objective: Measurement-based care has been endorsed but not embraced in mental health settings. There is currently little guidance regarding the best methods to implement measurement-based care. Methods: A survey of mental health providers was conducted before (N=15) and after (N=17) the implementation of a patient self-report symptom measurement system. Results: At baseline, respondents rarely used the patient self-assessment information (mean±SD=1.8±1.8); they reported the patient data to be marginally useful (4.1 ±1.9), and only slightly recommended the use of patient assessments (4.3± 2.0). Possible scores ranged from 1 to 7, with higher scores indicating more positivity. At follow-up, respondents almost always used the information in the assess- merits (6.3±1.7), found the patient report data very useful (6.4±.8), and highly recommended continued use of patient surveys in the integrated clinic (6.6±.5). Conclusions: Providers' lack of enthusiasm about integration of routine data collection and reporting of patient symptoms may be overcome by simply exposing providers to this process. [ABSTRACT FROM AUTHOR]

Despite widespread use of the breakthrough series (BTS) collaborative in healthcare, there is limited literature on how to operationalize the method in healthcare settings. A recent modification to the model is the virtual breakthrough series (VBTS), in which all work is done remotely via telephone and web-based platforms. With virtual methods gaining popularity, this manuscript presents guidance on methods to conduct a virtual breakthrough series collaborative to assist clinical teams in implementing evidence-based practices. Manuscript describes planning activities and implementation steps for individuals interested in conducting a VBTS collaborative. Topics presented include planning/preparation activities (e.g., developing a planning committee and change package of the evidence-based interventions), estimated resources required (i.e., personnel, percent effort), activities to prepare participants for the project (e.g., orientation calls), specific actions during the virtual collaborative, and evaluation approaches. The manuscript also presents examples from our work and templates for end users. This paper is a first attempt to describe the infrastructure and processes of a VBTS collaborative and offer reproducible methods currently employed in the U.S. Veterans Health Administration. [ABSTRACT FROM AUTHOR]