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Disasters occur frequently in the United States (US) and their impact on acute morbidity, mortality and short-term increased health needs has been well described. However, barring mental health, little is known about the medium or longer-term health impacts of disasters. This study sought to determine if there is an association between community-level disaster exposure and individual-level changes in disability and/or the risk of death for older Americans. Using the US Federal Emergency Management Agency's database of disaster declarations, 602 disasters occurred between August 1998 and December 2010 and were characterized by their presence, intensity, duration and type. Repeated measurements of a disability score (based on activities of daily living) and dates of death were observed between January 2000 and November 2010 for 18,102 American individuals aged 50–89 years, who were participating in the national longitudinal Health and Retirement Study. Longitudinal (disability) and time-to-event (death) data were modelled simultaneously using a ‘joint modelling’ approach. There was no evidence of an association between community-level disaster exposure and individual-level changes in disability or the risk of death. Our results suggest that future research should focus on individual-level disaster exposures, moderate to severe disaster events, or higher-risk groups of individuals.

BACKGROUND Patient travel distances, coupled with variation in facility-level resources, create barriers for prostate cancer care in the Veterans Health Administration integrated delivery system. For these reasons, the authors investigated the degree to which these barriers impact the quality of prostate cancer care. METHODS The Veterans Affairs Central Cancer Registry was used to identify all men who were diagnosed with prostate cancer in 2008. Patient residence was characterized using Rural Urban Commuting Area codes. The authors then examined whether rural residence, compared with urban residence, was associated with less access to cancer-related resources and worse quality of care for 5 prostate cancer quality measures. RESULTS Approximately 25% of the 11,368 patients who were diagnosed with prostate cancer in 2008 lived in either a rural area or a large town. Rural patients tended to be white (62% urban vs 86% rural) and married (47% urban vs 63% rural), and they tended to have slightly higher incomes (all P

Objective Nonspecific back pain is associated with high use of diagnostic imaging in primary care, yet current evidence suggests that routine imaging of the spine is unnecessary. The objective of this study is to describe current practice patterns in spine radiograph utilization among doctors of chiropractic enrolled in an American provider network. Methods A cross-sectional analysis of administrative claims data from one of the largest providers of complementary health care networks for health plans in the United States was performed. Survey data containing provider demographics were linked with routinely collected data on spine radiograph utilization and patient characteristics aggregated at the provider level. We calculated rates and variations of spine radiographs over 12 months. Negative binomial regression was performed to identify significant predictors of high radiograph utilization and to estimate the associated incidence risk ratio. Results Complete data for 6946 doctors of chiropractic and 249 193 adult patients were available for analyses. In 2010, claims were paid for a total of 91 542 new patient examinations and 23 369 spine radiographs (including17 511 ordered within 5 days of initial patient examination). The rate of spine radiographs within 5 days of an initial patient visit was 204 per 1000 new patient examinations. Significant predictors of higher radiograph utilization rates included the following: practicing in the Midwest or South US census regions, practicing in an urban or suburban setting, chiropractic school attended, and being a male provider in full-time practice with more than 20 years of experience. Conclusion Chiropractic school attended and practice location were the most influential predictors of spine radiograph utilization among network chiropractors. This information may help to inform the development and evaluation of a tailored intervention to address overuse of radiograph utilization.

Background The program “Implementing Goals of Care Conversations with Veterans in VA LTC Settings” is proposed in partnership with the US Veterans Health Administration (VA) National Center for Ethics in Health Care and the Geriatrics and Extended Care Program Offices, together with the VA Office of Nursing Services. The three projects in this program are designed to support a new system-wide mandate requiring providers to conduct and systematically record conversations with veterans about their preferences for care, particularly life-sustaining treatments. These treatments include cardiac resuscitation, mechanical ventilation, and other forms of life support. However, veteran preferences for care go beyond whether or not they receive life-sustaining treatments to include issues such as whether or not they want to be hospitalized if they are acutely ill, and what kinds of comfort care they would like to receive. Methods Three projects, all focused on improving the provision of veteran-centered care, are proposed. The projects will be conducted in Community Living Centers (VA-owned nursing homes) and VA Home-Based Primary Care programs in five regional networks in the Veterans Health Administration. In all the projects, we will use data from context and barrier and facilitator assessments to design feedback reports for staff to help them understand how well they are meeting the requirement to have conversations with veterans about their preferences and to document them appropriately. We will also use learning collaboratives—meetings in which staff teams come together and problem-solve issues they encounter in how to get veterans’ preferences expressed and documented, and acted on—to support action planning to improve performance. Discussion We will use data over time to track implementation success, measured as the proportions of veterans in Community Living Centers (CLCs) and Home-Based Primary Care (HBPC) who have a documented goals of care conversation soon after admission. We will work with our operational partners to spread approaches that work throughout the Veterans Health Administration. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0497-0) contains supplementary material, which is available to authorized users.

A1 Introduction to the 8th Annual Conference on the Science of Dissemination and Implementation: Optimizing Personal and Population Health David Chambers1, Lisa Simpson2 1Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, MD, 20850, USA; 2AcademyHealth, Washington, DC, 20036, USA For the second year in a row, we are pleased to be able to share the proceedings of the Annual Conference on the Science of Dissemination and Implementation in Health, a large meeting reflecting the expanding and evolving research field that seeks to optimize the use of evidence, interventions, and tools from health research within the myriad of settings where people receive health care, make health-related decisions, and increase knowledge of influences on the health of the population. We once again benefitted from a strong partnership, co-led by AcademyHealth and the National Institutes of Health (NIH), with co-sponsorship from the Agency for Healthcare Research and Quality (AHRQ), the Patient Centered Outcomes Research Institute (PCORI), the Robert Wood Johnson Foundation (RWJF), the US Department of Veterans Affairs (VA), and the WT Grant Foundation. In addition, we benefitted from the collaboration of staff from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). NIH and AcademyHealth again co-led the program planning committee, which focused on the development of the plenary sessions, and convened a scientific advisory panel to suggest speakers and advise on the overall conference development. The planning committee identified four key areas around which to focus the plenary panels and keynote address. Dr. America Bracho, M.D., M.P.H., Executive Director of Latino Health Access in Orange County, California, spoke about the opportunities for implementation science to inform efforts to improve community health and engage underserved populations. The three plenary panels each focused on a significant future direction for dissemination and implementation (D & I) research: the interface between D&I science and population health, emerging opportunities for global implementation science, and the challenges around implementation of precision medicine. The plenary sessions were complemented by facilitated lunchtime discussions on the same three topics, which offered participants an opportunity to identify key research questions for each and brainstorm next steps. Synopses of the lunchtime discussions are included in this supplement. Given the overwhelming success of the 2014 conference and the large number of abstracts received in 2014 (660), the program planning committee identified eight program tracks for abstract submitters to respond to, and through which the concurrent sessions of the conference would be organized. These tracks—Behavioral Health, Big Data and Technology for Dissemination and Implementation Research, Clinical Care Settings, Global Dissemination and Implementation, Promoting Health Equity and Eliminating Disparities, Health Policy Dissemination and Implementation, Prevention and Public Health, and Models, Measures and Methods— were designed to enable conference participants to follow a consistent theme across the multiple sessions of the conference and form the structure of this supplement. The call for abstracts, including individual paper presentations, individual posters and panel presentations, resulted in 515 submissions, spread across the eight thematic tracks. Over one hundred reviewers devoted their time to ensuring a comprehensive and expert review, and reviews were conducted within each track and coordinated by the track leads. For the final program, 64 oral presentations, 12 panels, and 263 posters were presented over the two-day meeting. Slides for the oral presentations and panels (with the agreement of the authors) were posted on the conference website (http://diconference.academyhealth.org/archives/2015archives) and all abstracts were included on the conference webapp (https://academyhealth.confex.com/academyhealth/2015di/meetingapp.cgi). This supplement has compiled the abstracts for presented papers, panel sessions, and lunchtime discussions from the 8th Annual Meeting on the Science of Dissemination and Implementation in Health: Optimizing Personal and Population Health. We are pleased to have the abstracts from the conference together in one volume once again, and look forward to the 9th Annual meeting, scheduled for December in Washington, D.C.

Unfortunately, the original version of this article [1] contained an error in abstract S1. The corresponding author for the abstract ‘Gabriele Meyer’ was included in the 'Correspondence' section but accidentally omitted from the author list. The correct author list should be as below: Gabriele Meyer1*, Sascha Kopke2, Jane Noyes3, Jackie Chandler4 1Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, D-06112 Halle (Saale), Germany 2University of Lubeck, Germany 3Bangor University, UK 4Cochrane Collaboration, Oxford, UK Correspondence: Gabriele Meyer (Gabriele.Meyer@medizin.uni-halle.de) – Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, D-06112 Halle (Saale), Germany

OBJECTIVES: Access to subspecialty care may be difficult for patients with liver disease, but it is unknown whether access influences outcomes among this population. Our objectives were to determine rates and predictors of access to ambulatory gastrointestinal (GI) subspecialty care for patients with liver disease and to determine whether access to subspecialty GI care is associated with better survival. METHODS: We studied 28,861 patients within the Veterans Administration VISN 11 Liver Disease cohort who had an ICD-9-CM diagnosis code for liver disease from 1 January 2000 through 30 May 2011. Access was defined as a completed outpatient clinic visit with a gastroenterologist or hepatologist at any time after diagnosis. Multivariable logistic regression was used to determine predictors of access to a GI subspecialist. Survival curves were compared between those who did and those who did not see a specialist, with propensity score adjustment to account for other covariates that may affect access. RESULTS: Overall, 10,710 patients (37%) had a completed GI visit. On multivariable regression, older patients (odds ratio (OR) 0.98, P

Anticoagulation clinics were initially developed to provide safe and effective care for warfarin-treated patients with atrial fibrillation, venous thromboembolism, and mechanical valve replacement. Traditionally, these patients required ongoing laboratory monitoring and warfarin dose adjustment by expert providers. With the introduction of direct oral anticoagulants (dabigatran, rivaroxaban, apixaban, and edoxaban), many have questioned the need for anticoagulation clinic. However, we think that the growing number of oral anticoagulant choices creates an urgent need for expanding the traditional role of the anticoagulation clinic. We outline 3 key purposes that a reimagined anticoagulation clinic would serve: (1) to assist patients and clinicians with selecting the most appropriate drug and dose from a growing list of anticoagulant options (including warfarin), (2) to help patients minimize the risk of serious bleeding complications with careful long-term monitoring and peri-procedural management, and (3) to encourage ongoing adherence to these life-saving medications. We also describe how repurposing anticoagulation clinics as broader medication safety clinics would promote safe and effective care across a range of cardiovascular conditions for high-risk medications (eg, spironolactone, amiodarone). Finally, we highlight a few existing health systems that are overcoming key challenges to implementing a reimagined anticoagulation or medication safety clinic structure.

Electronic practice data are increasingly being used to provide feedback to encourage practice improvement. However, evidence suggests that despite decades of experience, the effects of such interventions vary greatly and are not improving over time. Guidance on providing more effective feedback does exist, but it is distributed across a wide range of disciplines and theoretical perspectives. Through expert interviews; systematic reviews; and experience with providing, evaluating, and receiving practice feedback, 15 suggestions that are believed to be associated with effective feedback interventions have been identified. These suggestions are intended to provide practical guidance to quality improvement professionals, information technology developers, educators, administrators, and practitioners who receive such interventions. Designing interventions with these suggestions in mind should improve their effect, and studying the mechanisms underlying these suggestions will advance a stagnant literature.

To assess the relationship between volume of nonoperative mechanically ventilated patients receiving care in a specific Veterans Health Administration hospital and their mortality.Retrospective cohort study.One-hundred nineteen Veterans Health Administration medical centers.We identified 5,131 hospitalizations involving mechanically ventilated patients in an intensive care unit during 2009, who did not receive surgery.None.We extracted demographic and clinical data from the VA Inpatient Evaluation Center. For each hospital, we defined volume as the total number of nonsurgical admissions receiving mechanical ventilation in an intensive care unit during 2009. We examined the hospital contribution to 30-day mortality using multilevel logistic regression models with a random intercept for each hospital. We quantified the extent of interhospital variation in 30-day mortality using the intraclass correlation coefficient and median odds ratio. We used generalized estimating equations to examine the relationship between volume and 30-day mortality and risk-adjusted all models using a patient-level prognostic score derived from clinical data representing the risk of death conditional on treatment at a high-volume hospital. Mean age for the sample was 65 (SD 11) yrs, 97% were men, and 60% were white. The median VA hospital cared for 40 (interquartile range 19-62) mechanically ventilated patients in 2009. Crude 30-day mortality for these patients was 36.9%. After reliability and risk adjustment to the median patient, adjusted hospital-level mortality varied from 33.5% to 40.6%. The intraclass correlation coefficient for the hospital-level variation was 0.6% (95% confidence interval 0.1, 3.4%), with a median odds ratio of 1.15 (95% confidence interval 1.06, 1.38). The relationship between hospital volume of mechanically ventilated and 30-day mortality was not statistically significant: each 50-patient increase in volume was associated with a nonsignificant 2% decrease in the odds of death within 30 days (odds ratio 0.98, 95% confidence interval 0.87-1.10).Veterans Health Administration hospitals caring for lower volumes of mechanically ventilated patients do not have worse mortality. Mechanisms underlying this finding are unclear, but, if elucidated, may offer other integrated health systems ways to overcome the disadvantages of small-volume centers in achieving good outcomes.

Objectives: To evaluate the effect of emergency department (ED) clinical decision units (CDUs) on over-all ED patient flow in a pilot project funded in 2008 by the Ontario Ministry of Health and Long-TermCare (MOHLTC).Methods: A retrospective analysis of unscheduled ED visits at seven CDU pilot and nine control siteswas conducted using administrative data. The authors examined trends in CDU utilization and comparedoutcomes between pilot-CDU and control sites 1 year prior to implementation, with the first 18 monthsof CDU operation. Sites that were unsuccessful in their applications for CDU program funding served ascontrols. Outcomes included ED length of stay (LOS), admission rates, and ED revisit rates.Results: At CDU sites, roughly 4% of ED patients were admitted to CDUs. The presence of a pilot-CDUwas independently associated with a small reduction in ED LOS for all low-acuity patients ()0.14 hour,95% confidence interval [CI] = )0.22 to )0.07) and nonadmitted patients ()0.11 hour, 95% CI = )0.16 to)0.07). A small independent effect on absolute hospital admission rate for all high-acuity patients()0.8%, 95% CI = )1.5% to )0.03%) and moderate-acuity patients ()0.6%, 95% CI = )1.1% to )0.2%)was also observed. Pilot-CDUs were not associated with changes in ED revisit rates.Conclusions: With only 4% of ED patients admitted to CDUs, the potential for efficiency gains in theseEDs was limited. Nonetheless, these findings suggest small improvements in the operation of the EDthrough CDU implementation. Although marginal, the observed effects of CDU operation were in thedesired direction of reduced ED LOS, reduced admission rate, and no increase in ED revisit rate.ACADEMIC EMERGENCY MEDICINE 2012; 19:828–836 a 2012 by the Society for Academic EmergencyMedicineISSN 1069-6563 a 2012 by the Society for Academic Emergency Medicine828 PII ISSN 1069-6563583 doi: 10.1111/j.1553-2712.2012.01396.xFrom the Institute for Clinical Evaluative Sciences (MJS, MJV, TAS, AG, CAL), Toronto, Ontario; the Institute of Health Policy,Management and Evaluation (MJS, TAS, AG), the Division of Emergency Medicine, Department of Medicine (MJS), and theDepartment of Paediatrics (AG), University of Toronto, Toronto, Ontario; the Clinical Epidemiology Unit, Sunnybrook Health Sci-ences Centre (MJS, TAS), Toronto, Ontario; the Sick Kids Hospital (AG), Toronto, Ontario; and the Department of EmergencyMedicine (BHR), the School of Public Health (BHR), and the Faculty of Nursing (AS), University of Alberta, Edmonton, Alberta,Canada.Received December 5, 2011; revisions received March 5 and March 12, 2012; accepted March 19, 2012.Presented at the Canadian Association of Emergency Physicians meeting, St. John, Newfoundland, June 2011.Dr. Schull is supported by an Applied Chair in Health Services and Policy Research from the Canadian Institutes of Health Research(CIHR) through the Government of Canada (Ottawa, ON). Dr. Rowe’s research is supported by a Tier I Canada Research Chair inEvidence Based Emergency Medicine from CIHR. Dr. Guttmann is supported by a CIHR New Investigator award. The rest of theauthors have no disclosures or conflicts of interest to report. This study was supported by a grant from the Ontario Ministry ofHealth and Long-Term Care and by the Institute for Clinical Evaluative Sciences,whichisfundedbyanannualgrantfromthe Ministryof Health and Long-Term Care. The funding sources had no involvement in the study design, analysis, interpretation, or decision tosubmit this work.The authors have no relevant financial information or potential conflicts of interest to disclose.Supervising Editor: Steven Bernstein, MD.Address for correspondence and reprints: Dr. Michael Schull, e-mail: mjs@ices.on.ca.

Background Standardized resident or client assessments, including the Resident Assessment Instrument (RAI), have been available in long term care and home care settings (continuing care sector) in many jurisdictions for a number of years. Although using these data can make quality improvement activities more efficient and less costly, there has not been a review of the literature reporting quality improvement interventions using standardized data. Objectives To address 2 questions: (1) How have RAI and other standardized data been used in process or quality improvement activities in the continuing care sector? and (2) Has the use of RAI and similar data resulted in improvements to resident or other outcomes? Data Sources Searches using a combination of keyword and controlled vocabulary term searches were conducted in MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, the Cochrane Library, and PsychINFO. Eligibility Criteria, Participants, and Interventions English language publications from database inception to October 2008 were included. Eligibility criteria included the following: (1) set in continuing care (long-term care facility or home care), (2) involved some form of intervention designed to improve quality or process of care, and (3) used standardized data in the quality or process improvement intervention. Study Appraisal and Synthesis Methods After reviewing the articles, we grouped the studies according to the type of intervention used to initiate process improvement. Four different intervention types were identified. We organized the results and discussion by these 4 intervention types. Results Key word searches identified 713 articles, of which we excluded 639 on abstract review because they did not meet inclusion criteria. A further 50 articles were excluded on full-text review, leaving a total of 24 articles. Of the 24 studies, 10 used a defined process improvement model, 8 used a combination of interventions (multimodal), 5 implemented new guidelines or protocols, and 1 used an education intervention. Conclusions/Implications The most frequently cited issues contributing to unsuccessful quality improvement interventions were lack of staff, high staff turnover, and limited time available to train staff in ways that would improve client care. Innovative strategies and supporting research are required to determine how to intervene successfully to improve quality in these settings characterized by low staffing levels and predominantly nonprofessional staff. Research on how to effectively enable practitioners to use data to improve quality of care, and ultimately quality of life, needs to be a priority.

Aim. To describe the frequency of aggressive acts experienced by frontline staff working in two models of dementia care: Residential Alzheimer's Care Centers and Secured Dementia Units and to explore the associations between aggressive acts experienced by frontline staff and factors related to the work context and care providers. Background. Aggression towards healthcare providers in residential long-term care settings is well documented. However, few studies have examined associations between aggressive behaviours towards care providers and organisational factors. Design. A cross-sectional survey. Method. The survey included demographic items and questions about aggressive acts experienced by staff and contextual factors. Analyses included: (1) descriptive statistics, (2) tests of difference (i.e. Student's t-test, Mann-Whitney U-test, chi-squared test and anova), (3) bivariate associations (i.e. Pearson and Spearman rank order correlations) and (4) multivariate linear regression. Results. Ninety-one health care aides and licensed practical nurses working in four nursing units using two models of dementia care participated (response rate 81%). The most frequently reported types of aggression were physical assault (50% of staff, n = 45) and emotional abuse (48% of staff, n = 44). Aggressive acts were significantly associated with working in Secured Dementia Units rather than Residential Alzheimer's Care Centers. Conclusions. Frontline staff working in Secured Dementia Units were exposed to higher frequencies of various types of aggressive acts mainly initiated by residents. Future research needs to explore modifiable workplace factors associated with aggressive acts in a larger sample across a variety of long-term care settings. Relevance to clinical practice. To prevent staff perceived aggressive acts, leaders and managers in dementia care need to acknowledge the complex topic of workplace aggression and encourage an open discussion among frontline staff without assigning blame. Care provider strategies for dealing with aggressive behaviour have to be implemented in policies and clinical practice. Language: en

In-hospital mortality rates associated with an ICU stay are high and vary widely among units. This variation may be related to organizational factors such as staffing patterns, ICU structure, and care processes. We aimed to identify organizational factors associated with variation in in-hospital mortality for patients with an ICU stay. This was a retrospective observational cross-sectional study using administrative data from 34 093 patients from 171 ICUs in 119 Veterans Health Administration hospitals. Staffing and patient data came from Veterans Health Administration national databases. ICU characteristics came from a survey in 2004 of ICUs within the Veterans Health Administration. We conducted multilevel multivariable estimation with patient-, unit-, and hospital-level data. The primary outcome was in-hospital mortality. Of 34 093 patients, 2141 (6.3%)died in the hospital. At the patient level, risk of complications and having a medical diagnosis were significantly associated with a higher risk of mortality. At the unit level, having an interface with the electronic medical record was significantly associated with a lower risk of mortality. The finding that electronic medical records integrated with ICU information systems are associated with lower in-hospital mortality adds support to existing evidence on organizational characteristics associated with in-hospital mortality among ICU patients.

OBJECTIVE Studies suggest that a business case for improving nurse staffing can be made to increase registered nurse (RN) skill mix without changing total licensed nursing hours. It is unclear whether a business case for increasing RN skill mix can be justified equally among patients of varying health needs. This study evaluated whether nursing hours per patient day (HPPD) and skill mix are associated with higher inpatient care costs within acute medical/surgical inpatient units using data from the Veterans Health Administration. METHODS Retrospective cross-sectional study, including 139,360 inpatient admissions to 292 acute medical/surgical units at 125 Veterans Health Administration medical centers between February and June 2003, was conducted. Dependent variables were inpatient costs per admission and costs per patient day. RESULTS The average costs per surgical and medical admission were $18,624 and $6,636, respectively. Costs per admission were positively associated with total nursing HPPD among medical admissions ($164.49 per additional HPPD, P

ICU telemedicine uses audiovisual conferencing technology to provide critical care from a remote location. Research is needed to best define the optimal use of ICU telemedicine, but efforts are hindered by methodological challenges and the lack of an organized delivery approach. We convened an interdisciplinary working group to develop a research agenda in ICU telemedicine, addressing both methodological and knowledge gaps in the field. To best inform clinical decision-making and health policy, future research should be organized around a conceptual framework that enables consistent descriptions of both the study setting and the telemedicine intervention. The framework should include standardized methods for assessing the preimplementation ICU environment and describing the telemedicine program. This framework will facilitate comparisons across studies and improve generalizability by permitting context-specific interpretation. Research based on this framework should consider the multidisciplinary nature of ICU care and describe the specific program goals. Key topic areas to be addressed include the effect of ICU telemedicine on the structure, process, and outcome of critical care delivery. Ideally, future research should attempt to address causation instead of simply associations and elucidate the mechanism of action in order to determine exactly how ICU telemedicine achieves its effects. ICU telemedicine has significant potential to improve critical care delivery, but high-quality research is needed to best inform its use. We propose an agenda to advance the science of ICU telemedicine and generate research with the greatest potential to improve patient care.

Background The infection rates of multidrug-resistant organisms (MDRO) are increasing in Canada and the United States. The prevention and control of MDRO infections remain an important issue in acute care hospitals. Although comprehensive infection prevention and control programs have been recommended, there is little evidence to date of their effectiveness or of what aspects are most important. Objectives Our objectives were to review and critique the literature on the relationship between an MDRO infection and control program and MDRO rates in acute care hospitals. Methods Studies including original research published between January 1, 1998, and May 14, 2009, were identified through MEDLINE, CINAHL, EMBASE, PUBMED, The Cochrane Library, and expert consultation. A comprehensive search strategy was developed with a librarian to find studies that covered the main subject areas of this integrative review. Results Of the 1,382 papers retrieved, 47 were reviewed, and 32 studies met the inclusion criteria. The interventions in the included studies were assessed using the tier 1/tier 2 framework. A total of 18 (56.25%) studies had an administrative measure as an intervention; 20 (62.5%) studies had education and training of health care personnel; 8 (25.0%) studies had judicious use of antimicrobial agents; 17 (53.1%) studies used surveillance; 24 (75.0%) studies had infection control precautions to prevent transmission; 7 studies (21.9%) introduced environmental measures; and 9 (28.1%) studies used patient decolonization. Although all the 32 studies were quasiexperimental studies, only 2 (5.9%) studies provided sample size calculations, and only 5 studies reported confounding factors. Whereas 27 used an interrupted time series design and 2 were controlled pre- and post-intervention designs, 3 were pre- and post-intervention without control groups. Conclusion This integrative review demonstrated that the evidence of the relationship between MDRO infection prevention and control programs and the rates of MDRO is weak. Although major methodologic weaknesses exist in the published literature making it not possible to exclude other plausible explanations for the reduction of the acquisition of MDRO, the overall evidence does support the use of multiple interventions to reduce the rates of MDRO in acute care hospitals. Whereas it is unclear which bundles of interventions are effective, there is a clear suggestion that multiple simultaneous interventions can be effective in reducing MDRO infections. In addition, despite the limitations of interrupted time series, multiple studies employing active surveillance cultures were associated with reduced MDRO infections. Future individual reports of outbreaks and intervention studies should be written in a standardized manner using the recommended Outbreak Reports and Intervention Studies of Nosocomial Infection (ORION) guidelines. Further research is needed on the proposed tier 1/tier 2 framework clearly indicating all the interventions implemented.

The aim of this study was to identify the proportion and characteristics of Registered Nurses who reported having had an access to the Web in the year 2000 National Sample Survey of Registered Nurses. We conducted a secondary data analysis using more than 25 000 respondents to the year 2000 National Sample Survey of Registered Nurses. Using bivariate and logistic regression, we examined the association of reporting access to the Web with demographic, educational, and other characteristics of Registered Nurse respondents to the survey. We found that several factors were associated with the increased likelihood of Registered Nurses' reporting having had an access to the Web in the year 2000. These included race/ethnicity, marital and family status, highest level of nursing education, current enrollment in a nursing education program, annual household income, and continuing education in informatics. The likelihood of reporting having had access decreased with sex, age, experience since first nursing degree, and primary job responsibility. The results of this study indicate that having access to the Web enhances Registered Nurses' participation in professional development and continuing education opportunities.

This study used a cross-sectional survey design with a concurrent process evaluation to examine the feasibility of using Web surveys in a population of acute care neonatal and pediatric nurses. The purpose of conducting a process evaluation was to understand if using strategies such as maximizing face-to-face communication with participants, sending reminder notices, and providing continuous support would encourage nurses to use a Web-based survey. In addition, we sought feedback about where nurses completed the survey, the number of sittings and length of time it took, and why participants that selected the print mode chose not to use the Web.

The Veterans Health Administration (VHA), the largest integrated health care delivery system in the United States, has transformed itself over the past 15 years from a hospital-centered health care system to one that has a robust primary care infrastructure and access points throughout the United States.

In this article, we describe the development of a BScN (Honors) Program in a large Canadian university. We describe the elements of the program, including the application of a research apprenticeship model as the core of the program. We provide examples of student learning experiences culminating in the Honors project. Recruitment, balancing clinical and research interests, financial support, and manageability of the Honors project emerged as key challenges in our first offerings of the program. Overall, students perceived that experiential research learning enhanced their research skills, increased appreciation of the process and outcomes of nursing research, and inspired confidence to pursue graduate education. We conclude that an apprenticeship model providing students with experiential research learning with established faculty researchers is an effective and efficient way to deliver the Honors Program in the context of a research-intensive nursing faculty.

Background: Continuing education is one method for acquiring competency in informatics among nurses. However, little is known about nurses’ participation in continuing education in informatics and the factors or characteristics that motivate them to pursue this type of education. This article identifies the proportion and characteristics of U.S. registered nurses reporting continuing education in informatics in 2000. Methods: A secondary data analysis was conducted with data from the National Sample Survey of Registered Nurses. More than 25,000 nurses responded to this survey in 2000. Bivariate and logistic regression analyses were conducted to examine the association of reported continuing education in informatics with demographic, educational, and other characteristics of respondents to the survey. Results: Of the respondents, 21% reported continuing education in informatics in the year before the survey. The probability of continuing education in informatics increased with Internet access and decreased for nurses working outside hospitals or providing direct patient care. Conclusion: Relatively low proportions of registered nurses report continuing education in informatics, but some opportunities exist to increase rates.

Article-at-a-Glance Background Catheter-associated urinary tract infection (CAUTI), a frequent health care–associated infection (HAI), is a costly and common condition resulting in patient discomfort, activity restriction, and hospital discharge delays. The Centers for Medicare & Medicaid Services (CMS) no longer reimburses hospitals for the extra cost of caring for patients who develop CAUTI. The Michigan Health and Hospital Association (MHA) Keystone Center for Patient Safety & Quality has initiated a statewide initiative, MHA Keystone HAI, to help ameliorate the burden of disease associated with indwelling catheterization. In addition, a long-term research project is being conducted to evaluate the current initiative and to identify practical strategies to ensure the effective use of proven infection prevention and patient safety practices. Overview of the Bladder Bundle Initiative in Michigan The bladder bundle as conceived by MHA Keystone HAI focuses on preventing CAUTI by optimizing the use of urinary catheters with a specific emphasis on continual assessment and catheter removal as soon as possible, especially for patients without a clear indication. Collaboration Between Researchers and State wide Patient Safety Organizations A synergistic collaboration between patient safety researchers and a statewide patient safety organization is aimed at identifying effective strategies to move evidence from peer-reviewed literature to the bedside. Practical strategies that facilitate implementation of the bundle will be developed and tested using mixed quantitative and qualitative methods. Discussion Simply disseminating scientific evidence is often ineffective in changing clinical practice. Therefore, learning how to implement these findings is critically important to promoting high-quality care and a safe health care environment.

The impact of co-morbid illnesses on adherence to guideline recommendations in chronic illness is of growing concern. We tested a framework [Piette and Kerr, Diabetes Care. 29(3):725-31, 2006] of provider adherence to guidelines in the presence of co-morbid conditions, which suggests that the effect of co-morbid conditions depends on treatment recommendations for the co-morbid conditions and how symptomatic they are.We conducted an exploratory analysis to assess the framework using chart audit data for 1,240 post-acute myocardial infarction (AMI) Medicare beneficiaries in Alabama. We assessed level of guideline-adherent post-AMI care from chart-based quality indicators and constructed scores reflecting how much care for the co-morbid condition was similar to post-AMI care (concordance) and how symptomatic the co-morbid condition is, based on expert opinion.Patients had a mean age of 74 years, mean co-morbidities of 2, and 61% were white. Both concordance and symptomatic scores were positively associated with guideline compliance, with correlations of 0.32 and 0.14, respectively (p0.001 for each). We found positive correlations between highly concordant co-morbid conditions and post-AMI quality scores and negative correlations between highly symptomatic conditions and post-AMI quality scores; both findings support the framework. However, the framework performed less well for conditions that were not highly concordant or highly symptomatic, and the magnitudes of the associations were not large.The framework was related to the association of co-morbid conditions with adherence by providers to guideline-recommended treatment for post-AMI patients. The framework holds promise for evaluating and possibly predicting guideline adherence.

Previous studies have shown that women have decreased survival and receive fewer cardiac procedures after acute myocardial infarction (AMI) compared with men, raising concerns for sexual bias in provision of care. The objective of this study is to describe clinical characteristics, treatment, and survival in women veterans compared with men after admission to VA hospitals for AMI.This is a retrospective inception cohort study using data drawn from the VA Cardiac Care Follow-up Clinical Study, describing patients admitted for AMI to VA hospitals from October 1, 2003 to March 31, 2005. Subjects were followed for 1 year.There were 236 women and 13,259 men admitted during the study period to VA hospitals with AMI. Women were less likely to have a history of heart failure compared with men (18.2% of women vs. 27.2% of men, p = 0.002) and previous coronary artery bypass grafting (CABG) (11.4% of women vs. 19.6% of men, p = 0.002). Diagnostic cardiac catheterization was similar in women and men (36.9% and 34.9%, p = 0.539). Crude in-hospital mortality was 4.2% for women and 7.6% for men (p = 0.051). After adjusting for comorbidities and treatment variables, in-hospital mortality was not significantly different for women compared with men (hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.60-1.12).Women veterans receive a level of care similar to men veterans for MI treated in VA hospitals. Differences in mortality between women and men were not significant and do not suggest that women fare worse.

Nurse staffing is not the same across an entire hospital. Nursing care is delivered in geographically-based units, with wide variation in staffing levels. In particular, staffing in intensive care is much richer than in nonintensive care acute units.To evaluate the association of in-hospital patient mortality with registered nurse staffing and skill mix comparing hospital and unit level analysis using data from the Veterans Health Administration (VHA).A retrospective observational study using administrative data from 129,579 patients from 453 nursing units (171 ICU and 282 non-ICU) in 123 VHA hospitals.We used hierarchical multilevel regression models to adjust for patient, unit, and hospital characteristics, stratifying by whether or not patients had an ICU stay during admission.In-hospital mortality.: Of the 129,579 patients, mortality was 2.9% overall: 6.7% for patients with an ICU stay compared with 1.6% for those without. Whether the analysis was done at the hospital or unit level affected findings. RN staffing was not significantly associated with in-hospital mortality for patients with an ICU stay (OR, 1.02; 95% CI, 0.99-1.03). For non-ICU patients, increased RN staffing was significantly associated with decreased mortality risk (OR, 0.91; 95% CI, 0.86-0.96). RN education was not significantly associated with mortality.Our findings suggest that the association between RN staffing and skill mix and in-hospital patient mortality depends on whether the analysis is conducted at the hospital or unit level. Variable staffing on non-ICU units may significantly contribute to in-hospital mortality risk.

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

'Push' and 'pull' factors motivate Filipino registered nurses (RNs) to leave for employment in foreign countries making the Philippines the leading source country for nurses overseas.To assess the current RN-staffing situation in Philippine hospitals.A self-administered survey was mailed to a sample of 200 Philippine hospital chiefs of nurses.According to respondents, the majority of RNs in their hospitals (73%) were aged 40 years and younger and female (85%); government hospital RNs earned higher wages than private hospital RNs; and on average, RN vacancy rates and RN turnover rates were lower in government hospitals than private hospitals. All respondents reported no difficulty recruiting RNs with less than 12 months of work experience. However, recruitment of more experienced RNs was somewhat or very difficult for private hospitals compared with government hospitals. Higher salaries, better benefits and good career opportunities were identified as most effective incentives for both recruitment and retention.RN staffing in government hospitals is more favourable than in private hospitals as measured by employment tenure, vacancy rates, turnover rates and ability to recruit and retain more experienced RNs. On average, respondents reported over half (59%) of total RN turnover was the result of nurse migration overseas.

Depicted in this presentation is the relationship of the aims of the original articles in this issue--using theory in a substantive way; introducing a strong focus on the organization as a contributor to patient, provider, and system outcomes; accounting for organizational level; and moving the field toward a view of research utilization as an intermediate, not terminal, outcome--to outcomes research in health services generally and in nursing health services research more specifically. The insights and innovations described in this set of articles contribute significantly to the literature on research use in healthcare, specifically including the need to account more fully for organizational structure and hierarchy than has been the case to date in health services outcomes research, as well as a strong intimation that research use is not only an important intervening variable in the causal chain producing outcomes at the patient, provider, and system levels but also a latent or unobservable variable.

Background Health professionals strive to deliver high-quality care in an inherently complex and error-prone environment. Underreporting of medical errors challenges attempts to understand causative factors and impedes efforts to implement preventive strategies. Audit with feedback is a knowledge translation strategy that has potential to modify health professionals’ medical error reporting behaviour. However, evidence regarding which aspects of this complex, multi-dimensional intervention work best is lacking. The aims of the Safe Medication Audit Reporting Translation (SMART) study are to: 1. Implement and refine a reporting mechanism to feed audit data on medication errors back to nurses 2. Test the feedback reporting mechanism to determine its utility and effect 3. Identify characteristics of organisational context associated with error reporting in response to feedback Methods/design A quasi-experimental design, incorporating two pairs of matched wards at an acute care hospital, is used. Randomisation occurs at the ward level; one ward from each pair is randomised to receive the intervention. A key stakeholder reference group informs the design and delivery of the feedback intervention. Nurses on the intervention wards receive the feedback intervention (feedback of analysed audit data) on a quarterly basis for 12 months. Data for the feedback intervention come from medication documentation point-prevalence audits and weekly reports on routinely collected medication error data. Weekly reports on these data are obtained for the control wards. A controlled interrupted time series analysis is used to evaluate the effect of the feedback intervention. Self-report data are also collected from nurses on all four wards at baseline and at completion of the intervention to elicit their perceptions of the work context. Additionally, following each feedback cycle, nurses on the intervention wards are invited to complete a survey to evaluate the feedback and to establish their intentions to change their reporting behaviour. To assess sustainability of the intervention, at 6 months following completion of the intervention a point-prevalence chart audit is undertaken and a report of routinely collected medication errors for the previous 6 months is obtained. This intervention will have wider application for delivery of feedback to promote behaviour change for other areas of preventable error and adverse events.

Brooks Carthon and colleagues1 assess the relationship between the quality of hospital work environments for registered nurses and ‘missed care’ reported by nurses. Similar to other authors, they define missed care as care that nurses regarded as necessary but left undone due to a lack of time.2–4 Brooks Carthon and colleagues1 also explore the relationship between both of these variables and hospital readmissions for heart failure. Their analysis represents an important step in moving beyond the literature describing relationships between nurse staffing and patient outcomes.5–7 For patients with heart failure in the large sample of hospitals included in their secondary analysis, Brooks Carthon et al 1 find that nurses’ self-report of missing important elements of care correlates with readmissions in this group of ill, vulnerable patients. For 4 of the 10 nursing activities they studied, each 10-percentage-point increase in the number of nurses reporting having missed the activity was associated with an increase in the odds of readmission by 2%–8% after adjusting for patient and hospital characteristics. Interestingly, they also showed that missed nursing care no longer predicted readmission once adjusting for the nurse work environment, except in the case of the delivery of treatments and procedures (as opposed to processes of care such as care …

In the late summer of 2004, the Veterans Health Administration (VHA) convened an invitational symposium, one in a series of state-of-the-art (SOTA) conferences. VHA's SOTAs are high-level “think tank” sessions with a defined agenda focusing on a specific health care topic. The theme of this SOTA conference was “Implementing the Evidence: Transforming Practices, Systems, and Organizations.” About 100 individuals from across North America, not just from within VHA, gathered for 2 days in the Nation's capital. These were the perceived thought leaders in the implementation sciences, enriched by a few influential “movers” within the largest single health care system in the United States (the VHA). To maximize the yield of the 2 days of SOTA conference brainstorming, VHA commissioned papers to be circulated in draft form before the SOTA, with the intent of priming the pump for discussions organized into specific work groups. This issue of the Journal presents these commissioned papers, revised after the conference, selected and refined through peer review, and augmented by additional manuscripts from SOTA participants and their collaborators who responded to a thematic solicitation.

This paper presents a case for careful consideration of theory in planning to implement evidence-based practices into clinical care. As described, theory should be tightly linked to strategic planning through careful choice or creation of an implementation framework. Strategies should be linked to specific interventions and/or intervention components to be implemented, and the choice of tools should match the interventions and overall strategy, linking back to the original theory and framework. The thesis advanced is that in most studies where there is an attempt to implement planned change in clinical processes, theory is used loosely. An example of linking theory to intervention design is presented from a Mental Health Quality Enhancement Research Initiative effort to increase appropriate use of antipsychotic medication among patients with schizophrenia in the Veterans Health Administration.

The mission of the Veterans Health Administration's (VHA) quality enhancement research initiative (QUERI) is to enhance the quality of VHA health care by implementing clinical research findings into routine care. This paper presents lessons that QUERI investigators have learned through their initial attempts to pursue the QUERI mission. The lessons in this paper represent those that were common across multiple QUERI projects and were mutually agreed on as having substantial impact on the success of implementation. While the lessons are consistent with commonly recognized ingredients of successful implementation efforts, the examples highlight the fact that, even with a thorough knowledge of the literature and thoughtful planning, unexpected circumstances arise during implementation efforts that require flexibility and adaptability. The findings stress the importance of utilizing formative evaluation techniques to identify barriers to successful implementation and strategies to address these barriers.

To assess characteristics and perceptions of nurses working in the Veterans Health Administration (VHA), comparing types of nursing personnel, to benchmark to prior studies across healthcare systems.Prior studies have shown relationships between positive registered nurse (RN) perceptions of the practice environment and patient outcomes. To date, no study has reported the comparison of RN perceptions of the practice environment in hospital nursing with those of non-RN nursing personnel. This study is the first to offer a more comprehensive look at perceptions of practice environment from the full range of the nursing work force and may shed light on issues such as the relationship of skill mix to nurse and patient outcomes.Cross-sectional observational study with a mailed survey administered to all nursing personnel in 125 VA Medical Centers between February and June 2003.Compared with other types of nursing personnel in the VHA, RNs are generally less positive about their practice environments. However, compared with RNs in other countries and particularly with other RNs in the United States (Pennsylvania), VHA RNs are generally more positive about their practice environment and express more job satisfaction.The nursing work force of the VHA has some unique characteristics. The practice environment for nurses in the VHA is relatively positive, and may indicate that the VHA, as a system, provides an environment that is more like magnet hospitals. This is significant for a public sector hospital system.

To investigate factors associated with residents’ choice of type of Medicaid-funded community residential care setting in western Washington State. Method: Prospective cohort design including residents new to any of three setting types (264 residents entering 170 different facilities), using data from state and Medicaid databases and in-person interviews. The authors used analysis of variance and multinomial logistic regression to examine bivariate associations and estimate effects of resident and facility characteristics on choice of facility type at baseline. Results: Several resident characteristics appear to be associated with choice of community residential care setting, including age, marital status, education, functional status, and reported memory and behavior problems. Facility policies differ significantly among types of facilities and also appear to be associated with choice of setting. Discussion: Selection processes operate in choice of community residential care setting, with residents choosing facility type based on the fit of their needs with facility characteristics.

The VA Puget Sound Health Care System (VAPSHCS) started a palliative care service (PCS) in October 2001 to provide case management for patients with advanced cancer.To examine resource use during the last 60 days of life for patients dying of cancer who received PCS compared to patients receiving usual care (non-PCS) during the same time period.Retrospective nonrandomized comparison of resource use using administrative data.Tertiary care Veterans Affairs medical center.All patients who died of cancer between October 1, 2001 and October 31, 2002 at VAPSHCS.Two hundred sixty-five patients died of cancer during the specified time period, including 82 PCS and 183 non-PCS patients. PCS patients received case management for a mean of 79 days, and were younger, had more comorbid conditions, and were more likely to have had chemotherapy in the last 60 days of life than non-PCS patients. Variables associated with more acute care bed days in the last 60 days of life included: chemotherapy in the last 60 days of life, and a length of stay on PCS less than 60 days. Variables associated with fewer acute care bed days within the last 60 days of life included: being married, and a length of stay on PCS 60 days or more. Compared to non-PCS patients, the place of death for PCS patients was less likely to be acute care.PCS for 60 or more days prior to death was associated with decreased use of acute care hospital resources for patients dying of cancer.

Background: Ischemic heart disease (IHD) is the leading cause of death in the United States. Lowering serum cholesterol levels reduces coronary events and mortality; this effect is most evident in patients with preexisting IHD. Aims: The primary aim of this article is to describe a set of interventions that were piloted in a single, regional Veterans Integrated Service Network (VISN) to promote secondary prevention among patients with IHD and to explore the effect of those interventions on patient outcomes. Methods: An observational, before-and-after study of clinical interventions to improve lipid guideline compliance in VISN 20 (the Veterans Administration Northwest Network) was conducted. A total of 2,467 patients with established coronary artery disease from three medical facilities in VISN 20 were included. Each medical facility chose different interventions to lower low-density lipoprotein cholesterol (LDL-c) levels in their patients. One facility chose a paper point-of-care reminder, a second chose a lipid clinic, and a third chose audit/feedback to clinicians in addition to a patient-education component. Data came from a relational database that mirrors the clinical information system at each site. Outcomes included the proportion of patients who had their LDL-c measured, the proportion of patients who had lipid-lowering agents prescribed, and the proportion of patients at LDL-c goal of lower than 100 mg/dL measured before, during, and after the intervention period. Results: Statistically significant improvements were observed within sites after the interventions were implemented. Implications for Practice: Interventions that focused on secondary prevention in this high-risk group were moderately successful in changing practice. Tailoring interventions to the needs of a specific site of care is feasible and may add to the likelihood of succeeding. Conclusion: Overall, the three facilities improved in lipid measurement and management for patients with coronary artery disease.

Objective: To identify barriers and facilitators to implementation of pilot interventions designed to improve measurement and management of low-density lipoprotein cholesterol (LDL-c) levels in coronary heart disease patients using the evidence/context/facilitation model of implementation of evidence-based practice. Design: Theory-based conceptual content analysis of structured interviews conducted between January and April 2001. Setting: Six medical centers in the United States Veterans Health Administration Northwest Network. Participants: Fifty-one of 64 individuals (physicians, nurses, pharmacists, dieticians, quality managers, and other clinical and nonclinical staff) who participated in planning and/or implementing pilot interventions. Main Findings: Barriers to successful implementation related primarily to the intervention process and secondarily to characteristics of the intervention context. Interview responses indicated that planning, including identification of resources and assessment of potential barriers and facilitators, was a critical and universally underutilized step in the intervention process. Conclusions: Organized team process, documented plans for intervention activities, and ongoing evaluation are essential for sustaining intervention activities. A top priority for facilitating interventions should be the development of educational materials, such as “how to” guides, that teach intervention teams how to anticipate barriers and make plans to address them, as well as identifying and fostering local experts in planning and implementing interventions.

Background Although there is accumulating evidence that renal insufficiency is an independent risk factor for mortality after acute myocardial infarction (AMI), it is not known whether renal dysfunction is associated with an increased mortality rate after a broad range of acute coronary syndromes, including unstable angina. Methods We examined consecutive patients from 24 Veterans Affairs hospitals with confirmed AMI or unstable angina between March 1998 and February 1999, who were categorized into groups according to estimated glomerular filtration rate (GFR). Multivariable regression was used to assess the independent association between GFR and the 7-month mortality rate, adjusting for differences in patient characteristics and treatment. Results Of the 2706 patients, 436 (16%) had normal renal function (GFR >90 mL/min/1.73 m 2 ), 1169 (43%) had mild renal insufficiency (GFR 60–89 mL/min/1.73 m 2 ), 864 (32%) had moderate renal insufficiency (GFR 30–59 mL/min/1.73 m 2 ), and 237 (9%) had severe renal insufficiency (GFR 2 ). Patients with renal insufficiency were less likely to undergo coronary angiography or to receive aspirin or β-blockers at discharge. In multivariable models, renal insufficiency was associated with a higher odds of death (mild renal insufficiency: odds ratio [OR] = 1.76; 95% CI, 0.93–3.33; moderate renal insufficiency: OR=2.72; 95% CI, 1.43–5.15; and severe renal insufficiency: OR=6.18; 95% CI, 3.09–12.36; all compared with normal renal function). The associations between renal insufficiency and mortality rate were similar in both the AMI and unstable angina subgroups ( P value for interaction=.45). Conclusions Renal insufficiency is common and is associated with higher risks for death in patients with a broad range of ACS at presentation. Future efforts should be dedicated to determining whether more aggressive treatment will optimize outcomes in this patient population.

Purpose Although of great importance to clinicians, hospitals, and health care systems, little is known about factors that influence treatment satisfaction after acute coronary syndromes (ACS). The objective of this study was to identify potentially modifiable factors associated with treatment satisfaction 7 months after ACS. Methods The study population included 1957 patients with ACS who were enrolled in the multicenter, prospective Veterans' Health Administration Access to Cardiology Study. The primary outcome was treatment satisfaction 7 months after ACS as measured by the Seattle Angina Questionnaire. Multivariable regression models were developed to determine the association between treatment satisfaction and patient characteristics, physician-patient communication, and current angina frequency. Results Patient characteristics associated with reduced treatment satisfaction included a history of depression, atrial fibrillation, prior heart surgery, arthritis, hypertension, younger age, and a discharge diagnosis of unstable angina (as opposed to myocardial infarction). After adjusting for patient characteristics, patient-reported inability to reach one or more of their physicians (OR, 2.40; 95% CI, 1.47 to 3.91), being given confusing information (OR, 3.48; 95% CI, 2.08 to 5.83), and poor overall communication with one or more of their physicians (OR, 4.94; 95% CI, 2.93 to 8.34) were all associated with reduced satisfaction. Finally, after adjustment for both patient characteristics and physician communication, weekly (OR, 3.52; 95% CI, 2.28 to 5.45) and daily angina (OR, 3.88; 95% CI, 2.23 to 6.75) were associated with worse treatment satisfaction. Conclusions Current angina symptoms and aspects of physician communication are independently associated with treatment satisfaction after ACS. These results suggest that treatment satisfaction may be improved through better communication and better control of angina symptoms.

The Veterans Health Administration (VHA) is the largest public-sector health care system in the United States, and one of the largest nationwide health care systems in the country. Over the last seven years, VHA has developed regional network structures and enhanced integration among tertiary and non-tertiary facilities in regionally based delivery systems (Kizer 1996; Ciesco and Greenblatt 1999). In addition, VHA initiated performance measures at the regional network level, holding Network Directors accountable for their network's performance (Kizer, Demakis, and Feussner 2000; Veterans Health Administration 2000). Networks are ranked by their performance on these measures, and directors' compensation packages depend to some degree on how their network performs. The Performance Measurement Plan has been evolving since 1996. During the period covered by the analysis presented here, the plan included four domains: Quality, Access, Satisfaction, and Cost. Because of the national performance measures, VHA provides an important model for health care systems examining the performance of profiling and case-mix measures across several facilities within an integrated delivery system. However, VHA performance measures are not adjusted for case-mix differences. Studies of outcomes and utilization measures in the VHA, consistent with studies in other health care systems, have found that case-mix adjustment affects rankings of facilities and outlier status in clinical outcomes and utilization measures (Phibbs, Swindle, and Recine 1997; Berlowitz et al. 1998; Selim et al. 2002). The veterans who use the VHA system have been shown to be sicker than those who do not (Wilson and Kizer 1997; Kazis et al. 1999). The VHA is similar to other highly segmented health care markets, experiencing significant adverse selection, and providing specialized services to a specialized population. The factors driving market segmentation are not well understood, but in general, the more alternatives in a market area (that is, the more competitive health care is in an area), the lower the VHA market share. This suggests that veterans' selection of VHA as their health care system is largely market-driven. This study and other analyses suggest that patient populations across VHA facilities vary by age, gender, health status, and proportion of patients suffering from major illness conditions (Au et al. 2001; Sloan et al. 2003). Further, the rate of using of VHA services varies across facilities (Ashton et al. 1998). Therefore, the risk across VHA facilities may be different. In this paper, we assess the ability of the RxRisk-V model, a risk assessment model based on automated pharmacy data refined for use in the VHA (Sloan et al. 2003; Sales et al. 2003), to predict concurrent health service utilization measured as bed days of care and number of ambulatory provider visits. The bed days of care measure has been included in the Network Directors' Performance Measurement set since 1996 (http://vaww.opq.med.va.gov/). The ambulatory provider visits measure is not currently included in the Performance Measurement set, but the provider visits measure is often used by other health care systems as a performance or profiling measure and has been discussed as a potential measure within VHA, particularly in the context of provider profiling. We also compare the power of the RxRisk-V to predict health services utilization with three commonly used diagnosis-based case-mix adjustment measures, Diagnostic Cost Groups (DCG), Adjusted Clinical Groups (ACG), and Chronic Illness and Disability Payment System (CDPS). Finally, we compare the rankings for specific measures of health utilization across facilities using different case-mix adjustment measures.

Community residential care (CRC) is growing, with cognitive impairment the most common reason for CRC placement. We enrolled cognitively impaired and noncognitively impaired residents, informal caregivers, and providers in 219 CRC facilities for this study. Residents with cognitive impairment were older (p < .001), needed more activities of daily living (ADL) assistance (p < .001), and had a higher frequency of behavior problems (p < .001) than noncognitively impaired residents. Cognitively impaired and noncognitively impaired residents did not significantly differ in the facility-related factors they perceived as important or in the amount of control they felt they had over the decision to move. Including residents with cognitive impairment in future research and separately analyzing residents by cognitive status will give a more accurate picture of the needs of CRC residents.

“There's something happening hereWhat it is ain't exactly clear…”—Buffalo Springfield Improving the efficiency and quality of care that hospitalised patients receive is clearly important. The study by Glasgow and colleagues in this issue of BMJ Quality and Safety provides interesting insights into the summative outcomes of a large, national quality collaborative focused on reducing length of stay and discharging hospitalised patients before noon. Additionally, the authors included mortality and 30-day readmissions as secondary outcomes as part of their robust evaluation of a large mandatory collaborative (termed ‘FIX’) that occurred within the 130 hospitals that are part of the Veterans Health Administration (VHA). The findings of this ambitious study extend the literature evaluating quality-improvement projects. We applaud the authors on their achievement in reporting short-term outcomes of this large-scale initiative, and in going further to assess how any gains achieved in the initiative endured. Their innovative approach to measuring sustainability is an important step forward, and hopefully will encourage others with access to large systems with longitudinal data to continue metric development. Their key finding was that less than half the hospitals showed improvement in the primary outcomes—length of stay and discharge before noon—beyond what would have been expected from trends unrelated to the initiative. However, even among hospitals that showed initial improvement, sustainability was difficult to achieve. Specifically, of the 130 hospitals participating in FIX, only 27 had both initial and sustained improvement in length of stay, while only 19 hospitals had both initial and sustained improvement in discharges before noon. Only five hospitals were able to …

This article addresses an increasingly important issue in medical practice and health services research—the effect of financial incentives on physician behavior. Specifically, this study estimates the impact of financial incentives on physician productivity in medical groups. The medical group represents a natural organized setting for observing variation in financial incentives and the impact of those incentives on physician behavior. For example, salary compensation and income-sharing methods are only observable within groups, not solo practices. Moreover, the majority of active patient care physicians practice in medical groups of three or more members (Gaynor 1994), and that proportion has been growing over time. The American Medical Association (Havlicek 1996) reports that the number of physicians in groups rose by 18.5 percent from 1988 to 1991 and 14.3 percent from 1991 to 1995. Simultaneously, group practice size has been increasing, and the share of physicians in solo practice has declined from more than one-third in 1991 to just more than one-quarter in 1995 (Gaynor and Haas-Wilson 1999). In the medical group, two “tiers” of financial incentives bear on physician productivity: (1) the method of payment by health plans and organized purchasers (e.g., employer groups contracting directly with provider organizations) to the medical group; (2) the method used by the medical group to compensate individual physicians (Hillman, Welch, and Pauly 1992). Both the plan-to-group and group-to-individual physician incentive tiers are expected to influence individual physician behavior: the first via a “group” effect, the latter through the direct effect of individual physician compensation. The current study builds on a strong tradition of empirical research regarding the effects of financial incentives on physician productivity. The major previous econometric studies by Reinhardt, Pauly, and Held (1979), Gaynor and Pauly (1990), and Gaynor and Gertler (1995) all drew on a nationwide survey of medical group practices conducted by Mathematica Policy Research during the period March to June of 1978. One important contribution of the current paper is to update the prior econometric work to the current managed care and policy environment, using a nationwide sample of medical groups responding to two surveys (1997 data) of the Medical Group Management Association: The Compensation and Production Survey and the Cost Survey. Second, the rich data set provided by the MGMA surveys allows us to account for the role of a variety of potential productivity “drivers” within the medical group: ownership form, presence of monitoring mechanisms, size of the group, physician specialty mix, and individual physician characteristics. Third, this research examines a wider range of ownership forms and specialty types of medical group practice—nonprimary care single-specialty groups, primary care groups, and multispecialty groups—than previous empirical studies of physician productivity. In contrast, the analyses of Gaynor and Pauly (1990) and Gaynor and Gertler (1995) were restricted to primary care groups and the partnership form of practice. Fourth, by virtue of the broader array of specialty groups in the MGMA sample, the current study will be able to distinguish differential responses to financial incentives and organization design features among primary care physicians (PCPs), medical specialists, and surgical specialists.

Background There is considerable evidence about the effectiveness of audit coupled with feedback for provider behavior change, although few feedback interventions have been conducted in long-term care settings. The primary purpose of the Data for Improvement and Clinical Excellence-Long-Term Care (DICE-LTC) project was to assess the effects of a feedback intervention delivered to all direct care providers on resident outcomes. Our objective in this report is to assess the effect of feedback reporting on rates of pain assessment, depression screening, and falls over time. Methods The intervention consisted of monthly feedback reports delivered to all direct care providers, facility and unit administrators, and support staff, delivered over 13 months in nine LTC units across four facilities. Data for feedback reports came from the Resident Assessment Instrument Minimum Data Set (RAI) version 2.0, a standardized instrument mandated in LTC facilities throughout Alberta. The primary evaluation used an interrupted time series design with a comparison group (units not included in the feedback intervention) and a comparison condition (pressure ulcers). We used segmented regression analysis to assess the effect of the feedback intervention. Results The primary outcome of the study, falls, showed little change over the period of the intervention, except for a small increase in the rate of falls during the intervention period. The only outcome that improved during the intervention period was the proportion of residents with high pain scores, which decreased at the beginning of the intervention. The proportion of residents with high depression scores appeared to worsen during the intervention. Conclusions Maintaining all nine units in the study for its 13-month duration was a positive outcome. The feedback reports, without any other intervention included, did not achieve the desired reduction in proportion of falls and elevated depression scores. The survey on intention to change pain assessment practice which was conducted shortly after most of the feedback distribution cycles may have acted as a co-intervention supporting a reduction in pain scores. The processing and delivery of feedback reports could be accomplished at relatively low cost because the data are mandated and could be added to other intervention approaches to support implementation of evidence-based practices. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0161-5) contains supplementary material, which is available to authorized users.

Background Long-term care settings provide care to a large proportion of predominantly older, highly disabled adults across the United States and Canada. Managing and improving quality of care is challenging, in part because staffing is highly dependent on relatively non-professional health care aides and resources are limited. Feedback interventions in these settings are relatively rare, and there has been little published information about the process of feedback intervention. Our objectives were to describe the key components of uptake of the feedback reports, as well as other indicators of participant response to the intervention. Methods We conducted this project in nine long-term care units in four facilities in Edmonton, Canada. We used mixed methods, including observations during a 13-month feedback report intervention with nine post-feedback survey cycles, to conduct a process evaluation of a feedback report intervention in these units. We included all facility-based direct care providers (staff) in the feedback report distribution and survey administration. We conducted descriptive analyses of the data from observations and surveys, presenting this in tabular and graphic form. We constructed a short scale to measure uptake of the feedback reports. Our analysis evaluated feedback report uptake by provider type over the 13 months of the intervention. Results We received a total of 1,080 survey responses over the period of the intervention, which varied by type of provider, facility, and survey month. Total number of reports distributed ranged from 103 in cycle 12 to 229 in cycle 3, although the method of delivery varied widely across the period, from 12% to 65% delivered directly to individuals and 15% to 84% left for later distribution. The key elements of feedback uptake, including receiving, reading, understanding, discussing, and reporting a perception that the reports were useful, varied by survey cycle and provider type, as well as by facility. Uptake, as we measured it, was consistently high overall, but varied widely by provider type and time period. Conclusions We report detailed process data describing the aspects of uptake of a feedback report during an intensive, longitudinal feedback intervention in long-term care facilities. Uptake is a complex process for which we used multiple measures. We demonstrate the feasibility of conducting a complex longitudinal feedback intervention in relatively resource-poor long-term care facilities to a wider range of provider types than have been included in prior feedback interventions. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0208-2) contains supplementary material, which is available to authorized users.

Article-at-a-Glance Background Quality improvement approaches such as continuous quality improvement (CQI) and total quality management are widely used, but little is known about how much it costs to use the principles and techniques required to implement CQI processes. In the Robert Wood Johnson Foundation's Improving the Quality of Hospital Care (IQHC) program, four consortia of hospitals were funded in the early 1990s. Interviews with quality managers at 38 of the consortia hospitals were conducted in 1995 to determine the costs of conducting CQI projects to allow an estimation of the marginal cost of using CQI processes (particularly cross-disciplinary teams) to improve quality of care. CQI projects Quality managers described 69% of project outcomes as critical to clinical services. Team members identified the issues their teams addressed and selected the project 64% of the time, the methods of analysis 87% of the time, and the approaches to resolving the problem or issue 97% of the time. Most of the respondents agreed that the team members had the authority to resolve the problem without appealing to higher levels of management. Costs for hospitals' most recently completed projects varied widely, from $148 for the entire project to $18,590. The length or duration of the projects also varied widely, from 1 month to 66 months. Discussion In the hospitals included in this sample, all of which were highly self-selected (evidenced by their participation in a voluntary consortium of hospitals focused on quality of care), knowledge of CQI processes appeared to be fairly thorough. Teams appeared to have a reasonable amount of autonomy. New CQI projects should be subjected to scrutiny in terms of their likely contribution to quality of care, as distinct from other positive outcomes.