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Introduction: Individuals with spinal cord injury (SCI) are vulnerable to obesity. Annual obesity screening using body mass index (BMI) is the standard of care mandated by US Veterans Health Administration (VHA) guidelines. Our objective was to determine the rates, variability, and predictors of guideline-concordant annual screening for obesity, given potential challenges of height and weight measurements in individuals with SCI. Methods: This is a cross-sectional retrospective study using US national VA databases. We identified all VHA patients with chronic SCI in the fiscal year (FY) 2019, their treating facility and frequency of recorded height and weight. We applied mixed-effects logistic regression models to assess associations between annual BMI screening and patient- and facility-level characteristics. Results: Of 20,978 individuals with chronic SCI in VHA in FY19, guideline-concordant annual BMI screening was lacking in 37.9%. Accounting for facility-level factors (geographic region, SCI facility type, volume of patients with SCI treated at the facility), a mixed-effects logistic regression model demonstrated that lack of annual obesity screening was significantly associated with older patient age (p < 0.001) and fewer outpatient encounters (p < 0.001) but not other patient-level factors such as sex, race, level of injury, or rurality. The rate of obesity screening among different facilities within VHA varied widely from 11.1% to 75.7%. Conclusion: A large proportion of persons with SCI receiving care in VHA do not receive guideline-concordant annual obesity screening, an especially acute problem in some facilities. Older patients with fewer outpatient encounters are more likely to be missed. To inform the design of interventions to improve identification and documentation of obesity, further study is needed to assess potential barriers to obesity screening in the population with SCI.

PURPOSE To understand how informal caregivers are affected by weight and weight management of care recipients with SCI. MATERIALS AND METHODS In-depth qualitative interviews were conducted with 24 informal caregivers of community-dwelling Veterans and civilians with SCI. Thematic analysis was conducted. RESULTS Three themes described how the care recipient's weight management efforts impacted the caregiver, including: (1) motivation and involvement in weight management efforts for themselves, (2) emotional well-being (positive and negative aspects), and (3) physical tasks (both ease and burden). Caregivers may experience emotional and/or physical burden by taking on extra caregiving tasks to help with care recipient's weight management. Caregivers also may experience positive impacts from the care recipient's weight management efforts, regardless of who drove the efforts, including improvement in their own motivation and involvement in weight management, enhanced emotional well-being (happiness for and with the care-recipient), and making physical caregiving tasks easier. CONCLUSIONS Rehabilitation providers can use these findings to educate dyads about potential impacts of weight management efforts for the care recipient, specifying areas that may cause burden but emphasizing the potential benefits for both recipient and caregiver. Integrating this education into rehabilitation practice may reduce overweight-related problems with function and declines in disability among dyads.Implications for RehabilitationInformal caregivers experience both positive and negative consequences with regard to weight management for individuals with SCI.Helping their loved one with weight management can facilitate informal caregivers' involvement in their own weight management activities.Findings may offer guidance to healthcare and rehabilitation providers as they incorporate weight management into education programs for informal caregivers of persons with SCI.Integrating this education into rehabilitation practice may reduce or delay overweight-related problems with function and declines in disability among dyads.

IntroductionPerceived social isolation and loneliness are understudied in individuals with spinal cord injuries and disorders (SCI/D). The few existing studies reported that they are common, yet poorly treated, in persons with SCI/D. We developed an intervention called Caring Connections (CC) aimed at reducing loneliness and perceived social isolation in persons with SCI/D. CC is a peer-based, recurrent letter writing programme designed to provide moments of positivity. We will conduct and evaluate a randomised controlled trial (RCT) to assess changes in loneliness and social isolation outcomes between the CC intervention and control conditions in community-dwelling individuals with SCI/D.Methods and analysisRCT to compare outcomes of community-dwelling individuals with SCI/D undergoing the CC intervention to an attention control group (receiving informational materials on life domains important to a good quality of life). Eligible participants include adults with chronic SCI/D who have been injured for>1 year. The primary outcome is loneliness, measured using the UCLA (University of California, Los Angeles) 3-item Loneliness Scale. Other outcomes include perceived social isolation and social support. A post-trial process evaluation will assess perceived benefits, negative impacts and satisfaction with the intervention, and areas for improvement. We will test the hypotheses of reduced loneliness and perceived social isolation in the CC intervention arm from baseline to 6 months and will also measure the magnitude of effect (difference between CC arm and attention control arm). We will use generalised linear models for repeated measures. We will assume a one-tailed, α=0.05 level of significance for comparisons. Process outcomes will be analysed using mixed methods, including frequencies for the rating items and thematic analysis for open-ended item responses.Ethics and disseminationThis study has received Hines Veterans Affairs Institutional Review Board approval (#1673654). Findings will be disseminated widely through healthcare organisations, peer-reviewed publications and conferences.Trial registration numberNCT05295108

Objectives We conducted 2 complementary scoping reviews to identify instruments that assess the experience and outcomes of custom ankle-foot orthosis (AFO) care in individuals with neurologic and traumatic conditions and to determine to what extent they might be psychometrically sound for AFO users. A stakeholder advisory committee considered to what extent the identified and psychometrically sound instruments might be feasible for use in developing quality measures for custom AFO users. Data Sources Both scoping reviews were conducted using PubMed, the Cumulative Index to Nursing and Allied Health Literature, Embase, and Cochrane Systematic Reviews. The following were used for the first scoping review only: Cochrane Central Register of Controlled Trials and the Physiotherapy Evidence Database. Study Selection The initial scoping review yielded 79 articles with 82 instruments, 16 of which were used in 4 or more studies. The second scoping review yielded 57 articles reporting psychometric properties. Data Extraction Psychometric properties for populations who use AFOs were summarized for 15 of the 16 instruments. The advisory committee eliminated 2 insrtruments, noted overlap between 4 instruments in terms of the constructs measured, and suggested 6 potential contemporary substitutes. Data Synthesis Most instruments assessed activity (specifically mobility) and pertained to the National Quality Forum domain of “Health-Related Quality of Life.” The 10-meter walk test, 6-minute walk test, Berg Balance Scale, Timed Up and Go, and Rivermead Mobility Index were reported to have adequate reliability and validity, and were considered feasible for administration in a clinical setting. Conclusions Complementary scoping reviews demonstrated that some instruments with reasonable psychometric properties are available that are feasible to use in developing quality measures for custom AFO care. However, experience of care instruments suitable for this population were not identified but are needed for a comprehensive evaluation of care quality for AFO users.

Objectives: To explore the personal meanings of healthy eating and physical activity among individuals living with spinal cord injury (SCI) and the information and resources they find beneficial. Methods: We conducted in-depth semistructured individual interviews to understand the personal meanings of healthy eating and physical activity among individuals with SCI. We completed a thematic analysis of qualitative data. Results: Participants were 11 Veterans and 14 civilians, predominantly male, non-Hispanic White, and with paraplegia. Data were described across two categories, including the personal meaning of healthy eating and the personal meaning of physical activity/exercise. Individuals with SCI described their meaning of healthy eating around four themes: types of food, amounts/portions of food, conscious/mindful eating, and eating to enhance health. Individuals wanted information on tailored diets for individuals with paraplegia and tetraplegia and healthy foods that are easy to prepare by people with SCI. Their personal meaning of physical activity/exercise focused on four themes: types of physical activity and exercise, staying active, moving/movement, and differences from non-SCI. Desired information around physical activity included cardiovascular workouts that are effective and possible to do in a wheelchair so that people with SCI can burn enough of the calories they consume to lose or maintain weight. Conclusion: Results provide a better understanding of what healthy eating and physical activity mean to people with SCI and information they desire toward these goals, which can be used to guide patient–provider discussions, develop health promotion programs, and tailor interventions to capitalize on meaningful concepts and beliefs that facilitate healthy behaviors.

Health providers often focus on secondary conditions and spend less time prioritising overweight/obesity care. Informal caregivers are well positioned to facilitate health-promoting behaviours of healthy eating and physical activity among community-dwelling care recipients with spinal cord injury (SCI) for prevention and management of overweight/obesity. Literature has typically focused on caregiver adjustment post-injury and burden related to their roles in secondary condition care. The novel objective of this study was to describe informal caregivers' perspectives of their roles in facilitating health-promoting weight management behaviours, healthy eating and physical activity, for care recipients with SCI. This was a qualitative study that used semi-structured interviews with informal caregivers for data collection in 2019. Braun & Clarke's established thematic phases were used for analysis. Participants included informal caregivers of individuals with SCI living in the community (n = 24). Caregivers identified eight themes to describe their role in facilitating weight management for care recipients. Themes included: (1) meal planning/shopping, (2) meal preparation/cooking, (3) using portion control, (4) serving/feeding, (5) helping the care recipient with physical activity and/or leisure activities, (6) mutually participating in weight management activities, (7) providing motivation and encouragement and (8) being an information liaison. In summary, informal caregivers have an intimate understanding of care recipients' needs and have insights on obstacles and enablers to health-promoting behaviours, making their involvement in facilitating weight management in individuals with SCI vital. Caregivers self-identified several significant roles for promoting weight management. This is especially valuable for conditions such as overweight/obesity for which prevention and treatment involve health-promoting behaviours that need consistent attention in the community setting. It is important to ensure that informal caregivers and care recipients have the information required in order to facilitate healthy eating and physical activity in persons with SCI and have opportunities for mutual dyadic participation when both partners are interested.

Objective: To gain a fuller understanding, in the context of biopsychoecological factors, of drivers/motivators, goal setting, and feedback, individuals with spinal cord injury (SCI) find helpful to gauge their weight management progress. Research Method/Design: We conducted in-depth interviews around weight management in SCI. Participants included veterans and civilians with SCI. Thematic analysis methodology was used to categorize data into relevant recurrent and/or conceptually significant themes. Results: Twenty-five individuals identified three primary reasons they wanted to participate in weight management, including overall health and wellness, appearance, and functional mobility. Their self-identified weight management goals included reaching/maintaining a specific body weight and/or trimming a focused body part; engaging in any or more physical activity/exercise; gaining strength and endurance; participating in life and activities; and alleviating weight-related health symptoms (e.g., pain). Individuals identified progress assessments, recognition, regular check-ins, and encouragement as helpful feedback toward weight management achievement. Conclusions/Implications: Our work identified what drives weight management in individuals with SCI, what is important to them in terms of goal setting, and what feedback they would find helpful. These findings may be used in intervention planning and program development to facilitate participation and behavior modification. Weight management efforts and interventions are needed that 1) incorporate motivators for weight management that are important to individuals with SCI; 2) help them identify actionable process and performance goals to facilitate achievement of self-identified meaningful outcome goals; and 3) provide person-centered weight management progress feedback such as those identified in this study (progress assessments, recognition, regular check-ins, and encouragement). (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Purpose: To describe the priorities of orthotists and physical therapists about quality measurement themes, and the feasibility and utility of collecting data from persons using custom AFOs that co...

Objective To describe current practices used by Veterans Administration (VA) mental health (MH) providers involved in post-traumatic stress disorder (PTSD) treatment planning to support engagement of veterans with PTSD in shared decision-making (SDM). Methods Semi-structured interviews with MH providers (n = 9) were conducted at 1 large VA, audio-recorded, and transcribed verbatim. Transcripts were analyzed deductively, guided by a published account of the integral SDM components for MH care. Results While discussing forming a cohesive team with patients, providers noted the importance of establishing rapport and assessing treatment readiness. Providers’ clinical knowledge/expertise, knowledge of the facility’s treatment options, knowledge of how to navigate the VA MH care system, and patient factors (goals/preferences, factors influencing treatment engagement) were noted as important to consider when patients and providers exchange information. When negotiating the treatment plan, providers indicated that conversations should include treatment recommendations and concurrent opportunities for personalization. They also emphasized the importance of discussions to finalize a mutually agreeable patient- and provider-informed treatment plan and measure treatment impact. Conclusion These results offer a preliminary understanding of VA MH providers’ facilitation of SDM for PTSD care. Findings may provide insights for MH providers who wish to engage patients with PTSD in SDM.

STUDY DESIGN: This is a descriptive qualitative study. OBJECTIVES: To explore recommended strategies employed by healthcare providers to support individuals with SCI in weight management. SETTING: Fourteen veteran administration hospitals in the United States and the Shirley Ryan AbilityLab (SRALab) SCI Model Systems in Illinois. METHODS: Semi-structured interviews were conducted with interprofessional SCI providers involved in weight management with individuals living with SCI. Thematic analysis methods were used. RESULTS: A total of 25 interprofessional providers were interviewed. Providing clinical expertise to assist in weight management included (1) checking progress or status of weight over time, (2) monitoring and tracking other health-related indicators, (3) stressing weight-related health risks, (4) providing education, (5) encouraging healthy behaviors, and (6) identifying and accessing resources. Fostering provider–patient relationships included (1) establishing and maintaining rapport and (2) tailoring/individualizing weight management treatment. Coordinating a team approach included (1) involving a dietitian or nutritionist, (2) communicating the same message, and (3) involving the informal caregiver/family. CONCLUSION: Weight management strategies should incorporate patient preferences and goals, informed through provider expert and personalized clinical advice, and supported within the context of interprofessional team collaboration that includes caregivers and family.

The objective of this study was to understand veteran perspectives of grief/loss associated with their spinal cord injury (SCI).Qualitative descriptive design using semistructured interviews with veterans with SCI (n = 15) was performed using interview questions informed by the literature. Analysis was conducted using a deductive/inductive approach.The 15 participants' mean age was 64 years; six had paraplegia, eight had tetraplegia, one had unknown level of injury, six were ambulatory, and nine were not ambulatory. The grief/loss experience was individual and constant, consisting of seven phases: experiencing shock, releasing emotion, withdrawing, focusing on losses, problem solving, realizing strength and motivation, and accepting a new life. Veteran coping strategies used in each phase of the grief experience were also identified, as well as triggers that increased or decreased the grief/loss experience.A better understanding of veterans living with SCI grief experience, coping strategies, and triggering events can help healthcare providers support veterans with SCI.

Study Design: Qualitative descriptive study using semi-structured interviews Objective: The purpose of this study was to examine the barriers and facilitators of weight management in individuals with spinal cord injury (SCI) from the perspective of SCI health care providers. Setting: Veterans Health Administration and Midwest Regional SCI Care Systems Methods: Health care providers (n=25) who care for individuals with SCI completed semi-structured interviews. Thematic analysis methodology was used to identify emergent themes around barriers and facilitators to weight management in SCI. Results: Sixteen subthemes emerged for barriers and 7 subthemes emerged for facilitators for weight management in SCI. Barriers included individual-level factors (e.g., physical ability/mobility limitations, lack of interest, psychological obstacles, lack of knowledge, poor dietary strategies), socio-environmental factors (e.g., challenges with family support, lack of access to weight management resources, dependency on others, difficulties obtaining weight measurement), and organizational factors (e.g., lack of integration/ inconsistent weight management support from healthcare systems, pushing calorie intake early post-injury). Facilitators included individual-level factors (e.g., motivation, education/knowledge, participation in exercise and physical activity) and socio-environmental factors (e.g., positive support network, access to/use of healthy dietary strategies, access to exercise facilities/adaptive equipment, participating in weight management with others). Conclusions: Healthcare providers identified individual-level, socio-environmental, and organizational barriers and facilitators that influence weight management efforts in individuals with SCI. Future weight management resources and programs should consider addressing common barriers identified by healthcare providers, individuals with SCI, and their caregivers, and develop strategies to promote facilitators to enhance weight management in this population.

Background Healthcare organizations increasingly are focused on providing care which is patient-centered rather than disease-focused. Yet little is known about how best to transform the culture of care in these organizations. We sought to understand key organizational factors for implementing patient-centered care cultural transformation through an examination of efforts in the US Department of Veterans Affairs. Methods We conducted multi-day site visits at four US Department of Veterans Affairs medical centers designated as leaders in providing patient-centered care. We conducted qualitative semi-structured interviews with 108 employees (22 senior leaders, 42 middle managers, 37 front-line providers and 7 staff). Transcripts of audio recordings were analyzed using a priori codes based on the Consolidated Framework for Implementation Research. We used constant comparison analysis to synthesize codes into meaningful domains. Results Sites described actions taken to foster patient-centered care in seven domains: 1) leadership; 2) patient and family engagement; 3) staff engagement; 4) focus on innovations; 5) alignment of staff roles and priorities; 6) organizational structures and processes; 7) environment of care. Within each domain, we identified multi-faceted strategies for implementing change. These included efforts by all levels of organizational leaders who modeled patient-centered care in their interactions and fostered willingness to try novel approaches to care amongst staff. Alignment and integration of patient centered care within the organization, particularly surrounding roles, priorities and bureaucratic rules, remained major challenges. Conclusions Transforming healthcare systems to focus on patient-centered care and better serve the “whole” patient is a complex endeavor. Efforts to transform healthcare culture require robust, multi-pronged efforts at all levels of the organization; leadership is only the beginning. Challenges remain for incorporating patient-centered approaches in the context of competing priorities and regulations. Through actions within each of the domains, organizations may begin to truly transform to patient-driven care.

Background Patient-centred care is now ubiquitous in health services research, and healthcare systems are moving ahead with patient-centred care implementation. Yet, little is known about how healthcare employees, charged with implementing patient-centred care, conceptualize what they are implementing. Objective To examine how hospital employees conceptualize patient-centred care. Research design We conducted qualitative interviews about patient-centred care during site four visits, from January to April 2013. Subjects We interviewed 107 employees, including leadership, middle managers, front line providers and staff at four US Veteran Health Administration (VHA) medical centres leading VHA's patient-centred care transformation. Measures Data were analysed using grounded thematic analysis. Findings were then mapped to established patient-centred care constructs identified in the literature: taking a biopsychosocial perspective; viewing the patient-as-person; sharing power and responsibility; establishing a therapeutic alliance; and viewing the doctor-as-person. Results We identified three distinct conceptualizations: (i) those that were well aligned with established patient-centred care constructs surrounding the clinical encounter; (ii) others that extended conceptualizations of patient-centred care into the organizational culture, encompassing the entire patient-experience; and (iii) still others that were poorly aligned with patient-centred care constructs, reflecting more traditional patient care practices. Conclusions Patient-centred care ideals have permeated into healthcare systems. Additionally, patient-centred care has been expanded to encompass a cultural shift in care delivery, beginning with patients' experiences entering a facility. However, some healthcare employees, namely leadership, see patient-centred care so broadly, it encompasses on-going hospital initiatives, while others consider patient-centred care as inherent to specific positions. These latter conceptualizations risk undermining patient-centred care implementation by limiting transformational initiatives to specific providers or simply repackaging existing programmes.

OBJECTIVE The objective of the study was to test the hypothesis that the influence of environmental barriers on participation will be fully mediated by psychosocial factors (resilience, grief or loss, and self-efficacy) among individuals with spinal cord injuries and disorders. METHOD This was a cross-sectional mailed survey with a national sample of veterans with spinal cord injuries and disorders (n = 565), which included measures of demographics, perceived environmental barriers, participation, resilience, grief or loss, and self-efficacy. Data were analyzed using a latent variable path analysis; the model fit was assessed using χ2, normed χ2, root mean square error of approximation (RMSEA

The objectives of this study were to examine differences in social participation among Veterans with spinal cord injuries/disorders with and without post-traumatic stress disorder, and determine if lower social participation was independently associated with having post-traumatic stress disorder.A cross-sectional mailed national survey was sent to a national sample of Veterans with spinal cord injuries/disorders who received prior-year Veterans Affairs healthcare. Surveys provided data on: demographics, health conditions, injury characteristics, and social participation. Analyses included bivariate comparisons, and multivariate logistic regression to determine if lower social participation was independently associated with post-traumatic stress disorder.Veterans with (vs. without) post-traumatic stress disorder (n = 896) reported lower social participation (40.2 vs. 43.9, p 0.0001). Multivariate analyses showed that longer duration of injury (OR = 0.98, 95% CI: 0.97-1.00, p = 0.04) and white race (OR = 0.62, 95% CI: 0.38-1.01, p = 0.05) were associated with lower odds of post-traumatic stress disorder, while a greater number of health conditions (OR = 1.43, 95% CI: 1.25-1.64, p 0.0001) was associated with greater odds. When controlling for covariates, lower social participation was independently associated with post-traumatic stress disorder (OR = 0.94, 95% CI: 0.90-0.98, p = 0.003).Results indicate post-traumatic stress disorder is associated with lower social participation in Veterans with spinal cord injuries/disorders, independent of other factors that may impact participation. Efforts to screen for and treat post-traumatic stress disorder among persons with spinal cord injuries/disorders, regardless of injury-specific factors, are needed to improve participation. Implications for Rehabilitation Individuals with spinal cord injuries/disorders often have post-traumatic stress disorder; in Veterans with spinal cord injuries/disorders this may be compounded by trauma incurred through military experiences. Social participation, an important aspect of rehabilitation and community integration following spinal cord injury or disorder, may be hindered by symptoms of post-traumatic stress disorder. Our data show that post-traumatic stress disorder is associated with lower social participation in Veterans with spinal cord injuries/disorders, independent of other factors that may impact participation. These results indicate that efforts to screen for and treat post-traumatic stress disorder among persons with spinal cord injuries/disorders, regardless of injury-specific factors, are needed to improve participation in this patient population.

Data were collected via a cross-sectional mailed survey with Veterans with spinal cord injury and disorders (SCI/D). To examine self-efficacy in Veterans with SCI/D reporting high versus low perceptions of physical function. Department of Veterans Affairs (VA) Spinal Cord Injury System of Care—nation-wide, 24 Spinal Cord Injury (SCI) Centers. The survey provided patient-reported data on demographic and injury characteristics, basic mobility and fine motor function, and perceived self-efficacy. Bivariate comparisons were conducted to compare perceptions of self-efficacy between Veterans with SCI/D reporting perceptions of ‘high’ versus ‘low’ basic mobility and fine motor function. A multivariate logistic regression was conducted to identify factors independently associated with high physical function when controlling for covariates. Response rate (896/1452=61.7%). Multivariate analysis showed that age (odds ratio (OR)=0.98, 95% confidence interval (CI): 0.96–1.00, P=0.03), tetraplegia (OR=0.20, 95% CI: 0.13–0.32, P⩽0.0001), diabetes (OR=0.53, 95% CI: 0.31–0.91, P=0.02), depression (OR=0.62, 95% CI: 0.39–0.98, P=0.04) and pressure ulcers (OR=0.42, 95% CI: 0.25–0.72, P=0.001) were all independently associated with lower odds of high physical function. When controlling for covariates, persons with high self-efficacy were nearly two times more likely to have high physical function (OR=1.98, 95% CI: 1.22–3.22, P=0.01). Lower perceptions of basic mobility and fine motor function among individuals with SCI/D were correlated with lower self-efficacy, even when controlling for other covariates. The relationship between physical function and self-efficacy suggests that interventions focused on improving self-efficacy or physical function may also see improvements in the other. Further, studies exploring the impact of interventions on the relationship between self-efficacy and physical function are needed to understand the relationship between the two.

Objective As in all healthcare areas, there is a need to improve quality relevant to orthotic practice, but we lack information as to what aspects of healthcare quality are meaningful to measure. Thus, the objective was to identify issues that are important to the quality-of-care for people who use custom ankle-foot orthoses as identified by ankle-foot orthosis users, orthotists, and physical therapists. Design We conducted focus groups with custom ankle-foot orthosis users, orthotists, and physical therapists. A stenographer took verbatim notes and provided transcripts. Research staff members assessed the transcripts using thematic analysis. Results Participants included 5 ankle-foot orthosis users (1 focus group), 17 orthotists (2 focus groups), and 7 physical therapists (1 focus group). They discussed domains of quality-of-care relevant for people with ankle-foot orthoses. We identified 28 thematic codes addressing 10 broad themes of quality-of-care. Six of the broad themes (organizational characteristics, patient-clinician communication, care coordination, device fit and comfort, body function, activity, and participation) mapped to the National Quality Forum's person- and family-centered care concepts. Environment of care, clinician competencies, and device characteristics and usage were important to orthotic practice but do not map to any National Quality Forum concept. Participants did not mention the National Quality Forum concept of shared decision-making. Conclusions The quality themes provide information as to what aspects of healthcare quality are meaningful to measure with respect to orthotic care, thus providing guidance on how to measure and improve ankle-foot orthosis service delivery.

STUDY DESIGN: Retrospective cohort study OBJECTIVES: The goal of this study was to assess the impact of multi-drug resistant gram-negative organisms (MDRGNOs) on outcomes in those with SCI/D. SETTING: VA SCI System of Care, Department of Veterans Affairs, United States. METHODS: Multi-drug resistance (MDR) was defined as being non-susceptible to ≥1 antibiotic in ≥ 3 antibiotic classes. Multivariable cluster adjusted regression models were fit to assess the association of MDRGNOs with 1-year mortality, 30-day readmission, and post-culture length of stay (LOS) stratified by case setting patients. Only the first culture per patient during the study period was included. RESULTS: 8,681 individuals with SCI/D had a culture with gram-negative bacteria during the study period, of which 33.0% had a MDRGNO. 954 (10.9%) died within 1 year of culture date. Poisson regression showed that MDR was associated with 1-year mortality among outpatients (IRR: 1.28, 95% CI, 1.06–1.54) and long-term care patients (OR: 2.06, 95% CI, 1.28–3.31). MDR significantly impacted post-culture LOS in inpatients, as evidenced by a 10% longer LOS in MDR vs. non-MDR (IRR: 1.10, 95%CI, 1.02–1.19). MDR was not associated with increased 30-day readmission. CONCLUSIONS: MDRGNOs are prevalent in SCI/D and MDR may result in poor outcomes. Further attention to prevention of infections, antibiotic stewardship and management are warranted in this population.

BACKGROUND: Assessments of function in persons with spinal cord injury (SCI) often utilize pre-defined constructs and measures without consideration of patient context, including how patients define function and what matters to them. OBJECTIVES/HYPOTHESIS: We utilized photovoice to understand how individuals define function, facilitators and barriers to function, and adaptations to support functioning. METHODS: Veterans with SCI were provided with cameras and guidelines to take photographs of things that: (1) help with functioning, (2) are barriers to function, and (3) represent adaptations used to support functioning. Interviews to discuss photographs followed and were audio-recorded, transcribed, and analyzed using grounded-thematic coding. Nvivo 8 was used to store and organize data. RESULTS: Participants (n = 9) were male (89%), Caucasian (67%), had paraplegia (75%), averaged 64 years of age, and were injured, on average, for 22 years. Function was described in several ways: the concept of ‘normalcy,’ aspects of daily living, and ability to be independent. Facilitators included: helpful tools, physical therapy/therapists, transportation, and caregivers. Barriers included: wheelchair-related issues and interior/exterior barriers both in the community and in the hospital. Examples of adaptations included: traditional examples like ramps, and also creative examples like the use of rubber bands on a can to help with grip. CONCLUSION(S): Patient-perspectives elicited in-depth information that expanded the common definition of function by highlighting the concept of “normality,” facilitators and barriers to function, and adaptations to optimize function. These insights emphasize function within a patient-context, emphasizing a holistic definition of function that can be used to develop personalized, patient-driven care plans. Published by Elsevier Inc.

Filtering face-piece respirators (FFRs) are worn to protect health care personnel from airborne particles; however, clinical studies have demonstrated that FFR adherence is relatively low in some settings, in part, due to discomfort and intolerance. The objective of this study was to develop and initially evaluate the psychometric properties of an instrument designed to measure the comfort and tolerability of FFRs. Instrument items were developed through literature reviews, focus groups, and several iterations of ranking and refining by experts. Psychometric evaluation of the instrument was conducted using Rasch partial credit model (PCM) analysis. Pivot anchoring was used to specify the threshold defining item difficulty; in our analyses, this was the point that participants moved from possessing none of the trait to some of the trait. The final instrument was completed by 165 health care personnel from 3 Veterans Health Administration facilities, and data were analyzed using Rasch PCM. Seven items were removed because they: (1) violated the assumption of independence; (2) were mis-fitting; and/or (3) were deemed not relevant. Category function analysis demonstrated that all categories progressed monotonically. Principal components analysis demonstrated the existence of three subscales (Discomfort, General Wearing Experience, and Function). Final reliability analyses showed that the scale had moderate to high person reliability and high item reliability. The final instrument contained 21 items. Until now, to our knowledge no instrument with evidence supporting its reliability and validity to assess discomfort and tolerance of FFRs among health care personnel has been published. A 21-item psychometrically sound measure of comfort and tolerability of FFRs, Respirator Comfort, Wearing Experience, and Function Instrument (R-COMFI), was developed. The significance of developing such an instrument is that it will help identify respirators that are likely to have better adherence in practice settings. The R-COMFI may be used within and beyond the VA healthcare system as a psychometrically sound instrument to evaluate the comfort and tolerability of respirators, including developmental prototypes.

INTRODUCTION Family-centered care (FCC) involves partnering with patients and family/caregivers ("caregivers"), engaging them in decisions, and providing support. FCC may be measured across 3 dimensions: respect, collaboration, and support and needs likely vary by caregiver age. The objective was to examine and compare caregiver perceptions of FCC by age. METHOD We mailed surveys to family/caregivers of Veterans. We collected demographics and measured respect, collaboration, and support using the Family-Centered Care Survey (FCCS). We calculated mean values and conducted bivariate comparisons, dichotomized by caregiver age (≥60 vs.

This cross-sectional chart review study included 100 US Veterans with spinal cord injuries/disorders (SCI/D) who received care at a Veterans Affairs (VA) SCI facility during a 12-month period. Progress notes were examined to extract need for weight management (WM), patient–provider discussions about risk due to overweight/obesity, recommended lifestyle changes and/or follow-up and WM education. To understand what WM services are offered to Veterans with SCI/D within the VA SCI System of Care during comprehensive preventive health evaluations (annual evaluations), inpatient stays and outpatient visits. VA SCI System of Care, Department of Veterans Affairs, United States. Overall, 73% demonstrated a need for WM. Weight was most frequently addressed during the nutrition assessment of annual evaluations, but this assessment was most likely to be skipped. Nutrition histories were missing many key components. Over half received WM education; individuals who were described as overweight/obese by their provider were more likely to receive education. Most of the Veterans who were seen in an inpatient setting were weighed; weight was only discussed with 12%. Less than half of the Veterans with outpatient visits were weighed, and 23% received WM recommendations. Weight was frequently discussed during nutrition assessments, but infrequently addressed during outpatient or inpatient encounters. Few Veterans received specific recommendations on caloric/nutrient requirements and nutrition histories were missing recommended elements. Additional work is needed to help providers to incorporate WM information into care.

Given the burden of multiple chronic conditions (MCCs) in the Veterans Affairs (VA) Health Care System, understanding perspectives of Veterans with MCC is essential to evaluate chronic care and ensure that care and quality improvement efforts align with patient needs. The purpose of this study was to use the Patient Assessment of Chronic Illness Care (PACIC) instrument to examine perceptions of chronic care among Veterans with MCC.We conducted a nation-wide, cross-sectional mailed survey. Study inclusion criteria were Veteran patients with MCC who receive care from eight VA facilities. The survey included questions on patient demographics, recent hospital or doctor visits, and the PACIC instrument. Chronic condition and health care utilization data were extracted from VA administrative databases.The sample (n = 3,519) was mostly male; average age was 68.1 years. Mean PACIC summary score was 3.05 (standard deviation [SD] = 1.12). Respondents achieved higher scores (favorable perceptions) in the Delivery System Design and Patient Activation subscales, and lowest scores (unfavorable perceptions) in the Follow-up/Coordination subscale. Characteristics associated with higher scores included non-white race, recent VA doctor visit, and high school or less education.Perceptions of chronic care were high; however, quality improvements are needed to enhance care continuity and coordination.

Patient-reported experience measures (PREMs) are useful for assessing health care quality and safety and patients' perceptions of health care.We aimed to assess the relationship between PREMS [e.g., measures of patient-centered care (PCC)] and health care quality metrics.We conducted a national survey via mail. Survey data were supplemented with US Department of Veteran Affairs (VA) administrative data.Veteran (n = 5512) VA health care users participated in the study.PCC measures included: patient activation; shared decision-making (SDM); empathy and holistic care; chronic illness care; perceptions of participation, respect for choices, and support; and overall health care experience. Health care quality measures included: preventive care screening receipt; chronic condition management (diabetes, hypertension); and health care utilization (hospitalizations, emergency room (ER) visits). Analyses included: bivariate comparisons of PCC measures by health care quality measures; and multivariate linear regression to identify variables associated with attaining multiple positive health care quality indicators (when controlling for potential confounders).PREMs assessing factors relating to patient-provider communication (e.g., empathic provider care, shared decision-making) are mainly related to clinical indicators representing good chronic condition management, while those relating more broadly to health care in general (e.g., patient activation, chronic illness care) are mainly related to measures of appropriate health care use (e.g., preventive care screening receipt; potentially avoidable hospitalizations; unscheduled care, such as ER visits). When controlling for potential confounders, higher perceptions of the decision-making effectiveness component of SDM (β = 0.004, p = 0.03) and empathy and holistic care (β = 0.01, p = 0.02) showed a weak but positive relationship with attaining a greater number of positive health care quality indicators, while a weak but negative relationship emerged for perceptions of participation, respect for choices, and support (β = -0.003, p = 0.03) and overall VA experiences (β = -0.10, p = 0.04).PREMs that measure PCC offer rich data about health care quality while engaging patients, and considering patient experiences and preferences, in performance assessment. PREMs may be used to supplement existing performance metrics.

BackgroundU.S. health care personnel (HCP) have reported that some respiratory protective devices (RPD) commonly used in health care have suboptimal tolerability. Between 2012 and 2016, the U.S. National Institute for Occupational Safety and Health, and the Veterans Health Administration collaborated with two respirator manufacturers, Company A and B, to bring new RPD with improved tolerability to the U.S. health care marketplace. The purpose of this study was to compare the tolerability of four new prototype RPD to two models commonly used in U.S. health care delivery.MethodsA randomized, simulated workplace study was conducted to compare self-reported tolerability of four new prototype RPD (A1, A2, B1, and B2) worn by HCP and two N95 control respirators commonly used in U.S. health care delivery, the 1870 and 1860, manufactured by 3M Corporation. A new survey tool, the Respirator Comfort, Wearing Experience, and Function Instrument (R-COMFI), developed previously in part for the current study, was used as the primary outcome metric. With a maximum total score of 47, lower R-COMFI scores reflected better self-reported tolerability. Poisson regression analyses were used to estimate prototype relative risks compared to controls.ResultsConducted between 2014 and 2015 in two inpatient care rooms at the North Florida/South Georgia Veterans Health System, among 383 participants who enrolled, 335 (87.5%) completed the study. Mean total R-COMFI scores for the 3M 1870, 3M 1860, and prototypes A1, A2, B1, and B2 were 8.26, 9.36, 5.79, 7.70, 6.09, and 5.71, respectively. Compared to the 3M 1870, total R-COMFI unadjusted relative risks (RR) and 95 percent confidence intervals (CI) were A1 (RR 0.70, CI 0.60, 0.82), A2 (RR 0.93, CI 0.82, 1.06), B1 (RR 0.74, CI 0.64, 0.85), and B2 (RR 0.69, CI 0.60, 0.80). Compared to the 3M 1860, prototype total R-COMFI unadjusted RR and 95 percent CI were A1 (RR 0.62, CI 0.53, 0.72), A2 (RR 0.82, CI 0.73, 0.93), B1 (RR 0.65, CI 0.57, 0.74), and B2 (RR 0.61, CI 0.53, 0.70). Similarly, models adjusted for demographic characteristics showed that prototypes A1, B1, and B2 significantly improved tolerability scores compared to both controls, while prototype A2 was significantly improved compared to the 3M 1860.ConclusionsCompared to the 3M 1870 and 3M 1860, two RPDs commonly used in U.S. health care delivery, tolerability improved for three of four newly developed prototypes in this simulated workplace study. The R-COMFI tool, used in this study to assess tolerability, should be useful for future comparative studies of RPD.

Background: There is a need to engage persons with spinal cord injuries/disorders (SCI/D) in research methodologies beyond traditional approaches. This provides an opportunity for individuals to convey their perspectives in a variety of ways. Photovoice empowers people to share their perspectives through photographs and narrative; this is well-suited for individuals who are less comfortable speaking up when other methods are used, such as focus groups. Objective: To examine photovoice methodology in US Veterans with SCI/D to describe their experiences with and the utility of photovoice. We also provide a sample of content (qualitative data) to illustrate how individuals with SCI/D conceptualized function and factors important to them. Methods: Photovoice, a qualitative participatory research method, was used to collect photographs from Veterans with SCI/D, which was followed by personal narratives describing the meaning of their photos. Results: Participants (N = 9) were 64 years old, on average, and 75% had paraplegia. Participants discussed the challenges with taking photographs, but they enjoyed participating, appreciated inclusion, and hoped the information they provided would help others with disabilities. Conclusion: These findings suggest that despite challenges and ethical barriers, individuals with SCI/D are interested in, highly capable of, and should be given the opportunity to be included in studies like this that empower participants to share their views using novel ways of expression. These findings demonstrate the desirability, feasibility, and utility of using photovoice in individuals with SCI/D. This method may be used to understand factors impacting health and well-being and can be made available to individuals with SCI/D to minimize inequalities in research opportunities.

Objective The objective of this paper is to demonstrate the utility of the CFIR framework for evaluating broad-scale change by discussing the challenges to be addressed when planning the assessment of broad-scale change and the solutions developed by the evaluation team to address those challenges. The evaluation of implementation of Patient-centered Care and Cultural Transformation (PCC&CT) within the Department of Veterans Affairs (VA) will be used as a demonstrative example. Patient-Centered Care (PCC) is personalized health care that considers a patient’s circumstances and goals. The Department of Veterans Affairs (VA) is working towards implementing PCC throughout its healthcare system, comprised of multiple interventions with a singular long-term goal of cultural transformation, however little is known about the factors influencing its implementation. This paper discusses the issues that arose using CFIR to qualitatively assess the factors influencing implementation of cultural transformation. Results Application of CFIR to this broad-scale evaluation revealed three strategies recommended for use in evaluating implementation of broad-scale change: (1) the need for adapted definitions for CFIR constructs (especially due to new application to broad-scale change), (2) the use of a mixed deductive-inductive approach with thematic coding to capture emergent themes not encompassed by CFIR, and (3) its use for expedited analysis and synthesis for rapid delivery of findings to operational partners. This paper is among the first to describe use of CFIR to guide the evaluation of a broad-scale transformation, as opposed to discrete interventions. The processes and strategies described in this paper provide a detailed example and structured approach that can be utilized and expanded upon by others evaluating implementation of broad-scale evaluations. Although CFIR was the framework selected for this evaluation, the strategies described in this paper including: use of adapted definitions, use of mixed deductive-inductive approach, and the approach for expedited analysis and synthesis can be transferred and tested with other frameworks.

Objective: To examine variables associated with satisfaction with life (SWL) in individuals with a spinal cord injury (SCI). Design: Cross-sectional, national survey to assess SWL, demographic and injury characteristics, health care utilization, chronic conditions (obesity, diabetes, heart problems, lung problems, hypertension, high cholesterol), symptoms (poor sleep, pain, depression), social support, grief/loss, and independence. Setting/Participants: Community-dwelling Veterans with SCI. Outcome Measures/Analyses: Bivariate analyses were conducted to assess differences in demographics, injury characteristics, chronic conditions, symptoms, social support, grief/loss, and independence in individuals who reported low SWL (≤20) vs. average/high SWL (21-35). Multivariate logistic regression assessed factors independently associated with low SWL. Results: 896 Veterans with SCI (62%) responded. Average age was 62 years, the majority were male (94%), Caucasian (77%), and had paraplegia (61%). Odds of low SWL were 2.4 times greater for individuals experiencing pain (OR = 2.43, CI95: 1.47-4.02, P = 0.0005). Odds of low SWL were increased for individuals reporting greater grief/loss due to their SCI (OR = 1.14, CI95: 1.10-1.18, P

BACKGROUND: PROMIS® items have not been widely or systematically used within the Veterans Health Administration (VA). OBJECTIVE: To examine the concordance of PROMIS-29® scores and medical record diagnosis in US Veterans and to compare Veteran scores relative to US population norms. DESIGN/PARTICIPANTS: Cross-sectional multi-site survey of Veterans (n = 3221) provided sociodemographic and PROMIS-29® domain data. Electronic medical records provided health condition (depression, anxiety, sleep disorders, pain disorders) diagnosis data. MAIN MEASURES: For each domain, we calculated PROMIS® standardized T scores and used t tests to compare PROMIS® scores for Veterans diagnosed with each targeted health condition vs. those without that documented clinical diagnosis and compare mean Veterans’ PROMIS-29® with US adult population norms. KEY RESULTS: Veterans with (vs. without) a depression diagnosis reported significantly higher PROMIS® depression scores (60.3 vs. 49.6, p

In this methodological article, we examine participatory methods in depth to demonstrate how these methods can be adopted for quality improvement (QI) projects in health care. We draw on existing literature and our QI initiatives in the Department of Veterans Affairs to discuss the application of photovoice and guided tours in QI efforts. We highlight lessons learned and several benefits of using participatory methods in this area. Using participatory methods, evaluators can engage patients, providers, and other stakeholders as partners to enhance care. Participant involvement helps yield actionable data that can be translated into improved care practices. Use of these methods also helps generate key insights to inform improvements that truly resonate with stakeholders. Using participatory methods is a valuable strategy to harness participant engagement and drive improvements that address individual needs. In applying these innovative methodologies, evaluators can transcend traditional approaches to uniquely support evaluations and improvements in health care.

Influenza is associated with high rates of morbidity and mortality. The most effective way to prevent influenza or severe consequences from the illness is vaccination, and key organizations recommend that all health care workers (HCWs) be vaccinated annually for influenza. Recent literature suggests declination form programs (DFPs) are a useful approach to improve HCW influenza vaccination rates.To understand support for and beliefs about use of an influenza vaccination DFP, and how this is associated with HCW beliefs about other influenza vaccination improvement strategies.Data were collected via a cross-sectional mailed national survey. Participants included HCWs providing care to Veterans with spinal cord injuries and disorders (SCI/D) from 23 nationwide Veterans Affairs facilities. Analyses included bivariate analyses of outcomes among DFP supporters vs. non-supporters.Of the HCW respondents, 67% reported that they would support a DFP at their facility. A greater proportion of HCWs who support (vs. do not support) DFPs reported receiving an annual influenza vaccination (86.35% vs. 65.81%, p0.0001). Similarly, a significantly greater proportion of HCWs who support DFPs (vs. do not support) reported willingness to receive an influenza vaccination (83.79% vs. 61.48%, p0.0001) and nasal spray influenza vaccination (45.75% vs. 32.50%, p=0.0156). HCWs who support DFPs were more likely to report a great deal of influence in almost all typical vaccination improvement campaign strategies on their decision to be vaccinated, and less likely to endorse commonly provided reasons for refusing vaccination as valid.More HCWs who support DFPs engage in important influenza-related health behaviors (e.g., vaccination), and support other influenza vaccination improvement strategies. Facilities may benefit from implementing DFPs as part of their vaccination improvement campaign. Support for DFPs among HCWs is high, suggesting implementing this as a policy would be well-received by staff, and potentially effective in increasing HCW influenza vaccination.

Changes to the work environment prompted by the movement toward patient-centered care have the potential to improve occupational stress among health care workers by improving team-based work activities, collaboration, and employee-driven quality improvement. This study was conducted to examine professional quality of life among providers at patient-centered care pilot facilities. Surveys were conducted with 76 Veterans Affairs employees/providers at facilities piloting patient-centered care interventions, to assess demographics, workplace practices and views (team-based environment, employee voice, quality of communication, and turnover intention), and professional quality of life (compassion satisfaction, burnout, and secondary traumatic stress).Professional quality-of-life subscales were not related to employee position type, age, or gender. Employee voice measures were related to lower burnout and higher compassion satisfaction. In addition, employees who were considering leaving their position showed higher burnout and lower compassion satisfaction scores. None of the work practices showed relationships with secondary traumatic stress.

Objective: To examine providers’ perspectives on the care environment and patient-centered care (PCC) through the eyes of the veteran patient, using guided tours qualitative methodology. Background: Environmental factors, such as attractiveness and function, have the potential to improve patients’ experiences. Participatory qualitative methods allow researchers to explore the environment and facilitate discussion. Methods: Guided tours were conducted with 25 health care providers/employees at two Veterans Affairs (VA) health care facilities. In guided tours, participants lead the researcher through an environment, commenting on their surroundings, thoughts, and feelings. The researcher walks along with the participant, asking open-ended questions as needed to foster discussion and gain an understanding of the participant’s view. Participants were asked to walk through the facility as though they were a veteran. Tours were audio recorded, with participant permission, and transcribed verbatim by research assistants. Three qualitative researchers were responsible for codebook development and coding transcripts and used data-driven coding approaches. Results: Participants discussed physical appearance of the environment and how that influences perceptions about care. Overall, participants highlighted the need to shed the “institutional” appearance. Differences between VA and non-VA health care facilities were discussed, including availability of private rooms and staff to assist with navigating the facility. They reviewed resources in the facility, such as the information desk to assist patients and families. Finally, they offered suggestions for future improvements, including improvements to waiting areas and quiet areas for patients to relax and “get away” from their rooms. Conclusions: Participants highlighted many small changes to the care environment that could enhance the patient experience. Additionally, they examined the environment from the patient's perspective, to identify elements that enhance, or detract from, the patient's care experience.

OBJECTIVES The study objectives were to compare psychosocial well-being in individuals with spinal cord injuries/disorders (SCI/D) and above-mean ("high") versus below-mean ("low") pain interference, and to determine whether psychosocial well-being was negatively associated with pain interference. METHODS Data were collected via a cross-sectional survey mailed in late 2014 to early 2015 to a national sample of veterans with SCI/D who received prior-year Veterans Affairs healthcare and assessed demographics, injury-related factors, select health conditions, pain interference, and psychosocial well-being. Bivariate comparisons and multivariate linear regressions identified factors related to higher pain interference. RESULTS Approximately 79% of the sample (n = 813) reported high pain interference. Veterans with high (vs. low) pain interference reported worse perceptions of all included psychosocial well-being measures. Regression results indicated that higher pain interference was associated with higher grief/loss (β = 0.38, P < .0001) and negative psychosocial illness impact (β = 0.39, P < .0001), and lower positive affect (β = -0.39, P < .0001), resilience (β = -0.31, P < .0001), and life satisfaction (β = -0.39, P < .0001). CONCLUSIONS The pain experience is independently associated with poor psychosocial well-being among individuals with SCI/D. Efforts to decrease perceptions of pain interference and improve factors associated with psychosocial well-being may symbiotically improve outcomes in SCI/D cohorts. Such efforts may focus on effective pain management programs aligned with patients' treatment preferences.

OBJECTIVEInfections caused by multidrug-resistant gram-negative organisms (MDRGNOs) have been increasing every year. The objective of this study was to describe the prevalence of MDRGNOs and factors associated with MDRGNOs in patients with spinal cord injury or disorder (SCI/D).DESIGNRetrospective cohort study.METHODSDepartment of Veterans Affairs (VA) electronic health record data from 142 VA facilities were evaluated for 19,642 patients with SCI/D. Multivariable cluster-adjusted models were fit to identify factors associated with MDRGNO.RESULTSGram-negative (GN) cultures occurred in 44% of patients with SCI/D receiving care at VA facilities, and 11,527 (41.3%) GN cultures had an MDRGNO. The most frequent GN organisms (GNOs) were Escherichia coli (28.5%), Klebsiella pneumoniae (17.0%), and Pseudomonas aeruginosa (16.0%). Two-thirds of GN cultures were from the outpatient setting, where MDRGNO prevalence was 37.6%. Significant geographic variation in the prevalence of MDRGNOs was identified (South, 44.7%; Northeast, 44.3%; West, 36.8%; Midwest, 34.4%). Other factors associated with an MDRGNO were older age, injury characteristics, comorbidities, specimen type, healthcare setting, and healthcare exposure. Black (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.39–1.78) and Hispanic race (OR, 1.58; 95% CI, 1.28–1.95), polymicrobial culture (OR, 2.67; 95% CI, 2.46–2.90), and antibiotic use in the previous 90 days (OR, 1.62; 95% CI, 1.50–1.76) were also associated with having an MDRGNO.CONCLUSIONSMDRGNOs were common in community and healthcare settings among veterans with SCI/D, with significant geographic variation. Health care and antibiotic exposures were significant factors associated with MDRGNOs. Priority should be given to controlling the spread of MDRGNOs in this special population, including a focus on judicious use of antibiotics.Infect Control Hosp Epidemiol 2017;38:1464–1471

Filtering face-piece respirators (FFRs) are one method of protecting health care workers from airborne particles; however, research suggests adherence is poor, perhaps due to worker discomfort. Three separate focus groups were conducted at two Veterans Affairs health care facilities. Seventeen health care workers who reported using FFRs as part of their job duties were in the focus groups. Focus group transcripts were coded using qualitative descriptive coding techniques. Participants described experiences of discomfort and physical mask features they believed contributed to discomfort. Participants believed FFRs influenced patient care because some patients felt uneasy and changed health care workers' behaviors (e.g., doffing procedures, loss of concentration, rushed patient care, and avoidance of patients in isolation resulting from FFR discomfort). Assessment of comfort and tolerability should occur during fit-testing. These factors should also be taken into account by management when training employees on the proper use of FFRs, as well as in future research to improve comfort and tolerability.

To compare outcomes among caregivers of adults with spinal cord injuries (SCIs) to caregivers of adults with other neurological conditions, and determine if caregiving for SCI is associated with poor health status and chronic conditions.Secondary data analysis of 2009/2010 Behavioral Risk Factor Surveillance System survey.Informal caregivers of adults with neurological conditions.Sociodemographics, caregiving factors (e.g. role, emotional support, life satisfaction), lifestyle behaviors, chronic conditions, and health status.Demographics and lifestyle behaviors did not differ in caregivers of adults with SCI vs. caregivers of adults with other neurological conditions (except younger age of SCI caregivers). Greater proportions of caregivers of adults with SCI had coronary heart disease (CHD) (12% vs. 6%, P = 0.06) and were obese (43% vs. 28%, P = 0.03). Frequent physical distress was reported by 20% of caregivers of persons with SCI (vs. 12% of other caregivers, P = 0.09), but mental health did not differ between caregiver groups. A greater proportion of caregivers of adults with SCI experienced insufficient sleep (47% vs. 30%, P = 0.008) and more days without enough sleep (13 vs. 9 days, P = 0.008). Odds of being younger, caregiver of a spouse, having CHD, and being obese were associated with being a caregiver of an adult with SCI.Caregivers of adults with SCI report similar mental health status, but more poor sleep, and have increased odds of CHD and obesity. Interventions to address physical distress, improve sleep, and address CHD and obesity are needed in this cohort.

OBJECTIVE To examine preferences for relational continuity and rapid accessibility for telephone care. METHODS A mixed-methods sequential explanatory design was utilized. Structured telephone interviews were conducted with 448 Veterans receiving primary care from Veterans Affairs facilities, who rated the importance of relational continuity and rapid accessibility. Seventeen focus groups were conducted with 123 Veterans to examine preferences for continuity versus accessibility and factors affecting these preferences. RESULTS Higher proportions of interview patients rated talking with a nurse from their own primary care team (69%) and talking with a nurse with whom they have previous primary care contact (60%) as very important, compared with talking to any nurse as soon as possible (53%) and receiving advice immediately (50%). Focus group participants preferred a familiar provider within 24 hours over immediate contact with an unfamiliar provider, particularly for routine needs. Rapid accessibility was more frequently preferred for urgent questions/concerns. Preference for relational continuity was mitigated by patient age, and access to electronic medical records in larger, but not smaller, facilities. CONCLUSIONS Health care systems supplementing in-person care with telephone care need to ensure that this care aligns with patient preferences and provide opportunities for both relational continuity and rapid accessibility where possible.

Objective To gain an in-depth understanding of patient barriers to accessing telephone care, subsequent responses to telephone access issues and recommendations for system improvement within a large integrated health-care system. Study Design Cross-sectional qualitative focus group study. Methods One focus group was conducted at each of 17 Veterans Affairs facilities with a total of 123 Veteran users of VA health care. All facilities followed a focus group discussion guide, and purposively sampled patients receiving care at their VA facility in primary and/or specialty care. Focus groups' recordings were sent to the authors' independent evaluation centre, transcribed verbatim and analysed using qualitative content analysis methodology. Results Participants described many issues with the phone system that resulted in delays to care needs being addressed, including difficulty getting someone to answer the phone, out-dated phone directories, frequent disconnections and incorrect transfers. Participants most frequently responded to access issues by doing nothing or waiting to contact at a later time, or seeking unscheduled in-person care in the emergency department or primary care clinic. Participants offered recommendations for improving telephone care, including access to direct extensions, and upgrades to the telephone system. Conclusions Telephone access issues could result in increased patient harm and/or increased wait times for in-person primary care or emergency services. Periodic evaluation of telephone systems is necessary to ensure telephone systems adequately meet patient needs while using resources efficiently to optimize the delivery of high quality, safe health care.

Accounting for patient views and context is essential in evaluating and improving patient-centered care initiatives, yet few studies have examined the patient perspective. In the Veterans Affairs (VA) Health Care System, several VA facilities have transitioned from traditionally disease- or problem-based care to patient-centered care. We used photovoice to explore perceptions and experiences related to patient-centered care among Veterans receiving care in VA facilities that have implemented patient-centered care initiatives. Participants were provided prompts to facilitate their photography, and were asked to capture salient features in their environment that may describe their experiences and perceptions related to patient-centered care. Follow-up interviews were conducted with each participant to learn more about their photographs and intended meanings. Participant demographic data were also collected. Twenty-two Veteran patients (n = 22) across two VA sites participated in the photovoice protocol. Participants defined patient-centered care broadly as caring for a person as a whole while accommodating for individual needs and concerns. Participant-generated photography and interview data revealed various contextual factors influencing patient-centered care perceptions, including patient–provider communication and relationships, physical and social environments of care, and accessibility of care. This study contributes to the growing knowledge base around patient views and preferences regarding their care, care quality, and environments of care. Factors that shaped patient-centered care perceptions and the patient experience included communication with providers and staff, decor and signage, accessibility and transportation, programs and services offered, and informational resources. Our findings may be integrated into system redesign innovations and care design strategies that embody what is most meaningful to patients.

Aim To examine associations between perceptions of evidence (research evidence, clinical expertise, patient preferences) and outcomes of a nationwide programme to implement H1N1 influenza prevention guidelines. Background Healthcare workers do not consistently adhere to recommended infection control practices and this may be associated with their perceptions of evidence sources. Design Cross-sectional mailed survey. Method A survey of healthcare workers was administered in August 2010 after implementation of H1N1 prevention guidelines. Outcomes of interest were ratings of adherence to H1N1 prevention guidelines. Findings Respondents with complete data (N = 283) were included in analyses. Facility-level adherence to guidelines was associated with opinions of clinical experts. Healthcare workers who rated clinical expertise as aligning with recommendations also rated their facilities as being more adherent to guidelines. Perceptions of research evidence and patient preferences were not associated with facility adherence. Personal adherence was not associated with perceptions of evidence, except among those healthcare workers who rated both clinical experts and patients as unsupportive of guidelines; these practitioners were less likely to adhere to recommended personal hygiene practices. Conclusion Efforts to implement guidelines might be most effective when capitalizing on the influence of clinical experts. To better explain variability in guideline adherence, inclusion of a broader array of variables is recommended for future studies.

Many Veterans Affairs (VA) primary care (PC) patients prefer telephone-delivered care to other health care delivery modalities.To evaluate PC patients' telephone experiences and outcomes before and after a national telephone transformation quality improvement (QI) collaborative.Cross-sectional surveys were conducted pre- and post-collaborative. We used bivariate analyses to assess differences in pre/post outcomes and multivariate regression to identify variables associated with patients' perceptions of poor quality care.Patients from 13 VA facilities participated (n = 730; pre-intervention = 314, post-intervention = 416); most of them were males (90%) with a mean age of 62 years. After the collaborative (versus pre-collaborative), few experienced transfers (52% versus 62%, P = 0.0006) and most reported timely call answer (88% versus 80%, P = 0.003). Improvements in staff understanding why patients were calling and providing needed medical information were also found. There were measurable improvements in patient satisfaction (87% versus 82% very/mostly satisfied, P = 0.04) and perceived quality of telephone care (85% versus 78% excellent/good quality, P = 0.01) post- collaborative. The proportion of veterans who reported delayed care due to telephone access issues decreased from 41% to 15% after the collaborative, P0.0001. Perceptions of poor quality care were higher when calls were for urgent care needs did not result in receipt of needed information and included a transfer or untimely answer.The QI collaborative led to improvements in timeliness of answering calls, patient satisfaction and perceptions of high-quality telephone care and fewer reports of health care delays. Barriers to optimal telephone care 'quality' include untimely answer, transfers, non-receipt of needed information and urgent care needs.

Empiric proton pump inhibitor use is common for gastroesophageal reflux disease (GERD), but initial proton pump inhibitor (PPI) prescription patterns in Veterans are unknown.The study aims were to determine initial PPI prescriptions in Veterans diagnosed with GERD, and to characterize subsequent PPI use over the 2 years following initial prescription.We conducted a retrospective study using Veteran's Administration (VA) administrative data and chart review.Patients diagnosed with GERD and provided an initial PPI prescription at Hines VA Hospital from 2003 to 2007, with 2 year follow-up for each patient (through 2009). MEASURES AND OUTCOMES: Initial PPI prescriptions were categorized as standard total daily dose or high total daily dose, and accuracy was confirmed by manual chart review. Descriptive statistics were calculated and bivariate analyses were used to assess for differences in demographics, prescriptions, and subsequent use by initial PPI dosage category.Of the 1,621 patients included in the study, 378 (23.3 %) had high total daily dose initial PPI prescriptions and 1,243 (76.7 %) patients had standard total daily dose initial prescriptions. The majority of patients (65.8 %) received a 90-day or greater initial prescription. Over the 2 years following the initial PPI prescription, 13.0 % of patients with initial standard daily dose prescriptions had evidence of step-up therapy. Only 7.1 % of patients with initial high daily dose PPI prescriptions had evidence of step-down therapy. A large majority of patients (83.8 %) had at least one refill over 2 years, and the overall medication possession ratio was 0.86.Many Veterans receive high total daily dose PPI prescriptions as initial therapy for a GERD diagnosis, and few patients have evidence for cessation or reduction of therapy. These results provide detailed data on prescribing and use of PPIs to help guide efforts for optimal PPI use in US Veterans.

The Promoting Action on Research Implementation in Health Services (PARIHS) framework has been used by implementation researchers to assess factors impacting implementation and to use that information to identify optimal interventions and implementation strategies. In this paper, two studies are presented demonstrating the utility of PARIHS as a tool for retrospective and prospective evaluation of implementation in the health care setting.Descriptive case study.A qualitative consensus process was used to evaluate provider perceptions of PARIHS constructs of evidence, context, and facilitation and their subelements which were scored on a continuum of low to high.The first example demonstrates retrospective use of PARIHS which provided insight into the factors contributing to variations in implementation across sites in an ongoing program. Evidence was strong (high), whereas context noted some challenges in culture and measurement (mixed), and the presence of dedicated program facilitators was positive but dual roles limited their ability to fully support implementation (mixed). The second example demonstrates prospective use of PARIHS for evaluation which gathered information about intervention sites for the purposes of selecting implementation strategies responsive to site needs. Evidence supporting the intervention was limited (low), context noted that limited awareness of the intervention was a challenge (low), and that a strong internal facilitator supported implementation (high).The descriptive case study presented here underscores the value of a theory-guided approach to implementation and highlights that PARIHS can help implementers understand factors impacting implementation, identify areas for future intervention, and inform selection of strategies to support or enhance implementation efforts.

Background The Veterans Health Administration piloted patient-centered care (PCC) innovations beginning in 2010 to improve patient and provider experience and environment in ambulatory care. We use secondary data to look at longitudinal trends, evaluate system redesign, and identify areas for further quality improvement. Methods This was a retrospective, observational study using existing secondary data from multiple US Department of Veteran Affairs sources to evaluate changes in veteran and facility outcomes associated with PCC innovations at 2 innovation and matched comparison sites between FY 2008-2010 (pre-PCC innovations) and FY 2011-2012 (post-PCC innovations). Outcomes included access to primary care providers (PCPs); primary, specialty, and emergency care use; and clinical indicators for chronic disease. Results Longitudinal trends revealed a different story at each site. One site demonstrated better PCP access, decrease in emergency and primary care use, increase in specialty care use, and improvement in diabetic glucose control. The other site demonstrated a decrease in PCP access and primary care use, no change in specialty care use, and an increase in diastolic blood pressure in relation to the comparison site. Conclusion Secondary data analysis can reveal longitudinal trends associated with system changes, thereby informing program evaluation and identifying opportunities for quality improvement.

In the wake of uncertainty due to the H1N1 influenza pandemic, amount and sources of H1N1-related information were examined in a cohort at high-risk for respiratory complications. Factors associated with adequate amount of information were identified. A cross-sectional mailed survey was conducted in 2010 with veterans with spinal cord injuries and disorders. Bivariate comparisons assessed adequate H1N1-realted information versus not enough and too much. Multivariate regression identified variables associated with receipt of adequate information. A greater proportion who received adequate versus not enough information received H1N1 vaccination (61.87 vs. 48.49 %, p < 0.0001). A greater proportion who received adequate versus too much information received seasonal vaccination (84.90 vs. 71.02 %, p < 0.0001) and H1N1 vaccination (61.87 vs. 42.45 %, p < 0.0001). Variables associated with greater odds of receiving adequate information included being white, a college graduate, and having VA health professionals as their primary information source. Receiving adequate information was associated with lower odds of staying home with flu/flu-like symptoms, and higher odds of H1N1 vaccine receipt and wearing a facemask. Receiving appropriate amounts of information from valid sources may impact adherence to infection control recommendations during pandemics. Findings can be used to facilitate efforts ensuring information is received by high-risk populations.

To understand preventive healthcare use by males with multiple sclerosis (MS).Cross-sectional survey with secondary comparative data.Primary survey data were collected from male veterans with MS (n = 1142) and compared with national surveillance data for a general veteran population (n = 31,500) and a general population (n = 68,357). Analyses compared use by group and identified variables associated with service use by male veterans with MS.More veterans with MS had a cholesterol check (93%) than the general veteran population (89%, P 0.001) and the general population (78%, P 0.001). More veterans with MS had received annual influenza vaccination (69%) than the general veteran population (58%, P 0.001) and the general population (42%, P 0.001). More veterans with MS (81%) had ever received pneumonia vaccination than the general veteran population (67%) and the general population (51%) (P 0.001). Colon screening was received by 55% of veterans with MS, 49% of the general veteran population (P 0.001), and 39% of the general population (P 0.0001). Fewer veterans with MS (34%) had received a prostate-specific antigen (PSA) test and digital rectal examination than the general veteran population (46%, P 0.001) and the general population (36%, not significant). In males with MS, variables independently associated with cholesterol checks were: white race [odds ratio (OR) = 3.75] and living in the south (OR = 1.95); variables independently associated with influenza vaccination were increased age (OR = 1.03) and being a non-smoker (OR = 0.55); increased age was independently associated with colon screening (OR = 1.02); variables independently associated with PSA testing were increased age (OR = 1.08) and being employed (OR = 3.31), and being unemployed was independently associated with pneumonia vaccination (OR = 0.16).More males with MS received several recommended preventive health services (e.g. cholesterol and colon screening, influenza and pneumonia vaccination) than males without MS. The Veterans Health Administration is meeting many prevention needs in males with MS, but there is room for improvement in areas such as reducing disparities in PSA screening and increasing respiratory vaccinations to meet national targets.

Cross-sectional survey of veterans with spinal cord injuries and disorders (SCI/D). To describe sleep dysfunction (independent of sleep apnea) in persons with traumatic and non-traumatic SCI/D, and to examine characteristics and health outcomes independently associated with sleep dysfunction unrelated to sleep apnea. Seven Veterans Affairs SCI care facilities in the United States. Mailed cross-sectional survey with follow-up calls completed by end of 2008. Bivariate analyses to compare measures outcomes in persons with SCI/D who were dysfunctional sleepers vs those who were not. Multivariate logistic regression used to identify variables independently associated with dysfunctional sleep in veterans with SCI/D. Overall, 49% of the sample had sleep dysfunction unrelated to sleep apnea. In this subgroup, bivariate analyses showed that a greater proportion of dysfunctional sleepers than non-dysfunctional sleepers were current smokers, had problems with drinking alcohol, hypertension, asthma, chronic obstructive pulmonary disease (COPD) and problematic weight gain. Variables independently associated with higher odds of dysfunctional sleep included white race, being a current smoker, problems with drinking alcohol, asthma, COPD and problematic weight gain. Consistent with epidemiological evidence for the general population, we found significant associations of sleep dysfunction with weight gain, smoking, alcohol misuse and select chronic conditions (COPD, asthma). Sustained sleep dysfunction may contribute to health deterioration and mortality, highlighting the need to address the high prevalence of sleep dysfunction (independent of sleep apnea) in persons with SCI/D. In particular, efforts aimed at modifying problematic weight gain, alcohol misuse and smoking are warranted in this cohort to improve sleep.