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Identifying risk factors for early onset colorectal cancer (EOCRC) could help reverse its rising incidence through risk factor reduction and/or early screening. We sought to identify EOCRC risk factors that could be used for decisions about early screening. Using electronic databases and medical record review, we compared male veterans aged 35-49 years diagnosed with sporadic EOCRC (2008-2015) matched 1:4 to clinic and colonoscopy controls without CRC, excluding those with established inflammatory bowel disease, high-risk polyposis and non-polyposis syndromes, prior bowel resection, and high-risk family history. We ascertained sociodemographic and lifestyle factors, family and personal medical history, physical measures, vital signs, medications, and laboratory values 6-18 months prior to case diagnosis. In the derivation cohort (75% of the total sample), univariate and multivariate logistic regression models were used to derive a full model and a more parsimonious model. Both models were tested using a validation cohort. Among 600 cases of sporadic EOCRC (mean [SD] age 45.2 [3.5] years; 66% White), 1200 primary care clinic controls (43.4 [4.2] years; 68% White), and 1200 colonoscopy controls (44.7 [3.8] years; 63% White), independent risk factors included age, cohabitation and employment status, BMI, comorbidity, CRC or other visceral cancer in a first- or second-degree relative; alcohol use; exercise; hyperlipidemia; use of statins, NSAIDs, and multivitamins. Validation c-statistics were 0.75-0.76 for the full model and 0.74-0.75 for the parsimonious model, respectively. These independent risk factors for EOCRC may identify veterans for whom CRC screening prior to age 45 or 50 years should be considered.

Objective The current article describes efforts to develop and test a measure of recovery-oriented inpatient care. Method The Recovery-oriented Acute INpatient (RAIN) scale was based on prior literature and current Veterans Health Administration (VHA) policy and resources and further revised based on data collection from 34 VHA acute inpatient units. Results A final scale of 23, behaviorally anchored items demonstrated a four-factor structure including the following factors: inpatient treatment planning, outpatient treatment planning, group programming, and milieu. While several items require additional revision to address psychometric concerns, the scale demonstrated adequate model fit and was consistent with prior literature on recovery-oriented inpatient care. Conclusions and Implementations for Practice: The RAIN scale represents an important tool for future implementation and empirical study of recovery-oriented inpatient care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

This article examines the relationship between inpatient mental health units' adherence to recovery-oriented care and 30-day patient readmission.The sample included patients admitted to one of 34 Veterans Health Administration inpatient mental health units. Recovery-oriented care was assessed using interviews and site visits. Patient characteristics and readmission data were derived from administrative data.Overall recovery orientation was not associated with readmission. Exploratory analyses found higher scores on a subsample of items pertaining to inpatient therapeutic programming were associated with lower patient readmissions. Additionally, patients with more prior service use and substance abuse or personality disorders were more likely to be readmitted.A growing body of literature supports the association between psychotherapeutic services in inpatient units and better patient outcomes. However, further research is needed to examine this association. More work is needed to develop appropriate psychotherapy services for the inpatient setting and support their implementation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Background and Purpose: We determined the association between hospital factors, performance on transient ischemic attack (TIA) process measures, and 90-day ischemic stroke incidence. Methods: Longitudinal analysis of retrospectively obtained data on 9168 veterans ≥18 years with TIA presenting to the emergency department or inpatient unit at 69 Veterans Affairs hospitals with ≥10 eligible patients per year in fiscal years 2015 to 2018. Process measures were high/moderate potency statin within 7 days of discharge, antithrombotic by day 2, and hypertension control ( Results: During the 4-year study period, hospitals significantly increased statin use (adjusted odds ratio [aOR] per 1-year increase, 1.24 [95% CI, 1.17–1.32]; P P =0.44) nor antithrombotic use ( P =0.82) improved over time. Hospitals that admitted a higher proportion of TIA patients versus emergency department discharge had significantly greater use of statins (aOR per 10-percentage point increase in the proportion of TIA patients admitted, 1.09 [1.03–1.16]; P =0.003) and antithrombotics (aOR per 10-percentage point increase in TIA patients admitted, 1.14 [1.06–1.23]; P P =0.008 and aOR per 10-patient decrease in volume, 1.09 [1.01–1.16]; P =0.02). Higher emergency physician staffing was associated with lower 90-day stroke incidence (aOR per 1 full-time physician increase, 0.96 [0.92–0.99]; P =0.02) but other hospital factors were not. Conclusions: Hospitals admitting higher percentages of TIA patients and having higher emergency physician staffing have greater performance on select guideline-concordant process measures for TIA. Higher emergency physician staffing was associated with improved outcomes 90 days after TIA.

As the Department of Veterans Affairs (VA) healthcare system seeks to expand access to comprehensive geriatric assessments, evidence-based models of care are needed to support community-dwelling older persons. We evaluated the VA Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program's effect on mortality and readmissions, as well as patient, caregiver, and staff satisfaction.This retrospective cohort included patients admitted to the Richard L. Roudebush VA hospital (2010-2019) who received VA-GRACE services post-discharge and usual care controls who were potentially eligible for VA-GRACE but did not receive services. The VA-GRACE program provided home-based comprehensive, multi-disciplinary geriatrics assessment, and ongoing care. Primary outcomes included 90-day and 1-year all-cause readmissions and mortality, and patient, caregiver, and staff satisfaction. We used propensity score modeling with overlapping weighting to adjust for differences in characteristics between groups.VA-GRACE patients (N = 683) were older than controls (N = 4313) (mean age 78.3 ± 8.2 standard deviation vs. 72.2 ± 6.9 years; p 0.001) and had greater comorbidity (median Charlson Comorbidity Index 3 vs. 0; p 0.001). VA-GRACE patients had higher 90-day readmissions (adjusted odds ratio [aOR] 1.55 [95%CI 1.01-2.38]) and higher 1-year readmissions (aOR 1.74 [95%CI 1.22-2.48]). However, VA-GRACE patients had lower 90-day mortality (aOR 0.31 [95%CI 0.11-0.92]), but no statistically significant difference in 1-year mortality was observed (aOR 0.88 [95%CI 0.55-1.41]). Patients and caregivers reported that VA-GRACE home visits reduced travel burden and the program linked Veterans and caregivers to needed resources. Primary care providers reported that the VA-GRACE team helped to reduce their workload, improved medication management for their patients, and provided a view into patients' daily living situation.The VA-GRACE program provides comprehensive geriatric assessments and care to high-risk, community-dwelling older persons with high rates of satisfaction from patients, caregivers, and providers. Widespread deployment of programs like VA-GRACE will be required to support Veterans aging in place.

Background The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was designed to address systemic barriers to providing timely guideline-concordant care for patients with transient ischemic attack (TIA). Objective We evaluated an implementation bundle used to promote local adaptation and adoption of a multi-component, complex quality improvement (QI) intervention to improve the quality of TIA care Bravata et al. (BMC Neurology 19:294, 2019). Design A stepped-wedge implementation trial with six geographically diverse sites. Participants The six facility QI teams were multi-disciplinary, clinical staff. Interventions PREVENT employed a bundle of key implementation strategies: team activation; external facilitation; and a community of practice. This strategy bundle had direct ties to four constructs from the Consolidated Framework for Implementation Research (CFIR): Champions, Reflecting & Evaluating, Planning, and Goals & Feedback. Main Measures Using a mixed-methods approach guided by the CFIR and data matrix analyses, we evaluated the degree to which implementation success and clinical improvement were associated with implementation strategies. The primary outcomes were the number of completed implementation activities, the level of team organization and > 15 points improvement in the Without Fail Rate (WFR) over 1 year. Key Results Facility QI teams actively engaged in the implementation strategies with high utilization. Facilities with the greatest implementation success were those with central champions whose teams engaged in planning and goal setting, and regularly reflected upon their quality data and evaluated their progress against their QI plan. The strong presence of effective champions acted as a pre-condition for the strong presence of Reflecting & Evaluating, Goals & Feedback, and Planning (rather than the other way around), helping to explain how champions at the +2 level influenced ongoing implementation. Conclusions The CFIR-guided bundle of implementation strategies facilitated the local implementation of the PREVENT QI program and was associated with clinical improvement in the national VA healthcare system. Trial registration: clinicaltrials.gov: NCT02769338

Background Questions persist about how learning healthcare systems should integrate audit and feedback (A&F) into quality improvement (QI) projects to support clinical teams’ use of performance data to improve care quality. Objective To identify how a virtual “Hub” dashboard that provided performance data for patients with transient ischemic attack (TIA), a resource library, and a forum for sharing QI plans and tools supported QI activities among newly formed multidisciplinary clinical teams at six Department of Veterans Affairs (VA) medical centers. Design An observational, qualitative evaluation of how team members used a web-based Hub. Participants External facilitators and multidisciplinary team members at VA facilities engaged in QI to improve the quality of TIA care. Approach Qualitative implementation process and summative evaluation of observational Hub data (interviews with Hub users, structured field notes) to identify emergent, contextual themes and patterns of Hub usage. Key Results The Hub supported newly formed multidisciplinary teams in implementing QI plans in three main ways: as an information interface for integrated monitoring of TIA performance; as a repository used by local teams and facility champions; and as a tool for team activation. The Hub enabled access to data that were previously inaccessible and unavailable and integrated that data with benchmark and scientific evidence to serve as a common data infrastructure. Led by champions, each implementation team used the Hub differently: local adoption of the staff and patient education materials; benchmarking facility performance against national rates and peer facilities; and positive reinforcement for QI plan development and monitoring. External facilitators used the Hub to help teams leverage data to target areas of improvement and disseminate local adaptations to promote resource sharing across teams. Conclusions As a dynamic platform for A&F operating within learning health systems, hubs represent a promising strategy to support local implementation of QI programs by newly formed, multidisciplinary teams.

Background To understand the impact of the COVID-19 pandemic on sleep services within the US Department of Veterans Affairs (VA) using separate surveys from “pre-COVID” and pandemic periods (N=140 VA facilities). Most sleep services were interrupted secondary to the COVID-19 pandemic: more than three-quarters of facilities that responded to the survey discontinued in-lab studies, approximately two-thirds suspended in-person positive airway pressure (PAP) clinics, and one-third stopped home sleep testing (HST). As the pandemic progressed, in-lab diagnostic and titration studies resumed at more than half of sites, less than half provided in-person PAP services, whereas all facilities restarted HST. Most expanded or started telehealth services. Infection control precautions were common. Increased stress, anxiety, fear, and burnout related to the pandemic and workflow changes were often reported by respondents. Methods Data from a pre-pandemic survey (September-November 2019) were combined with data from a pandemic-period survey (August-November 2020) to VA sleep medicine providers about their local sleep medicine services. Results A total of 67 (47.9%) facilities responded to the pandemic online survey. In-lab diagnostic and titration sleep studies were stopped at 91.1% of facilities during the pandemic; 76.5% of facilities resumed diagnostic studies and 60.8% resumed titration studies by the time of the second survey. Half of facilities suspended home sleep testing; all facilities resumed these services. In-person positive airway pressure (PAP) clinics were stopped at 76.3% of facilities; 46.7% resumed these clinics. Video telehealth was either available or in development at 86.6% of facilities and was considered a lasting addition to sleep services. COVID-19 transmission precautions occurred at high rates. Sleep personnel experienced high levels of stress, anxiety, fear, and burnout because of the pandemic and in response to unexpected changes in sleep medicine care delivery. Conclusions Sleep medicine services within the VA evolved during the pandemic with many key services being interrupted. The pandemic adversely affected sleep medicine personnel as they sought to maintain access to care. Trial RegistrationThis manuscript does not report on a clinical trial.

ImportancePostcolonoscopy colorectal cancer (PCCRC) refers to colorectal cancer (CRC) diagnosed after a colonoscopy in which no cancer was found and is reflective of colonoscopy quality at the individual and system levels. Colonoscopy is widely performed in the Veterans Affairs (VA) health care system, but the prevalence of PCCRC and its associated mortality are unknown.ObjectiveTo examine PCCRC prevalence and its all-cause mortality (ACM) and CRC-specific mortality (CSM) within the VA health care system.Design, Setting, and ParticipantsThis retrospective cohort study used VA-Medicare administrative data to identify 29 877 veterans aged 50 to 85 years with newly diagnosed CRC between January 1, 2003, and December 31, 2013. Patients whose colonoscopy occurred less than 6 months before CRC diagnosis with no other colonoscopy within the previous 36 months were categorized as having detected CRC (DCRC). Those who had a colonoscopy that did not detect CRC between 6 and 36 months before CRC diagnosis were categorized as having postcolonoscopy CRC (PCCRC-3y). A third group included patients with CRC and no colonoscopy within the prior 36 months. The final analysis of the data was performed in September 2022.ExposuresPrior receipt of colonoscopy.Main Outcomes and MeasuresCox proportional hazards regression (with censoring, last follow-up December 31, 2018) analyses were conducted to compare PCCRC-3y and DCRC for 5-year ACM and CSM after CRC diagnosis.ResultsOf 29 877 patients with CRC (median [IQR] age, 67 [60-75] years; 29 353 [98%] male; 5284 [18%] Black, 23 971 [80%] White, and 622 [2%] other), 1785 (6%) were classified as having PCCRC-3y and 21 811 (73%) as having DCRC. The 5-year ACM rates were 46% vs 42% for patients with PCCRC-3y vs patients with DCRC. The 5-year CSM rates were 26% vs 25% for patients with PCCRC-3y vs patients with DCRC. In multivariable Cox proportional hazards regression analysis, there was no significant difference in ACM and CSM between patients with PCCRC-3y (adjusted hazard ratio [aHR], 1.04; 95% CI, 0.98-1.11; P = .18) and patients with DCRC (aHR, 1.04; 95% CI, 0.95-1.13; P = .42). However, compared with patients with DCRC, patients with no prior colonoscopy had significantly higher ACM (aHR, 1.76; 95% CI, 1.70-1.82; P P P Conclusions and RelevanceThis study found that PCCRC-3y constituted 6% of CRCs in the VA system, which is similar to other settings. Compared with patients with CRC detected by colonoscopy, those with PCCRC-3y have comparable ACM and CSM.

Hospitalizations for acute ischemic stroke (AIS) and transient ischemic attack (TIA) decreased during the COVID-19 pandemic. We compared the quality of care and outcomes for patients with AIS/TIA before vs. during the COVID-19 pandemic across the United States Department of Veterans Affairs healthcare system.This retrospective cohort study compared AIS/TIA care quality before (March-September 2019) vs. during (March-September 2020) the pandemic. Electronic health record data were used to identify patient characteristics, quality of care and outcomes. The without-fail rate was a composite measure summarizing whether an individual patient received all of the seven processes for which they were eligible. Mixed effects logistic regression modeling was used to assess differences between the two periods.A decrease in presentations occurred during the pandemic (N = 4360 vs. N = 5636 patients; p = 0.003) and was greater for patients with TIA (-30.4%) than for AIS (-18.7%). The without-fail rate improved during the pandemic (56.2 vs. before 50.1%). The use of high/moderate potency statins increased among AIS patients (OR 1.26 [1.06-1.48]) and remained unchanged among those with TIA (OR 1.04 [0.83,1.29]). Blood pressure measurement within 90-days of discharge was less frequent during the pandemic (57.8 vs. 89.2%, p 0.001). Hypertension control decreased among patients with AIS (OR 0.73 [0.60-0.90]) and TIA (OR 0.72 [0.54-0.96]). The average systolic and diastolic blood pressure was 1.9/1.4 mmHg higher during the pandemic than before (p 0.001). Compared to before, during the pandemic fewer AIS patients had a primary care visit (52.5% vs. 79.8%; p = 0.0001) or a neurology visit (27.9 vs. 41.1%; p = 0.085). Both 30- and 90-day unadjusted all-cause mortality rates were higher in 2020 (3.6% and 6.7%) vs. 2019 (2.9, 5.4%; p = 0.041 and p = 0.006); but these differences were not statistically significant after risk adjustment.Overall quality of care for patients with AIS/TIA did not decline during the COVID-19 pandemic.

Prior studies have demonstrated disruption to outpatient mental health services after the onset of the COVID-19 pandemic. Inpatient mental health services have received less attention. The current study utilized an existing cohort of 33 Veterans Health Affairs (VHA) acute inpatient mental health units to examine disruptions to inpatient services. It further explored the association between patient demographic, clinical, and services variables on relapse rates. Inpatient admissions and therapeutic services (group and individual therapy and peer support) were lower amongst the COVID-19 sample than prior to the onset of COVID-19 while lengths of stay were longer. Relapse rates did not differ between cohorts. Patients with prior emergent services use as well as substance abuse or personality disorder diagnoses were at higher risk for relapse. Receiving group therapy while admitted was associated with lower risk of relapse. Inpatient mental health services saw substantial disruptions across the cohort. Inpatient mental health services, including group therapy, may be an important tool to prevent subsequent relapse.

Objectives: To understand the impact of the coronavirus disease-2019 pandemic on sleep services within the United States Department of Veterans Affairs using separate surveys from “pre-COVID” and pandemic periods. Methods: Data from a pre-pandemic survey (September to November 2019) were combined with data from a pandemic-period survey (August to November 2020) to Veterans Affairs sleep medicine providers about their local sleep services within 140 Veterans Affairs facilities). Results: A total of 67 (47.9%) facilities responded to the pandemic online survey. In-lab diagnostic and titration sleep studies were stopped at 91.1% of facilities during the pandemic; 76.5% of facilities resumed diagnostic studies and 60.8% resumed titration studies by the time of the second survey. Half of the facilities suspended home sleep testing; all facilities resumed these services. In-person positive airway pressure clinics were stopped at 76.3% of facilities; 46.7% resumed these clinics. Video telehealth was either available or in development at 86.6% of facilities and was considered a lasting addition to sleep services. Coronavirus disease-2019 transmission precautions occurred at high rates. Sleep personnel experienced high levels of stress, anxiety, fear, and burnout because of the pandemic and in response to unexpected changes in sleep medicine care delivery. Conclusions: Sleep medicine services within the Veterans Affairs evolved during the pandemic with many key services being interrupted, including in-lab studies and in-person positive airway pressure clinics. Expansion and initiation of telehealth sleep services occurred commonly. The pandemic adversely affected sleep medicine personnel as they sought to maintain access to care.

Background Risk-stratification tools that have been developed to identify transient ischemic attack (TIA) patients at risk of recurrent vascular events typically include factors which are not readily available in electronic health record systems. Our objective was to evaluate two TIA risk stratification approaches using electronic health record data. Methods Patients with TIA who were cared for in Department of Veterans Affairs hospitals (October 2015—September 2018) were included. The six outcomes were mortality, recurrent ischemic stroke, and the combined endpoint of stroke or death at 90-days and 1-year post-index TIA event. The cohort was split into development and validation samples. We examined the risk stratification of two scores constructed using electronic health record data. The Clinical Assessment Needs (CAN) score is a validated measure of risk of hospitalization or death. The PREVENT score was developed specifically for TIA risk stratification. Results A total of N = 5250 TIA patients were included in the derivation sample and N = 4248 in the validation sample. The PREVENT score had higher c-statistics than the CAN score across all outcomes in both samples. Within the validation sample the c-statistics for the PREVENT score were: 0.847 for 90-day mortality, 0.814 for 1-year mortality, 0.665 for 90-day stroke, and 0.653 for 1-year stroke, 0.699 for 90-day stroke or death, and 0.744 for 1-year stroke or death. The PREVENT score classified patients into categories with extreme nadir and zenith outcome rates. The observed 1-year mortality rate among validation patients was 7.1%; the PREVENT score lowest decile of patients had 0% mortality and the highest decile group had 30.4% mortality. Conclusions The PREVENT score had strong c-statistics for the mortality outcomes and classified patients into distinct risk categories. Learning healthcare systems could implement TIA risk stratification tools within electronic health records to support ongoing quality improvement. Registration ClinicalTrials.gov Identifier: NCT02769338.

Background and Purpose: Practice guidelines recommend that most patients receive moderate- or high-potency statins after ischemic stroke or transient ischemic attack (TIA) of atherosclerotic origin. We tested the association of different patterns of potency for prescribed statin therapy—assessed before admission and at hospital discharge for ischemic stroke or TIA—on mortality in a large, nationwide sample of US Veterans. Methods: The study population included patients with an ischemic stroke or TIA occurring during 2011 at any of the 134 Veterans Health Administration facilities. We used electronic outpatient pharmacy files to identify statin dose at hospital admission and within 7 days after hospital discharge. We categorized statin dosing as low, moderate, or high potency; moderate or high potency was considered at goal. We created 6 mutually exclusive groups to reflect patterns of statin potency from hospital admission to discharge: goal to goal, low to goal, goal to low or goal to none (deintensification), none to none, none to low, and low to low. We used logistic regression to compare 30-day and 1-year mortality across statin potency groups. Results: The population included 9380 predominately White (71.1%) men (96.3%) who were hospitalized for stroke or TIA. In this sample, 34.1% of patients (n=3194) were discharged off a statin medication. Deintensification occurred in 14.0% of patients (n=1312) and none to none in 20.5% (n=1924). Deintensification and none to none were associated with a higher odds of mortality as compared with goal to goal (adjusted odds ratio 1-year mortality: deintensification versus goal to goal, 1.26 [95% CI, 1.02–1.57]; none to none versus goal to goal, 1.59 [95% CI, 1.30–1.93]). Adjustments for differences in baseline characteristics using propensity weighted scores demonstrated similar results. Conclusions: Underutilization of statins, including no treatment or underdosing after stroke (deintensification), was observed in approximately one-third of veterans with ischemic stroke or TIA and was associated with higher mortality when compared with patients who were at goal for statin prescription dosing.

ObjectiveStudies describe COVID-19 patient characteristics and outcomes across populations, but reports of variation across healthcare facilities are lacking. The objectives were to examine differences in COVID-19 patient volume and mortality across facilities, and understand whether facility variation in mortality was due primarily to differences in patient versus facility characteristics.DesignObservational cohort study with multilevel mixed effects logistic regression modelling.SettingThe Veterans Health Administration (VA) is the largest healthcare system in the USA.ParticipantsPatients with COVID-19.Main outcomeAll-cause mortality within 45 days after COVID-19 testing (March–May, follow-up through 16 July 2020).ResultsAmong 13 510 patients with COVID-19, 3942 (29.2%) were admitted (2266/3942 (57.5%) ward; 1676/3942 (42.5%) intensive care unit (ICU)) and 679/3942 (17.2%) received mechanical ventilation. Marked heterogeneity was observed across facilities in median age (range: 34.3–83.9 years; facility mean: 64.7, SD 7.2 years); patient volume (range: 1–737 at 160 facilities; facility median: 48.5, IQR 14–105.5); hospital admissions (range: 1–286 at 133 facilities; facility median: 11, IQR 1–26.5); ICU caseload (range: 1–85 at 115 facilities; facility median: 4, IQR 0–12); and mechanical ventilation (range: 1–53 at 90 facilities; facility median: 1, IQR 0–5). Heterogeneity was also observed in facility mortality for all patients with COVID-19 (range: 0%–29.7%; facility median: 8.9%, IQR 2.4%–13.7%); inpatients (range: 0%–100%; facility median: 18.0%, IQR 5.6%–28.6%); ICU patients (range: 0%–100%; facility median: 28.6%, IQR 14.3%–50.0%); and mechanical ventilator patients (range: 0%–100%; facility median: 52.7%, IQR 33.3%–80.6%). The majority of variation in facility mortality was attributable to differences in patient characteristics (eg, age).ConclusionsMarked heterogeneity in COVID-19 patient volume, characteristics and mortality were observed across VA facilities nationwide. Differences in patient characteristics accounted for the majority of explained variation in mortality across sites. Variation in unadjusted COVID-19 mortality across facilities or nations should be considered with caution.

BACKGROUND Sustaining quality improvement has been recognized as a key implementation challenge. The objectives of this study were to evaluate sustainment during the implementation of a novel quality improvement intervention for Transient Ischemic Attack (TIA) across six geographically diverse medical centers and to identify specific factors contributing to sustainment. METHODS The PREVENT study was a five-year, stepped-wedge implementation trial at six US Department of Veterans Affairs sites; active implementation was initiated in three waves, with two facilities per wave. Six control sites were matched to each of the six PREVENT active implementation sites (total number of control sites was 36). Mixed methods were used to assess change in quality of care from baseline to active implementation to sustainment (measured by the “without-fail rate” and to identify factors which promoted or hindered sustainment. RESULTS The without-fail rate at PREVENT sites improved from 36.7% at baseline to 54.0% during active implementation and settled to 48.3% during sustainment. At control sites, the without-fail rate improved from 38.6% at baseline to 41.8% during active implementation and remained steady at 43.0% during sustainment. Changes in quality of care during sustainment varied across PREVENT sites: the without-fail rate improved at three sites, declined at two sites, and remained unchanged at one site. In adjusted analyses, although the without-fail rate improved at PREVENT sites compared with control sites during active implementation, no statistically significant difference in quality between intervention and control sites was identified during the sustainment phase. Factors that promoted sustainment were integration of key processes of care into routine practice and establishing systems for reflecting and evaluating on performance data to plan quality improvement activities or respond to changes in quality. Challenges during sustainment included competing demands from new facility quality priorities, low patient volume, and potential problems with coding impairing use of performance data. CONCLUSIONS Facilities seeking to sustain evidence-based practices while embodying the Learning Healthcare System’s core values can harness the combined power of staff and data systems by embedding quality improvement processes within routine care and establishing systems for reviewing and reflecting upon performance data.TRIAL REGISTRATION clinicaltrials.gov: NCT02769338

Background: Telestroke consultation is increasingly used to provide stroke care. Much like in-person stroke consults, stroke mimics are common. This study sought to identify patient and hospital characteristics more likely to be associated with a Telestroke diagnosis of stroke mimic. Methods: We analyzed 2 years of video consults by the VA National Telestroke Program (NTSP). Stroke mimic was defined as a Telestroke consult coded as a diagnosis of “other.” Text responses for “other” diagnoses were grouped into clinical categories. We used Chi-squared and t-tests analysis to compare characteristics of patients with a stroke mimic diagnosis and those without. Co-variates studied included age, gender, co-morbid conditions (history of dementia, cancer, or alcohol abuse), NIHSS, time of consult (night/weekend vs day), location of consult (emergency department vs inpatient), hospital rurality; hospital consult volume, and duration of institutional participation in NTSP at time of consult. Variables with a p-value < 0.25 in the bivariate analysis were included in the multivariate model. Results: There were 561 stroke mimics. The most common mimics were toxic metabolic encephalopathy (19%) and seizure (12%). Variables significantly associated with stroke mimic in bivariate analyses were age, gender, history of alcohol abuse, history of atrial fibrillation, history of dementia, NIHSS, nights/weekend consults, and hospital rurality. In multivariate analyses, female sex [OR=1.63, p=0.001], inpatient consultations [OR=1.55, p= 0.019], history of dementia [OR=1.85, p=0.0002], and alcohol abuse [OR=1.42, p=0.002] were associated with a stroke mimic. Consults during nights/weekends [OR=0.76, p=0.001], and patients with atrial fibrillation [OR=0.81, p=0.031], increasing age [OR=0.90, p=0.019], and increasing NIHSS [OR=0.97, p=0.0042] were less likely to be a mimic. Conclusion: Patient and consult characteristics influenced the likelihood of a stroke mimic diagnosis. Medical history may reflect conditions likely to cause neurologic symptoms, and patients hospitalized who have new symptoms represent a challenging subset to accurately distinguish stroke from mimics. Awareness of these factors may alert providers to diagnoses other than stroke.

Despite high risk for HIV, South African adolescent girls and young women (AGYW) experience numerous challenges with adherence to PrEP. To better understand AGYW's motivations for PrEP and factors that impact PrEP adherence, we conducted serial in-depth interviews with 22 South African AGYW during a 12 month prospective study. Interviews explored motivations and initial experiences of PrEP use, patterns of adherence, social support, and reasons for stopping or persisting with PrEP. We also assessed drug levels as a biomarker of adherence; dried blood spots were collected at months 1, 2, 3, 6, and 12 to assess intracellular tenofovir diphosphate levels. An end-user journey analytical approach revealed themes related to behavioral and emotional aspects of use, including multilevel factors leading to divergent PrEP adherence trajectories. Our findings highlight how internal versus external motivations drive PrEP use, as well as how positive identity formation and challenges are handled, which are essential to understand AGYW in their PrEP journeys.

Blood pressure control has been shown to reduce risk of vascular events and mortality after an ischemic stroke or transient ischemic attack (TIA). Yet, questions remain about effectiveness, timing, and targeted blood pressure reduction.We analyzed data from a retrospective cohort of 18,837 veterans cared for 12 months prior and up to 12 months after an emergency department visit or inpatient admission for stroke or TIA. Latent class growth analysis was used to classify patients into systolic blood pressure trajectories. With Cox proportional hazard models, we examined relationships between blood pressure trajectories, intensification of antihypertensive medication, and stroke (fatal or non-fatal) and all-cause mortality in 12 months following the index event.The cohort was classified into 4 systolic blood pressure trajectories: 19% with a low systolic blood pressure trajectory (mean systolic blood pressure = 116 mm Hg); 65% with a medium systolic blood pressure trajectory (mean systolic blood pressure = 136 mm Hg); 15% with a high systolic blood pressure trajectory (mean systolic blood pressure = 158 mm Hg), and 1% with a very high trajectory (mean systolic blood pressure = 183 mm Hg). After the stroke or TIA, individuals in the high and very high systolic blood pressure trajectories experienced a substantial decrease in systolic blood pressure that coincided with intensification of antihypertensive medication. Patients with very low and very high systolic blood pressure trajectories had a significantly greater (P.05) hazard of mortality, while medication intensification was related significantly (P.05) to lower hazard of mortality.These findings point to the importance of monitoring blood pressure over multiple time points and of instituting enhanced hypertension management after stroke or TIA, particularly for individuals with high or very high blood pressure trajectories.

Chronic pain is associated with profound negative effects, and racial disparities are well-documented in chronic pain treatment. In addition, Black patients report poorer communication with providers and exhibit lower levels of patient activation (self-management self-efficacy) than White patients. Although the causes of healthcare disparities are complex and require intervention at multiple levels, empowering patients is one critical path to achieving health equity. The current study is a coaching intervention focused on increasing patient activation and building communication skills for Black patients with chronic pain.In this randomized controlled trial, 250 Black patients with chronic pain were randomized to either the coaching intervention or an attention control arm. Intervention patients attended 6 telephone-delivered individual coaching sessions over 12 weeks. Coaching focused on clarifying and prioritizing goals and on communication skills, such as agenda setting. The primary outcome is patient activation. Secondary outcomes include communication self-efficacy, pain intensity and interference, and psychological functioning.Having the knowledge and confidence to participate in one's pain care, coupled with the skills needed to effectively communicate with providers, is essential to optimize chronic pain care. This is particularly important for Black patients who often experience lower quality pain care. Interventions such as COOPERATE hold promise for helping patients to acquire the requisite tools to take greater control of their chronic pain care.clinicaltrials.gov, # NCT03562793.

BackgroundConfigurational methods are increasingly being used in health services research.ObjectivesTo use configurational analysis and logistic regression within a single data set to compare results from the two methods.DesignSecondary analysis of an observational cohort; a split-sample design involved randomly dividing patients into training and validation samples.Participants and settingPatients who had a transient ischaemic attack (TIA) in US Department of Veterans Affairs hospitals.MeasuresThe patient outcome was the combined endpoint of all-cause mortality or recurrent ischaemic stroke within 1 year post-TIA. The quality-of-care outcome was the without-fail rate (proportion of patients who received all processes for which they were eligible, among seven processes).ResultsFor the recurrent stroke or death outcome, configurational analysis yielded a three-pathway model identifying a set of (validation sample) patients where the prevalence was 15.0% (83/552), substantially higher than the overall sample prevalence of 11.0% (relative difference, 36%). The configurational model had a sensitivity (coverage) of 84.7% and specificity of 40.6%. The logistic regression model identified six factors associated with the combined endpoint (c-statistic, 0.632; sensitivity, 63.3%; specificity, 63.1%). None of these factors were elements of the configurational model. For the quality outcome, configurational analysis yielded a single-pathway model identifying a set of (validation sample) patients where the without-fail rate was 64.3% (231/359), nearly twice the overall sample prevalence (33.7%). The configurational model had a sensitivity (coverage) of 77.3% and specificity of 78.2%. The logistic regression model identified seven factors associated with the without-fail rate (c-statistic, 0.822; sensitivity, 80.3%; specificity, 84.2%). Two of these factors were also identified in the configurational analysis.ConclusionsConfigurational analysis and logistic regression represent different methods that can enhance our understanding of a data set when paired together. Configurational models optimise sensitivity with relatively few conditions. Logistic regression models discriminate cases from controls and provided inferential relationships between outcomes and independent variables.

This cohort study examines the association of patient caseload and demand with mortality among patients with coronavirus disease 2019 (COVID-19) in US Veterans Affairs (VA) intensive care units., Key Points Question Is greater coronavirus disease 2019 (COVID-19) intensive care unit (ICU) strain associated with increased COVID-19 mortality? Findings In this cohort study of 8516 patients with COVID-19 admitted to 88 US Veterans Affairs hospitals, strains on critical care capacity were associated with increased COVID-19 mortality. Among patients with COVID-19, those treated in the ICU during periods of peak COVID-19 ICU demand had a nearly 2-fold increased risk of mortality compared with those treated during periods of low demand. Meaning These findings suggest that public health officials and hospital administrators should consider interventions that reduce COVID-19 ICU demand to improve survival among patients with COVID-19 in the ICU., Importance Although strain on hospital capacity has been associated with increased mortality in nonpandemic settings, studies are needed to examine the association between coronavirus disease 2019 (COVID-19) critical care capacity and mortality. Objective To examine whether COVID-19 mortality was associated with COVID-19 intensive care unit (ICU) strain. Design, Setting, and Participants This cohort study was conducted among veterans with COVID-19, as confirmed by polymerase chain reaction or antigen testing in the laboratory from March through August 2020, cared for at any Department of Veterans Affairs (VA) hospital with 10 or more patients with COVID-19 in the ICU. The follow-up period was through November 2020. Data were analyzed from March to November 2020. Exposures Receiving treatment for COVID-19 in the ICU during a period of increased COVID-19 ICU load, with load defined as mean number of patients with COVID-19 in the ICU during the patient’s hospital stay divided by the number of ICU beds at that facility, or increased COVID-19 ICU demand, with demand defined as mean number of patients with COVID-19 in the ICU during the patient’s stay divided by the maximum number of patients with COVID-19 in the ICU. Main Outcomes and Measures All-cause mortality was recorded through 30 days after discharge from the hospital. Results Among 8516 patients with COVID-19 admitted to 88 VA hospitals, 8014 (94.1%) were men and mean (SD) age was 67.9 (14.2) years. Mortality varied over time, with 218 of 954 patients (22.9%) dying in March, 399 of 1594 patients (25.0%) dying in April, 143 of 920 patients (15.5%) dying in May, 179 of 1314 patients (13.6%) dying in June, 297 of 2373 patients (12.5%) dying in July, and 174 of 1361 (12.8%) patients dying in August (P

Background: The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was a complex quality improvement (QI) intervention targeting transient ischemic attack (TIA) evidence-based care. The aim of this study was to evaluate program acceptability among the QI teams and factors associated with degrees of acceptability.Methods: QI teams from six Veterans Administration facilities participated in active implementation for a one-year period. We employed mixed methods to evaluate program acceptability. Multiple data sources were collected over implementation phases and triangulated for this evaluation. First, we conducted 30 onsite, semi-structured interviews during active implementation with 35 participants at 6 months; 27 interviews with 28 participants at 12 months; and 19 participants during program sustainment. Second, we collected participant automated response survey data during the team kick-off meeting. Third, we conducted debriefing meetings after onsite visits and monthly virtual collaborative calls. All interviews and debriefings were audiotaped, transcribed, and de-identified. De-identified files were qualitatively coded and analyzed for common themes and acceptability patterns. We conducted mixed-methods matrix analyses comparing acceptability by satisfaction ratings and by the Theoretical Framework of Acceptability (TFA). Results: Overall, the QI teams reported the PREVENT program was acceptable. At pre-implementation phase, reviewing quality data, team brainstorming solutions and development of action plans were rated as most useful during the team kickoff meetings. Program acceptability perceptions varied over time across active implementation and after teams accomplished actions plans and moved into sustainment. We observed team acceptability growth over a year of active implementation in concert with the QI team’s self-efficacy to improve quality of care. Guided by the TFA, the QI teams’ acceptability was represented by the respective seven components of the multifaceted acceptability construct.Conclusions: Program acceptability varied by time, by champion role on QI team, by team self-efficacy, and by perceived effectiveness to improve quality of care aligned with the TFA. A complex quality improvement program that fostered flexibility in local adaptation and supported users with access to data, resources, and implementation strategies was deemed acceptable and appropriate by front-line clinicians implementing practice changes in a large, national healthcare organization.Trial Registration: clinicaltrials.gov: NCT02769338

Patients with chronic obstructive pulmonary disease (COPD) commonly experience dyspnea, which may limit activities of daily living. Pursed-lip breathing improves dyspnea for COPD patients; however, access to pursed-lip breathing training is limited.The proposed MELodica Orchestra for DYspnea (MELODY) study will be a single-site pilot study to assess the safety, feasibility, and efficacy of a music-based approach to teach pursed-lip breathing. Patients with COPD and moderate-severe dyspnea are randomized to intervention, education-control, or usual care control groups. Intervention patients meet twice weekly for eight weeks for melodica instruction, group music-making, and COPD education. Safety, feasibility, and efficacy is assessed qualitatively and quantitatively.This manuscript describes the rationale and methods of the MELODY pilot project.If pilot data demonstrate efficacy, then a multi-site randomized control trial will be conducted to evaluate program effectiveness and implementation.

This nonrandomized cluster trial with matched controls implements the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) intervention to improve transient ischemic attack quality of care., Key Points Question Is the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) program associated with improved care for transient ischemic attack? Findings This nonrandomized cluster trial with matched controls (including 6 PREVENT sites and 36 matched control sites) evaluated quality of care for transient ischemic attach across 7 guideline-recommended processes of care measured by the without-fail rate. Over the course of a 1-year implementation period, the mean without-fail rate improved 17% at the 6 PREVENT sites and only 3% at 36 matched control sites. Meaning These findings suggest that implementation of a multicomponent program such as PREVENT may improve quality of care for transient ischemic attack., Importance Patients with transient ischemic attack (TIA) are at high risk of recurrent vascular events. Timely management can reduce that risk by 70%; however, gaps in TIA quality of care exist. Objective To assess the performance of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) intervention to improve TIA quality of care. Design, Setting, and Participants This nonrandomized cluster trial with matched controls evaluated a multicomponent intervention to improve TIA quality of care at 6 diverse medical centers in 6 geographically diverse states in the US and assessed change over time in quality of care among 36 matched control sites (6 control sites matched to each PREVENT site on TIA patient volume, facility complexity, and quality of care). The study period (defined as the data period) started on August 21, 2015, and extended to May 12, 2019, including 1-year baseline and active implementation periods for each site. The intervention targeted clinical teams caring for patients with TIA. Intervention The quality improvement (QI) intervention included the following 5 components: clinical programs, data feedback, professional education, electronic health record tools, and QI support. Main Outcomes and Measures The primary outcome was the without-fail rate, which was calculated as the proportion of veterans with TIA at a specific facility who received all 7 guideline-recommended processes of care for which they were eligible (ie, anticoagulation for atrial fibrillation, antithrombotic use, brain imaging, carotid artery imaging, high- or moderate-potency statin therapy, hypertension control, and neurological consultation). Generalized mixed-effects models with multilevel hierarchical random effects were constructed to evaluate the intervention associations with the change in the mean without-fail rate from the 1-year baseline period to the 1-year intervention period. Results Six facilities implemented the PREVENT QI intervention, and 36 facilities were identified as matched control sites. The mean (SD) age of patients at baseline was 69.85 (11.19) years at PREVENT sites and 71.66 (11.29) years at matched control sites. Most patients were male (95.1% [154 of 162] at PREVENT sites and 94.6% [920 of 973] at matched control sites at baseline). Among the PREVENT sites, the mean without-fail rate improved substantially from 36.7% (58 of 158 patients) at baseline to 54.0% (95 of 176 patients) during a 1-year implementation period (adjusted odds ratio, 2.10; 95% CI, 1.27-3.48; P = .004). Comparing the change in quality at the PREVENT sites with the matched control sites, the improvement in the mean without-fail rate was greater at the PREVENT sites than at the matched control sites (36.7% [58 of 158 patients] to 54.0% [95 of 176 patients] [17.3% absolute improvement] vs 38.6% [345 of 893 patients] to 41.8% [363 of 869 patients] [3.2% absolute improvement], respectively; absolute difference, 14%; P = .008). Conclusions and Relevance The implementation of this multifaceted program was associated with improved TIA quality of care across the participating sites. The PREVENT QI program is an example of a health care system using QI strategies to improve performance, and may serve as a model for other health systems seeking to provide better care. Trial Registration ClinicalTrials.gov Identifier: NCT02769338

Background The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was a complex quality improvement (QI) intervention targeting transient ischemic attack (TIA) evidence-based care. The aim of this study was to evaluate program acceptability among the QI teams and factors associated with degrees of acceptability. Methods QI teams from six Veterans Administration facilities participated in active implementation for a one-year period. We employed a mixed methods study to evaluate program acceptability. Multiple data sources were collected over implementation phases and triangulated for this evaluation. First, we conducted 30 onsite, semi-structured interviews during active implementation with 35 participants at 6 months; 27 interviews with 28 participants at 12 months; and 19 participants during program sustainment. Second, we conducted debriefing meetings after onsite visits and monthly virtual collaborative calls. All interviews and debriefings were audiotaped, transcribed, and de-identified. De-identified files were qualitatively coded and analyzed for common themes and acceptability patterns. We conducted mixed-methods matrix analyses comparing acceptability by satisfaction ratings and by the Theoretical Framework of Acceptability (TFA). Results Overall, the QI teams reported the PREVENT program was acceptable. The clinical champions reported high acceptability of the PREVENT program. At pre-implementation phase, reviewing quality data, team brainstorming solutions and development of action plans were rated as most useful during the team kickoff meetings. Program acceptability perceptions varied over time across active implementation and after teams accomplished actions plans and moved into sustainment. We observed team acceptability growth over a year of active implementation in concert with the QI team’s self-efficacy to improve quality of care. Guided by the TFA, the QI teams’ acceptability was represented by the respective seven components of the multifaceted acceptability construct. Conclusions Program acceptability varied by time, by champion role on QI team, by team self-efficacy, and by perceived effectiveness to improve quality of care aligned with the TFA. A complex quality improvement program that fostered flexibility in local adaptation and supported users with access to data, resources, and implementation strategies was deemed acceptable and appropriate by front-line clinicians implementing practice changes in a large, national healthcare organization. Trial registration clinicaltrials.gov: NCT02769338.

Introduction Although African Americans have the highest colorectal cancer (CRC) incidence and mortality rates of any racial group, their screening rates remain low. Study design/purpose This randomized controlled trial compared efficacy of two clinic-based interventions for increasing CRC screening among African American primary care patients. Methods African American patients from 11 clinics who were not current with CRC screening were randomized to receive a computer-tailored intervention (n = 335) or a non-tailored brochure (n = 358) designed to promote adherence to CRC screening. Interventions were delivered in clinic immediately prior to a provider visit. Univariate and multivariable logistic regression models analyzed predictors of screening test completion. Moderators and mediators were determined using multivariable linear and logistic regression analyses. Results Significant effects of the computer-tailored intervention were observed for completion of a stool blood test (SBT) and completion of any CRC screening test (SBT or colonoscopy). The colonoscopy screening rate was higher among those receiving the computer-tailored intervention group compared to the nontailored brochure but the difference was not significant. Predictors of SBT completion were: receipt of the computer-tailored intervention; being seen at a Veterans Affairs Medical Center clinic; baseline stage of adoption; and reason for visit. Mediators of intervention effects were changes in perceived SBT barriers, changes in perceived colonoscopy benefits, changes in CRC knowledge, and patient-provider discussion. Moderators of intervention effects were age, employment, and family/friend recommendation of screening. Conclusion This one-time computer-tailored intervention significantly improved CRC screening rates among low-income African American patients. This finding was largely driven by increasing SBT but the impact of the intervention on colonoscopy screening was strong. Implementation of a CRC screening quality improvement program in the VA site that included provision of stool blood test kits and follow-up likely contributed to the strong intervention effect observed at that site. The trial is registered at ClinicalTrials.gov as NCT00672828 .

Background and Aims: In the Veterans Administration, we found an absence of acute TIA care protocols and broad clinician uncertainty. To address these gaps, the PREVENT program was implemented in a stepped-wedge trial involving 6 medical facilities. To promote local adaptation, we employed external facilitation (EF) delivered by nurse as a key implementation strategy. The specific aim of this evaluation was to examine the effect of EF strategy on PREVENT implementation. Methods: We adapted an EF tracking template to prospectively monitor facilitation type, dose and temporality. We defined 17 apriori facilitation EF activity codes based upon the PREVENT protocol, and Consolidated Framework for Implementation Research (CFIR). We evaluated the EF activities delivered at each site over a 1 year and how the EF dose corresponded to the number of implementation activities completed and the level of team cohesion (beginning, developing, basic, intermediate, advanced) for providing and improving TIA care. Results: A total of 1209 EF activities delivered were delivered to QI teams and most frequently to the clinical champions; with a mean number of 242 EF activities per facility (range 182-295). Facility-level clinical champions were most likely to participate in EF activities compared to other team members. The most common EF activities delivered were: education (mean=34.3); planning (mean=27.8); overcoming barriers (mean=22.2) and ongoing quality process monitoring (mean=32.3). Teams with high initial team cohesion, &gt intermediate level, used EF early in the implementation process while teams that gradually developed cohesion over time, developing to basic levels of team cohesion, utilized EF later. QI teams with greater success in implementation activities had far more implementation activities completed (IA= 29-39) than EF activities related to barriers (B=18-28). However, QI teams with the least success in implementation activities (IA=11-25) had similar levels of EF activities related to barriers or higher (B=18-25). Conclusions: EF impacts real-world implementation by facilitating team education; planning; navigating the barriers; and enhancing the champions' skills. Early team cohesion was related to greater implementation success.

Background: Programs emphasizing early evaluation and management have reduced 70% of transient ischemic attack (TIA) patients’ recurrent events. One barrier to guideline-concordant care is inadequate care coordination. Purpose: Our objective was to evaluate adoption of nurse care coordination programs on TIA care quality at two Veteran Health Administration (VHA) facilities. Methods: Nurse care coordination programs with real-time patient identification and using Consolidated Framework for Implementation Research (CFIR) to guide local adoption, were evaluated at 2 VHA facilities. Programs were coordinated by an Emergency Department (ED) Nurse Navigator or Neurology Stroke Nurse Coordinator. The nurses used a Patient Identification Tool which was updated daily and displayed: TIA patient’s name, event and discharge dates, diagnosis, visit type (ED or inpatient), and primary care team. Nurses reviewed patients’ charts for key care components (e.g., medications), identified gaps in care, and provided follow-up. TIA care quality was evaluated by Without Fail Rate (WFR) which describes the facility-level proportion of patients who received all eligible processes of care (anticoagulation for atrial fibrillation, antithrombotics, brain imaging, carotid artery imaging, hypertension control, moderate/high intensity statin, neurology consultation). Results: We compared the WFR before (Fiscal Year [FY] 2017) and after (FY2019) implementation of the care coordination programs: Site-1, 59.6% (N=48) to 71.4% (N=30), p=0.332 (not significant); Site-2, 15.9% (N=47) to 38.5% (N=29), p=0.045 (significant). The individual process of care with greatest improvement was high/moderate potency statin at Site-1 (68.4% to 82.6%, p=0.250 [not significant]) and neurology consultation at Site-2 (39.5% to 80.8%, p=0.001 [significant]). Conclusions: Nurse care coordination programs using real-time patient identification were associated with improved quality of care. These broadly generalizable programs were important components of a comprehensive, multidisciplinary quality improvement initiative. Healthcare systems interested in improving care for TIA patients may find real-time patient identification useful in coordinating their care.

Introduction: Joint National Committee (JNC)-8 goal blood pressure (BP) recommendation of < 140/90 mmHg has been supplanted by 2017 ACC/AHA goal of < 130/80 mmHg for patients with ischemic stroke/TIA. Understanding potential mortality benefit for patients reaching ACC/AHA goal is needed. Hypothesis: Stroke/TIA patients reaching ACC/AHA goal BP will experience lower 1-year all-cause mortality compared to those reaching JNC-8 BP goals. Methods: This is a retrospective cohort of Veterans with stroke/TIA (N=39,053) who received their longitudinal outpatient primary care within a Veterans Administration Medical Center between 10/2014 and 9/2018. Patients were excluded (n=25,381) if they had missing or physiologically improbable BP values, died, or had less than 1 year of follow-up for analysis of 1-year mortality. We calculated average SBP during 90 days after discharge and assessed it in categorical form (≤115 mmHg, 106-115 mmHg, 116-130, mmHg, 131-140 mmHg, and >140 mmHg) and continuous form. Multivariate COX proportional hazard regression was used to examine the relationship between average SBP groups and time to mortality 90 days after discharge up to 1 year. In multivariate logistic regression, we used continuous SBP along with its quadratic term to predict 1-year mortality. Results: A total of 12,337 eligible patients were included in the final analysis. COX proportional regression demonstrated a statistically significant higher risk of death among patients with SBP lower than 105 mmHg as compared to those with > 140 mmHg (HR = 1.79, 95% CI= 1.37-2.34), but no statistical differences were found in other SBP groups. Predicted probability of 1-year mortality generated from the logistic regression was plotted and showed a “U” shaped relationship between SBP and mortality, whereas SBP ranges encompassing both AHA/ACC and JNC-8 goal BP recommendations are found on the “flat” part of the curve. Conclusions: In considering BP reached by 90-days, there was no differential 1-year all-cause mortality benefit between JNC-8 and ACC/AHA BP recommendations, whereas patients experiencing low SBPs were at increased risk for higher mortality. Providers should be aware of the association between lower SBP and higher mortality when treating BP.

Objectives: Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) trial evaluated the implementation of a quality improvement (QI) program aligned with Learning Healthcare System principles to improve TIA care. Methods: A facility-based, stepped-wedge trial was conducted at six diverse sites. The intervention included five components: clinical programs, data feedback, professional education, electronic health record tools, and QI support. Implementation strategies included: team activation via audit and feedback, goal setting, reflecting and evaluating, and planning; external facilitation; and building a community of practice. The primary effectiveness outcome was the Without Fail rate (WFR); proportion of TIA patients who received all processes of care for which they were eligible among: brain imaging, carotid artery imaging, neurology consultation, hypertension control, anticoagulation for atrial fibrillation, antithrombotics, high/moderate potency statins. The primary implementation outcomes were the number of improvement activities completed and the Group Organization (GO) scores for providing and improving care (scale of 1-10). Results: The 6 PREVENT facilities cared for N=162 control period TIA patients and N=191 intervention period TIA patients. The mean facility WFR increased from 36.7% (baseline) to 53.9% (active implementation); p=0.002 (adjusted for temporal trend, hospital admission). The mean number of improvement activities completed during the 1-year implementation period was 26 (range 11-39). The mean facility GO scores increased: providing care, 1.2 to 6.5; improving care, 1.0 to 6.7. Conclusions: PREVENT advances three aspects of a learning healthcare system: Learning from Data (teams interacted with their facility’s performance data to explore hypotheses, plan QI activities, and evaluate change over time); Learning from Each Other (teams participated in monthly virtual collaborative conferences), and Sharing Best Practices (teams shared tools and protocols).

Introduction: Joint National Committee (JNC)-8 goal blood pressure (BP) recommendation of < 140/90 mmHg has been supplanted by 2017 ACC/AHA goal of < 130/80 mmHg for patients with ischemic stroke/TIA. Understanding the potential benefit in preventing recurrent vascular events for patients reaching ACC/AHA BP goals is necessary to inform clinical care. Methods: This is a retrospective cohort of Veterans with stroke/TIA (N=39,053) who received their longitudinal outpatient primary care within a Veterans Administration Medical Center between 10/2014 and 9/2018. Patients were excluded (n=25,381) if they had missing or physiologically improbable BP values, died, or had less than 1 year of follow-up. Vascular events were defined as cerebrovascular-only, cardiovascular-only, and the composite of each. We calculated average SBP during 90 days after discharge and assessed it in categorical form (≤115 mmHg, 106-115 mmHg, 116-130, mmHg, 131-140 mmHg, and >140 mmHg) and continuous form. Multivariate COX proportional hazard regression was used to examine the relationship between average SBP groups and time to recurrent event 90 days after discharge up to 1 year. In multivariate logistic regression, we used continuous SBP along with its quadratic term to predict 1-year recurrent vascular event rates. Results: A total of 12,337 eligible patients were included in the final analysis. Compared to those with SBP > 140 mmHg, patients reaching ACC/AHA BP goal had significant lower risk of cerebrovascular recurrent events (HR=0.77, 95% CI=0.60-0.99) but not cardiovascular recurrence or both combined. Conclusions: In considering BP reached by 90-days, ACC/AHA BP guidelines showed protective effects on cerebrovascular event recurrence only.

Background and Aims Patients with advanced colorectal adenomas (AA) are directed to undergo intensive surveillance. However, the benefit derived from surveillance may be outweighed by the risk of death from non-colorectal cancer (CRC) causes, leading to uncertainty on how best to individualize follow-up. The aim of this study was to derive a risk prediction model and risk index that estimates and stratifies the risk for non-colorectal cancer mortality (NCM) subsequent to diagnosis and removal of AA. Methods We conducted a retrospective cohort study of Veterans > 40 years who had colonoscopy for diagnostic or screening indications at 13 VAMCs between 2002 and 2009, and had one or more AAs. The primary outcome was non-CRC mortality (NCM) using a fixed follow-up time period of 5 years. Logistic regression using the lasso technique was used to identify factors independently associated with non-CRC mortality (NCM), and an index based on points from regression coefficients was constructed to estimate risk of 5-year NCM. Results We identified 2,943 Veterans with AA (mean age (SD) 63 (8.6) years, 98% male, 74% white), with an overall 5-year mortality of 16.7%, which was nearly all due to NCM (16.6%). Age, comorbidity burden, specific comorbid conditions, and hospitalization within the preceding year were independently associated with NCM. The risk prediction model had a goodness of fit (calibration) p-value of 0.41, and c-statistic (discrimination) of 0.74 (95% CI, 0.71-0.76). Based on comparable 5-year risks of NCM, the scores comprised 3 risk categories: low (score of 0-1), intermediate (score of 2-4) and high (score of ≥ 5), in which NCM occurred in 6.5%, 14.1%, and 33.2%, respectively. Conclusions We derived a risk prediction model that identifies Veterans at high risk of NCM within 5 years, and who are thus unlikely to benefit from further surveillance.

Patients with transient ischemic attacks (TIA) are at high risk of subsequent vascular events. Hospitalization improves quality of care, yet admission rates for TIA patients vary considerably. We sought to identify factors associated with the decision to admit patents with TIA. We conducted a secondary analysis of a prior study’s data including semi-structured interviews, administrative data, and chart review. We interviewed multidisciplinary clinical staff involved with TIA care. Administrative data included information for TIA patients in emergency departments or inpatient settings at VA medical centers (VAMCs) for fiscal years (FY) 2011 and 2014. Chart reviews were conducted on a subset of patients from 12 VAMCs in FY 2011. For the qualitative data, we focused on interviewees’ responses to the prompt: “Tell me what influences you in the decision to or not to admit TIA patients.” We used administrative data to identify admission rates and chart review data to identify ABCD2 scores (a tool to classify stroke risk after TIA). Providers’ decisions to admit TIA patients were related to uncertainty in several domains: lack of a facility TIA-specific policy, inconsistent use of ABCD2 score, and concerns about facilities’ ability to complete a timely workup. There was a disconnect between staff perceptions about TIA admission and facility admission rates. According to chart review data, staff at facilities with higher admission rates in FY 2011 reported consistent reliance on ABCD2 scores and related guidelines in admission decision-making. Many factors contributed to decisions regarding admitting a patient with TIA; however, clinicians’ uncertainty appeared to be a key driver. Further quality improvement interventions for TIA care should focus on facility adoption of TIA protocols to address uncertainty in TIA admission decision-making and to standardize timely evaluation of TIA patients and delivery of secondary prevention strategies.

BackgroundAmerican Heart Association/American Stroke Association expert consensus guidelines recommend consideration of cardiac stress testing to screen for occult coronary heart disease (CHD) among patients with ischemic stroke/TIA who have a high-risk Framingham Cardiac Risk Score (FCRS). Whether this guideline is being implemented in routine clinical practice, and the association of its implementation with mortality, is less clear.MethodsStudy participants were Veterans with stroke/TIA (n = 11,306) during fiscal year 2011 who presented to a VA Emergency Department or who were admitted. Patients were excluded (n = 6,915) based on prior CHD/angina/chest pain history, receipt of cardiac stress testing within 18 months prior to cerebrovascular event, death within 90 days of discharge, discharge to hospice, transfer to a non-VA acute care facility, or missing/unknown race. FCRS ≥20% was classified as high risk for CHD. ICD-9 and Common Procedural Terminology codes were used to identify receipt of any cardiac stress testing.ResultsAmong 4,391 eligible patients, 62.8% (n = 2,759) had FCRS ≥20%. Cardiac stress testing was performed infrequently and in similar proportion among high-risk (4.5% [123/2,759]) vs low/intermediate-risk (4.4% [72/1,632]) patients (adjusted odds ratio [aOR] 0.77, 95% confidence interval [CI] 0.54–1.10). Receipt of stress testing was not associated with reduced 1-year mortality (aOR 0.59, CI 0.26–1.30).ConclusionsIn this observational cohort study of patients with cerebrovascular disease, cardiac screening was relatively uncommon and was not associated with 1-year mortality. Additional work is needed to understand the utility of CHD screening among high-risk patients with cerebrovascular disease.

Objective:To identify key barriers and facilitators to the delivery of guideline-based care of patients with TIA in the national Veterans Health Administration (VHA).Methods:We conducted a cross-sectional, observational study of 70 audiotaped interviews of multidisciplinary clinical staff involved in TIA care at 14 VHA hospitals. We de-identified and analyzed all transcribed interviews. We identified emergent themes and patterns of barriers to providing TIA care and of facilitators applied to overcome these barriers.Results:Identified barriers to providing timely acute and follow-up TIA care included difficulties accessing brain imaging, a constantly rotating pool of housestaff, lack of care coordination, resource constraints, and inadequate staff education. Key informants revealed that both stroke nurse coordinators and system-level factors facilitated the provision of TIA care. Few facilities had specific TIA protocols. However, stroke nurse coordinators often expanded upon their role to include TIA. They facilitated TIA care by (1) coordinating patient care across services, communicating across service lines, and educating clinical staff about facility policies and evidence-based practices; (2) tracking individual patients from emergency departments to inpatient settings and to discharge for timely follow-up care; (3) providing and referring TIA patients to risk factor management programs; and (4) performing regular audit and feedback of quality performance data. System-level facilitators included clinical service leadership engagement and use of electronic tools for continuous care across services.Conclusions:The local organization within a health care facility may be targeted to cultivate internal facilitators and a systemic infrastructure to provide evidence-based TIA care.