Steven M. Asch MD, MPH is a Vice-Chief for Research, Division of Primary Care and Population Health at Stanford University and the Associate Chief of Staff for Clinical Effectiveness at the Palo Alto VA. Dr. Asch also serves as an Associate Dean for Research, leading the KL2 Research Training Program, the Stanford Intermountain Fellowship, and VA fellowships in Health Services Research and Informatics. In total, he has mentored and supervised over 80 graduate student and post-doctoral fellows and physicians.

Dr. Asch’s research evaluates quality measurement and improvement systems, testing organizational innovations to make medical care more collaborative and efficient using implementation science methods. He is a practicing internist and palliative care physician and the author of more than 450 peer-reviewed articles.

Dr. Asch has been awarded and honored for his teaching and research including: VA Health Services Career Development Award, 1997, 2000, 2001; Presidential Early Career Scientists and Engineer Award (PECASE), 2004, Daniel Deykin Mentorship Award 2016; and Under Secretary’s Award for Outstanding Achievement in Health Services Research, VA’s highest HSR&D honor, 2019.

Academic Appointments

Administrative Appointments

  • Associate Dean for Research, Stanford School of Medicine (2020 - Present)
  • Director, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System (2011 - 2021)
  • Associate Chief of Staff for Clinical Effectiveness, VA Palo Alto Health Care System (2011 - Present)
  • Professor of Medicine, Stanford University (2011 - Present)
  • Co-Director, then Director, Spectrum KL2 Program (2011 - Present)
  • Associate then Vice-Chief, Division of Primary Care and Population Health (2011 - Present)

Honors & Awards

  • Undersecretary's Award for Health Services Research, VA

Professional Education

  • Diplomate, ABIM, Palliative Care (2002)
  • RWJ Clinical Scholar, UCLA (1994)
  • MPH, UCLA, Epidemiology (1994)
  • Diplomate, ABIM, Internal Medicine (1991)
  • MD, UCSD (1988)

Current Research and Scholarly Interests

Steven M. Asch MD, MPH is the Vice-Chief for Research, Stanford Division of Primary Care and Population Health and the Associate Chief of Staff for Clinical Effectiveness at the VA Palo Alto Healthcare System. He develops and evaluates quality measurement and improvement systems using implementation science methods. Dr. Asch has led several national projects developing broad-based quality measurement tools for veterans, Medicare beneficiaries, and the community. He has directed the Center of Innovation to Implementation (Ci2i), focusing on how to maximize value by testing organizational innovations to improve medical care. His educational efforts are focused on training physician fellows in health services research and junior faculty in the KL2 program, for which he serves as an Associate Dean. Dr. Asch is a tenured professor and practicing internist and palliative care physician and the author of more than 450 peer-reviewed articles.

2023-24 Courses

Stanford Advisees

All Publications

  • Healthcare utilization and left ventricular ejection fraction distribution in methamphetamine use associated heart failure hospitalizations. American heart journal Manja, V., Sandhu, A. T., Asch, S., Frayne, S., McGovern, M., Chen, C., Heidenreich, P. 2024; 270: 156-160


    Although methamphetamine use associated heart failure (MU-HF) is increasing, data on its clinical course are limited due to a preponderance of single center studies and significant heterogeneity in the definition of MU-HF in the published literature. Our objective was to evaluate left ventricular ejection fraction (LVEF) distribution, methamphetamine use treatment engagement and postdischarge healthcare utilization among Veterans with heart failure hospitalization in the department of Veterans Affairs (VA) medical centers for MU-HF versus HF not associated with methamphetamine use (other-HF).Observational study including a cohort of Veterans with a first heart failure hospitalization during 2007 - 2020 using data in the VA Corporate Data Warehouse. MU-HF was identified based on the presence of an ICD-code for methamphetmaine use or positive toxicology results within 1-year of heart failure hospitalization. LVEF values entered in the medical record were identified using a validated natural language processing algorithm. Healthcare utilization data was obtained using clinic stop-codes and hosptilaization records.Of 203,005 first-time heart failure hospitlaizations, 4080 were categorized as MU-HF. Median (interquartile range) of LVEF was 30 (20-45) % for MU-HF versus 40 (25-55)% for other-HF (P < .0001). Eighteen percent of MU-HF had LVEF ≥ 50% compared to 28% in other-HF. Discharge against medical advice was higher in MU-HF (8% vs 2%). Among Veterans with MU-HF, post hospital discharge methamphetamine use treatment engagement was low (18% at 30 days post discharge), with higher follow-up in primary care (76% at 30 days). Post discharge emergency department visits (33% versus 22% at 30 days) and rehospitalizations (24% versus 18% at 30 days) were higher in MU-HF compared to other-HF.While the majority of MU-HF hospitalizations are HFrEF, a sizeable minority have HFpEF. This finding has implications for accurate MU-HF classification, treatment, and prognosis. Patients with MU-HF have low addiction treatment receipt and high postdischarge unplanned healthcare utilization. Increasing substance use disorder treatment in this population must be a priority to improve health outcomes. Care-coordination and linkage interventions are urgently needed to increase post-hospitalization addiction treatment and follow-up in an effort to increase evidence-base care and mitigate unplanned healthcare utilization.

    View details for DOI 10.1016/j.ahj.2023.12.014

    View details for PubMedID 38492945

  • Defining the Denominator for Measuring Quality of End-of-Life Care in Children with Cancer: Results of a Nominal Group Technique. The Journal of pediatrics Johnston, E. E., Tefera, R., Ananth, P., Martinez, I., Porter, A., Snaman, J. M., Thienprayoon, R., Asch, S., Bhatia, S., O'Beirne, R. 2024: 114038


    To determine which groups of children with cancer for whom to apply the newly developed quality measures for end-of-life (EOL) care.In a series of nominal groups, panelists answered the question: "Which children, diagnoses, conditions, or prognoses should be included when examining the quality of EOL care for children with cancer?" In each group, individual panelists proposed answers to the question. After collating individual responses, each panelist ranked their 5 top answers and points were assigned (5 pts for the best answer, 4 pts the second best, etc.). A team of pediatric oncology and palliative care clinician-scientists developed and applied a coding structure for responses and associated themes and subthemes for responses.We conducted five nominal groups with a total of 44 participants. Most participants identified as female (88%) and Non-Hispanic White (86%). Seventy-nine percent were clinicians, mainly in pediatric palliative care, pediatric oncology, or hospice; 40% were researchers and 12% were bereaved parents. Responses fell into 5 themes: (1) poor prognosis cancer; (2) specific treatment scenarios; (3) certain populations; (4) certain symptoms; (5) specific utilization scenarios. Poor prognosis cancer and specific treatment scenarios received the most points (320 pts [49%]; 147 pts [23%], respectively).Participants developed a framework to identify which children should be included in EOL quality measures for children with cancer. The deliberate identification of the denominator for pediatric quality measures serves as a potent tool for enhancing quality, conducting research, and developing clinical programs.

    View details for DOI 10.1016/j.jpeds.2024.114038

    View details for PubMedID 38554745

  • Effectiveness of an Artificial Intelligence-Enabled Intervention for Detecting Clinical Deterioration. JAMA internal medicine Gallo, R. J., Shieh, L., Smith, M., Marafino, B. J., Geldsetzer, P., Asch, S. M., Shum, K., Lin, S., Westphal, J., Hong, G., Li, R. C. 2024


    Inpatient clinical deterioration is associated with substantial morbidity and mortality but may be easily missed by clinicians. Early warning scores have been developed to alert clinicians to patients at high risk of clinical deterioration, but there is limited evidence for their effectiveness.To evaluate the effectiveness of an artificial intelligence deterioration model-enabled intervention to reduce the risk of escalations in care among hospitalized patients using a study design that facilitates stronger causal inference.This cohort study used a regression discontinuity design that controlled for confounding and was based on Epic Deterioration Index (EDI; Epic Systems Corporation) prediction model scores. Compared with other observational research, the regression discontinuity design facilitates causal analysis. Hospitalized adults were included from 4 general internal medicine units in 1 academic hospital from January 17, 2021, through November 16, 2022.An artificial intelligence deterioration model-enabled intervention, consisting of alerts based on an EDI score threshold with an associated collaborative workflow among nurses and physicians.The primary outcome was escalations in care, including rapid response team activation, transfer to the intensive care unit, or cardiopulmonary arrest during hospitalization.During the study, 9938 patients were admitted to 1 of the 4 units, with 963 patients (median [IQR] age, 76.1 [64.2-86.2] years; 498 males [52.3%]) included within the primary regression discontinuity analysis. The median (IQR) Elixhauser Comorbidity Index score in the primary analysis cohort was 10 (0-24). The intervention was associated with a -10.4-percentage point (95% CI, -20.1 to -0.8 percentage points; P = .03) absolute risk reduction in the primary outcome for patients at the EDI score threshold. There was no evidence of a discontinuity in measured confounders at the EDI score threshold.Using a regression discontinuity design, this cohort study found that the implementation of an artificial intelligence deterioration model-enabled intervention was associated with a significantly decreased risk of escalations in care among inpatients. These results provide evidence for the effectiveness of this intervention and support its further expansion and testing in other care settings.

    View details for DOI 10.1001/jamainternmed.2024.0084

    View details for PubMedID 38526472

  • Towards global model generalizability: independent cross-site feature evaluation for patient-level risk prediction models using the OHDSI network. Journal of the American Medical Informatics Association : JAMIA Naderalvojoud, B., Curtin, C. M., Yanover, C., El-Hay, T., Choi, B., Park, R. W., Tabuenca, J. G., Reeve, M. P., Falconer, T., Humphreys, K., Asch, S. M., Hernandez-Boussard, T. 2024


    Predictive models show promise in healthcare, but their successful deployment is challenging due to limited generalizability. Current external validation often focuses on model performance with restricted feature use from the original training data, lacking insights into their suitability at external sites. Our study introduces an innovative methodology for evaluating features during both the development phase and the validation, focusing on creating and validating predictive models for post-surgery patient outcomes with improved generalizability.Electronic health records (EHRs) from 4 countries (United States, United Kingdom, Finland, and Korea) were mapped to the OMOP Common Data Model (CDM), 2008-2019. Machine learning (ML) models were developed to predict post-surgery prolonged opioid use (POU) risks using data collected 6 months before surgery. Both local and cross-site feature selection methods were applied in the development and external validation datasets. Models were developed using Observational Health Data Sciences and Informatics (OHDSI) tools and validated on separate patient cohorts.Model development included 41 929 patients, 14.6% with POU. The external validation included 31 932 (UK), 23 100 (US), 7295 (Korea), and 3934 (Finland) patients with POU of 44.2%, 22.0%, 15.8%, and 21.8%, respectively. The top-performing model, Lasso logistic regression, achieved an area under the receiver operating characteristic curve (AUROC) of 0.75 during local validation and 0.69 (SD = 0.02) (averaged) in external validation. Models trained with cross-site feature selection significantly outperformed those using only features from the development site through external validation (P < .05).Using EHRs across four countries mapped to the OMOP CDM, we developed generalizable predictive models for POU. Our approach demonstrates the significant impact of cross-site feature selection in improving model performance, underscoring the importance of incorporating diverse feature sets from various clinical settings to enhance the generalizability and utility of predictive healthcare models.

    View details for DOI 10.1093/jamia/ocae028

    View details for PubMedID 38412331

  • Relationship Between Patient Portal Tool Use and Medication Adherence and Viral Load Among Patients Living with HIV. Journal of general internal medicine Midboe, A. M., Cave, S., Shimada, S. L., Griffin, A. C., Avoundjian, T., Asch, S. M., Gifford, A. L., McInnes, D. K., Troszak, L. K. 2024


    BACKGROUND: Patient portals play an increasingly critical role in engaging patients in their health care. They have the potential to significantly impact the health of those living with chronic diseases, such as HIV, for whom consistent care engagement is both critical and complex.OBJECTIVE: The primary aim was to examine the longitudinal relationships between individual portal tool use and health-related outcomes in patients living with HIV.DESIGN: Retrospective cohort study using electronic health record data to examine the relationship between patient portal tool use and key HIV-specific, health-related outcomes in patients engaged in care in the Veterans Health Administration (VA) through the application of marginal structural models.PARTICIPANTS: A national sample of patients living with HIV (PLWH) active in VA care who were registered to use the VA's patient portal, My HealtheVet (MHV; n = 18,390) between 10/1/2012 and 4/1/2017.MAIN MEASURES: The MHV tools examined were prescription refill (including prescription refill of an antiretroviral (ART) medication and any medication), secure messaging, view appointments, and view labs. Primary outcomes were viral load test receipt, viral load suppression, and ART medication adherence (measured as proportion of days covered).KEY RESULTS: The use of prescription refill for any medication or for ART was positively associated with ART adherence. Secure messaging was positively associated with ART adherence but not with viral load test receipt or viral load suppression. The use of view appointments was positively associated with ART adherence and viral load test receipt but not viral load suppression. The use of view labs was positively associated with viral load suppression but not ART adherence or viral load test receipt.CONCLUSIONS: These findings highlight the valuable role patient portals may play in improving health-related outcomes among PLWH and have implications for patients living with other types of chronic disease.

    View details for DOI 10.1007/s11606-023-08474-z

    View details for PubMedID 38252241

  • Hypertension Control During the Coronavirus Disease 2019 Pandemic: A Cohort Study Among U.S. Veterans. Medical care Korves, C., Peixoto, A. J., Lucas, B. P., Davies, L., Weinberger, D. M., Rentsch, C., Vashi, A., Young-Xu, Y., King, J. J., Asch, S. M., Justice, A. C. 2024


    DESIGN: Retrospective cohort study.OBJECTIVE: We sought to examine whether disruptions in follow-up intervals contributed to hypertension control.BACKGROUND: Disruptions in health care were widespread during the coronavirus disease 2019 pandemic.PATIENTS AND METHODS: We identified a cohort of individuals with hypertension in both prepandemic (March 2019-February 2020) and pandemic periods (March 2020-February 2022) in the Veterans Health Administration. First, we calculated follow-up intervals between the last prepandemic and first pandemic blood pressure measurement during a primary care clinic visit, and between measurements in the prepandemic period. Next, we estimated the association between the maintenance of (or achieving) hypertension control and the period using generalized estimating equations. We assessed associations between follow-up interval and control separately for periods. Finally, we evaluated the interaction between period and follow-up length.RESULTS: A total of 1,648,424 individuals met the study inclusion criteria. Among individuals with controlled hypertension, the likelihood of maintaining control was lower during the pandemic versus the prepandemic (relative risk: 0.93; 95% CI: 0.93, 0.93). Longer follow-up intervals were associated with a decreasing likelihood of maintaining controlled hypertension in both periods. Accounting for follow-up intervals, the likelihood of maintaining control was 2% lower during the pandemic versus the prepandemic. For uncontrolled hypertension, the likelihood of gaining control was modestly higher during the pandemic versus the prepandemic (relative risk: 1.01; 95% CI: 1.01, 1.01). The likelihood of gaining control decreased with follow-up length during the prepandemic but not pandemic.CONCLUSIONS: During the pandemic, longer follow-up between measurements contributed to the lower likelihood of maintaining control. Those with uncontrolled hypertension were modestly more likely to gain control in the pandemic.

    View details for DOI 10.1097/MLR.0000000000001971

    View details for PubMedID 38284412

  • "Diving in the deep-end and swimming": a mixed methods study using normalization process theory to evaluate a learning collaborative approach for the implementation of palliative care practices in hemodialysis centers. BMC health services research Holdsworth, L. M., Stedman, M., Gustafsson, E. S., Han, J., Asch, S. M., Harbert, G., Lorenz, K. A., Lupu, D. E., Malcolm, E., Moss, A. H., Nicklas, A., Tamura, M. K. 2023; 23 (1): 1384


    Normalization Process Theory (NPT) is an implementation theory that can be used to explain how and why implementation strategies work or not in particular circumstances. We used it to understand the mechanisms that lead to the adoption and routinization of palliative care within hemodialysis centers.We employed a longitudinal, mixed methods approach to comprehensively evaluate the implementation of palliative care practices among ten hemodialysis centers participating in an Institute for Healthcare Improvement Breakthrough- Series learning collaborative. Qualitative methods included longitudinal observations of collaborative activities, and interviews with implementers at the end of the study. We used an inductive and deductive approach to thematic analysis informed by NPT constructs (coherence, cognitive participation, collective action, reflexive monitoring) and implementation outcomes. The NoMAD survey, which measures NPT constructs, was completed by implementers at each hemodialysis center during early and late implementation.The four mechanisms posited in NPT had a dynamic and layered relationship during the implementation process. Collaborative participants participated because they believed in the value and legitimacy of palliative care for patients receiving hemodialysis and thus had high levels of cognitive participation at the start. Didactic Learning Sessions were important for building practice coherence, and sense-making was solidified through testing new skills in practice and first-hand observation during coaching visits by an expert. Collective action was hampered by limited time among team members and practical issues such as arranging meetings with patients. Reflexive monitoring of the positive benefit to patient and family experiences was key in shifting mindsets from disease-centric towards a patient-centered model of care. NoMAD survey scores showed modest improvement over time, with collective action having the lowest scores.NPT was a useful framework for understanding the implementation of palliative care practices within hemodialysis centers. We found a nonlinear relationship among the mechanisms which is reflected in our model of implementation of palliative care practices through a learning collaborative. These findings suggest that the implementation of complex practices such as palliative care may be more successful through iterative learning and practice opportunities as the mechanisms for change are layered and mutually, NCT04125537 . Registered 14 October 2019 - Retrospectively registered.

    View details for DOI 10.1186/s12913-023-10360-7

    View details for PubMedID 38082293

    View details for PubMedCentralID PMC10712060

  • From the Editors Desk: Bittersweet Reflections on Our Term as Editors JOURNAL OF GENERAL INTERNAL MEDICINE Bates, C. K., Jackson, J. L., Asch, S. 2023; 38 (16): 3449-3450

    View details for DOI 10.1007/s11606-023-08412-z

    View details for Web of Science ID 001156446500022

    View details for PubMedID 37747594

    View details for PubMedCentralID PMC10713932

  • Physician- and Patient-Elicited Barriers and Facilitators to Implementation of a Machine Learning-Based Screening Tool for Peripheral Arterial Disease: Preimplementation Study With Physician and Patient Stakeholders. JMIR cardio Ho, V., Brown Johnson, C., Ghanzouri, I., Amal, S., Asch, S., Ross, E. 2023; 7: e44732


    BACKGROUND: Peripheral arterial disease (PAD) is underdiagnosed, partially due to a high prevalence of atypical symptoms and a lack of physician and patient awareness. Implementing clinical decision support tools powered by machine learning algorithms may help physicians identify high-risk patients for diagnostic workup.OBJECTIVE: This study aims to evaluate barriers and facilitators to the implementation of a novel machine learning-based screening tool for PAD among physician and patient stakeholders using the Consolidated Framework for Implementation Research (CFIR).METHODS: We performed semistructured interviews with physicians and patients from the Stanford University Department of Primary Care and Population Health, Division of Cardiology, and Division of Vascular Medicine. Participants answered questions regarding their perceptions toward machine learning and clinical decision support for PAD detection. Rapid thematic analysis was performed using templates incorporating codes from CFIR constructs.RESULTS: A total of 12 physicians (6 primary care physicians and 6 cardiovascular specialists) and 14 patients were interviewed. Barriers to implementation arose from 6 CFIR constructs: complexity, evidence strength and quality, relative priority, external policies and incentives, knowledge and beliefs about intervention, and individual identification with the organization. Facilitators arose from 5 CFIR constructs: intervention source, relative advantage, learning climate, patient needs and resources, and knowledge and beliefs about intervention. Physicians felt that a machine learning-powered diagnostic tool for PAD would improve patient care but cited limited time and authority in asking patients to undergo additional screening procedures. Patients were interested in having their physicians use this tool but raised concerns about such technologies replacing human decision-making.CONCLUSIONS: Patient- and physician-reported barriers toward the implementation of a machine learning-powered PAD diagnostic tool followed four interdependent themes: (1) low familiarity or urgency in detecting PAD; (2) concerns regarding the reliability of machine learning; (3) differential perceptions of responsibility for PAD care among primary care versus specialty physicians; and (4) patient preference for physicians to remain primary interpreters of health care data. Facilitators followed two interdependent themes: (1) enthusiasm for clinical use of the predictive model and (2) willingness to incorporate machine learning into clinical care. Implementation of machine learning-powered diagnostic tools for PAD should leverage provider support while simultaneously educating stakeholders on the importance of early PAD diagnosis. High predictive validity is necessary for machine learning models but not sufficient for implementation.

    View details for DOI 10.2196/44732

    View details for PubMedID 37930755

  • K Grant Funding to Internal Medicine Specialties. Journal of general internal medicine Gallo, R. J., Asch, S. M., Chan, D. C. 2023

    View details for DOI 10.1007/s11606-023-08483-y

    View details for PubMedID 37904071

  • Expansion of Abdominal Aortic Aneurysm Screening and Ultrasound Utilization and Diagnosis. JAMA surgery Ho, V. T., Cabot, J. H., George, E. L., Garcia-Toca, M., Chen, J. H., Asch, S. M., Lee, J. T. 2023

    View details for DOI 10.1001/jamasurg.2023.4662

    View details for PubMedID 37851462

    View details for PubMedCentralID PMC10585488

  • Postoperative opioid prescribing patients with diabetes: Opportunities for personalized pain management. PloS one Zammit, A., Coquet, J., Hah, J., El Hajouji, O., Asch, S. M., Carroll, I., Curtin, C. M., Hernandez-Boussard, T. 2023; 18 (8): e0287697


    Opioids are commonly prescribed for postoperative pain, but may lead to prolonged use and addiction. Diabetes impairs nerve function, complicates pain management, and makes opioid prescribing particularly challenging.This retrospective observational study included a cohort of postoperative patients from a multisite academic health system to assess the relationship between diabetes, pain, and prolonged opioid use (POU), 2008-2019. POU was defined as a new opioid prescription 3-6 months after discharge. The odds that a patient had POU was assessed using multivariate logistic regression controlling for patient factors (e.g., demographic and clinical factors, as well as prior pain and opiate use).A total of 43,654 patients were included, 12.4% with diabetes. Patients with diabetes had higher preoperative pain scores (2.1 vs 1.9, p<0.001) and lower opioid naïve rates (58.7% vs 68.6%, p<0.001). Following surgery, patients with diabetes had higher rates of POU (17.7% vs 12.7%, p<0.001) despite receiving similar opioid prescriptions at discharge. Patients with Type I diabetes were more likely to have POU compared to other patients (Odds Ratio [OR]: 2.22; 95% Confidence Interval [CI]:1.69-2.90 and OR:1.44, CI: 1.33-1.56, respectively).In conclusion, surgical patients with diabetes are at increased risk for POU even after controlling for likely covariates, yet they receive similar postoperative opiate therapy. The results suggest a more tailored approach to diabetic postoperative pain management is warranted.

    View details for DOI 10.1371/journal.pone.0287697

    View details for PubMedID 37616195

    View details for PubMedCentralID PMC10449216

  • Types of Engagement Strategies to Engage High-Risk Patients in VA. Journal of general internal medicine Bergman, A. A., Stockdale, S. E., Zulman, D. M., Katz, M. L., Asch, S. M., Chang, E. T. 2023


    Many healthcare systems seek to improve care for complex high-risk patients, but engaging such patients to actively participate in their healthcare can be challenging.To identify and describe types of patient engagement strategies reported as successfully deployed by providers/teams and experienced by patients in a Veterans Health Administration (VA) intensive primary care (IPC) pilot program.We conducted semi-structured qualitative telephone interviews with 29 VA IPC staff (e.g., physicians, nurses, psychologists) and 51 patients who had at least four IPC team encounters. Interviews were recorded, transcribed, and analyzed thematically using a combination a priori/inductive approach.The engagement strategies successfully deployed by the IPC providers/teams could be considered either more "facilitative," i.e., facilitated by and dependent on staff actions, or more "self-sustaining," i.e., taught to patients, thus cultivating their ongoing patient self-care. Facilitative strategies revolved around enhancing patient access and coordination of care, trust-building, and addressing social determinants of health. Self-sustaining strategies were oriented around patient empowerment and education, caregiver and/or community support, and boundaries and responsibilities. When patients described their experiences with the "facilitative" strategies, many discussed positive proximal outcomes (e.g., increased access to healthcare providers). Self-sustaining strategies led to positive (self-reported) longer-term clinical outcomes, such as behavior change.We identified two categories of strategies for successfully engaging complex, high-risk patients: facilitative and self-sustaining. Intensive primary care program leaders may consider thoughtfully building "self-sustaining" engagement strategies into program development. Future research can confirm their effectiveness in improving health outcomes.

    View details for DOI 10.1007/s11606-023-08336-8

    View details for PubMedID 37620722

    View details for PubMedCentralID 4401870

  • Variation in Methamphetamine-Associated Heart Failure Hospitalizations Across the United States. Journal of cardiac failure Manja, V., Sandhu, A. T., Frayne, S., Asch, S., McGovern, M., Chen, C., Heidenreich, P. 2023

    View details for DOI 10.1016/j.cardfail.2023.07.015

    View details for PubMedID 37611844

  • Prediction of opioid-related outcomes in a medicaid surgical population: Evidence to guide postoperative opiate therapy and monitoring. PLoS computational biology El Hajouji, O., Sun, R. S., Zammit, A., Humphreys, K., Asch, S. M., Carroll, I., Curtin, C. M., Hernandez-Boussard, T. 2023; 19 (8): e1011376


    BACKGROUND: Treatment of surgical pain is a common reason for opioid prescriptions. Being able to predict which patients are at risk for opioid abuse, dependence, and overdose (opioid-related adverse outcomes [OR-AE]) could help physicians make safer prescription decisions. We aimed to develop a machine-learning algorithm to predict the risk of OR-AE following surgery using Medicaid data with external validation across states.METHODS: Five machine learning models were developed and validated across seven US states (90-10 data split). The model output was the risk of OR-AE 6-months following surgery. The models were evaluated using standard metrics and area under the receiver operating characteristic curve (AUC) was used for model comparison. We assessed calibration for the top performing model and generated bootstrap estimations for standard deviations. Decision curves were generated for the top-performing model and logistic regression.RESULTS: We evaluated 96,974 surgical patients aged 15 and 64. During the 6-month period following surgery, 10,464 (10.8%) patients had an OR-AE. Outcome rates were significantly higher for patients with depression (17.5%), diabetes (13.1%) or obesity (11.1%). The random forest model achieved the best predictive performance (AUC: 0.877; F1-score: 0.57; recall: 0.69; precision:0.48). An opioid disorder diagnosis prior to surgery was the most important feature for the model, which was well calibrated and had good discrimination.CONCLUSIONS: A machine learning models to predict risk of OR-AE following surgery performed well in external validation. This work could be used to assist pain management following surgery for Medicaid beneficiaries and supports a precision medicine approach to opioid prescribing.

    View details for DOI 10.1371/journal.pcbi.1011376

    View details for PubMedID 37578969

  • Cost of Care for Patients with Cirrhosis. The American journal of gastroenterology Kanwal, F., Nelson, R., Liu, Y., Kramer, J. R., Hernaez, R., Cholankeril, G., Rana, A., Flores, A., Smith, D., Cao, Y., Beech, B., Asch, S. M. 2023


    BACKGROUND: There are limited longitudinal data on the cost of treating patients with cirrhosis which hampers value-based improvement initatives.METHODS: We conducted a retrospective cohort study of patients with cirrhosis seen in the Veterans Affairs healthcare system from 2011 to 2015. Patients were followed up through 2019. We identified a sex- and age-matched control cohort without cirrhosis. We estimated incremental annual health care costs attributable to cirrhosis for 4 years overall and in subgroups based on severity (compensated, decompensated), cirrhosis complications (ascites, encephalopathy, varices, hepatocellular cancer, acute kidney injury), and comorbidity (Deyo index).RESULTS: We compared 39,361 patients with cirrhosis and 138,964 controls. The incremental adjusted costs for caring of patients with cirrhosis were $35,029 (95% CI, $32,473-$37,585) during the first year and ranged from $14,216 to $17,629 in the subsequent 3 years. Cirrhosis complications accounted for most of these costs. Cost of managing patients with hepatic encephalopathy (year 1 cost, $50,080) or ascites ($50,364) were higher than the cost of managing patients with varices ($20,488) or hepatocellular cancer ($37,639) in the first year. Subgroups with acute kidney injury or those who had multimorbidity were the most costly at $64,413 and $66,653 in the first year, respectively.CONCLUSION: Patients with cirrhosis had substantially higher healthcare costs than matched controls and multimorbid patients had even higher costs. Cirrhosis complications accounted for most of the excess cost, so preventing complications has the largest potential for cost saving and could serve as targets for improvement.

    View details for DOI 10.14309/ajg.0000000000002472

    View details for PubMedID 37561079

  • "Incidentalomas" in the Age of Artificial Intelligence. Journal of general internal medicine Dudum, R., Asch, S. M. 2023

    View details for DOI 10.1007/s11606-023-08325-x

    View details for PubMedID 37528253

    View details for PubMedCentralID 6724186

  • Healthcare costs and use before and after opioid overdose in Veterans Health Administration patients with opioid use disorder. Addiction (Abingdon, England) Joyce, V. R., Oliva, E. M., Garcia, C. C., Trafton, J., Asch, S. M., Wagner, T. H., Humphreys, K., Owens, D. K., Bounthavong, M. 2023


    To compare healthcare costs and use between United States (US) Veterans Health Administration (VHA) patients with opioid use disorder (OUD) who experienced an opioid overdose (OD cohort) and patients with OUD who did not experience an opioid overdose (non-OD cohort).This is a retrospective cohort study of administrative and clinical data.The largest integrated national health-care system is the US Veterans Health Administration's healthcare systems.We included VHA patients diagnosed with OUD from October 1, 2017 through September 30, 2018. We identified the index date of overdose for patients who had an overdose. Our control group, which included patients with OUD who did not have an overdose, was randomly assigned an index date. A total of 66 513 patients with OUD were included for analysis (OD cohort: n = 1413; non-OD cohort: n = 65 100).Monthly adjusted healthcare-related costs and use in the year before and after the index date. We used generalized estimating equation models to compare patients with an opioid overdose and controls in a difference-in-differences framework.Compared with the non-OD cohort, an opioid overdose was associated with an increase of $16 890 [95% confidence interval (CI) = $15 611-18 169; P < 0.001] in healthcare costs for an estimated $23.9 million in direct costs to VHA (95% CI = $22.1 million, $25.7 million) within the 30 days following overdose after adjusting for baseline characteristics. Inpatient costs ($13 515; 95% CI = $12 378-14 652; P < 0.001) reflected most of this increase. Inpatient days (+6.15 days; 95% CI, = 5.33-6.97; P < 0.001), inpatient admissions (+1.01 admissions; 95% CI = 0.93-1.10; P < 0.001) and outpatient visits (+1.59 visits; 95% CI = 1.34-1.84; P < 0.001) also increased in the month after opioid overdose. Within the overdose cohort, healthcare costs and use remained higher in the year after overdose compared with pre-overdose trends.The US Veterans Health Administration patients with opioid use disorder (OUD) who have experienced an opioid overdose have increased healthcare costs and use that remain significantly higher in the month and continuing through the year after overdose than OUD patients who have not experienced an overdose.

    View details for DOI 10.1111/add.16289

    View details for PubMedID 37465971

  • Myocardial Infarction Across COVID-19 Pandemic Phases: Insights From the Veterans Health Affairs System. Journal of the American Heart Association Yong, C. M., Graham, L., Beyene, T. J., Sadri, S., Hong, J., Burdon, T., Fearon, W. F., Asch, S. M., Turakhia, M., Heidenreich, P. 2023: e029910


    Background Cardiovascular procedural treatments were deferred at scale during the COVID-19 pandemic, with unclear impact on patients presenting with non-ST-segment-elevation myocardial infarction (NSTEMI). Methods and Results In a retrospective cohort study of all patients diagnosed with NSTEMI in the US Veterans Affairs Healthcare System from January 1, 2019 to October 30, 2022 (n=67 125), procedural treatments and outcomes were compared between the prepandemic period and 6 unique pandemic phases: (1) acute phase, (2) community spread, (3) first peak, (4) post vaccine, (5) second peak, and (6) recovery. Multivariable regression analysis was performed to assess the association between pandemic phases and 30-day mortality. NSTEMI volumes dropped significantly with the pandemic onset (62.7% of prepandemic peak) and did not revert to prepandemic levels in subsequent phases, even after vaccine availability. Percutaneous coronary intervention and coronary artery bypass grafting volumes declined proportionally. Compared with the prepandemic period, patients with NSTEMI experienced higher 30-day mortality during Phases 2 and 3, even after adjustment for COVID-19-positive status, demographics, baseline comorbidities, and receipt of procedural treatment (adjusted odds ratio for Phases 2 and 3 combined, 1.26 [95% CI, 1.13-1.43], P<0.01). Patients receiving Veterans Affairs-paid community care had a higher adjusted risk of 30-day mortality compared with those at Veterans Affairs hospitals across all 6 pandemic phases. Conclusions Higher mortality after NSTEMI occurred during the initial spread and first peak of the pandemic but resolved before the second, higher peak-suggesting effective adaptation of care delivery but a costly delay to implementation. Investigation into the vulnerabilities of the early pandemic spread are vital to informing future resource-constrained practices.

    View details for DOI 10.1161/JAHA.123.029910

    View details for PubMedID 37421288

  • Awakening and breathing coordination: A mixed-methods analysis of determinants of implementation. Annals of the American Thoracic Society Olsen, G. H., Gee, P. M., Wolfe, D., Winberg, C., Carpenter, L., Jones, C., Jacobs, J. R., Leither, L., Peltan, I. D., Singer, S. J., Asch, S. M., Grissom, C. K., Srivastava, R., Knighton, A. J. 2023


    RATIONALE: Routine spontaneous awakening and breathing trial coordination (SAT/SBT) improves outcomes for mechanically ventilated patients, but adherence varies. Understanding barriers and facilitators (implementation determinants) to consistent daily use of SAT/SBT can guide the development of implementation strategies to increase adherence to these evidence-based interventions.OBJECTIVE(S): We conducted an explanatory, sequential mixed-methods study to measure variation in the routine daily use of SAT/SBT and to identify implementation determinants that might explain variation in SAT/SBT use across 15 intensive care units (ICUs) in urban and rural locations within an integrated, community-based health system.METHODS: We described the patient population and measured adherence to daily use of coordinated SAT/SBT from January-June 2021, selecting 4 sites with varied adherence levels for semi-structured field interviews. We conducted key informant interviews with critical care nurses, respiratory therapists, and physicians/advanced practice clinicians (n=55) from these four sites between October - December 2021 and performed content analysis to identify implementation determinants to SAT/SBT use.RESULTS: The 15 sites had 1901 ICU admissions receiving invasive mechanical ventilation (IMV) ≥24 hours during the measurement period. Mean IMV patient age was 58 years with median IMV duration of 5.3 days [IQR: 2.5-11.9] Coordinated SAT/SBT adherence (within two hours) was estimated at 21% systemwide (site range: 9-68%). ICU clinicians were generally familiar with SAT/SBT but varied in their knowledge and beliefs about what constituted an evidence-based SAT/SBT. Clinicians reported SAT/SBT coordination was difficult in the context of existing ICU workflows, and existing protocols did not explicitly define how coordination should be performed. The lack of an agreed upon system-level measure for tracking daily use of SAT/SBT led to uncertainty regarding what constituted adherence. The effects of the COVID-19 pandemic increased clinician workloads, impacting performance.CONCLUSION: Coordinated SAT/SBT adherence varied substantially across 15 ICUs within an integrated, community-based health system. Implementation strategies that address barriers identified by this study, including knowledge deficits, challenges around workflow coordination, and the lack of performance measurement, should be tested in future hybrid implementation-effectiveness trials to increase adherence to daily use of coordinated SAT/SBT and minimize harm related to the prolonged use of mechanical ventilation and sedation.CLINICAL TRIAL REGISTRATION: None Primary Source of Funding: National Heart, Lung, Blood Institute (U01HL159878) and the National Center for Advancing Translational Science (KL2TR002539) of the National Institutes of Health, and the National Science Foundation Future of Work at the Human Technology Frontier (#2026498).

    View details for DOI 10.1513/AnnalsATS.202212-1048OC

    View details for PubMedID 37413692

  • Adapting a Telephone-Based, Dyadic Self-management Program to Be Delivered Over the Web: Methodology and Usability Testing. JMIR formative research Trivedi, R., Hirayama, S. K., Risbud, R., Suresh, M., Humber, M. B., Butler, K., Razze, A., Timko, C., Nelson, K., Zulman, D. M., Asch, S. M., Humphreys, K., Piette, J. D. 2023; 7: e43903


    The COVID-19 pandemic has amplified the need for web-based behavioral interventions to support individuals who are diagnosed with chronic conditions and their informal caregivers. However, most interventions focus on patient outcomes. Dyadic technology-enabled interventions that simultaneously improve outcomes for patients and caregivers are needed.This study aimed to describe the methodology used to adapt a telephone-based, facilitated, and dyadic self-management program called Self-care Using Collaborative Coping Enhancement in Diseases (SUCCEED) into a self-guided, web-based version (web-SUCCEED) and to conduct usability testing for web-SUCCEED.We developed web-SUCCEED in 6 steps: ideation-determine the intervention content areas; prototyping-develop the wireframes, illustrating the look and feel of the website; prototype refinement via feedback from focus groups; finalizing the module content; programming web-SUCCEED; and usability testing. A diverse team of stakeholders including content experts, web designers, patients, and caregivers provided input at various stages of development. Costs, including full-time equivalent employee, were summarized.At the ideation stage, we determined the content of web-SUCCEED based on feedback from the program's original pilot study. At the prototyping stage, the principal investigator and web designers iteratively developed prototypes that included inclusive design elements (eg, large font size). Feedback about these prototypes was elicited through 2 focus groups of veterans with chronic conditions (n=13). Rapid thematic analysis identified two themes: (1) web-based interventions can be useful for many but should include ways to connect with other users and (2) prototypes were sufficient to elicit feedback about the esthetics, but a live website allowing for continual feedback and updating would be better. Focus group feedback was incorporated into building a functional website. In parallel, the content experts worked in small groups to adapt SUCCEED's content, so that it could be delivered in a didactic, self-guided format. Usability testing was completed by veterans (8/16, 50%) and caregivers (8/16, 50%). Veterans and caregivers gave web-SUCCEED high usability scores, noting that it was easy to understand, easy to use, and not overly burdensome. Notable negative feedback included "slightly agreeing" that the site was confusing and awkward. All veterans (8/8, 100%) agreed that they would choose this type of program in the future to access an intervention that aims to improve their health. Developing and maintaining the software and hosting together cost approximately US $100,000, excluding salary and fringe benefits for project personnel (steps 1-3: US $25,000; steps 4-6: US $75,000).Adapting an existing, facilitated self-management support program for delivery via the web is feasible, and such programs can remotely deliver content. Input from a multidisciplinary team of experts and stakeholders can ensure the program's success. Those interested in adapting programs should have a realistic estimate of the budget and staffing requirements.

    View details for DOI 10.2196/43903

    View details for PubMedID 37327057

  • Engagement of Patients with Advanced Cancer (EPAC) randomized clinical trial: Long-term effects on survival and healthcare use Patel, M. I., Agrawal, M., Kapphahn, K., Blayney, D. W., Asch, S., Bundorf, M., Milstein, A. LIPPINCOTT WILLIAMS & WILKINS. 2023
  • Evaluating the Implementation of Patient-Reported Outcomes in Heart Failure Clinic: A Qualitative Assessment. Circulation. Cardiovascular quality and outcomes Brown-Johnson, C., Calma, J., Amano, A., Winget, M., Harris, S. R., Vilendrer, S., Asch, S. M., Heidenreich, P., Sandhu, A. T., Kalwani, N. M. 2023: e009677


    Patient-reported outcomes (PROs) may improve care for patients with heart failure. The Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) is a patient survey that captures symptom frequency, symptom burden, physical limitations, social limitations, and quality of life. Despite the utility of PROs and the KCCQ-12, the implementation and routine use of these measures can be difficult. We conducted an evaluation of clinician perceptions of the KCCQ-12 to identify barriers and facilitators to implementation into clinical practice.We conducted interviews with cardiologists from 4 institutions across the United States and Canada (n=16) and observed clinic visits at 1 institution in Northern California (n=5). Qualitative analysis was conducted in 2 rounds: (1) rapid analysis constructed around major themes related to the aims of the study and (2) content analysis with codes derived from the rapid analysis and implementation science.Most heart failure physicians and advanced practice clinicians reported that the KCCQ-12 was acceptable, appropriate, and useful in clinical care. Clinician engagement efforts, trialability, and the straightforward design of the KCCQ-12 facilitated its use in clinical care. Further opportunities identified to facilitate implementation include more streamlined integration into the electronic health record and comprehensive staff education on PROs. Participants highlighted that the KCCQ-12 was useful in clinic visits to improve the consistency of patient history taking, focus patient-clinician conversations, collect a more accurate account of patient quality of life, track trends in patient well-being over time, and refine clinical decision-making.In this qualitative study, clinicians reported that the KCCQ-12 enhanced several aspects of heart failure patient care. Use of the KCCQ-12 was facilitated by a robust clinician engagement campaign and the design of the KCCQ-12 itself. Future implementation of PROs in heart failure clinic should focus on streamlining electronic health record integration and providing additional staff education on the value of PROs.URL:; Unique identifier: NCT04164004.

    View details for DOI 10.1161/CIRCOUTCOMES.122.009677

    View details for PubMedID 37114990

  • Factors influencing pediatric transfusion: A complex decision impacting quality of care. Transfusion Steffen, K. M., Spinella, P. C., Holdsworth, L. M., Ford, M., Lee, G. M., Asch, S. M., Proctor, E. K., Doctor, A. 2023


    The risks of red blood cell transfusion may outweigh the benefits for many patients in pediatric intensive care units (PICUs), but guidelines from the Transfusion and Anemia eXpertise Initiative (TAXI) have not been consistently adopted. We sought to identify factors that influenced transfusion decision-making in PICUs to explore potential barriers and facilitators to implementing the guidelines.A total of 50 ICU providers working in eight US ICUs of different types (non-cardiac PICUs, cardiovascular ICUs, combined units) and variable sizes (11-32 beds) completed semi-structured interviews. Providers included ICU attendings and trainees, nurse practitioners, nurses, and subspecialty physicians. Interviews examined factors that influenced transfusion decisions, transfusion practices, and provider beliefs. Qualitative analysis utilized a Framework Approach. Summarized data was compared between provider roles and units with consideration to identify patterns and unique informative statements.Providers cited clinical, physiologic, anatomic, and logistic factors they considered in making transfusion decisions. Improving oxygen carrying capacity, hemodynamics and perfusion, respiratory function, volume deficits, and correcting laboratory values were among the reasons given for transfusion. Other sought-after benefits included alleviating symptoms of anemia, improving ICU throughput, and decreasing blood waste. Providers in different roles approached transfusion decisions differently, with the largest differences noted between nurses and subspecialists as compared with other ICU providers. While ICU attendings most often made the decision to transfuse, all providers influenced the decision-making.Implementation of transfusion guidelines requires multi-professional approaches that emphasize the known risks of transfusion, its limited benefits, and highlight evidence around the safety and benefit of restrictive approaches.

    View details for DOI 10.1111/trf.17364

    View details for PubMedID 37078686

  • Low Oral Anticoagulant Use Among Veteran Nursing Home Residents with Atrial Fibrillation Manja, V., Li, Y., Lee, S. J., Graham, L., Jing, B., Steinman, M., asch, S., Fung, K., Odden, M. WILEY. 2023: S153
  • Integrating Patient and Expert Perspectives to Conceptualize High-Quality Palliative Cancer Care for Symptoms in the US Veterans Health Administration: A Qualitative Study. Inquiry : a journal of medical care organization, provision and financing O'Hanlon, C. E., Giannitrapani, K. F., Gamboa, R. C., Walling, A. M., Lindvall, C., Garrido, M., Asch, S. M., Lorenz, K. A. 2023; 60: 469580231160374


    Quality measurement is typically the domain of clinical experts and health system leaders; patient/caregiver perspectives are rarely solicited. We aimed to describe and integrate clinician and patient/caregiver conceptualizations of high-quality palliative symptom care for patients receiving care for advanced cancer within the US Veterans Health Administration in the context of existing quality measures. We conducted a secondary qualitative analysis of transcripts from prioritization discussions of process quality measures relevant to cancer palliative care. These discussions occurred during 2 modified RAND-UCLA appropriateness panels: a panel of 10 palliative care clinical expert stakeholders (7 physicians, 2 nurses, 1 social worker) and a panel of 9 patients/caregivers with cancer experience. Discussions were recorded, transcribed, and independently double-coded using an a priori logical framework. Content analysis was used to identify subthemes within codes and axial coding was used to identify crosscutting themes. Patients/caregivers and clinical experts contributed important perspectives to 3 crosscutting themes. First, proactive elicitation of symptoms is critical. Patients/caregivers especially emphasized importance of comprehensive and proactive screening and assessment, especially for pain and mental health. Second, screening and assessment alone is not enough; information elicited from patients must inform care. Measuring screening/assessment and management care processes separately has important limitations. Lastly, high-quality symptom management can be broadly defined if it is patient-centered; high-quality care takes an individualized approach and might include non-medical or non-pharmacological symptom management. Integrating the perspectives of clinical experts and patients/caregivers is critical for health systems to consider as they design and implement quality measures for palliative cancer care.

    View details for DOI 10.1177/00469580231160374

    View details for PubMedID 36891952

  • Most Privately Insured Patients Do Not Receive Federally Recommended Abdominal Aortic Aneurysm Screening. Journal of vascular surgery Ho, V. T., Tran, K., George, E. L., Asch, S. M., Chen, J. H., Dalman, R. L., Lee, J. T. 2023


    Since 2005, the United States Preventative Services Task Force (USPSTF) has recommended abdominal aortic aneurysm (AAA) ultrasound screening for 65- to 75-year-old male ever-smokers. Integrated health systems such as Kaiser Permanente and the Veterans Affairs (VA) healthcare system report 74-79% adherence, but compliance rates in the private sector are unknown.The IBM Marketscan® Commercial and Medicare Supplemental databases (2006 -2017) were queried for male ever-smokers continuously enrolled from age 65 to 75. Exclusion criteria were previous history of abdominal aortic aneurysm, connective tissue disorder, and aortic surgery. Patients with abdominal computed tomographic or magnetic resonance imaging from ages 65 to 75 were also excluded. Screening was defined as a complete abdominal, retroperitoneal, or aortic ultrasound. A logistic mixed-effects model utilizing state as a random intercept was used to identify patient characteristics associated with screening.Of 35,154 eligible patients, 13,612 (38.7%, Table 1) underwent screening. Compliance varied by state, ranging from 24.4% in Minnesota to 51.6% in Montana (p <0.05, Figure 1). Screening activity increased yearly, with 0.7% of screening activity occurring in 2008 versus 22.2% in 2016 (p <0.05, Figure 2). In a logistic mixed-effects model adjusting for state as a random intercept, history of hypertension (OR 1.07, 95% CI [1.03 - 1.13]), coronary artery disease (OR 1.17, 95% CI [1.10, 1.22]), congestive heart failure (OR 1.14, 95% CI [1.01 - 1.22]), diabetes (OR 1.1, 95% CI [1.06 - 1.16]) and chronic kidney disease (OR 1.4 95% CI [1.24 - 1.53]) were associated with screening. Living outside of a census-designated metropolitan area was negatively associated with screening (OR 0.92, 95% CI [0.87 - 0.97], Table 2).In a private claims database representing 250 million claimants, 38.7% of eligible patients received UPSTF-recommended AAA screening. Compliance was nearly half that of integrated health systems and was significantly lower for patients living outside of metropolitan areas. Efforts to improve early detection of AAA should include targeting non-metropolitan areas and modifying Medicare reimbursement and incentivization strategies to improve guideline adherence.

    View details for DOI 10.1016/j.jvs.2023.01.202

    View details for PubMedID 36781115

  • Utilizing Remote Access for Electronic Medical Records Reduces Overall EMR Time for Vascular Surgery Residents. Journal of vascular surgery Ho, V. T., Sgroi, M. D., Chandra, V., Asch, S. M., Chen, J. H., Lee, J. T. 2023


    Survey data suggests that surgical residents spend 20-30% of training time using the electronic medical record (EMR), raising concerns about burnout and insufficient operative experience. We characterize trainee EMR activity in the vascular surgery service of a quaternary care center to identify modifiable factors associated with high EMR use.Resident activity while on the Vascular Surgery service was queried from the EMR. Weekends and holidays were excluded to focus on typical staffing periods. Variables including daily time spent, post-graduate year (PGY), remote access via mobile device or personal laptop, and patient census including operative caseload were extracted. Univariate analysis was performed with t-tests and chi-squared tests where appropriate. We then fit a linear mixed-effects model with normalized daily EMR time as the outcome variable, random slopes for resident and patient census, and fixed effects of PGY level, academic year, and fractional time spent using remote access.EMR activity for 53 residents from July 2015 to June 2019 was included. The mean daily EMR usage was 1.6 hours, ranging from 3.6 hours per day in PGY1 residents to 1.1 hours in PGY4-5 residents. Across all post-graduate years, the most time-consuming EMR activities were chart review (43.0-46.6%) and notes review (22.4-27.0%). In the linear mixed-effects model, increased patient census was associated with increased daily EMR usage (Coefficient = 0.61, p-value < 0.001). Resident seniority (Coefficient = -1.2, p-value < 0.001) and increased remote access (Coefficient = -0.44, p-value < 0.001) were associated with reduced daily EMR usage. Over the study period, total EMR usage decreased significantly from the 2015-2016 academic year to 2018-2019 (mean difference 2.4 hours vs 1.78, p-value <0.001).In an audit of EMR activity logs on a vascular surgery service, mean EMR time was 1.6 hours a day, which is lower than survey estimates. Resident seniority and remote access utilization were associated with reduced time spent on the EMR, independent of patient census. While increasing EMR accessibility via mobile devices and personal computers have been hypothesized to contribute to poor work-life balance, our study suggests a possible time-saving effect by enabling expedient access for data review, which constitutes the majority of resident EMR activity. Further research in other institutions and specialties is needed for external validation and exploring implications for resident wellness initiatives.

    View details for DOI 10.1016/j.jvs.2023.01.198

    View details for PubMedID 36758909

  • Long-term opioid therapy trajectories and overdose in patients with and without cancer. BMJ oncology Merlin, J. S., Black, A. C., Midboe, A. M., Troszak, L., Asch, S. M., Bohnert, A., Fenton, B. T., Giannitrapani, K. F., Glassman, P., Kerns, R. D., Silveira, M., Lorenz, K. A., Abel, E. A., Becker, W. C. 2023; 2 (1)


    Objective: Pain is experienced by most patients with cancer and opioids are a cornerstone of management. Our objectives were (1) to identify patterns or trajectories of long-term opioid therapy (LTOT) and their correlates among patients with and without cancer and (2) to assess the association between trajectories and risk for opioid overdose, considering the potential moderating role of cancer.Methods and Analysis: We conducted a retrospective cohort study among individuals in the US Veterans Health Administration (VHA) database with incident LTOT with and without cancer (N=44,351; N=285,772, respectively) between 2010-2017. We investigated the relationship between LTOT trajectory and all International Classification of Diseases-9 and 10-defined accidental and intentional opioid-related overdoses.Results: Trajectories of opioid receipt observed in patients without cancer and replicated in patients with cancer were: low-dose/stable trend, low-dose/de-escalating trend, moderate-dose/stable trend, moderate-dose/escalating with quadratic downturn trend, and high-dose/escalating with quadratic downturn trend. Time to first overdose was significantly predicted by higher-dose and escalating trajectories; the two low-dose trajectories conferred similar, lower risk. Conditional hazard ratios (99% CI) for the moderate-dose, moderate-dose/escalating with quadratic downturn and high-dose/escalating with quadratic downturn trends were 1·84 (1·18, 2·85), 2·56 (1·54, 4·25), and 2·41 (1·37, 4·26), respectively. Effects of trajectories on time to overdose did not differ by presence of cancer; inferences were replicated when restricting to patients with stage 3/4 cancer.Conclusion: Patients with cancer face opioid overdose risks like patients without cancer. Future studies should seek to expand and address our knowledge about opioid risk in cancer patients.Trial registration: None.

    View details for DOI 10.1136/bmjonc-2022-000023

    View details for PubMedID 38259328

  • Excess Mortality Among Patients in the Veterans Affairs Health System Compared With the Overall US Population During the First Year of the COVID-19 Pandemic. JAMA network open Weinberger, D. M., Rose, L., Rentsch, C., Asch, S. M., Columbo, J. A., King, J. J., Korves, C., Lucas, B. P., Taub, C., Young-Xu, Y., Vashi, A., Davies, L., Justice, A. C. 2023; 6 (5): e2312140


    Importance: During the first year of the COVID-19 pandemic, there was a substantial increase in the rate of death in the United States. It is unclear whether those who had access to comprehensive medical care through the Department of Veterans Affairs (VA) health care system had different death rates compared with the overall US population.Objective: To quantify and compare the increase in death rates during the first year of the COVID-19 pandemic between individuals who received comprehensive medical care through the VA health care system and those in the general US population.Design, Setting, and Participants: This cohort study compared 10.9 million enrollees in the VA, including 6.8 million active users of VA health care (those with a visit in the last 2 years), with the general population of the US, with deaths occurring from January 1, 2014, to December 31, 2020. Statistical analysis was conducted from May 17, 2021, to March 15, 2023.Main Outcomes and Measures: Changes in rates of death from any cause during the COVID-19 pandemic in 2020 compared with previous years. Changes in all-cause death rates by quarter were stratified by age, sex, race and ethnicity, and region, based on individual-level data. Multilevel regression models were fit in a bayesian setting. Standardized rates were used for comparison between populations.Results: There were 10.9 million enrollees in the VA health care system and 6.8 million active users. The demographic characteristics of the VA populations were predominantly male (>85% in the VA health care system vs 49% in the general US population), older (mean [SD], 61.0 [18.2] years in the VA health care system vs 39.0 [23.1] years in the US population), and had a larger proportion of patients who were White (73% in the VA health care system vs 61% in the US population) or Black (17% in the VA health care system vs 13% in the US population). Increases in death rates were apparent across all of the adult age groups (≥25 years) in both the VA populations and the general US population. Across all of 2020, the relative increase in death rates compared with expected values was similar for VA enrollees (risk ratio [RR], 1.20 [95% CI, 1.14-1.29]), VA active users (RR, 1.19 [95% CI, 1.14-1.26]), and the general US population (RR, 1.20 [95% CI, 1.17-1.22]). Because the prepandemic standardized mortality rates were higher in the VA populations prior to the pandemic, the absolute rates of excess mortality were higher in the VA populations.Conclusions and Relevance: In this cohort study, a comparison of excess deaths between populations suggests that active users of the VA health system had similar relative increases in mortality compared with the general US population during the first 10 months of the COVID-19 pandemic.

    View details for DOI 10.1001/jamanetworkopen.2023.12140

    View details for PubMedID 37155169

  • Clostridium difficile and other adverse events from overprescribed antibiotics for acute upper respiratory infection. Journal of internal medicine Carmichael, H., Asch, S. M., Bendavid, E. 2022


    BACKGROUND: Guidelines widely recommend avoiding antibiotics for many acute upper respiratory infections (aURIs) to avert adverse events in absence of likely benefit. However, the extent of harm from these antibiotics remains a subject of debate and could inform patient-centered decision-making. Prior estimates finding a number needed to harm (NNH) between 8-10 rely on patient-reported adverse events of any severity. In this analysis, we sought to estimate adverse events by only measuring comparatively severe events that require subsequent clinical evaluation.METHODS: We constructed a retrospective cohort including 51 million patient encounters. Using logistic regression models, we determined the adjusted odds ratio (aOR) of clinically detectable adverse events following antibiotic use compared with events among unexposed individuals with aURIs. Our outcomes included: candidiasis, diarrhea, Clostridium difficile infection (CDI), and a composite outcome.FINDINGS: From our analysis, 62.4% of the population received antibiotics in an aURI encounter. Observed adverse events in the antibiotic-exposed group were 54,279 and 46,936 for diarrhea and candidiasis, respectively, yielding an aOR of 1.24 and 1.61, and a NNH of 3126 and 1975. Observed events of CDI in the exposed group were 30,133, and aORs of isolated CDI and combined adverse events were 1.07 and 1.30, resulting in a NNH of 17,695 and 1150, respectively. Females were more likely to be diagnosed with any adverse event. Overall antibiotics were found to result in 5.7 additional cases of CDI per 100,000 outpatient prescriptions following an upper respiratory tract infection.INTERPRETATION: Despite higher NNH than previous methods of analysis, we find substantial iatrogenic harm associated with prescribing antibiotics in aURIs. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/joim.13597

    View details for PubMedID 36460621

  • A computational approach to measure the linguistic characteristics of psychotherapy timing, responsiveness, and consistency. Npj mental health research Miner, A. S., Fleming, S. L., Haque, A., Fries, J. A., Althoff, T., Wilfley, D. E., Agras, W. S., Milstein, A., Hancock, J., Asch, S. M., Stirman, S. W., Arnow, B. A., Shah, N. H. 2022; 1 (1): 19


    Although individual psychotherapy is generally effective for a range of mental health conditions, little is known about the moment-to-moment language use of effective therapists. Increased access to computational power, coupled with a rise in computer-mediated communication (telehealth), makes feasible the large-scale analyses of language use during psychotherapy. Transparent methodological approaches are lacking, however. Here we present novel methods to increase the efficiency of efforts to examine language use in psychotherapy. We evaluate three important aspects of therapist language use - timing, responsiveness, and consistency - across five clinically relevant language domains: pronouns, time orientation, emotional polarity, therapist tactics, and paralinguistic style. We find therapist language is dynamic within sessions, responds to patient language, and relates to patient symptom diagnosis but not symptom severity. Our results demonstrate that analyzing therapist language at scale is feasible and may help answer longstanding questions about specific behaviors of effective therapists.

    View details for DOI 10.1038/s44184-022-00020-9

    View details for PubMedID 38609510

    View details for PubMedCentralID 3665892

  • Methamphetamine-associated heart failure: a systematic review of observational studies. Heart (British Cardiac Society) Manja, V., Nrusimha, A., Gao, Y., Sheikh, A., McGovern, M., Heidenreich, P. A., Sandhu, A. T., Asch, S. 2022


    To conduct a systematic review of observational studies on methamphetamine-associated heart failure (MethHF) .Six databases were searched for original publications on the topic. Title/abstract and included full-text publications were reviewed in duplicate. Data extraction and critical appraisal for risk of bias were performed in duplicate.Twenty-one studies are included in the final analysis. Results could not be combined because of heterogeneity in study design, population, comparator, and outcome assessment. Overall risk of bias is moderate due to the presence of confounders, selection bias and poor matching; overall certainty in the evidence is very low. MethHF is increasing in prevalence, affects diverse racial/ethnic/sociodemographic groups with a male predominance; up to 44% have preserved left-ventricular ejection fraction. MethHF is associated with significant morbidity including worse heart failure symptoms compared with non-methamphetamine related heart failure. Female sex, methamphetamine abstinence and guideline-directed heart failure therapy are associated with improved outcomes. Chamber dimensions on echocardiography and fibrosis on biopsy predict the extent of recovery after abstinence.The increasing prevalence of MethHF with associated morbidity underscores the urgent need for well designed prospective studies of people who use methamphetamine to accurately assess the epidemiology, clinical features, disease trajectory and outcomes of MethHF. Methamphetamine abstinence is an integral part of MethHF treatment; increased availability of effective non-pharmacological interventions for treatment of methamphetamine addiction is an essential first step. Availability of effective pharmacological treatment for methamphetamine addiction will further support MethHF treatment. Using harm reduction principles in an integrated addiction/HF treatment programme will bolster efforts to stem the increasing tide of MethHF.

    View details for DOI 10.1136/heartjnl-2022-321610

    View details for PubMedID 36456204

  • Antecedents to COVID-19 vaccine uptake among patients and employees in the Veterans Health Administration. Translational behavioral medicine LoBrutto, L. R., Elwy, A. R., Miano, D., Ann Petrakis, B., Kyrish, A., Javier, S., Erhardt, T., Midboe, A. M., Carbonaro, R., Jasuja, G. K., McInnes, D. K., Maguire, E. M., Asch, S. M., Gifford, A. L., Clayman, M. L. 2022


    The present study sought to understand the antecedents to COVID-19 vaccination among those reporting a change in vaccine intention in order to improve COVID-19 vaccine uptake in the United States. We employed semi-structured interviews and one focus group discussion with vaccinated and unvaccinated Veterans Health Administration (VHA) employees and Veterans at three Veterans' Affairs medical centers between January and June 2021. A subset of these participants (n=21) self-reported a change in COVID-19 vaccine intention and were selected for additional analysis. We combined thematic analysis using the 5C scale (confidence, collective responsibility, complacency, calculation, constraints) as our theoretical framework with a constant comparative method from codes based on the SAGE Working Group on Vaccine Hesitancy. We generated 13 themes distributed across the 5C constructs that appeared to be associated with a change in COVID-19 vaccine intention. Themes included a trusted family member, friend or colleague in a healthcare field, a trusted healthcare professional, distrust of government or politics (confidence); duty to family and protection of others (collective responsibility); perceived health status and normative beliefs (complacency); perceived vaccine safety, perceived risk-benefit, and orientation towards deliberation (calculation); and ease of process (constraints). Key factors in promoting vaccine uptake included a desire to protect family; and conversations with as key factors in promoting vaccine uptake. Constructs from the 5C scale are useful in understanding intrapersonal changes in vaccine intentions over time, which may help public health practitioners improve future vaccine uptake.

    View details for DOI 10.1093/tbm/ibac085

    View details for PubMedID 36448882

  • Pandemic Through the Lens of Black Barbershops: COVID-19's Impact and Barbers' Potential Role as Public Health Extenders. Journal of immigrant and minority health Taylor, N. K., Faulks, M., Brown-Johnson, C. G., Rosas, L. G., Shaw, J. G., Saliba-Gustafsson, E. A., Asch, S. M. 2022


    We examined the impact of COVID-19 on Black barbershops and their potential role as public health extenders. A 30-item survey was distributed to predominantly Black barbershop owners and barbers across 40 different states/territories in the US between June and October 2020. The survey addressed the impact of COVID-19 on Black barbershops, and barbers' interest in engaging in health outreach programs. The majority reported that stay-at-home orders had significant to severe impact on their business; few were prepared for the financial impact and less than half thought they qualified for government assistance. The majority were already providing health education and outreach to the Black community and showed interest in continuing to provide such services, like information on COVID-19. Barbers in Black-serving barbershops, a well-documented effective place for public health outreach to the Black community, show promise as public health extenders in the response to the COVID-19 pandemic.

    View details for DOI 10.1007/s10903-022-01420-x

    View details for PubMedID 36417031

  • Variation in Initial and Continued use of Primary, Mental Health, and Specialty Video Care among Veterans. Health services research Ferguson, J. M., Wray, C. M., Jacobs, J., Greene, L., Wagner, T. H., Odden, M. C., Freese, J., Van Campen, J., Asch, S. M., Heyworth, L., Zulman, D. M. 2022


    OBJECTIVE: To identify which Veteran populations are routinely accessing video-based care.DATA SOURCES AND STUDY SETTING: National, secondary administrative data from electronic health records at the Veterans Health Administration (VHA), 2019-2021 STUDY DESIGN: This retrospective cohort analysis identified patient characteristics associated with the odds of using any video care; and then, among those with a previous video visit, the annual rate of video care utilization. Video care use was reported overall and stratified into care type (e.g., primary, mental health, and specialty video care) between March 10, 2020 and February 28, 2021.DATA COLLECTION: Veterans active in VA health care (>1 outpatient visit between March 11, 2019 and March 10, 2020) were included in this study.PRINCIPAL FINDINGS: Among 5,389,129 Veterans in this evaluation, approximately 27.4% of Veterans had at least one video visit. We found differences in video care utilization by type of video care: 14.7% of Veterans had at least one primary care video visit, 10.6% a mental health video visit, and 5.9% a specialty care video visit. Veterans with a history of housing instability had a higher overall rate of video care driven by their higher usage of video for mental health care compared with Veterans in stable housing. American Indian/Alaska Native Veterans had reduced odds of video visits, yet similar rates of video care when compared to White Veterans. Low-income Veterans had lower odds of using primary video care yet slightly elevated rates of primary video care among those with at least one video visit when compared to Veterans enrolled at VA without special considerations.CONCLUSIONS: Variation in video care utilization patterns by type of care identified Veteran populations that might require greater resources and support to initiate and sustain video care use. Our data support service specific outreach to homeless and American Indian/Alaska Native Veterans.

    View details for DOI 10.1111/1475-6773.14098

    View details for PubMedID 36345235

  • The Patient-Reported Outcome Measurement in Heart Failure Clinic Trial: Rationale and Methods of The PRO-HF Trial. American heart journal Kalwani, N. M., Calma, J., Varghese, G. M., Gupta, A., Zheng, J., Brown-Johnson, C., Amano, A., Vilendrer, S., Winget, M., Asch, S. M., Heidenreich, P., Sandhu, A. 2022


    BACKGROUND: Among patients with heart failure (HF), patient-reported health status provides information beyond standard clinician assessment. Although HF management guidelines recommend collecting patient-reported health status as part of routine care, there is minimal data on the impact of this intervention.STUDY DESIGN: The Patient-Reported Outcomes in Heart Failure Clinic (PRO-HF) trial is a pragmatic, randomized, implementation-effectiveness trial testing the hypothesis that routine health status assessment via the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) leads to an improvement in patient-reported health status among patients treated in a tertiary health system HF clinic. PRO-HF has completed randomization of 1,248 participants to routine KCCQ-12 assessment or usual care. Patients randomized to the KCCQ-12 arm complete KCCQ-12 assessments before each HF clinic visit with the results shared with their treating clinician. Clinicians received education regarding the interpretation and potential utility of the KCCQ-12. The primary endpoint is the change in KCCQ-12 over 1 year. Secondary outcomes are HF therapy patterns and healthcare utilization, including clinic visits, testing, hospitalizations, and emergency department (ED) visits. As a sub-study, PRO-HF also evaluated the impact of routine KCCQ-12 assessment on patient experience and the accuracy of clinician-assessed health status. In addition, clinicians completed semi-structured interviews to capture their perceptions on the trial's implementation of routine KCCQ-12 assessment in clinical practice.CONCLUSIONS: PRO-HF is a pragmatic, randomized trial based in a real-world HF clinic to determine the feasibility of routinely assessing patient-reported health status and the impact of this intervention on health status, care delivery, patient experience, and the accuracy of clinician health status assessment.

    View details for DOI 10.1016/j.ahj.2022.10.081

    View details for PubMedID 36309127

  • Who Pays the Cancer Tax? Patients' Narratives in a Movement to Reduce Their Invisible Work ORGANIZATION SCIENCE Valentine, M. A., Asch, S. M., Ahn, E. 2022
  • Evaluating clinician-led quality improvement initiatives: A system-wide embedded research partnership at Stanford Medicine. Learning health systems Vilendrer, S., Saliba-Gustafsson, E. A., Asch, S. M., Brown-Johnson, C. G., Kling, S. M., Shaw, J. G., Winget, M., Larson, D. B. 2022; 6 (4): e10335


    Many healthcare delivery systems have developed clinician-led quality improvement (QI) initiatives but fewer have also developed in-house evaluation units. Engagement between the two entities creates unique opportunities. Stanford Medicine funded a collaboration between their Improvement Capability Development Program (ICDP), which coordinates and incentivizes clinician-led QI efforts, and the Evaluation Sciences Unit (ESU), a multidisciplinary group of embedded researchers with expertise in implementation and evaluation sciences.To describe the ICDP-ESU partnership and report key learnings from the first 2 y of operation September 2019 to August 2021.Department-level physician and operational QI leaders were offered an ESU consultation to workshop design, methods, and overall scope of their annual QI projects. A steering committee of high-level stakeholders from operational, clinical, and research perspectives subsequently selected three projects for in-depth partnered evaluation with the ESU based on evaluability, importance to the health system, and broader relevance. Selected project teams met regularly with the ESU to develop mixed methods evaluations informed by relevant implementation science frameworks, while aligning the evaluation approach with the clinical teams' QI goals.Sixty and 62 ICDP projects were initiated during the 2 cycles, respectively, across 18 departments, of which ESU consulted with 15 (83%). Within each annual cycle, evaluators made actionable, summative findings rapidly available to partners to inform ongoing improvement. Other reported benefits of the partnership included rapid adaptation to COVID-19 needs, expanded clinician evaluation skills, external knowledge dissemination through scholarship, and health system-wide knowledge exchange. Ongoing considerations for improving the collaboration included the need for multi-year support to enable nimble response to dynamic health system needs and timely data access.Presence of embedded evaluation partners in the enterprise-wide QI program supported identification of analogous endeavors (eg, telemedicine adoption) and cross-cutting lessons across QI efforts, clinician capacity building, and knowledge dissemination through scholarship.

    View details for DOI 10.1002/lrh2.10335

    View details for PubMedID 36263267

    View details for PubMedCentralID PMC9576232

  • Most Privately Insured Patients do not Receive Federally Recommended Abdominal Aortic Aneurysm Screening Ho, V., Tran, K., George, E., Asch, S., Chen, J., Dalman, R., Lee, J. MOSBY-ELSEVIER. 2022: E78
  • The Quality of Occupational Healthcare for Carpal Tunnel Syndrome, Healthcare Expenditures, and Disability Outcomes: A Prospective Observational Study. Muscle & nerve Nuckols, T. K., Dworsky, M., Conlon, C., Robbins, M., Benner, D., Seabury, S., Asch, S. M. 2022


    INTRODUCTION/AIMS: In prior work, higher quality care for work-associated carpal tunnel syndrome (CTS) was associated with improved symptoms, functional status, and overall health. We sought to examine whether quality of care is associated with healthcare expenditures or disability.METHODS: Among 343 adults with workers' compensation claims for CTS, we created patient-level aggregate quality scores for underuse (not receiving highly beneficial care) and overuse (receiving care for which risks exceed benefits). We assessed whether each aggregate quality score (0-100%, 100% = better care) was associated with healthcare expenditures (18-month expenditures, any anticipated need for future expenditures) or disability (days on temporary disability, permanent impairment rating at 18 months).RESULTS: Mean aggregate quality scores were 77.8% (standard deviation [S.D.] 16.5%) for underuse and 89.2% (S.D. 11.0%) for overuse. An underuse score of 100% was associated with higher risk-adjusted 18-month expenditures ($3,672; 95% CI $324 to $7,021) but not with future expenditures (-0.07 percentage points; 95% CI -0.48 to 0.34), relative to a score of 0%. An overuse score of 100% was associated with lower 18-month expenditures (-$4,549, 95% CI -$8,792 to -$306) and a modestly lower likelihood of future expenditures (-0.62 percentage points, 95% CI -1.23 to -0.02). Quality of care was not associated with disability.DISCUSSION: Improving quality of care could increase or lower short-term healthcare expenditures, depending on how often care is currently underused or overused. Future research is needed on quality of care in varied workers' compensation contexts, as well as effective and economical strategies for improving quality. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/mus.27718

    View details for PubMedID 36106901

  • Implementation and Effectiveness of a Learning Collaborative to Improve Palliative Care for Seriously Ill Hemodialysis Patients. Clinical journal of the American Society of Nephrology : CJASN Kurella Tamura, M., Holdsworth, L., Stedman, M., Aldous, A., Asch, S. M., Han, J., Harbert, G., Lorenz, K. A., Malcolm, E., Nicklas, A., Moss, A. H., Lupu, D. E. 2022


    BACKGROUND AND OBJECTIVES: Limited implementation of palliative care practices in hemodialysis may contribute to end-of-life care that is intensive and not patient centered. We determined whether a learning collaborative for hemodialysis center providers improved delivery of palliative care best practices.DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Ten US hemodialysis centers participated in a pre-post study targeting seriously ill patients between April 2019 and September 2020. Three practices were prioritized: screening for serious illness, goals of care discussions, and use of a palliative dialysis care pathway. The collaborative educational bundle consisted of learning sessions, communication skills training, and implementation support. The primary outcome was change in the probability of complete advance care planning documentation among seriously ill patients. Health care utilization was a secondary outcome, and implementation outcomes of acceptability, adoption, feasibility, and penetration were assessed using mixed methods.RESULTS: One center dropped out due to the coronavirus disease 2019 pandemic. Among the remaining nine centers, 20% (273 of 1395) of patients were identified as seriously ill preimplementation, and 16% (203 of 1254) were identified as seriously ill postimplementation. From the preimplementation to postimplementation period, the adjusted probability of complete advance care planning documentation among seriously ill patients increased by 34.5 percentage points (95% confidence interval, 4.4 to 68.5). There was no difference in mortality or in utilization of palliative hemodialysis, hospice referral, or hemodialysis discontinuation. Screening for serious illness was widely adopted, and goals of care discussions were adopted with incomplete integration. There was limited adoption of a palliative dialysis care pathway.CONCLUSIONS: A learning collaborative for hemodialysis centers spanning the coronavirus disease 2019 pandemic was associated with adoption of serious illness screening and goals of care discussions as well as improved documentation of advance care planning for seriously ill patients.CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: Pathways Project: Kidney Supportive Care, NCT04125537.

    View details for DOI 10.2215/CJN.00090122

    View details for PubMedID 36104084

  • Two mental models of integrated care for advanced liver disease: qualitative study of multidisciplinary health professionals BMJ OPEN Arney, J., Gray, C., Walling, A. M., Clark, J. A., Smith, D., Melcher, J., Asch, S., Kanwal, F., Naik, A. D. 2022; 12 (9)
  • Interruptive Electronic Alerts for Choosing Wisely Recommendations: A Cluster Randomized Controlled Trial. Journal of the American Medical Informatics Association : JAMIA Ho, V. T., Aikens, R. C., Tso, G., Heidenreich, P. A., Sharp, C., Asch, S. M., Chen, J. H., Shah, N. K. 2022


    OBJECTIVE: To assess the efficacy of interruptive electronic alerts in improving adherence to the American Board of Internal Medicine's Choosing Wisely recommendations to reduce unnecessary laboratory testing.MATERIALS AND METHODS: We administered 5 cluster randomized controlled trials simultaneously, using electronic medical record alerts regarding prostate-specific antigen (PSA) testing, acute sinusitis treatment, vitamin D testing, carotid artery ultrasound screening, and human papillomavirus testing. For each alert, we assigned 5 outpatient clinics to an interruptive alert and 5 were observed as a control. Primary and secondary outcomes were the number of postalert orders per 100 patients at each clinic and number of triggered alerts divided by orders, respectively. Post hoc analysis evaluated whether physicians experiencing interruptive alerts reduced their alert-triggering behaviors.RESULTS: Median postalert orders per 100 patients did not differ significantly between treatment and control groups; absolute median differences ranging from 0.04 to 0.40 for PSA testing. Median alerts per 100 orders did not differ significantly between treatment and control groups; absolute median differences ranged from 0.004 to 0.03. In post hoc analysis, providers receiving alerts regarding PSA testing in men were significantly less likely to trigger additional PSA alerts than those in the control sites (Incidence Rate Ratio 0.12, 95% CI [0.03-0.52]).DISCUSSION: Interruptive point-of-care alerts did not yield detectable changes in the overall rate of undesired orders or the order-to-alert ratio between active and silent sites. Complementary behavioral or educational interventions are likely needed to improve efforts to curb medical overuse.CONCLUSION: Implementation of interruptive alerts at the time of ordering was not associated with improved adherence to 5 Choosing Wisely guidelines.TRIAL REGISTRATION: NCT02709772.

    View details for DOI 10.1093/jamia/ocac139

    View details for PubMedID 36018731

  • Evaluating clinician-led quality improvement initiatives: A system-wide embedded research partnership at Stanford Medicine LEARNING HEALTH SYSTEMS Vilendrer, S., Saliba-Gustafsson, E. A., Asch, S. M., Brown-Johnson, C. G., Kling, S. R., Shaw, J. G., Winget, M., Larson, D. B. 2022

    View details for DOI 10.1002/lrh2.10335

    View details for Web of Science ID 000843397900001

  • Barriers and Facilitators to the Implementation of Family-Centered Technology in Complex Care: Feasibility Study. Journal of medical Internet research Lin, J. L., Huber, B., Amir, O., Gehrmann, S., Ramirez, K. S., Ochoa, K. M., Asch, S. M., Gajos, K. Z., Grosz, B. J., Sanders, L. M. 2022; 24 (8): e30902


    BACKGROUND: Care coordination is challenging but crucial for children with medical complexity (CMC). Technology-based solutions are increasingly prevalent but little is known about how to successfully deploy them in the care of CMC.OBJECTIVE: The aim of this study was to assess the feasibility and acceptability of GoalKeeper (GK), an internet-based system for eliciting and monitoring family-centered goals for CMC, and to identify barriers and facilitators to implementation.METHODS: We used the Consolidated Framework for Implementation Research (CFIR) to explore the barriers and facilitators to the implementation of GK as part of a clinical trial of GK in ambulatory clinics at a children's hospital (NCT03620071). The study was conducted in 3 phases: preimplementation, implementation (trial), and postimplementation. For the trial, we recruited providers at participating clinics and English-speaking parents of CMC<12 years of age with home internet access. All participants used GK during an initial clinic visit and for 3 months after. We conducted preimplementation focus groups and postimplementation semistructured exit interviews using the CFIR interview guide. Participant exit surveys assessed GK feasibility and acceptability on a 5-point Likert scale. For each interview, 3 independent coders used content analysis and serial coding reviews based on the CFIR qualitative analytic plan and assigned quantitative ratings to each CFIR construct (-2 strong barrier to +2 strong facilitator).RESULTS: Preimplementation focus groups included 2 parents (1 male participant and 1 female participant) and 3 providers (1 in complex care, 1 in clinical informatics, and 1 in neurology). From focus groups, we developed 3 implementation strategies: education (parents: 5-minute demo; providers: 30-minute tutorial and 5-minute video on use in a clinic visit; both: instructional manual), tech support (in-person, virtual), and automated email reminders for parents. For implementation (April 1, 2019, to December 21, 2020), we enrolled 11 providers (7 female participants, 5 in complex care) and 35 parents (mean age 38.3, SD 7.8 years; n=28, 80% female; n=17, 49% Caucasian; n=16, 46% Hispanic; and n=30, 86% at least some college). One parent-provider pair did not use GK in the clinic visit, and few used GK after the visit. In 18 parent and 9 provider exit interviews, the key facilitators were shared goal setting, GK's internet accessibility and email reminders (parents), and GK's ability to set long-term goals and use at the end of visits (providers). A key barrier was GK's lack of integration into the electronic health record or patient portal. Most parents (13/19) and providers (6/9) would recommend GK to their peers.CONCLUSIONS: Family-centered technologies like GK are feasible and acceptable for the care of CMC, but sustained use depends on integration into electronic health records.TRIAL REGISTRATION: NCT03620071;

    View details for DOI 10.2196/30902

    View details for PubMedID 35998021

  • Professional Behavior and Value Erosion: A Qualitative Study of Physicians and the Electronic Health Record. Journal of healthcare management / American College of Healthcare Executives Skeff, K. M., Brown-Johnson, C. G., Asch, S. M., Zionts, D. L., Winget, M., Kerem, Y. 2022


    GOAL: Occurrences of physician burnout have reached epidemic numbers, and the electronic health record (EHR) is a commonly cited cause of the distress. To enhance current understanding of the relationship between burnout and the EHR, we explored the connections between physicians' distress and the EHR.METHODS: In this qualitative study, physicians and graduate medical trainees from two healthcare organizations in California were interviewed about EHR-related distressing events and the impact on their emotions and actions. We analyzed physician responses to identify themes regarding the negative impact of the EHR on physician experience and actions. EHR "distressing events" were categorized using the Accreditation Council for Graduate Medical Education (ACGME) Physician Professional Competencies.PRINCIPAL FINDINGS: Every participating physician reported EHR-related distress affecting professional activities. Five main themes emerged from our analysis: system blocks to patient care; poor implementation, design, and functionality of the EHR; billing priorities conflicting with ideal workflow and best-practice care; lack of efficiency; and poor teamwork function. When mapped to the ACGME competencies, physician distress frequently stemmed from situations where physicians prioritized systems-based practice above other desired professional actions and behaviors. Physicians also reported a climate of silence in which physicians would not share problems due to fear of retribution or lack of confidence that the problems would be addressed.PRACTICAL APPLICATIONS: Physicians and administrators need to address the hierarchy of values that prioritizes system requirements such as those required by the EHR above physicians' other desired professional actions and behaviors. Balancing the importance of competing competencies may help to address rising burnout. We also recommend that administrators consider qualitative anonymous interviews as an effective method to uncover and understand physician distress in light of physicians' reported climate of silence.

    View details for DOI 10.1097/JHM-D-21-00070

    View details for PubMedID 35984408

  • Performance and usability testing of an automated tool for detection of peripheral artery disease using electronic health records. Scientific reports Ghanzouri, I., Amal, S., Ho, V., Safarnejad, L., Cabot, J., Brown-Johnson, C. G., Leeper, N., Asch, S., Shah, N. H., Ross, E. G. 2022; 12 (1): 13364


    Peripheral artery disease (PAD) is a common cardiovascular disorder that is frequently underdiagnosed, which can lead to poorer outcomes due to lower rates of medical optimization. We aimed to develop an automated tool to identify undiagnosed PAD and evaluate physician acceptance of a dashboard representation of risk assessment. Data were derived from electronic health records (EHR). We developed and compared traditional risk score models to novel machine learning models. For usability testing, primary and specialty care physicians were recruited and interviewed until thematic saturation. Data from 3168 patients with PAD and 16,863 controls were utilized. Results showed a deep learning model that utilized time engineered features outperformed random forest and traditional logistic regression models (average AUCs 0.96, 0.91 and 0.81, respectively), P < 0.0001. Of interviewed physicians, 75% were receptive to an EHR-based automated PAD model. Feedback emphasized workflow optimization, including integrating risk assessments directly into the EHR, using dashboard designs that minimize clicks, and providing risk assessments for clinically complex patients. In conclusion, we demonstrate that EHR-based machine learning models can accurately detect risk of PAD and that physicians are receptive to automated risk detection for PAD. Future research aims to prospectively validate model performance and impact on patient outcomes.

    View details for DOI 10.1038/s41598-022-17180-5

    View details for PubMedID 35922657

    View details for PubMedCentralID PMC9349186

  • Teledermatology to Facilitate Patient Care Transitions From Inpatient to Outpatient Dermatology: Mixed Methods Evaluation. Journal of medical Internet research Kling, S. M., Saliba-Gustafsson, E. A., Winget, M., Aleshin, M. A., Garvert, D. W., Amano, A., Brown-Johnson, C. G., Kwong, B. Y., Calugar, A., El-Banna, G., Shaw, J. G., Asch, S. M., Ko, J. M. 2022; 24 (8): e38792


    BACKGROUND: Both clinicians and patients have increasingly turned to telemedicine to improve care access, even in physical examination-dependent specialties such as dermatology. However, little is known about whether teledermatology supports effective and timely transitions from inpatient to outpatient care, which is a common care coordination gap.OBJECTIVE: Using mixed methods, this study sought to retrospectively evaluate how teledermatology affected clinic capacity, scheduling efficiency, and timeliness of follow-up care for patients transitioning from inpatient to outpatient dermatology care.METHODS: Patient-level encounter scheduling data were used to compare the number and proportion of patients who were scheduled and received in-clinic or video dermatology follow-ups within 14 and 90 days after discharge across 3 phases: June to September 2019 (before teledermatology), June to September 2020 (early teledermatology), and February to May 2021 (sustained teledermatology). The time from discharge to scheduling and completion of patient follow-up visits for each care modality was also compared. Dermatology clinicians and schedulers were also interviewed between April and May 2021 to assess their perceptions of teledermatology for postdischarge patients.RESULTS: More patients completed follow-up within 90 days after discharge during early (n=101) and sustained (n=100) teledermatology use than at baseline (n=74). Thus, the clinic's capacity to provide follow-up to patients transitioning from inpatient increased from baseline by 36% in the early (101 from 74) and sustained (100 from 74) teledermatology periods. During early teledermatology use, 61.4% (62/101) of the follow-ups were conducted via video. This decreased significantly to 47% (47/100) in the following year, when COVID-19-related restrictions started to lift (P=.04), indicating more targeted but still substantial use. The proportion of patients who were followed up within the recommended 14 days after discharge did not differ significantly between video and in-clinic visits during the early (33/62, 53% vs 15/39, 38%; P=.15) or sustained (26/53, 60% vs 28/47, 49%; P=.29) teledermatology periods. Interviewees agreed that teledermatology would continue to be offered. Most considered postdischarge follow-up patients to be ideal candidates for teledermatology as they had undergone a recent in-person assessment and might have difficulty attending in-clinic visits because of competing health priorities. Some reported patients needing technological support. Ultimately, most agreed that the choice of follow-up care modality should be the patient's own.CONCLUSIONS: Teledermatology could be an important tool for maintaining accessible, flexible, and convenient care for recently discharged patients needing follow-up care. Teledermatology increased clinic capacity, even during the pandemic, although the timeliness of care transitions did not improve. Ultimately, the care modality should be determined through communication with patients to incorporate their and their caregivers' preferences.

    View details for DOI 10.2196/38792

    View details for PubMedID 35921146

  • Performance of a rule-based semi-automated method to optimize chart abstraction for surveillance imaging among patients treated for non-small cell lung cancer. BMC medical informatics and decision making Byrd, C., Ajawara, U., Laundry, R., Radin, J., Bhandari, P., Leung, A., Han, S., Asch, S. M., Zeliadt, S., Harris, A. H., Backhus, L. 2022; 22 (1): 148


    BACKGROUND: We aim to develop and test performance of a semi-automated method (computerized query combined with manual review) for chart abstraction in the identification and characterization of surveillance radiology imaging for post-treatment non-small cell lung cancer patients.METHODS: A gold standard dataset consisting of 3011 radiology reports from 361 lung cancer patients treated at the Veterans Health Administration from 2008 to 2016 was manually created by an abstractor coding image type, image indication, and image findings. Computerized queries using a text search tool were performed to code reports. The primary endpoint of query performance was evaluated by sensitivity, positive predictive value (PPV), and F1 score. The secondary endpoint of efficiency compared semi-automated abstraction time to manual abstraction time using a separate dataset and the Wilcoxon rank-sum test.RESULTS: Query for image type demonstrated the highest sensitivity of 85%, PPV 95%, and F1 score 0.90. Query for image indication demonstrated sensitivity 72%, PPV 70%, and F1 score 0.71. The image findings queries ranged from sensitivity 75-85%, PPV 23-25%, and F1 score 0.36-0.37. Semi-automated abstraction with our best performing query (image type) improved abstraction times by 68% per patient compared to manual abstraction alone (from median 21.5min (interquartile range 16.0) to 6.9min (interquartile range 9.5), p<0.005).CONCLUSIONS: Semi-automated abstraction using the best performing query of image type improved abstraction efficiency while preserving data accuracy. The computerized query acts as a pre-processing tool for manual abstraction by restricting effort to relevant images. Determining image indication and findings requires the addition of manual review for a semi-automatic abstraction approach in order to ensure data accuracy.

    View details for DOI 10.1186/s12911-022-01863-0

    View details for PubMedID 35659230

  • Remote Access to Electronic Medical Records Reduces Overall EMR Time for Vascular Surgery Residents Ho, V., Sgroi, M., Chandra, V., Asch, S., Chen, J. H., Lee, J. T. MOSBY-ELSEVIER. 2022: E135
  • A qualitative assessment of medical assistant professional aspirations and their alignment with career ladders across three institutions. BMC primary care Vilendrer, S., Amano, A., Johnson, C. B., Morrison, T., Asch, S. 2022; 23 (1): 117


    BACKGROUND: Growing demand for medical assistants (MAs) in team-based primary care has led health systems to explore career ladders based on expanded MA responsibilities as a solution to improve MA recruitment and retention. However, the practical implementation of career ladders remains a challenge for many health systems. In this study, we aim to understand MA career aspirations and their alignment with available advancement opportunities.METHODS: Semi-structured focus groups were conducted August to December 2019 in primary care clinics based in three health systems in California and Utah. MA perspectives of career aspirations and their alignment with existing career ladders were discussed, recorded, and qualitatively analyzed.RESULTS: Ten focus groups conducted with 59 participants revealed three major themes: mixed perceptions of expanded MA roles with concern over increased responsibility without commensurate increase in pay; divergent career aspirations among MAs not addressed by existing career ladders; and career ladder implementation challenges including opaque advancement requirements and lack of consistency across practice settings.CONCLUSION: MAs held positive perceptions of career ladders in theory, yet recommended a number of improvements to their practical implementation across three institutions including improving clarity and consistency around requirements for advancement and matching compensation to job responsibilities. The emergence of two distinct clusters of MA professional needs and desires suggests an opportunity to further optimize career ladders to provide tailored support to MAs in order to strengthen the healthcare workforce and talent pipeline.

    View details for DOI 10.1186/s12875-022-01712-z

    View details for PubMedID 35578176

  • Long-term Opioid Therapy and Overdose in Patients with and without Cancer Merlin, J. S., Black, A. C., Midboe, A. M., Troszak, L., Asch, S. M., Bohnert, A., Fenton, B. T., Giannitrapani, K. F., Glassman, P., Kerns, R. D., Silveira, M., Lorenz, K. A., Becker, W. C. CHURCHILL LIVINGSTONE. 2022: 60
  • The steatosis-associated fibrosis estimator (SAFE) score: A tool to detect low-risk non-alcoholic fatty liver disease in primary care. Hepatology (Baltimore, Md.) Sripongpun, P., Kim, W. R., Mannalithara, A., Charu, V., Vidovszky, A., Asch, S., Desai, M., Kim, S. H., Kwong, A. J. 2022


    Non-alcoholic fatty liver disease (NAFLD) is common in primary care. Liver fibrosis stage 2 or higher (≥F2) increases future risk of morbidity and mortality. We developed and validated a score to aid in the initial assessment of liver fibrosis for NAFLD in primary care.Biopsy-proven NAFLD patients' data were extracted from the 'NASH CRN' observational study (n = 676). Using logistic regression and machine-learning methods, we constructed prediction models to distinguish ≥F2 from F0/1. The models were tested in participants in a trial ('FLINT', n = 280) and local NAFLD patients with magnetic resonance elastography data (n = 130). The final model was applied to examinees in the National Health and Nutrition Examination Survey III (NHANES, n = 11,953) to correlate with longterm mortality.A multivariable logistic regression model was selected as the Steatosis-Associated Fibrosis Estimator (SAFE) score, which consists of age, body mass index, diabetes, platelets, aspartate and alanine aminotransferases and globulins (total serum protein minus albumin). The model yielded areas under receiver operating characteristic curves ≥0.80 in distinguishing F0/1 from ≥F2 in testing datasets, consistently higher than those of FIB-4 and NAFLD Fibrosis Scores. The negative predictive values in ruling out ≥F2 at SAFE of 0 were 88% and 92% in the two testing sets. In the NHANES III set, survival up to 25 years of subjects with SAFE <0 was comparable to that of those without steatosis (p = 0.34), while increasing SAFE scores correlated with shorter survival with an adjusted hazard ratio of 1.54 (p < 0.01) for subjects with SAFE>100.The SAFE score, which uses widely available variables to estimate liver fibrosis in patients diagnosed with NAFLD, may be used in primary care to recognize low-risk NAFLD.

    View details for DOI 10.1002/hep.32545

    View details for PubMedID 35477908

  • UNMET NEEDS AND PERCEIVED BARRIERS TO ACCESSING HOME AND COMMUNITY-BASED SERVICES AMONG CAREGIVERS OF VETERANS OF ALL ERAS Trivedi, R. B., Desai, S., Risbud, R. D., Humber, M. B., Lee, T., Ngo, V., Jacobs, J., Yefimova, M., Lorenz, K., Asch, S. M., Gallagher-Thompson, D. OXFORD UNIV PRESS INC. 2022: S582
  • Temporal trends in transcatheter aortic valve replacement use and outcomes by race, ethnicity, and sex. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions Yong, C. M., Jaluba, K., Batchelor, W., Gummipundi, S., Asch, S. M., Heidenreich, P. 2022


    To identify trends in transcatheter aortic valve replacement (TAVR) use and outcomes by race (non-Hispanic White, Black), ethnicity (Hispanic), and sex over time.Despite rapid growth in TAVR use over time, our understanding of its use and outcomes among males and females of underrepresented racial/ethnic groups remains limited.A retrospective analysis of hospitalizations from 2013 to 2017 from the Healthcare Cost and Utilization Project database was performed.White patients comprised 65% (n = 2.16 × 107 ) of all hospitalizations, yet they comprised 83% (n = 176,887) of the admissions for aortic stenosis (p < 0.0001). Among 91,693 hospitalizations for aortic valve replacement, 64,069 were surgical (34.0% female, 7.0% Hispanic, and 5.9% Black) and 27,624 were transcatheter (46.6% female, 4.5% Hispanic, and 4.4% Black). Growth in TAVR volumes was the slowest among minorities and females. Hispanic males, Hispanic females, and White females had the highest in-hospital mortality (2.7%-3.3%; compared to White males, adjusted odds ratio: Hispanic males 1.9 [1.2-3.0], Hispanic females 1.9 [1.2-3.1], and White females 1.4 [1.2-1.7]). Despite less baseline vascular disease, females of all races/ethnicities had more vascular complications than men (female 5% vs. male 3.5%, p ≤ 0.001). Further adjustment for vascular complications only partially attenuated mortality differences. Black and Hispanic patients had a longer mean length of hospital stay than White patients, which was most pronounced among females. Pacemaker requirements were consistently low among all groups.Differences in TAVR growth and outcomes by race, ethnicity, and sex over time highlight areas for focused efforts to close gaps in minimally invasive structural heart disease care.

    View details for DOI 10.1002/ccd.30182

    View details for PubMedID 35395131

  • Cost effectiveness of computed tomography versus ultrasound-based surveillance following endovascular aortic repair of intact infrarenal abdominal aortic aneurysms. Journal of vascular surgery Ho, V. T., Nguyen, A. T., Stern, J. R., Asch, S. M., Owens, D. K., Salomon, J. A., Dalman, R. L., Lee, J. T. 2022


    BACKGROUND: While Society for Vascular Surgery guidelines recommend computed tomography angiography (CTA) or ultrasound for surveillance following infrarenal endovascular aortic repair (EVAR), there is a lack of consensus regarding optimal timing and modalities. We hypothesized that ultrasound-based approaches would be more cost-effective and developed a cost-effectiveness analysis to estimate the lifetime costs and outcomes of various strategies.METHODS: We developed a decision tree with nested Markov models to compare five surveillance strategies: yearly CTA, yearly CDU, yearly CEU, CTA at first year followed by CDU, and CTA at first year followed by CEU. The model accounted for differential sensitivity, specificity, and risk of acute kidney injury after CTA, and was implemented on a monthly cycle with a willingness-to-pay threshold of $50,000 per quality-adjusted life year (QALY) and 3% annual discounting.RESULTS: Under base case assumptions, the CTA-CDU strategy was cost effective with a lifetime cost of $77950 for 7.74 QALYs. In sensitivity analysis, the CTA-CDU approach remained cost-effective when CEU specificity was less than 95%, and risk of acute kidney injury following CTA was less than 20%. At diagnostic sensitivities below 75% for CEU and 55% for CDU, a yearly CTA strategy maximized QALYs.CONCLUSION: A hybrid strategy in which CTA is performed in the first year and CDU is performed annually thereafter is the most cost-effective strategy for infrarenal EVAR surveillance in patients with less than a 20% risk of contrast-induced nephropathy. If the sensitivity of CEU and CDU are at the lower end of plausible estimates, a yearly CTA strategy is reasonable. Further research should aim to identify patients who may benefit from alternative surveillance strategies.

    View details for DOI 10.1016/j.jvs.2022.02.057

    View details for PubMedID 35278655

  • Outpatient care fragmentation in Veterans Affairs patients at high-risk for hospitalization. Health services research Zulman, D. M., Greene, L., Slightam, C., Singer, S. J., Maciejewski, M. L., Goldstein, M. K., Vanneman, M. E., Yoon, J., Trivedi, R. B., Wagner, T., Asch, S. M., Boothroyd, D. 2022


    OBJECTIVE: To examine outpatient care fragmentation and its association with future hospitalization among patients at high risk for hospitalization.DATA SOURCES: Veterans Affairs (VA) and Medicare data.STUDY DESIGN: We conducted a longitudinal study, using logistic regression to examine how outpatient care fragmentation in FY14 (as measured by number of unique providers, Breslau's Usual Provider of Care (UPC), Bice-Boxerman's Continuity of Care Index (COCI), and Modified Modified Continuity Index (MMCI)) was associated with all-cause hospitalizations and hospitalizations related to ambulatory care sensitive conditions (ACSC) in FY15. We also examined how fragmentation varied by patient's age, gender, race, ethnicity, marital status, rural status, history of homelessness, number of chronic conditions, Medicare utilization, and mental healthcare utilization.DATA EXTRACTION METHODS: We extracted data for 130,704 VA patients ≥65years old with a hospitalization risk ≥90th percentile and≥four outpatient visits in the baseline year.PRINCIPAL FINDINGS: Mean (standard deviation) of FY14 outpatient visits was 13.2 (8.6). Fragmented care (more providers, less care with a usual provider, more dispersed care based on COCI) was more common among patients with more chronic conditions and those receiving mental health care. In adjusted models, most fragmentation measures were not associated with all-cause hospitalization, and patients with low levels of fragmentation (more concentrated care based on UPC, COCI, and MMCI) had a higher likelihood of an ACSC-related hospitalization (AOR, 95% CI=1.21 (1.09-1.35), 1.27 (1.14-1.42), and 1.28 (1.18-1.40), respectively).CONCLUSIONS: Contrary to expectations, outpatient care fragmentation was not associated with elevated all-cause hospitalization rates among VA patients in the top 10th percentile for risk of admission; in fact, fragmented care was linked to lower rates of hospitalization for ACSCs. In integrated settings such as the VA, multiple providers and dispersed care might offer access to timely or specialized care that offsets risks of fragmentation, particularly for conditions that are sensitive to ambulatory care.

    View details for DOI 10.1111/1475-6773.13956

    View details for PubMedID 35178702

  • Surveying the Landscape of Quality-of-Care Measures for Mental and Substance Use Disorders. Psychiatric services (Washington, D.C.) Schmidt, E. M., Liu, P., Combs, A., Trafton, J., Asch, S., Harris, A. H. 2022: appips202000913


    OBJECTIVE: Quality measures that are used to evaluate health care services have a central role in monitoring and incentivizing quality improvement and the provision of evidence-based treatment. This systematic scan aimed to catalog quality-of-care measures for mental and substance use disorders and assess gaps and redundancies to inform efforts to develop and retire measures.METHODS: Quality measure inventories were analyzed from six organizations that evaluate health care quality in the United States. Measures were included if they were defined via symptoms or diagnoses of mental and substance use disorders or specialty treatments or treatment settings for adults.RESULTS: Of 4,420 measures analyzed, 635 (14%) met inclusion criteria, and 376 unique quality-of-care measure constructs were cataloged and characterized. Symptoms or diagnoses of disorders were most commonly used to define measures (46%, N=172). Few measures were available for certain disorders (e.g., anxiety disorders), evidence-based treatments (e.g., psychotherapy), and quality domains (e.g., equity). Only one in four measures was endorsed by the National Quality Forum, which independently and critically evaluates quality measures. Among measures that were actively in use for national quality improvement initiatives (N=319), process measures (57%) were most common, followed by outcome measures (30%), the latter of which focused most often on experience of care.CONCLUSIONS: A vast landscape of mental and substance use disorder quality-of-care measures currently exists, and continued efforts to harmonize duplicative measures and to develop measures for underrepresented evidence-based treatments and quality domains are warranted. The authors recommend reinvesting in a national, centralized system for measure curation, with a stakeholder-centered process for independent measure review and endorsement.

    View details for DOI 10.1176/

    View details for PubMedID 35172590

  • Engaging Frontline Physicians in Value Improvement: A Qualitative Evaluation of Physician-Directed Reinvestment. Journal of healthcare leadership Vilendrer, S., Amano, A., Asch, S. M., Brown-Johnson, C., Lu, A. C., Maggio, P. 2022; 14: 31-45


    Purpose: Physicians can limit upward trending healthcare costs, yet legal and ethical barriers prevent the use of direct financial incentives to engage physicians in cost-reduction initiatives. Physician-directed reinvestment is an alternative value-sharing arrangement in which a health system reinvests a portion of savings attributed to physician-led cost reduction initiatives back into professional areas of the physicians' choosing. Formal evaluations of such programs are lacking.Methods: To understand the impact of Stanford Health Care's physician-directed reinvestment in its first year (2017-2018) on physician engagement, adherence to program requirements around safety and fund use, and factors facilitating program dissemination, semi-structured qualitative interviews with physician participants, non-participants, and administrative stakeholders were conducted July-November 2019. Interview transcripts were qualitatively analyzed through an implementation science lens. To support contextual analysis of the qualitative data, a directional estimation of the program's impact on cost from the perspective of the health system was calculated by subtracting annual maintenance cost (derived from interview self-reported time estimates and public salary data) from internal cost accounting of the total savings from first year cohort to obtain annual net benefit, which was then divided by the annual maintenance cost.Results: Physician participation was low compared with the overall physician population (n=14 of approximately 2300 faculty physicians), though 32 qualitative interviews suggested deep engagement across physician participants and adherence to target program requirements. Reinvestment funds activated intrinsic motivators such as autonomy, purpose and inter-professional relations, and extrinsic motivators, such as the direction of resources and external recognition. Ongoing challenges included limited physician awareness of healthcare costs and the need for increased clarity around which projects rise above one's existing job responsibilities. Administrative data excluding physician time, which was not directly compensated, showed a direct cost savings of $8.9M. This implied an 11-fold return on investment excluding uncompensated physician time.Conclusion: A physician-directed reinvestment program appeared to facilitate latent frontline physician innovation towards value, though additional evaluation is needed to understand its long-term impact.

    View details for DOI 10.2147/JHL.S335763

    View details for PubMedID 35422669

  • Changes in postoperative opioid prescribing across three diverse healthcare systems, 2010-2020. Frontiers in digital health Coquet, J., Zammit, A., Hajouji, O. E., Humphreys, K., Asch, S. M., Osborne, T. F., Curtin, C. M., Hernandez-Boussard, T. 2022; 4: 995497


    Objective: The opioid crisis brought scrutiny to opioid prescribing. Understanding how opioid prescribing patterns and corresponding patient outcomes changed during the epidemic is essential for future targeted policies. Many studies attempt to model trends in opioid prescriptions therefore understanding the temporal shift in opioid prescribing patterns across populations is necessary. This study characterized postoperative opioid prescribing patterns across different populations, 2010-2020.Data Source: Administrative data from Veteran Health Administration (VHA), six Medicaid state programs and an Academic Medical Center (AMC).Data extraction: Surgeries were identified using the Clinical Classifications Software.Study Design: Trends in average daily discharge Morphine Milligram Equivalent (MME), postoperative pain and subsequent opioid prescription were compared using regression and likelihood ratio test statistics.Principal Findings: The cohorts included 595,106 patients, with populations that varied considerably in demographics. Over the study period, MME decreased significantly at VHA (37.5-30.1; p=0.002) and Medicaid (41.6-31.3; p=0.019), and increased at AMC (36.9-41.7; p<0.001). Persistent opioid users decreased after 2015 in VHA (p<0.001) and Medicaid (p=0.002) and increase at the AMC (p=0.003), although a low rate was maintained. Average postoperative pain scores remained constant over the study period.Conclusions: VHA and Medicaid programs decreased opioid prescribing over the past decade, with differing response times and rates. In 2020, these systems achieved comparable opioid prescribing patterns and outcomes despite having very different populations. Acknowledging and incorporating these temporal distribution shifts into data learning models is essential for robust and generalizable models.

    View details for DOI 10.3389/fdgth.2022.995497

    View details for PubMedID 36561925

  • Prescription quantity and duration predict progression from acute to chronic opioid use in opioid-naive Medicaid patients. PLOS digital health Johnson, D. G., Ho, V. T., Hah, J. M., Humphreys, K., Carroll, I., Curtin, C., Asch, S. M., Hernandez-Boussard, T. 2022; 1 (8)


    Opiates used for acute pain are an established risk factor for chronic opioid use (COU). Patient characteristics contribute to progression from acute opioid use to COU, but most are not clinically modifiable. To develop and validate machine-learning algorithms that use claims data to predict progression from acute to COU in the Medicaid population, Adult opioid naive Medicaid patients from 6 anonymized states who received an opioid prescription between 2015 and 2019 were included. Five machine learning (ML) Models were developed, and model performance assessed by area under the receiver operating characteristic curve (auROC), precision and recall. In the study, 29.9% (53820/180000) of patients transitioned from acute opioid use to COU. Initial opioid prescriptions in COU patients had increased morphine milligram equivalents (MME) (33.2 vs. 23.2), tablets per prescription (45.6 vs. 36.54), longer prescriptions (26.63 vs 24.69 days), and higher proportions of tramadol (16.06% vs. 13.44%) and long acting oxycodone (0.24% vs 0.04%) compared to non- COU patients. The top performing model was XGBoost that achieved average precision of 0.87 and auROC of 0.63 in testing and 0.55 and 0.69 in validation, respectively. Top-ranking prescription-related features in the model included quantity of tablets per prescription, prescription length, and emergency department claims. In this study, the Medicaid population, opioid prescriptions with increased tablet quantity and days supply predict increased risk of progression from acute to COU in opioid-naive patients. Future research should evaluate the effects of modifying these risk factors on COU incidence.

    View details for DOI 10.1371/journal.pdig.0000075

    View details for PubMedID 36203857

  • Patient and Clinician Perspectives of New and Return Ambulatory Teleneurology Visits. Neurology. Clinical practice Kling, S. M., Falco-Walter, J. J., Saliba-Gustafsson, E. A., Garvert, D. W., Brown-Johnson, C. G., Miller-Kuhlmann, R., Shaw, J. G., Asch, S. M., Yang, L., Gold, C. A., Winget, M. 1800; 11 (6): 472-483


    Background and Objectives: To evaluate the adoption and perceived utility of video visits for new and return patient encounters in ambulatory neurology subspecialties.Methods: Video visits were launched in an academic, multi-subspecialty, ambulatory neurology clinic in March 2020. Adoption of video visits for new and return patient visits was assessed using clinician-level scheduling data from March 22 to May 16, 2020. Perceived utility of video visits was explored via a clinician survey and semistructured interviews with clinicians and patients/caregivers. Findings were compared across 5 subspecialties and 2 visit types (new vs return).Results: Video visits were adopted rapidly; all clinicians (n = 65) integrated video visits into their workflow within the first 6 weeks, and 92% of visits were conducted via video, although this varied by subspecialty. Utility of video visits was higher for return than new patient visits, as indicated by surveyed (n = 48) and interviewed clinicians (n = 30), aligning with adoption patterns. Compared with in-person visits, clinicians believed that it was easier to achieve a similar physical examination, patient-clinician rapport, and perceived quality of care over video for return rather than new patient visits. Of the 25 patients/caregivers interviewed, most were satisfied with the care provided via video, regardless of visit type, with the main limitation being the physical examination.Discussion: Teleneurology was robustly adopted for both new and return ambulatory neurology patients during the COVID-19 pandemic. Return patient visits were preferred over new patient visits, but both were feasible. These results provide a foundation for developing targeted guidelines for sustaining teleneurology in ambulatory care.

    View details for DOI 10.1212/CPJ.0000000000001065

    View details for PubMedID 34992955

  • Correction to: Patient and Caregiver Prioritization of Palliative and End-of-Life Cancer Care Quality Measures. Journal of general internal medicine O'Hanlon, C. E., Giannitrapani, K. F., Lindvall, C., Gamboa, R. C., Canning, M., Asch, S. M., Garrido, M. M., ImPACS Patient and Caregiver Panel, Walling, A. M., Lorenz, K. A. 2021

    View details for DOI 10.1007/s11606-021-07160-2

    View details for PubMedID 34731438

  • Attitudes and Intentions of US Veterans Regarding COVID-19 Vaccination. JAMA network open Jasuja, G. K., Meterko, M., Bradshaw, L. D., Carbonaro, R., Clayman, M. L., LoBrutto, L., Miano, D., Maguire, E. M., Midboe, A. M., Asch, S. M., Gifford, A. L., McInnes, D. K., Elwy, A. R. 2021; 4 (11): e2132548


    Importance: Compared with the general population, veterans are at high risk for COVID-19 and have a complex relationship with the government. This potentially affects their attitudes toward receiving COVID-19 vaccines.Objective: To assess veterans' attitudes toward and intentions to receive COVID-19 vaccines.Design, Setting, and Participants: This cross-sectional web-based survey study used data from the Department of Veterans Affairs (VA) Survey of Healthcare Experiences of Patients' Veterans Insight Panel, fielded between March 12 and 28, 2021. Of 3420 veterans who were sent a link to complete a 58-item web-based survey, 1178 veterans (34%) completed the survey. Data were analyzed from April 1 to August 25, 2021.Exposures: Veterans eligible for COVID-19 vaccines.Main Outcomes and Measures: The outcomes of interest were veterans' experiences with COVID-19, vaccination status and intention groups, reasons for receiving or not receiving a vaccine, self-reported health status, and trusted and preferred sources of information about COVID-19 vaccines. Reasons for not getting vaccinated were classified into categories of vaccine deliberation, dissent, distrust, indifference, skepticism, and policy and processes.Results: Among 1178 respondents, 974 (83%) were men, 130 (11%) were women, and 141 (12%) were transgender or nonbinary; 58 respondents (5%) were Black, 54 veterans (5%) were Hispanic or Latino, and 987 veterans (84%) were non-Hispanic White. The mean (SD) age of respondents was 66.7 (10.1) years. A total of 817 respondents (71%) self-reported being vaccinated against COVID-19. Of 339 respondents (29%) who were not vaccinated, those unsure of getting vaccinated were more likely to report fair or poor overall health (32 respondents [43%]) and mental health (33 respondents [44%]) than other nonvaccinated groups (overall health: range, 20%-32%; mental health: range, 18%-40%). Top reasons for not being vaccinated were skepticism (120 respondents [36%] were concerned about side effects; 65 respondents [20%] preferred using few medications; 63 respondents [19%] preferred gaining natural immunity), deliberation (74 respondents [22%] preferred to wait because vaccine is new), and distrust (61 respondents [18%] did not trust the health care system). Among respondents who were vaccinated, preventing oneself from getting sick (462 respondents [57%]) and contributing to the end of the COVID-19 pandemic (453 respondents [56%]) were top reasons for getting vaccinated. All veterans reported the VA as 1 of their top trusted sources of information. The proportion of respondents trusting their VA health care practitioner as a source of vaccine information was higher among those unsure about vaccination compared with those who indicated they would definitely not or probably not get vaccinated (18 respondents [26%] vs 15 respondents [15%]). There were no significant associations between vaccine intention groups and age (chi24=5.90; P=.21) or gender (chi22=3.99; P=.14).Conclusions and Relevance: These findings provide information needed to develop trusted messages used in conversations between VA health care practitioners and veterans addressing specific vaccine hesitancy reasons, as well as those in worse health. Conversations need to emphasize societal reasons for getting vaccinated and benefits to one's own health.

    View details for DOI 10.1001/jamanetworkopen.2021.32548

    View details for PubMedID 34730819

  • Developing best practices for PPE Portraits across 25 sites: a systematic assessment ofimplementation and spread of adaptations using FRAME. BMC health services research Baratta, J., Amano, A., Parsons, P. K., Vilendrer, S., Winter, S. G., Verano, M., Perez, C., Kalanithi, L., Asch, S. M., Heffernan, M. B., Brown-Johnson, C. 2021; 21 (1): 1182


    BACKGROUND: Adaptation, a form of modification that aims to improve an intervention's acceptability and sustainability in each context, is essential to successful implementation in some settings. Due to the COVID-19 pandemic, clinicians have rapidly adapted how they deliver patient care. PPE Portraits are a form of adaptation, whereby health workers affix a postcard size portrait of themselves to the front of their personal protective equipment (PPE) to foster human connection during COVID-19.METHODS: We used the expanded framework for reporting adaptations and modifications to evidence-based interventions (FRAME) method to better understand the reasoning behind and results of each adaptation. We hypothesized that using the FRAME in conjunction with design-thinking would lead to emerging best practices and that we would find adaptation similarities across sites. Throughout multiple implementations across 25 institutions, we piloted, tracked, and analyzed adaptations using FRAME and design thinking. For each adaptation, we assessed the stage of implementation, whether the change was planned, decision makers involved, level of delivery impacted, fidelity to original intervention, and the goal and reasoning for adaptation. We added three crucial components to the FRAME: original purpose of the adaptation, unintended consequences, and alternative adaptations.RESULTS: When implementing PPE Portraits across settings, from a local assisted living center's memory unit to a pediatric emergency department, several requests for adaptations arose during early development stages before implementation. Adaptations primarily related to (1) provider convenience and comfort, (2) patient populations, and (3) scale. Providers preferred smaller portraits and rounded (rather than square) laminated edges that could potentially injure a patient. Affixing the portrait with a magnet was rejected given the potential choking hazard the magnetic strip presented for children. Other adaptations, related to ease of dissemination, included slowing the process down during early development and providing buttons, which could be produced easily at scale.CONCLUSIONS: The FRAME was used to curate the reasoning for each adaptation and to inform future dissemination. We look forward to utilizing FRAME including our additions and design thinking, to build out a range of PPE Portrait best practices with accompanying costs and benefits.

    View details for DOI 10.1186/s12913-021-06922-2

    View details for PubMedID 34717597

  • What Did the COVID Stress Test Reveal About How We Should Deliver Care in the USA? Journal of general internal medicine Asch, S. M. 2021

    View details for DOI 10.1007/s11606-021-07150-4

    View details for PubMedID 34709581

  • Cost Effectiveness of Computed Tomography Versus Ultrasound-Based Surveillance Following Endovascular Aortic Repair of Intact Abdominal Aortic Aneurysms Ho, V. T., Nguyen, A. T., Stern, J. R., Asch, S. M., Owens, D. K., Salomon, J. A., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2021: E414-E415
  • Assessment of Changes in US Veterans Health Administration Care Delivery Methods During the COVID-19 Pandemic. JAMA network open Rose, L., Tran, L. D., Asch, S. M., Vashi, A. 2021; 4 (10): e2129139

    View details for DOI 10.1001/jamanetworkopen.2021.29139

    View details for PubMedID 34648015

  • Gaps in standardized postoperative pain management quality measures: A systematic review. Surgery Joseph, J. M., Gori, D., Curtin, C., Hah, J., Ho, V. T., Asch, S. M., Hernandez-Boussard, T. 2021


    BACKGROUND: The goal of this study was an assessment of availability postoperative pain management quality measures and National Quality Forum-endorsed measures. Postoperative pain is an important clinical timepoint because poor pain control can lead to patient suffering, chronic opiate use, and/or chronic pain. Quality measures can guide best practices, but it is unclear whether there are measures for managing pain after surgery.METHODS: The National Quality Forum Quality Positioning System, Agency for Healthcare Research and Quality Indicators, and Centers for Medicare and Medicaid Services Measures Inventory Tool databases were searched in November 2019. We conducted a systematic literature review to further identify quality measures in research publications, clinical practice guidelines, and gray literature for the period between March 11, 2015 and March 11,2020.RESULTS: Our systematic review yielded 1,328 publications, of which 206 were pertinent. Nineteen pain management quality measures were identified from the quality measure databases, and 5 were endorsed by National Quality Forum. The National Quality Forum measures were not specific to postoperative pain management. Three of the non-endorsed measures were specific to postoperative pain.CONCLUSION: The dearth of published postoperative pain management quality measures, especially National Quality Forum-endorsed measures, highlights the need for more rigorous evidence and widely endorsed postoperative pain quality measures to guide best practices.

    View details for DOI 10.1016/j.surg.2021.08.004

    View details for PubMedID 34538340

  • What Is the Return on Investment of Caring for Complex High-need, High-cost Patients? Journal of general internal medicine Chang, E. T., Asch, S. M., Eng, J., Gutierrez, F., Denietolis, A., Atkins, D. 2021


    Randomized controlled trials to improve care for complex, high-need, high-cost patients have not consistently demonstrated a relative decrease in acute care utilization or cost savings. However, the Veterans Health Administration (VHA) has been able to glean lessons from these trials and generate realistic expectations for success. Lessons include the following: (1) combining population management tools (e.g., risk scores) and clinician judgment is more effective than either alone to identify the patients best suited for intensive management; (2) treatment adherence and engagement may contribute more to preventable emergency department visits and hospitalizations than care coordination; and (3) efforts should focus on assessing for and treating those risk factors that are most amenable to intervention. Because it is unlikely that cost savings can fund add-on intensive management programs, the VHA Office of Primary Care plans to incorporate those intensive management practices that are feasible into existing patient-centered medical homes as a high reliability organization.

    View details for DOI 10.1007/s11606-021-07110-y

    View details for PubMedID 34508291

  • Increasing Chronic Opioid Usage Despite Reduced Prescriptions After Vascular Surgery Ho, V. T., Fu, S., Chattopadhyay, A., Asch, S. M., Stern, J. R., Chen, J. MOSBY-ELSEVIER. 2021: E285-E286
  • Patient/Caregiver and Expert Stakeholder Perspectives on High-Quality Palliative Care for Patients with Advanced Cancer O'Hanlon, C., Giannitrapani, K., Gamboa, R., Walling, A., Lindvall, C., Garrido, M., Asch, S., Canning, M., Lorenz, K. WILEY. 2021: 11-12
  • Technology-Enabled and Artificial Intelligence Support for Pre-Visit Planning in Ambulatory Care: Findings From an Environmental Scan. Annals of family medicine Holdsworth, L. M., Park, C., Asch, S. M., Lin, S. 2021; 19 (5): 419-426


    PURPOSE: Pre-visit planning (PVP) is believed to improve effectiveness, efficiency, and experience of care, yet numerous implementation barriers exist. There are opportunities for technology-enabled and artificial intelligence (AI) support to augment existing human-driven PVP processes-from appointment reminders and pre-visit questionnaires to pre-visit order sets and care gap closures. This study aimed to explore the current state of PVP, barriers to implementation, evidence of impact, and potential use of non-AI and AI tools to support PVP.METHODS: We used an environmental scan approach involving: (1) literature review; (2) key informant interviews with PVP experts in ambulatory care; and (3) a search of the public domain for technology-enabled and AI solutions that support PVP. We then synthesized the findings using a qualitative matrix analysis.RESULTS: We found 26 unique PVP implementations in the literature and conducted 16 key informant interviews. Demonstration of impact is typically limited to process outcomes, with improved patient outcomes remaining elusive. Our key informants reported that many PVP barriers are human effort-related and see potential for non-AI and AI technologies to support certain aspects of PVP. We identified 8 examples of commercially available technology-enabled tools that support PVP, some with AI capabilities; however, few of these have been independently evaluated.CONCLUSIONS: As health systems transition toward value-based payment models in a world where the coronavirus disease 2019 pandemic has shifted patient care into the virtual space, PVP activities-driven by humans and supported by technology-may become more important and powerful and should be rigorously evaluated.

    View details for DOI 10.1370/afm.2716

    View details for PubMedID 34546948

  • Financial Incentives for Medical Assistants: A Mixed-Methods Exploration of Bonus Structures, Motivation, and Population Health Quality Measures. Annals of family medicine Vilendrer, S., Brown-Johnson, C., Kling, S. M., Veruttipong, D., Amano, A., Bohman, B., Daines, W. P., Overton, D., Srivastava, R., Asch, S. M. 2021; 19 (5): 427-436


    PURPOSE: Medical assistants (MAs) have seen their roles expand as a result of team-based primary care models. Unlike their physician counterparts, MAs rarely receive financial incentives as a part of their compensation. This exploratory study aims to understand MA acceptability of financial incentives and perceived MA control over common population health measures.METHODS: We conducted semistructured focus groups between August and December of 2019 across 10 clinics affiliated with 3 institutions in California and Utah. MAs' perceptions of experienced and hypothetical financial incentives, their potential influence on workflow processes, and perceived levels of control over population health measures were discussed, recorded, and qualitatively analyzed for emerging themes. Perceived levels of control were further quantified using a Likert survey; measures were grouped into factors representing vaccinations, and workflow completed in the same day or multiple days (multiday). Mean scores for each factor were compared using repeated 1-way ANOVA with Tukey-Kramer adjustment.RESULTS: MAs reported little direct experience with financial incentives. They indicated that a hypothetical bonus representing 2% to 3% of their average annual base pay would be acceptable and influential in improving consistent performance during patient rooming workflow. MAs reported having greater perceived control over vaccinations (P <.001) and same-day measures (P <.001) as compared with multiday measures.CONCLUSIONS: MAs perceived that relatively small financial incentives would increase their motivation and quality of care. Our findings suggests target measures should focus on MA work processes that are completed in the same day as the patient encounter, particularly vaccinations. Future investigation is needed to understand the effectiveness of MA financial incentives in practice.

    View details for DOI 10.1370/afm.2719

    View details for PubMedID 34546949

  • Cost Effectiveness of Computed Tomography Versus Ultrasound-Based Surveillance After Endovascular Aortic Repair of Intact Abdominal Aortic Aneurysms Ho, V. T., Nguyen, A. T., Stern, J. R., Asch, S. M., Owens, D. K., Salomon, J. A., Dalman, R. L., Lee, J. T. MOSBY-ELSEVIER. 2021: E190-E191
  • How Feedback Is Given Matters: A Cross-Sectional Survey of Patient Satisfaction Feedback Delivery and Physician Well-being. Mayo Clinic proceedings Vilendrer, S. M., Kling, S. M., Wang, H., Brown-Johnson, C., Jayaraman, T., Trockel, M., Asch, S. M., Shanafelt, T. D. 2021


    OBJECTIVE: To evaluate how variation in the way patient satisfaction feedback is delivered relates to physician well-being and perceptions of its impact on patient care, job satisfaction, and clinical decision making.PARTICIPANTS AND METHODS: A cross-sectional electronic survey was sent to faculty physicians from a large academic medical center in March 29, 2019. Physicians reported their exposure to feedback (timing, performance relative to peers, or channel) and related perceptions. The Professional Fulfillment Index captured burnout and professional fulfillment. Associations between feedback characteristics and well-being or perceived impact were tested using analysis of variance or logistic regression adjusted for covariates.RESULTS: Of 1016 survey respondents, 569 (56.0%) reported receiving patient satisfaction feedback. Among those receiving feedback, 303 (53.2%) did not believe that this feedback improved patient care. Compared with physicians who never received feedback, those who received any type of feedback had higher professional fulfillment scores (mean, 6.6±2.1 vs 6.3±2.0; P=.03) but also reported an unfavorable impact on clinical decision making (odds ratio [OR], 2.9; 95% CI, 1.8 to 4.7; P<.001). Physicians who received feedback that included one-on-one discussions (as opposed to feedback without this channel) held more positive perceptions of the feedback's impact on patient care (OR, 2.0; 95% CI, 1.3 to 3.0; P=.003), whereas perceptions were less positive in physicians whose feedback included comparisons to named colleagues (OR, 0.5; 95% CI, 0.3 to 0.8; P=.003).CONCLUSION: Providing patient satisfaction feedback to physicians was associated with mixed results, and physician perceptions of the impact of feedback depended on the characteristics of feedback delivery. Our findings suggest that feedback is viewed most constructively by physicians when delivered through one-on-one discussions and without comparison to peers.

    View details for DOI 10.1016/j.mayocp.2021.03.039

    View details for PubMedID 34479736

  • Patient and Caregiver Prioritization of Palliative and End-of-Life Cancer Care Quality Measures. Journal of general internal medicine O'Hanlon, C. E., Giannitrapani, K. F., Lindvall, C., Gamboa, R. C., Canning, M., Asch, S. M., Garrido, M. M., ImPACS Patient and Caregiver Panel, Walling, A. M., Lorenz, K. A., Bernstein, E., Branstetter, J., Bunch, D., Carroll, F., Guzman, E., Krutz, M., Maizel, J., Moe, J. 2021


    BACKGROUND: Development and prioritization of quality measures typically relies on experts in clinical medicine, but patients and their caregivers may have different perspectives on quality measurement priorities.OBJECTIVE: To inform priorities for health system implementation of palliative cancer and end-of-life care quality measures by eliciting perspectives of patients and caregivers.DESIGN: Using modified RAND-UCLA Appropriateness Panel methods and materials tailored for knowledgeable lay participants, we convened a panel to rate cancer palliative care process quality measure concepts before and after a 1-day, in-person meeting.PARTICIPANTS: Nine patients and caregivers with experience living with or caring for patients with cancer.MAIN MEASURES: Panelists rated each concept on importance for providing patient- and family-centered care on a nine-point scale and each panelist nominated five highest priority measure concepts ("top 5").KEY RESULTS: Cancer patient and caregiver panelists rated all measure concepts presented as highly important to patient- and family- centered care (median rating ≥ 7) in pre-panel (mean rating range, 6.9-8.8) and post-panel ratings (mean rating range, 7.2-8.9). Forced choice nominations of the "top 5" helped distinguish similarly rated measure concepts. Measure concepts nominated into the "top 5" by three or more panelists included two measure concepts of communication (goals of care discussions and discussion of prognosis), one measure concept on providing comprehensive assessments of patients, and three on symptoms including pain management plans, improvement in pain, and depression management plans. Patients and caregivers nominated one additional measure concept (pain screening) back into consideration, bringing the total number of measure concepts under consideration to 21.CONCLUSIONS: Input from cancer patients and caregivers helped identify quality measurement priorities for health system implementation. Forced choice nominations were useful to discriminate concepts with the highest perceived importance. Our approach serves as a model for incorporating patient and caregiver priorities in quality measure development and implementation.

    View details for DOI 10.1007/s11606-021-07041-8

    View details for PubMedID 34405352

  • How Can Medical Journals Promote Equity and Counter Racism? Journal of general internal medicine Jackson, J. L., Bates, C., Asch, S. M., Roberts, R., Clarkson, J. R. 2021

    View details for DOI 10.1007/s11606-021-06984-2

    View details for PubMedID 34389939

  • A Specialized Acute COVID-19 Outpatient Clinic at an Academic Medical Center. American journal of medical quality : the official journal of the American College of Medical Quality Artandi, M., Barman, L., Srinivasan, M., Thomas, S., Singh, J., Asch, S. M., Vilendrer, S. 2021


    Health systems are challenged to provide equitable access to coronavirus disease 2019 (COVID-19) outpatient care during the pandemic. Infected patients may have difficulties accessing regular care and rely on emergency rooms. With the goal to improve system efficiencies and access to care, Stanford launched a designated outpatient COVID-19 "Care and Respiratory Observation of Patients With Novel Coronavirus" clinic in April 2020 in which all adult Stanford patients with newly diagnosed severe acute respiratory syndrome coronavirus 2 were offered follow-up for 2-3 weeks through video, telephone, and in-person encounters. Patients were triaged into risk categories and received home pulse oximeters based on a standardized protocol. Between April 15, 2020, and March 26, 2021, the Care and Respiratory Observation of Patients With Novel Coronavirus clinic enrolled 1317 patients. The clinic provided evaluation of Patients under Investigation, management of acute COVID-19 symptoms, care for COVID-19 patients after hospital discharge, clinical advice, and opportunities for research. The authors share crucial implementation lessons related to team agility, care personalization, and resource optimization.

    View details for DOI 10.1097/JMQ.0000000000000006

    View details for PubMedID 34310381

  • Quality measures for end-of-life care for children with cancer: A modified Delphi approach CANCER Johnston, E. E., Martinez, I., Wolfe, J., Asch, S. M. 2021; 127 (14): 2571-2578
  • Predicting and Responding to Clinical Deterioration in Hospitalized Patients by Using Artificial Intelligence: Protocol for a Mixed Methods, Stepped Wedge Study. JMIR research protocols Holdsworth, L. M., Kling, S. M., Smith, M., Safaeinili, N., Shieh, L., Vilendrer, S., Garvert, D. W., Winget, M., Asch, S. M., Li, R. C. 2021; 10 (7): e27532


    BACKGROUND: The early identification of clinical deterioration in patients in hospital units can decrease mortality rates and improve other patient outcomes; yet, this remains a challenge in busy hospital settings. Artificial intelligence (AI), in the form of predictive models, is increasingly being explored for its potential to assist clinicians in predicting clinical deterioration.OBJECTIVE: Using the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model, this study aims to assess whether an AI-enabled work system improves clinical outcomes, describe how the clinical deterioration index (CDI) predictive model and associated work processes are implemented, and define the emergent properties of the AI-enabled work system that mediate the observed clinical outcomes.METHODS: This study will use a mixed methods approach that is informed by the SEIPS 2.0 model to assess both processes and outcomes and focus on how physician-nurse clinical teams are affected by the presence of AI. The intervention will be implemented in hospital medicine units based on a modified stepped wedge design featuring three stages over 11 months-stage 0 represents a baseline period 10 months before the implementation of the intervention; stage 1 introduces the CDI predictions to physicians only and triggers a physician-driven workflow; and stage 2 introduces the CDI predictions to the multidisciplinary team, which includes physicians and nurses, and triggers a nurse-driven workflow. Quantitative data will be collected from the electronic health record for the clinical processes and outcomes. Interviews will be conducted with members of the multidisciplinary team to understand how the intervention changes the existing work system and processes. The SEIPS 2.0 model will provide an analytic framework for a mixed methods analysis.RESULTS: A pilot period for the study began in December 2020, and the results are expected in mid-2022.CONCLUSIONS: This protocol paper proposes an approach to evaluation that recognizes the importance of assessing both processes and outcomes to understand how a multifaceted AI-enabled intervention affects the complex team-based work of identifying and managing clinical deterioration.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/27532.

    View details for DOI 10.2196/27532

    View details for PubMedID 34255728

  • Risk Communication After Health Care Exposures: An Experimental Vignette Survey With Patients MDM POLICY & PRACTICE Elwy, A., Maguire, E. M., Gallagher, T. H., Asch, S. M., Durfee, J. M., Martinello, R. A., Bokhour, B. G., Gifford, A. L., Taylor, T. J., Wagner, T. H. 2021; 6 (2): 23814683211045659


    Purpose. We investigated how health care systems should communicate with patients about possible exposures to blood-borne pathogens that may have occurred during their care. Our goal was to determine how best to communicate uncertain risk information in a way that would minimize harm to patients, maintain their trust, and encourage patients to seek follow-up treatment. Methods. Participants (N = 1103) were randomized to receive one of six vignette surveys; 997 (98.4%) responded. All vignettes described the same event, but differed by risk level and recommendations (lower risk v. higher risk) and by communication mode (telephone, letter, social media). We measured participants' perceived risk of blood-borne infection, trust in the health care system, and shared decision making about next clinical steps. Open-ended questions were analyzed using grounded thematic analysis. Results. When the vignette requested patients to undergo testing and practice certain health behaviors (higher risk), participants' likelihood of seeking follow-up testing for blood-borne pathogens and their understanding of health issues increased. Perceived trust was unaffected by risk level or communication processes. Qualitative data indicated a desire for telephone communication from providers known to the patient. Limitations. It is not clear whether higher risk language or objective risk levels in vignettes motivated patients' behavioral intentions. Conclusion. Using higher risk language when disclosing large-scale adverse events increased participants' willingness to seek follow-up care. Implications. Health care organizations' disclosures should focus on the next steps to take after health care exposures. This communication should involve helping patients to understand their personal health issues better, make them feel that they know which steps to take following the receipt of this information, and encouraging them to seek follow-up infectious disease testing in order to better take care of themselves.

    View details for DOI 10.1177/23814683211045659

    View details for Web of Science ID 000938275000011

    View details for PubMedID 34553068

    View details for PubMedCentralID PMC8451260

  • Outcomes of a randomized quality improvement trial for high-risk Veterans in year two. Health services research Chang, E. T., Yoon, J., Esmaeili, A., Zulman, D. M., Ong, M. K., Stockdale, S. E., Jimenez, E. E., Chu, K., Atkins, D., Denietolis, A., Asch, S. M., PACT Intensive Management (PIM) Demonstration Sites, P. N. 2021


    OBJECTIVE: The Veterans Health Administration (VHA) conducted a randomized quality improvement evaluation to determine whether augmenting patient-centered medical homes with Primary care Intensive Management (PIM) decreased utilization of acute care and health care costs among patients at high risk for hospitalization. PIM was cost-neutral in the first year; we analyzed changes in utilization and costs in the second year.DATA SOURCES: VHA administrative data for five demonstration sites from August 2013 to March 2019.DATA SOURCES: Administrative data extracted from VHA's Corporate Data Warehouse.STUDY DESIGN: Veterans with a risk of 90-day hospitalization in the top 10th percentile and recent hospitalization or emergency department (ED) visit were randomly assigned to usual primary care vs primary care augmented by PIM. PIM included interdisciplinary teams, comprehensive patient assessment, intensive case management, and care coordination services. We compared the change in mean VHA inpatient and outpatient utilization and costs (including PIM expenses) per patient for the 12-month period before randomization and 13-24months after randomization for PIM vs usual care using difference-in-differences.PRINCIPAL FINDINGS: Both PIM patients (n=1902) and usual care patients (n=1882) had a mean of 5.6 chronic conditions. PIM patients had a greater number of primary care visits compared to those in usual care (mean 4.6 visits/patient/year vs 3.7 visits/patient/year, p<0.05), but ED visits (p=0.45) and hospitalizations (p=0.95) were not significantly different. We found a small relative increase in outpatient costs among PIM patients compared to those in usual care (mean difference+$928/patient/year, p=0.053), but no significant differences in mean inpatient costs (+$245/patient/year, p=0.97). Total mean health care costs were similar between the two groups during the second year (mean difference+$1479/patient/year, p=0.73).CONCLUSIONS: Approaches that target patients solely based on the high risk of hospitalization are unlikely to reduce acute care use or total costs in VHA, which already offers patient-centered medical homes.

    View details for DOI 10.1111/1475-6773.13674

    View details for PubMedID 34145564

  • Community Urgent Care Use Following Implementation of the Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks Act. Medical care Vashi, A. A., Urech, T., Wu, S., Boothroyd, D., Mehta, P., Dalton, A. L., Brill, E., Kessler, C., Asch, S. M. 2021; 59 (Suppl 3): S314–S321


    BACKGROUND: Effective June 6, 2019, Veterans Affairs (VA) began offering a new urgent care (UC) benefit that provides eligible Veterans with greater choice and access to care for the treatment of minor injuries and illnesses in their local communities.OBJECTIVES: The aim was to describe trends in UC use, identify predictors of UC benefit use, and understand the factors associated with community UC use versus VA emergency department (ED) or urgent care center (UCC) use.STUDY DESIGN: Using VA administrative data, this was a retrospective cross-sectional study of Veterans that were enrolled in VA in FY19. Veterans were classified into 3 groups: UC benefit users, benefit non-users, and VA ED/UCC users.METHODS: We used summary statistics to compare population characteristics across user groups. To determine whether predisposing, enabling, and need factors predicted UC benefit use and setting choice (community UCC vs. VA ED/UCC), 2 logistic regression models were fitted to assess odds of UC use.RESULTS: From June 6, 2019 through February 29, 2020, 138,305 Veterans made 175,821 community UC visits. The majority of visits were made by White males who were not subject to co-pays. The average cost to VA for UC visits was $132 (SD=$135). Upper respiratory infections were the most common reason for UC use. Being younger, female, and living farther from a VA ED/UCC was associated with greater UC benefit use compared with both benefit non-users and VA ED/UCC users.CONCLUSIONS: The new benefit expands Veteran access to UC services for low-acuity conditions.

    View details for DOI 10.1097/MLR.0000000000001549

    View details for PubMedID 33976082

  • The Veterans Health Administration (VHA) Innovators Network: Evaluation design, methods and lessons learned through an embedded research approach. Healthcare (Amsterdam, Netherlands) Vashi, A. A., Orvek, E. A., Tuepker, A., Jackson, G. L., Amrhein, A., Cole, B., Asch, S. M., Gifford, A. L., Lindquist, J., Marshall, N. J., Newell, S., Smigelsky, M. A., White, B. S., White, L. K., Cutrona, S. L. 2021; 8 Suppl 1: 100477


    BACKGROUND: Collaboration between researchers, implementers and policymakers improves uptake of health systems research. In 2018, researchers and VHA Innovators Network (iNET) leadership used an embedded research model to conduct an evaluation of iNET. We describe our evaluation design, early results, and lessons learned.METHODS: This mixed-methods evaluation incorporated primary data collection via electronic survey, descriptive analysis using existing VA datasets (examining associations between facility characteristics and iNET participation), and qualitative interviews to support real-time program implementation and to probe perceived impacts, benefits and challenges of participation.RESULTS: We developed reporting tools and collected data regarding site participation, providing iNET leadership rapid access to needed information on projects (e.g., target populations reached, milestones achieved, and barriers encountered). Secondary data analyses indicated iNET membership was greater among larger, more complex VA facilities. Of the 37 iNET member sites, over half (n=22) did not have any of the six major types of VA research centers; thus iNET is supporting VA sites not traditionally served by research innovation pathways. Qualitative findings highlighted enhanced engagement and perceived value of social and informational networks.CONCLUSIONS: Working alongside our iNET partners, we supported and influenced iNET's development through our embedded evaluation's preliminary findings. We also provided training and guidance aimed at building capacity among iNET participants.IMPLICATIONS: Embedded research can yield successful collaborative efforts between researchers and partners. An embedded research team can help programs pivot to ensure effective use of limited resources. Such models inform program development and expansion, supporting strategic planning and demonstrating value.

    View details for DOI 10.1016/j.hjdsi.2020.100477

    View details for PubMedID 34175094

  • Factors Associated With Access to and Receipt of Liver Transplantation in Veterans With End-Stage Liver Disease. JAMA internal medicine Kanwal, F., Hernaez, R., Liu, Y., Taylor, T. J., Rana, A., Kramer, J. R., Naik, A. D., Smith, D., Taddei, T., Asch, S. M. 2021


    Importance: Organ scarcity means few patients with advanced liver disease undergo a transplant, making equitable distribution all the more crucial. Disparities may arise at any stage in the complex process leading up to this curative therapy.Objective: To examine the rate of and factors associated with referral, wait-listing, and receipt of liver allografts.Design, Setting, and Participants: This retrospective cohort study used linked data from comprehensive electronic medical records and the United Network of Organ Sharing. Adult patients with cirrhosis and a Model for End-Stage Liver Disease with addition of sodium score of at least 15 points between October 1, 2011, and December 31, 2017, were included in the study. Patients were from 129 hospitals in the integrated, US Department of Veterans Affairs health care system and were followed up through December 31, 2018. Statistical analyses were performed from April 28, 2020, to January 31, 2021.Exposures: Sociodemographic (eg, age, insurance, income), clinical (eg, liver disease etiology, severity, comorbidity), and health care facility (eg, complexity, rural or urban, presence of a liver transplant program) factors were evaluated.Main Outcomes and Measures: Referral, wait-listing, and liver transplantation.Results: Of the 34 494 patients with cirrhosis (mean [SD] age, 62 [7.7] years; 33 560 men [97.29%]; 22 509 White patients [65.25%]), 1534 (4.45%) were referred, 1035 (3.00%) were wait-listed, and 549 (1.59%) underwent a liver transplant within 3 years of meeting clinical criteria for transplantation. Patient age of 70 years or older was associated with lower rates of referral (hazard ratio [HR], 0.09; 95% CI, 0.06-0.13), wait-listing (HR, 0.07; 95% CI, 0.04-0.12), and transplant (HR, 0.08; 95% CI, 0.04-0.16). Alcohol etiology for liver cirrhosis was associated with lower rates of referral (HR, 0.38; 95% CI, 0.33-0.44), wait-listing (HR, 0.32; 95% CI, 0.27-0.38), and transplant (HR, 0.30; 95% CI, 0.23-0.37). In addition, comorbidity (none vs >1 comorbidity) was associated with lower rates of referral (HR, 0.47; 95% CI, 0.40-0.56), wait-listing (HR, 0.38; 95% CI, 0.31-0.46), and transplant (HR, 0.28; 95% CI, 0.21-0.38). African American patients were less likely to be referred (HR, 0.82; 95% CI, 0.70-0.95) and wait-listed (HR, 0.73; 95% CI, 0.61-0.88). Patients with lower annual income and those seen in facilities in the West were less likely to be referred (HR, 0.70; 95% CI, 0.53-0.93), wait-listed (HR, 0.48; 95% CI, 0.36-0.64), or undergo a transplant (HR, 0.50; 95% CI, 0.34-0.74). In a review of the medical records for 333 patients who had limited comorbidity but were not referred, organ transplant was considered as a potential option in 176 (52.85%). When documented, medical and psychosocial barriers explained most of the deficits in referral.Conclusions and Relevance: In this cohort study, few patients with advanced liver disease received referrals, were wait-listed, or underwent a transplant. The greatest deficits occurred at the referral step. Although health systems routinely track rates and disparities for organ transplants among wait-listed patients, extending monitoring to the earlier stages may help improve equity and manage potentially modifiable barriers to transplantation.

    View details for DOI 10.1001/jamainternmed.2021.2051

    View details for PubMedID 34028505

  • Inpatient telemedicine implementation as an infection control response to COVID-19: A qualitative process evaluation. JMIR formative research Safaeinili, N., Vilendrer, S., Williamson, E., Zhao, Z., Brown-Johnson, C., Asch, S. M., Shieh, L. 2021


    BACKGROUND: The COVID-19 pandemic created new challenges to delivering safe and effective healthcare while minimizing staff and non-COVID-19 patient exposure to the virus. Health systems worldwide have moved quickly to implement telemedicine in diverse settings to reduce infection, but little is understood about how best to connect acutely ill patients with nearby clinical team members, even in the next room.OBJECTIVE: To inform these efforts, this paper provides an early example of inpatient telemedicine implementation and its perceived acceptability and effectiveness.METHODS: Using purposive sampling, this study conducted 15 semi-structured interviews with nurses (n=5) and attending (n=5) and resident (n=15) physicians on a single COVID-19 unit within Stanford Health Care to evaluate implementation outcomes and perceived effectiveness of inpatient telemedicine. Semi-structured interview protocols and qualitative analysis were framed around the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework and identified key themes using a rapid analytic process and consensus approach.RESULTS: All clinical team members reported wide reach of inpatient telemedicine, with some use for almost all COVID-19 patients. Inpatient telemedicine was perceived to be effective in reducing COVID-19 exposure and personal protective equipment (PPE) use without significantly compromising quality of care. Physician workflows remained relatively stable as most standard clinical activities were conducted via telemedicine following the initial intake examination, though resident physicians reported reduced educational opportunities given limited opportunities to conduct physical exams. Nurse workflows required significant adaptations to cover non-nursing duties such as food delivery and facilitating technology connections for patients and physicians alike. Perceived patient impact included consistent care quality, with some considerations around privacy. Reported challenges included: patient-clinical team communication and personal connection with the patient, perceptions of patient isolation, ongoing technical challenges, and certain aspects of the physical exam.CONCLUSIONS: Clinical team members reported inpatient telemedicine encounters as acceptable and effective in reducing COVID-19 exposure and PPE use. Nurses adapted their workflows more than physicians to implement the new technology and bore a higher burden of in-person care and technical support. Recommendations for improved inpatient telemedicine use include information technology (IT) support and training, increased technical functionality, and remote access for the clinical team.CLINICALTRIAL:

    View details for DOI 10.2196/26452

    View details for PubMedID 34033576

  • Outcomes that Matter: High-Needs Patients' and Primary Care Leaders' Perspectives on an Intensive Primary Care Pilot. Journal of general internal medicine Wong, M. S., Luger, T. M., Katz, M. L., Stockdale, S. E., Ewigman, N. L., Jackson, J. L., Zulman, D. M., Asch, S. M., Ong, M. K., Chang, E. T. 2021


    BACKGROUND: Quantitative evaluations of the effectiveness of intensive primary care (IPC) programs for high-needs patients have yielded mixed results for improving healthcare utilization, cost, and mortality. However, IPC programs may provide other value.OBJECTIVE: To understand the perspectives of high-needs patients and primary care facility leaders on the effects of a Veterans Affairs (VA) IPC program on patients.DESIGN: A total of 66 semi-structured telephone interviews with high-needs VA patients and primary care facility leaders were conducted as part of the IPC program evaluation.PARTICIPANTS: High-needs patients (n = 51) and primary care facility leaders (n = 15) at 5 VA pilot sites.APPROACH: We used content analysis to examine interview transcripts for both a priori and emergent themes about perceived IPC program effects.KEY RESULTS: Patients enrolled in VA IPCs reported improvements in their experience of VA care (e.g., patient-provider relationship, access to their team). Both patients and leaders reported improvements in patient motivation to engage with self-care and with their IPC team, and behaviors, especially diet, exercise, and medication management. Patients also perceived improvements in health and described receiving assistance with social needs. Despite this, patients and leaders also outlined patient health characteristics and contextual factors (e.g., chronic health conditions, housing insecurity) that may have limited the effectiveness of the program on healthcare cost and utilization.CONCLUSIONS: Patients and primary care facility leaders report benefits for high-needs patients from IPC interventions that translated into perceived improvements in healthcare, health behaviors, and physical and mental health status. Most program evaluations focus on cost and utilization, which may be less amenable to change given this cohort's numerous comorbid health conditions and complex social circumstances. Future IPC program evaluations should additionally examine IPC's effects on quality of care, patient satisfaction, quality of life, and patient health behaviors other than utilization (e.g., engagement, self-efficacy).

    View details for DOI 10.1007/s11606-021-06869-4

    View details for PubMedID 33987789

  • Learning from Past Respiratory Failure Patients to Triage COVID-19 Patient Ventilator Needs: A Multi-Institutional Study. Journal of biomedical informatics Carmichael, H., Coquet, J., Sun, R., Sang, S., Groat, D., Asch, S. M., Bledsoe, J., Peltan, I. D., Jacobs, J. R., Hernandez-Boussard, T. 2021: 103802


    BACKGROUND: Unlike well-established diseases that base clinical care on randomized trials, past experiences, and training, prognosis in COVID19 relies on a weaker foundation. Knowledge from other respiratory failure diseases may inform clinical decisions in this novel disease. The objective was to predict 48-hour invasive mechanical ventilation (IMV) within 48 hours in patients hospitalized with COVID-19 using COVID-like diseases (CLD).METHODS: This retrospective multicenter study trained machine learning (ML) models on patients hospitalized with CLD to predict IMV within 48 hours in COVID-19 patients. CLD patients were identified using diagnosis codes for bacterial pneumonia, viral pneumonia, influenza, unspecified pneumonia and acute respiratory distress syndrome (ARDS), 2008-2019. A total of 16 cohorts were constructed, including any combinations of the four diseases plus an exploratory ARDS cohort, to determine the most appropriate cohort to use. Candidate predictors included demographic and clinical parameters that were previously associated with poor COVID-19 outcomes. Model development included the implementation of logistic regression and three ensemble tree-based algorithms: decision tree, AdaBoost, and XGBoost. Models were validated in hospitalized COVID-19 patients at two healthcare systems, March 2020-July 2020. ML models were trained on CLD patients at Stanford Hospital Alliance (SHA). Models were validated on hospitalized COVID-19 patients at both SHA and Intermountain Healthcare.RESULTS: CLD training data were obtained from SHA (n=14,030), and validation data included 444 adult COVID-19 hospitalized patients from SHA (n=185) and Intermountain (n=259). XGBoost was the top-performing ML model, and among the 16 CLD training cohorts, the best model achieved an area under curve (AUC) of 0.883 in the validation set. In COVID-19 patients, the prediction models exhibited moderate discrimination performance, with the best models achieving an AUC of 0.77 at SHA and 0.65 at Intermountain. The model trained on all pneumonia and influenza cohorts had the best overall performance (SHA: positive predictive value (PPV) 0.29, negative predictive value (NPV) 0.97, positive likelihood ratio (PLR) 10.7; Intermountain: PPV, 0.23, NPV 0.97, PLR 10.3). We identified important factors associated with IMV that are not traditionally considered for respiratory diseases.CONCLUSIONS: The performance of prediction models derived from CLD for 48-hour IMV in patients hospitalized with COVID-19 demonstrate high specificity and can be used as a triage tool at point of care. Novel predictors of IMV identified in COVID-19 are often overlooked in clinical practice. Lessons learned from our approach may assist other research institutes seeking to build artificial intelligence technologies for novel or rare diseases with limited data for training and validation.

    View details for DOI 10.1016/j.jbi.2021.103802

    View details for PubMedID 33965640

  • Cross Disciplinary Role Agreement is Needed When Coordinating Long-Term Opioid Prescribing for Cancer: a Qualitative Study. Journal of general internal medicine Giannitrapani, K. F., Silveira, M. J., Azarfar, A., Glassman, P. A., Singer, S. J., Asch, S. M., Midboe, A. M., Zenoni, M. A., Gamboa, R. C., Becker, W. C., Lorenz, K. A. 2021


    BACKGROUND: Cancer pain is highly prevalent and often managed in primary care or by oncology providers in combination with primary care providers.OBJECTIVES: To understand interdisciplinary provider experiences coordinating opioid pain management for patients with chronic cancer-related pain in a large integrated healthcare system.DESIGN: Qualitative research.PARTICIPANTS: We conducted 20 semi-structured interviews with interdisciplinary providers in two large academically affiliated VA Medical Centers and their associated community-based outpatient clinics. Participants included primary care providers (PCPs) and oncology-based personnel (OBPs).APPROACH: We deductively identified 94 examples of care coordination for cancer pain in the 20 interviews. We secondarily used an inductive open coding approach and identified themes through constant comparison coming to research team consensus.RESULTS: Theme 1: PCPs and OBPs generally believed one provider should handle all opioid prescribing for a specific patient, but did not always agree on who that prescriber should be in the context of cancer pain. Theme 2: There are special circumstances where having multiple prescribers is appropriate (e.g., a pain crisis). Theme 3: A collaborative process to opioid cancer pain management would include real-time communication and negotiation between PCPs and oncology around who will handle opioid prescribing. Theme 4: Providers identified multiple barriers in coordinating cancer pain management across disciplines.CONCLUSIONS: Our findings highlight how real-time negotiation about roles in opioid pain management is needed between interdisciplinary clinicians. Lack of cross-disciplinary role agreement may result in delays in clinically appropriate cancer pain management.

    View details for DOI 10.1007/s11606-021-06747-z

    View details for PubMedID 33948790

  • Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool. Surgery Brown-Johnson, C. G., Spargo, T., Kling, S. M., Saliba-Gustafsson, E. A., Lestoquoy, A. S., Garvert, D. W., Vilendrer, S., Winget, M., Asch, S. M., Maggio, P., Nazerali, R. S. 2021


    BACKGROUND: Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility.METHODS: This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n= 20) and surgeons (n= 10) to explore stakeholder perspectives on video visits.RESULTS: During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics.CONCLUSION: Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.

    View details for DOI 10.1016/j.surg.2021.03.029

    View details for PubMedID 33941389

  • How Should We Organize Care for Patients With Human Immunodeficiency Virus and Comorbidities? A Multisite Qualitative Study of Human Immunodeficiency Virus Care in the United States Department of Veterans Affairs. Medical care Bokhour, B. G., Bolton, R. E., Asch, S. M., Dvorin, K., Fix, G. M., Gifford, A. L., Hyde, J. K., McInnes, D. K., Parker, V. A., Richardson, K., Skolnik, A. A., Vaughan-Sarrazin, M. S., Wu, J., Ohl, M. E. 2021


    BACKGROUND: With human immunodeficiency virus (HIV) now managed as a chronic disease, health care has had to change and expand to include management of other critical comorbidities. We sought to understand how variation in the organization, structure and processes of HIV and comorbidity care, based on patient-centered medical home (PCMH) principles, was related to care quality for Veterans with HIV.RESEARCH DESIGN: Qualitative site visits were conducted at a purposive sample of 8 Department of Veterans Affairs Medical Centers, varying in care quality and outcomes for HIV and common comorbidities. Site visits entailed conduct of patient interviews (n=60); HIV care team interviews (n=60); direct observation of clinic processes and team interactions (n=22); and direct observations of patient-provider clinical encounters (n=45). Data were analyzed using a priori and emergent codes, construction of site syntheses and comparing sites with varying levels of quality.RESULTS: Sites highest and lowest in both HIV and comorbidity care quality demonstrated clear differences in provision of PCMH-principled care. The highest site provided greater team-based, comprehensive, patient-centered, and data-driven care and engaged in continuous improvement. Sites with higher HIV care quality attended more to psychosocial needs. Sites that had consistent processes for comorbidity care, whether in HIV or primary care clinics, had higher quality of comorbidity care.CONCLUSIONS: Provision of high-quality HIV care and high-quality co-morbidity care require different care structures and processes. Provision of both requires a focus on providing care aligned with PCMH principles, integrating psychosocial needs into care, and establishing explicit consistent approaches to comorbidity management.

    View details for DOI 10.1097/MLR.0000000000001563

    View details for PubMedID 33900271

  • US National Trends in Vascular Surgical Practice During the COVID-19 Pandemic. JAMA surgery Ho, V. T., Eberhard, A. V., Asch, S. M., Leeper, N. J., Fukaya, E., Arya, S., Ross, E. G. 2021

    View details for DOI 10.1001/jamasurg.2021.1708

    View details for PubMedID 33856428

  • Evaluation of Patient and Clinician Perspectives for New and Return Ambulatory Teleneurology Visits, with special attention to subspecialty differences Falco-Walter, J., Kling, S., Saliba-Gustafsson, E., Yang, L., Miller-Kuhlmann, R., Garvert, D., Brown-Johnson, C., Shaw, J., Asch, S., Winget, M., Gold, C. LIPPINCOTT WILLIAMS & WILKINS. 2021
  • ADAPTING A DYADIC CHRONIC ILLNESS SELF-CARE PROGRAM FOR THE INTERNET: METHODOLOGY AND USABILITY Trivedi, R. B., Hirayama, S. K., Suresh, M., Risbud, R., Humber, M. B., Zulman, D. M., Asch, S. M., Nelson, K., Timko, C., Humphreys, K., Piette, J. OXFORD UNIV PRESS INC. 2021: S34
  • Cost-effectiveness of Treatments for Opioid Use Disorder. JAMA psychiatry Fairley, M., Humphreys, K., Joyce, V. R., Bounthavong, M., Trafton, J., Combs, A., Oliva, E. M., Goldhaber-Fiebert, J. D., Asch, S. M., Brandeau, M. L., Owens, D. K. 2021


    Importance: Opioid use disorder (OUD) is a significant cause of morbidity and mortality in the US, yet many individuals with OUD do not receive treatment.Objective: To assess the cost-effectiveness of OUD treatments and association of these treatments with outcomes in the US.Design and Setting: This model-based cost-effectiveness analysis included a US population with OUD.Interventions: Medication-assisted treatment (MAT) with buprenorphine, methadone, or injectable extended-release naltrexone; psychotherapy (beyond standard counseling); overdose education and naloxone distribution (OEND); and contingency management (CM).Main Outcomes and Measures: Fatal and nonfatal overdoses and deaths throughout 5 years, discounted lifetime quality-adjusted life-years (QALYs), and costs.Results: In the base case, in the absence of treatment, 42 717 overdoses (4132 fatal, 38 585 nonfatal) and 12 660 deaths were estimated to occur in a cohort of 100 000 patients over 5 years, and 11.58 discounted lifetime QALYs were estimated to be experienced per person. An estimated reduction in overdoses was associated with MAT with methadone (10.7%), MAT with buprenorphine or naltrexone (22.0%), and when combined with CM and psychotherapy (range, 21.0%-31.4%). Estimated deceased deaths were associated with MAT with methadone (6%), MAT with buprenorphine or naltrexone (13.9%), and when combined with CM, OEND, and psychotherapy (16.9%). MAT yielded discounted gains of 1.02 to 1.07 QALYs per person. Including only health care sector costs, methadone cost $16 000/QALY gained compared with no treatment, followed by methadone with OEND ($22 000/QALY gained), then by buprenorphine with OEND and CM ($42 000/QALY gained), and then by buprenorphine with OEND, CM, and psychotherapy ($250 000/QALY gained). MAT with naltrexone was dominated by other treatment alternatives. When criminal justice costs were included, all forms of MAT (with buprenorphine, methadone, and naltrexone) were associated with cost savings compared with no treatment, yielding savings of $25 000 to $105 000 in lifetime costs per person. The largest cost savings were associated with methadone plus CM. Results were qualitatively unchanged over a wide range of sensitivity analyses. An analysis using demographic and cost data for Veterans Health Administration patients yielded similar findings.Conclusions and Relevance: In this cost-effectiveness analysis, expanded access to MAT, combined with OEND and CM, was associated with cost-saving reductions in morbidity and mortality from OUD. Lack of widespread MAT availability limits access to a cost-saving medical intervention that reduces morbidity and mortality from OUD. Opioid overdoses in the US likely reached a record high in 2020 because of COVID-19 increasing substance use, exacerbating stress and social isolation, and interfering with opioid treatment. It is essential to understand the cost-effectiveness of alternative forms of MAT to treat OUD.

    View details for DOI 10.1001/jamapsychiatry.2021.0247

    View details for PubMedID 33787832

  • Quality measures for end-of-life care for children with cancer: A modified Delphi approach. Cancer Johnston, E. E., Martinez, I., Wolfe, J., Asch, S. M. 2021


    BACKGROUND: The quality of adult end-of-life (EOL) cancer care has benefited from quality measures, but corresponding pediatric measures are lacking. Therefore, the authors used a validated expert panel method to recommend EOL quality measures for pediatric oncology.METHODS: The authors used the modified Delphi method to assess potential quality measures. Panelists were selected on the basis of professional organization nominations and expert qualifications. Pediatric and adult oncology, pediatric palliative care, social work, nursing, and hospice were represented. The authors provided the panel with a literature review on 20 proposed measures derived from adult measures and bereaved family interviews. The panel first scored the importance of each measure on a 9-point scale and then discussed the measures via a conference call. The panel then rescored the measures. According to a priori standards, measures with median scores ≥ 7 with at least 7 of 9 experts ranking it as ≥4 were endorsed.RESULTS: The 16 endorsed measures included measures related to avoidance of medically intense care (eg, intensive care unit death and intubation in the last 14 days of life), death location (eg, death in the preferred location), hospital policies/programs (eg, the removal of visitor restrictions at EOL and the presence of a bereavement program), and supportive care services (eg, pediatric palliative care involvement and sibling needs assessment). Unendorsed measures included avoidance of chemotherapy at EOL and home death.CONCLUSIONS: Expert panel-endorsed quality measures have been developed for EOL care in pediatric oncology. The measures need validation with bereaved families and further refinement before they are ready for real-world application as a tool for standardizing EOL care in pediatric oncology.LAY SUMMARY: Quality measures for end-of-life care for children with cancer lag behind adult quality measures. Therefore, the authors have conducted an expert panel to develop an endorsed list of quality measures for end-of-life care for children with cancer. The 16 endorsed measures include measures related to avoidance of medically intense care (eg, intensive care unit death and intubation in the last 14 days of life), location of death (eg, death in the preferred location), hospital policies/programs (eg, the removal of visitor restrictions at the end of life and the presence of a bereavement program), and supportive care services (eg, pediatric palliative care involvement and sibling needs assessment).

    View details for DOI 10.1002/cncr.33546

    View details for PubMedID 33784408

  • Building Bridges Between Community Health Centers and Academic Medical Centers in a COVID-19 Pandemic. Journal of the American Board of Family Medicine : JABFM Taylor, N. K., Aboelata, N., Mahoney, M., Seay-Morrison, T., Singh, B., Chang, S., Asch, S. M., Shaw, J. G. 2021; 34 (Supplement): S229–S232


    The threat to the public health of the United States from the COVID-19 pandemic is causing rapid, unprecedented shifts in the health care landscape. Community health centers serve the patient populations most vulnerable to the disease yet often have inadequate resources to combat it. Academic medical centers do not always have the community connections needed for the most effective population health approaches. We describe how a bridge between a community health center partner (Roots Community Health Center) and a large academic medical center (Stanford Medicine) brought complementary strengths together to address the regional public health crisis. The 2 institutions began the crisis with an overlapping clinical and research faculty member (NKT). Building on that foundation, we worked in 3 areas. First, we partnered to reach underserved populations with the academic center's newly developed COVID test. Second, we developed and distributed evidence-based resources to these same communities via a large community health navigator team. Third, as telemedicine became the norm for medical consultation, the 2 institutions began to research how reducing the digital divide could help improve access to care. We continue to think about how best to create enduring partnerships forged through ongoing deeper relationships beyond the pandemic.

    View details for DOI 10.3122/jabfm.2021.S1.200182

    View details for PubMedID 33622844

  • Improving Uptake of a National Web-Based Psychoeducational Workshop for Informal Caregivers of Veterans: Mixed Methods Implementation Evaluation. Journal of medical Internet research Yank, V., Gale, R. C., Nevedal, A., Okwara, L., Koenig, C. J., Trivedi, R. B., Dupke, N. J., Kabat, M., Asch, S. M. 2021; 23 (1): e16495


    BACKGROUND: Although web-based psychoeducational programs may be an efficient, accessible, and scalable option for improving participant well-being, they seldom are sustained beyond trial publication. Implementation evaluations may help optimize program uptake, but few are performed. When the US Department of Veterans Affairs (VA) launched the web-based psychoeducational workshop Building Better Caregivers (BBC) for informal caregivers of veterans nationwide in 2013, the workshop did not enroll as many caregivers as anticipated.OBJECTIVE: This study aims to identify the strengths and weaknesses of initial implementation, strategies likely to improve workshop uptake, whether the VA adopted these strategies, and whether workshop enrollment changed.METHODS: We used mixed methods and the Promoting Action on Research Implementation in Health Services (PARIHS) implementation evaluation framework. In stage 1, we conducted semistructured interviews with caregivers, local staff, and regional and national VA leaders and surveys with caregivers and staff. We collected and analyzed survey and interview data concurrently and integrated the results to identify implementation strengths and weaknesses, and strategies likely to improve workshop uptake. In stage 2, we reinterviewed national leaders to determine whether the VA adopted recommended strategies and used national data to determine whether workshop enrollment changed over time.RESULTS: A total of 54 caregivers (n=32, 59%), staff (n=13, 24%), and regional (n=5, 9%) and national (n=4, 7%) leaders were interviewed. We received survey responses from 72% (23/32) of caregivers and 77% (10/13) of local staff. In stage 1, survey and interview results were consistent across multiple PARIHS constructs. Although participants from low-enrollment centers reported fewer implementation strengths and more weaknesses, qualitative themes were consistent across high- and low-enrollment centers, and across caregiver, staff, and leadership respondent groups. Identified strengths included belief in a positive workshop impact and the use of some successful outreach approaches. Implementation weaknesses included missed opportunities to improve outreach and to better support local staff. From these, we identified and recommended new and enhanced implementation strategies-increased investment in outreach and marketing capabilities; tailoring outreach strategies to multiple stakeholder groups; use of campaigns that are personal, repeated, and detailed, and have diverse delivery options; recurrent training and mentoring for new staff; and comprehensive data management and reporting capabilities. In stage 2, we determined that the VA had adopted several of these strategies in 2016. In the 3 years before and after adoption, cumulative BBC enrollment increased from 2139 (2013-2015) to 4030 (2016-2018) caregivers.CONCLUSIONS: This study expands the limited implementation science literature on best practices to use when implementing web-based psychoeducational programs. We found that robust outreach and marketing strategies and support for local staff were critical to the implementation success of the BBC workshop. Other health systems may want to deploy these strategies when implementing their web-based programs.

    View details for DOI 10.2196/16495

    View details for PubMedID 33410759

  • Supporting First Responders and Essential Workers During a Pandemic: Needs Assessment and Mixed-Methods Implementation Evaluation of a COVID-19 App-Based Intervention. Journal of medical Internet research Vilendrer, S. n., Amano, A. n., Brown Johnson, C. G., Favet, M. n., Safaeinili, N. n., Villasenor, J. n., Shaw, J. G., Hertelendy, A. J., Asch, S. M., Mahoney, M. n. 2021


    The COVID-19 pandemic has created unprecedented challenges for first responders (e.g., police, fire, and emergency medical services) and non-medical essential workers (e.g., food, transportation and other industries). Health systems may be uniquely suited to support these workers given their medical expertise, and mobile applications ("apps") can reach local communities despite social distancing requirements. Formal evaluation of real-world mobile app-based interventions are lacking.We aimed to evaluate the adoption, acceptability and appropriateness of an academic medical center's app-based intervention (COVID-19 Guide App) designed to support first responders and essential workers' access to COVID-19 information and testing services. We also sought to better understand the COVID-19 related needs of these workers early in the pandemic.To understand overall community adoption, COVID-19 Guide App views and download data were described. To understand adoption, appropriateness and acceptability of the app and workers' unmet needs, semi-structured qualitative interviews were conducted by phone, video and in-person with first responder and essential workers in the San Francisco Bay Area, recruited through purposive, convenience, and snowball sampling. Interview transcripts and field notes were qualitatively analyzed and presented using an implementation outcomes framework.From April 2020 launch to September 2020, the app received 8,262 views from unique devices and 6,640 downloads (80.4% conversion rate, 0.61% adoption rate across the Bay Area). App acceptability was mixed amongst 17 first responders interviewed and high amongst 10 essential workers interviewed. Select themes included the need for personalized and accurate information, access to testing, and securing personal safety. First responders faced additional challenges related to inter-professional coordination and a culture of heroism that could both protect against and exacerbate health vulnerability.First responders and essential workers both report challenges related to obtaining accurate information, testing services, and other resources. A mobile app intervention has the potential to combat these challenges through the provision of disease-specific information and access to testing services but may be most effective if delivered as part of a larger ecosystem of support. Differentiated interventions that acknowledge and address the divergent needs between first responders and non-first responder essential workers may optimize acceptance and adoption.

    View details for DOI 10.2196/26573

    View details for PubMedID 33878023

  • From implementation to sustainment: A large-scale adverse event disclosure support program generated through embedded research in the Veterans Health Administration. Healthcare (Amsterdam, Netherlands) Elwy, A. R., Maguire, E. M., McCullough, M., George, J., Bokhour, B. G., Durfee, J. M., Martinello, R. A., Wagner, T. H., Asch, S. M., Gifford, A. L., Gallagher, T. H., Walker, Y., Sharpe, V. A., Geppert, C., Holodniy, M., West, G. 2021; 8 Suppl 1: 100496


    In 2008, the Veterans Health Administration published a groundbreaking policy on disclosing large-scale adverse events to patients in order to promote transparent communication in cases where harm may not be obvious or even certain. Without embedded research, the evidence on whether or not implementation of this policy was generating more harm than good among Veteran patients was unknown. Through an embedded research-operations partnership, we conducted four research projects that led to the development of an evidence-based large-scale disclosure toolkit and disclosure support program, and its implementation across VA healthcare. Guided by the Consolidated Framework for Implementation Research, we identified specific activities corresponding to planning, engaging, executing, reflecting and evaluating phases in the process of implementation. These activities included planning with operational leaders to establish a shared research agenda; engaging with stakeholders to discuss early results, establishing buy-in of our efforts and receiving feedback; joining existing operational teams to execute the toolkit implementation; partnering with clinical operations to evaluate the toolkit during real-time disclosures; and redesigning the toolkit to meet stakeholders' needs. Critical lessons learned for implementation success included a need for stakeholder collaboration and engagement, an organizational culture involving a strong belief in evidence, a willingness to embed researchers in clinical operation activities, allowing for testing and evaluation of innovative practices, and researchers open to constructive feedback. At the conclusion of the research, VA operations worked with the researchers to continue to support efforts to spread, scale-up and sustain toolkit use across the VA healthcare system, with the final goal to establish long-term sustainability.

    View details for DOI 10.1016/j.hjdsi.2020.100496

    View details for PubMedID 34175102

  • Vaccine Hesitancy as an Opportunity for Engagement: a Rapid Qualitative Study of Patients and Employees in the U.S. Veterans Affairs Healthcare System. Vaccine: X Rani Elwy, A., Clayman, M. L., LoBrutto, L., Miano, D., Ann Petrakis, B., Javier, S., Erhardt, T., Midboe, A. M., Carbonaro, R., Jasuja, G. K., Maguire, E. M., Kyrish, A., Asch, S. M., Gifford, A. L., Keith McInnes, D. 2021: 100116


    Although COVID-19 vaccines have been available to many U.S. Veterans Affairs (VA) healthcare system employees and Veteran patients since early 2021, vaccine receipt data indicates some groups are not receiving them. Our objective was to conduct a rapid qualitative assessment of Veterans' and VA employees' views on COVID-19 vaccination to inform clinical leaders' ongoing efforts to increase vaccine uptake across the VA. We employed semi-structured interviews and a focus group involving employees and Veterans as part of a quality improvement project between January and June 2021 at three VA medical centers. Thirty-one employees and 27 Veterans participated in semi-structured interviews; 5 Veterans from a national stakeholder organization participated in a focus group. Data were analyzed using directed content analysis, involving an a priori coding framework comprised of four domains with subcodes under each: contextual influences, barriers and facilitators, vaccine-specific issues, and VA/military experiences. We then classified initial codes into five categories of hesitancy: vaccine deliberation, dissent, distrust, indifference and skepticism. A subset of Veterans (n=14) and employees (n=8) identified as vaccine hesitant. Vaccine hesitancy categories were represented by subcodes of religion, culture, gender or socio-economic factors, perceptions of politics and policies, role of healthcare providers, and historical influences; (contextual influences); knowledge or awareness of vaccines, perceived susceptibility to COVID-19, and beliefs and attitudes about health and illness (barriers and facilitators); vaccine development process (vaccine-specific issues) and military experiences (VA/military factors). Facilitators involved talking with trusted others, ease of vaccine access, and perceptions of family and societal benefits of vaccines. Vaccine hesitancy is multi-faceted and likely requires multiple strategies for engaging in conversations to address Veteran and VA employee concerns. Messages should involve patient-centered communication strategies delivered by trusted healthcare providers and peers and should focus on addressing expected benefits for family, friends, and society.

    View details for DOI 10.1016/j.jvacx.2021.100116

    View details for PubMedID 34580652

    View details for PubMedCentralID PMC8457639

  • Factors Influencing Implementation of Blood Transfusion Recommendations in Pediatric Critical Care Units. Frontiers in pediatrics Steffen, K. M., Spinella, P. C., Holdsworth, L. M., Ford, M. A., Lee, G. M., Asch, S. M., Proctor, E. K., Doctor, A. 1800; 9: 800461


    Purpose: Risks of red blood cell transfusion may outweigh benefits for many patients in Pediatric Intensive Care Units (PICUs). The Transfusion and Anemia eXpertise Initiative (TAXI) recommendations seek to limit unnecessary and potentially harmful transfusions, but use has been variable. We sought to identify barriers and facilitators to using the TAXI recommendations to inform implementation efforts. Materials and Methods: The integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework guided semi-structured interviews conducted in 8 U.S. ICUs; 50 providers in multiple ICU roles completed interviews. Adapted Framework analysis, a form of content analysis, used the iPARIHS innovation, recipient, context and facilitation constructs and subconstructs to categorize data and identify patterns as well as unique informative statements. Results: Providers perceived that the TAXI recommendations would reduce transfusion rates and practice variability, but adoption faced challenges posed by attitudes around transfusion and care in busy and complex units. Development of widespread buy-in and inclusion in implementation, integration into workflow, designating committed champions, and monitoring outcomes data were expected to enhance implementation. Conclusions: Targeted activities to create buy-in, educate, and plan for use are necessary for TAXI implementation. Recognition of contextual challenges posed by the PICU environment and an approach that adjusts for barriers may optimize adoption.

    View details for DOI 10.3389/fped.2021.800461

    View details for PubMedID 34976903

  • Changing Institutional Culture Around Hospice Using LEAN Tools to Improve Hospice Utilization in a Veteran Population. Journal of pain and symptom management Yamarik, R. L., Wenziger, C. n., Streja, E. n., Ngoc-Thao, A. n., Wei, K. S., Bedi, B. n., Asch, S. n. 2021


    Longer hospice length of stay improves the palliation of symptoms, quality of life, and the dying process for patients and their caregivers. We used a Lean designed Rapid Improvement Event (RIE) to facilitate earlier entry into hospice.Our primary outcome was hospice length of stay. Secondary outcomes were avoiding unwanted inpatient utilization and hospice location.We conducted a 5-day RIE utilizing Lean tools targeting the inpatient medicine wards.Hospice length of stay increased from a median (interquartile range (IQR)) of 11(7,27) days prior to 37(7,73) days following the RIE. Home hospice and outside Skilled Nursing Home (SNF) hospice use increased while use of the onsite VA hospice decreased.LEAN tools can be used successfully to improve end of life outcomes in an inpatient VA setting. The 90-day sustainment period following the RIE uncovers barriers to implementation and allows for adjustments to implementation.

    View details for DOI 10.1016/j.jpainsymman.2021.03.021

    View details for PubMedID 33831462

  • Implementation of clinical practice changes in the PICU: a qualitative study using and refining the iPARIHS framework. Implementation science : IS Steffen, K. M., Holdsworth, L. M., Ford, M. A., Lee, G. M., Asch, S. M., Proctor, E. K. 2021; 16 (1): 15


    Like in many settings, implementation of evidence-based practices often fall short in pediatric intensive care units (PICU). Very few prior studies have applied implementation science frameworks to understand how best to improve practices in this unique environment. We used the relatively new integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework to assess practice improvement in the PICU and to explore the utility of the framework itself for that purpose.We used the iPARIHS framework to guide development of a semi-structured interview tool to examine barriers, facilitators, and the process of change in the PICU. A framework approach to qualitative analysis, developed around iPARIHS constructs and subconstructs, helped identify patterns and themes in provider interviews. We assessed the utility of iPARIHS to inform PICU practice change.Fifty multi-professional providers working in 8 U.S. PICUs completed interviews. iPARIHS constructs shaped the development of a process model for change that consisted of phases that include planning, a decision to adopt change, implementation and facilitation, and sustainability; the PICU environment shaped each phase. Large, complex multi-professional teams, and high-stakes work at near-capacity impaired receptivity to change. While the unit leaders made decisions to pursue change, providers' willingness to accept change was based on the evidence for the change, and provider's experiences, beliefs, and capacity to integrate change into a demanding workflow. Limited analytic structures and resources frustrated attempts to monitor changes' impacts. Variable provider engagement, time allocated to work on changes, and limited collaboration impacted facilitation. iPARIHS constructs were useful in exploring implementation; however, we identified inter-relation of subconstructs, unique concepts not captured by the framework, and a need for subconstructs to further describe facilitation.The PICU environment significantly shaped the implementation. The described process model for implementation may be useful to guide efforts to integrate changes and select implementation strategies. iPARIHS was adequate to identify barriers and facilitators of change; however, further elaboration of subconstructs for facilitation would be helpful to operationalize the framework.Not applicable, as no health care intervention was performed.

    View details for DOI 10.1186/s13012-021-01080-9

    View details for PubMedID 33509190

  • Cost-Effectiveness of Open Versus Endoscopic Carpal Tunnel Release. The Journal of bone and joint surgery. American volume Barnes, J. I., Paci, G. n., Zhuang, T. n., Baker, L. C., Asch, S. M., Kamal, R. N. 2021; 103 (4): 343–55


    Carpal tunnel syndrome is the most common upper-extremity nerve compression syndrome. Over 500,000 carpal tunnel release (CTR) procedures are performed in the U.S. yearly. We estimated the cost-effectiveness of endoscopic CTR (ECTR) versus open CTR (OCTR) using data from published meta-analyses comparing outcomes for ECTR and OCTR.We developed a Markov model to examine the cost-effectiveness of OCTR versus ECTR for patients undergoing unilateral CTR in an office setting under local anesthesia and in an operating-room (OR) setting under monitored anesthesia care. The main outcomes were costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We modeled societal (modeled with a 50-year-old patient) and Medicare payer (modeled with a 65-year-old patient) perspectives, adopting a lifetime time horizon. We performed deterministic and probabilistic sensitivity analyses (PSAs).ECTR resulted in 0.00141 additional QALY compared with OCTR. From a societal perspective, assuming 8.21 fewer days of work missed after ECTR than after OCTR, ECTR cost less across all procedure settings. The results are sensitive to the number of days of work missed following surgery. From a payer perspective, ECTR in the OR (ECTROR) cost $1,872 more than OCTR in the office (OCTRoffice), for an ICER of approximately $1,332,000/QALY. The ECTROR cost $654 more than the OCTROR, for an ICER of $464,000/QALY. The ECTRoffice cost $107 more than the OCTRoffice, for an ICER of $76,000/QALY. From a payer perspective, for a willingness-to-pay threshold of $100,000/QALY, OCTRoffice was preferred over ECTROR in 77% of the PSA iterations. From a societal perspective, ECTROR was preferred over OCTRoffice in 61% of the PSA iterations.From a societal perspective, ECTR is associated with lower costs as a result of an earlier return to work and leads to higher QALYs. Additional research on return to work is needed to confirm these findings on the basis of contemporary return-to-work practices. From a payer perspective, ECTR is more expensive and is cost-effective only if performed in an office setting under local anesthesia.Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.2106/JBJS.19.01354

    View details for PubMedID 33591684

  • Expert Stakeholder Prioritization of Process Quality Measures to Achieve Patient- and Family-Centered Palliative and End-of-Life Cancer Care. Journal of palliative medicine O'Hanlon, C. E., Lindvall, C. n., Giannitrapani, K. F., Garrido, M. n., Ritchie, C. n., Asch, S. n., Gamboa, R. C., Canning, M. n., Lorenz, K. A., Walling, A. M. 2021


    Importance: Quality measures of palliative and end-of-life care relevant to patients with advanced cancer have been developed, but few are in routine use. It is unclear which of these measures are most important for providing patient- and family-centered care and have high potential for improving quality of care. Objective: To prioritize process quality measures for assessing delivery of patient- and family-centered palliative and end-of-life cancer care in US Veterans Affairs (VA) health care facilities. Design, Setting, Participants: A panel of 10 palliative and cancer care expert stakeholders (7 physicians, 2 nurses, 1 social worker) rated process quality measure concepts before and after a 1-day meeting. Measures: Panelists rated 64 measure concepts on a nine-point scale on: (1) importance to providing patient- and family-centered care, and (2) potential for quality improvement (QI). Panelists also nominated five highest priority measure concepts ("top 5") on each attribute. Results: Panelists rated most measure concepts (54 premeeting, 56 post-meeting) as highly important to patient- and family-centered care (median rating ≥7). Considerably fewer (17 premeeting, 22 post-meeting) were rated as having high potential for QI. Measure concepts having postpanel median ratings ≥7 and nominated by one or more panelists as "top 5" on either attribute comprised a shortlist of 20 measure concepts. Conclusions: A panel of expert stakeholders helped prioritize 64 measure concepts into a shortlist of 20. Half of the shortlisted measures were related to communication about patient preferences and decision making, and half were related to symptom assessment and treatment.

    View details for DOI 10.1089/jpm.2020.0633

    View details for PubMedID 33605800

  • Facility-Level Variation in Dialysis Use and Mortality Among Older Veterans With Incident Kidney Failure. JAMA network open Bradshaw, C. n., Thomas, I. C., Montez-Rath, M. E., Lorenz, K. A., Asch, S. M., Leppert, J. T., Wang, V. n., O'Hare, A. M., Kurella Tamura, M. n. 2021; 4 (1): e2034084


    Current guidelines lack consensus regarding the treatment of patients who may not benefit from dialysis; this lack of consensus may be associated with the substantial variation in dialysis use and outcomes across health care facilities.To assess the degree to which variation in dialysis use and mortality was associated with patient rather than facility characteristics and to distinguish which features identified the US Department of Veterans Affairs (VA) facilities with high rates of dialysis use.This cohort study analyzed data of veterans with stage 3 or 4 chronic kidney disease that progressed to kidney failure between January 1, 2011, and December 31, 2014. These patients received care from VA facilities across the US. Data sources included laboratory and administrative records from the VA, Medicare, and United States Renal Data System. Data analysis was conducted from August 1, 2019, to September 1, 2020.The primary exposure was the VA facility in which patients received most of their care before the onset of incident kidney failure defined as the first occurrence of either a sustained estimated glomerular filtration rate of less than 15 mL/min/1.73 m2 or the initiation of maintenance dialysis.The primary outcomes were dialysis use and mortality within 2 years of incident kidney failure. Median rate ratio was used to quantify facility-level variation, and variance partition coefficient was used to quantify the sources of unexplained variation.The cohort included 8695 older veterans with a mean (SD) age of 78.8 (7.5) years who were predominantly male (8573 [99%]) and White (6102 [70%]) individuals treated at 108 VA facilities. The observed frequency of dialysis use across facilities ranged from 25.0% to 81.4%, with a median (interquartile range [IQR]) rate of 51.7% (48.4%-60.0%). The observed frequency of mortality across facilities ranged from 27.2% to 60.0%, with a median (IQR) rate of 45.2% (41.2%-48.6%). The median rate ratio (adjusted for multiple patient and facility characteristics) was 1.40 for dialysis use and 1.08 for mortality. The unexplained variation in both outcomes mainly derived from patient characteristics rather than facility characteristics. No correlation was found between dialysis use and mortality at the facility level (correlation coefficient = 0.03).This study found sizable variation in dialysis use for older adults that was poorly correlated with facility-level mortality rates and was not accounted for by differences in measured patient and facility characteristics. These findings suggest opportunities to improve the degree to which dialysis use practices align with the values, goals, and preferences of older adults with kidney failure.

    View details for DOI 10.1001/jamanetworkopen.2020.34084

    View details for PubMedID 33449098

  • End-of-Life Cost Trajectories in Cancer Patients Treated by Medicare versus the Veterans Health Administration. Journal of the American Geriatrics Society Gidwani, R., Asch, S. M., Needleman, J., Faricy-Anderson, K., Boothroyd, D. B., Illarmo, S., Lorenz, K. A., Patel, M. I., Hsin, G., Ramchandran, K., Wagner, T. H. 2020


    BACKGROUND/OBJECTIVES: To evaluate differences in end-of-life cost trajectories for cancer patients treated through Medicare versus by the Veterans Health Administration (VA).DESIGN: A retrospective analysis of VA and Medicare administrative data from FY 2010 to 2014. We employed three-level generalized estimating equation to evaluate monthly cost trajectories experienced by patients in their last year of live, with patients nested within hospital referral region.SETTING: Care received at VA facilities or by Medicare-reimbursed providers nationwide.PARTICIPANTS: A total of 36,401 patients dying from cancer and dually enrolled in VA and Medicare.MEASUREMENTS: We evaluated trajectories for total, inpatient, outpatient, and drug costs, using the last 12months of life. Cost trajectories were prioritized as costs are not directly comparable across Medicare and VA. Patients were assigned to be VA-reliant, Medicare-reliant or Mixed-reliant based on their healthcare utilization in the last year of life.RESULTS: All three groups experienced significantly different cost trajectories for total costs in the last year of life. Inpatient cost trajectories were significantly different between Medicare-reliant and VA-reliant patients, but did not differ between VA-reliant and Mixed-reliant patients. Outpatient and drug cost trajectories exhibited the inverse pattern: they were significantly different between VA-reliant and Mixed-reliant patients, but not between VA-reliant and Medicare-reliant patients. However, visual examination of cost trajectories revealed similar cost patterns in the last year of life among all three groups; there was a sharp rise in costs as patients approach death, largely due to inpatient care.CONCLUSION: Despite substantially different financial incentives and organization, VA- and Medicare-treated patients exhibit similar patterns of increasing end-of-life costs, largely driven by inpatient costs. Both systems require improvement to ensure quality of end-of-life care is aligned with recommended practice.

    View details for DOI 10.1111/jgs.16941

    View details for PubMedID 33368171

  • Clinical Uses and Impacts of Emergency Manuals During Perioperative Crises. Anesthesia and analgesia Goldhaber-Fiebert, S. N., Bereknyei Merrell, S., Agarwala, A. V., De La Cruz, M. M., Cooper, J. B., Howard, S. K., Asch, S. M., Gaba, D. M. 2020; 131 (6): 1815–26


    BACKGROUND: Performing key actions efficiently during crises can determine clinical outcomes, yet even expert clinicians omit key actions. Simulation-based studies of crises show that correct performance of key actions dramatically increases when emergency manuals (EMs) are used. Despite widespread dissemination of EMs, there is a need to understand in clinical contexts, when, how, and how often EMs are used and not used, along with perceived impacts.METHODS: We conducted interviews with the anesthesia professionals involved in perioperative crises, identified with criterion-based sampling, occurring between October 2014 and May 2016 at 2 large academic medical centers with a history of EM training and implementation. Our convergent, mixed-methods study of the interview data extracted quantitative counts and qualitative themes of EM use and nonuse during clinical crises.RESULTS: Interviews with 53 anesthesia professionals yielded 80 descriptions of applicable clinical crises, with varying durations and event types. Of 69 unique patients whose cases involved crises, the EM was used during 37 (54%; 95% confidence interval [CI], 41-66). Impacts on clinician team members included decreased stress for individual anesthesia professionals (95%), enabled teamwork (73%), and calmed atmosphere (46%). Impacts on delivery of patient care included specific action improvements, including catching errors of omission, for example, turning off anesthetic during cardiac arrest, only after EM use (59%); process improvements, for example, double-checking all actions were completed (41%); and impediments (0%). In 8% of crises, EM use was associated with potential distractions, although none were perceived to harm delivery of patient care. For 32 EM nonuses (46%; 95% CI, 34-59), participants self-identified errors of omission or delays in key actions (56%), all key actions performed (13%), and crisis too brief for EM to be used (31%).CONCLUSIONS: This study provides evidence that EMs in operating rooms are being used during many applicable crises and that clinicians perceive EM use to add value. The reported negative effects were minimal and potentially offset by positive effects.

    View details for DOI 10.1213/ANE.0000000000005012

    View details for PubMedID 33197160

  • If Kindness Were a Drug, the FDA Would Approve It. Journal of general internal medicine Asch, S. M., Atkins, D. V., Walling, A. 2020

    View details for DOI 10.1007/s11606-020-06343-7

    View details for PubMedID 33245513

  • Mitigating the Impact of COVID-19 on Funded Clinical Research: Crucial Next Steps. Journal of general internal medicine Walker, R. J., Jackson, J. L., Asch, S. M., Egede, L. E. 2020

    View details for DOI 10.1007/s11606-020-06342-8

    View details for PubMedID 33201425

  • Development, Validation, and Evaluation of a Simple Machine Learning Model to Predict Cirrhosis Mortality. JAMA network open Kanwal, F., Taylor, T. J., Kramer, J. R., Cao, Y., Smith, D., Gifford, A. L., El-Serag, H. B., Naik, A. D., Asch, S. M. 2020; 3 (11): e2023780


    Importance: Machine-learning algorithms offer better predictive accuracy than traditional prognostic models but are too complex and opaque for clinical use.Objective: To compare different machine learning methods in predicting overall mortality in cirrhosis and to use machine learning to select easily scored clinical variables for a novel cirrhosis prognostic model.Design, Setting, and Participants: This prognostic study used a retrospective cohort of adult patients with cirrhosis or its complications seen in 130 hospitals and affiliated ambulatory clinics in the integrated, national Veterans Affairs health care system from October 1, 2011, to September 30, 2015. Patients were followed up through December 31, 2018. Data were analyzed from October 1, 2017, to May 31, 2020.Exposures: Potential predictors included demographic characteristics; liver disease etiology, severity, and complications; use of health care resources; comorbid conditions; and comprehensive laboratory and medication data. Patients were randomly selected for model development (66.7%) and validation (33.3%). Three different statistical and machine learning methods were evaluated: gradient descent boosting, logistic regression with least absolute shrinkage and selection operator (LASSO) regularization, and logistic regression with LASSO constrained to select no more than 10 predictors (partial pathway model). Predictor inclusion and model performance were evaluated in a 5-fold cross-validation. Last, the predictors identified in the most parsimonious (the partial path) model were refit using maximum-likelihood estimation (Cirrhosis Mortality Model [CiMM]), and its predictive performance was compared with that of the widely used Model for End Stage Liver Disease with sodium (MELD-Na) score.Main Outcomes and Measures: All-cause mortality.Results: Of the 107 939 patients with cirrhosis (mean [SD] age, 62.7 [9.6] years; 96.6% male; 66.3% white, 18.4% African American), the annual mortality rate ranged from 8.8% to 15.3%. In total, 32.7% of patients died within 3 years, and 46.2% died within 5 years after the index date. Models predicting 1-year mortality had good discrimination for the gradient descent boosting (area under the receiver operating characteristics curve [AUC], 0.81; 95% CI, 0.80-0.82), logistic regression with LASSO regularization (AUC, 0.78; 95% CI, 0.77-0.79), and the partial path logistic model (AUC, 0.78; 95% CI, 0.76-0.78). All models showed good calibration. The final CiMM model with machine learning-derived clinical variables offered significantly better discrimination than the MELD-Na score, with AUCs of 0.78 (95% CI, 0.77-0.79) vs 0.67 (95% CI, 0.66-0.68) for 1-year mortality, respectively (DeLong z=17.00; P<.001).Conclusions and Relevance: In this study, simple machine learning techniques performed as well as the more advanced ensemble gradient boosting. Using the clinical variables identified from simple machine learning in a cirrhosis mortality model produced a new score more transparent than machine learning and more predictive than the MELD-Na score.

    View details for DOI 10.1001/jamanetworkopen.2020.23780

    View details for PubMedID 33141161

  • OrderRex clinical user testing: a randomized trial of recommender system decision support on simulated cases. Journal of the American Medical Informatics Association : JAMIA Kumar, A., Aikens, R. C., Hom, J., Shieh, L., Chiang, J., Morales, D., Saini, D., Musen, M., Baiocchi, M., Altman, R., Goldstein, M. K., Asch, S., Chen, J. H. 2020


    OBJECTIVE: To assess usability and usefulness of a machine learning-based order recommender system applied to simulated clinical cases.MATERIALS AND METHODS: 43 physicians entered orders for 5 simulated clinical cases using a clinical order entry interface with or without access to a previously developed automated order recommender system. Cases were randomly allocated to the recommender system in a 3:2 ratio. A panel of clinicians scored whether the orders placed were clinically appropriate. Our primary outcome included the difference in clinical appropriateness scores. Secondary outcomes included total number of orders, case time, and survey responses.RESULTS: Clinical appropriateness scores per order were comparable for cases randomized to the order recommender system (mean difference -0.11 order per score, 95% CI: [-0.41, 0.20]). Physicians using the recommender placed more orders (median 16 vs 15 orders, incidence rate ratio 1.09, 95%CI: [1.01-1.17]). Case times were comparable with the recommender system. Order suggestions generated from the recommender system were more likely to match physician needs than standard manual search options. Physicians used recommender suggestions in 98% of available cases. Approximately 95% of participants agreed the system would be useful for their workflows.DISCUSSION: User testing with a simulated electronic medical record interface can assess the value of machine learning and clinical decision support tools for clinician usability and acceptance before live deployments.CONCLUSIONS: Clinicians can use and accept machine learned clinical order recommendations integrated into an electronic order entry interface in a simulated setting. The clinical appropriateness of orders entered was comparable even when supported by automated recommendations.

    View details for DOI 10.1093/jamia/ocaa190

    View details for PubMedID 33106874

  • Peer Review at JGIM. Journal of general internal medicine Jackson, J. L., Bates, C. K., Asch, S. M. 2020

    View details for DOI 10.1007/s11606-020-06270-7

    View details for PubMedID 33078302

  • Impact of VHA's primary care intensive management program on dual system use. Healthcare (Amsterdam, Netherlands) Wong, E. S., Guo, R., Yoon, J., Zulman, D. M., Asch, S. M., Ong, M. K., Chang, E. T. 2020; 8 (3): 100450

    View details for DOI 10.1016/j.hjdsi.2020.100450

    View details for PubMedID 32919588

  • Developing a delivery science for artificial intelligence in healthcare. NPJ digital medicine Li, R. C., Asch, S. M., Shah, N. H. 2020; 3 (1): 107

    View details for DOI 10.1038/s41746-020-00318-y

    View details for PubMedID 33597602

  • Comorbidity Assessment Is Uneven Across Veterans Health Administration and Medicare for the Same Patient: Implications for Risk Adjustment. Medical care Gidwani-Marszowski, R., Boothroyd, D., Needleman, J., Illarmo, S., Asch, S. M. 2020; 58 (8): 717–21


    OBJECTIVE: Compare comorbidity identification in Medicare and Veterans Health Administration (VA) data for the purposes of risk adjustment.DATA SOURCES: Analysis of Medicare and VA datasets for dually-enrolled Veterans receiving care in both settings, fiscal years 2010-2014.STUDY DESIGN: A retrospective analysis of administrative data for a national sample of cancer decedents.DATA EXTRACTION METHODS: Comorbidities were evaluated using Elixhauser and Charlson coding algorithms.PRINCIPAL FINDINGS: Clinical comorbidities were more likely to be recorded in Medicare than in VA datasets. Of 42 comorbidities, 36 (86%) were recorded at a different frequency. For example, congestive heart failure was recorded for 22.0% of patients in Medicare data and for 11.3% of patients in VA data (P<0.001).CONCLUSION: There are large differences in comorbidity assessment across VA and Medicare administrative data for the same patient, posing challenges for risk adjustment.

    View details for DOI 10.1097/MLR.0000000000001329

    View details for PubMedID 32692137

  • An Incentive to Innovate: Improving Health Care Value and Restoring Physician Autonomy Through Physician-Directed Reinvestment. Academic medicine : journal of the Association of American Medical Colleges Vilendrer, S. M., Asch, S. M., Anzai, Y., Maggio, P. 2020


    PROBLEM: Many health care systems in the United States are shifting from a fee-for-service reimbursement model to a value-based payment model. To remain competitive, health care administrators must engage frontline clinicians in their efforts to reduce costs and improve patient outcomes. Engaging physicians and other clinicians is challenging, however, as many feel overwhelmed with clinical responsibilities and do not view cost reduction as in their purview. Even if they are willing, providing a direct financial incentive to clinicians to control costs poses ethical and legal challenges. An effective incentive in the current system must motivate clinicians to engage in creative problem solving and mitigate ethical and legal risk.APPROACH: Evidence suggests the most successful behavior change interventions in physicians are multi-faceted and combine intrinsic motivators, such as increased autonomy, with extrinsic motivators, such as access to funding or social recognition. Two academic health centers-the University of Utah Health and Stanford Health Care-have begun experimenting with an alternative value-sharing arrangement. Physician-directed reinvestment is an explicit agreement in which a health care system reinvests a portion of savings attributed to physician-led cost reduction initiatives back into areas of the physician's choosing, such as capital investment, research, or education.OUTCOMES: Both organizations reported similar positive outcomes, including increased engagement from clinicians and administrators, sustained or improved quality of care, reduced costs of care, and benefits from reinvested funds. Many savings opportunities were previously unknown to administrators.NEXT STEPS: Physician-directed reinvestment appears to effectively engage physicians in ongoing efforts to improve value in health care, although formal evaluation is still needed. This incentive structure may hold promise in other configurations, such as inviting non-physicians to apply as project leaders (clinician-directed reinvestment) and expanding the program to non-academic and ambulatory settings.

    View details for DOI 10.1097/ACM.0000000000003650

    View details for PubMedID 32739931

  • OUTPATIENT CARE FRAGMENTATION PATTERNS AND ASSOCIATION WITH HOSPITALIZATION IN HIGH-RISK VA PATIENTS Zulman, D. M., Greene, A. L., Wagner, T. H., Maciejewski, M., Singer, S., Slightam, C., Trivedi, R., Vanneman, M., Asch, S., Yoon, J., Goldstein, M. K., Boothroyd, D. SPRINGER. 2020: S216
  • PPE Portraits-a Way to Humanize Personal Protective Equipment. Journal of general internal medicine Brown-Johnson, C., Vilendrer, S., Heffernan, M. B., Winter, S., Khong, T., Reidy, J., Asch, S. M. 2020


    The use of personal protective equipment (PPE) has skyrocketed, as providers don masks, glasses, and gowns to protect their eyes, noses, and mouths from COVID-19. Yet these same facial features express human individuality, and are crucial to nonverbal communication. Isolated ICU patients may develop "post intensive-care syndrome," which mimics PTSD with sometimes debilitating consequences. While far from a complete solution, PPE Portraits (disposable portrait picture stickers- 4" * 5") have the potential to humanize care. Preparing for a larger effectiveness evaluation on patient and provider experience, we collected initial qualitative implementation insights during Spring 2020's chaotic surge preparation. Front-line providers reported more comfort with patient interactions while wearing PPE Portraits: "It makes it feel less like a disaster zone [for the patient]." A brief pilot showed signs of significant adoption: a participating physician requested PPE Portraits at their clinic, shift nurses had taken PPE Portraits with them to inpatient services, and masked medical assistant team-members requested PPE Portraits to wear over scrubs. We believe PPE Portraits may support patient care and health, and even potentially healthcare team function and provider wellness. While we await data on these effects, we hope hospitals can use our findings to speed their own implementation testing.

    View details for DOI 10.1007/s11606-020-05875-2

    View details for PubMedID 32410125

  • Potentially avoidable hospitalizations after chemotherapy: Differences across medicare and the Veterans Health Administration. Cancer Gidwani-Marszowski, R., Faricy-Anderson, K., Asch, S. M., Illarmo, S., Ananth, L., Patel, M. I. 2020


    BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) has released quality measures regarding potentially avoidable hospitalizations visits in the 30days after receipt of outpatient chemotherapy. This study evaluated the proportions of patients treated by Medicare-reimbursed clinicians and Veterans Health Administration (VA) clinicians who experienced avoidable acute care in orderto evaluate differences in health system performance.METHODS: This retrospective evaluation of Medicare and VA administrative data used a cohort of cancer decedents (fiscal years 2010-2014). Cohort members were veterans aged 66years or older at death who were dually enrolled in Medicare and the VA. Chemotherapy was identified through International Classification of Diseases, Ninth Revision and Current Procedural Terminology(ICD-9) codes. CMS definesavoidable hospitalizations as those related to anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, or sepsis in the 30days after chemotherapy. Following CMS guidance, this study compared the proportions of patients with potentially avoidable hospitalizations, using hierarchicalgeneralized estimating equations.RESULTS: There were 27,443 patients who received outpatient chemotherapy. Patients receiving Medicare chemotherapy were significantly more likely to have potentially avoidable hospitalizations than patients receiving VA chemotherapy (adjusted odds ratio, 1.58; 95% confidence interval, 1.41-1.78; P<.001). In predicted estimates, 7.1% of Medicare-treated veterans had potentially avoidable hospitalizations in the 30days after chemotherapy, compared with4.6% of VA-treated veterans.CONCLUSIONS: Results indicate veterans with cancer receiving chemotherapy in the VA have higher quality care with respect to avoidable hospitalizations than veterans receiving chemotherapy through Medicare. As more veterans seek care in the private sector under the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act, concerted efforts may be warranted to ensure that veterans do not experience a decline in care quality.

    View details for DOI 10.1002/cncr.32896

    View details for PubMedID 32401340

  • From the Editor's Desk: JGIM and COVID-19. Journal of general internal medicine Bates, C. K., Jackson, J., Asch, S. 2020

    View details for DOI 10.1007/s11606-020-05852-9

    View details for PubMedID 32323135

  • The Stanford Lightning Report Method: A comparison of rapid qualitative synthesis results across four implementation evaluations. Learning health systems Brown-Johnson, C., Safaeinili, N., Zionts, D., Holdsworth, L. M., Shaw, J. G., Asch, S. M., Mahoney, M., Winget, M. 2020; 4 (2): e10210


    Current evaluation methods are mismatched with the speed of health care innovation and needs of health care delivery partners. We introduce a qualitative approach called the lightning report method and its specific product-the "Lightning Report." We compare implementation evaluation results across four projects to explore report sensitivity and the potential depth and breadth of lightning report method findings.The lightning report method was refined over 2.5 years across four projects: team-based primary care, cancer center transformation, precision health in primary care, and a national life-sustaining decisions initiative. The novelty of the lightning report method is the application of Plus/Delta/Insight debriefing to dynamic implementation evaluation. This analytic structure captures Plus ("what works"), Delta ("what needs to be changed"), and Insights (participant or evaluator insights, ideas, and recommendations). We used structured coding based on implementation science barriers and facilitators outlined in the Consolidated Framework for Implementation Research (CFIR) applied to 17 Lightning Reports from four projects.Health care partners reported that Lighting Reports were valuable, easy to understand, and they implied reports supported "corrective action" for implementations. Comparative analysis revealed cross-project emphasis on the domains of Inner Setting and Intervention Characteristics, with themes of communication, resources/staffing, feedback/reflection, alignment with simultaneous interventions and traditional care, and team cohesion. In three of the four assessed projects, the largest proportion of coding was to the clinic-level domain of Inner Setting-ranging from 39% for the cancer center project to a high of 56% for the life-sustaining decisions project.The lightning report method can fill a gap in rapid qualitative approaches and is generalizable with consistent but flexible core methods. Comparative analysis suggests it is a sensitive tool, capable of uncovering differences and insights in implementation across projects. The Lightning Report facilitates partnered evaluation and communication with stakeholders by providing real-time, actionable insights in dynamic health care implementations.

    View details for DOI 10.1002/lrh2.10210

    View details for PubMedID 32313836

    View details for PubMedCentralID PMC7156867

  • Research translation for military and veteran health: research, practice, policy. Translational behavioral medicine Haibach, J. P., Hoerster, K. D., Dorflinger, L., McAndrew, L. M., Cassidy, D. G., Goodrich, D. E., Bormann, J. E., Lowery, J., Asch, S. M., Raffa, S. D., Moin, T., Peterson, A. L., Goldstein, M. G., Neal-Walden, T., Talcott, G. W., Hunter, C. L., Knight, S. J. 2020


    Military service presents unique challenges and opportunities for health care and public health. In the USA, there are over 2 million military servicemembers, 20 million veterans, and millions more military and veteran family members. Military servicemembers and eligible family members, many veterans, and retirees receive health care through the two largest learning health care systems in the USA, managed and delivered through the Departments of Defense (DoD), Veterans Affairs (VA), and contracted health care organizations. Through a network of collaborative relationships, DoD, VA, and partnering health care and research organizations (university, corporate, community, and government) accelerate research translation into best practices and policy across the USA and beyond. This article outlines military and veteran health research translation as summarized from a collaborative workshop led by experts across health care research, practice, and administration in DoD, VA, the National Institutes of Health, and affiliated universities. Key themes and recommendations for research translation are outlined in areas of: (a) stakeholder engagement and collaboration; (b) implementation science methods; and (c) funding along the translation continuum. Overall, the ability to rapidly translate research into clinical practice and policy for positive health outcomes requires collaborative relationships among many stakeholders. This includes servicemembers, veterans, and their families along with researchers, health care clinicians, and administrators, as well as policymakers and the broader population.

    View details for DOI 10.1093/tbm/ibz195

    View details for PubMedID 32043529

  • "Along for the Ride": A Qualitative Study Exploring Patient and Caregiver Perceptions of Decision Making in Cancer Care. MDM policy & practice Holdsworth, L. M., Zionts, D. n., Asch, S. M., Winget, M. n. 2020; 5 (1): 2381468320933576


    Background. Shared decision making is a cornerstone of an informed consent process for cancer treatment, yet there are often many physician and patient-related barriers to participation in the process. Decisions in cancer care are often perceived as relating to a discrete, treatment decision event, yet there is evidence that decisions are longitudinal in nature and reflect a multifactorial experience. Objective. To explore patient and caregiver perceptions of the choices and decision-making opportunities within cancer care. Design. Qualitative in-depth interviews with 37 cancer patients and 7 caregivers carried out as part of an evaluation of a cancer center's effort to improve patient experience. Results. Participants described decision making related to four distinct phases in complex cancer care, with physicians leading, and often limiting, decisions related to disease assessment and treatment options and access, and patients leading decisions related to physician selection. Though physicians led many decisions, patients had a moderating influence on treatment, such that if patients did not like options presented, they would reconsider their options and sometimes switch physicians. Patients had various strategies for dealing with uncertainty when faced with decisions, such as seeking additional information to make an informed choice or making a conscious choice to defer decision making to the physician. Limitations. Patients were sampled from one academic cancer center that serves a predominantly Caucasian, Asian, and Hispanic/Latino population and received complex treatment. Conclusion. Because of the complexity of cancer treatment, many patients felt as though they were a "passenger" in decision making about care and did not lead many of the decisions, though many patients trusted their doctors to make the best decisions and were comforted by their expertise.

    View details for DOI 10.1177/2381468320933576

    View details for PubMedID 32587894

    View details for PubMedCentralID PMC7294494

  • Measure Scan and Synthesis of Palliative and End-of-Life Process Quality Measures for Advanced Cancer. JCO oncology practice O'Hanlon, C. E., Lindvall, C. n., Lorenz, K. A., Giannitrapani, K. F., Garrido, M. n., Asch, S. M., Wenger, N. n., Malin, J. n., Dy, S. M., Canning, M. n., Gamboa, R. C., Walling, A. M. 2020: OP2000240


    Monitoring and improving the quality of palliative and end-of-life cancer care remain pressing needs in the United States. Among existing measures that assess the quality of palliative and end-of-life care, many operationalize similar concepts. We identified existing palliative care process measures and synthesized these measures to aid stakeholder prioritization that will facilitate health system implementation in patients with advanced cancer.We reviewed MEDLINE/PubMed-indexed articles for process quality measures related to palliative and end-of-life care for patients with advanced cancer, supplemented by expert input. Measures were inductively grouped into "measure concepts" and higher-level groups.Literature review identified 226 unique measures from 23 measure sources, which we grouped into 64 measure concepts within 12 groups. Groups were advance care planning (11 measure concepts), pain (7), dyspnea (9), palliative care-specific issues (6), other specific symptoms (17), comprehensive assessment (2), symptom assessment (1), hospice/palliative care referral (1), spiritual care (2), mental health (5), information provision (2), and culturally appropriate care (1).Measure concepts covered the spectrum of care from acute symptom management to advance care planning and psychosocial needs, with variability in the number of measure concepts per group. This taxonomy of process quality measure concepts can be used by health systems seeking stakeholder input to prioritize targets for improving palliative and end-of-life care quality in patients with advanced cancer.

    View details for DOI 10.1200/OP.20.00240

    View details for PubMedID 32758085

  • Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter. JAMA Zulman, D. M., Haverfield, M. C., Shaw, J. G., Brown-Johnson, C. G., Schwartz, R. n., Tierney, A. A., Zionts, D. L., Safaeinili, N. n., Fischer, M. n., Thadaney Israni, S. n., Asch, S. M., Verghese, A. n. 2020; 323 (1): 70–81


    Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.Preliminary practices were derived through a systematic literature review (from January 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (-4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their "top 5" practices from among those with median ratings of at least +2 for all 3 criteria. Final recommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient's story (consider life circumstances that influence the patient's health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient's emotions).This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.

    View details for DOI 10.1001/jama.2019.19003

    View details for PubMedID 31910284

  • Can Patient-Provider Interpersonal Interventions Achieve the Quadruple Aim of Healthcare? A Systematic Review. Journal of general internal medicine Haverfield, M. C., Tierney, A. n., Schwartz, R. n., Bass, M. B., Brown-Johnson, C. n., Zionts, D. L., Safaeinili, N. n., Fischer, M. n., Shaw, J. G., Thadaney, S. n., Piccininni, G. n., Lorenz, K. A., Asch, S. M., Verghese, A. n., Zulman, D. M. 2020


    Human connection is at the heart of medical care, but questions remain as to the effectiveness of interpersonal interventions. The purpose of this review was to characterize the associations between patient-provider interpersonal interventions and the quadruple aim outcomes (population health, patient experience, cost, and provider experience).We sourced data from PubMed, EMBASE, and PsycInfo (January 1997-August 2017). Selected studies included randomized controlled trials and controlled observational studies that examined the association between patient-provider interpersonal interventions and at least one outcome measure of the quadruple aim. Two abstractors independently extracted information about study design, methods, and quality. We characterized evidence related to the objective of the intervention, type and duration of intervention training, target recipient (provider-only vs. provider-patient dyad), and quadruple aim outcomes.Seventy-three out of 21,835 studies met the design and outcome inclusion criteria. The methodological quality of research was moderate to high for most included studies; 67% of interventions targeted the provider. Most studies measured impact on patient experience; improvements in experience (e.g., satisfaction, patient-centeredness, reduced unmet needs) often corresponded with a positive impact on other patient health outcomes (e.g., quality of life, depression, adherence). Enhanced interpersonal interactions improved provider well-being, burnout, stress, and confidence in communicating with difficult patients. Roughly a quarter of studies evaluated cost, but the majority reported no significant differences between intervention and control groups. Among studies that measured time in the clinical encounter, intervention effects varied. Interventions with lower demands on provider time and effort were often as effective as those with higher demands.Simple, low-demand patient-provider interpersonal interventions may have the potential to improve patient health and patient and provider experience, but there is limited evidence that these interventions influence cost-related outcomes.

    View details for DOI 10.1007/s11606-019-05525-2

    View details for PubMedID 31919725

  • Cardiac Procedural Deferral during the Coronavirus (COVID-19) Pandemic. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions Yong, C. M., Ang, L. n., Welt, F. G., Gummidipundi, S. n., Henry, T. D., Pinto, D. S., Cox, D. n., Wang, P. n., Asch, S. n., Mahmud, E. n., Fearon, W. F. 2020


    We aimed to examine factors impacting variability in cardiac procedural deferral during the COVID-19 pandemic and assess cardiologists' perspectives regarding its implications.Unprecedented cardiac procedural deferral was implemented nationwide during the COVID-19 pandemic.A web-based survey was administered by SCAI and the ACC Interventional Council to cardiac catheterization laboratory (CCL) directors and interventional cardiologists across the United States during the COVID-19 pandemic.Among 414 total responses, 48 states and 360 unique cardiac catheterization laboratories were represented, with mean inpatient COVID-19 burden 16.4+21.9%. There was a spectrum of deferral by procedure type, varying by both severity of COVID-19 burden and procedural urgency (p<0.001). Percutaneous coronary intervention volumes dropped by 55% (p<0.0001) and transcatheter aortic valve replacement volumes dropped by 64%, (p=0.004), with cardiologists reporting an increase in late presenting ST-Elevation Myocardial Infarctions and deaths among patients waiting for transcatheter aortic valve replacement. Almost 1/3 of catheterization laboratories had at least one interventionalist testing positive for COVID-19. Salary reductions did not influence procedural deferral or speed of reinstituting normal volumes. Pandemic preparedness improved significantly over time, with the most pressing current problems focused on inadequate testing and staff health risks.During the COVID-19 pandemic, cardiac procedural deferrals were associated with procedural urgency and severity of hospital COVID-19 burden. Yet patients did not appear to be similarly influenced, with cardiologists reporting increases in late presenting ST-Elevation Myocardial Infarctions independent of local COVID-19 burden. The safety and importance of seeking healthcare during this pandemic deserves emphasis. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/ccd.29262

    View details for PubMedID 32882075

  • Rapid Deployment of Inpatient Telemedicine In Response to COVID-19 Across Three Health Systems. Journal of the American Medical Informatics Association : JAMIA Vilendrer, S. n., Patel, B. n., Chadwick, W. n., Hwa, M. n., Asch, S. n., Pageler, N. n., Ramdeo, R. n., Saliba-Gustafsson, E. A., Strong, P. n., Sharp, C. n. 2020


    To reduce pathogen exposure, conserve personal protective equipment, and facilitate health care personnel work participation in the setting of the COVID-19 pandemic, three affiliated institutions rapidly and independently deployed inpatient telemedicine programs during March 2020. We describe key features and early learnings of these programs in the hospital setting.Relevant clinical and operational leadership from an academic medical center, pediatric teaching hospital, and safety net county health system met to share learnings shortly after deploying inpatient telemedicine. A summative analysis of their learnings was re-circulated for approval.All three institutions faced pressure to urgently standup new telemedicine systems while still maintaining secure information exchange. Differences across patient demographics and technological capabilities led to variation in solution design, though key technical considerations were similar. Rapid deployment in each system relied on readily available consumer-grade technology, given the existing familiarity to patients and clinicians and minimal infrastructure investment. Preliminary data from the academic medical center over one month suggested positive adoption with 631 inpatient video calls lasting an average (standard deviation) of 16.5 minutes (19.6) based on inclusion criteria.The threat of an imminent surge of COVID-19 patients drove three institutions to rapidly develop inpatient telemedicine solutions. Concurrently, federal and state regulators temporarily relaxed restrictions that would have previously limited these efforts. Strategic direction from executive leadership, leveraging off-the-shelf hardware, vendor engagement, and clinical workflow integration facilitated rapid deployment.The rapid deployment of inpatient telemedicine is feasible across diverse settings as a response to the COVID-19 pandemic.

    View details for DOI 10.1093/jamia/ocaa077

    View details for PubMedID 32495830

  • Rapid implementation of video visits in neurology during COVID-19: a mixed methods evaluation. Journal of medical Internet research Saliba-Gustafsson, E. A., Miller-Kuhlmann, R. n., Kling, S. M., Garvert, D. W., Brown-Johnson, C. G., Lestoquoy, A. S., Verano, M. R., Yang, L. n., Falco-Walter, J. n., Shaw, J. G., Asch, S. M., Gold, C. A., Winget, M. n. 2020


    Telemedicine has been used for decades; yet, despite its many advantages, its uptake and rigorous evaluation of feasibility across neurology's ambulatory subspecialties has been sparse. The SARS-CoV-2 (COVID-19) pandemic however, prompted healthcare systems worldwide to reconsider traditional healthcare delivery. To safeguard healthcare workers and patients many healthcare systems quickly transitioned to telemedicine, including across neurology subspecialties, providing a new opportunity to evaluate this modality of care.To evaluate the accelerated implementation of video visits in ambulatory neurology during the COVID-19 pandemic, we used mixed methods to assess the adoption, acceptability, appropriateness, and perceptions of potential sustainability.Video visits were launched rapidly in ambulatory neurology clinics of a large academic medical center. To assess adoption, we analyzed clinician-level scheduling data collected between March 22 and May 16, 2020. We assessed acceptability, appropriateness, and sustainability via a clinician survey (n=48) and semi-structured interviews with providers (n=30) completed between March and May 2020.Video visits were adopted rapidly; 65 (98%) clinicians integrated video visits into their workflow within the first 6 implementation weeks and 92% of all visits were conducted via video. Video visits were largely considered acceptable by clinicians, although various technological issues impacted satisfaction. Video visits were reported to be more convenient for patients, families, and/or caregivers than in-person visits; however, access to technology, the patient's technological capacity, and language difficulties were considered barriers. Many clinicians expressed optimism about future utilization of video visits in neurology. They believed that video visits promote continuity of care and can be incorporated into their practice long-term, although several insisted that they can never replace the in-person examination.Video visits are an important addition to clinical care in ambulatory neurology and are anticipated to remain a permanent supplement to in-person visits, promoting patient care continuity, and flexibility for patients and clinicians alike.

    View details for DOI 10.2196/24328

    View details for PubMedID 33245699

  • Organizational Characteristics Associated With ICU Liberation (ABCDEF) Bundle Implementation by Adult ICUs in Michigan. Critical care explorations Barr, J. n., Ghaferi, A. A., Costa, D. K., Hedlin, H. K., Ding, V. Y., Ross, C. n., Pun, B. T., Watson, S. R., Asch, S. M. 2020; 2 (8): e0169


    The ICU Liberation (ABCDEF) Bundle can help to improve care and outcomes for ICU patients, but bundle implementation is far from universal. Understanding how ICU organizational characteristics influence bundle implementation could inform quality improvement efforts. We surveyed all hospitals in Michigan with adult ICUs to determine whether organizational characteristics were associated with bundle implementation and to determine the level of agreement between ICU physician and nurse leaders around ICU organizational characteristics and bundle implementation.We surveyed ICU physician and nurse leaders, assessing their safety culture, ICU team collaboration, and work environment. Using logistic and linear regression models, we compared these organizational characteristics to bundle element implementation, and also compared physician and nurse leaders' perceptions about organizational characteristics and bundle implementation.All (n = 72) acute care hospitals with adult ICUs in Michigan.ICU physician and nurse leader pairs from each hospital's main ICU.We developed, pilot-tested, and deployed an electronic survey to all subjects over a 3 month period in 2016.Results from 73 surveys (28 physicians, 45 nurses, 60% hospital response rate) demonstrated significant variation in hospital and ICU size and type, organizational characteristics, and physician/nurse perceptions of ICU organization and bundle implementation. We found that a robust safety culture and collaborative work environment that uses checklists to facilitate team communication are strongly associated with bundle implementation. There is also a significant dose-response effect between safety culture, a collaborative work environment, and overall bundle implementation.We identified several specific ICU practices that can facilitate ABCDEF Bundle implementation. Our results can be used to develop effective bundle implementation strategies that leverage safety culture, interprofessional collaboration, and routine checklist use in ICUs to improve bundle implementation and performance.

    View details for DOI 10.1097/CCE.0000000000000169

    View details for PubMedID 32885171

    View details for PubMedCentralID PMC7437774

  • Facilitating ethical quality improvement initiatives: Design and implementation of an initiative-specific ethics committee. Healthcare (Amsterdam, Netherlands) Bottrell, M. M., Simon, A. n., Geppert, C. n., Chang, E. T., Asch, S. M., Rubenstein, L. n. 2020; 8 (2): 100425


    Like all facets of healthcare practice, quality improvement (QI) should be conducted in an ethically responsible manner. For methodologically complex QI, accountability and thoughtful ethical monitoring might be particularly important. Yet, access to ethical guidance for QI, as opposed to research, is often limited. Available mechanisms tend to be ill-equipped to accommodate the rapid cycle nature of QI, and monitoring standards for QI are not well defined. Providing appropriate ethical guidance for complex, multi-site QI initiatives can be especially challenging, as the body providing guidance must be familiar with QI methods, recognize the competing interests of stakeholder groups, respond to numerous requests, and understand the initiative's design. This case report describes our solution-an initiative-specific QI Ethics Committee that provided ethical guidance and consultation to a Veterans Administration QI initiative employing local innovations and a centralized evaluation. Enhanced by multiple tables, we discuss structuring and staffing the committee, the committee's role, functions and activities, requests for ethics guidance, and our strategy applying initiative-specific ethical principles to guide recommendations. Supported by feedback obtained from stakeholder interviews, we share key insights regarding the value of: • Clarifying and marketing the committee's role to users. • Reconciling conflicting interests between site-based team members and cross-site evaluators. • Separating ethics guidance from regulatory oversight. • Addressing the ethics of evaluative design. • Adjusting the intensity of the committee's work over time. • Creating tangible products. Our approach shows promise in supporting the ethical practice of methodologically complex QI, especially in institutions that lack applicable ethics monitoring mechanisms. Building on this approach, other complex QI initiatives can develop effective and feasible methods to protect participants from unintentional ethical lapses.

    View details for DOI 10.1016/j.hjdsi.2020.100425

    View details for PubMedID 32553523

  • Qualitative Assessment of Rapid System Transformation to Primary Care Video Visits at an Academic Medical Center. Annals of internal medicine Srinivasan, M. n., Asch, S. n., Vilendrer, S. n., Thomas, S. C., Bajra, R. n., Barman, L. n., Edwards, L. M., Filipowicz, H. n., Giang, L. n., Jee, O. n., Mahoney, M. n., Nelligan, I. n., Phadke, A. J., Torres, E. n., Artandi, M. n. 2020


    The coronavirus disease 2019 pandemic spurred health systems across the world to quickly shift from in-person visits to safer video visits.To seek stakeholder perspectives on video visits' acceptability and effect 3 weeks after near-total transition to video visits.Semistructured qualitative interviews.6 Stanford general primary care and express care clinics at 6 northern California sites, with 81 providers, 123 staff, and 97 614 patient visits in 2019.Fifty-three program participants (overlapping roles as medical providers [n = 20], medical assistants [n = 16], nurses [n = 4], technologists [n = 4], and administrators [n = 13]) were interviewed about video visit transition and challenges.In 3 weeks, express care and primary care video visits increased from less than 10% to greater than 80% and from less than 10% to greater than 75%, respectively. New video visit providers received video visit training and care quality feedback. New system workflows were created to accommodate the new visit method.Nine faculty, trained in qualitative research methods, conducted 53 stakeholder interviews in 4 days using purposeful (administrators and technologists) and convenience (medical assistant, nurses, and providers) sampling. A rapid qualitative analytic approach for thematic analysis was used.The analysis revealed 12 themes, including Pandemic as Catalyst; Joy in Medicine; Safety in Medicine; Slipping Through the Cracks; My Role, Redefined; and The New Normal. Themes were analyzed using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to identify critical issues for continued program utilization.Evaluation was done immediately after deployment. Although viewpoints may have evolved later, immediate evaluation allowed for prompt program changes and identified broader issues to address for program sustainability.After pandemic-related systems transformation at Stanford, critical issues to sustain video visit long-term viability were identified. Specifically, technology ease of use must improve and support multiparty videoconferencing. Providers should be able to care for their patients, regardless of geography. Providers need decision-making support with virtual examination training and home-based patient diagnostics. Finally, ongoing video visit reimbursement should be commensurate with value to the patients' health and well-being.Stanford Department of Medicine and Stanford Health Care.

    View details for DOI 10.7326/M20-1814

    View details for PubMedID 32628536

  • Adapting rapid assessment procedures for implementation research using a team-based approach to analysis: a case example of patient quality and safety interventions in the ICU. Implementation science : IS Holdsworth, L. M., Safaeinili, N. n., Winget, M. n., Lorenz, K. A., Lough, M. n., Asch, S. n., Malcolm, E. n. 2020; 15 (1): 12


    Innovations to improve quality and safety in healthcare are increasingly complex, targeting multiple disciplines and organizational levels, and often requiring significant behavior change by those delivering care. Learning health systems must tackle the crucial task of understanding the implementation and effectiveness of complex interventions, but may be hampered in their efforts by limitations in study design imposed by business-cycle timelines and implementation into fast-paced clinical environments. Rapid assessment procedures are a pragmatic option for producing timely, contextually rich evaluative information about complex interventions implemented into dynamic clinical settings.We describe our adaptation of rapid assessment procedures and introduce a rapid team-based analysis process using an example of an evaluation of an intensive care unit (ICU) redesign initiative aimed at improving patient safety in four academic medical centers across the USA. Steps in our approach included (1) iteratively working with stakeholders to develop evaluation questions; (2) integration of implementation science frameworks into field guides and analytic tools; (3) selecting and training a multidisciplinary site visit team; (4) preparation and trust building for 2-day site visits; (5) engaging sites in a participatory approach to data collection; (6) rapid team analysis and triangulation of data sources and methods using a priori charts derived from implementation frameworks; and (7) validation of findings with sites.We used the rapid assessment approach at each of the four ICU sites to evaluate the implementation of the sites' innovations. Though the ICU projects all included three common components, they were individually developed to suit the local context and had mixed implementation outcomes. We generated in-depth case summaries describing the overall implementation process for each site; implementation barriers and facilitators for all four sites are presented. One of the site case summaries is presented as an example of findings generated using the method.A rapid team-based approach to qualitative analysis using charts and team discussion using validation techniques, such as member-checking, can be included as part of rapid assessment procedures. Our work demonstrates the value of including rapid assessment procedures for implementation research when time and resources are limited.

    View details for DOI 10.1186/s13012-020-0972-5

    View details for PubMedID 32087724

  • Arts, Humanities, Medicine, and Discovery: a Creative Calling. Journal of general internal medicine Charon, R., Ship, A., Asch, S. M. 2019

    View details for DOI 10.1007/s11606-019-05513-6

    View details for PubMedID 31792859

  • Negotiating Lay and Clinical Issues: Implementing a Lay Navigation Program in Cancer Care. Journal of oncology practice Holdsworth, L. M., Zionts, D., Wang, S., Veruttipong, D., Brown-Johnson, C., Asch, S. M., Rosenthal, E. L., Winget, M. 2019: JOP1900339


    PURPOSE: Patients with cancer face daunting coordination problems at a vulnerable time. Lay navigation programs offer 1 approach to address these problems, but how to best implement these programs presents challenges. We sought to describe those implementation challenges at 1 academic cancer center to inform future efforts.METHODS: We performed a mixed methods study using standard implementation outcomes 1 year after program initiation. Quantitative data from the electronic medical record and qualitative data from in-depth interviews, focus groups, and ethnographic observations were included in analyses. The study took place at a National Cancer Institute-designated comprehensive cancer center across 12 tumor-specific clinics.RESULTS: Supportive care concerns, scheduling, and clinical-related issues were the most frequent issues navigators encountered. Effective navigation required continuous, time-consuming, invisible work, including building and maintaining a broad knowledge base of resources and health system processes, as well as cultivating relationships with diverse and changing clinical teams. The acceptability and appropriateness of lay navigator activities were mixed among clinic and social work staff, related to negotiating lines between clinical and nonclinical care.CONCLUSION: After 1 year of implementation, lay navigators still found it difficult to interpret and prioritize complex patient needs in a way that all clinical staff found appropriate. Negotiating these issues has made it difficult to develop the strong relationships with clinical teams that are needed for an integrated approach to patient care. To successfully coordinate patient care, it seems that lay navigation programs should be integrated with clinical teams to provide more seamless patient care.

    View details for DOI 10.1200/JOP.19.00339

    View details for PubMedID 31693450

  • Effect of Metabolic Traits on the Risk of Cirrhosis and Hepatocellular Cancer in Non-alcoholic Fatty Liver Disease. Hepatology (Baltimore, Md.) Kanwal, F., Kramer, J., Li, L., Dai, J., Natarajan, Y., Yu, X., Asch, S. M., El-Serag, H. B. 2019


    Non-alcoholic fatty liver disease (NAFLD) is now the most common liver condition. Predicting its progression could help clinicians manage and potentially prevent complications. We evaluated the independent and joint effects of metabolic traits on the risk of cirrhosis and hepatocellular carcinoma (HCC) among patients with NAFLD. We assembled a retrospective cohort of patients with NAFLD diagnosed at 130 facilities in the Veterans Administration between 1/1/2004 and 12/31/2008 with follow-up through 12/31/2015. We performed competing risk, adjusted cause-specific Cox models to evaluate the effects of metabolic traits (diabetes, hypertension, dyslipidemia, obesity) as additive or combined indicators on time to develop cirrhosis or HCC or a composite endpoint of both. Of the 271,906 patients, 22,794 developed cirrhosis, and 253 developed HCC during a mean of 9 years follow up. At baseline, the mean BMI was 31.6 (SD, 5.6), 28.7% had diabetes, 70.3% hypertension, and 62.3% had dyslipidemia with substantial overlap among the these traits. The risk of progression was the lowest in patients with only one or no metabolic trait. There was a stepwise increase in risk with each additional metabolic trait. Compared to patients with no metabolic trait, patients with both hypertension and dyslipidemia had 1.8-fold higher risk of progression to cirrhosis/HCC (hazard ratio (HR) =1.8, 95% CI=1.59-2.06); the risk was 2.6-fold higher in patients with diabetes, obesity, dyslipidemia and hypertension (HR=2.6, 95% CI=2.3,2.9). These associations were stronger for HCC. Diabetes had the strongest association with HCC in this cohort. CONCLUSIONS: Each additional metabolic trait increased the risk of cirrhosis and HCC in patients with NAFLD. Diabetes conferred the highest risk of progression to HCC. Diabetic patients with co-existing hypertension and obesity may be important targets for secondary prevention.

    View details for DOI 10.1002/hep.31014

    View details for PubMedID 31675427

  • Medical Record Documentation of Goals-of-Care Discussions Among Older Veterans With Incident Kidney Failure. American journal of kidney diseases : the official journal of the National Kidney Foundation Bradshaw, C. L., Gale, R. C., Chettiar, A., Ghaus, S. J., Thomas, I., Fung, E., Lorenz, K., Asch, S. M., Anand, S., Kurella Tamura, M. 2019


    RATIONALE & OBJECTIVE: Elicitation and documentation of patient preferences is at the core of shared decision making and is particularly important among patients with high anticipated mortality. The extent to which older patients with incident kidney failure undertake such discussions with their providers is unknown and its characterization was the focus of this study.STUDY DESIGN: Retrospective cohort study.SETTING & PARTICIPANTS: A random sample of veterans 67 years and older with incident kidney failure receiving care from the US Veterans Health Administration between 2005 and2010.EXPOSURES: Demographic and facility characteristics, as well as predicted 6-month mortality risk after dialysis initiation and documentation of resuscitation preferences.OUTCOMES: Documented discussions of dialysis treatment and supportive care.ANALYTICAL APPROACH: We reviewed medical records over the 2 years before incident kidney failure and up to 1 year afterward to ascertain the frequency and timing of documented discussions about dialysis treatment, supportive care, and resuscitation. Logistic regression was used to identify factors associated with these documented discussions.RESULTS: The cohort of 821 veterans had a mean age of 80.9±7.2 years, and 37.2% had a predicted 6-month mortality risk>20% with dialysis. Documented discussions addressing dialysis treatment and resuscitation were present in 55.6% and 77.1% of patients, respectively. Those addressing supportive care were present in 32.4%. The frequency of documentation varied by mortality risk and whether the patient ultimately started dialysis. In adjusted analyses, the frequency and pattern of documentation were more strongly associated with geographic location and receipt of outpatient nephrology care than with patient demographic or clinical characteristics.LIMITATIONS: Documentation may not fully reflect the quality and content of discussions, and generalizability to nonveteran patients is limited.CONCLUSIONS: Among older veterans with incident kidney failure, discussions of dialysis treatment are decoupled from other aspects of advance care planning and are suboptimally documented, even among patients at high risk for mortality.

    View details for DOI 10.1053/j.ajkd.2019.07.024

    View details for PubMedID 31679746

  • Trajectory analysis for postoperative pain using electronic health records: A nonparametric method with robust linear regression and K-medians cluster analysis. Health informatics journal Weng, Y., Tian, L., Tedesco, D., Desai, K., Asch, S. M., Carroll, I., Curtin, C., McDonald, K. M., Hernandez-Boussard, T. 2019: 1460458219881339


    Postoperative pain scores are widely monitored and collected in the electronic health record, yet current methods fail to fully leverage the data with fast implementation. A robust linear regression was fitted to describe the association between the log-scaled pain score and time from discharge after total knee replacement. The estimated trajectories were used for a subsequent K-medians cluster analysis to categorize the longitudinal pain score patterns into distinct clusters. For each cluster, a mixture regression model estimated the association between pain score and time to discharge adjusting for confounding. The fitted regression model generated the pain trajectory pattern for given cluster. Finally, regression analyses examined the association between pain trajectories and patient outcomes. A total of 3442 surgeries were identified with a median of 22 pain scores at an academic hospital during 2009-2016. Four pain trajectory patterns were identified and one was associated with higher rates of outcomes. In conclusion, we described a novel approach with fast implementation to model patients' pain experience using electronic health records. In the era of big data science, clinical research should be learning from all available data regarding a patient's episode of care instead of focusing on the "average" patient outcomes.

    View details for DOI 10.1177/1460458219881339

    View details for PubMedID 31621460

  • The Future of the Patient-Centered Outcomes Research Institute (PCORI). Journal of general internal medicine Fischer, M. A., Asch, S. M. 2019

    View details for DOI 10.1007/s11606-019-05324-9

    View details for PubMedID 31529376

  • The Promise of Virtual Complex Care Management. Journal of general internal medicine Hochman, M., Asch, S. M. 2019

    View details for DOI 10.1007/s11606-019-05341-8

    View details for PubMedID 31515737

  • Signature Informed Consent for Long-Term Opioid Therapy in Patients with Cancer: Perspectives of Patients and Providers. Journal of pain and symptom management Giannitrapani, K., Fereydooni, S., Azarfar, A., Silveira, M. J., Glassman, P. A., Midboe, A., Bohnert, A., Zenoni, M., Kerns, R. D., Pearlman, R. A., Asch, S. M., Becker, W., Lorenz, K. A. 2019


    CONTEXT: Signature informed consent (SIC) is a part of a Veterans Health Administration (VHA) ethics initiative for patient education and shared decision-making with long-term opioid therapy (LTOT). Historically, patients with cancer-related pain receiving LTOT are exempt from this process.OBJECTIVES: Our objective is to understand patients' and providers' perspectives on using signature informed consent for LTOT in patients with cancer-related pain.METHODS: Semi-structured interviews with 20 opioid prescribers and 20 patients who were prescribed opioids at two large academically-affiliated VHA Medical Centers. We employed a combination of deductive and inductive approaches in content analysis to produce emergent themes.RESULTS: Potential advantages of SIC are that it can clarify and help patients comprehend LTOT risks and benefits, provide clear upfront boundaries and expectations, and involve the patient in shared decision-making. Potential disadvantages of SIC include time delay to treatment, discouragement from recommended opioid use, and impaired trust in the patient-provider relationship. Providers and patients have misconceptions about the definition of SIC. Providers and patients question if SIC for LTOT is really informed consent. Providers and patients advocate for strategies to improve comprehension of SIC content. Providers had divergent perspectives on exemptions from SIC. Oncologists want SIC for LTOT to be tailored for patients with cancer.CONCLUSION: Provider and patient interviews highlight various aspects about the advantages and disadvantages of requiring SIC for LTOT in cancer-related pain. Tailoring SIC for LTOT to be specific to cancer related concerns and to have an appropriate literacy level are important considerations.

    View details for DOI 10.1016/j.jpainsymman.2019.08.020

    View details for PubMedID 31476361

  • Identification of Emergency Care-Sensitive Conditions and Characteristics of Emergency Department Utilization. JAMA network open Vashi, A. A., Urech, T., Carr, B., Greene, L., Warsavage, T. J., Hsia, R., Asch, S. M. 2019; 2 (8): e198642


    Importance: Monitoring emergency care quality requires understanding which conditions benefit most from timely, quality emergency care.Objectives: To identify a set of emergency care-sensitive conditions (ECSCs) that are treated in most emergency departments (EDs), are associated with a spectrum of adult age groups, and represent common reasons for seeking emergency care and to provide benchmark national estimates of ECSC acute care utilization.Design, Setting, and Participants: A modified Delphi method was used to identify ECSCs. In a cross-sectional analysis, ECSC-associated visits by adults (aged ≥18 years) were identified based on International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes and analyzed with nationally representative data from the 2016 US Nationwide Emergency Department Sample. Data analysis was conducted from January 2018 to December 2018.Main Outcomes and Measures: Identification of ECSCs and ECSC-associated ED utilization patterns, length of stay, and charges.Results: An expert panel rated 51 condition groups as emergency care sensitive. Emergency care-sensitive conditions represented 16 033 359 of 114 323 044 ED visits (14.0%) in 2016. On average, 8 535 261 of 17 886 220 ED admissions (47.7%) were attributed to ECSCs. The most common ECSC ED visits were for sepsis (1 716 004 [10.7%]), chronic obstructive pulmonary disease (1 273 319 [7.9%]), pneumonia (1 263 971 [7.9%]), asthma (970 829 [6.1%]), and heart failure (911 602 [5.7%]) but varied by age group. Median (interquartile range) length of stay for ECSC ED admissions was longer than non-ECSC ED admissions (3.2 [1.7-5.8] days vs 2.7 [1.4-4.9] days; P<.001). In 2016, median (interquartile range) ED charges per visit for ECSCs were $2736 ($1684-$4605) compared with $2179 ($1118-$4359) per visit for non-ECSC ED visits (P<.001).Conclusions and Relevance: This comprehensive list of ECSCs can be used to guide indicator development for pre-ED, intra-ED, and post-ED care and overall assessment of the adult, non-mental health, acute care system. Health care utilization and costs among patients with ECSCs are substantial and warrant future study of validation, variations in care, and outcomes associated with ECSCs.

    View details for DOI 10.1001/jamanetworkopen.2019.8642

    View details for PubMedID 31390036

  • The Costs of Hepatitis C by Liver Disease Stage: Estimates from the Veterans Health Administration APPLIED HEALTH ECONOMICS AND HEALTH POLICY Gidwani-Marszowski, R., Owens, D. K., Lo, J., Goldhaber-Fiebert, J. D., Asch, S. M., Barnett, P. G. 2019; 17 (4): 513–21
  • Integrated Model for Patient-Centered Advanced Liver Disease Care. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association Naik, A. D., Arney, J., Clark, J. A., Martin, L. A., Walling, A. M., Stevenson, A., Smith, D., Asch, S. M., Kanwal, F. 2019


    Advanced liver disease (AdvLD) is a high-risk common condition with a progressive, highly morbid, and often fatal course. Despite effective treatments, there are substantial shortfalls in access to and use of evidence-based supportive and palliative care for AdvLD. Although patient-centered, chronic illness models that integrate early supportive and palliative care with curative treatments hold promise, there are several knowledge gaps that hinder development of an integrated model for AdvLD. We review these evidence gaps. We also describe a conceptual framework for a patient-centered approach that explicates key elements needed to improve integrated care. An integrated model of AdvLD would allow clinicians, patients, and caregivers to work collaboratively to identify treatments and other healthcare that best align with patients' priorities.

    View details for DOI 10.1016/j.cgh.2019.07.043

    View details for PubMedID 31357029

  • Role definition is key-Rapid qualitative ethnography findings from a team-based primary care transformation. Learning health systems Brown-Johnson, C., Shaw, J. G., Safaeinili, N., Chan, G. K., Mahoney, M., Asch, S., Winget, M. 2019; 3 (3): e10188


    Purpose: Implementing team-based care into existing primary care is challenging; understanding facilitators and barriers to implementation is critical. We assessed adoption and acceptability of new roles in the first 6months of launching a team-based care model focused on preventive care, population health, and psychosocial support.Methods: We conducted qualitative rapid ethnography at a community-based test clinic, including 74hours of observations and 28 semi-structured interviews. We identified implementation themes related to team-based care and specifically the integration of three roles purposively designed to enhance coordination for better patient outcomes, including preventive screening and mental health: (1) medical assistants as care coordinators; (2) extended care team specialists, including clinical pharmacist and behavioral health professional; and (3) advanced practice providers (APPs)-ie, nurse practitioners and physician assistants.Results: All stakeholders (ie, patients, providers, and staff) reported positive perceptions of care coordinators and extended care specialists; these roles were well defined and quickly implemented. Care coordinators effectively managed care between visits and established strong patient relationships. Specialist colocation facilitated patient access and well-supported diabetes services and mental health care. We also observed unanticipated value: Care coordinators relayed encounter-relevant chart information to providers while scribing; extended care specialists supported informal continuing medical education. In contrast, we observed uncertain definition and expectations of the APP role across stakeholders; accordingly, adoption and acceptability of the role varied.Conclusions: Practice redesign can redistribute responsibility and patient connection throughout a team but should emphasize well-defined roles. Ethnography, conducted early in implementation with multistakeholder perspectives, can provide rapid and actionable insights about where roles may need refinement or redefinition to support ultimate physical and mental health outcomes for patients.

    View details for DOI 10.1002/lrh2.10188

    View details for PubMedID 31317071

  • Impact of Health Aid Investments on Public Opinion of the United States: Analysis of Global Attitude Surveys From 45 Countries, 2002-2016 AMERICAN JOURNAL OF PUBLIC HEALTH Jakubowski, A., Mai, D., Asch, S. M., Bendavid, E. 2019; 109 (7): 1034–41
  • The Connectedness of Mental Health Providers Referring Patients to a Treatment Study for Post-Traumatic Stress: A Social Network Study. Administration and policy in mental health Elwy, A. R., Kim, B., Plumb, D. N., Wang, S., Gifford, A. L., Asch, S. M., Bormann, J. E., Mittman, B. S., Valente, T. W., Palinkas, L. A. 2019


    We conducted a process evaluation in the context of a Hybrid Type 1 randomized controlled trial testing two treatments for post-traumatic stress, using a web-based social network survey and semi-structured interviews to illustrate the relationship between providers' influence and likelihood of referring patients to the RCT. Providers with high indegree centrality (designated by other providers as someone they seek information from) were significantly more likely to refer patients to the RCT, and serve as an influence to others' referral behavior. Interviews provided additional data to consider for future studies aimed at increasing the uptake of evidence-based practices.

    View details for DOI 10.1007/s10488-019-00945-y

    View details for PubMedID 31236732

  • Long-term risk of hepatocellular carcinoma in HCV patients treated with direct acting antiviral agents. Hepatology (Baltimore, Md.) Kanwal, F., Kramer, J. R., Asch, S. M., Cao, Y., Li, L., El-Serag, H. B. 2019


    Sustained virologic response (SVR) after direct acting antiviral agents (DAA) holds promise for reducing hepatocellular cancer (HCC). DAA have recently been available long enough to estimate the long-term risk. We conducted a retrospective cohort study of HCV patients who achieved SVR with DAA from 129 Veterans Health Administration hospitals between 1/1/2015 and 12/31/2015 with follow-up through 09/30/2018. We calculated the overall and quarterly HCC incidence rates. We examined the effect of demographic, clinical, and behavioral factors and the decline or increase of FIB-4 and AST to platelet ratio index (APRI) on HCC risk. Among 18,076 patients with SVR, 544 incident cases of HCC were diagnosed during mean 2.9 years of follow-up. The cumulative 1, 2 and 3-year risks of HCC were 1.1%, 1.9% and 2.8%, respectively. Cirrhosis was strongly associated with HCC risk (adjusted hazard ratio=4.13, 95%CI=3.34-5.11). The quarterly incidence rate of HCC remained stable between 1.00 and 1.23/100 PY and 1.5 to 2.3/100 PY in patients with cirrhosis. The risk of HCC was the highest in patients who had persistently high FIB-4/APRI in both cirrhosis and non-cirrhosis patients. HCC risk fell in cirrhosis patients who experienced decrease of FIB-4/APRI scores yet remained higher than the accepted threshold for HCC surveillance. HCC risk was also higher in patients with alcohol use, older age and infection with HCV genotype 3. Most patients treated at an early stage of liver fibrosis had stable low risk. In conclusion, patients successfully treated with DAA, HCC risk did not regress after 3.6 years of follow-up. HCC risk remained above the accepted thresholds for surveillance in patients with cirrhosis. These data have important implications for HCC surveillance in cured HCV patients. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/hep.30823

    View details for PubMedID 31222774

  • Can We Improve Patient Adherence by Harnessing Social Forces? JOURNAL OF GENERAL INTERNAL MEDICINE Trivedi, R., Asch, S. M. 2019; 34 (6): 785–86
  • Effects of Intensive Primary Care on High-Need Patient Experiences: Survey Findings from a Veterans Affairs Randomized Quality Improvement Trial. Journal of general internal medicine Zulman, D. M., Chang, E. T., Wong, A., Yoon, J., Stockdale, S. E., Ong, M. K., Rubenstein, L. V., Asch, S. M. 2019


    BACKGROUND: Intensive primary care programs aim to coordinate care for patients with medical, behavioral, and social complexity, but little is known about their impact on patient experience when implemented in a medical home.OBJECTIVE: Determine how augmenting the VA's medical home (Patient Aligned Care Team, PACT) with a PACT-Intensive Management (PIM) program influences patient experiences with care coordination, access, provider relationships, and satisfaction.DESIGN: Cross-sectional analysis of patient survey data from a five-site randomized quality improvement study.PARTICIPANTS: Two thousand five hundred sixty-six Veterans with hospitalization risk scores ≥90th percentile and recent acute care.INTERVENTION: PIM offered patients intensive care coordination, including home visits, accompaniment to specialists, acute care follow-up, and case management from a team staffed by primary care providers, social workers, psychologists, nurses, and/or other support staff.MAIN MEASURES: Patient-reported experiences with care coordination (e.g., health goal assessment, test and appointment follow-up, Patient Assessment of Chronic Illness Care (PACIC)), access to healthcare services, provider relationships, and satisfaction.KEY RESULTS: Seven hundred fifty-nine PIM and 768 PACT patients responded to the survey (response rate 60%). Patients randomized to PIM were more likely than those in PACT to report that they were asked about their health goals (AOR=1.26; P=0.046) and that they have a VA provider whom they trust (AOR=1.35; P=0.005). PIM patients also had higher mean (SD) PACIC scores compared with PACT patients (2.91 (1.31) vs. 2.75 (1.25), respectively; P=0.022) and were more likely to report 10 out of 10 on satisfaction with primary care (AOR=1.25; P=0.048). However, other effects on coordination, access, and satisfaction did not achieve statistical significance.CONCLUSIONS: Augmenting VA's patient-centered medical home with intensive primary care had a modestly positive influence on high-risk patients' experiences with care coordination and provider relationships, but did not have a significant impact on most patient-reported access and satisfaction measures.

    View details for DOI 10.1007/s11606-019-04965-0

    View details for PubMedID 31098977

  • Coordinating Care Across VA Providers and Settings: Policy and Research Recommendations from VA's State of the Art Conference. Journal of general internal medicine Cordasco, K. M., Frayne, S. M., Kansagara, D., Zulman, D. M., Asch, S. M., Burke, R. E., Post, E. P., Fihn, S. D., Klobucar, T., Meyer, L. J., Kirsh, S. R., Atkins, D. 2019


    Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran.

    View details for DOI 10.1007/s11606-019-04970-3

    View details for PubMedID 31098966

  • Humanwide: A Comprehensive Data Base for Precision Health in Primary Care. Annals of family medicine Mahoney, M. R., Asch, S. M. 2019; 17 (3): 273

    View details for PubMedID 31085532

  • Managing professional knowledge boundaries during ECHO telementoring consultations in two Veterans Affairs specialty care liver clinics: A theme-oriented discourse analysis JOURNAL OF TELEMEDICINE AND TELECARE Koenig, C. J., Wenger, M., Graham, G. D., Asch, S., Rongey, C. 2019; 25 (3): 181–89
  • Integrating Adjuvant Analgesics into Perioperative Pain Practice: Results from an Academic Medical Center. Pain medicine (Malden, Mass.) Chin, K., Carroll, I., Desai, K., Asch, S., Seto, T., McDonald, K. M., Curtin, C., Hernandez-Boussard, T. 2019


    BACKGROUND: Opioid-sparing postoperative pain management therapies are important considering the opioid epidemic. Total knee arthroplasty (TKA) is a common and painful procedure accounting for a large number of opioid prescriptions. Adjuvant analgesics, nonopioid drugs with primary indications other than pain, have shown beneficial pain management and opioid-sparing effects following TKA in clinical trials. We evaluated the adjuvant analgesic gabapentin for its usage patterns and its effects on opioid use, pain, and readmissions.METHODS: This retrospective, observational study included 4,046 patients who received primary TKA between 2009 and 2017 using electronic health records from an academic tertiary care medical institute. Descriptive statistics and multivariate modeling were used to estimate associations between inpatient gabapentin use and adverse pain outcomes as well as inpatient oral morphine equivalents per day (OME).RESULTS: Overall, there was an 8.72% annual increase in gabapentin use (P<0.001). Modeled estimates suggest that gabapentin is associated with a significant decrease in opioid consumption (estimate = 0.63, 95% confidence interval = 0.49-0.82, P<0.001) when controlling for patient characteristics. Patients receiving gabapentin had similar discharge pain scores, follow-up pain scores, and 30-day unplanned readmission rates compared with patients receiving no adjuvant analgesics (P>0.05).CONCLUSIONS: When assessed in a real-world setting over a large cohort of TKA patients, gabapentin is an effective pain management therapy that is associated with reduced opioid consumption-a national priority in this time of opioid crisis-while maintaining the same quality of pain management.

    View details for PubMedID 30933284

  • A Qualitative Study of Primary Care Providers' Experiences with the Veterans Choice Program JOURNAL OF GENERAL INTERNAL MEDICINE Nevedal, A. L., Wagner, T. H., Ellerbe, L. S., Asch, S. M., Koenig, C. J. 2019; 34 (4): 598–603
  • Lean Enterprise Transformation in VA: a national evaluation framework and study protocol. BMC health services research Vashi, A. A., Lerner, B., Urech, T. H., Asch, S. M., Charns, M. P. 2019; 19 (1): 98


    BACKGROUND: The goal of Lean Enterprise Transformation (LET) is to go beyond simply using Lean tools and instead embed Lean principles and practices in the system so that it becomes a fundamental, collective mindset of the entire enterprise. The Veterans Engineering Resource Center (VERC) launched the Veterans Affairs (VA) LET pilot program to improve quality, safety, and the Veteran's experience. A national evaluation will examine the pilot program sites' implementation processes, outcomes and impacts, and abilities to improve LET adoption and sustainment. This paper describes the evaluation design for the VA LET national evaluation and describes development of a conceptual framework to evaluate LET specifically in healthcare settings.METHODS: A targeted literature review of Lean evaluation frameworks was performed to inform the development of the conceptual framework. Key domains were identified by a multidisciplinary expert group and then validated with key stakeholders. The national evaluation design will examine LET implementation using qualitative, survey, and quantitative methods at ten VA facilities. Qualitative data include site visits, interviews, and field observation notes. Survey data include an employee engagement survey to be administered to front-line staff at all pilot sites. Quantitative data include site-level quality improvement metrics collected by the Veterans Services Support Center. Qualitative, quantitative, and mixed-methods analyses will be conducted to examine implementation of LET strategic initiatives and variations in implementation success across sites.DISCUSSION: This national evaluation of a large-scale LET implementation effort will provide insights helpful to other systems interested in embarking on a Lean journey. Additionally, we created a multi-faceted conceptual framework to capture the specific features of a Lean healthcare organization. This framework will guide this evaluation and may be useful as an assessment tool for other organizations interested in implementing Lean principles at an enterprise level.

    View details for PubMedID 30717729

  • Extremely large outlier treatment effects may be a footprint of bias in trials from less developed countries: randomized trials of gabapentinoids JOURNAL OF CLINICAL EPIDEMIOLOGY Desai, K., Carroll, I., Asch, S., Hernandez-Boussard, T., Ioannidis, J. A. 2019; 106: 80–87
  • Measuring the Quality of Palliative Care for Patients with End Stage Liver Disease Patel, A., Asch, S., Antonio, A., Kanwal, F., Lorenz, K., Riopelle, D., Lee, M., Walling, A. ELSEVIER SCIENCE INC. 2019: 513–14
  • Improving Patient Flow: Analysis of an Initiative to Improve Early Discharge JOURNAL OF HOSPITAL MEDICINE Destino, L., Bennett, D., Wood, M., Acuna, C., Goodman, S., Asch, S. M., Platchek, T. 2019; 14 (1): 22–27

    View details for DOI 10.12788/jhm.3133

    View details for Web of Science ID 000457470100004

  • Pneumonia Prevention Strategies for Children With Neurologic Impairment. Pediatrics Lin, J. L., Van Haren, K. n., Rigdon, J. n., Saynina, O. n., Song, H. n., Buu, M. C., Thakur, Y. n., Srinivas, N. n., Asch, S. M., Sanders, L. M. 2019


    Children with neurologic impairment (NI) face high risk of recurrent severe pneumonia, with prevention strategies of unknown effectiveness. We evaluated the comparative effectiveness of secondary prevention strategies for severe pneumonia in children with NI.We included children enrolled in California Children's Services between July 1, 2009, and June 30, 2014, with NI and 1 pneumonia hospitalization. We examined associations between subsequent pneumonia hospitalization and expert-recommended prevention strategies: dental care, oral secretion management, gastric acid suppression, gastrostomy tube placement, chest physiotherapy, outpatient antibiotics before index hospitalization, and clinic visit before or after index hospitalization. We used a 1:2 propensity score matched model to adjust for covariates, including sociodemographics, medical complexity, and severity of index hospitalization.Among 3632 children with NI and index pneumonia hospitalization, 1362 (37.5%) had subsequent pneumonia hospitalization. Only dental care was associated with decreased risk of subsequent pneumonia hospitalization (adjusted odds ratio [aOR]: 0.64; 95% confidence interval [CI]: 0.49-0.85). Exposures associated with increased risk included gastrostomy tube placement (aOR: 2.15; 95% CI: 1.63-2.85), chest physiotherapy (aOR: 2.03; 95% CI: 1.29-3.20), outpatient antibiotics before hospitalization (aOR: 1.42; 95% CI: 1.06-1.92), clinic visit before (aOR: 1.30; 95% CI: 1.11-1.52), and after index hospitalization (aOR: 1.72; 95% CI: 1.35-2.20).Dental care was associated with decreased recurrence of severe pneumonia. Several strategies, including gastrostomy tube placement, were associated with increased recurrence, possibly due to unresolved confounding by indication. Our results support a clinical trial of dental care to prevent severe pneumonia in children with NI.

    View details for DOI 10.1542/peds.2019-0543

    View details for PubMedID 31537634

  • Mortality Among Veterans with Major Mental Illnesses Seen in Primary Care: Results of a National Study of Veteran Deaths. Journal of general internal medicine Trivedi, R. B., Post, E. P., Piegari, R. n., Simonetti, J. n., Boyko, E. J., Asch, S. M., Mori, A. n., Arnow, B. A., Fihn, S. D., Nelson, K. M., Maynard, C. n. 2019


    Premature mortality observed among the mentally ill is largely attributable to chronic illnesses. Veterans seen within Veterans Affairs (VA) have a higher prevalence of mental illness than the general population but there is limited investigation into the common causes of death of Veterans with mental illnesses.To characterize the life expectancy of mentally ill Veterans seen in VA primary care, and to determine the most death rates of combinations of mental illnesses.Retrospective cohort study of decedents.Veterans seen in VA primary care clinics between 2000 and 2011 were included. Records from the VA Corporate Data Warehouse (CDW) were merged with death information from the National Death Index.Mental illnesses were determined using ICD9 codes. Direct standardization methods were used to calculate age-adjusted gender and cause-specific death rates per 1000 deaths for patients with and without depression, anxiety, post-traumatic stress disorder (PTSD), substance use disorder (SUD), serious mental illness (SMI), and combinations of those diagnoses.Of the 1,763,982 death records for Veterans with 1 + primary care visit, 556,489 had at least one mental illness. Heart disease and cancer were the two leading causes of death among Veterans with or without a mental illness, accounting for approximately 1 in 4 deaths. Those with SUD (n = 204,950) had the lowest mean age at time of death (64 ± 12 years). Among men, the death rates were as follows: SUD (55.9/1000); anxiety (49.1/1000); depression (45.1/1000); SMI (40.3/1000); and PTSD (26.2/1000). Among women, death rates were as follows: SUD (55.8/1000); anxiety (36.7/1000); depression (45.1/1000); SMI (32.6/1000); and PTSD (23.1/1000 deaths). Compared to men (10.8/1000) and women (8.7/1000) without a mental illness, these rates were multiple-fold higher in men and in women with a mental illness. A greater number of mental illness diagnoses was associated with higher death rates among men and women (p < 0.0001).Veterans with mental illnesses, particularly those with SUD, and those with multiple diagnoses, had shorter life expectancy than those without a mental illness. Future studies should examine both patient and systemic sources of disparities in providing chronic illness care to Veterans with a mental illness.

    View details for DOI 10.1007/s11606-019-05307-w

    View details for PubMedID 31667746

  • Predicting inadequate postoperative pain management in depressed patients: A machine learning approach. PloS one Parthipan, A., Banerjee, I., Humphreys, K., Asch, S. M., Curtin, C., Carroll, I., Hernandez-Boussard, T. 2019; 14 (2): e0210575


    Widely-prescribed prodrug opioids (e.g., hydrocodone) require conversion by liver enzyme CYP-2D6 to exert their analgesic effects. The most commonly prescribed antidepressant, selective serotonin reuptake inhibitors (SSRIs), inhibits CYP-2D6 activity and therefore may reduce the effectiveness of prodrug opioids. We used a machine learning approach to identify patients prescribed a combination of SSRIs and prodrug opioids postoperatively and to examine the effect of this combination on postoperative pain control. Using EHR data from an academic medical center, we identified patients receiving surgery over a 9-year period. We developed and validated natural language processing (NLP) algorithms to extract depression-related information (diagnosis, SSRI use, symptoms) from structured and unstructured data elements. The primary outcome was the difference between preoperative pain score and postoperative pain at discharge, 3-week and 8-week time points. We developed computational models to predict the increase or decrease in the postoperative pain across the 3 time points by using the patient's EHR data (e.g. medications, vitals, demographics) captured before surgery. We evaluate the generalizability of the model using 10-fold cross-validation method where the holdout test method is repeated 10 times and mean area-under-the-curve (AUC) is considered as evaluation metrics for the prediction performance. We identified 4,306 surgical patients with symptoms of depression. A total of 14.1% were prescribed both an SSRI and a prodrug opioid, 29.4% were prescribed an SSRI and a non-prodrug opioid, 18.6% were prescribed a prodrug opioid but were not on SSRIs, and 37.5% were prescribed a non-prodrug opioid but were not on SSRIs. Our NLP algorithm identified depression with a F1 score of 0.95 against manual annotation of 300 randomly sampled clinical notes. On average, patients receiving prodrug opioids had lower average pain scores (p<0.05), with the exception of the SSRI+ group at 3-weeks postoperative follow-up. However, SSRI+/Prodrug+ had significantly worse pain control at discharge, 3 and 8-week follow-up (p < .01) compared to SSRI+/Prodrug- patients, whereas there was no difference in pain control among the SSRI- patients by prodrug opioid (p>0.05). The machine learning algorithm accurately predicted the increase or decrease of the discharge, 3-week and 8-week follow-up pain scores when compared to the pre-operative pain score using 10-fold cross validation (mean area under the receiver operating characteristic curve 0.87, 0.81, and 0.69, respectively). Preoperative pain, surgery type, and opioid tolerance were the strongest predictors of postoperative pain control. We provide the first direct clinical evidence that the known ability of SSRIs to inhibit prodrug opioid effectiveness is associated with worse pain control among depressed patients. Current prescribing patterns indicate that prescribers may not account for this interaction when choosing an opioid. The study results imply that prescribers might instead choose direct acting opioids (e.g. oxycodone or morphine) in depressed patients on SSRIs.

    View details for PubMedID 30726237

  • Applying Lean Principles to Reduce Wait Times in a VA Emergency Department MILITARY MEDICINE Vashi, A. A., Sheikhi, F. H., Nashton, L. A., Ellman, J., Rajagopal, P., Asch, S. M. 2019; 184 (1-2): E169–E178


    We describe the use of Lean quality improvement methodologies at a Veterans Affairs (VA) medical facility to redesign Emergency Department (ED) front-end operations and improve ED flow, specifically to reduce time from Veteran arrival to provider evaluation.The intervention, a Rapid Process Improvement Workshop (RPIW), took place during January 2014 at the VA Palo Alto Health Care System (VAPAHCS). Key changes made as a result of the RPIW included standardizing and streamlining evaluation and hand-off processes, better-delineating roles for RNs and MDs, more efficiently utilizing beds and improving team communication. We collected 13 months of pre-intervention and 13 months of post-intervention data. The primary outcome was the change in "Door to Doctor" time between the pre-intervention and post-intervention periods at VAPAHCS compared with contemporaneous national control facility sites. Secondary outcomes included the change in "Door to Triage" time and the rate at which patients left without being seen (LWBS). Data analyses were performed using a regression-adjusted difference-in-differences approach. This was a quality improvement project and the institutional review board determined that this project does not meet the definition of human subject research.Overall, "Door to Doctor" time at VAPAHCS decreased 12.6 minutes after the intervention, compared to 3.7 minutes in the control sites. Regression-adjusted difference-in-differences estimates for "Door to Doctor" time and "Door to Triage" time showed a significant reduction at VAPAHCS compared with control sites (8.9 minutes and 5.0 minutes, respectively), during the same time period (standard error = 3.5 min; p = 0.01 and standard error = 1.7 min; p = 0.004, respectively). Regression-adjusted difference-in-differences estimates for LWBS rates showed that LWBS did not significantly change at VAPAHCS compared with control sites (0.1% vs. 0.3%, p = 0.8).Using Lean principles, VAPAHCS was able to improve Veteran flow in the ED. Use of Lean methods foster interdisciplinary teams and problem-solving across departments and are one approach VA EDs can use to address systemic factors and contributors to ED crowding and improve care for Veterans. Future study should incorporate additional measures of quality to determine the effect of Lean on Veteran outcomes and should evaluate the long-term sustainability of the improvement.

    View details for PubMedID 30007347

  • Beyond satisfaction scores: exploring emotionally adverse patient experiences. The American journal of managed care Holdsworth, L. M., Zionts, D. L., De Sola-Smith, K. M., Valentine, M. n., Winget, M. D., Asch, S. M. 2019; 25 (5): e145–e152


    Although improving the average patient experience is at the center of recent efforts to make cancer care more patient centered, extreme experiences may be more informative for quality improvement. Little is known about the most deeply dissatisfying experiences that predispose disengagement and negatively influence patient outcomes. We sought to establish a framework for emotionally adverse patient experiences and identify the range of common causes.Qualitative study including in-depth interviews and free-text survey comments.Thematic analysis of 20 open-ended patient interviews and 2389 free-text survey comments collected in a medical center's cancer clinics.Emotionally adverse experiences were rarely reported in survey comments (96; 4.0%) but more frequently discussed in interviews (12 interview participants). Such experiences were identified through explicit statements of negative emotion, language, syntax, and tone. Among these rare comments, hostility as an indicator was easiest to identify, whereas passive expressions of fear or hopelessness were less reliably identified. We identified 3 mutually inclusive high-level domains of triggers of negative emotion-system issues, technical processes, and interpersonal processes-and 10 themes within those domains. There was wide variation in the causes of emotionally adverse experiences and evidence of a complex interplay of patient expectations and preconditions that influenced the perception of negative experiences.This study presents a taxonomy for classifying emotionally adverse patient experiences expressed in free-text format. Further research should test how perceptions of adverse experiences correspond to recorded ratings of patient satisfaction and subsequent enrollment or utilization.

    View details for PubMedID 31120711

  • The high resource impact of reformatting requirements for scientific papers. PloS one Jiang, Y. n., Lerrigo, R. n., Ullah, A. n., Alagappan, M. n., Asch, S. M., Goodman, S. N., Sinha, S. R. 2019; 14 (10): e0223976


    Most research manuscripts are not accepted for publication on first submission. A major part of the resubmission process is reformatting to another journal's specific requirements, a process separate from revising the scientific content. There has been little research to understand the magnitude of the burden imposed by the current resubmission process.We analyzed original research article submission requirements from twelve randomly selected journals in each of eight scientific and clinical focus areas from the InCites Journal Citation Reports database. From the 96 journals selected, we randomly identified three recently published manuscripts and sent surveys to those first and/or corresponding authors (288 total) to solicit information on time spent reformatting resubmissions and opinions on the process.There was significant variation in manuscript submission requirements for journals within the same scientific focus and only 4% of journals offered a fully format-free initial submission. Of 203 authors responding (71.5% response rate), only 11.8% expressed satisfaction with the resubmission process and 91% desired reforming the current system. Time spent on reformatting delays most publications by at least two weeks and by over three months in about 20% of manuscripts. The effort to comply with submission requirements has significant global economic burden, estimated at over $1.1 billion dollars annually when accounting for a research team's time.We demonstrate that there is significant resource utilization associated with resubmitting manuscripts, heretofore not properly quantified. The vast majority of authors are not satisfied with the current process. Addressing these issues by reconciling reformatting requirements among journals or adopting a universal format-free initial submission policy would help resolve a major subject for the scientific research community and provide more efficient dissemination of findings.

    View details for DOI 10.1371/journal.pone.0223976

    View details for PubMedID 31665156

  • Health System and Beneficiary Costs Associated With Intensive End-of-Life Medical Services. JAMA network open Gidwani-Marszowski, R. n., Asch, S. M., Mor, V. n., Wagner, T. H., Faricy-Anderson, K. n., Illarmo, S. n., Hsin, G. n., Patel, M. I., Ramchandran, K. n., Lorenz, K. A., Needleman, J. n. 2019; 2 (9): e1912161


    Despite recommendations to reduce intensive medical treatment at the end of life, many patients with cancer continue to receive such services.To quantify expected beneficiary and health system costs incurred in association with receipt of intensive medical services in the last month of life.This retrospective cohort study used data collected nationally from Medicare and the Veterans Health Administration for care provided in fiscal years 2010 to 2014. Participants were 48 937 adults aged 66 years or older who died of solid tumor and were continuously enrolled in fee-for-service Medicare and the Veterans Health Administration in the 12 months prior to death. The data were analyzed from February to August 2019.American Society of Clinical Oncology metrics regarding medically intensive services provided in the last month of life, including hospital stay, intensive care unit stay, chemotherapy, 2 or more emergency department visits, or hospice for 3 or fewer days.Costs in the last month of life associated with receipt of intensive medical services were evaluated for both beneficiaries and the health system. Costs were estimated from generalized linear models, adjusting for patient demographics and comorbidities and conditioning on geographic region.Of 48 937 veterans who received care through the Veterans Health Administration and Medicare, most were white (90.8%) and male (98.9%). More than half (58.9%) received at least 1 medically intensive service in the last month of life. Patients who received no medically intensive service generated a mean (SD) health system cost of $7660 ($1793), whereas patients who received 1 or more medically intensive services generated a mean (SD) health system cost of $23 612 ($5528); thus, the additional financial consequence to the health care system for medically intensive services was $15 952 (95% CI, $15 676-$16 206; P < .001). The biggest contributor to these differences was $21 093 (95% CI, $20 364-$21 689) for intensive care unit stay, while the smallest contributor was $3460 (95% CI, $2927-$3880) for chemotherapy. Mean (SD) expected beneficiary costs for the last month of life were $133 ($50) for patients with no medically intensive service and $1257 ($408) for patients with at least 1 medically intensive service (P < .001).Given the low income of many elderly patients in the United States, the financial consequences of medically intensive services may be substantial. Costs of medically intensive services at the end of life, including patient financial consequences, should be considered by both physicians and families.

    View details for DOI 10.1001/jamanetworkopen.2019.12161

    View details for PubMedID 31560384

  • Comparing the Barriers and Facilitators of Heart Failure Management as Perceived by Patients, Caregivers, and Clinical Providers. The Journal of cardiovascular nursing Trivedi, R. B., Slightam, C. n., Nevedal, A. n., Guetterman, T. C., Fan, V. S., Nelson, K. M., Rosland, A. M., Heidenreich, P. A., Timko, C. n., Asch, S. M., Piette, J. D. 2019


    Heart failure (HF) management requires the participation of patients, their significant others, and clinical providers. Each group may face barriers to HF management that may be unique or may overlap.The aim of this study was to compare the barriers and facilitators of HF management as perceived by patients, significant others, and clinical providers.Participants were recruited from a Veterans Health Administration facility. Eligible patients had a diagnosis of HF (ICD9 code 428.XX), 1 or more HF-related visit in the previous year, and a significant other who was their primary caregiver. Significant others were adults with no history of cognitive impairments caring for patients with HF. Providers were eligible if they cared for patients with HF. All participants completed semistructured interviews designed to elicit barriers to managing HF and strategies that they used to overcome these barriers. Interviews were transcribed and analyzed using latent thematic analysis, and recruitment continued until thematic saturation was attained.A total of 17 couples and 12 providers were recruited. All 3 groups identified poor communication as a key barrier to HF management, including communication between patients and their significant other, between couples and providers, and providers with each other. Significant others noted that the lack of direct communication with clinical providers hindered their efforts to care for the patient. All 3 groups emphasized the importance of family members in optimizing adherence to HF self-management recommendations.Providers, patients, and significant others all play important and distinct roles in the management of HF. Tools to enhance communication and collaboration for all 3 and supporting the needs of significant others are missing components of current HF care.

    View details for DOI 10.1097/JCN.0000000000000591

    View details for PubMedID 31365440

  • Effectiveness of a Lay Navigation Program in an Academic Cancer Center. Journal of oncology practice Winget, M. n., Holdsworth, L. n., Wang, S. n., Veruttipong, D. n., Zionts, D. n., Rosenthal, E. L., Asch, S. M. 2019: JOP1900337


    A navigation program with lay navigators that targets patients with cancer who are receiving multiple treatment modalities was launched with the goal of improving care coordination.Pseudo-randomization and mixed methods were used to evaluate the program: patients with even-numbered medical records were assigned to navigation help, and patients with odd-numbered medical records made up the control group. Eligible patients were those scheduled to receive at least two treatment modalities. Intent-to-treat, as-treated, and high-user cohorts with propensity matched controls were used to assess the outcomes: patient experience, emergency room (ER) use, and unplanned hospitalizations. In-depth patient interviews explored how and why patients interacted with the navigator program and overall patient experience.Marginally lower incidence rate ratios (IRRs) for both ER visits (IRR, 1.17; 95% CI, 1.00 to 1.36) and unplanned hospitalizations (IRR, 1.18; 95% CI, 0.97 to 1.43) occurred in as-treated patients who used navigation help and who lived within 50 miles of Stanford Hospital compared with their matched controls; other cohort analyses had similar results. Survey scores for patients who received help with navigation did not differ significantly from those for corresponding controls in any of the analytic cohorts. Patient interviews suggested that the navigation program had low visibility among patients and that lay navigators drove use of the program. Patient-reported positive experiences included getting help with complex scheduling, alleviating anxiousness through access to information and educational resources, and getting help with activities outside traditional health care; negative experiences stemmed from having expectations that were not met.Marginally lower rates of ER visits and unplanned hospitalizations for a small subset of patients, low penetration of the navigation program, and mixed comments from patient interviews suggest that a navigation program with a broad scope that targets a large population is not effective. Modifying the program to have a narrower scope of practice may help better target anxious or high-risk patients.

    View details for DOI 10.1200/JOP.19.00337

    View details for PubMedID 31647691

  • Rising rates of bilateral mastectomy with reconstruction following neoadjuvant chemotherapy INTERNATIONAL JOURNAL OF CANCER Pollom, E. L., Qian, Y., Chin, A. L., Dirbas, F. M., Asch, S. M., Kurian, A. W., Horst, K. C., Tsai, C. 2018; 143 (12): 3262–72

    View details for DOI 10.1002/ijc.31747

    View details for Web of Science ID 000451115900020

  • Advance Care Planning Needs in Patients With Glioblastoma Undergoing Radiotherapy JOURNAL OF PAIN AND SYMPTOM MANAGEMENT Pollom, E. L., Sborov, K. D., Soltys, S. G., Asch, S. M., Sudore, R. L., Aslakson, R. A. 2018; 56 (6): E6–E8
  • What are the key elements for implementing intensive primary care? A multisite Veterans Health Administration case study HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION Chang, E. T., Raja, P., Stockdale, S. E., Katz, M. L., Zulman, D. M., Eng, J. A., Hedrick, K. H., Jackson, J. L., Pathak, N., Watts, B., Patton, C., Schectman, G., Asch, S. M. 2018; 6 (4): 231–37


    Many integrated health systems and accountable care organizations have turned to intensive primary care programs to improve quality of care and reduce costs for high-need high-cost patients. How best to implement such programs remains an active area of discussion. In 2014, the Veterans Health Administration (VHA) implemented five distinct intensive primary care programs as part of a demonstration project that targeted Veterans at the highest risk for hospitalization. We found that programs evolved over time, eventually converging on the implementation of the following elements: 1) an interdisciplinary care team, 2) chronic disease management, 3) comprehensive patient assessment and evaluation, 4) care and case management, 5) transitional care support, 6) preventive home visits, 7) pharmaceutical services, 8) chronic disease self-management, 9) caregiver support services, 10) health coaching, and 11) advanced care planning. The teams also found that including social workers and mental health providers on the interdisciplinary teams was critical to effectively address psychosocial needs of these complex patients. Having a central implementation coordinator facilitated the convergence of these program features across diverse demonstration sites. In future iterations of these programs, VHA intends to standardize staffing and key features to develop a scalable program that can be disseminated throughout the system.

    View details for PubMedID 29102480

  • The moral discourse of HIV providers within their organizational context: An ethnographic case study PATIENT EDUCATION AND COUNSELING Fix, G. M., Hyde, J. K., Bolton, R. E., Parker, V. A., Dvorin, K., Wu, J., Skolnik, A. A., McInnes, D., Midboe, A. M., Asch, S. M., Gifford, A. L., Bokhour, B. G. 2018; 101 (12): 2226–32


    Providers make judgments to inform treatment planning, especially when adherence is crucial, as in HIV. We examined the extent these judgments may become intertwined with moral ones, extraneous to patient care, and how these in turn are situated within specific organizational contexts.Our ethnographic case study included interviews and observations. Data were analyzed for linguistic markers indexing how providers conceptualized patients and clinic organizational structures and processes.We interviewed 30 providers, observed 43 clinical encounters, and recorded fieldnotes of 30 clinic observations, across 8 geographically-diverse HIV clinics. We found variation, and identified two distinct judgment paradigms: 1) Behavior as individual responsibility: patients were characterized as "good," "behaving," or "socio-paths," and "flakes." Clinical encounters focused on medication reconciliation; 2) Behaviors as socio-culturally embedded: patients were characterized as struggling with housing, work, or relationships. Encounters broadened to problem-solving within patients' life-contexts. In sites with individualized conceptualizations, providers worked independently with limited support services. Sites with socio-culturally embedded conceptualizations had multidisciplinary teams with resources to address patients' life challenges.When self-management is viewed as an individual's responsibility, nonadherence may be seen as a moral failing. Multidisciplinary teams may foster perceptions of patients' behaviors as socially embedded.

    View details for PubMedID 30131263

  • Risk of Hepatocellular Cancer in Patients With Non-Alcoholic Fatty Liver Disease GASTROENTEROLOGY Kanwal, F., Kramer, J. R., Mapakshi, S., Natarajan, Y., Chayanupatkul, M., Richardson, P. A., Li, L., Desiderio, R., Thrift, A. P., Asch, S. M., Chu, J., El-Serag, H. B. 2018; 155 (6): 1828-+


    There are limited data on the risk of hepatocellular cancer (HCC) in patients with non-alcoholic fatty liver disease (NAFLD). We aimed to estimate the risk of incident HCC among patients with NAFLD.We conducted a retrospective cohort study from a total of 130 facilities in the Veterans Health Administration. Patients with NAFLD diagnosed between January 1, 2004 and December 31, 2008 were included and followed until HCC diagnosis, death, or December 31, 2015. We also identified a sex- and age-matched control cohort without NAFLD. We ascertained all new HCC cases from the Central Cancer Registry and manual chart reviews. We calculated incidence rates for HCC by NAFLD status, as well as in subgroups of NAFLD patients. We used competing risk models to compare the risk of HCC in patients with NAFLD vs those without NAFLD. We reviewed electronic medical records of all HCC cases that developed in NAFLD patients without cirrhosis.We compared 296,707 NAFLD patients with 296,707 matched controls. During 2,382,289 person-years [PYs] of follow-up, 490 NAFLD patients developed HCC (0.21/1000 PYs). HCC incidence was significantly higher among NAFLD patients vs controls (0.02/1000 PYs; hazard ratio, 7.62; 95% confidence interval, 5.76-10.09). Among patients with NAFLD, those with cirrhosis had the highest annual incidence of HCC (10.6/1000 PYs). Among patients with NAFLD cirrhosis, HCC risk ranged from 1.6 to 23.7 per 1000 PYs based on other demographic characteristics; risk of HCC was the highest in older Hispanics with cirrhosis. In medical record reviews, 20% of NAFLD patients with HCC had no evidence of cirrhosis.Risk of HCC was higher in NAFLD patients than that observed in general clinical population. Most HCC cases in NAFLD developed in patients with cirrhosis. The absolute risk of HCC was higher than the accepted thresholds for HCC surveillance for most patients with NAFLD cirrhosis.

    View details for PubMedID 30144434

    View details for PubMedCentralID PMC6279617

  • Patient Activation Changes as a Potential Signal for Changes in Health Care Costs: Cohort Study of US High-Cost Patients JOURNAL OF GENERAL INTERNAL MEDICINE Lindsay, A., Hibbard, J. H., Boothroyd, D. B., Glaseroff, A., Asch, S. M. 2018; 33 (12): 2106–12
  • Selection of Higher Risk Pregnancies into Veterans Health Administration Programs: Discoveries from Linked Department of Veterans Affairs and California Birth Data HEALTH SERVICES RESEARCH Shaw, J. G., Joyce, V. R., Schmitt, S. K., Frayne, S. M., Shaw, K. A., Danielsen, B., Kimerling, R., Asch, S. M., Phibbs, C. S. 2018; 53: 5260–84
  • Is there congruence between the types of triggers that cause delight or disgust in cancer care? Holdsworth, L. M., Zionts, D., Asch, S., Winget, M. AMER SOC CLINICAL ONCOLOGY. 2018
  • Who are the cancer patients most likely to utilize lay navigation services and what types of issues do they ask for help? Winget, M., Veruttipong, D., Holdsworth, L. M., Zionts, D., Asch, S. M. AMER SOC CLINICAL ONCOLOGY. 2018
  • Effect of a Lay HealthWorker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and Satisfaction Among Patients With Cancer A Randomized Clinical Trial JAMA ONCOLOGY Patel, M. I., Sundaram, V., Desai, M., Periyakoil, V. S., Kahn, J. S., Bhattacharya, J., Asch, S. M., Milstein, A., Bundorf, M. 2018; 4 (10): 1359–66
  • Longer Term Risk of Hepatocellular Cancer in HCV Patients Treated with Direct Acting Antiviral Agents Kanwal, F., Kramer, J. R., Asch, S. M., Cao, Y., El-Serag, H. B. WILEY. 2018: 521A
  • Emergency Department Visits Related to Emergency Care-Sensitive Conditions: Patterns and Predictors Vashi, A., Warsavage, T., Urech, T., Carr, B., Hsia, R., Asch, S. MOSBY-ELSEVIER. 2018: S38
  • Ethical Pitfalls When Estimating Life Expectancy for Patients with Prostate Cancer JOURNAL OF UROLOGY Leppert, J. T., Asch, S. M., Bergman, J. 2018; 200 (4): 709–11
  • It's OK to Talk About It: Exceptions to the Ingelfinger Rule. Journal of general internal medicine Asch, S. M. 2018

    View details for DOI 10.1007/s11606-018-4634-0

    View details for PubMedID 30203355

  • Implementation of a Population-Based Cirrhosis Identification and Management System CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Kanwal, F., Mapaskhi, S., Smith, D., Taddei, T., Hussain, K., Madu, S., Ngoc Duong, White, D., Cao, Y., Mehta, R., El-Serag, H., Asch, S., Midboe, A. 2018; 16 (8): 1182-+

    View details for PubMedID 29803805

  • A Randomized Trial of Off-Site Collaborative Care for Depression in Chronic Hepatitis C Virus HEALTH SERVICES RESEARCH Kanwal, F., Pyne, J. M., Tavakoli-Tabasi, S., Nicholson, S., Dieckgraefe, B., Storay, E., Goetz, M., Kramer, J. R., Smith, D., Sansgiry, S., Tansel, A., Gifford, A. L., Asch, S. M. 2018; 53 (4): 2547–66


    To test the effectiveness of a collaborative depression care model in improving depression and hepatitis C virus (HCV) care.Hepatitis C virus clinic patients who screened positive for depression at four Veterans Affairs Hospitals.We compared off-site depression collaborative care (delivered by depression care manager, pharmacist, and psychiatrist) with usual care in a randomized trial. Primary depression outcomes were treatment response (≥50 percent decrease in 20-item Hopkins Symptoms Checklist [SCL-20] score), remission (mean SCL-20 score, <0.5), and depression-free days (DFDs). Primary HCV outcome was receipt of HCV treatment.Patient data were collected by self-report telephone surveys at baseline and 12 months, and from electronic medical records.Baseline screening identified 292 HCV-infected patients with depression, and 242 patients completed 12-month follow-up (82.9 percent). Intervention participants were more likely to report depression treatment response, remission, and more DFDs than usual care participants. Intervention participants were more likely to receive antiviral treatment; however, the difference was not statistically significant.Off-site depression collaborative care improved depression outcomes in HCV patients and may serve as a model for collaboration between mental health and specialty physical health providers in other high co-occurring conditions.

    View details for DOI 10.1111/1475-6773.12758

    View details for Web of Science ID 000439548300030

    View details for PubMedID 28891153

    View details for PubMedCentralID PMC6051980

  • Dialysis versus Medical Management at Different Ages and Levels of Kidney Function in Veterans with Advanced CKD JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Tamura, M., Desai, M., Kapphahn, K. I., Thomas, I., Asch, S. M., Chertow, G. M. 2018; 29 (8): 2169–77
  • Utilization and effectiveness of multimodal discharge analgesia for postoperative pain management JOURNAL OF SURGICAL RESEARCH Desai, K., Carroll, I., Asch, S. M., Seto, T., McDonald, K. M., Curtin, C., Hernandez-Boussard, T. 2018; 228: 160–69
  • Use of an Emergency Manual During an Intraoperative Cardiac Arrest by an Interprofessional Team: A Positive-Exemplar Case Study of a New Patient Safety Tool JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Merrell, S., Gaba, D. M., Agarwala, A., Cooper, J. B., Nevedal, A. L., Asch, S. M., Howard, S. K., Goldhaber-Fiebert, S. N. 2018; 44 (8): 477–84


    An emergency manual (EM) is a set of evidence-based crisis checklists, or cognitive aids, that can improve team performance. EMs are used in other safety-critical industries, and health care simulation studies have shown their efficacy, but use in clinical settings is nascent. A case study was conducted on the use of an EM during one intraoperative crisis, which entailed the assessment of the impact of the EM's use on teamwork and patient care and the identification of lessons for effectively using EMs during future clinical crises.In a case study of a single crisis, an EM was used during a cardiac arrest at a tertiary care hospital that had systematically implemented perioperative EMs. Semistructured interviews were conducted with all six clinicians present, interview transcripts were iteratively coded, and thematic analysis was performed.All clinician participants stated that EM use enabled effective team functioning via reducing stress of individual clinicians, fostering a calm work environment, and improving teamwork and communication. These impacts in turn improved the delivery of patient care during a clinical crisis and influenced participants' intended EM use during future appropriate crises.In this positive-exemplar case study, an EM was used to improve delivery of evidence-based patient care through effective clinical team functioning. EM use must complement rather than replace good clinician education, judgment, and teamwork. More broadly, understanding why and how things go well via analyzing positive-exemplar case studies, as a converse of root cause analyses for negative events, can be used to identify effective applications of safety innovations.

    View details for PubMedID 30071967

  • Oncologists' Views on Using Value to Guide Cancer Treatment Decisions VALUE IN HEALTH Gidwani-Marszowski, R., Nevedal, A. L., Blayney, D. W., Patel, M., Kelly, P., Timko, C., Ramchandran, K., Murrell, S. S., Asch, S. M. 2018; 21 (8): 931–37


    Cancer costs have increased substantially in the past decades, prompting specialty societies to urge oncologists to consider value in clinical decision making. Despite oncologists' crucial role in guiding cancer care, current literature is sparse with respect to the oncologists' views on value. Here, we evaluated oncologists perceptions of the use and measurement of value in cancer care.We conducted in-depth, open-ended interviews with 31 US oncologists practicing nationwide in various environments. Oncologists discussed the definition, measurement, and implementation of value. Transcripts were analyzed using matrix and thematic analysis.Oncologists' definitions of value varied greatly. Some described versions of the standard health economic definition of value, that is, cost relative to health outcomes. Many others did not include cost in their definition of value. Oncologists considered patient goals and quality of life as important components of value that they perceived were missing from current value measurement. Oncologists prioritized a patient-centric view of value over societal or other perspectives. Oncologists were inclined to consider the value of a treatment only if they perceived treatment would pose a financial burden to patients. Oncologists had differing opinions regarding who should be responsible for determining whether care is low value but generally felt this should remain within the purview of the oncology community.Oncologists agreed that cost was an important issue, but disagreed about whether cost was involved in value as well as the role of value in guiding treatment. Better clarity and alignment on the definition of and appropriate way to measure value is critical to the success of efforts to improve value in cancer care.

    View details for PubMedID 30098670

  • Patient and provider perspectives on the development of personalized medicine: a mixed-methods approach JOURNAL OF COMMUNITY GENETICS Puryear, L., Downs, N., Nevedal, A., Lewis, E. T., Ormond, K. E., Bregendahl, M., Suarez, C. J., David, S. P., Charlap, S., Chu, I., Asch, S. M., Pakdaman, N., Chang, S., Cullen, M. R., Palaniappan, L. 2018; 9 (3): 283–91
  • Impact of Primary Care Intensive Management on High-Risk Veterans' Costs and Utilization A Randomized Quality Improvement Trial ANNALS OF INTERNAL MEDICINE Yoon, J., Chang, E., Rubenstein, L., Park, A., Zulman, D. M., Stockdale, S., Ong, M. K., Atkins, D., Schectman, G., Asch, S. M. 2018; 168 (12): 846-+


    Primary care models that offer comprehensive, accessible care to all patients may provide insufficient resources to meet the needs of patients with complex conditions who have the greatest risk for hospitalization.To assess whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk patients.Randomized quality improvement trial. ( NCT03100526).5 U.S. Department of Veterans Affairs (VA) medical centers.Primary care patients at high risk for hospitalization who had a recent acute care episode.Locally tailored intensive management programs providing care coordination, goals assessment, health coaching, medication reconciliation, and home visits through an interdisciplinary team, including a physician or nurse practitioner, a nurse, and psychosocial experts.Utilization and costs (including intensive management program expenses) 12 months before and after randomization.2210 patients were randomly assigned, 1105 to intensive management and 1105 to usual care. Patients had a mean age of 63 years and an average of 7 chronic conditions; 90% were men. Of the patients assigned to intensive management, 487 (44%) received intensive outpatient care (that is, ≥3 encounters in person or by telephone) and 204 (18%) received limited intervention. From the pre- to postrandomization periods, mean inpatient costs decreased more for the intensive management than the usual care group (-$2164 [95% CI, -$7916 to $3587]). Outpatient costs increased more for the intensive management than the usual care group ($2636 [CI, $524 to $4748]), driven by greater use of primary care, home care, telephone care, and telehealth. Mean total costs were similar in the 2 groups before and after randomization.Sites took up to several months to contact eligible patients, limiting the time between treatment and outcome assessment. Only VA costs were assessed.High-risk patients with access to an intensive management program received more outpatient care with no increase in total costs.Veterans Health Administration Primary Care Services.

    View details for PubMedID 29868706

  • Racial Differences in Quality of Care and Outcomes After Acute Coronary Syndrome AMERICAN JOURNAL OF CARDIOLOGY Yong, C. M., Ungar, L., Abnousi, F., Asch, S. M., Heidenreich, P. A. 2018; 121 (12): 1489–95
  • QUALITY OF CARE AND PATIENT-REPORTED OUTCOMES IN CARPAL TUNNEL SYNDROME: A PROSPECTIVE OBSERVATIONAL STUDY MUSCLE & NERVE Nuckols, T. K., Conlon, C., Robbins, M., Dworsky, M., Lai, J., Roth, C. P., Levitan, B., Seabury, S., Seelam, R., Benner, D., Asch, S. M. 2018; 57 (6): 896–904


    Higher quality care for carpal tunnel syndrome (CTS) may be associated with better outcomes.This prospective observational study recruited adults diagnosed with CTS from 30 occupational health centers, evaluated physicians' adherence to recommended care processes, and assessed results of the Boston Carpal Tunnel Questionnaire (BCTQ) and Short Form Health Survey version 2 (SF-12v2) at recruitment and at 18 months.Among 343 individuals, receiving better care (80th vs. 20th percentile for adherence) was associated with greater improvements in BCTQ Symptom Severity scores (-0.18, 95% confidence interval [CI] -0.32 to -0.05), BCTQ Functional Status scores (-0.21, 95% CI -0.34 to -0.08), and SF12-v2 Physical Component scores (1.75, 95% CI 0.33-3.16). Symptoms improved more when physicians assessed and managed activity, patients underwent necessary surgery, and employers adjusted job tasks.Efforts should be made to ensure that patients with CTS receive essential care processes including necessary surgery and activity assessment and management. Muscle Nerve 57: 896-904, 2018.

    View details for PubMedID 29272038

  • An operations-partnered evaluation of care redesign for high-risk patients in the Veterans Health Administration (VHA): Study protocol for the PACT Intensive Management (PIM) randomized quality improvement evaluation CONTEMPORARY CLINICAL TRIALS Chang, E. T., Zulman, D. M., Asch, S. M., Stockdale, S. E., Yoon, J., Ong, M. K., Lee, M., Simon, A., Atkins, D., Schectman, G., Kirsh, S. R., Rubenstein, L. V., PIM Executive Comm Demonstrati 2018; 69: 65–75


    Patient-centered medical homes have made great strides providing comprehensive care for patients with chronic conditions, but may not provide sufficient support for patients at highest risk for acute care use. To address this, the Veterans Health Administration (VHA) initiated a five-site demonstration project to evaluate the effectiveness of augmenting the VA's Patient Aligned Care Team (PACT) medical home with PACT Intensive Management (PIM) teams for Veterans at highest risk for hospitalization.Researchers partnered with VHA leadership to design a mixed-methods prospective multi-site evaluation that met leadership's desire for a rigorous evaluation conducted as quality improvement rather than research. We conducted a randomized QI evaluation and assigned high-risk patients to participate in PIM and compared them with high-risk Veterans receiving usual care through PACT. The summative evaluation examines whether PIM: 1) decreases VHA emergency department and hospital use; 2) increases satisfaction with VHA care; 3) decreases provider burnout; and 4) generates positive returns on investment. The formative evaluation aims to support improved care for high-risk patients at demonstration sites and to inform future initiatives for high-risk patients. The evaluation was reviewed by representatives from the VHA Office of Research and Development and the Office of Research Oversight and met criteria for quality improvement.VHA aims to function as a learning organization by rapidly implementing and rigorously testing QI innovations prior to final program or policy development. We observed challenges and opportunities in designing an evaluation consistent with QI standards and operations priorities, while also maintaining scientific rigor.This trial was retrospectively registered at on April 3, 2017: NCT03100526. Protocol v1, FY14-17.

    View details for PubMedID 29698772

  • From the Editors' Desk: Truth Rules, or the Upside of Bureaucracy. Journal of general internal medicine Asch, S. M. 2018

    View details for DOI 10.1007/s11606-018-4453-3

    View details for PubMedID 29736751

  • How does sagittal imbalance affect the appropriateness of surgical indications and selection of procedure in the treatment of degenerative scoliosis? Findings from the RAND/UCLA Appropriate Use Criteria study SPINE JOURNAL Daubs, M. D., Brara, H. S., Raaen, L. B., Chen, P., Anderson, A. T., Asch, S. M., Nuckols, T. K. 2018; 18 (5): 900–911


    Degenerative lumbar scoliosis (DLS) is often associated with sagittal imbalance, which may affect patients' health outcomes before and after surgery. The appropriateness of surgery and preferred operative approaches has not been examined in detail for patients with DLS and sagittal imbalance.The goals of this article were to describe what is currently known about the relationship between sagittal imbalance and health outcomes among patients with DLS and to determine how indications for surgery in patients with DLS differ when sagittal imbalance is present.This study included a literature review and an expert panel using the RAND/University of California at Los Angeles (UCLA) Appropriateness Method.To develop appropriate use criteria for DLS, researchers at the RAND Corporation recently employed the RAND/UCLA Appropriateness Method, which involves a systematic review of the literature and multidisciplinary expert panel process. Experts reviewed a synopsis of published literature and rated the appropriateness of five common operative approaches for 260 different clinical scenarios. In the present work, we updated the literature review and compared panelists' ratings in scenarios where imbalance was present versus absent. This work was funded by the Collaborative Spine Research Foundation, a group of surgical specialty societies and device manufacturers.On the basis of 13 eligible studies that examined sagittal imbalance and outcomes in patients with DLS, imbalance was associated with worse functional status in the absence of surgery and worse symptoms and complications postoperatively. Panelists' ratings demonstrated a consistent pattern across the diverse clinical scenarios. In general, when imbalance was present, surgery was more likely to be appropriate or necessary, including in some situations where surgery would otherwise be inappropriate. For patients with moderate to severe symptoms and imbalance, a deformity correction procedure was usually appropriate and frequently necessary, except in some patients with severe risk factors for complications. Conversely, procedures that did not correct imbalance, when present, were usually inappropriate.Clinical experts agreed that sagittal imbalance is a major factor affecting both when surgery is appropriate and which type of procedure is preferred among patients with DLS.

    View details for PubMedID 29412187

  • Reimagining Clinical Documentation With Artificial Intelligence MAYO CLINIC PROCEEDINGS Lin, S. Y., Shanafelt, T. D., Asch, S. M. 2018; 93 (5): 563–65
  • Dialysis Initiation and Mortality Among Older Veterans With Kidney Failure Treated in Medicare vs the Department of Veterans Affairs JAMA INTERNAL MEDICINE Tamura, M., Thomas, I., Montez-Rath, M. E., Kapphahn, K., Desai, M., Gale, R. C., Asch, S. M. 2018; 178 (5): 657–64


    The benefits of maintenance dialysis for older adults with end-stage renal disease (ESRD) are uncertain. Whether the setting of pre-ESRD nephrology care influences initiation of dialysis and mortality is not known.To compare initiation of dialysis and mortality among older veterans with incident kidney failure who received pre-ESRD nephrology care in fee-for-service Medicare vs the Department of Veterans Affairs (VA).Retrospective cohort study of patients from the US Medicare and VA health care systems evaluated 11 215 veterans aged 67 years or older with incident kidney failure between January 1, 2008, and December 31, 2011. Data analysis was performed March 15, 2016, through September 20, 2017.Pre-ESRD nephrology care in Medicare vs VA health care systems.Dialysis treatment and death within 2 years.Of the 11 215 patients included in the study, 11 085 (98.8%) were men; mean (SD) age was 79.1 (6.9) years. Within 2 years of incident kidney failure, 7071 (63.0%) of the patients started dialysis and 5280 (47.1%) died. Patients who received pre-ESRD nephrology care in Medicare were more likely to undergo dialysis compared with patients who received pre-ESRD nephrology care in VA (82% vs 53%; adjusted risk difference, 28 percentage points; 95% CI, 26-30 percentage points). Differences in dialysis initiation between Medicare and VA were more pronounced among patients aged 80 years or older and patients with dementia or metastatic cancer, and less pronounced among patients with paralysis (P < .05 for interaction). Two-year mortality was higher for patients who received pre-ESRD care in Medicare compared with VA (53% vs 44%; adjusted risk difference, 5 percentage points; 95% CI, 3-7 percentage points). The findings were similar in a propensity-matched analysis.Veterans who receive pre-ESRD nephrology care in Medicare receive dialysis more often yet are also more likely to die within 2 years compared with those in VA. The VA's integrated health care system and financing appear to favor lower-intensity treatment for kidney failure in older patients without a concomitant increase in mortality.

    View details for PubMedID 29630695

  • Patient and Facility Correlates of Racial Differences in Viral Control for Black and White Veterans with HIV Infection in the Veterans Administration AIDS PATIENT CARE AND STDS Sarrazin, M., Ohl, M. E., Richardson, K. K., Asch, S. M., Gifford, A. L., Bokhour, B. G. 2018; 32 (3): 84–91


    Black persons with HIV are less likely than white persons to experience viral control even while in treatment. We sought to understand whether patient characteristics and site of care explain these differences using a cross-sectional analysis of medical records. Our cohort included 8779 black and 7836 white patients in the Veterans Administration (VA) health system with HIV who received antiretroviral medication during 2013. Our primary outcome, viral control, was defined as HIV serum RNA <200 copies/mL. We examined the degree to which racial differences in viral control are related to site of care, patient characteristics (demographics, HIV treatment history, comorbid conditions, time in care, and medication adherence), retention in care, and combination antiretroviral therapy (cART) adherence, using multi-variable logistic regression models. Compared to whites, blacks were younger and had lower CD4 counts, more comorbidities, lower retention in care, and poorer medication adherence. The odds of uncontrolled viral load were 2.02 (p < 0.001) for black relative to white patients without risk adjustment (15% vs. 8% uncontrolled viral load, respectively). The odds decreased to 1.83 (p < 0.001), 1.65 (p < 0.001), 1.62 (p < 0.001), and 1.24 (p = 0.01) in models that sequentially controlled for site of care, age and clinical characteristics, care retention, and cART adherence, respectively. Overall, 51% of the viral control difference between blacks and whites was accounted for by adherence; 26% by site of care. We conclude that differences in the site of HIV care and cART adherence account for most of the difference in viral control between black and white persons receiving HIV care, although the exact pathway by which this relationship occurs is unknown. Targeting poorer performing sites for quality improvement and focusing on improving antiretroviral adherence in black patients may help alleviate disparities in viral control.

    View details for PubMedID 29620926

  • Development of a Tailored Survey to Evaluate a Patient-Centered Initiative AMERICAN JOURNAL OF MANAGED CARE Winget, M., Haji-Sheikhi, F., Asch, S. M. 2018; 24 (2): E37–E44


    Patient-centered care initiatives have proliferated, but assessing their effectiveness requires measures tailored to their likely effects. In this article, we describe the development and pilot testing of patient surveys used to assess change in patients' cancer care experiences over time in response to a patient-centered care initiative.Prospective case series.Domains of patient-centered care were informed by the goals of the initiative and a review of existing tools. Items were selected and modified from 6 domains of validated or semivalidated instruments. Items were piloted with patients with cancer in waiting room settings to further assess the relevance and clarity of items, whether important concepts were missing, and acceptability regarding place and timing of the surveys and to estimate baseline top box scores (percentage of patients scoring an item the highest quality level) to minimize likely ceiling effects. The instrument was then administered to a consecutive sample of Stanford Cancer Center patients. Baseline item responses, Cronbach's alpha, and response bias were estimated.Items were modified based on patient feedback, top box scores, and reassessment of the domains. Over 6 months, 11,273 patients were surveyed, with a 49.7% response rate. Baseline top box scores ranged from 41.7% to 75.0% for any given item. Reliability and internal consistency were high for all domains (Cronbach's alpha ≥0.80) except for the access domain.We developed reliable instruments to evaluate the essential elements of a patient-centered care initiative at an academic medical center, which minimized patient burden and maximized the response rate.

    View details for PubMedID 29461850

  • Intensive Outpatient Program Effects on High-need Patients' Access, Continuity, Coordination, and Engagement MEDICAL CARE Wu, F. M., Slightam, C. A., Wong, A. C., Asch, S. M., Zulman, D. M. 2018; 56 (1): 19–24
  • Effect of Interferon-Free Regimens on Disparities in Hepatitis C Treatment of US Veterans. Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research Barnett, P. G., Joyce, V. R., Lo, J. n., Gidwani-Marszowski, R. n., Goldhaber-Fiebert, J. D., Desai, M. n., Asch, S. M., Holodniy, M. n., Owens, D. K. 2018; 21 (8): 921–30


    To determine whether implementation of interferon-free treatment for hepatitis C virus (HCV) reached groups less likely to benefit from earlier therapies, including patients with genotype 1 virus or contraindications to interferon treatment, and groups that faced treatment disparities: African Americans, patients with HIV co-infection, and those with drug use disorder.Electronic medical records of the US Veterans Health Administration (VHA) were used to characterize patients with chronic HCV infection and the treatments they received. Initiation of treatment in 206,544 patients with chronic HCV characterized by viral genotype, demographic characteristics, and comorbid medical and mental illness was studied using a competing events Cox regression over 6 years.With the advent of interferon-free regimens, the proportion treated increased from 2.4% in 2010 to 18.1% in 2015, an absolute increase of 15.7%. Patients with genotype 1 virus, poor response to previous treatment, and liver disease had the greatest increase. Large absolute increases in the proportion treated were observed in patients with HIV co-infection (18.6%), alcohol use disorder (11.9%), and drug use disorder (12.6%) and in African American (13.7%) and Hispanic (13.5%) patients, groups that were less likely to receive interferon-containing treatment. The VHA spent $962 million on interferon-free treatments in 2015, 1.5% of its operating budget.The proportion of patients with HCV treated in VHA increased sevenfold. The VHA was successful in implementing interferon treatment in previously undertreated populations, and this may become the community standard of care.

    View details for PubMedID 30098669

  • Quality Of End-Of-Life Care Is Higher In The VA Compared To Care Paid For By Traditional Medicare HEALTH AFFAIRS Gidwani-Marszowski, R., Needleman, J., Mor, V., Faricy-Anderson, K., Boothroyd, D. B., Hsin, G., Wagner, T. H., Lorenz, K. A., Patel, M. I., Joyce, V. R., Murrell, S. S., Ramchandran, K., Asch, S. M. 2018; 37 (1): 95–103


    Congressional and Veterans Affairs (VA) leaders have recommended the VA become more of a purchaser than a provider of health care. Fee-for-service Medicare provides an example of how purchased care differs from the VA's directly provided care. Using established indicators of overly intensive end-of-life care, we compared the quality of care provided through the two systems to veterans dying of cancer in fiscal years 2010-14. The Medicare-reliant veterans were significantly more likely to receive high-intensity care, in the form of chemotherapy, hospital stays, admission to the intensive care unit, more days spent in the hospital, and death in the hospital. However, they were significantly less likely than VA-reliant patients to have multiple emergency department visits. Higher-intensity end-of-life care may be driven by financial incentives present in fee-for-service Medicare but not in the VA's integrated system. To avoid putting VA-reliant veterans at risk of receiving lower-quality care, VA care-purchasing programs should develop coordination and quality monitoring programs to guard against overly intensive end-of-life care.

    View details for PubMedID 29309227

  • Receipt of Nephrology Care and Clinical Outcomes Among Veterans With Advanced CKD AMERICAN JOURNAL OF KIDNEY DISEASES Fung, E., Chang, T. I., Chertow, G. M., Thomas, I., Asch, S. M., Tamura, M. 2017; 70 (5): 705–14


    Clinical practice guidelines recommend referral to nephrology when estimated glomerular filtration rate (eGFR) decreases to <30mL/min/1.73m2; however, evidence for benefits of nephrology care are mixed.Observational cohort using landmark analysis.A national cohort of veterans with advanced chronic kidney disease, defined as an outpatient eGFR≤30mL/min/1.73m2 for January 1, 2010, through December 31, 2010, and a prior eGFR<60mL/min/1.73m2, using administrative and laboratory data from the Department of Veterans Affairs and the US Renal Data System.Receipt and frequency of outpatient nephrology care over 12 months.Survival and progression to end-stage renal disease (ESRD; receipt of dialysis or kidney transplantation) were the primary outcomes. In addition, control of associated clinical parameters over 12 months were intermediate outcomes.Of 39,669 patients included in the cohort, 14,983 (37.8%) received nephrology care. Older age, heart failure, dementia, depression, and rapidly declining kidney function were independently associated with the absence of nephrology care. During a mean follow-up of 2.9 years, 14,719 (37.1%) patients died and 4,310 (10.9%) progressed to ESRD. In models adjusting for demographics, comorbid conditions, and trajectory of kidney function, nephrology care was associated with lower risk for death (HR, 0.88; 95% CI, 0.85-0.91), but higher risk for ESRD (HR, 1.48; 95% CI, 1.38-1.58). Among patients with clinical parameters outside guideline recommendations at cohort entry, a significantly higher adjusted proportion of patients who received nephrology care had improvement in control of hemoglobin, potassium, albumin, calcium, and phosphorus concentrations compared with those who did not receive nephrology care.May not be generalizable to nonveterans.Among patients with advanced chronic kidney disease, nephrology care was associated with lower mortality, but was not associated with lower risk for progression to ESRD.

    View details for PubMedID 28811048

  • Hepatitis C virus-related complications are increasing in women veterans: A national cohort study JOURNAL OF VIRAL HEPATITIS Kramer, J. R., El-Serag, H. B., Taylor, T. J., White, D. L., Asch, S. M., Frayne, S. M., Cao, Y., Smith, D. L., Kanwal, F. 2017; 24 (11): 955–65


    There are gender-specific variations in the epidemiology and clinical course of hepatitis C virus (HCV) infection. However, few long-term longitudinal studies have examined trends in the incidence and prevalence of serious liver complications among women compared with men with HCV infection. We used the Veterans Administration Corporate Data Warehouse to identify all veterans with positive HCV viraemia from January 2000 to December 2013. We calculated gender-specific annual incidence and prevalence rates of cirrhosis, decompensated cirrhosis and hepatocellular cancer (HCC) adjusting for age, diabetes, HIV and alcohol use. We also calculated the average annual per cent change (AAPC) for each outcome by gender using piecewise linear regression in the Joinpoint software. We identified 264 409 HCV-infected veterans during 2000-2013, of whom 7162 (2.7%) were women. There were statistically significant increases over time in the incidence rates of cirrhosis, decompensated cirrhosis and HCC for both men and women. The annual-adjusted incidence rates of cirrhosis, decompensated cirrhosis and HCC were higher in men than women for all study years. However, these complications increased at a similar rate in both groups. Specifically, the AAPC for cirrhosis was 13.1 and 15.2, while it was 15.6 and 16.9 for decompensated cirrhosis and 21.0 and 25.3 for HCC in men and women, respectively (all test of parallelism not significant). The results were similar in the prevalence analyses, although AAPCs were slightly smaller for each outcome. In conclusion, we found an ongoing upward trend in the incidence and prevalence of HCV complications in this cohort of HCV-infected women. This increase in cirrhosis complications in women with active HCV infection is similar to those in men. With cure from HCV now becoming a reality, most of the projected burden of HCV is potentially preventable. However, benefits of HCV treatment will need to extend to all patients in order to stem the rising tide of HCV complications.

    View details for DOI 10.1111/jvh.12728

    View details for Web of Science ID 000412859300006

    View details for PubMedID 28815822

    View details for PubMedCentralID PMC5638671

  • Barriers to hepatitis C treatment in the era of direct-acting anti-viral agents ALIMENTARY PHARMACOLOGY & THERAPEUTICS Lin, M., Kramer, J., White, D., Cao, Y., Tavakoli-Tabasi, S., Madu, S., Smith, D., Asch, S. M., El-Serag, H. B., Kanwal, F. 2017; 46 (10): 992–1000


    Direct-acting anti-virals (DAA) are safe, effective treatment of hepatitis C virus (HCV). Suboptimal linkage to specialists and access to DAAs are the leading barriers to treatment; however, data are limited.To determine predictors of follow-up, receipt of DAAs, and reasons for the lack thereof.We used clinical data from retrospective cohort of HCV-infected patients with previously established HCV care in the US Department of Veterans Affairs to examine predictors of follow-up in HCV clinics and DAA treatment (during 12/1/2013-4/30/2015). We then conducted a structured review of medical charts of HCV patients to determine reasons for lack of follow-up and treatment.We identified 84 221 veterans who were previously seen in HCV clinics during the pre-DAA era. Of these, 47 165 (56.0%) followed-up in HCV specialty clinics, 13 532 (28.7%) of whom received DAAs. Older age, prior treatment, presence of cirrhosis or HCC, HIV/HBV co-infection and psychiatric illness were predictors of follow-up. Alcohol/drug abuse and medical co-morbidity were predictors of lack of treatment. Of the 905 prospectively recruited patients, 56.2% patients had a specialist visit and 28% received DAAs. Common reasons for lack of follow-up were relocation (n = 148, 37.4%) and missed/cancelled appointments (n = 63, 15.9%). Reasons for lack of treatment included waiting for newer therapy (n = 99, 38.8%), co-morbidities (n = 66, 25.9%) and alcohol/drug abuse (n = 63, 24.7%).Half of patients with established HCV care were followed-up in the DAA era and only 29% received DAAs. Targeted efforts focusing on patient and system-levels may improve the reach of treatment with the new DAAs.

    View details for PubMedID 28949020

    View details for PubMedCentralID PMC5800315

  • Risk of Hepatocellular Cancer in HCV Patients Treated With Direct-Acting Antiviral Agents GASTROENTEROLOGY Kanwal, F., Kramer, J., Asch, S. M., Chayanupatkul, M., Cao, Y., El-Serag, H. B. 2017; 153 (4): 996-+


    The risk of hepatocellular cancer (HCC) after sustained virological response (SVR) with direct-acting antivirals (DAA) is unclear. Our aim was to examine the risk and determinants of HCC in patients cured with DAA.We conducted a retrospective cohort study of hepatitis C virus patients who were treated with DAA in any of the 129 Veterans Health Administration hospitals between January 1, 2015 and December 31, 2015. We calculated the annual incidence rates of HCC by SVR. We used Cox regression models to compare the risk of HCC in patients with vs those without SVR and to identify factors associated with incident HCC among patients with SVR. We reviewed a sample of HCC patients for tumor size and stage at diagnosis.Among 22,500 patients treated with DAA (19,518 with SVR; 2982 without SVR), the mean (standard deviation) age was 61.6 (6.1) years, and 39.0% had cirrhosis. There were 271 new cases of HCC, including 183 in patients with SVR. Compared with patients without SVR, those with SVR had a significantly reduced risk of HCC (0.90 vs 3.45 HCC/100 person-years; adjusted hazard ratio, 0.28, 95% CI=0.22-0.36). Patients with cirrhosis had the highest annual incidence of HCC after SVR (1.82 vs 0.34/100 person-years in patients without cirrhosis; adjusted hazard ratio, 4.73. 95% CI, 3.34-6.68). Most (>44.8%) HCC were classified as stage I. Maximum size of the largest lesion was ≤5 cm in over 75% of cases.Among patients treated with DAA, SVR was associated with a considerable reduction in the risk of HCC. We did not find any evidence to suggest that DAAs promote HCC. However, in patients with SVR, the absolute risk of HCC remained high in patients with established cirrhosis. These patients should be considered for ongoing HCC surveillance.

    View details for PubMedID 28642197

  • Social Isolation and Medicare Spending: Among Older Adults, Objective Social Isolation Increases Expenditures while Loneliness Does Not. Journal of aging and health Shaw, J. G., Farid, M., Noel-Miller, C., Joseph, N., Houser, A., Asch, S. M., Bhattacharya, J., Flowers, L. 2017; 29 (7): 1119-1143


    Evaluate objective isolation and loneliness' impact on Medicare spending and outcomes.We linked Health and Retirement Study data to Medicare claims to analyze objective isolation (scaled composite of social contacts and network) and loneliness (positive response to 3-item loneliness scale) as predictors of subsequent Medicare spending. In multivariable regression adjusting for health and demographics, we determined marginal differences in Medicare expenditures. Secondary outcomes included spending by setting, and mortality.Objective isolation predicts greater spending, $1,644(p<0.001) per beneficiary annually, whereas loneliness predicts reduced spending, -$768(p<0.001). Increased spending concentrated in inpatient and nursing-home (SNF) care; despite more healthcare, objectively isolated beneficiaries had 31%(p<0.001) greater risk of death. Loneliness did not predict SNF use nor mortality, but predicted slightly less inpatient and outpatient care.Objectively isolated seniors have higher Medicare spending, driven by increased hospitalization and institutionalization, and face greater mortality. Policies supporting social connectedness could reap significant savings.

    View details for DOI 10.1177/0898264317703559

    View details for PubMedID 29545676

    View details for PubMedCentralID PMC5847278

  • Crowdsourced Health Data: Comparability to a US National Survey, 2013-2015 AMERICAN JOURNAL OF PUBLIC HEALTH Yank, V., Agarwal, S., Loftus, P., Asch, S., Rehkopf, D. 2017; 107 (8): 1283–89


    To determine the generalizability of crowdsourced, electronic health data from self-selected individuals using a national survey as a reference.Using the world's largest crowdsourcing platform in 2015, we collected data on characteristics known to influence cardiovascular disease risk and identified comparable data from the 2013 Behavioral Risk Factor Surveillance System. We used age-stratified logistic regression models to identify differences among groups.Crowdsourced respondents were younger, more likely to be non-Hispanic and White, and had higher educational attainment. Those aged 40 to 59 years were similar to US adults in the rates of smoking, diabetes, hypertension, and hyperlipidemia. Those aged 18 to 39 years were less similar, whereas those aged 60 to 75 years were underrepresented among crowdsourced respondents.Crowdsourced health data might be most generalizable to adults aged 40 to 59 years, but studies of younger or older populations, racial and ethnic minorities, or those with lower educational attainment should approach crowdsourced data with caution. Public Health Implications. Policymakers, the national Precision Medicine Initiative, and others planning to use crowdsourced data should take explicit steps to define and address anticipated underrepresentation by important population subgroups.

    View details for PubMedID 28640681

    View details for PubMedCentralID PMC5508142

  • Trends in 30-Day and 1-Year Mortality Among Patients Hospitalized With Cirrhosis From 2004 to 2013 AMERICAN JOURNAL OF GASTROENTEROLOGY Kanwal, F., Tansel, A., Kramer, J. R., Feng, H., Asch, S. M., El-Serag, H. B. 2017; 112 (8): 1287–97


    Recent data suggest decreasing in-patient mortality in patients hospitalized with cirrhosis. We sought to determine if improvements in short-term outcomes for patients with cirrhosis are associated with changes in longer-term outcomes.We examined temporal trends in 30 days and 1-year postdischarge mortality among patients hospitalized with cirrhosis at any of the 126 Veterans Administration hospitals from 2004 and 2013. We adjusted for a range of demographic, liver disease severity, and comorbidity-related factors to account for differences in patient cohorts over time.We identified 109,358 unique patients who were hospitalized with cirrhosis between 2004 and 2013. In-hospital mortality decreased from 11.4 to 7.6%, whereas 1-year mortality decreased from 34.5 to 33.2%. Over a third of out-of-hospital deaths occurred within the first 30 days after discharge; 30-day mortality increased from 9.3 to 10.1%. After adjusting for patient factors, the odds of in-hospital mortality in 2013 were 30% lower (adjusted odds ratio (OR)=0.70, 95% confidence interval (CI), 0.64-0.78), 1-year mortality were 13% lower (adjusted OR=0.87, 95% CI=0.82-0.93), whereas the 30-day mortality were 10% higher than 2004 (adjusted OR=1.10, 95% CI=0.99-1.21), although the latter did not reach statistical significance.In patients admitted with cirrhosis, reduction in in-hospital mortality was associated with less marked reduction in 1-year mortality, and an unchanged, if not higher, 30-day mortality following discharge. Our data suggest that some of the burden of mortality in cirrhosis has shifted from in-hospital to the immediate postdischarge period.

    View details for PubMedID 28607480

  • Machine Learning and Prediction in Medicine - Beyond the Peak of Inflated Expectations NEW ENGLAND JOURNAL OF MEDICINE Chen, J. H., Asch, S. M. 2017; 376 (26): 2507–9

    View details for PubMedID 28657867

    View details for PubMedCentralID PMC5953825

  • Primary Care-Based Skin Cancer Screening in a Veterans Affairs Health Care System. JAMA dermatology Swetter, S. M., Chang, J., Shaub, A. R., Weinstock, M. A., Lewis, E. T., Asch, S. M. 2017


    Skin cancer screening may improve melanoma outcomes and keratinocyte carcinoma morbidity, but little is known about the feasibility of skin cancer training and clinical skin examination (CSE) by primary care practitioners (PCPs) in large health care systems.To assess the association of skin cancer training and screening by PCPs with dermatology referral patterns and rates of skin biopsies.In this pilot interventional study performed at the Veterans Affairs Palo Alto Health Care System, patients 35 years or older scheduled for an annual health habits screen in the PCP general medicine clinics were studied.Six PCPs underwent Internet Curriculum for Melanoma Early Detection (INFORMED) training in May 2015, and 5 screened patients during the following 14 months.Proportion of dermatology referrals, subsequent skin biopsies, and PCP diagnostic accuracy for skin cancer or precancer compared with dermatologist diagnosis were assessed in screened patients 14 months before the intervention (February 18, 2014, through April 30, 2015) and after the intervention (June 18, 2015, through August 30, 2016).Among 258 patients offered screening (median age, 70 years; age range, 35-94 years; 255 [98.8%] male), 189 (73.3%) received CSE and 69 (26.7%) declined. A total of 62 of 189 patients (32.8%) were referred to a dermatologist after intervention: 33 (53.2%) for presumptive skin cancers and 15 (24.2%) for precancers. Nine of 50 patients (18.0%) evaluated in dermatology clinic underwent biopsy to exclude skin cancer. Correct diagnoses were made by PCPs in 13 of 38 patients (34.2%; 4 of 27 patients [14.8%] diagnosed with skin cancers and 5 of 11 patients [45.5%] diagnosed with actinic keratoses). Comparison of all outpatient visits for the 5 main participating PCPs before vs after intervention revealed no significant differences in dermatology referrals overall and those for presumptive skin cancer or actinic keratoses, skin biopsies, or PCP diagnostic accuracy with the exception of significantly fewer postintervention dermatology referrals that lacked specific diagnoses (25 [1.0%] vs 10 [0.4%], P = .01).This pilot study suggests that PCP-based skin cancer training and screening are feasible and have the potential to improve PCP diagnostic accuracy without increasing specialty referrals or skin biopsies. Additional studies comparing screening rates, specialty referrals, and patient outcomes in trained vs untrained PCPs are needed before screening is widely implemented in large health care systems in the United States.

    View details for DOI 10.1001/jamadermatol.2017.1324

    View details for PubMedID 28593242

  • Decaying relevance of clinical data towards future decisions in data-driven inpatient clinical order sets. International journal of medical informatics Chen, J. H., Alagappan, M., Goldstein, M. K., Asch, S. M., Altman, R. B. 2017; 102: 71-79


    Determine how varying longitudinal historical training data can impact prediction of future clinical decisions. Estimate the "decay rate" of clinical data source relevance.We trained a clinical order recommender system, analogous to Netflix or Amazon's "Customers who bought A also bought B..." product recommenders, based on a tertiary academic hospital's structured electronic health record data. We used this system to predict future (2013) admission orders based on different subsets of historical training data (2009 through 2012), relative to existing human-authored order sets.Predicting future (2013) inpatient orders is more accurate with models trained on just one month of recent (2012) data than with 12 months of older (2009) data (ROC AUC 0.91 vs. 0.88, precision 27% vs. 22%, recall 52% vs. 43%, all P<10(-10)). Algorithmically learned models from even the older (2009) data was still more effective than existing human-authored order sets (ROC AUC 0.81, precision 16% recall 35%). Training with more longitudinal data (2009-2012) was no better than using only the most recent (2012) data, unless applying a decaying weighting scheme with a "half-life" of data relevance about 4 months.Clinical practice patterns (automatically) learned from electronic health record data can vary substantially across years. Gold standards for clinical decision support are elusive moving targets, reinforcing the need for automated methods that can adapt to evolving information.Prioritizing small amounts of recent data is more effective than using larger amounts of older data towards future clinical predictions.

    View details for DOI 10.1016/j.ijmedinf.2017.03.006

    View details for PubMedID 28495350

  • Disrupting end-of-life cancer care delivery: Results from the engagment of patients with advanced cancer trial. Patel, M. I., Sundaram, V., Desai, M., Periyakoil, V. J., Kahn, J., Asch, S. M., Milstein, A., Bundorf, K. AMER SOC CLINICAL ONCOLOGY. 2017
  • Post-traumatic Stress Disorder and Antepartum Complications: a Novel Risk Factor for Gestational Diabetes and Preeclampsia PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Shaw, J. G., Asch, S. M., Katon, J. G., Shaw, K. A., Kimerling, R., Frayne, S. M., Phibbs, C. S. 2017; 31 (3): 185-194


    Prior work shows that Post-traumatic Stress Disorder (PTSD) predicts an increased risk of preterm birth, but the causal pathway(s) are uncertain. We evaluate the associations between PTSD and antepartum complications to explore how PTSD's pathophysiology impacts pregnancy.This retrospective cohort analysis of all Veterans Health Administration (VA)-covered deliveries from 2000-12 used the data of VA clinical and administration. Mothers with current PTSD were identified using the ICD-9 diagnostic codes (i.e. code present during the antepartum year), as were those with historical PTSD. Medical and administrative data were used to identify the relevant obstetric diagnoses, demographics and health, and military deployment history. We used Poisson regression with robust error variance to derive the adjusted relative risk estimates (RR) for the association of PTSD with five clinically relevant antepartum complications [gestational diabetes (GDM), preeclampsia, gestational hypertension, growth restriction, and abruption]. Secondary outcomes included proxies for obstetric complexity (repeat hospitalisation, prolonged delivery hospitalisation, and caesarean delivery).Of the 15 986 singleton deliveries, 2977 (19%) were in mothers with PTSD diagnoses (1880 (12%) current PTSD). Mothers with the complication GDM were 4.9% and those with preeclampsia were 4.6% of all births. After adjustment, a current PTSD diagnosis (reference = no PTSD) was associated with an increased risk of GDM (RR 1.4, 95% confidence interval (CI) 1.2, 1.7) and preeclampsia (RR 1.3, 95% CI 1.1, 1.6). PTSD also predicted prolonged (>4 day) delivery hospitalisation (RR 1.2, 95% CI 1.01, 1.4), and repeat hospitalisations (RR 1.4, 95% CI 1.2, 1.6), but not caesarean delivery.The observed association of PTSD with GDM and preeclampsia is consistent with our nascent understanding of PTSD as a disruptor of neuroendocrine and cardiovascular health.

    View details for DOI 10.1111/ppe.12349

    View details for Web of Science ID 000400170000004

    View details for PubMedID 28328031

  • The Appropriate Provision of Primary versus Specialist Palliative Care to Cancer Patients: Oncologists' Perspectives JOURNAL OF PALLIATIVE MEDICINE Gidwani, R., Nevedal, A., Patel, M., Blayney, D. W., Timko, C., Ramchandran, K., Kelly, P. A., Asch, S. M. 2017; 20 (4): 395-403


    Many cancer patients do not receive recommended palliative care (PC). Oncologists' perspectives about PC have not been adequately described qualitatively and may explain some of the gaps in the delivery of PC.To characterize U.S. oncologists' perceptions of: primary and specialist PC; experiences interacting with PC specialists; and the optimal interface of PC and oncology in providing PC.In-depth interviews with practicing oncologists.Oncologists working in: the general community, academic medical centers (AMC), and Veterans Health Administration.Semistructured telephone interviews with 31 oncologists analyzed using matrix and thematic approaches.Seven major themes emerged: PC was perceived as appropriate throughout the disease trajectory but due to resource constraints was largely provided at end of life; oncologists had three schools of thought on primary versus specialist PC; there was an under-availability of outpatient PC; poor communication about prognosis and care plans created tension between providers; PC was perceived as a "team of outsiders"; PC had too narrow a focus of care; and AMC-based PC evidence did not generalize to community practices. Oncologists noted three ways to improve the interface between oncologists and PC providers: a clear division of responsibility, in-person collaboration, and sharing of nonphysician palliative team members.Oncologists in our sample were supportive of PC, but they reported obstacles related to care coordination and inpatient PC. Inpatient PC posed some unique challenges with respect to conflicting prognoses and care practices that would be mitigated through the increased availability and use of outpatient PC.

    View details for DOI 10.1089/jpm.2016.0399

    View details for Web of Science ID 000398452000016

  • Redesigning Cancer Care Delivery: Views From Patients and Caregivers. Journal of oncology practice Patel, M. I., Periyakoil, V. S., Blayney, D. W., Moore, D., Nevedal, A., Asch, S., Milstein, A., Coker, T. R. 2017; 13 (4): e291-e302


    Cancer is a leading cause of death in the United States. Although treatments have improved, patients and caregivers continue to report significant gaps in their care. The objective of this study was to examine the views of patients and caregivers on their experiences with current cancer care delivery and identify key strategies to improve the delivery of care.Semistructured interviews were conducted with 75 patients and 45 caregivers across the United States. The interviews were recorded, transcribed, and analyzed using constant comparative method of qualitative analysis.Participants reported multiple gaps in care delivery, including barriers in health communication with health care providers, lack of elucidation of care goals, lack of care coordination, and challenges in accessing care. Participants identified that greater use of nonphysician providers and alternative formats, such as telephone-based care and home and community-based care, would narrow these gaps.Understanding patients' and caregivers' experiences with gaps in cancer care delivery can inform cancer care delivery redesign efforts and lead to targeted interventions that result in patient-centered and family-oriented care.

    View details for DOI 10.1200/JOP.2016.017327

    View details for PubMedID 28399387

  • PRELIMINARY ANALYSIS OF LIFE EXPECTANCY AND COMMON CAUSES OF DEATH AMONG VETERANS WITH MENTAL ILLNESSES Trivedi, R., Post, E. P., Piegari, R. I., Simonetti, J. A., Boyko, E. J., Asch, S., Mori, A. M., Arnow, B. A., Fihn, S. D., Nelson, K. M., Maynard, C. SPRINGER. 2017: S284
  • Using Lean Management to Reduce Emergency Department Length of Stay for Medicine Admissions QUALITY MANAGEMENT IN HEALTH CARE Allaudeen, N., Vashi, A., Breckenridge, J. S., Haji-Sheikhi, F., Wagner, S., Posley, K. A., Asch, S. M. 2017; 26 (2): 91-96


    The practice of boarding admitted patients in the emergency department (ED) carries negative operational, clinical, and patient satisfaction consequences. Lean tools have been used to improve ED workflow. Interventions focused on reducing ED length of stay (LOS) for admitted patients are less explored.To evaluate a Lean-based initiative to reduce ED LOS for medicine admissions.Prospective quality improvement initiative performed at a single university-affiliated Department of Veterans Affairs (VA) medical center from February 2013 to February 2016.We performed a Lean-based multidisciplinary initiative beginning with a rapid process improvement workshop to evaluate current processes, identify root causes of delays, and develop countermeasures. Frontline staff developed standard work for each phase of the ED stay. Units developed a daily management system to reinforce, evaluate, and refine standard work.The primary outcome was the change in ED LOS for medicine admissions pre- and postintervention. ED LOS at the intervention site was compared with other similar VA facilities as controls over the same time period using a difference-in-differences approach.ED LOS for medicine admissions reduced 26.4%, from 8.7 to 6.4 hours. Difference-in-differences analysis showed that ED LOS for combined medicine and surgical admissions decreased from 6.7 to 6.0 hours (-0.7 hours, P = .003) at the intervention site compared with no change (5.6 hours, P = .2) at the control sites.We utilized Lean management to significantly reduce ED LOS for medicine admissions. Specifically, the development and management of standard work were key to sustaining these results.

    View details for DOI 10.1097/QMH.0000000000000132

    View details for PubMedID 28375955

  • Disparities in receipt of recommended care among younger versus older medicare beneficiaries: a cohort study BMC HEALTH SERVICES RESEARCH Na, L., Streim, J. E., Pezzin, L. E., Kurichi, J. E., Xie, D., Bogner, H. R., Kwong, P. L., Asch, S. M., Hennessy, S. 2017; 17: 241


    Although health disparities have been documented between Medicare beneficiaries based on age (<65 years vs. older age groups), underuse of recommended medical care in younger beneficiaries has not been thoroughly investigated. In this study, we aim to identify and characterize vulnerabilities of the younger Medicare age group (aged <65 years) in relation to older age groups (aged 65-74 years and ≥75 years) and to explore age group as a determinant of use of recommended care among Medicare beneficiaries.We conducted a cohort study of community-dwelling Medicare beneficiaries who participated in the Medicare Current Beneficiary Survey between 2001 and 2008 (N = 30,117). Age group characteristics were compared using cross-sectional data at baseline. During follow-up, we assessed the association between age and receipt of recommended care on 38 recommended care indicators, adjusting for sociodemographic and clinical characteristics. Follow-up periods differed by component indicator.At baseline, a higher proportion of younger beneficiaries experienced social disadvantage, disability and certain morbidities than older age groups. During follow-up, younger beneficiaries were significantly less likely to receive overall recommended care compared to those 65-74 years of age (adjusted odds ratio and 95% confidence interval: 0.75, 0.70-0.80). In addition, male gender, non-Hispanic black race, less than high school education, living alone, with children or with others, psychiatric disorders and higher activity limitation stages were all associated with underuse of recommended care.Younger Medicare beneficiary status appears to be an independent risk factor for underuse of appropriate care. Support to ameliorate disparities in different social and health aspects may be warranted.

    View details for PubMedID 28356149

  • RACIAL DIFFERENCES IN QUALITY OF CARE AND OUTCOMES AFTER ACUTE CORONARY SYNDROME Yong, C. M., Ungar, L., Abnousi, F., Bibbins-Domingo, K., Knight, S., Asch, S., Heidenreich, P. ELSEVIER SCIENCE INC. 2017: 2569
  • Development and pilot of brief surveys to evaluate the quality of patient-centered cancer care. Winget, M., Haji-Sheikhi, F., Asch, S. AMER SOC CLINICAL ONCOLOGY. 2017
  • The implementation of a lay care navigation service at the Stanford Cancer Institute. Brown-Johnson, C., Holdsworth, L. J., Rosenthal, E., Asch, S., Winget, M. AMER SOC CLINICAL ONCOLOGY. 2017
  • Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations. Journal of general internal medicine Hochman, M., Asch, S. M. 2017


    Starfield and colleagues have suggested four overarching attributes of good primary care: "first-contact access for each need; long-term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere." As this series on reinventing primary care highlights, there is a compelling need for new care delivery models that would advance these objectives. This need is particularly urgent for high-needs, high-cost (HNHC) populations. By definition, HNHC patients require extensive attention and consume a disproportionate share of resources, and as a result they strain traditional office-based primary care practices. In this essay, we offer a clinical vignette highlighting the challenges of caring for HNHC populations. We then describe two categories of primary care-based approaches for managing HNHC populations: complex case management, and specialized clinics focused on HNHC patients. Although complex case management programs can be incorporated into or superimposed on the traditional primary care system, such efforts often fail to engage primary care clinicians and HNHC patients, and proven benefits have been modest to date. In contrast, specialized clinics for HNHC populations are more disruptive, as care for HNHC patients must be transferred to a multidisciplinary team that can offer enhanced care coordination and other support. Such specialized clinics may produce more substantial benefits, though rigorous evaluation of these programs is needed. We conclude by suggesting policy reforms to improve care for HNHC populations.

    View details for DOI 10.1007/s11606-016-3945-2

    View details for PubMedID 28243870

  • Iraq and Afghanistan Veterans' Use of Veterans Health Administration and Purchased Care Before and After Veterans Choice Program Implementation. Medical care Vanneman, M. E., Harris, A. H., Asch, S. M., Scott, W. J., Murrell, S. S., Wagner, T. H. 2017


    The veterans choice program (VCP), enacted by Congress after concerns surfaced about access, enables veterans to receive care outside Veterans Health Administration (VHA) facilities. Veterans who face long wait times, large driving distances, or particular hardships are eligible for VCP. Prior purchased care programs were comparatively limited in scope.We sought to describe utilization of VHA-provided and purchased outpatient care by veterans eligible for VCP before and after VCP implementation. We focused on veterans recently eligible for VHA as they are of particular policy relevance and might have less established care patterns.We identified all Iraq and Afghanistan veterans who were eligible for VCP in 2015. We tabulated their use of VHA and purchased outpatient care for 3 years before (FY2012-2014) and 1 year after VCP implementation (FY2015).Our study population consisted of 214,449 Iraq and Afghanistan veterans who were eligible for VCP due to wait-time, distance, or hardship issues.In the first year of the program, 3821 (2%) of these Iraq and Afghanistan veterans used non-VHA services through VCP. Per capita VHA utilization tended to decline slightly after VCP implementation, but these changes varied by type of outpatient care.There was low uptake of VCP services in the first year of the program. Data from additional years are needed to better understand the impact of this policy.

    View details for DOI 10.1097/MLR.0000000000000678

    View details for PubMedID 28146036

  • Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients: A Randomized Clinical Trial. JAMA internal medicine Zulman, D. M., Pal Chee, C., Ezeji-Okoye, S. C., Shaw, J. G., Holmes, T. H., Kahn, J. S., Asch, S. M. 2017; 177 (2): 166-175


    Many organizations are adopting intensive outpatient care programs for high-need patients, yet little is known about their effectiveness in integrated systems with established patient-centered medical homes.To evaluate how augmenting the Veterans Affairs (VA) medical home (Patient Aligned Care Teams [PACT]) with an Intensive Management program (ImPACT) influences high-need patients' costs, health care utilization, and experience.Randomized clinical trial at a single VA facility. Among 583 eligible high-need outpatients whose health care costs or hospitalization risk were in the top 5% for the facility, 150 were randomly selected for ImPACT; the remaining 433 received standard PACT care.The ImPACT multidisciplinary team addressed health care needs and quality of life through comprehensive patient assessments, intensive case management, care coordination, and social and recreational services.Primary difference-in-difference analyses examined changes in health care costs and acute and extended care utilization over a 16-month baseline and 17-month follow-up period. Secondary analyses estimated the intervention's effect on ImPACT participants (using randomization as an instrument) and for patients with key sociodemographic and clinical characteristics. ImPACT participants' satisfaction and activation levels were assessed using responses to quality improvement surveys administered at baseline and 6 months.Of 140 patients assigned to ImPACT, 96 (69%) engaged in the program (mean [SD] age, 68.3 [14.2] years; 89 [93%] male; mean [SD] number of chronic conditions, 10 [4]; 62 [65%] had a mental health diagnosis; 21 [22%] had a history of homelessness). After accounting for program costs, adjusted person-level monthly health care expenditures decreased similarly for ImPACT and PACT patients (difference-in-difference [SE] -$101 [$623]), as did acute and extended care utilization rates. Among respondents to the ImPACT follow-up survey (n = 54 [56% response rate]), 52 (96%) reported that they would recommend the program to others, and pre-post analyses revealed modest increases in satisfaction with VA care (mean [SD] increased from 2.90 [0.72] to 3.16 [0.60]; P = .04) and communication (mean [SD] increased from 2.99 [0.74] to 3.18 [0.60]; P = .03).Intensive outpatient care for high-need patients did not reduce acute care utilization or costs compared with standard VA care, although there were positive effects on experience among patients who participated. Implementing intensive outpatient care programs in integrated settings with well-established medical homes may not prevent hospitalizations or achieve substantial cost Identifier: NCT02932228.

    View details for DOI 10.1001/jamainternmed.2016.8021

    View details for PubMedID 28027338

  • Effect of a Dialysis Access Coordinator on Preemptive Access Placement among Veterans: A Quality Improvement Initiative AMERICAN JOURNAL OF NEPHROLOGY Gale, R. C., Kehoe, D., Lit, Y. Z., Asch, S. M., Tamura, M. K. 2017; 45 (1): 14-21


    Preemptive placement of permanent dialysis access is recommended in order to reduce the morbidity associated with central venous catheters. We assessed the effect of a dialysis access coordinator on preemptive access placement in veterans who are at high risk for end-stage renal disease (ESRD).Pre-post evaluation of a dialysis access coordinator in the nephrology clinics of the Veterans Affairs Palo Alto. The access coordinator streamlined access referrals, prioritized surgical waiting lists and addressed patient barriers. We compared the frequency of preemptive access referral, surgery, and use for dialysis during the intervention period, July 1, 2013 to May 31, 2016, to a pre-intervention period, January 1, 2011 to December 31, 2013, among all patients with a predicted 1-year risk for ESRD ≥20%.There were 156 patients in the historical cohort and 131 in the intervention cohort. The mean age was 69.9 ± 11.6 years and the mean estimated glomerular filtration rate was 14.5 ± 5.7 ml/min/1.73 m2. The intervention was associated with an 11.8% increase in access referral (p value = 0.03), and a 9.4% increase in completed access surgery (p value = 0.05). Increases in permanent access at the start of dialysis (15.2%), and functional permanent access at the start of dialysis (12.4%) did not reach statistical significance. Among patients who received access surgery, there was no significant difference in the prevalence of unused access.Implementation of an access coordinator was associated with a modest increase in preemptive access placement among patients who are at high risk for ESRD without increasing the prevalence of unused access.

    View details for DOI 10.1159/000452346

    View details for Web of Science ID 000391428900003

  • Opioid Abuse And Poisoning: Trends In Inpatient And Emergency Department Discharges. Health affairs (Project Hope) Tedesco, D. n., Asch, S. M., Curtin, C. n., Hah, J. n., McDonald, K. M., Fantini, M. P., Hernandez-Boussard, T. n. 2017; 36 (10): 1748–53


    Addressing the opioid epidemic is a national priority. We analyzed national trends in inpatient and emergency department (ED) discharges for opioid abuse, dependence, and poisoning using Healthcare Cost and Utilization Project data. Inpatient and ED discharge rates increased overall across the study period, but a decline was observed for prescription opioid-related discharges beginning in 2010, while a sharp increase in heroin-related discharges began in 2008.

    View details for PubMedID 28971919

  • Drug-Free Interventions to Reduce Pain or Opioid Consumption After Total Knee Arthroplasty: A Systematic Review and Meta-analysis. JAMA surgery Tedesco, D. n., Gori, D. n., Desai, K. R., Asch, S. n., Carroll, I. R., Curtin, C. n., McDonald, K. M., Fantini, M. P., Hernandez-Boussard, T. n. 2017: e172872


    There is increased interest in nonpharmacological treatments to reduce pain after total knee arthroplasty. Yet, little consensus supports the effectiveness of these interventions.To systematically review and meta-analyze evidence of nonpharmacological interventions for postoperative pain management after total knee arthroplasty.Database searches of MEDLINE (PubMed), EMBASE (OVID), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Web of Science (ISI database), Physiotherapy Evidence (PEDRO) database, and for the period between January 1946 and April 2016.Randomized clinical trials comparing nonpharmacological interventions with other interventions in combination with standard care were included.Two reviewers independently extracted the data from selected articles using a standardized form and assessed the risk of bias. A random-effects model was used for the analyses.Postoperative pain and consumption of opioids and analgesics.Of 5509 studies, 39 randomized clinical trials were included in the meta-analysis (2391 patients). The most commonly performed interventions included continuous passive motion, preoperative exercise, cryotherapy, electrotherapy, and acupuncture. Moderate-certainty evidence showed that electrotherapy reduced the use of opioids (mean difference, -3.50; 95% CI, -5.90 to -1.10 morphine equivalents in milligrams per kilogram per 48 hours; P = .004; I2 = 17%) and that acupuncture delayed opioid use (mean difference, 46.17; 95% CI, 20.84 to 71.50 minutes to the first patient-controlled analgesia; P < .001; I2 = 19%). There was low-certainty evidence that acupuncture improved pain (mean difference, -1.14; 95% CI, -1.90 to -0.38 on a visual analog scale at 2 days; P = .003; I2 = 0%). Very low-certainty evidence showed that cryotherapy was associated with a reduction in opioid consumption (mean difference, -0.13; 95% CI, -0.26 to -0.01 morphine equivalents in milligrams per kilogram per 48 hours; P = .03; I2 = 86%) and in pain improvement (mean difference, -0.51; 95% CI, -1.00 to -0.02 on the visual analog scale; P < .05; I2 = 62%). Low-certainty or very low-certainty evidence showed that continuous passive motion and preoperative exercise had no pain improvement and reduction in opioid consumption: for continuous passive motion, the mean differences were -0.05 (95% CI, -0.35 to 0.25) on the visual analog scale (P = .74; I2 = 52%) and 6.58 (95% CI, -6.33 to 19.49) opioid consumption at 1 and 2 weeks (P = .32, I2 = 87%), and for preoperative exercise, the mean difference was -0.14 (95% CI, -1.11 to 0.84) on the Western Ontario and McMaster Universities Arthritis Index Scale (P = .78, I2 = 65%).In this meta-analysis, electrotherapy and acupuncture after total knee arthroplasty were associated with reduced and delayed opioid consumption.

    View details for PubMedID 28813550

  • Quality of Care for Work-Associated Carpal Tunnel Syndrome JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Nuckols, T., Conlon, C., Robbins, M., Dworsky, M., Lai, J., Roth, C. P., Levitan, B., Seabury, S., Seelam, R., Asch, S. M. 2017; 59 (1): 47-53


    To evaluate the quality of care provided to individuals with workers' compensation claims related to Carpal tunnel syndrome (CTS) and identify patient characteristics associated with receiving better care.We recruited subjects with new claims for CTS from 30 occupational clinics affiliated with Kaiser Permanente Northern California. We applied 45 process-oriented quality measures to 477 subjects' medical records, and performed multivariate logistic regression to identify patient characteristics associated with quality.Overall, 81.6% of care adhered to recommended standards. Certain tasks related to assessing and managing activity were underused. Patients with classic/probable Katz diagrams, positive electrodiagnostic tests, and higher incomes received better care. However, age, sex, and race/ethnicity were not associated with quality.Care processes for work-associated CTS frequently adhered to quality measures. Clinical factors were more strongly associated with quality than demographic and socioeconomic ones.

    View details for DOI 10.1097/JOM.0000000000000916

    View details for Web of Science ID 000391123100010

    View details for PubMedID 28045797

    View details for PubMedCentralID PMC5382986

  • Should Human Immunodeficiency Virus Specialty Clinics Treat Patients With Hypertension or Refer to Primary Care? An Analysis of Treatment Outcomes. Open forum infectious diseases Appenheimer, A. B., Bokhour, B., McInnes, D. K., Richardson, K. K., Thurman, A. L., Beck, B. F., Vaughan-Sarrazin, M., Asch, S. M., Midboe, A. M., Taylor, T., Dvorin, K., Gifford, A. L., Ohl, M. E. 2017; 4 (1): ofx005-?


    Care for people with human immunodeficiency virus (HIV) increasingly focuses on comorbidities, including hypertension. Evidence indicates that antiretroviral therapy and opportunistic infections are best managed by providers experienced in HIV medicine, but it is unclear how to structure comorbidity care. Approaches include providing comorbidity care in HIV clinics ("consolidated care") or combining HIV care with comorbidity management in primary care clinics ("shared care"). We compared blood pressure (BP) control in HIV clinics practicing consolidated care versus shared care.We created a national cohort of Veterans with HIV and hypertension receiving care in HIV clinics in Veterans Administration facilities and merged these data with a survey asking HIV providers how they delivered hypertension care (5794 Veterans in 73 clinics). We defined BP control as BP ≤140/90 mmHg on the most recent measure. We compared patients' likelihood of experiencing BP control in clinics offering consolidated versus shared care, adjusting for patient and clinic characteristics.Forty-two of 73 clinics (57.5%) practiced consolidated care for hypertension. These clinics were larger and more likely to use multidisciplinary teams. The unadjusted frequency of BP control was 65.6% in consolidated care clinics vs 59.4% in shared care clinics (P < .01). The likelihood of BP control remained higher for patients in consolidated care clinics after adjusting for patient and clinic characteristics (odds ratio, 1.32; 95% confidence interval, 1.04-1.68).Patients were more likely to experience BP control in clinics reporting consolidated care compared with clinics reporting shared care. For shared-care clinics, improving care coordination between HIV and primary care clinics may improve outcomes.

    View details for DOI 10.1093/ofid/ofx005

    View details for PubMedID 28480278

  • "I had to change so much in my life to live with my new limitations": Multimorbid patients' descriptions of their most bothersome chronic conditions. Chronic illness Slightam, C. A., Brandt, K., Jenchura, E. C., Lewis, E. T., Asch, S. M., Zulman, D. M. 2017: 1742395317699448-?


    Objective To characterize diseases that are described as most bothersome by individuals with multiple chronic conditions and to identify themes that characterize their experiences with their most bothersome condition. Methods In a survey of patients at an academic center and a Veterans Affairs hospital, we asked individuals with multiple chronic conditions to identify their most bothersome chronic condition and describe why it is challenging. Standard content analysis methods were used to code responses and identify themes reflecting characteristics of most bothersome conditions. Results The most commonly cited bothersome conditions were chronic pain (52%), diabetes (43%), post-traumatic stress disorder (25%), heart failure (24%), and lung problems (20%). Conditions were described as most bothersome due to: (a) impact on function and quality of life (e.g. active symptoms, activity limitations), (b) health consequences or sequelae (e.g. risk of complications), and (c) challenges associated with treatment or self-management. Patterns of theme dominance varied for conditions with different characteristics. Discussion The conditions that patients with multiple chronic conditions identify as most bothersome vary depending on individuals' diseases and their health-related preferences and priorities. Ascertaining patients' most bothersome conditions and associated challenges, stress, and frustrations may help ensure that management decisions are aligned with patient preferences and priorities.

    View details for DOI 10.1177/1742395317699448

    View details for PubMedID 28449592

  • Palliative Care Quality Indicators for Patients with End-Stage Liver Disease Due to Cirrhosis DIGESTIVE DISEASES AND SCIENCES Walling, A. M., Ahluwalia, S. C., Wenger, N. S., Booth, M., Roth, C. P., Lorenz, K., Kanwal, F., Dy, S., Asch, S. M. 2017; 62 (1): 84-92


    There are guidelines for the medical management of cirrhosis and associated quality indicators (QIs), but QIs focusing on standards for palliative aspects of care are needed.We convened a 9-member, multidisciplinary expert panel and used RAND/UCLA modified Delphi methods to develop palliative care quality indicators for patients with cirrhosis. Experts were provided with a report based on a systematic review of the literature that contained evidence concerning the proposed candidate QIs. Panelists rated QIs prior to a planned meeting using a standard 9-point RAND appropriateness scale. These ratings guided discussion during a day-long phone conference meeting, and final ratings were then provided by panel members. Final QI scores were computed and QIs with a final median score of greater than or equal to 7, and no disagreement was included in the final set.Among 28 candidate QIs, the panel rated 19 as valid measures of quality care. These 19 quality indicators cover care related to information and care planning (13) and supportive care (6).These QIs are evidence-based process measures of care that may be useful to improve the quality of palliative care. Research is needed to better understand the quality of palliative care provided to patients with cirrhosis.

    View details for DOI 10.1007/s10620-016-4339-3

    View details for Web of Science ID 000392312200015

    View details for PubMedCentralID PMC5384571


    View details for DOI 10.4473/TPM23.4.2

    View details for Web of Science ID 000392141000003

  • Breast Density Notification Legislation and Breast Cancer Stage at Diagnosis: Early Evidence from the SEER Registry. Journal of general internal medicine Richman, I., Asch, S. M., Bendavid, E., Bhattacharya, J., Owens, D. K. 2016: -?


    Twenty-eight states have passed breast density notification laws, which require physicians to inform women of a finding of dense breasts on mammography.To evaluate changes in breast cancer stage at diagnosis after enactment of breast density notification legislation.Using a difference-in-differences analysis, we examined changes in stage at diagnosis among women with breast cancer in Connecticut, the first state to enact legislation, compared to changes among women in control states. We used data from the Surveillance, Epidemiology, and End Results Program (SEER) registry, 2005-2013.Women ages 40-74 with breast cancer.Breast density notification legislation, enacted in Connecticut in October of 2009.Breast cancer stage at diagnosis.Our study included 466,930 women, 25,592 of whom lived in Connecticut. Legislation was associated with a 1.38-percentage-point (95 % CI 0.12 to 2.63) increase in the proportion of women in Connecticut versus control states who had localized invasive cancer at the time of diagnosis, and a 1.12-percentage-point (95 % CI -2.21 to -0.08) decline in the proportion of women with ductal carcinoma in situ at diagnosis. Breast density notification legislation was not associated with a change in the proportion of women in Connecticut versus control states with regional-stage (-0.09 percentage points, 95 % CI -1.01 to 1.02) or metastatic disease (-0.24, 95 % CI -0.75 to 0.28). County-level analyses and analyses limited to women younger than 50 found no statistically significant associations.Single intervention state, limited follow-up, potential confounding from unobserved trends.Breast density notification legislation in Connecticut was associated with a small increase in the proportion of women diagnosed with localized invasive breast cancer in individual-level but not county-level analyses. Whether this finding reflects potentially beneficial early detection or potentially harmful overdiagnosis is not known. Legislation was not associated with changes in regional or metastatic disease.

    View details for PubMedID 27844260

  • Evaluating the implementation of a national disclosure policy for large-scale adverse events in an integrated health care system: identification of gaps and successes BMC HEALTH SERVICES RESEARCH Maguire, E. M., Bokhour, B. G., Wagner, T. H., Asch, S. M., Gifford, A. L., Gallagher, T. H., Durfee, J. M., Martinello, R. A., Elwy, A. R. 2016; 16


    Many healthcare organizations have developed disclosure policies for large-scale adverse events, including the Veterans Health Administration (VA). This study evaluated VA's national large-scale disclosure policy and identifies gaps and successes in its implementation.Semi-structured qualitative interviews were conducted with leaders, hospital employees, and patients at nine sites to elicit their perceptions of recent large-scale adverse events notifications and the national disclosure policy. Data were coded using the constructs of the Consolidated Framework for Implementation Research (CFIR).We conducted 97 interviews. Insights included how to handle the communication of large-scale disclosures through multiple levels of a large healthcare organization and manage ongoing communications about the event with employees. Of the 5 CFIR constructs and 26 sub-constructs assessed, seven were prominent in interviews. Leaders and employees specifically mentioned key problem areas involving 1) networks and communications during disclosure, 2) organizational culture, 3) engagement of external change agents during disclosure, and 4) a need for reflecting on and evaluating the policy implementation and disclosure itself. Patients shared 5) preferences for personal outreach by phone in place of the current use of certified letters. All interviewees discussed 6) issues with execution and 7) costs of the disclosure.CFIR analysis reveals key problem areas that need to be addresses during disclosure, including: timely communication patterns throughout the organization, establishing a supportive culture prior to implementation, using patient-approved, effective communications strategies during disclosures; providing follow-up support for employees and patients, and sharing lessons learned.

    View details for DOI 10.1186/s12913-016-1903-7

    View details for Web of Science ID 000387540000003

    View details for PubMedID 27835983

    View details for PubMedCentralID PMC5106838

  • Asians suffer the highest in-hospital mortality rates after acute coronary syndrome despite high use of early invasive procedures Yong, C., Abnousi, F., Asch, S., Heidenreich, P. ELSEVIER SCIENCE INC. 2016: B40
  • Assessing the Value of High-Quality Care for Work-Associated Carpal Tunnel Syndrome in a Large Integrated Health Care System: Study Design. The Permanente journal Conlon, C., Asch, S., Hanson, M., Avins, A., Levitan, B., Roth, C., Robbins, M., Dworsky, M., Seabury, S., Nuckols, T. 2016; 20 (4)


    Little is known about quality of care for occupational health disorders, although it may affect worker health and workers' compensation costs. Carpal tunnel syndrome (CTS) is a common work-associated condition that causes substantial disability.To describe the design of a study that is assessing quality of care for work-associated CTS and associations with clinical outcomes and costs.Prospective observational study of 477 individuals with new workers' compensation claims for CTS without acute trauma who were treated at 30 occupational health clinics from 2011 to 2013 and followed for 18 months.Timing of key clinical events, adherence to 45 quality measures, changes in scores on the Boston Carpal Tunnel Questionnaire and 12-item Short Form Health Survey Version 2 (SF-12v2), and costs associated with medical care and disability.Two hundred sixty-seven subjects (56%) received a diagnosis of CTS and had claims filed around the first visit to occupational health, 104 (22%) received a diagnosis before that visit and claim, and 98 (21%) received a diagnosis or had claims filed after that visit. One hundred seventy-eight (37%) subjects had time off work, which started around the time of surgery in 147 (83%) cases and lasted a median of 41 days (interquartile range = 42 days).The timing of diagnosis varied, but time off work was generally short and related to surgery. If associations of quality of care with key medical, economic, and quality-of-life outcomes are identified for work-associated CTS, systematic efforts to evaluate and improve quality of medical care for this condition are warranted.

    View details for DOI 10.7812/TPP/15-220

    View details for PubMedID 27723446

  • Cost-Effectiveness of Treatments for Genotype 1 Hepatitis C Virus Infection in non-VA and VA Populations. MDM policy & practice Liu, S., Barnett, P. G., Holodniy, M., Lo, J., Joyce, V. R., Gidwani, R., Asch, S. M., Owens, D. K., Goldhaber-Fiebert, J. D. 2016; 1


    Chronic hepatitis C viral (HCV) infection affects millions of Americans. Healthcare systems face complex choices between multiple highly efficacious, costly treatments. This study assessed the cost-effectiveness of HCV treatments for chronic, genotype 1 HCV monoinfected, treatment-naïve individuals in the Department of Veterans Affairs (VA) and general U.S. healthcare systems.We conducted a decision-analytic Markov model-based cost-effectiveness analysis, employing appropriate payer perspectives and time horizons, and discounting benefits and costs at 3% annually. Interventions included: Sofosbuvir/ledipasvir (SOF-LDV); ombitasvir/paritaprevir/ritonavir/dasabuvir (3D); sofosbuvir/simeprevir (SOF-SMV); sofosbuvir/pegylated interferon/ribavirin (SOF-RBV-PEG); boceprevir/pegylated interferon/ribavirin (BOC-RBV-PEG); and pegylated interferon/ribavirin (PEG-RBV). Outcomes were sustained virologic response (SVR), advanced liver disease, costs, quality adjusted life years (QALYs), and incremental cost-effectiveness.SOF-LDV and 3D achieve higher SVR rates compared to older regimens and reduce advanced liver disease (>20% relative to no treatment), increasing QALYs by over 2 years per person. For the non-VA population, at current prices ($5,040 per week for SOF-LDV and $4,796 per week for 3D), SOF-LDV's lifetime cost ($293,370) is $18,000 lower than 3D's because of its shorter treatment duration in subgroups. SOF-LDV costs $17,100 per QALY gained relative to no treatment. 3D costs $208,000 per QALY gained relative to SOF-LDV. Both dominate other treatments and are even more cost-effective for the VA, though VA aggregate treatment costs still exceed $4 billion at SOF-LDV prices of $3,308 per week. Drug prices strongly determine relative cost-effectiveness for SOF-LDV and 3D; With sufficient price reductions (approximately 20-30% depending on the health system), 3D could be cost-effective relative to SOF-LDV. Limitations include the lack of long-term head-to-head regimen effectiveness trials.New HCV treatments are cost-effective in multiple healthcare systems if trial-estimated efficacy is achieved in practice, though, at current prices, total expenditures could present substantial challenges.

    View details for DOI 10.1177/2381468316671946

    View details for PubMedID 29756049

    View details for PubMedCentralID PMC5942888

  • Palliative Care Specialist Consultation Is Associated With Supportive Care Quality in Advanced Cancer. Journal of pain and symptom management Walling, A. M., Tisnado, D., Ettner, S. L., Asch, S. M., Dy, S. M., Pantoja, P., Lee, M., Ahluwalia, S. C., Schreibeis-Baum, H., Malin, J. L., Lorenz, K. A. 2016; 52 (4): 507-514


    Although recent randomized controlled trials support early palliative care for patients with advanced cancer, the specific processes of care associated with these findings and whether these improvements can be replicated in the broader health care system are uncertain.The aim of this study was to evaluate the occurrence of palliative care consultation and its association with specific processes of supportive care in a national cohort of Veterans using the Cancer Quality ASSIST (Assessing Symptoms Side Effects and Indicators of Supportive Treatment) measures.We abstracted data from 719 patients' medical records diagnosed with advanced lung, colorectal, or pancreatic cancer in 2008 over a period of three years or until death who received care in the Veterans Affairs Health System to evaluate the association of palliative care specialty consultation with the quality of supportive care overall and by domain using a multivariate regression model.All but 54 of 719 patients died within three years and 293 received at least one palliative care consult. Patients evaluated by a palliative care specialist at diagnosis scored seven percentage points higher overall (P < 0.001) and 11 percentage points higher (P < 0.001) within the information and care planning domain compared with those without a consult.Early palliative care specialist consultation is associated with better quality of supportive care in three advanced cancers, predominantly driven by improvements in information and care planning. This study supports the effectiveness of early palliative care consultation in three common advanced cancers within the Veterans Affairs Health System and provides a greater understanding of what care processes palliative care teams influence.

    View details for DOI 10.1016/j.jpainsymman.2016.04.005

    View details for PubMedID 27401515

    View details for PubMedCentralID PMC5173291

  • Risk Adjustment Tools for Learning Health Systems: A Comparison of DxCG and CMS-HCC V21. Health services research Wagner, T. H., Upadhyay, A., Cowgill, E., Stefos, T., Moran, E., Asch, S. M., Almenoff, P. 2016; 51 (5): 2002-2019


    To compare risk scores computed by DxCG (Verisk) and Centers for Medicare and Medicaid Services (CMS) V21.Analysis of administrative data from the Department of Veterans Affairs (VA) for fiscal years 2010 and 2011.We regressed total annual VA costs on predicted risk scores. Model fit was judged by R-squared, root mean squared error, mean absolute error, and Hosmer-Lemeshow goodness-of-fit tests. Recalibrated models were tested using split samples with pharmacy data.We created six analytical files: a random sample (n = 2 million), high cost users (n = 261,487), users over age 75 (n = 644,524), mental health and substance use users (n = 830,832), multimorbid users (n = 817,951), and low-risk users (n = 78,032).The DxCG Medicaid with pharmacy risk score yielded substantial gains in fit over the V21 model. Recalibrating the V21 model using VA pharmacy data-generated risk scores with similar fit statistics to the DxCG risk scores.Although the CMS V21 and DxCG prospective risk scores were similar, the DxCG model with pharmacy data offered improved fit over V21. However, health care systems, such as the VA, can recalibrate the V21 model with additional variables to develop a tailored risk score that compares favorably to the DxCG models.

    View details for DOI 10.1111/1475-6773.12454

    View details for PubMedID 26839976

    View details for PubMedCentralID PMC5034200

  • Collaborative Care for Depression in Chronic Hepatitis C Clinics. Psychiatric services Kanwal, F., Pyne, J. M., Tavakoli-Tabasi, S., Nicholson, S., Dieckgraefe, B., Storay, E., Bidwell Goetz, M., Smith, D. L., Sansgiry, S., Gifford, A., Asch, S. M. 2016; 67 (10): 1076-1082


    Depression is highly prevalent yet underdiagnosed and undertreated among patients with chronic hepatitis C virus (HCV) infection. Collaborative care models have improved depression outcomes in primary care settings, and this study aimed to provide more information on testing such methods in specialty HCV care.Hepatitis C Translating Initiatives for Depression Into Effective Solutions (HEPTIDES) was a randomized controlled trial that tested a collaborative depression care model in HCV clinics at four Veterans Affairs facilities. The HEPTIDES intervention consisted of an offsite depression care team (depression care manager, pharmacist, and psychiatrist) that delivered collaborative care. Participant interview data were collected at baseline and at six months. The outcome was depression severity measured with the Hopkins Symptom Checklist (SCL-20) and reported as treatment response (≥50% decrease in SCL-20 item score), remission (mean SCL-20 item score <.5), and depression-free days (DFDs).Baseline screening identified 263 HCV-infected patients with depression. In unadjusted analyses, intervention participants' reports trended toward more treatment response (19% versus 13%) and remission (12% versus 6%), but total number of DFDs (50.9) was similar to that of usual care participants (50.7). These trends did not reach statistical significance for the overall sample in the adjusted analyses: response (odds ratio [OR]=2.02, 95% confidence interval [CI]=.98-4.20), remission (OR=2.63, CI=1.00-6.94), and DFDs (β=7.6 days, CI=-.99 to 16.2). However, the intervention was effective in improving all three outcomes for patients who did not meet criteria for remission at baseline (SCL-20 score >.5, N=245).Depression collaborative care resulted in modest improvements in HCV patient depression outcomes. Future research should investigate intervention modifications to improve outcomes in specialty HCV clinics.

    View details for PubMedID 27364808

  • Predicting inpatient clinical order patterns with probabilistic topic models vs conventional order sets. Journal of the American Medical Informatics Association Chen, J. H., Goldstein, M. K., Asch, S. M., Mackey, L., Altman, R. B. 2016


    Build probabilistic topic model representations of hospital admissions processes and compare the ability of such models to predict clinical order patterns as compared to preconstructed order sets.The authors evaluated the first 24 hours of structured electronic health record data for > 10 K inpatients. Drawing an analogy between structured items (e.g., clinical orders) to words in a text document, the authors performed latent Dirichlet allocation probabilistic topic modeling. These topic models use initial clinical information to predict clinical orders for a separate validation set of > 4 K patients. The authors evaluated these topic model-based predictions vs existing human-authored order sets by area under the receiver operating characteristic curve, precision, and recall for subsequent clinical orders.Existing order sets predict clinical orders used within 24 hours with area under the receiver operating characteristic curve 0.81, precision 16%, and recall 35%. This can be improved to 0.90, 24%, and 47% ( P  < 10 -20 ) by using probabilistic topic models to summarize clinical data into up to 32 topics. Many of these latent topics yield natural clinical interpretations (e.g., "critical care," "pneumonia," "neurologic evaluation").Existing order sets tend to provide nonspecific, process-oriented aid, with usability limitations impairing more precise, patient-focused support. Algorithmic summarization has the potential to breach this usability barrier by automatically inferring patient context, but with potential tradeoffs in interpretability.Probabilistic topic modeling provides an automated approach to detect thematic trends in patient care and generate decision support content. A potential use case finds related clinical orders for decision support.

    View details for DOI 10.1093/jamia/ocw136

    View details for PubMedID 27655861

  • Public Reporting of Hospital-Level Cancer Surgical Volumes in California: An Opportunity to Inform Decision Making and Improve Quality. Journal of oncology practice Clarke, C. A., Asch, S. M., Baker, L., Bilimoria, K., Dudley, R. A., Fong, N., Holliday-Hanson, M. L., Hopkins, D. S., Imholz, E. M., Malin, J., Moy, L., O'Sullivan, M., Parker, J. P., Saigal, C. S., Spurlock, B., Teleki, S., Zingmond, D., Lang, L. 2016


    Most patients, providers, and payers make decisions about cancer hospitals without any objective data regarding quality or outcomes. We developed two online resources allowing users to search and compare timely data regarding hospital cancer surgery volumes.Hospital cancer surgery volumes for all California hospitals were calculated using ICD-9 coded hospital discharge summary data. Cancer surgeries included (bladder, brain, breast, colon, esophagus, liver, lung, pancreas, prostate, rectum, and stomach) were selected on the basis of a rigorous literature review to confirm sufficient evidence of a positive association between volume and mortality. The literature could not identify threshold numbers of surgeries associated with better or worse outcomes. A multidisciplinary working group oversaw the project and ensured sound methodology.In California in 2014, about 60% of surgeries were performed at top-quintile-volume hospitals, but the per-hospital median numbers of surgeries for esophageal, pancreatic, stomach, liver, or bladder cancer surgeries were four or fewer. At least 670 patients received cancer surgery at hospitals that performed only one or two surgeries for a particular cancer type; 72% of those patients lived within 50 miles of a top-quintile-volume hospital.There is clear potential for more readily available information about hospital volumes to help patient, providers, and payers choose cancer surgery hospitals. Our successful public reporting of hospital volumes in California represents an important first step toward making publicly available even more provider-specific data regarding cancer care quality, costs, and outcomes, so those data can inform decision-making and encourage quality improvement.

    View details for PubMedID 27601510

  • Acceptance of Advance Directives and Palliative Care Referral for Veterans With Advanced Cancer: A Retrospective Analysis. The American journal of hospice & palliative care Patel, M. I., Bhattacharya, J., Asch, S. M., Kahn, J. 2016; 33 (8): 742-747


    To evaluate the documentation of advance directive (ADs) and physician orders for life-sustaining treatment (POLST) with acceptance of palliative care (PC) services referral among patients with cancer.We retrospectively reviewed veterans with advanced cancers at the Veterans Administration Palo Alto Health Care System. Chi-square tests estimated AD and POLST documentation and referral to PC. Logistic regression models estimated the odds of AD and POLST documentation and PC referral.Two hundred and forty-six veterans were diagnosed with cancer. In all, 53% had a documented AD, 5% had a POLST, and 47% accepted referral to PC. The AD documentation was not associated with acceptance of PC.We found no association of AD documentation and PC referral. Future studies should evaluate other factors that influence referral to these services.

    View details for DOI 10.1177/1049909115595216

    View details for PubMedID 26169523

  • Opportunities to Improve the Value of Outpatient Surgical Care AMERICAN JOURNAL OF MANAGED CARE Erhun, F., Malcolm, E., Kalani, M., Brayton, K., Nguyen, C., Asch, S. M., Platchek, T., Milstein, A. 2016; 22 (9): E329-?


    Nearly 57 million outpatient surgeries-invasive procedures performed on an outpatient basis in hospital outpatient departments (HOPDs) or ambulatory surgery centers (ASCs)-produced annually in the United States account for roughly 7% of healthcare expenditures. Although moving inpatient surgeries to outpatient settings has lowered the cost of care, substantial opportunities to improve the value of outpatient surgery remain. To exploit these remaining opportunities, we composed an evidence-based care delivery composite for national discussion and pilot testing.Evidence-based care delivery composite.We synthesized peer-reviewed publications describing efforts to improve the value of outpatient surgical care, interviewed patients and clinicians to understand their most deeply felt discontents, reviewed potentially relevant emerging science and technology, and observed surgeries at healthcare organizations nominated by researchers as exemplars of efficiency and effectiveness. Primed by this information, we iterated potential new designs utilizing criticism from practicing clinicians, health services researchers, and healthcare managers.We found that 3 opportunities are most likely to improve value: 1) maximizing the appropriate use of surgeries via decision aids, clinical decision support, and a remote surgical coach for physicians considering a surgical referral; 2) safely shifting surgeries from HOPDs to high-volume, multi-specialty ASCs where costs are much lower; and 3) standardizing processes in ASCs from referral to recovery.Extrapolation based on published studies of the effects of each component suggests that the proposed 3-part composite may lower annual national outpatient surgical spending by as much as one-fifth, while maintaining or improving outcomes and the care experience for patients and clinicians. Pilot testing and evaluation will allow refinement of this composite.

    View details for Web of Science ID 000384740300004

    View details for PubMedID 27662397

  • Overall Survival in Patients with Localized Prostate Cancer in the US Veterans Health Administration: Is PIVOT Generalizable? EUROPEAN UROLOGY Barbosa, P. V., Thomas, I., Srinivas, S., Buyyounouski, M. K., Chung, B. I., Chertow, G. M., Asch, S. M., Wagner, T. H., Brooks, J. D., Leppert, J. T. 2016; 70 (2): 227-230


    A better understanding of overall survival among patients with clinically localized prostate cancer (PCa) in the US Veterans Health Administration (VHA) is critical to inform PCa treatment decisions, especially in light of data from the Prostate Intervention Versus Observation Trial (PIVOT). We sought to describe patterns of survival for all patients with clinically localized PCa treated by the VHA. We created an analytic cohort of 35 954 patients with clinically localized PCa diagnosed from 1995 to 2001, approximating the PIVOT inclusion criteria (age of diagnosis ≤75 yr and clinical stage T2 or lower). Mean patient age was 65.9 yr, and median follow-up was 161 mo. Overall, 22.5% of patients were treated with surgery, 16.6% were treated with radiotherapy, and 23.1% were treated with androgen deprivation. Median survival of the entire cohort was 14 yr (25th, 75th percentiles, range: 7.9-20 yr). Among patients who received treatment with curative intent, median survival was 17.9 yr following surgery and 12.9 yr following radiotherapy. One-third of patients died within 10 yr of diagnosis compared with nearly half of the participants in PIVOT. This finding sounds a note of caution when generalizing the mortality data from PIVOT to VHA patients and those in the community.More than one-third of patients diagnosed with clinically localized prostate cancer treated through the US Veterans Health Administration from 1995 to 2001 died within 10 yr of their diagnosis. Caution should be used when generalizing the estimates of competing mortality data from PIVOT.

    View details for DOI 10.1016/j.eururo.2016.02.037

    View details for PubMedID 26948397

  • Race and Gender Differences in the Use of Direct Acting Antiviral Agents for Hepatitis C Virus CLINICAL INFECTIOUS DISEASES Kanwal, F., Kramer, J. R., El-Serag, H. B., Frayne, S., Clark, J., Cao, Y., Taylor, T., Smith, D., White, D., Asch, S. M. 2016; 63 (3): 291-299


    Direct acting antiviral agents (DAA) are highly effective yet expensive. Disparities by race and/or gender often exist in the use of costly medical advances as they become available.We examined a cohort of hepatitis C virus (HCV) patients who received care at the Veterans Administration facilities nationwide. We evaluated the effect of race and gender on DAA receipt after adjusting for socioeconomic status, liver disease severity, comorbidity, and propensity for healthcare use. To determine if disparities had changed over time, we conducted a similar analysis of HCV patients who were seen in the previous standard of care treatment era.Of the 145 596 patients seen in the current DAA era, 17 791 (10.2%) received treatment during the first 16 months of DAA approval. Black patients had 21% lower odds of receiving DAA than whites (odds ratio [OR] = 0.79; 95% confidence interval [CI], .75, .84). Overall, women were as likely to receive treatment as men (OR = 0.99; 95% CI, .90-1.09). However, the odds of receiving DAAs were 29% lower for younger women compared with younger men (OR = 0.71, 95% CI, .54-.93). Similar to the DAA cohort, black patients had significantly lower odds of receiving treatment than whites (OR = 0.74, 95% CI, .69-.79) in the previous treatment era. The racial difference between the 2 eras did not reach statistical significance.There were unexplained differences among HCV population subgroups in the receipt of new DAA treatment. Targeted interventions are needed for black patients and younger women.

    View details for DOI 10.1093/cid/ciw249

    View details for Web of Science ID 000383201900001

    View details for PubMedID 27131869

  • Effect of opioid prescribing guidelines in primary care. Medicine Chen, J. H., Hom, J., Richman, I., Asch, S. M., Podchiyska, T., Johansen, N. A. 2016; 95 (35)


    Long-term opioid use for noncancer pain is increasingly prevalent yet controversial given the risks of addiction, diversion, and overdose. Prior literature has identified the problem and proposed management guidelines, but limited evidence exists on the actual effectiveness of implementing such guidelines in a primary care setting.A multidisciplinary working group of institutional experts assembled comprehensive guidelines for chronic opioid prescribing, including monitoring and referral recommendations. The guidelines were disseminated in September 2013 to our medical center's primary care clinics via in person and electronic education.We extracted electronic medical records for patients with noncancer pain receiving opioid prescriptions (Rxs) in seasonally matched preintervention (11/1/2012-6/1/2013) and postintervention (11/1/2013-6/1/2014) periods. For patients receiving chronic (3 or more) opioid Rxs, we assessed the rates of drug screening, specialty referrals, clinic visits, emergency room visits, and quantity of opioids prescribed.After disseminating guidelines, the percentage of noncancer clinic patients receiving any opioid Rxs dropped from 3.9% to 3.4% (P = 0.02). The percentage of noncancer patients receiving chronic opioid Rxs decreased from 2.0% to 1.6% (P = 0.03). The rate of urine drug screening increased from 9.2% to 17.3% (P = 0.005) amongst noncancer chronic opioid patients. No significant differences were detected for other metrics or demographics assessed.An educational intervention for primary care opioid prescribing is feasible and was temporally associated with a modest reduction in overall opioid Rx rates. Provider use of routine drug screening increased, but overall rates of screening and specialty referral remained low despite the intervention. Despite national pressures to introduce opioid prescribing guidelines for chronic pain, doing so alone does not necessarily yield substantial changes in clinical practice.

    View details for DOI 10.1097/MD.0000000000004760

    View details for PubMedID 27583928

  • Electronic Release of Pathology and Radiology Results to Patients: Opinions and Experiences of Oncologists. Journal of oncology practice / American Society of Clinical Oncology Winget, M., Haji-Sheikhi, F., Brown-Johnson, C., Rosenthal, E. L., Sharp, C., Buyyounouski, M. K., Asch, S. M. 2016; 12 (8): e792-9


    There is an emerging standard to provide patients rapid electronic access to elements of their medical records. Although surveys of patients generally support it, this practice is controversial among oncologists, because few empiric data are available for scenarios of potentially life-threatening conditions like cancer. We report the views of oncologists about patient electronic access to radiology and pathology results that could potentially indicate disease progression.Four months before oncologists were surveyed, final results of radiology/pathology reports were routinely made available to patients online through a secure portal after a 7-day, hold to provide clinicians time to review and communicate results with the patients. Mixed methods were used to assess physician attitudes and experiences toward this change.One hundred twenty-nine oncologists were surveyed, and 82 (64%) responded. A small majority (54%) responded that the release of reports was somewhat or very beneficial for patients who received normal radiology/pathology results before discussion with a physician, but 87% said it was somewhat or very harmful for patients to receive abnormal results before discussion. Forty-nine percent reported that release of reports had a somewhat or very negative impact on communication with their patients.Almost half of oncologists reported that sharing digital radiology and pathology records had a negative impact on their communication with patients. Patient surveys in similar cancer populations would complement the physician perspective. Efforts are needed to improve consensus among oncologists and patients on how to best communicate such results in a timely fashion.

    View details for DOI 10.1200/JOP.2016.011098

    View details for PubMedID 27382001

  • Early Outpatient Follow-up and 30-Day Outcomes in Patients Hospitalized With Cirrhosis HEPATOLOGY Kanwal, F., Asch, S. M., Kramer, J. R., Cao, Y., Asrani, S., El-Serag, H. B. 2016; 64 (2): 569-581


    Preventing readmission has been the focus of numerous quality improvement efforts across many conditions. Early outpatient follow-up has been proposed as the best mechanism for reducing readmissions. The extent to which early outpatient follow-up averts readmission or improves outcomes in cirrhosis is not known. We evaluated the relationship between early outpatient follow-up and short-term readmission and mortality in patients with cirrhosis. We conducted a retrospective cohort study of patients with cirrhosis who were hospitalized with a liver-related diagnosis and discharged to home from 122 Veterans Administration hospitals between 2010 and 2013. We defined early follow-up as an outpatient visit with a clinician within 7 days after discharge. We propensity matched patients who received early visit with those who did not have any visit and examined the associations between early follow-up and all-cause readmission and mortality within 8-30 days after discharge. Of 25,217 patients hospitalized with cirrhosis, 8,123 (32.2%) had an early follow-up visit within 7 days of discharge. A total of 3,492 (13.8%) patients were readmitted and 1,185 (4.6%) died between 8 and 30 days after discharge. In the propensity-matched sample (N = 16,238), patients with early outpatient follow-up visit had a slightly higher risk of readmission (15.3% vs. 13.8%; hazard ratio [HR] =1.10; 95% confidence interval [CI] = 1.02-1.19), but significantly lower risk of mortality (3.2% vs. 5.2%; HR = 0.60; 95% CI = 0.51-0.70) than those without early visit. The findings persisted in several subgroup and sensitivity analyses.Early outpatient follow-up after discharge was associated with a small increase in readmissions but lower overall mortality in patients with cirrhosis. Transitional care may be effective in improving short-term outcomes in patients with cirrhosis, but readmission performance measures would miss this effect. (Hepatology 2016;64:569-581).

    View details for DOI 10.1002/hep.28558

    View details for Web of Science ID 000380034500026

    View details for PubMedID 26991920

  • Predictive validity of a quality measure for intensive substance use disorder treatment. Substance abuse Schmidt, E. M., Gupta, S., Bowe, T., Ellerbe, L. S., Phelps, T. E., Finney, J. W., Asch, S. M., Humphreys, K., Trafton, J., Vanneman, M., Harris, A. H. 2016: 1-7


    Measures of substance use disorder (SUD) treatment quality are essential tools for performance improvement. The Veterans Health Administration (VHA) developed a measure of access to and engagement in intensive outpatient programs (IOPs) for SUD. However, predictive validity, or associations between this measure and treatment outcomes, has not been examined.Data on veterans with SUD came from 3 samples: the Outcomes Monitoring Project (N = 5436), a national evaluation of VHA mental health services (N = 339,887), and patients receiving detoxification services (N = 23,572). Propensity score-weighted mixed-effects regressions modeled associations between receiving at least 1 week of IOP treatment and patient outcomes, controlling for facility-level performance and a random effect for facility.Propensity score weighting reduced or eliminated observable baseline differences between patient groups. Patients who accessed IOPs versus those who did not reported significantly reduced alcohol- and drug-related symptom severity, with significantly fewer past-month days drinking alcohol (b = 1.83, P < .001) and fewer past-month days intoxicated (b = 1.55, P < .001). Patients who received IOP after detoxification services had higher 6-month utilization of SUD outpatient visits (b = 2.09, P < .001), more subsequent detoxification episodes (b = 0.25, P < .001), and lower odds of 2-year mortality (odds ratio [OR] = 0.68, 95% confidence interval [CI]: 0.61-0.75; P < .001).Receiving at least 1 week of SUD treatment in an IOP was associated with higher follow-up utilization, improved health outcomes, and reduced mortality. These associations lend support to the predictive validity of VHA's IOP quality measure. Future research should focus on measure feasibility and validity outside of VHA, and whether predictive validity is maintained once this quality measure is tied to performance incentives.

    View details for PubMedID 27435754

  • How Will New Guidelines Affect CD4 Testing in Veterans With HIV? CLINICAL INFECTIOUS DISEASES Barnett, P. G., Schmitt, S. K., Yu, W., Goetz, M. B., Ohl, M. E., Asch, S. M. 2016; 63 (1): 96-100


    Guidelines now recommend limited use of routine CD4 cell count testing in human immunodeficiency virus (HIV)-infected patients with successful viral control who are not immunocompromised.CD4 and viral load tests for patients receiving HIV care from the US Department of Veterans Affairs during 2009-2013 were evaluated to determine trends in CD4 testing frequency and the number, cost, and results of CD4 tests considered optional under the guidelines.There were 28 530 individuals with sufficient testing to be included. At the time of the last CD4 test, 19.8% of the cohort was eligible for optional monitoring and 15.6% for minimal monitoring. CD4 testing frequency declined by 10.8% over 4 years, reducing the direct cost of testing by US$196 000 per year. Full implementation of new treatment guidelines could reduce CD4 testing a further 28.9%, an additional annual savings of US$600 000. CD4 tests conducted during periods of potentially reduced monitoring were rarely <200 cells/µL: 1.1% of the tests conducted when minimal monitoring was recommended and just 0.3% of tests conducted when optional monitoring was recommended were less than this value.Reduced CD4 monitoring of HIV-infected patients would result in modest cost savings and likely reduce patient anxiety, with little or no impact on the quality of care. Veterans Affairs has made substantial progress in reducing the frequency of optional CD4 testing, but further reductions may still be warranted.

    View details for DOI 10.1093/cid/ciw194

    View details for Web of Science ID 000381226600019

    View details for PubMedID 27045125

  • Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses PUBLIC HEALTH Maguire, E. M., Bokhour, B. G., Asch, S. M., Wagner, T. H., Gifford, A. L., Gallagher, T. H., Durfee, J. M., Martinello, R. A., Elwy, A. R. 2016; 135: 75-82


    We examined print, broadcast and social media reports about health care systems' disclosures of large scale adverse events to develop future effective messaging.Directed content analysis.We systematically searched four communication databases, YouTube and Really Simple Syndication (RSS) feeds relating to six disclosures of lapses in infection control practices in the Department of Veterans Affairs occurring between 2009 and 2012. We assessed these with a coding frame derived from effective crisis and risk communication models.We identified 148 unique media reports. Some components of effective communication (discussion of cause, reassurance, self-efficacy) were more present than others (apology, lessons learned). Media about 'promoting secrecy' and 'slow response' appeared in reports when time from event discovery to patient notification was over 75 days. Elected officials' quotes (n = 115) were often negative (83%). Hospital officials' comments (n = 165) were predominantly neutral (92%), and focused on information sharing.Health care systems should work to ensure that they develop clear messages focused on what is not well covered by the media, including authentic apologies, remedial actions taken, and shorten the timeframe between event identification and disclosure to patients.

    View details for DOI 10.1016/j.puhe.2015.10.016

    View details for Web of Science ID 000377414200010

    View details for PubMedID 27026251

  • Can lay health workers achieve the triple aim? Results from the Engagement of Patients with Advanced Cancer (EPAC) trial Patel, M. I., Periyakoil, V., Bundorf, K., Thom, D., Milstein, A., Asch, S. M., Kahn, J. AMER SOC CLINICAL ONCOLOGY. 2016
  • Development and pilot of brief surveys to evaluate the quality of coordinated, patient-centered cancer care. Winget, M., Sheikhi, F., Asch, S. AMER SOC CLINICAL ONCOLOGY. 2016
  • The ideal interface between oncology and palliative care: Views from the field. Gidwani, R., Blayney, D. W., Patel, M. I., Asch, S. M., Kelly, P., Nevedal, A. AMER SOC CLINICAL ONCOLOGY. 2016
  • What role should value play in cancer care? Gidwani, R., Blayney, D. W., Patel, M. I., Asch, S. M., Kelly, A., Nevedal, A. AMER SOC CLINICAL ONCOLOGY. 2016
  • Surgery for Degenerative Lumbar Scoliosis The Development of Appropriateness Criteria SPINE Chen, P. G., Daubs, M. D., Berven, S., Raaen, L. B., Anderson, A. T., Asch, S. M., Nuckols, T. K. 2016; 41 (10): 910-918


    The RAND/UCLA Appropriateness Method is a well-established means of developing criteria for assessing the appropriateness of surgery in specific subpopulations. It involves a systematic review of the literature and ratings by a multidisciplinary panel of national experts.To evaluate the appropriateness of surgical interventions for degenerative lumbar scoliosis (DLS), including identifying clinical characteristics that influence when surgery is inappropriate, appropriate, or necessary, and which procedures are preferable.DLS presents with diverse clinical symptoms and radiographic findings. Variability exists in both nonoperative and operative management. The appropriateness of surgery, and of specific surgical procedures, has not been defined for this important pathology of the aging spine.We selected a panel of 11 experts, including surgical specialists from multiple disciplines. Next, we systematically reviewed relevant literature. Finally, in a three-round, modified-Delphi process, panelists rated the appropriateness and necessity of five different surgical procedures (dependent variables) on a nine-point scale for 260 different clinical scenarios that stratified patients according to age, medical comorbidities, symptoms, signs, and radiographic variables (independent variables).The 59 eligible studies identified via the systematic review were generally small or used weak designs. Panelists judged that surgery was generally appropriate for patients with at least moderate symptoms and larger or progressive deformities, moderate spinal or foraminal stenosis, or sagittal plane imbalance. Surgery was generally inappropriate for mild symptoms and smaller stable deformities, without sagittal imbalance or moderate stenosis, particularly among patients with advanced age and multiple comorbidities. For patients with larger or progressive deformities, imbalance, or severe multilevel stenosis, more extensive fusion and deformity correction procedures were generally preferred.Defining the appropriateness of surgery for patients with DLS will be useful to improve evidence-based clinical decision making as well as the consistency and quality of care for patients with DLS.3.

    View details for DOI 10.1097/BRS.0000000000001392

    View details for Web of Science ID 000375626200022

    View details for PubMedID 26679874

  • Medical Record Quality Assessments of Palliative Care for Intensive Care Unit Patients Do They Match the Perspectives of Nurses and Families? ANNALS OF THE AMERICAN THORACIC SOCIETY Mularski, R. A., Hansen, L., Rosenkranz, S. J., Leo, M. C., Nagy, P., Asch, S. M. 2016; 13 (5): 690–98


    To understand how well palliative care is provided in the intensive care unit (ICU) and to direct improvements, measurement of the quality of care delivered is requisite.To measure the quality of palliative care delivered in the ICU, using chart review-derived process quality measures of palliative care in critically ill patients, and to compare these measures with family and nursing perspectives on the quality of care provided.We developed and operationalized a comprehensive quality evaluation measure set from previously endorsed palliative care measure statements, using a rigorous multidisciplinary Delphi process focused on optimizing the validity and feasibility of chart review-derived metrics. Fourteen process measures assessed the quality of care delivered across established domains of palliative care for the ICU. We assessed the quality of care for ICU patients with ICU length of stay exceeding 2 days from three perspectives: medical record reviews, family satisfaction reports, and nurse ratings from those providing care in the ICU.We evaluated the care over a 7-month period of 150 patients (mean age, 63.9 yr [SD 13.4], average ICU length of stay, 7.5 d [SD 7.2]). Overall, ICU patients received 53.1% of recommended palliative care. The Family Satisfaction with Care in the Intensive Care Unit total scores from 136 family members (response rate, 91%) were high, 85.7 (SE 2.0) and 86.0 (SE 1.6), at the two sites but not correlated to measured quality delivered. Nurses rated the quality of care higher than medical record review (mean, 77.3% [SD 13.4]; n = 135) and similarly correlation with chart based process measures was poor.Delivering high-quality palliative care in the ICU requires assessing key patient-centered domains. However, assessments from different perspectives do not always agree with technical quality of care as measured through chart-based metrics. We found deficits across seven domains of technical quality that were not correlated with either nurse or family ratings. Despite care gaps, families were generally satisfied with the care delivered. We conclude that each measurement perspective provides an independent view that can guide quality improvement and innovation work as well as subsequent research.

    View details for PubMedID 27144795

  • Opportunities to Enhance Value-Related Research in the U.S. Department of Veterans Affairs. Journal of general internal medicine Wagner, T. H., Burstin, H., Frakt, A. B., Krein, S. L., Lorenz, K., Maciejewski, M. L., Pizer, S. D., Weiner, M., Yoon, J., Zulman, D. M., Asch, S. M. 2016; 31: 78-83

    View details for DOI 10.1007/s11606-015-3538-5

    View details for PubMedID 26951279

  • Measuring What Matters in Health: Lessons from the Veterans Health Administration State of the Art Conference JOURNAL OF GENERAL INTERNAL MEDICINE Asch, S. M., Kerr, E. A. 2016; 31: 1–2

    View details for PubMedID 26951269

    View details for PubMedCentralID PMC4803670

  • Colorectal Cancer Screening in the Era of the Affordable Care Act. Journal of general internal medicine Richman, I., Asch, S. M., Bhattacharya, J., Owens, D. K. 2016; 31 (3): 315-320


    The Affordable Care Act (ACA) eliminated cost-sharing for evidence-based preventive services in an effort to encourage use.To evaluate use of colorectal cancer (CRC) screening in a national population-based sample before and after implementation of the ACA.Repeated cross-sectional analysis of the Medical Expenditure Panel Survey (MEPS) between 2009 and 2012 comparing CRC screening rates before and after implementation of the ACA.Adults 50-64 with private health insurance and adults 65-75 with Medicare.Self-reported receipt of screening colonoscopy, sigmoidoscopy, or fecal occult blood test (FOBT) within the past year among those eligible for screening.Our study included 8617 adults aged 50-64 and 3761 adults aged 65-75. MEPS response rates ranged from 58 to 63%. Among adults aged 50-64, 18.9-20.9% received a colonoscopy in the survey year, 0.59-2.1% received a sigmoidoscopy, and 7.9-10.4% received an FOBT. For adults aged 65-75, 23.6-27.7% received a colonoscopy, 1.3-3.2% a sigmoidoscopy, and 13.5-16.4% an FOBT. In adjusted analyses, among participants aged 50-64, there was no increase in yearly rates of colonoscopy (-0.28 percentage points, 95% CI -2.3 to 1.7, p = 0.78), sigmoidoscopy (-1.1%, 95% CI -1.7 to -0.46, p = <0.001), or FOBT (-1.6%, 95% CI -3.2 to -0.03, p = 0.046) post-ACA. For those aged 65-75, rates of colonoscopy (+2.3%, 95% CI -1.4 to 6.0, p = 0.22), sigmoidoscopy (+0.34%, 95% CI 0.88 to 1.6, p = 0.58) and FOBT (-0.65, 95% CI -4.1 to 2.8, p = 0.72) did not increase. Among those aged 65-75 with Medicare and no additional insurance, the use of colonoscopy rose by 12.0% (95% CI 3.3 to 20.8, p = 0.007). Among participants with Medicare living in poverty, colonoscopy use also increased (+5.7%, 95% CI 0.18 to 11.3, p = 0.043).Eliminating cost-sharing for CRC screening has not resulted in changes in the use of CRC screening services for many Americans, although use may have increased in the post-ACA period among some Medicare beneficiaries.

    View details for DOI 10.1007/s11606-015-3504-2

    View details for PubMedID 26349953

  • Oncologists' opinions and experiences with electronic release of radiology and pathology results to patients. Winget, M., Sheikhi, F., Rosenthal, E., Sharp, C., Buyyounouski, M. K., Asch, S. AMER SOC CLINICAL ONCOLOGY. 2016
  • Achieving the triple aim in cancer care through a tri-part research collaboration. Patel, M. I., Ramirez, D., Nguyen, A., Hagan, C., Asch, S. M., Agajanian, H. H., Agajanian, R., Milstein, A., Blayney, D. W. AMER SOC CLINICAL ONCOLOGY. 2016
  • Key ingredients for implementing intensive outpatient programs within patient-centered medical homes: A literature review and qualitative analysis. Healthcare (Amsterdam, Netherlands) Breland, J. Y., Asch, S. M., Slightam, C., Wong, A., Zulman, D. M. 2016; 4 (1): 22-29


    Intensive outpatient programs aim to transform care while conserving resources for high-need, high-cost patients, but little is known about factors that influence their implementation within patient-centered medical homes (PCMHs).In this mixed-methods study, we reviewed the literature to identify factors affecting intensive outpatient program implementation, then used semi-structured interviews to determine how these factors influenced the implementation of an intensive outpatient program within the Veterans Affairs' (VA) PCMH. Interviewees included facility leadership and clinical staff who were involved in a pilot Intensive Management Patient Aligned Care Team (ImPACT) intervention for high-need, high-cost VA PCMH patents. We classified implementation factors in the literature review and qualitative analysis using the Consolidated Framework for Implementation Research (CFIR).The literature review (n=9 studies) and analyses of interviews (n=15) revealed key implementation factors in three CFIR domains. First, the Inner Setting (i.e., the organizational and PCMH environment), mostly enabled implementation through a culture of innovation, good networks and communication, and positive tension for change. Second, Characteristics of Individuals, including creativity, flexibility, and interpersonal skills, allowed program staff to augment existing PCMH services. Finally, certain Intervention Characteristics (e.g., adaptability) enabled implementation, while others (e.g., complexity) generated implementation barriers.Resources and structural features common to PCMHs can facilitate implementation of intensive outpatient programs, but program success is also dependent on staff creativity and flexibility, and intervention adaptations to meet patient and organizational needs.Established PCMHs likely provide resources and environments that permit accelerated implementation of intensive outpatient programs.V.

    View details for DOI 10.1016/j.hjdsi.2015.12.005

    View details for PubMedID 27001095

  • The facilitators and barriers associated with implementation of a patient-centered medical home in VHA IMPLEMENTATION SCIENCE Helfrich, C. D., Sylling, P. W., Gale, R. C., Mohr, D. C., Stockdale, S. E., Joos, S., Brown, E. J., Grembowski, D., Asch, S. M., Fihn, S. D., Nelson, K. M., Meredith, L. S. 2016; 11


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

    View details for DOI 10.1186/s13012-016-0386-6

    View details for Web of Science ID 000370924200001

    View details for PubMedID 26911135

    View details for PubMedCentralID PMC4766632

  • Inappropriate Ordering of Lumbar Spine Magnetic Resonance Imaging: Are Providers Choosing Wisely? AMERICAN JOURNAL OF MANAGED CARE Gidwani, R., Sinnott, P., Avoundjian, T., Lo, J., Asch, S. M., Barnett, P. G. 2016; 22 (2): E68-E76


    To analyze inappropriate use of magnetic resonance imaging (MRI) for patients with low back pain in a healthcare system with no financial incentives for overuse.We used administrative data to assess the appropriateness of lumbar spine (LS) MRI in the Veterans Health Administration.All veterans who received LS MRI in the outpatient setting in fiscal year 2012 were included. We based our assessments of appropriateness on CMS criteria, which have been endorsed by the National Quality Forum. Generalized estimating equations were used to evaluate characteristics of inappropriate scans.Of the 110,661 LS MRIs performed, 31% were classified as inappropriate. Most scans that were considered appropriate were characterized as such because they were preceded by conservative therapy (53%). "Red flag" conditions were responsible for a much smaller percentage of scans being considered appropriate; 13% of scans were preceded by conservative therapy and were performed in patients with a red flag condition, while only 4% of scans were considered appropriate because of red flag conditions only. Scans ordered in the emergency department and in urgent care, primary care, and internal medicine clinics were most likely to be classified as inappropriate. Resident physicians were significantly less likely than other provider types to order inappropriate LS MRIs (odds ratio, 0.80; P < .0001). Approximately 24% of providers ordered 74% of inappropriate scans.We found that 31% of LS MRIs were inappropriate in a healthcare system largely absent of financial and other incentives for ordering. The problem of inappropriate ordering of LS MRI is concentrated in a small number of providers; any provider-facing interventions to reduce inappropriate order should therefore be targeted, rather than aimed at all providers who order LS MRI.

    View details for Web of Science ID 000373571700004

    View details for PubMedID 26881322

  • Quality of HIV Care and Mortality Rates in HIV-Infected Patients CLINICAL INFECTIOUS DISEASES Korthuis, P. T., McGinnis, K. A., Kraemer, K. L., Gordon, A. J., Skanderson, M., Justice, A. C., Crystal, S., Goetz, M. B., Gibert, C. L., Rimland, D., Fiellin, L. E., Gaither, J. R., Wang, K., Asch, S. M., McInnes, D. K., Ohl, M. E., Bryant, K., Tate, J. P., Duggal, M., Fiellin, D. A. 2016; 62 (2): 233-239


    The Patient Protection and Affordable Care Act encourages healthcare systems to track quality-of-care measures; little is known about their impact on mortality rates. The objective of this study was to assess associations between HIV quality of care and mortality rates.A longitudinal survival analysis of the Veterans Aging Cohort Study included 3038 human immunodeficiency virus (HIV)-infected patients enrolled between June 2002 and July 2008. The independent variable was receipt of ≥80% of 9 HIV quality indicators (QIs) abstracted from medical records in the 12 months after enrollment. Overall mortality rates through 2014 were assessed from the Veterans Health Administration, Medicare, and Social Security National Death Index records. We assessed associations between receiving ≥80% of HIV QIs and mortality rates using Kaplan-Meier survival analysis and adjusted Cox proportional hazards models. Results were stratified by unhealthy alcohol and illicit drug use.The majority of participants were male (97.5%) and black (66.8%), with a mean (standard deviation) age of 49.0 (8.8) years. Overall, 25.9% reported past-year unhealthy alcohol use and 28.4% reported past-year illicit drug use. During 24 805 person-years of follow-up (mean [standard deviation], 8.2 [3.3] years), those who received ≥80% of QIs experienced lower age-adjusted mortality rates (adjusted hazard ratio, 0.75; 95% confidence interval, .65-.86). Adjustment for disease severity attenuated the association.Receipt of ≥80% of select HIV QIs is associated with improved survival in a sample of predominantly male, black, HIV-infected patients but was insufficient to overcome adjustment for disease severity. Interventions to ensure high-quality care and address underlying chronic illness may improve survival in HIV-infected patients.

    View details for DOI 10.1093/cid/civ762

    View details for Web of Science ID 000368622300022

    View details for PubMedCentralID PMC4690479

  • A Couples' Based Self-Management Program for Heart Failure: Results of a Feasibility Study. Frontiers in public health Trivedi, R., Slightam, C., Fan, V. S., Rosland, A., Nelson, K., Timko, C., Asch, S. M., Zeliadt, S. B., Heidenreich, P., Hebert, P. L., Piette, J. D. 2016; 4: 171-?


    Heart failure (HF) is associated with frequent exacerbations and shortened lifespan. Informal caregivers such as significant others often support self-management in patients with HF. However, existing programs that aim to enhance self-management seldom engage informal caregivers or provide tools that can help alleviate caregiver burden or improve collaboration between patients and their informal caregivers.To develop and pilot test a program targeting the needs of self-management support among HF patients as well as their significant others.We developed the Dyadic Health Behavior Change model and conducted semi-structured interviews to determine barriers to self-management from various perspectives. Participants' feedback was used to develop a family-centered self-management program called "SUCCEED: Self-management Using Couples' Coping EnhancEment in Diseases." The goals of this program are to improve HF self-management, quality of life, communication within couples, relationship quality, and stress and caregiver burden. We conducted a pilot study with 17 Veterans with HF and their significant others to determine acceptability of the program. We piloted psychosocial surveys at baseline and after participants' program completion to evaluate change in depressive symptoms, caregiver burden, self-management of HF, communication, quality of relationship, relationship mutuality, and quality of life.Of the 17 couples, 14 completed at least 1 SUCCEED session. Results showed high acceptability for each of SUCCEED's sessions. At baseline, patients reported poor quality of life, clinically significant depressive symptoms, and inadequate self-management of HF. After participating in SUCCEED, patients showed improvements in self-management of HF, communication, and relationship quality, while caregivers reported improvements in depressive symptoms and caregiver burden. Quality of life of both patients and significant others declined over time.In this small pilot study, we showed positive trends with involving significant others in self-management. SUCCEED has the potential of addressing the growing public health problem of HF among patients who receive care from their significant other.

    View details for DOI 10.3389/fpubh.2016.00171

    View details for PubMedID 27626029

    View details for PubMedCentralID PMC5004799

  • DYNAMICALLY EVOLVING CLINICAL PRACTICES AND IMPLICATIONS FOR PREDICTING MEDICAL DECISIONS Chen, J. H., Goldstein, M. K., Asch, S. M., Altman, R. B., Altman, R. B., Dunker, A. K., Hunter, L., Ritchie, M. D., Murray, T., Klein, T. E. WORLD SCIENTIFIC PUBL CO PTE LTD. 2016: 195–206
  • Racial Disparities in HIV Care Extend to Common Comorbidities: Implications for Implementation of Interventions to Reduce Disparities in HIV Care JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION Richardson, K. K., Bokhour, B., McInnes, K., Yakovchenko, V., Okwara, L., Midboe, A. M., Skolnik, A., Vaughan-Sarrazin, M., Asch, S. M., Gifford, A. L., Ohl, M. E. 2016; 108 (4): 201-U76


    Prior studies have described racial disparities in the quality of care for persons with HIV infection, but it is unknown if these disparities extend to common comorbid conditions. To inform implementation of interventions to reduce disparities in HIV care, we examined racial variation in a set of quality measures for common comorbid conditions among Veterans in care for HIV in the United States.The cohort included 23,974 Veterans in care for HIV in 2013 (53.4% black; 46.6% white). Measures extracted from electronic health record and administrative data were receipt of combination antiretroviral therapy (cART), HIV viral control (serum RNA < 200 copies/ml among those on cART), hypertension control (blood pressure < 140/90 mm Hg among those with hypertension), diabetes control (hemoglobin A1C < 9% among those with diabetes), lipid monitoring, guideline-concordant antidepressant prescribing, and initiation and engagement in substance use disorder (SUD) treatment. Black persons were less likely than their white counterparts to receive cART (90.2% vs. 93.2%, p<.001), and experience viral control (84.6% vs. 91.3%, p<.001), hypertension control (61.9% vs. 68.3%, p<.001), diabetes control (85.5% vs. 89.5%, p<.001), and lipid monitoring (81.5% vs. 85.2%, p<.001). Initiation and engagement in SUD treatment were similar among blacks and whites. Differences remained after adjusting for age, comorbidity, retention in HIV care, and a measure of neighborhood social disadvantage created from census data.Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities.

    View details for DOI 10.1016/j.jnma.2016.08.001

    View details for Web of Science ID 000397052500006

    View details for PubMedID 27979005

  • DYNAMICALLY EVOLVING CLINICAL PRACTICES AND IMPLICATIONS FOR PREDICTING MEDICAL DECISIONS. Pacific Symposium on Biocomputing. Pacific Symposium on Biocomputing Chen, J. H., Goldstein, M. K., Asch, S. M., Altman, R. B. 2016; 21: 195-206


    Automatically data-mining clinical practice patterns from electronic health records (EHR) can enable prediction of future practices as a form of clinical decision support (CDS). Our objective is to determine the stability of learned clinical practice patterns over time and what implication this has when using varying longitudinal historical data sources towards predicting future decisions. We trained an association rule engine for clinical orders (e.g., labs, imaging, medications) using structured inpatient data from a tertiary academic hospital. Comparing top order associations per admission diagnosis from training data in 2009 vs. 2012, we find practice variability from unstable diagnoses with rank biased overlap (RBO)<0.35 (e.g., pneumonia) to stable admissions for planned procedures (e.g., chemotherapy, surgery) with comparatively high RBO>0.6. Predicting admission orders for future (2013) patients with associations trained on recent (2012) vs. older (2009) data improved accuracy evaluated by area under the receiver operating characteristic curve (ROC-AUC) 0.89 to 0.92, precision at ten (positive predictive value of the top ten predictions against actual orders) 30% to 37%, and weighted recall (sensitivity) at ten 2.4% to 13%, (P<10(-10)). Training with more longitudinal data (2009-2012) was no better than only using recent (2012) data. Secular trends in practice patterns likely explain why smaller but more recent training data is more accurate at predicting future practices.

    View details for PubMedID 26776186

  • Integrated Care Increases Treatment and Improves Outcomes of Patients With Chronic Hepatitis C Virus Infection and Psychiatric Illness or Substance Abuse. Clinical gastroenterology and hepatology Ho, S. B., Bräu, N., Cheung, R., Liu, L., Sanchez, C., Sklar, M., Phelps, T. E., Marcus, S. G., Wasil, M. M., Tisi, A., Huynh, L., Robinson, S. K., Gifford, A. L., Asch, S. M., Groessl, E. J. 2015; 13 (11): 2005-2014 e3


    Patients with hepatitis C virus (HCV) infection with psychiatric disorders and/or substance abuse face significant barriers to antiviral treatment. New strategies are needed to improve treatment rates and outcomes. We investigated whether an integrated care (IC) protocol, which includes multidisciplinary care coordination and patient case management, could increase the proportion of patients with chronic HCV infection who receive antiviral treatment (a combination of interferon-based and direct-acting antiviral agents) and achieve a sustained virologic response (SVR).We performed a prospective randomized trial at 3 medical centers in the United States. Participants (n = 363 patients attending HCV clinics) had been screened and tested positive for depression, post-traumatic stress disorder, and/or substance use; they were assigned randomly to groups that received IC or usual care (controls) from March 2009 through February 2011. A midlevel mental health practitioner was placed at each HCV clinic to provide IC with brief mental health interventions and case management, according to formal protocol. The primary end point was SVR.Of the study participants, 63% were non-white, 51% were homeless in the past 5 years, 64% had psychiatric illness, 65% were substance abusers within 1 year before enrollment, 57% were at risk for post-traumatic stress disorder, 71% had active depression, 80% were infected with HCV genotype 1, and 23% had advanced fibrosis. Over a mean follow-up period of 28 months, a greater proportion of patients in the IC group began receiving antiviral therapy (31.9% vs 18.8% for controls; P = .005) and achieved a SVR (15.9% vs 7.7% of controls; odds ratio, 2.26; 95% confidence interval, 1.15-4.44; P = .018). There were no differences in serious adverse events between groups.Integrated care increases the proportion of patients with HCV infection and psychiatric illness and/or substance abuse who begin antiviral therapy and achieve SVRs, without serious adverse events. # NCT00722423.

    View details for DOI 10.1016/j.cgh.2015.02.022

    View details for PubMedID 25724704

  • SUCCEED: A PILOT STUDY OF A HEART FAILURE SELF-MANAGEMENT PROGRAM FOR COUPLES Trivedi, R., Slightam, C., Piette, J. D., Nelson, K., Rosland, A., Heidenreich, P., Asch, S., Timko, C. OXFORD UNIV PRESS INC. 2015: 822–23
  • Association of Early Patient-Physician Care Planning Discussions and End-of-Life Care Intensity in Advanced Cancer JOURNAL OF PALLIATIVE MEDICINE Ahluwalia, S. C., Tisnado, D. M., Walling, A. M., Dy, S. M., Asch, S. M., Ettner, S. L., Kim, B., Pantoja, P., Schreibeis-Baum, H. C., Lorenz, K. A. 2015; 18 (10): 834-841


    Early patient-physician care planning discussions may influence the intensity of end-of-life (EOL) care received by veterans with advanced cancer.The study objective was to evaluate the association between medical record documentation of patient-physician care planning discussions and intensity of EOL care among veterans with advanced cancer.This was a retrospective cohort study. Subjects were 665 veteran decedents diagnosed with stage IV colorectal, lung, or pancreatic cancer in 2008, and followed till death or the end of the study period in 2011. We estimated the effect of patient-physician care planning discussions documented within one month of metastatic diagnosis on the intensity of EOL care measured by receipt of acute care, intensive interventions, chemotherapy, and hospice care, using multivariate logistic regression models.Veterans in our study were predominantly male (97.1%), white (74.7%), with an average age at diagnosis of 66.4 years. Approximately 31% received some acute care, 9.3% received some intensive intervention, and 6.5% had a new chemotherapy regimen initiated in the last month of life. Approximately 41% of decedents received no hospice or were admitted within three days of death. Almost half (46.8%) had documentation of a care planning discussion within the first month after diagnosis and those who did were significantly less likely to receive acute care at EOL (OR: 0.67; p=0.025). Documented discussions were not significantly associated with intensive interventions, chemotherapy, or hospice care.Early care planning discussions are associated with lower rates of acute care use at the EOL in a system with already low rates of intensive EOL care.

    View details for DOI 10.1089/jpm.2014.0431

    View details for Web of Science ID 000362268900009

    View details for PubMedID 26186553

    View details for PubMedCentralID PMC4599129

  • Health Care Utilization Patterns Among High-Cost VA Patients With Mental Health Conditions. Psychiatric services Hunter, G., Yoon, J., Blonigen, D. M., Asch, S. M., Zulman, D. M. 2015; 66 (9): 952-958


    To inform development of intensive management programs for high-cost patients, this study investigated the relationship between psychiatric diagnoses and patterns of health care utilization among high-cost patients in the Department of Veterans Affairs (VA) health care system.The costliest 5% of patients who received care in the VA in fiscal year 2010 were assigned to five mutually exclusive hierarchical groups on the basis of diagnosis codes: no mental health condition, serious mental illness, substance use disorder, posttraumatic stress disorder (PTSD), and depression. Multivariable linear regression was used to examine associations between diagnostic groups and use of mental health and non-mental health care and costs of care, with adjustment for sociodemographic characteristics. The proportion of costs generated by mental health care was estimated for each group.Among 261,515 high-cost VA patients, rates of depression, substance use disorder, PTSD, and serious mental illness were 29%, 20%, 17%, and 13%, respectively. Individuals in the serious mental illness and substance use disorder groups were younger and had fewer chronic general medical conditions and higher adjusted rates of mental health care utilization; they also had a greater proportion of costs generated by mental health care (41% and 31%, respectively) compared with individuals in the PTSD and depression groups (18% and 11%, respectively).Optimal management of high-risk, high-cost patients may require stratification by psychiatric diagnoses, with integrated care models for patients with multiple chronic conditions and comorbid mental health conditions and intensive mental health services for patients whose primary needs stem from mental health conditions.

    View details for DOI 10.1176/

    View details for PubMedID 25930040

  • Rates and Predictors of Newly Diagnosed HIV Infection Among Veterans Receiving Routine Once-Per-Lifetime HIV Testing in the Veterans Health Administration JAIDS-JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES Goetz, M. B., Hoang, T., Kan, V. L., Rimland, D., Rodriguez-Barradas, M. C., Asch, S. M. 2015; 69 (5): 544-550


    To determine predictors and variations in the rate of newly diagnosed HIV infection among persons who underwent routine (ie, non-risk based) rather than risk-based HIV testing in Veterans Health Administration (VHA) facilities.Retrospective observational study of the HIV infection new rates during the period when VHA policy called for routine (2009-2012) versus risk-based (2006-2009) HIV testing. Source data for testing results at 18 VHA facilities were obtained from the VHA National Corporate Data Warehouse.New HIV diagnoses were established in 0.14% (95% confidence interval (CI): 0.12 to 0.46) of the 210,957 patients tested in the routine testing period versus 0.46% (95% CI: 0.42 to 1.29) of the 89,652 patients tested in the risk-based testing period. Among persons aged 65-74 years and 75 years or older, the new diagnosis rates were 0.07% (95% CI: 0.04 to 0.09) and 0.02% (95% CI: 0.00 to 0.03), respectively, and thus less than the generally accepted cost-effective threshold of 0.10%. Among African Americans, the upper bound of the 95% CI of the crude rate of new diagnoses during the routine-testing period was greater than 0.1% across all age strata. When assessed by year of testing, the adjusted rates of new diagnoses fell from 0.20% in 2010 to 0.10% in 2012.Routine HIV testing is cost-effective among persons younger than 65 years. Among older patients, risk-based testing may be a more efficient and cost-effective approach. This will be increasingly relevant if rates of new HIV diagnoses in persons undergoing routine testing continue to decrease.

    View details for DOI 10.1097/QAI.0000000000000653

    View details for Web of Science ID 000358208800005

    View details for PubMedID 25886931

  • How Can eHealth Technology Address Challenges Related to Multimorbidity? Perspectives from Patients with Multiple Chronic Conditions JOURNAL OF GENERAL INTERNAL MEDICINE Zulman, D. M., Jenchura, E. C., Cohen, D. M., Lewis, E. T., Houston, T. K., Asch, S. M. 2015; 30 (8): 1063-1070


    Patient eHealth technology offers potential support for disease self-management, but the value of existing applications for patients with multiple chronic conditions (MCCs) is unclear.To understand self-management and health care navigation challenges that patients face due to MCCs and to identify opportunities to support these patients through new and enhanced eHealth technology.After administering a screening survey, we conducted 10 focus groups of 3-8 patients grouped by age, sex, and common chronic conditions. Patients discussed challenges associated with having MCCs and their use of (and desires from) technology to support self-management. Three investigators used standard content analysis methods to code the focus group transcripts. Emergent themes were reviewed with all collaborators, and final themes and representative quotes were validated with a sample of participants.Fifty-three individuals with ≥3 chronic conditions and experience using technology for health-related purposes.Focus group participants had an average of five chronic conditions. Participants reported using technology most frequently to search for health information (96 %), communicate with health care providers (92 %), track medical information (83 %), track medications (77 %), and support decision-making about treatment (55 %). Three themes emerged to guide eHealth technology development: (1) Patients with MCCs manage a high volume of information, visits, and self-care tasks; (2) they need to coordinate, synthesize, and reconcile health information from multiple providers and about different conditions; (3) their unique position at the hub of multiple health issues requires self-advocacy and expertise. Focus groups identified desirable eHealth resources and tools that reflect these themes.Although patients with multiple health issues use eHealth technology to support self-care for specific conditions, they also desire tools that transcend disease boundaries. By addressing the holistic needs of patients with MCCs, eHealth technology can advance health care from a disease-centered to a patient-centered model.

    View details for DOI 10.1007/s11606-015-3222-9

    View details for Web of Science ID 000358359400012

    View details for PubMedCentralID PMC4510242

  • Implementing Computerized Provider Order Entry in Acute Care Hospitals in the United States Could Generate Substantial Savings to Society. Joint Commission journal on quality and patient safety / Joint Commission Resources Nuckols, T. K., Asch, S. M., Patel, V., Keeler, E., Anderson, L., Buntin, M. B., Escarce, J. J. 2015; 41 (8): 341-350


    Computerized provider order entry (CPOE) with clinical decision support is a basic criterion for hospitals' meaningful use of electronic health record systems. A study was conducted to evaluate from the societal perspective the cost-utility of implementing CPOE in acute care hospitals in the United States.A decision-analytical model compared CPOE with paper ordering among patients admitted to acute care hospitals with >25 beds. Parameters included start-up and maintenance costs, as well as costs for provider time use, medication and laboratory test ordering, and preventable adverse drug events. Probabilistic analyses produced incremental costs, effectiveness, and cost-effectiveness ratios for hospitals in four bed-size categories (25-72, 72-141, 141-267, 267-2,249).Relative to paper ordering and using typical estimates of implementation costs, CPOE had, on average, >99% probability of yielding savings to society and improving health. Per hospital in each size category, mean life-time savings -in millions-were $11.6 (standard deviation, $9.30), $34.4 ($21.2), $71.8 ($43.8), and $170 ($119) (2012 dollars), respectively, and quality-adjusted life-years (QALYs) gained were 19.9 (16.9), 53.7 (38.7), 109 (79.6), and 249 (205). Incremental effectiveness and costs were less favorable in certain circumstances, such as high implementation costs. Nationwide, anticipated increases in CPOE implementation from 2009 through 2015 could save $133 billion and 201,000 QALYs.In addition to improving health, implementing CPOE with clinical decision support could yield substantial long-term savings to society in the United States, although results for individual hospitals are likely to vary.

    View details for PubMedID 26215523

  • A Qualitative Evaluation of Web-Based Cancer Care Quality Improvement Toolkit Use in the Veterans Health Administration QUALITY MANAGEMENT IN HEALTH CARE Bowman, C., Luck, J., Gale, R. C., Smith, N., York, L. S., Asch, S. 2015; 24 (3): 147-161


    Disease severity, complexity, and patient burden highlight cancer care as a target for quality improvement (QI) interventions. The Veterans Health Administration (VHA) implemented a series of disease-specific online cancer care QI toolkits.To describe characteristics of the toolkits, target users, and VHA cancer care facilities that influenced toolkit access and use and assess whether such resources were beneficial for users.Deductive content analysis of detailed notes from 94 telephone interviews with individuals from 48 VHA facilities. We evaluated toolkit access and use across cancer types, participation in learning collaboratives, and affiliation with VHA cancer care facilities.The presence of champions was identified as a strong facilitator of toolkit use, and learning collaboratives were important for spreading information about toolkit availability. Identified barriers included lack of personnel and financial resources and complicated approval processes to support tool use.Online cancer care toolkits are well received across cancer specialties and provider types. Clinicians, administrators, and QI staff may benefit from the availability of toolkits as they become more reliant on rapid access to strategies that support comprehensive delivery of evidence-based care. Toolkits should be considered as a complement to other QI approaches.

    View details for DOI 10.1097/QMH.0000000000000063

    View details for PubMedID 26115063

  • Examining the Specification Validity of the HEDIS Quality Measures for Substance Use Disorders JOURNAL OF SUBSTANCE ABUSE TREATMENT Harris, A. H., Ellerbe, L., Phelps, T. E., Finney, J. W., Bowe, T., Gupta, S., Asch, S. M., Humphreys, K., Trafton, J. 2015; 53: 16-21


    Accurate operationalization is a major challenge in developing quality measures for substance use disorder treatment. Specification validity is a term used to describe whether a quality measure is operationalized such that it captures the intended care processes and patients. This study assessed the specification validity of the 2009 Healthcare Effectiveness Data and Information Set (HEDIS®) substance use disorder initiation and engagement measures by examining whether encounters assumed to include relevant treatment have corroborating evidence in the clinical progress notes. The positive predictive values were excellent (>90%) for residential and outpatient records selected from addiction treatment programs but more modest for records generated in non-addiction settings, and were highly variable across facilities. Stakeholders using these measures to compare care quality should be mindful of the clinical composition of the data and determine if similar validation work has been conducted on the systems being evaluated.

    View details for DOI 10.1016/j.jsat.2015.01.002

    View details for Web of Science ID 000354505900003

    View details for PubMedID 25736624

  • Uptake and utilization of directly acting antiviral medications for hepatitis C infection in US veterans JOURNAL OF VIRAL HEPATITIS Gidwani, R., Barnett, P. G., Goldhaber-Fiebert, J. D., Asch, S. M., Lo, J., Dally, S. K., Owens, D. K. 2015; 22 (5): 489-495


    New drugs therapies have revolutionized the treatment of hepatitis C virus (HCV) infection. The objectives of this study were to evaluate uptake and utilization of boceprevir and telaprevir in the Department of Veterans Affairs (VA). We evaluated whether therapies conformed to response-guided protocols, whether they replaced standard interferon plus ribavirin treatment, and whether IL-28B was used to guide treatment. We performed an administrative data-based analysis of all patients receiving pharmacologic treatment for HCV in VA from October 2009 to July 2013. There were 12 737 new HCV prescriptions in VA during this time, with 5564 boceprevir or telaprevir prescriptions (44%) and 7173 prescriptions (56%) written for standard interferon plus ribavirin treatment. Prescriptions for the new treatments heavily favoured boceprevir vs telaprevir (83% vs 17%). Sixty-two percent (62%) of boceprevir-treated patients completed their minimum-specified protocol, while 69.2% of telaprevir-treated patients completed their minimum-specified protocol. From October 2010 to July 2012, 4090 patients had an IL-28B test; less than 16% of these tests guided subsequent HCV prescriptions. Uptake of boceprevir and telaprevir was rapid; the number of patients initiating treatment approximately doubled in the period after their introduction. While new prescriptions favor boceprevir or telaprevir over standard interferon plus ribavirin therapy, there appears to still be a strong role of interferon plus ribavirin in treating HCV patients. This work can inform our understanding of how other new effective HCV therapies will be used, their diffusion, and the timing of their diffusion in actual clinical practice.

    View details for DOI 10.1111/jvh.12344

    View details for PubMedID 25417805

  • Intended and unintended effects of large-scale adverse event disclosure: a controlled before-after analysis of five large-scale notifications BMJ QUALITY & SAFETY Wagner, T. H., Taylor, T., Cowgill, E., Asch, S. M., Su, P., Bokhour, B., Durfee, J., Martinello, R. A., Maguire, E., Elwy, A. R. 2015; 24 (5): 295-302


    How patients respond to being notified of a large-scale adverse event (LSAE), such as improper sterilisation of medical equipment that exposes them to bloodborne pathogens, is not well known. The objective of this study was to determine, using administrative data, the intended and unintended consequences of patient notification following a LSAE.We examined five LSAEs where patients may have been inadvertently exposed to hepatitis C virus (HCV), HIV, and hepatitis B virus (HBV). A total of 9638 cases were identified at five Department of Veteran Affairs (VA) medical facilities between 2009 and 2012. We identified controls at the same facility prior to the exposure period and at neighbouring facilities (n=45 274). Difference-in-differences models were used with Veterans Health Administration (VHA) and Medicare data to examine infectious disease testing rates and subsequent utilisation patterns.Receipt of a LSAE notification was associated with a 73.2, 76.8 and 77.1 adjusted percentage point increase for HCV, HIV and HBV testing, respectively (all p<0.001). Compared with white patients, African-American patients were significantly less likely to return to VHA for follow-up testing. Patients exposed to a dental LSAE reduced their use of preventive and restorative dental care over the subsequent year, but they eventually came back to VHA for dental services 18-months post exposure.The majority of patients notified of a LSAE responded by getting tested for HCV, HIV and HBV, although there remains room for improvement. Potential exposure to a LSAE was associated with increased odds of subsequently using non-VA facilities, but the size and timing of the shift depended on the type of care.

    View details for DOI 10.1136/bmjqs-2014-003800

    View details for Web of Science ID 000353038100002

    View details for PubMedID 25882785

  • Implementing a user-driven online quality improvement toolkit for cancer care. Journal of oncology practice / American Society of Clinical Oncology Luck, J., York, L. S., Bowman, C., Gale, R. C., Smith, N., Asch, S. M. 2015; 11 (3): e421-7


    Peer-to-peer collaboration within integrated health systems requires a mechanism for sharing quality improvement lessons. The Veterans Health Administration (VA) developed online compendia of tools linked to specific cancer quality indicators. We evaluated awareness and use of the toolkits, variation across facilities, impact of social marketing, and factors influencing toolkit use.A diffusion of innovations conceptual framework guided the collection of user activity data from the Toolkit Series SharePoint site and an online survey of potential Lung Cancer Care Toolkit users.The VA Toolkit Series site had 5,088 unique visitors in its first 22 months; 5% of users accounted for 40% of page views. Social marketing communications were correlated with site usage. Of survey respondents (n = 355), 54% had visited the site, of whom 24% downloaded at least one tool. Respondents' awareness of the lung cancer quality performance of their facility, and facility participation in quality improvement collaboratives, were positively associated with Toolkit Series site use. Facility-level lung cancer tool implementation varied widely across tool types.The VA Toolkit Series achieved widespread use and a high degree of user engagement, although use varied widely across facilities. The most active users were aware of and active in cancer care quality improvement. Toolkit use seemed to be reinforced by other quality improvement activities. A combination of user-driven tool creation and centralized toolkit development seemed to be effective for leveraging health information technology to spread disease-specific quality improvement tools within an integrated health care system.

    View details for DOI 10.1200/JOP.2014.003012

    View details for PubMedID 25852141

  • The most used and most helpful facilitators for patient-centered medical home implementation IMPLEMENTATION SCIENCE Gale, R. C., Asch, S. M., Taylor, T., Nelson, K. M., Luck, J., Meredith, L. S., Helfrich, C. D. 2015; 10


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

    View details for DOI 10.1186/s13012-015-0246-9

    View details for PubMedID 25924611

  • Sex Differences in Mental Health and Substance Use Disorders and Treatment Entry Among Justice-involved Veterans in the Veterans Health Administration. Medical care Finlay, A. K., Binswanger, I. A., Smelson, D., Sawh, L., McGuire, J., Rosenthal, J., Blue-Howells, J., Timko, C., Blodgett, J. C., Harris, A. H., Asch, S. M., Frayne, S. 2015; 53 (4): S105-11


    Over half of veterans in the criminal justice system have mental health or substance use disorders. However, there is a critical lack of information about female veterans in the criminal justice system and how diagnosis prevalence and treatment entry differ by sex.To document prevalence of mental health and substance use disorder diagnoses and treatment entry rates among female veterans compared with male veterans in the justice system.Retrospective cohort study using national Veterans Health Administration clinical/administrative data from veterans seen by Veterans Justice Outreach Specialists in fiscal years 2010-2012.A total of 1535 females and 30,478 male veterans were included.Demographic characteristics (eg, sex, age, residence, homeless status), mental health disorders (eg, depression, post-traumatic stress disorder), substance use disorders (eg, alcohol and opioid use disorders), and treatment entry (eg, outpatient, residential, pharmacotherapy).Among female veterans, prevalence of mental health and substance use disorders was 88% and 58%, respectively, compared with 76% and 72% among male veterans. Women had higher odds of being diagnosed with a mental health disorder [adjusted odds ratio (AOR)=1.98; 95% confidence interval (CI), 1.68-2.34] and lower odds of being diagnosed with a substance use disorder (AOR=0.50; 95% CI, 0.45-0.56) compared with men. Women had lower odds of entering mental health residential treatment (AOR=0.69; 95% CI, 0.57-0.83).Female veterans involved in the justice system have a high burden of mental health disorders (88%) and more than half have substance use disorders (58%). Entry to mental health residential treatment for women is an important quality improvement target.

    View details for DOI 10.1097/MLR.0000000000000271

    View details for PubMedID 25767963

  • Proactive Case Finding To Improve Concurrently Curative and Palliative Care in Patients with End-Stage Liver Disease JOURNAL OF PALLIATIVE MEDICINE Walling, A. M., Schreibeis-Baum, H., Pimstone, N., Asch, S. M., Robinson, L., Korlekar, S., Lorenz, K., Nwajuaku, T., Rosenfeld, K. 2015; 18 (4): 378-381


    Palliative care and preparation for liver transplantation are often perceived as conflicting for patients with end-stage liver disease (ESLD). We sought to improve both simultaneously through a case finding and care coordination quality improvement intervention.We identified patients with cirrhosis using validated ICD-9 codes and screened them for ESLD by assessing medical records at a VA hospital for either a model for end-stage liver disease (MELD) ≥14 or a diagnosis of hepatocellular carcinoma (HCC) between October 2012 and January 2013. A care coordinator followed veterans from the index hospitalization through April 2013 and encouraged treating physicians to submit liver transplant evaluation consults for all veterans with a MELD ≥14 and palliative care consults for all veterans with a MELD ≥20 or inoperable HCC.We compared rates of consultation for 49 hospitalized veterans and compared their outcomes to 61 pre-intervention veterans. Veterans were more likely to be considered for liver transplantation (77.6% versus 31.1%, p<0.001) and receive palliative care consultation during the intervention period, although the latter finding did not reach statistical significance (62.5% versus 47.1%, p=0.38).Active case finding improved consideration for liver transplantation without decreasing palliative care consultation.

    View details for DOI 10.1089/jpm.2014.0265

    View details for Web of Science ID 000351274500013

    View details for PubMedID 25493552

    View details for PubMedCentralID PMC4367526

  • The role of evidence and context for implementing a multimodal intervention to increase HIV testing IMPLEMENTATION SCIENCE Bokhour, B. G., Saifu, H., Goetz, M. B., Fix, G. M., Burgess, J., Fletcher, M. D., Knapp, H., Asch, S. M. 2015; 10


    Increasing the use of routine preventive care such as HIV testing is important, yet implementation of such evidence-based clinical care is complex. The Promoting Action on Research Implementation in Health Services (PARiHS) model for implementation posits that implementation will be most successful when the evidence, context, and facilitation strategies are strong for the clinical practice. We evaluated the relative importance of perceived evidence, context, and facilitation of HIV testing during the implementation of a multimodal intervention in US Department of Veterans Affairs primary care clinics.A multimodal intervention including clinical reminders (CRs), academic detailing-providing education sessions for providers-and social marketing to improve HIV testing was implemented in 15 VA primary care clinics in three regions. We conducted qualitative formative and process evaluations using semi-structured interviews with HIV lead clinicians, primary care lead clinicians, nurse managers, and social workers. Interviews were analyzed thematically to identify barriers and facilitators to implementation of HIV testing and how these were addressed by the intervention. Sites were then rated high, medium, or low on the dimensions of perceived evidence and the context for testing. We then assessed the relationship of these ratings to improvements in HIV testing rates found in earlier quantitative analyses.Sites that showed greatest improvements in HIV testing rates also rated high on evidence and context. Conversely, sites that demonstrated the poorest improvements in testing rates rated low on both dimensions. Perceptions of evidence and several contextual aspects resulted in both barriers and facilitators to implementing testing. Evidence barriers included provider perceptions of evidence for routine testing as irrelevant to their population. Contextual barriers included clinical reminder overload, insufficient resources, onerous consent processes, stigma, provider discomfort, and concerns about linking individuals who test positive to HIV treatment. While most barriers were ameliorated by the intervention, HIV stigma in particular regions and concerns about linkage to care persisted.Interventions to implement evidence-based practices such as HIV testing can be successful when utilizing proven quality improvement techniques. However, it is critical to address providers' perceptions of evidence and consider aspects of the local context in order to fully implement new routine clinical practices such as HIV testing.

    View details for DOI 10.1186/s13012-015-0214-4

    View details for Web of Science ID 000350259700001

    View details for PubMedCentralID PMC4333886

  • Treating age-related macular degeneration: comparing the use of two drugs among medicare and veterans affairs populations. Health affairs Pershing, S., Pal Chee, C., Asch, S. M., Baker, L. C., Boothroyd, D., Wagner, T. H., Bundorf, M. K. 2015; 34 (2): 229-238


    While new biologics have revolutionized the treatment of age-related macular degeneration-the leading cause of severe vision loss among older adults-these new drugs have also raised concerns over the economic impact of medical innovation. The two leading agents are similar in effectiveness but vary greatly in price-up to $2,000 per injection for ranibizumab compared to $50 for bevacizumab. We examined the diffusion of these drugs in fee-for-service Medicare and Veterans Affairs (VA) systems during 2005-11, in part to assess the impact that differing financial incentives had on prescribing. Physicians treating Medicare patients have a direct financial incentive to prescribe the more expensive agent (ranibizumab), while VA physicians do not. Medicare injections of the more expensive ranibizumab peaked in 2007 at 47 percent. Beginning in 2009 the less expensive bevacizumab became the predominant therapy for Medicare patients, accounting for more than 60 percent of injections. For VA patients, the distribution of injections across the two drugs was relatively equal, particularly from 2009 to 2011. Our analysis indicates that there are opportunities in both the VA and Medicare to adopt more value-conscious treatment patterns and that multiple mechanisms exist to influence utilization.

    View details for DOI 10.1377/hlthaff.2014.1032

    View details for PubMedID 25646102

  • Prevalence of mental health disorders among justice-involved veterans. Epidemiologic reviews Blodgett, J. C., Avoundjian, T., Finlay, A. K., Rosenthal, J., Asch, S. M., Maisel, N. C., Midboe, A. M. 2015; 37 (1): 163-176


    Justice-involved veterans are a special population with unique mental health needs compared with other veterans or justice-involved adults. Prevalence estimates of mental health concerns of justice-involved veterans across 18 samples of these veterans (1987-2013), including both incarcerated and community samples, were identified through a systematic literature search of published studies supplemented by Department of Veterans Affairs Veterans Justice Programs data. Despite heterogeneity across samples and measures used, the review highlights several prominent mental health concerns among veterans. Many justice-involved veterans have likely experienced at least one traumatic event, and many have post-traumatic stress disorder (prevalence from 4% to 39% across samples). At least half of justice-involved veterans have an alcohol and/or drug use disorder (estimates as high as 71% and 65%, respectively), and other psychiatric disorders, such as depression (14%-51%) and psychotic disorders (4%-14%), are common. Justice-involved veterans with comorbid substance use and psychiatric disorders are at increased risk of negative outcomes, including homelessness and violent behavior. Overall, comparisons of justice-involved veterans with other justice-involved adults found a slightly higher rate of mental health concerns among justice-involved veterans, with some indication that intravenous drug use is more prevalent. Compared with other veterans, justice-involved veterans have consistently higher rates of mental health concerns, particularly substance use disorders.

    View details for DOI 10.1093/epirev/mxu003

    View details for PubMedID 25600416

  • Predictive validity of two process-of-care quality measures for residential substance use disorder treatment. Addiction science & clinical practice Harris, A. H., Gupta, S., Bowe, T., Ellerbe, L. S., Phelps, T. E., Rubinsky, A. D., Finney, J. W., Asch, S. M., Humphreys, K., Trafton, J. 2015; 10: 22-?


    In order to monitor and ultimately improve the quality of addiction treatment, professional societies, health care systems, and addiction treatment programs must establish clinical practice standards and then operationalize these standards into reliable, valid, and feasible quality measures. Before being implemented, quality measures should undergo tests of validity, including predictive validity. Predictive validity refers to the association between process-of-care quality measures and subsequent patient outcomes. This study evaluated the predictive validity of two process quality measures of residential substance use disorder (SUD) treatment.Washington Circle (WC) Continuity of Care quality measure is the proportion of patients having an outpatient SUD treatment encounter within 14 days after discharge from residential SUD treatment. The Early Discharge measure is the proportion of patients admitted to residential SUD treatment who discharged within 1 week of admission. The predictive validity of these process measures was evaluated in US Veterans Health Administration patients for whom utilization-based outcome and 2-year mortality data were available. Propensity score-weighted, mixed effects regression adjusted for pre-index imbalances between patients who did and did not meet the measures' criteria and clustering of patients within facilities.For the WC Continuity of Care measure, 76 % of 10,064 patients had a follow-up visit within 14 days of discharge. In propensity score-weighted models, patients who had a follow-up visit had a lower 2-year mortality rate [odds ratio (OR) = 0.77, p = 0.008], but no difference in subsequent detoxification episodes relative to patients without a follow-up visit. For the Early Discharge measure, 9.6 % of 10,176 discharged early and had significantly higher 2-year mortality (OR = 1.49, p < 0.001) and more subsequent detoxification episodes.These two measures of residential SUD treatment quality have strong associations with 2-year mortality and the Early Discharge measure is also associated with more subsequent detoxification episodes. These results provide initial support for the predictive validity of residential SUD treatment quality measures and represent the first time that any SUD quality measure has been shown to predict subsequent mortality.

    View details for DOI 10.1186/s13722-015-0042-5

    View details for PubMedID 26520402

    View details for PubMedCentralID PMC4672518

  • Using lean management to reduce blood culture contamination. Joint Commission journal on quality and patient safety / Joint Commission Resources Sinnott, P. L., Breckenridge, J. S., Helgerson, P., Asch, S. 2015; 41 (1): 26-22


    Blood culture contamination (BCC) is a common and avoidable complication of patient care and incurs considerable cost. A quality improvement (QI) initiative was undertaken at a large Department of Veterans Affairs (VA) medical center to reduce the BCC rate.Lean management QI methods, including a rapid process improvement workshop (RPIW), were used to identify root causes of variation in blood culture procedures and countermeasures (potential improvement strategies) to address each problem were developed. BCC rates were collected for five and one quarter years, including the pre-RPIW (baseline) period, and changes in the contamination rates were calculated. The observed change in BCC rates was compared to a forecast of the pre-RPIW trend and estimated BCCs avoided. Results for the primary medical center were compared with those of a similarly complex VA medical center during the same time periods using difference-in-differences methodology.Qualitative assessment of the processes of care identified four root cause problems, each of which was addressed with countermeasures. The BCC rate at the primary medical center decreased significantly from the baseline period in each year of follow-up, improving from 4.2% in the 19-month baseline period to 2.8% in the last 12 months of follow-up (April 2013-March 2014), while changes from baseline in the BCC rate at the comparison site were significant in only one year of follow-up. An estimated 261 BCCs were avoided at the primary medical center in the follow-up period.The QI initiative was successful in reducing BCC rates and in producing continued improvement for nearly four years of follow-up. Further study will determine if these results are generalizable to other settings.

    View details for PubMedID 25976721

  • Multimorbidity and healthcare utilisation among high-cost patients in the US Veterans Affairs Health Care System. BMJ open Zulman, D. M., Pal Chee, C., Wagner, T. H., Yoon, J., Cohen, D. M., Holmes, T. H., Ritchie, C., Asch, S. M. 2015; 5 (4)


    To investigate the relationship between multimorbidity and healthcare utilisation patterns among the highest cost patients in a large, integrated healthcare system.In this retrospective cross-sectional study of all patients in the U.S. Veterans Affairs (VA) Health Care System, we aggregated costs of individuals' outpatient and inpatient care, pharmacy services and VA-sponsored contract care received in 2010. We assessed chronic condition prevalence, multimorbidity as measured by comorbidity count, and multisystem multimorbidity (number of body systems affected by chronic conditions) among the 5% highest cost patients. Using multivariate regression, we examined the association between multimorbidity and healthcare utilisation and costs, adjusting for age, sex, race/ethnicity, marital status, homelessness and health insurance status.USA VA Health Care System.5.2 million VA patients.Annual total costs; absolute and share of costs generated through outpatient, inpatient, pharmacy and VA-sponsored contract care; number of visits to primary, specialty and mental healthcare; number of emergency department visits and hospitalisations.The 5% highest cost patients (n=261 699) accounted for 47% of total VA costs. Approximately two-thirds of these patients had chronic conditions affecting ≥3 body systems. Patients with cancer and schizophrenia were less likely to have documented comorbid conditions than other high-cost patients. Multimorbidity was generally associated with greater outpatient and inpatient utilisation. However, increased multisystem multimorbidity was associated with a higher outpatient share of total costs (1.6 percentage points per affected body system, p<0.01) but a lower inpatient share of total costs (-0.6 percentage points per affected body system, p<0.01).Multisystem multimorbidity is common among high-cost VA patients. While some patients might benefit from disease-specific programmes, for most patients with multimorbidity there is a need for interventions that coordinate and maximise efficiency of outpatient services across multiple conditions.

    View details for DOI 10.1136/bmjopen-2015-007771

    View details for PubMedID 25882486

    View details for PubMedCentralID PMC4401870

  • Using a Clinical Knowledge Base to Assess Comorbidity Interrelatedness Among Patients with Multiple Chronic Conditions. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium Zulman, D. M., Martins, S. B., Liu, Y., Tu, S. W., Hoffman, B. B., Asch, S. M., Goldstein, M. K. 2015; 2015: 1381-1389


    Decision support tools increasingly integrate clinical knowledge such as medication indications and contraindications with electronic health record (EHR) data to support clinical care and patient safety. The availability of this encoded information and patient data provides an opportunity to develop measures of clinical decision complexity that may be of value for quality improvement and research efforts. We investigated the feasibility of using encoded clinical knowledge and EHR data to develop a measure of comorbidity interrelatedness (the degree to which patients' co-occurring conditions interact to generate clinical complexity). Using a common clinical scenario-decisions about blood pressure medications in patients with hypertension-we quantified comorbidity interrelatedness by calculating the number of indications and contraindications to blood pressure medications that are generated by patients' comorbidities (e.g., diabetes, gout, depression). We examined properties of comorbidity interrelatedness using data from a decision support system for hypertension in the Veterans Affairs Health Care System.

    View details for PubMedID 26958279

  • Posttraumatic Stress Disorder and Risk of Spontaneous Preterm Birth OBSTETRICS AND GYNECOLOGY Shaw, J. G., Asch, S. M., Kimerling, R., Frayne, S. M., Shaw, K. A., Phibbs, C. S. 2014; 124 (6): 1111-1119


    To evaluate the association between antenatal posttraumatic stress disorder (PTSD) and spontaneous preterm delivery.We identified antenatal PTSD status and spontaneous preterm delivery in a retrospective cohort of 16,334 deliveries covered by the Veterans Health Administration from 2000 to 2012. We divided mothers with PTSD into those with diagnoses present the year before delivery (active PTSD) and those only with earlier diagnoses (historical PTSD). We identified spontaneous preterm birth and potential confounders including age, race, military deployment, twins, hypertension, substance use, depression, and results of military sexual trauma screening and then performed multivariate regression to estimate adjusted odds ratio (OR) of spontaneous preterm delivery as a function of PTSD status.Of 16,334 births, 3,049 (19%) were to mothers with PTSD diagnoses, of whom 1,921 (12%) had active PTSD. Spontaneous preterm delivery was higher in those with active PTSD (9.2%, n=176) than those with historical (8.0%, n=90) or no PTSD (7.4%, n=982) before adjustment (P=.02). The association between PTSD and preterm birth persisted, when adjusting for covariates, only in those with active PTSD (adjusted OR 1.35, 95% confidence interval [CI] 1.14-1.61). Analyses adjusting for comorbid psychiatric and medical diagnoses revealed the association with active PTSD to be robust.In this cohort, containing an unprecedented number of PTSD-affected pregnancies, mothers with active PTSD were significantly more likely to suffer spontaneous preterm birth with an attributable two excess preterm births per 100 deliveries (95% CI 1-4). Posttraumatic stress disorder's health effects may extend, through birth outcomes, into the next generation.

    View details for DOI 10.1097/AOG.0000000000000542

    View details for Web of Science ID 000345341100008

  • Socioeconomic Inequalities in Quality of Care and Outcomes Among Patients With Acute Coronary Syndrome in the Modern Era of Drug Eluting Stents JOURNAL OF THE AMERICAN HEART ASSOCIATION Yong, C. M., Abnousi, F., Asch, S. M., Heidenreich, P. A. 2014; 3 (6)


    The rapidly changing landscape of percutaneous coronary intervention provides a unique model for examining disparities over time. Previous studies have not examined socioeconomic inequalities in the current era of drug eluting stents (DES).We analyzed 835 070 hospitalizations for acute coronary syndrome (ACS) from the Healthcare Cost and Utilization Project across all insurance types from 2008 to 2011, examining whether quality of care and outcomes for patients with ACS differed by income (based on zip code of residence) with adjustment for patient characteristics and clustering by hospital. We found that lower-income patients were less likely to receive an angiogram within 24 hours of a ST elevation myocardial infarction (STEMI) (69.5% for IQ1 versus 73.7% for IQ4, P<0.0001, OR 0.79 [0.68 to 0.91]) or within 48 hours of a Non-STEMI (47.6% for IQ1 versus 51.8% for IQ4, P<0.0001, OR 0.86 [0.75 to 0.99]). Lower income was associated with less use of a DES (64.7% for IQ1 versus 71.2% for IQ4, P<0.0001, OR 0.83 [0.74 to 0.93]). However, no differences were found for coronary artery bypass surgery. Among STEMI patients, lower-income patients also had slightly increased adjusted mortality rates (10.8% for IQ1 versus 9.4% for IQ4, P<0.0001, OR 1.17 [1.11 to 1.25]). After further adjusting for time to reperfusion among STEMI patients, mortality differences across income groups decreased.For the most well accepted procedural treatments for ACS, income inequalities have faded. However, such inequalities have persisted for DES use, a relatively expensive and until recently, controversial revascularization procedure. Differences in mortality are significantly associated with differences in time to primary PCI, suggesting an important target for understanding why these inequalities persist.

    View details for DOI 10.1161/JAHA.114.001029

    View details for Web of Science ID 000345067600027

    View details for PubMedID 25398888

    View details for PubMedCentralID PMC4338689

  • Improving Healthcare Systems' Disclosures of Large-Scale Adverse Events: A Department of Veterans Affairs Leadership, Policymaker, Research and Stakeholder Partnership JOURNAL OF GENERAL INTERNAL MEDICINE Elwy, A. R., Bokhour, B. G., Maguire, E. M., Wagner, T. H., Asch, S. M., Gifford, A. L., Gallagher, T. H., Durfee, J. M., Martinello, R. A., Schiffner, S., Jesse, R. L. 2014; 29: S895-S903


    The Department of Veterans Affairs (VA) mandates disclosure of large-scale adverse events to patients, even if risk of harm is not clearly present. Concerns about past disclosures warranted further examination of the impact of this policy.Through a collaborative partnership between VA leaders, policymakers, researchers and stakeholders, the objective was to empirically identify critical aspects of disclosure processes as a first step towards improving future disclosures.Semi-structured interviews were conducted with participants at nine VA facilities where recent disclosures took place.Ninety-seven stakeholders participated in the interviews: 38 employees, 28 leaders (from facilities, regions and national offices), 27 Veteran patients and family members, and four congressional staff members.Facility and regional leaders were interviewed by telephone, followed by a two-day site visit where employees, patients and family members were interviewed face-to-face. National leaders and congressional staff also completed telephone interviews. Interviews were analyzed using rapid qualitative assessment processes. Themes were mapped to the stages of the Crisis and Emergency Risk Communication model: pre-crisis, initial event, maintenance, resolution and evaluation.Many areas for improvement during disclosure were identified, such as preparing facilities better (pre-crisis), creating rapid communications, modifying disclosure language, addressing perceptions of harm, reducing complexity, and seeking assistance from others (initial event), managing communication with other stakeholders (maintenance), minimizing effects on staff and improving trust (resolution), and addressing facilities' needs (evaluation).Through the partnership, five recommendations to improve disclosures during each stage of communication have been widely disseminated throughout the VA using non-academic strategies. Some improvements have been made; other recommendations will be addressed through implementation of a large-scale adverse event disclosure toolkit. These toolkit strategies will enable leaders to provide timely and transparent information to patients and families, while reducing the burden on employees and the healthcare system during these events.

    View details for DOI 10.1007/s11606-014-3034-3

    View details for Web of Science ID 000345410200014

    View details for PubMedCentralID PMC4239293

  • Building Strong Research Partnerships Between Public Health and Researchers: A VA Case Study JOURNAL OF GENERAL INTERNAL MEDICINE Midboe, A. M., Elwy, A. R., Durfee, J. M., Gifford, A. L., Yakovchenko, V., Martinello, R. A., Ross, D., Czarnogorski, M., Goetz, M. B., Asch, S. M. 2014; 29: S831-S834


    We are in a new era of partner-based implementation research, and we need clear strategies for how to navigate this new era. Drawing on principles from community-based participatory research, the Clinical Public Health group of the Department of Veterans Affairs and the HIV/Hepatitis Quality Enhancement Research Initiative (HHQUERI) forged a longstanding partnership that has improved the care of Veterans with Human Immunodeficiency Virus (HIV) and Hepatitis C Virus. An exemplar HIV testing project epitomizes this partnership and is discussed in terms of the lessons learned as a result of our high level of collaboration around design, analysis, implementation, and dissemination across projects over the past several years. Lessons learned through this partnered testing program involve respecting different time horizons among the partners, identifying relevant research questions for both parties, designing flexible studies, engaging all partners throughout the research, and placing an emphasis on relationship building at all times. These lessons and strategies can benefit others conducting partner-based research both within the Veterans Health Administration (VA) and in other integrated healthcare systems.

    View details for DOI 10.1007/s11606-014-3017-4

    View details for Web of Science ID 000345410200006

    View details for PubMedCentralID PMC4239290

  • Partnered Research in Healthcare Delivery Redesign for High-Need, High-Cost Patients: Development and Feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT) JOURNAL OF GENERAL INTERNAL MEDICINE Zulman, D. M., Ezeji-Okoye, S. C., Shaw, J. G., Hummel, D. L., Holloway, K. S., Smither, S. F., Breland, J. Y., Chardos, J. F., Kirsh, S., Kahn, J. S., Asch, S. M. 2014; 29: S861-S869


    We employed a partnered research healthcare delivery redesign process to improve care for high-need, high-cost (HNHC) patients within the Veterans Affairs (VA) healthcare system.Health services researchers partnered with VA national and Palo Alto facility leadership and clinicians to: 1) analyze characteristics and utilization patterns of HNHC patients, 2) synthesize evidence about intensive management programs for HNHC patients, 3) conduct needs-assessment interviews with HNHC patients (n = 17) across medical, access, social, and mental health domains, 4) survey providers (n = 8) about care challenges for HNHC patients, and 5) design, implement, and evaluate a pilot Intensive Management Patient-Aligned Care Team (ImPACT) for a random sample of 150 patients.HNHC patients accounted for over half (52 %) of VA facility patient costs. Most (94 %) had three or more chronic conditions, and 60 % had a mental health diagnosis. Formative data analyses and qualitative assessments revealed a need for intensive case management, care coordination, transitions navigation, and social support and services. The ImPACT multidisciplinary team developed care processes to meet these needs, including direct access to team members (including after-hours), chronic disease management protocols, case management, and rapid interventions in response to health changes or acute service use. Two-thirds of invited patients (n = 101) enrolled in ImPACT, 87 % of whom remained actively engaged at 9 months. ImPACT is now serving as a model for a national VA intensive management demonstration project.Partnered research that incorporated population data analysis, evidence synthesis, and stakeholder needs assessments led to the successful redesign and implementation of services for HNHC patients. The rigorous design process and evaluation facilitated dissemination of the intervention within the VA healthcare system.Employing partnered research to redesign care for high-need, high-cost patients may expedite development and dissemination of high-value, cost-saving interventions.

    View details for DOI 10.1007/s11606-014-3022-7

    View details for Web of Science ID 000345410200010

    View details for PubMedCentralID PMC4239286

  • Quality of supportive care for patients with advanced lung cancer in the Veterans Health Administration JOURNAL OF COMMUNITY AND SUPPORTIVE ONCOLOGY Oishi, S. M., Antonio, A. M., Ryoo, J., Ordin, D. L., Lorenz, K. A., He, R., Asch, S. M., Kim, B., Malin, J. 2014; 12 (10): 361–69

    View details for DOI 10.12788/jcso.0079

    View details for Web of Science ID 000422390900004

  • Retaining Homeless Veterans in Outpatient Care: A Pilot Study of Mobile Phone Text Message Appointment Reminders AMERICAN JOURNAL OF PUBLIC HEALTH McInnes, D. K., Petrakis, B. A., Gifford, A. L., Rao, S. R., Houston, T. K., Asch, S. M., O'Toole, T. P. 2014; 104: S588-S594


    We examined the feasibility of using mobile phone text messaging with homeless veterans to increase their engagement in care and reduce appointment no-shows.We sent 2 text message reminders to participants (n = 20) before each of their outpatient appointments at an urban Veterans Affairs medical center. Evaluation included pre- and postsurvey questionnaires, open-ended questions, and review of medical records. We estimated costs and savings of large-scale implementation.Participants were satisfied with the text-messaging intervention, had very few technical difficulties, and were interested in continuing. Patient-cancelled visits and no-shows trended downward from 53 to 37 and from 31 to 25, respectively. Participants also experienced a statistically significant reduction in emergency department visits, from 15 to 5 (difference of 10; 95% confidence interval [CI]  = 2.2, 17.8; P = .01), and a borderline significant reduction in hospitalizations, from 3 to 0 (difference of 3; 95% CI = -0.4, 6.4; P = .08).Text message reminders are a feasible means of reaching homeless veterans, and users consider it acceptable and useful. Implementation may reduce missed visits and emergency department use, and thus produce substantial cost savings.

    View details for DOI 10.2105/AJPH.2014.302061

    View details for Web of Science ID 000341363000018

    View details for PubMedID 25100425

  • Effect of electronic prescribing with formulary decision support on medication tier, copayments, and adherence BMC MEDICAL INFORMATICS AND DECISION MAKING Pevnick, J. M., Li, N., Asch, S. M., Jackevicius, C. A., Bell, D. S. 2014; 14


    Medication non-adherence is prevalent. We assessed the effect of electronic prescribing (e-prescribing) with formulary decision support on preferred formulary tier usage, copayment, and concomitant adherence.We retrospectively analyzed 14,682 initial pharmaceutical claims for angiotensin receptor blocker and inhaled steroid medications among 14,410 patients of 2189 primary care physicians (PCPs) who were offered e-prescribing with formulary decision support, including 297 PCPs who adopted it. Formulary decision support was initially non-interruptive, such that formulary tier symbols were displayed adjacent to medication names. Subsequently, interruptive formulary decision support alerts also interrupted e-prescribing when preferred-tier alternatives were available. A difference in differences design was used to compare the pre-post differences in medication tier for each new prescription attributed to non-adopters, low user (<30% usage rate), and high user PCPs (>30% usage rate). Second, we modeled the effect of formulary tier on prescription copayment. Last, we modeled the effect of copayment on adherence (proportion of days covered) to each new medication.Compared with non-adopters, high users of e-prescribing were more likely to prescribe preferred-tier medications (vs. non-preferred tier) when both non-interruptive and interruptive formulary decision support were in place (OR 1.9 [95% CI 1.0-3.4], p = 0.04), but no more likely to prescribe preferred-tier when only non-interruptive formulary decision support was in place (p = 0.90). Preferred-tier claims had only slightly lower mean monthly copayments than non-preferred tier claims (angiotensin receptor blocker: $10.60 versus $11.81, inhaled steroid: $14.86 versus $16.42, p < 0.0001). Medication possession ratio was 8% lower for each $1.00 increase in monthly copayment to the one quarter power (p < 0.0001). However, we detected no significant direct association between formulary decision support usage and adherence.Interruptive formulary decision support shifted prescribing toward preferred tiers, but these medications were only minimally less expensive in the studied patient population. In this context, formulary decision support did not significantly increase adherence. To impact cost-related non-adherence, formulary decision support will likely need to be paired with complementary drug benefit design. Formulary decision support should be studied further, with particular attention to its effect on adherence in the setting of different benefit designs.

    View details for DOI 10.1186/1472-6947-14-79

    View details for Web of Science ID 000344108600001

    View details for PubMedID 25167807

    View details for PubMedCentralID PMC4236533

  • Delivering PACT-Principled Care: Are Specialty Care Patients Being Left Behind? JOURNAL OF GENERAL INTERNAL MEDICINE Fix, G. M., Asch, S. M., Saifu, H. N., Fletcher, M. D., Gifford, A. L., Bokhour, B. G. 2014; 29: 695-702
  • Multimethod evaluation of the VA's peer-to-peer Toolkit for patient-centered medical home implementation. Journal of general internal medicine Luck, J., Bowman, C., York, L., Midboe, A., Taylor, T., Gale, R., Asch, S. 2014; 29: S572-8


    Effective implementation of the patient-centered medical home (PCMH) in primary care practices requires training and other resources, such as online toolkits, to share strategies and materials. The Veterans Health Administration (VA) developed an online Toolkit of user-sourced tools to support teams implementing its Patient Aligned Care Team (PACT) medical home model.To present findings from an evaluation of the PACT Toolkit, including use, variation across facilities, effect of social marketing, and factors influencing use.The Toolkit is an online repository of ready-to-use tools created by VA clinic staff that physicians, nurses, and other team members may share, download, and adopt in order to more effectively implement PCMH principles and improve local performance on VA metrics.Multimethod evaluation using: (1) website usage analytics, (2) an online survey of the PACT community of practice's use of the Toolkit, and (3) key informant interviews.Survey respondents were PACT team members and coaches (n = 544) at 136 VA facilities. Interview respondents were Toolkit users and non-users (n = 32).For survey data, multivariable logistic models were used to predict Toolkit awareness and use. Interviews and open-text survey comments were coded using a "common themes" framework. The Consolidated Framework for Implementation Research (CFIR) guided data collection and analyses.The Toolkit was used by 6,745 staff in the first 19 months of availability. Among members of the target audience, 80 % had heard of the Toolkit, and of those, 70 % had visited the website. Tools had been implemented at 65 % of facilities. Qualitative findings revealed a range of user perspectives from enthusiastic support to lack of sufficient time to browse the Toolkit.An online Toolkit to support PCMH implementation was used at VA facilities nationwide. Other complex health care organizations may benefit from adopting similar online peer-to-peer resource libraries.

    View details for DOI 10.1007/s11606-013-2738-0

    View details for PubMedID 24715401

  • The Quality of Care Provided to Patients With Varices in the Department of Veterans Affairs AMERICAN JOURNAL OF GASTROENTEROLOGY Buchanan, P. M., Kramer, J. R., El-Serag, H. B., Asch, S. M., Assioun, Y., Bacon, B. R., Kanwal, F. 2014; 109 (7): 934-940


    Practice guidelines define the criteria and standards of care in patients with cirrhosis and varices. However, the extent to which the patients receive recommended care is largely unknown. We evaluated the quality of varices related care and factors associated with receipt of such care.We conducted a retrospective cohort study of 550 patients with cirrhosis who sought care at three VA facilities between 2000 and 2007. Using administrative and clinical data, we assessed quality of varices care as measured by eight explicit Delphi panel-derived quality indicators. We also conducted a structured implicit review of patients' medical records to explore the role of patients' refusal, receipt of care outside the VA, or justifiable exclusions to certain care processes as explanations for non-adherence to the quality indicators.Quality scores (max. 100%) varied across individual indicators, ranging from 24.3% for upper endoscopy for varices screening to 72.4% for secondary prophylaxis for variceal bleeding. Justifiable exclusions to indicated care documented in charts were common for primary prophylaxis in patients with varices; receipt of endoscopy; and endoscopic treatment in patients with active bleeding. In contrast, significant shortfalls remained in the receipt of screening endoscopy, use of beta-blockers (in the absence of varices), and use of somatostatin analogs, antibiotics, and secondary prophylaxis in patients with variceal bleeding. Younger patients (<60 vs. >60 year, odds ratio (OR)=1.29, 95% confidence interval (CI) 1.01-1.68), those who saw a gastroenterologist (OR=1.55, 95% CI=1.09-2.21), or those who were seen in the facility with academic affiliation (OR=1.26, 95% CI=1.01-1.58) received higher quality care.Health-care quality, measured according to whether patients received recommended varices-related care, was suboptimal in this health-care setting. Care that included gastroenterologists was associated with high quality.

    View details for DOI 10.1038/ajg.2013.487

    View details for Web of Science ID 000344459100001

    View details for PubMedID 24989087

  • Using the Precaution Adoption Process model to describe a disaster preparedness intervention among low-income Latinos HEALTH EDUCATION RESEARCH Glik, D. C., Eisenman, D. P., Zhou, Q., Tseng, C., Asch, S. M. 2014; 29 (2): 272-283


    Only 40-50% of households in the United States are currently disaster prepared. In this intervention study, respondent-driven sampling was used to select a sample (n = 187) of low income, Latino residents of Los Angeles County, randomly assigned into two treatment conditions: (i) household preparedness education received through 'promotora' (community health worker) led small group meetings, and (ii) household preparedness education received through print media. Weinstein's Precaution Adoption Process, a stage model appropriate for risk communication guided the intervention. Outcomes are conceptualized as stages of decision making linked to having disaster supplies and creating a family communication plan. Quantitative results showed a significant shift over time from awareness to action and maintenance stages for disaster communication plans and supplies in both study arms; however, the shift in stage for a communication plan for those in the 'platica' study arm was (P < 0.0001) than for those in the media arm. For changes in stage linked to disaster supplies, people in both media and 'platica' study arms improved at the same rate. Simple media-based communications may be sufficient to encourage disadvantaged households to obtain disaster supplies; however, adoption of the more complex disaster family communication requires interpersonal education.

    View details for DOI 10.1093/her/cyt109

    View details for Web of Science ID 000333266100008

    View details for PubMedID 24399266

  • Facility Characteristics and Quality of Lung Cancer Care in an Integrated Health Care System JOURNAL OF THORACIC ONCOLOGY Ryoo, J. J., Malin, J. L., Ordin, D. L., Oishi, S. M., Kim, B., Asch, S. M., He, R., Gould, M. K. 2014; 9 (4): 447-455


    In a national, integrated health care system, we sought to identify facility-level attributes associated with better quality of lung cancer care.Adherence to 23 quality indicators across four domains (Diagnosis and Staging, Treatment, Supportive Care, End-of-Life Care) was assessed through abstraction of electronic records from 4804 lung cancer patients diagnosed in 2007 at 131 Veterans Health Administration facilities. Performance was reported as proportions of eligible patients fulfilling adherence criteria. With stratification of patients by stage, generalized estimating equations identified facility-level characteristics associated with performance by domain.Overall performance was high for the older (mean age 67.7 years, SD 9.4 years), predominantly male (98%) veterans. However, no facility did well on every measure, and range of adherence across facilities was large; 9% of facilities were in the highest quartile for one or more domain of care, more than 30% for two, and 65% for three. No facility performed consistently well across all domains. Less than 1% performed in the lowest quartile for all. Few facility-level characteristics were associated with care quality. For End-of-Life Care, diagnosis and treatment within the same facility, availability of cancer psychiatry/psychology consultation services, and availability of both inpatient and outpatient palliative care consultation services were associated with better adherence.Quality of Veterans Health Administration lung cancer care is generally high, though substantial variation exists across facilities. With the exception of the salutary impact of palliative care consultation services on end-of-life quality of care, observed facility-level characteristics did not consistently predict adherence to indicators, suggesting quality may be determined by complex local factors that are difficult to measure.

    View details for DOI 10.1097/JTO.0000000000000108

    View details for Web of Science ID 000333145300008

    View details for PubMedID 24736065

  • Developing an Informatics Tool To Advance Supportive Care: The Veterans Health Care Administration Palliative Care National Clinical Template JOURNAL OF PALLIATIVE MEDICINE Goebel, J. R., Ahluwalia, S. C., Chong, K., Shreve, S. T., Goldzweig, C. L., Austin, C., Asch, S. M., Lorenz, K. A. 2014; 17 (3): 266-273


    Increasing emphasis in performance-based payment, public reporting, and quality improvement (QI) has led to widespread interest in measuring and improving the quality of care. By 2014, hospice programs will be required to report quality data to the federal government or incur financial penalties. With this increased interest in quality reporting comes an opportunity to develop informatics tools to capture data that reflect the complex practices involved in palliative care (PC). Therefore, there is a need to disseminate information on developing tools that facilitate capturing data and fostering improved performance. The Veterans Health Care Administration, a national leader in health information technology (HIT) and PC, established the Quality Improvement Resource Center (QuIRC) to develop innovative HIT tools to standardize and improve PC practices throughout the 153 Department of Veterans Affairs (VA) medical centers nationwide.The aim of the paper is to describe the development of the Palliative Care-National Clinical Template (PC-NCT) for documenting initial PC consults.Domains of quality of life provided the foundation for this template. Principles of user-centered informatics design guided development activities. A national consensus panel of PC experts prioritized quality indicators as targets for QI. An interdisciplinary team of PC providers identified desired aspects of template functionality. QuIRC balanced PC providers' desired aspects of functionality against the feasibility within the VA HIT system. Formal pilot and usability testing contributed to numerous iterations of the PC-NCT currently piloted in five geographically distributed sites.This paper presents a robust approach to developing an informatics tool for PC practice. Data collected via the PC-NCT will bring variations in current practice into view and assist in directing resources at "important targets" for QI. Although the development of HIT tools to quantify PC practice is complex, there is enormous potential to improve the quality of care for patients and families facing serious illnesses.

    View details for DOI 10.1089/jpm.2013.0288

    View details for Web of Science ID 000337027700007

    View details for PubMedID 24548178

  • Impact of critical care medicine training programs' palliative care education and bedside tools on ICU use at the end of life. Journal of graduate medical education Saft, H. L., Richman, P. S., Berman, A. R., Mularski, R. A., Kvale, P. A., Ray, D. E., Selecky, P., Ford, D. W., Asch, S. M. 2014; 6 (1): 44-49


    Intensive care unit (ICU) use at the end of life is rising. Little research has focused on associations among critical care fellows' training, institutional support, and bedside tools with ICU use at the end of life.We evaluated whether hospital and critical care medicine program interventions were associated with ICU use in the last 6 months of life for patients with chronic illness.Our observational, retrospective study explored associations between results from a survey of critical care program directors and hospital-level Medicare data on ICU use in the last 6 months of life. Program directors evaluated quality of palliative care education in their critical care fellowships and reported on the number of bedside tools and the presence or absence of an inpatient palliative care consultation service.For the 89 hospitals and 71 affiliated training programs analyzed, there were statistically significant relationships between 2 of the explanatory variables-the quality of palliative care education and the number of bedside tools-in ICU use. Each level of increased educational quality (1-5 Likert scale) was associated with a 0.57-day decrease in ICU days, whereas, for each additional, evidence-based bedside tool, there was a 0.31-day decrease. The presence of an inpatient palliative care program was not a significant predictor of ICU use.We found that the quality of palliative care training in critical care medicine programs and the use of bedside tools were independently associated with reduced ICU use at the end of life.

    View details for DOI 10.4300/JGME-06-01-38

    View details for PubMedID 24701309

  • Quality of care for patients with multiple chronic conditions: the role of comorbidity interrelatedness. Journal of general internal medicine Zulman, D. M., Asch, S. M., Martins, S. B., Kerr, E. A., Hoffman, B. B., Goldstein, M. K. 2014; 29 (3): 529-537


    Multimorbidity-the presence of multiple chronic conditions in a patient-has a profound impact on health, health care utilization, and associated costs. Definitions of multimorbidity in clinical care and research have evolved over time, initially focusing on a patient's number of comorbidities and the associated magnitude of required care processes, and later recognizing the potential influence of comorbidity characteristics on patient care and outcomes. In this article, we review the relationship between multimorbidity and quality of care, and discuss how this relationship may be mediated by the degree to which conditions interact with one another to generate clinical complexity (comorbidity interrelatedness). Drawing on established theoretical frameworks from cognitive engineering and biomedical informatics, we describe how interactions among conditions result in clinical complexity and may affect quality of care. We discuss how this comorbidity interrelatedness influences the value of existing quality guidelines and performance metrics, and describe opportunities to quantify this construct using data widely available through electronic health records. Incorporating comorbidity interrelatedness into conceptualizations of multimorbidity has the potential to enhance clinical and research efforts that aim to improve care for patients with multiple chronic conditions.

    View details for DOI 10.1007/s11606-013-2616-9

    View details for PubMedID 24081443

  • Association Between Facility Characteristics and the Process of Care Delivered to Patients with Hepatitis C Virus Infection DIGESTIVE DISEASES AND SCIENCES Kanwal, F., Tuyen Hoang, T., Chrusciel, T., Kramer, J. R., El-Serag, H. B., Durfee, J., Dominitz, J. A., Yano, E. M., Asch, S. M. 2014; 59 (2): 273-281


    Available data suggest problems in the process of care provided to patients with chronic hepatitis C (HCV). However, the solutions to these problems are less obvious. Healthcare facility factors are potentially modifiable and may enhance process quality in HCV treatment.We evaluated the relationship between the process of HCV care and facility factors including number of weekly half-day HCV clinics per 1,000 HCV patients, HCV-specific quality-improvement initiatives, and administrative service of the HCV clinic (gastroenterology, infectious disease, primary care) for a cohort of 34,258 patients who sought care in 126 Veterans Affairs facilities during 2003-2006. We measured HCV care on the basis of 23 HCV-specific process measures capturing pretreatment (seven measures), preventive and/or comorbid (seven measures), and treatment and treatment monitoring care (nine measures).Patients seen at a facility with >8 half-day clinics were 52 % more likely to receive overall indicated care (OR 1.52, 95 % CI 1.13-2.05). Patients seen at a facility with >3 HCV quality improvement initiatives were more likely to receive better preventive and/or comorbid care (OR 1.32, 95 % CI 1.00-1.74). Compared with patients in facilities with no dedicated HCV clinic, patients at facilities with gastroenterology-based clinics received better pretreatment care (OR 1.36, 95 % CI 1.01-1.85) and more antiviral treatment (OR 1.45, 95 % CI 1.06-1.97) whereas those at facilities with infectious disease-based or primary care-based clinics received better preventive and/or comorbid care (OR 1.59, 95 % CI 1.06-2.39 and 1.84, 95 % CI 1.21-2.79 respectively).Several facility factors affected the process of HCV care. These factors may serve as targets for quality-improvement efforts.

    View details for DOI 10.1007/s10620-013-2773-z

    View details for Web of Science ID 000331651900008

  • The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Systematic reviews Nuckols, T. K., Smith-Spangler, C., Morton, S. C., Asch, S. M., Patel, V. M., Anderson, L. J., Deichsel, E. L., Shekelle, P. G. 2014; 3: 56-?


    The Health Information Technology for Economic and Clinical Health (HITECH) Act subsidizes implementation by hospitals of electronic health records with computerized provider order entry (CPOE), which may reduce patient injuries caused by medication errors (preventable adverse drug events, pADEs). Effects on pADEs have not been rigorously quantified, and effects on medication errors have been variable. The objectives of this analysis were to assess the effectiveness of CPOE at reducing pADEs in hospital-related settings, and examine reasons for heterogeneous effects on medication errors.Articles were identified using MEDLINE, Cochrane Library, Econlit, web-based databases, and bibliographies of previous systematic reviews (September 2013). Eligible studies compared CPOE with paper-order entry in acute care hospitals, and examined diverse pADEs or medication errors. Studies on children or with limited event-detection methods were excluded. Two investigators extracted data on events and factors potentially associated with effectiveness. We used random effects models to pool data.Sixteen studies addressing medication errors met pooling criteria; six also addressed pADEs. Thirteen studies used pre-post designs. Compared with paper-order entry, CPOE was associated with half as many pADEs (pooled risk ratio (RR) = 0.47, 95% CI 0.31 to 0.71) and medication errors (RR = 0.46, 95% CI 0.35 to 0.60). Regarding reasons for heterogeneous effects on medication errors, five intervention factors and two contextual factors were sufficiently reported to support subgroup analyses or meta-regression. Differences between commercial versus homegrown systems, presence and sophistication of clinical decision support, hospital-wide versus limited implementation, and US versus non-US studies were not significant, nor was timing of publication. Higher baseline rates of medication errors predicted greater reductions (P < 0.001). Other context and implementation variables were seldom reported.In hospital-related settings, implementing CPOE is associated with a greater than 50% decline in pADEs, although the studies used weak designs. Decreases in medication errors are similar and robust to variations in important aspects of intervention design and context. This suggests that CPOE implementation, as subsidized under the HITECH Act, may benefit public health. More detailed reporting of the context and process of implementation could shed light on factors associated with greater effectiveness.

    View details for DOI 10.1186/2046-4053-3-56

    View details for PubMedID 24894078

    View details for PubMedCentralID PMC4096499

  • Treatments for Recidivism Risk Among Justice-Involved Veterans JOURNAL OF OFFENDER REHABILITATION Timko, C., Midboe, A. M., Maisel, N. C., Blodgett, J. C., Asch, S. M., Rosenthal, J., Blonigen, D. M. 2014; 53 (8): 620–40
  • Impact of Rural Residence and Health System Structure on Quality of Liver Care PLOS ONE Rongey, C., Shen, H., Hamilton, N., Backus, L. I., Asch, S. M., Knight, S. 2013; 8 (12)


    Specialist physician concentration in urban areas can affect access and quality of care for rural patients. As effective drug treatment for hepatitis C (HCV) becomes increasingly available, the extent to which rural patients needing HCV specialists face access or quality deficits is unknown. We sought to determine the influence of rural residency on access to HCV specialists and quality of liver care.The study used a national cohort of 151,965 Veterans Health Administration (VHA) patients with HCV starting in 2005 and followed to 2009. The VHA's constant national benefit structure reduces the impact of insurance as an explanation for observed disparities. Multivariate cox proportion regression models for each quality indicator were performed.Thirty percent of VHA patients with HCV reside in rural and highly rural areas. Compared to urban residents, highly rural (HR 0.70, CI 0.65-0.75) and rural (HR 0.96, CI 0.94-0.97) residents were significantly less likely to access HCV specialty care. The quality indicators were more mixed. While rural residents were less likely to receive HIV screening, there were no significant differences in hepatitis vaccinations, endoscopic variceal and hepatocellular carcinoma screening between the geographic subgroups. Of note, highly rural (HR 1.31, CI 1.14-1.50) and rural residents (HR 1.06, CI 1.02-1.10) were more likely to receive HCV therapy. Of those treated for HCV, a third received therapy from a non-specialist provider.Rural patients have less access to HCV specialists, but this does not necessarily translate to quality deficits. The VHA's efforts to improve specialty care access, rural patient behavior and decentralization of HCV therapy beyond specialty providers may explain this contradiction. Lessons learned within the VHA are critical for US healthcare systems restructuring into accountable care organizations that acquire features of integrated systems.

    View details for DOI 10.1371/journal.pone.0084826

    View details for Web of Science ID 000329116700119

    View details for PubMedID 24386420

    View details for PubMedCentralID PMC3873451

  • The Quality of Supportive Cancer Care in the Veterans Affairs Health System and Targets for Improvement JAMA INTERNAL MEDICINE Walling, A. M., Tisnado, D., Asch, S. M., Malin, J. M., Pantoja, P., Dy, S. M., Ettner, S. L., Zisser, A. P., Schreibeis-Baum, H., Lee, M., Lorenz, K. A. 2013; 173 (22): 2071-2079


    Characterizing the quality of supportive cancer care can guide quality improvement.To evaluate nonhospice supportive cancer care comprehensively in a national sample of veterans.Using a retrospective cohort study design, we measured evidence-based cancer care processes using previously validated indicators of care quality in patients with advanced cancer, addressing pain, nonpain symptoms, and information and care planning among 719 veterans with a 2008 Veterans Affairs Central Cancer Registry diagnosis of stage IV colorectal (37.0%), pancreatic (29.8%), or lung (33.2%) cancer.We abstracted medical records from diagnosis for 3 years or until death among eligible veterans (lived ≥ 30 days following diagnosis with ≥ 1 Veterans Affairs hospitalization or ≥ 2 Veterans Affairs outpatient visits). Each indicator identified a clinical scenario and an appropriate action. For each indicator for which a veteran was eligible, we determined whether appropriate care was provided. We also determined patient-level quality overall and by pain, nonpain symptoms, and information and care planning domains.Most veterans were older (mean age, 66.2 years), male (97.2%), and white (74.3%). Eighty-five percent received both inpatient and outpatient care, and 92.5% died. Overall, the 719 veterans triggered a mean of 11.7 quality indicators (range, 1-22) and received a mean 49.5% of appropriate care. Notable gaps in care were that inpatient pain screening was common (96.5%) but lacking for outpatients (58.1%). With opioids, bowel prophylaxis occurred for only 52.2% of outpatients and 70.5% of inpatients. Few patients had a timely dyspnea evaluation (15.8%) or treatment (10.8%). Outpatient assessment of fatigue occurred for 31.3%. Of patients at high risk for diarrhea from chemotherapy, 24.2% were offered appropriate antidiarrheals. Only 17.7% of veterans had goals of care addressed in the month after a diagnosis of advanced cancer, and 63.7% had timely discussion of goals following intensive care unit admission. Most decedents (86.4%) were referred to palliative care or hospice before death. Single- vs multiple-fraction radiotherapy should have been considered in 28 veterans with bone metastasis, but none were offered this option.These care gaps reflect important targets for improving the patient and family experience of cancer care.

    View details for DOI 10.1001/jamainternmed.2013.10797

    View details for Web of Science ID 000330954800015

    View details for PubMedID 24126685

  • The Hepatitis C Self-Management Program: Sustainability of Primary Outcomes at 1 Year HEALTH EDUCATION & BEHAVIOR Groessl, E. J., Ho, S. B., Asch, S. M., Stepnowsky, C. J., Laurent, D., Gifford, A. L. 2013; 40 (6): 730-740


    Objective. Chronic hepatitis C infection afflicts millions of people worldwide. Although antiviral treatments are increasingly effective, many hepatitis C virus (HCV) patients avoid treatment, do not complete or respond to treatment, or have contraindications. Self-management interventions are one option for promoting behavioral changes leading to liver wellness and improved quality of life. Our objective was to evaluate whether the effects of the HCV self-management program were sustained at the 12-month follow-up assessment. Methods. Veteran Affairs patients with hepatitis C (N = 134; mean age = 54.6 years, 95% male, 41% ethnic minority, 48% homeless in last 5 years) were randomized to either a 6-week self-management workshop or an information-only intervention. The weekly 2-hour self-management sessions were based on a cognitive-behavioral program with hepatitis C-specific modules. Outcomes including hepatitis C knowledge, depression, energy, and health-related quality of life were measured at baseline, 6 weeks, 6 months, and 12 months later. Data were analyzed using repeated measures ANOVA. Results. Compared with the information-only group, participants attending the self-management workshop improved more on HCV knowledge (p < .005), SF-36 energy/vitality (p = .016), and the Quality of Well-Being Scale (p = .036). Similar trends were found for SF-36 physical functioning and Center for Epidemiologic Studies Short Depression Scale. Conclusion. Better outcomes were sustained among self-management participants at the 12-month assessment despite the intervention only lasting 6 weeks. HCV health care providers should consider adding self-management interventions for patients with chronic HCV.

    View details for DOI 10.1177/1090198113477112

    View details for Web of Science ID 000326980400012

    View details for PubMedID 23445604

  • Online toolkits for metric-driven quality improvement: the Veterans Health Administration managed grassroots approach. Joint Commission journal on quality and patient safety / Joint Commission Resources York, L., Bruce, B., Luck, J., Bowman, C., Midboe, A. M., Smith, N., Elenes, M., Girard, J., Griffith, D., Edwards, G., Ahluwalia, S., Zisser, A., Asch, S. 2013; 39 (12): 561-569

    View details for PubMedID 24416947

  • Cost Effectiveness of Direct-Acting Antiviral Therapy for Treatment-Naive Patients With Chronic HCV Genotype 1 Infection in the Veterans Health Administration CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Chan, K., Lai, M. N., Groessl, E. J., Hanchate, A. D., Wong, J. B., Clark, J. A., Asch, S. M., Gifford, A. L., Ho, S. B. 2013; 11 (11): 1503-1510


    BACKGROUND AND AIM: The Veterans Health Administration (VHA) is the largest single provider of care for hepatitis C virus (HCV) infection in the US. We analyzed the cost-effectiveness of treatment with the HCV protease inhibitors boceprevir and telaprevir in a defined managed care population of 102,851 patients with untreated chronic genotype 1 infection. METHODS: We used a decision-analytic Markov model to examine 4 strategies: standard dual-therapy with pegylated interferon-alfa and ribavirin (PR), the combination of boceprevir and PR triple therapy, the combination of telaprevir and PR, or no antiviral treatment; sensitivity analysis was performed. Sources of data included published rates of disease progression, the census bureau, and VHA pharmacy and hospitalization cost databases. RESULTS: The estimated costs for treating each patient were $8000 for PR, $31,300 for boceprevier and PR, and $41,700 for telaprevir and PR. Assuming VHA treatment rates of 22% and optimal rates of sustained viral response, PR, boceprevir and PR, and telaprevir and PR would reduce relative liver-related deaths by 5.2%, 10.9%, and 11.5%, respectively. Increasing treatment rates to 50% would reduce liver-related deaths by 12%, 24.7%, and 26.1%, respectively. The incremental cost-effectiveness ratios were $29,184/quality of adjusted-life years (QALY) for boceprevir and PR and $44,247/QALY for telaprevir and PR vs only PR. With the current 22% treatment rate, total system-wide costs to adopt boceprevir and PR or telaprevir and PR would range from $708 million to $943 million. CONCLUSIONS: Despite substantial upfront costs of treating HCV-infected patients in the VHA with PR, or telaprevir and PR, each regimen improves quality of life and extends life expectancy, by reducing liver-related morbidity and mortality, and should be cost effective. Further efforts to expand access to direct-acting antiviral therapy are warranted.

    View details for DOI 10.1016/j.cgh.2013.05.014

    View details for Web of Science ID 000325759900026

    View details for PubMedID 23707354

  • Is Emergency Department Crowding Associated With Increased "Bounceback" Admissions? MEDICAL CARE Hsia, R. Y., Asch, S. M., Weiss, R. E., Zingmond, D., Gabayan, G., Liang, L., Han, W., McCreath, H., Sun, B. C. 2013; 51 (11): 1008-1014


    Emergency department (ED) crowding is linked with poor quality of care and worse outcomes, including higher mortality. With the growing emphasis on hospital performance measures, there is additional concern whether inadequate care during crowded periods increases a patient's likelihood of subsequent inpatient admission. We sought to determine if ED crowding during the index visit was associated with these "bounceback" admissions.We used comprehensive, nonpublic, statewide ED and inpatient discharge data from the California Office of Statewide Health Planning and Development from 2007 to identify index outpatient ED visits and bounceback admissions within 7 days. We further used ambulance diversion data collected from California local emergency medical services agencies to identify crowded days using intrahospital daily diversion hour quartiles. Using a hierarchical logistic regression model, we then determined if patients visiting on crowded days were more likely to have a subsequent bounceback admission.We analyzed 3,368,527 index visits across 202 hospitals, of which 596,471 (17.7%) observations were on crowded days. We found no association between ED crowding and bounceback admissions. This lack of relationship persisted in both a discrete (high/low) model (OR, 1.01; 95% CI, 0.99, 1.02) and a secondary model using ambulance diversion hours as a continuous predictor (OR, 1.00; 95% CI, 1.00, 1.00).Crowding as measured by ambulance diversion does not have an association with hospitalization within 7 days of an ED visit discharge. Therefore, bounceback admission may be a poor measure of delayed or worsened quality of care due to crowding.

    View details for DOI 10.1097/MLR.0b013e3182a98310

    View details for PubMedID 24036997

  • Patient-Centered Medical Home Intervention at an Internal Medicine Resident Safety-Net Clinic JAMA INTERNAL MEDICINE Hochman, M. E., Asch, S., Jibilian, A., Chaudry, B., Ben-Ari, R., Hsieh, E., Berumen, M., Mokhtari, S., Raad, M., Hicks, E., Sanford, C., Aguirre, N., Tseng, C., Vangala, S., Mangione, C. M., Goldstein, D. A. 2013; 173 (18): 1694-1701


    The patient-centered medical home (PCMH) model holds promise for improving primary care delivery, but it has not been adequately tested in teaching settings.We implemented an intervention guided by PCMH principles at a safety-net teaching clinic with resident physician providers. Two similar clinics served as controls.Using a cross-sectional design, we measured the effect on patient and resident satisfaction using the Consumer Assessment of Healthcare Providers and Systems survey and a validated teaching clinic survey, respectively. Both surveys were conducted at baseline and 1 year after the intervention. We also measured the effect on emergency department and hospital utilization.Following implementation of our intervention, the clinic’s score on the National Committee for Quality Assurance’s PCMH certification tool improved from 35 to 53 of 100 possible points, although our clinic did not achieve all must-pass elements to qualify as a PCMH. During the 1-year study period, 4676 patients were exposed to the intervention; 39.9% of these used at least 1 program component. Compared with baseline, patient-reported access and overall satisfaction improved to a greater extent in the intervention clinic, and the composite satisfaction rating increased from 48% to 65% in the intervention clinic vs from 50% to 59% in the control sites (P = .04). The improvements were particularly notable for questions relating to access. For example, satisfaction with urgent appointment scheduling increased from 12% to 53% in the intervention clinic vs from 14% to 18% in the control clinics (P < .001). Resident satisfaction also improved in the intervention clinic: the composite satisfaction score increased from 39% to 51% in the intervention clinic vs a decrease from 46% to 42% in the control clinics (P = .01). Emergency department utilization did not differ significantly between the intervention and control clinics, and hospitalizations increased from 26 to 27 visits per 1000 patients per month in the intervention clinic vs a decrease from 28 to 25 in the control clinics (P = .02).Our PCMH-guided intervention, which represented a modest but substantive step toward the PCMH vision, had favorable effects on patient and resident satisfaction at a safety-net teaching clinic but did not reduce emergency department or hospital utilization in the first year. Our experience may provide lessons for other teaching clinics in safety-net settings hoping to implement PCMH-guided reforms.

    View details for DOI 10.1001/jamainternmed.2013.9241

    View details for Web of Science ID 000328193600007

    View details for PubMedID 24006034

    View details for PubMedCentralID PMC4254756

  • Central Implementation Strategies Outperform Local Ones in Improving HIV Testing in Veterans Healthcare Administration Facilities JOURNAL OF GENERAL INTERNAL MEDICINE Goetz, M. B., Tuyen Hoang, T., Knapp, H., Burgess, J., Fletcher, M. D., Gifford, A. L., Asch, S. M. 2013; 28 (10): 1311-1317


    Pilot data suggest that a multifaceted approach may increase HIV testing rates, but the scalability of this approach and the level of support needed for successful implementation remain unknown.To evaluate the effectiveness of a scaled-up multi-component intervention in increasing the rate of risk-based and routine HIV diagnostic testing in primary care clinics and the impact of differing levels of program support.Three arm, quasi-experimental implementation research study.Veterans Health Administration (VHA) facilities.Persons receiving primary care between June 2009 and September 2011 INTERVENTION: A multimodal program, including a real-time electronic clinical reminder to facilitate HIV testing, provider feedback reports and provider education, was implemented in Central and Local Arm Sites; sites in the Central Arm also received ongoing programmatic support. Control Arm sites had no interventionFrequency of performing HIV testing during the 6 months before and after implementation of a risk-based clinical reminder (phase I) or routine clinical reminder (phase II).The adjusted rate of risk-based testing increased by 0.4 %, 5.6 % and 10.1 % in the Control, Local and Central Arms, respectively (all comparisons, p < 0.01). During phase II, the adjusted rate of routine testing increased by 1.1 %, 6.3 % and 9.2 % in the Control, Local and Central Arms, respectively (all comparisons, p < 0.01). At study end, 70-80 % of patients had been offered an HIV test.Use of clinical reminders, provider feedback, education and social marketing significantly increased the frequency at which HIV testing is offered and performed in VHA facilities. These findings support a multimodal approach toward achieving the goal of having every American know their HIV status as a matter of routine clinical practice.

    View details for DOI 10.1007/s11606-013-2420-6

    View details for Web of Science ID 000325015000015

    View details for PubMedID 23605307

    View details for PubMedCentralID PMC3785651

  • How Do Providers Prioritize Prevention? A Qualitative Study AMERICAN JOURNAL OF MANAGED CARE Solomon, J. L., Gifford, A. L., Asch, S. M., Mueller, N., Thomas, C. M., Stevens, J. M., Bokhour, B. G. 2013; 19 (10): E342-?


    Preventive care is an essential element of comprehensive primary care medicine, yet many providers do not address the full range of recommended preventive care services. There is little understanding of how, during time-constrained clinical encounters, providers prioritize preventive care services.To identify and compare how Department of Veterans Affairs (VA) primary care providers (PCPs) prioritized general preventive care services, including HIV testing.A semistructured, qualitative interview design.We conducted semistructured phone interviews with 31 PCPs across 2 urban VA facilities. Interviews entailed questions about the most common preventive care services in primary care, how decisions are made to address some preventive care services but not others, and the role of clinical reminders (CRs) in prioritizing care. Interviews were audio-recorded and transcribed verbatim. We conducted an iterative thematic analysis of interview transcripts, utilizing NVivo 8, a qualitative data management and coding software.Most PCPs indicated they did not utilize CRs as a primary means of prioritizing general preventive care. Instead, PCPs prioritized general preventive care by attending to patients' individual needs and/or keeping in mind influential clinical training experiences. Prioritizing HIV testing included 1 or a combination of the following strategies: being attuned to HIV risk factors prior to the appearance of the CR, being prompted by the CR, and having a positive attitude toward CR design.Prioritizing preventive care can be accomplished using various strategies, including CRs. Healthcare systems might benefit from encouraging PCPs to use a range of strategies.

    View details for Web of Science ID 000326420300009

    View details for PubMedID 24304181

  • Factors Associated With Short-Term Bounce-Back Admissions After Emergency Department Discharge ANNALS OF EMERGENCY MEDICINE Gabayan, G. Z., Asch, S. M., Hsia, R. Y., Zingmond, D., Liang, L., Han, W., McCreath, H., Weiss, R. E., Sun, B. C. 2013; 62 (2): 136-144


    STUDY OBJECTIVE: Hospitalizations that occur shortly after emergency department (ED) discharge may reveal opportunities to improve ED or follow-up care. There currently is limited, population-level information about such events. We identify hospital- and visit-level predictors of bounce-back admissions, defined as 7-day unscheduled hospital admissions after ED discharge. METHODS: Using the California Office of Statewide Health Planning and Development files, we conducted a retrospective cohort analysis of adult (aged >18 years) ED visits resulting in discharge in 2007. Candidate predictors included index hospital structural characteristics such as ownership, teaching affiliation, trauma status, and index ED size, along with index visit patient characteristics of demographic information, day of service, against medical advice or eloped disposition, insurance, and ED primary discharge diagnosis. We fit a multivariable, hierarchic logistic regression to account for clustering of ED visits by hospitals. RESULTS: The study cohort contained a total of 5,035,833 visits to 288 facilities in 2007. Bounce-back admission within 7 days occurred in 130,526 (2.6%) visits and was associated with Medicaid (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.40 to 1.45) or Medicare insurance (OR 1.53; 95% CI 1.50 to 1.55) and a disposition of leaving against medical advice or before the evaluation was complete (OR 1.90; 95% CI 1.89 to 2.0). The 3 most common age-adjusted index ED discharge diagnoses associated with a bounce-back admission were chronic renal disease, not end stage (OR 3.3; 95% CI 2.8 to 3.8), end-stage renal disease (OR 2.9; 95% CI 2.4 to 3.6), and congestive heart failure (OR 2.5; 95% CI 2.3 to 2.6). Hospital characteristics associated with a higher bounce-back admission rate were for-profit status (OR 1.2; 95% CI 1.1 to 1.3) and teaching affiliation (OR 1.2; 95% CI 1.0 to 1.3). CONCLUSION: We found 2.6% of discharged patients from California EDs to have a bounce-back admission within 7 days. We identified vulnerable populations, such as the very old and the use of Medicaid insurance, and chronic or end-stage renal disease as being especially at risk. Our findings suggest that quality improvement efforts focus on high-risk individuals and that the disposition plan of patients consider vulnerable populations.

    View details for DOI 10.1016/j.annemergmed.2013.01.017

    View details for Web of Science ID 000323014800008

    View details for PubMedID 23465554

  • Qualitative Factors in Patients Who Die Shortly After Emergency Department Discharge ACADEMIC EMERGENCY MEDICINE Gabayan, G. Z., Sun, B. C., Asch, S. M., Timmermans, S., Sarkisian, C., Yiu, S., Lancaster, E. M., Poon, K. T., Kellermann, A. L., Ryan, G., Miniel, N. J., Flansbaum, D., Hoffman, J. R., Derose, S. F. 2013; 20 (8): 778-785


    Early death after emergency department (ED) discharge may signal opportunities to improve care. Prior studies are limited by incomplete mortality ascertainment and lack of clinically important information in administrative data. The goal in this hypothesis-generating study was to identify patient and process of care themes that may provide possible explanations for early postdischarge mortality.This was a qualitative analysis of medical records of adult patients who visited the ED of any of six hospitals in an integrated health system (Kaiser Permanente Southern California [KPSC]) and died within 7 days of discharge in 2007 and 2008. Nonmembers, visits to non-health plan hospitals, patients receiving or referred to hospice care, and patients with do not attempt resuscitation or do not intubate orders (DNAR/DNI) were excluded. Under the guidance of two qualitative research scientists, a team of three emergency physicians used grounded theory techniques to identify patient clinical presentations and processes of care that serve as potential explanations for poor outcome after discharge.The source population consisted of a total of 290,092 members with 446,120 discharges from six KPSC EDs in 2007 and 2008. A total of 203 deaths occurred within 7 days of ED discharge (0.05%). Sixty-one randomly chosen cases were reviewed. Patient-level themes that emerged included an unexplained persistent acute change in mental status, recent fall, abnormal vital signs, ill-appearing presentation, malfunctioning indwelling device, and presenting symptoms remaining at discharge. Process-of-care factors included a discrepancy in history of present illness, incomplete physical examination, and change of discharge plan by a third party, such as a consulting or admitting physician.In this hypothesis-generating study, qualitative research techniques were used to identify clinical and process-of-care factors in patients who died within days after discharge from an ED. These potential predictors will be formally tested in a future quantitative study.

    View details for DOI 10.1111/acem.12181

    View details for Web of Science ID 000323134300005

    View details for PubMedID 24033620

    View details for PubMedCentralID PMC3785011

  • Patient Preference and Contraindications in Measuring Quality of Care: What Do Administrative Data Miss? JOURNAL OF CLINICAL ONCOLOGY Ryoo, J. J., Ordin, D. L., Antonio, A. L., Oishi, S. M., Gould, M. K., Asch, S. M., Malin, J. L. 2013; 31 (21): 2716-?


    PURPOSE Prior studies report that half of patients with lung cancer do not receive guideline-concordant care. With data from a national Veterans Health Administration (VHA) study on quality of care, we sought to determine what proportion of patients refused or had a contraindication to recommended lung cancer therapy. PATIENTS AND METHODS Through medical record abstraction, we evaluated adherence to six quality indicators addressing lung cancer-directed therapy for patients diagnosed within the VHA during 2007 and calculated the proportion of patients receiving, refusing, or having contraindications to recommended treatment. Results Mean age of the predominantly male population was 67.7 years (standard deviation, 9.4 years), and 15% were black. Adherence to quality indicators ranged from 81% for adjuvant chemotherapy to 98% for curative resection; however, many patients met quality indicator criteria without actually receiving recommended therapy by having a refusal (0% to 14%) or contraindication (1% to 30%) documented. Less than 1% of patients refused palliative chemotherapy. Black patients were more likely to refuse or bear a contraindication to surgery even when controlling for comorbidity; race was not associated with refusals or contraindications to other treatments. CONCLUSION Refusals and contraindications are common and may account for previously demonstrated low rates of recommended lung cancer therapy performance at the VHA. Racial disparities in treatment may be explained, in part, by such factors. These results sound a cautionary note for quality measurement that depends on data that do not reflect patient preference or contraindications in conditions where such considerations are important.

    View details for DOI 10.1200/JCO.2012.45.7473

    View details for Web of Science ID 000330538700020

    View details for PubMedID 23752110

    View details for PubMedCentralID PMC3709057

  • Effect of emergency department crowding on outcomes of admitted patients. Annals of emergency medicine Sun, B. C., Hsia, R. Y., Weiss, R. E., Zingmond, D., Liang, L., Han, W., McCreath, H., Asch, S. M. 2013; 61 (6): 605-611 e6


    Emergency department (ED) crowding is a prevalent health delivery problem and may adversely affect the outcomes of patients requiring admission. We assess the association of ED crowding with subsequent outcomes in a general population of hospitalized patients.We performed a retrospective cohort analysis of patients admitted in 2007 through the EDs of nonfederal, acute care hospitals in California. The primary outcome was inpatient mortality. Secondary outcomes included hospital length of stay and costs. ED crowding was established by the proxy measure of ambulance diversion hours on the day of admission. To control for hospital-level confounders of ambulance diversion, we defined periods of high ED crowding as those days within the top quartile of diversion hours for a specific facility. Hierarchic regression models controlled for demographics, time variables, patient comorbidities, primary diagnosis, and hospital fixed effects. We used bootstrap sampling to estimate excess outcomes attributable to ED crowding.We studied 995,379 ED visits resulting in admission to 187 hospitals. Patients who were admitted on days with high ED crowding experienced 5% greater odds of inpatient death (95% confidence interval [CI] 2% to 8%), 0.8% longer hospital length of stay (95% CI 0.5% to 1%), and 1% increased costs per admission (95% CI 0.7% to 2%). Excess outcomes attributable to periods of high ED crowding included 300 inpatient deaths (95% CI 200 to 500 inpatient deaths), 6,200 hospital days (95% CI 2,800 to 8,900 hospital days), and $17 million (95% CI $11 to $23 million) in costs.Periods of high ED crowding were associated with increased inpatient mortality and modest increases in length of stay and costs for admitted patients.

    View details for DOI 10.1016/j.annemergmed.2012.10.026

    View details for PubMedID 23218508

  • MULTIMORBIDITY AND HEALTH CARE UTILIZATION AMONG HIGH-COST PATIENTS: IMPLICATIONS FOR CARE COORDINATION 36th Annual Meeting of the Society-of-General-Internal-Medicine Zulman, D., Yoon, J., Cohen, D. M., Wagner, T. H., Ritchie, C., Asch, S. SPRINGER. 2013: S123–S124
  • The effects of quality of care on costs: a conceptual framework. Milbank quarterly Nuckols, T. K., Escarce, J. J., Asch, S. M. 2013; 91 (2): 316-353


    The quality of health care and the financial costs affected by receiving care represent two fundamental dimensions for judging health care performance. No existing conceptual framework appears to have described how quality influences costs.We developed the Quality-Cost Framework, drawing from the work of Donabedian, the RAND/UCLA Appropriateness Method, reports by the Institute of Medicine, and other sources.The Quality-Cost Framework describes how health-related quality of care (aspects of quality that influence health status) affects health care and other costs. Structure influences process, which, in turn, affects proximate and ultimate outcomes. Within structure, subdomains include general structural characteristics, circumstance-specific (e.g., disease-specific) structural characteristics, and quality-improvement systems. Process subdomains include appropriateness of care and medical errors. Proximate outcomes consist of disease progression, disease complications, and care complications. Each of the preceding subdomains influences health care costs. For example, quality improvement systems often create costs associated with monitoring and feedback. Providing appropriate care frequently requires additional physician visits and medications. Care complications may result in costly hospitalizations or procedures. Ultimate outcomes include functional status as well as length and quality of life; the economic value of these outcomes can be measured in terms of health utility or health-status-related costs. We illustrate our framework using examples related to glycemic control for type 2 diabetes mellitus or the appropriateness of care for low back pain.The Quality-Cost Framework describes the mechanisms by which health-related quality of care affects health care and health status-related costs. Additional work will need to validate the framework by applying it to multiple clinical conditions. Applicability could be assessed by using the framework to classify the measures of quality and cost reported in published studies. Usefulness could be demonstrated by employing the framework to identify design flaws in published cost analyses, such as omitting the costs attributable to a relevant subdomain of quality.

    View details for DOI 10.1111/milq.12015

    View details for PubMedID 23758513

  • Provider Approaches to Palliative Dyspnea Assessment: Implications for Informatics-Based Clinical Tools AMERICAN JOURNAL OF HOSPICE & PALLIATIVE MEDICINE Ahluwalia, S. C., Leos, R. L., Goebel, J. R., Asch, S. M., Lorenz, K. A. 2013; 30 (3): 231-238


    To understand provider practices around dyspnea assessment to inform the development of an electronic medical record (EMR)-based dyspnea assessment module in an inpatient palliative care consultation template.Qualitative analysis of palliative care provider interviews.Three themes emerged: (1) integration of patient self-report of breathlessness with a clinical observation of dyspnea; (2) identification of patients for dyspnea assessment based on perceived patient need; and (3) variability in preferences for and use of existing severity scales for dyspnea.The assessment approaches described by providers underscore the challenge of developing an informatics tool that supports the natural clinical experience and facilitates standardized care. The complexity of the dyspnea assessment process and variation in provider practices necessitate a level of flexibility and choice to be built into a computer-based tool.

    View details for DOI 10.1177/1049909112448922

    View details for Web of Science ID 000317674300002

    View details for PubMedID 22669935

  • Development and evaluation of an internet and personal health record training program for low-income patients with HIV or hepatitis C. Medical care McInnes, D. K., Solomon, J. L., Shimada, S. L., Petrakis, B. A., Bokhour, B. G., Asch, S. M., Nazi, K. M., Houston, T. K., Gifford, A. L. 2013; 51 (3): S62-6


    Vulnerable populations face difficulties accessing and using the internet and personal health record (PHR) systems for health-related purposes. Populations disconnected from the internet also tend to be disconnected from health care services.To develop and evaluate an intervention to increase skills in health-related internet and PHR use for vulnerable populations with limited computer and internet experience.Preevaluation and postevaluation using quantitative surveys, semistructured interviews, focus groups, and ethnographic observation.Fourteen low-income Veterans receiving care at Veterans Affairs medical centers for human immunodeficiency virus or hepatitis C.Internet and PHR use, self-efficacy, patient activation, disease knowledge, predictors of medication adherence.At follow-up one (FU1), mean number of internet for health features used increased from 1.57 to 4.07 (P<0.001) as did number of PHR features, from 0.36 to 2.00 (P<0.001). Mean self-efficacy increased at FU1, from 7.12 to 8.60, (P=0.009) and was maintained at follow-up two (FU2). Patient activation increased only at FU2, from 3.42 to 3.61 (P=0.03). Disease specific knowledge showed borderline increase at FU1, from 67.9% to 72.2% (P=0.05), whereas there were no changes in predictors of medication adherence. Qualitative findings underscored the interest in using internet and PHRs and their contribution to increased engagement in care. Training cost per participant was $287.Group training of vulnerable patients represents a cost-effective method to increase internet and PHR skills, and improve patient confidence in finding health-related information, making online health-related transactions, and interacting with health care providers.

    View details for DOI 10.1097/MLR.0b013e31827808bf

    View details for PubMedID 23407015

  • Impact of Consideration of Transplantation on End-of-Life Care for Patients During a Terminal Hospitalization TRANSPLANTATION Walling, A. M., Asch, S. M., Lorenz, K. A., Wenger, N. S. 2013; 95 (4): 641-646


    Many patients considered for transplantation die before receiving the organ, underlining the importance of providing high-quality symptomatic relief and communication for all transplant patients.To study how consideration of transplantation affects the end-of-life care received by patients, care was evaluated by abstracting medical records for 496 adults who died in one high-volume transplant medical center between April 2005 and April 2006. Sixteen quality indicators from the Assessing Care of Vulnerable Elders set that focused on communication and symptom management were measured to calculate an overall patient-level quality score. We evaluated the predictors of quality of end-of-life care, with the main independent variable being whether the patient was being considered for transplantation. Restricting to patients who died an "expected death," we also evaluated the end-of-life treatments received.Twenty-five percent of decedent patients were considered for transplantation. In adjusted models, patients considered for transplantation received lower-quality end-of-life care, had longer hospital stays before death, and were more likely to receive aggressive life-sustaining treatments.Care models should incorporate an emphasis on symptom relief and communication along with transplant preparation.

    View details for DOI 10.1097/TP.0b013e318277f238

    View details for Web of Science ID 000315199200021

    View details for PubMedID 23197177

  • Facilitating out-of-home caregiving through health information technology: survey of informal caregivers' current practices, interests, and perceived barriers. Journal of medical Internet research Zulman, D. M., Piette, J. D., Jenchura, E. C., Asch, S. M., Rosland, A. 2013; 15 (7)


    Many patients with chronic conditions are supported by out-of-home informal caregivers-family members, friends, and other individuals who provide care and support without pay-who, if armed with effective consumer health information technology, could inexpensively facilitate their care.We sought to understand caregivers' use of, interest in, and perceived barriers to health information technology for out-of-home caregiving.We conducted 2 sequential Web-based surveys with a national sample of individuals who provide out-of-home caregiving to an adult family member or friend with a chronic illness. We queried respondents about their use of health information technology for out-of-home caregiving and used multivariable regression to investigate caregiver and care-recipient characteristics associated with caregivers' technology use for caregiving.Among 316 out-of-home caregiver respondents, 34.5% (109/316) reported using health information technology for caregiving activities. The likelihood of a caregiver using technology increased significantly with intensity of caregiving (as measured by number of out-of-home caregiving activities). Compared with very low intensity caregivers, the adjusted odds ratio (OR) of technology use was 1.88 (95% CI 1.01-3.50) for low intensity caregivers, 2.39 (95% CI 1.11-5.15) for moderate intensity caregivers, and 3.70 (95% CI 1.62-8.45) for high intensity caregivers. Over 70% (149/207) of technology nonusers reported interest in using technology in the future to support caregiving. The most commonly cited barriers to technology use for caregiving were health system privacy rules that restrict access to care-recipients' health information and lack of familiarity with programs or websites that facilitate out-of-home caregiving.Health information technology use for out-of-home caregiving is common, especially among individuals who provide more intense caregiving. Health care systems can address the mismatch between caregivers' interest in and use of technology by modifying privacy policies that impede information exchange.

    View details for DOI 10.2196/jmir.2472

    View details for PubMedID 23841987

    View details for PubMedCentralID PMC3713893

  • Development of a mild traumatic brain injury-specific vision screening protocol: A Delphi study JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT Goodrich, G. L., Martinsen, G. L., Flyg, H. M., Kirby, J., Asch, S. M., Brahm, K. D., Brand, J. M., Cajamarca, D., Cantrell, J. L., Chong, T., Dziadul, J. A., Hetrick, B. J., Huang, M. A., Ihrig, C., Ingalla, S. P., Meltzer, B. R., Rakoczy, C. M., Rone, A., Schwartz, E., Shea, J. E. 2013; 50 (6): 757-768


    Although traumatic brain injury (TBI) can happen to anyone at any time, the wars in Iraq and Afghanistan have brought it renewed attention. Fortunately, most cases of TBI from the recent conflicts are mild TBI (mTBI). Still, many physical, psychological, and social problems are associated with mTBI. Among the difficulties encountered are oculomotor and vision problems, many of which can impede daily activities such as reading. Therefore, correct diagnosis and treatment of these mTBI-related vision problems is an important part of patient recovery. Numerous eye care providers in the Department of Veterans Affairs, in military settings, and in civilian practices specialize and are proficient in examining patients who have a history of TBI. However, many do not have this level of experience working with and treating patients with mTBI. Recognizing this, we used a modified Delphi method to derive expert opinions from a panel of 16 optometrists concerning visual examination of the patient with mTBI. This process resulted in a clinical tool containing 17 history questions and 7 examination procedures. This tool provides a set of clinical guidelines that can be used as desired by any eye care provider either as a screening tool or adjunct to a full eye examination when seeing a patient with a history of mTBI. The goal of this process was to provide optimal and uniform vision care for the patient with mTBI.

    View details for DOI 10.1682/JRRD.2012.10.0184

    View details for Web of Science ID 000324350200005

    View details for PubMedID 24203539

  • POSTTRAUMATIC STRESS DISORDER, MILITARY SEXUAL TRAUMA AND PRETERM BIRTH Western Regional Meeting of the American-Federation-for-Medical-Research Shaw, J. G., Asch, S. M., Kimerling, R., Frayne, S. M., Shaw, K. A., Phibbs, C. S. LIPPINCOTT WILLIAMS & WILKINS. 2013: 226–26
  • Budget Impact Analysis of HIV Testing in the VA Healthcare System International-Association-of-Physicians in AIDS Care (IAPAC) Anaya, H. D., Chan, K., Karmarkar, U., Asch, S. M., Goetz, M. B. ELSEVIER SCIENCE INC. 2012: 1022–28


    The long-term cost effectiveness of routine HIV testing is favorable relative to other medical interventions. Facility-specific costs of expanded HIV testing and care for newly identified patients, however, are less well defined. To aid in resource allocation decisions, we developed a spreadsheet-based budget-impact tool populated with estimates of facility-specific HIV testing and care costs incurred with an expanded testing program.We modeled intervention effects on quarterly costs of antiretroviral therapy (ART), outpatient resource utilization, and staff expenditures in the Department of Veterans Affairs over a 2-year period of increasing HIV testing rates. We used HIV prevalence estimates, screening rates, counseling, positive tests, Veterans Affairs treatment, and published sources as inputs. We evaluated a single-facility cohort of 20,000 patients and at baseline assumed a serodiagnostic rate of 0.45%.Expanding testing from 2% to 15% annually identified 21 additional HIV-positive patients over 2 years at a cost of approximately $290,000, more than 60% of which was due to providing ART to newly diagnosed patients. While quarterly testing costs decreased longitudinally as fewer persons required testing, quarterly ART costs increased from $10,000 to more than $60,000 over 2 years as more infected patients were identified and started on ART. In sensitivity analyses, serodiagnostic and annual HIV testing rates had the greatest cost impact.Expanded HIV testing costs are greatest during initial implementation and predominantly due to ART for new patients. Cost determinations of expanded HIV testing provide an important tool for managers charged with allocating resources within integrated systems providing both HIV testing and care.

    View details for DOI 10.1016/j.jval.2012.08.2205

    View details for Web of Science ID 000312435300005

    View details for PubMedID 23244803

  • Perioperative processes and outcomes after implementation of a hospitalist-run preoperative clinic JOURNAL OF HOSPITAL MEDICINE Vazirani, S., Lankarani-Fard, A., Liang, L., Stelzner, M., Asch, S. M. 2012; 7 (9): 697-701


    A structured, medical preoperative evaluation may positively impact the perioperative course of medically complex patients. Hospitalists are in a unique position to assist in preoperative evaluations, given their expertise with inpatient medicine and postoperative surgical consultation.To evaluate specific outcomes after addition of a Hospitalist-run, medical Preoperative clinic to the standard Anesthesia preoperative evaluation.A pre/post retrospective, comparative review of outcomes of 5223 noncardiac surgical patients at a tertiary care Veterans Administration (VA) medical center.Length of stay was reduced for inpatients with an American Society of Anesthesia (ASA) score of 3 or higher (P < 0.0001). There was a trend towards a reduction in same-day, medically avoidable surgical cancellations (8.5% vs 4.9%, P = 0.065). More perioperative beta blockers were used (P < 0.0001) and more stress tests were ordered (P = 0.012). Inpatient mortality rates were reduced (1.27% vs 0.36%, P = 0.0158).A structured medical preoperative evaluation may benefit medically complex patients and improve perioperative processes and outcomes.

    View details for DOI 10.1002/jhm.1968

    View details for Web of Science ID 000312241600006

    View details for PubMedID 22961756

  • Adapting the PRO-CTCAE for Patient Reporting of Toxicity in Radiation Oncology McCloskey, S. A., Kupelian, P., Asch, S., Hays, R., Malin, J. ELSEVIER SCIENCE INC. 2012: S99–S100
  • Process of Care for Hepatitis C Infection Is Linked to Treatment Outcome and Virologic Response CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Kanwal, F., Hoang, T., Chrusciel, T., Kramer, J. R., El-Serag, H. B., Dominitz, J. A., Asch, S. M. 2012; 10 (11): 1270-?


    Process of care-based measures are used commonly to assess the quality of medical care provided to patients with chronic hepatitis C virus (HCV) infection. However, the links between these processes and patient outcomes are not clear.We conducted a large retrospective cohort study of 34,749 patients with HCV infection identified from the national Veterans Administration HCV Clinical Case Registry between 2003 and 2006. We examined the relationship between meeting process-based measures of HCV care (categorized into pretreatment, preventive or comorbid care, and treatment monitoring domains) and antiviral treatment-related outcomes. For each domain, we defined optimum care as receipt of all indicated care processes in that domain. Study end points were rates of antiviral treatment, treatment completion, and sustained virologic response (SVR), adjusted for patient demographics, comorbidities, use of health services, and intrafacility clustering.Patients who received optimum pretreatment care were significantly more likely to receive antiviral treatment (odds ratio [OR], 3.2; 95% confidence interval [CI], 2.9-3.5), complete treatment (OR, 1.26; 95% CI, 1.13-1.43), and achieve an SVR (OR, 1.29; 95% CI, 1.01-1.65), than those with suboptimum pretreatment care. Optimum preventive or comorbidity care also independently was associated with receipt of antiviral treatment (OR, 1.36; 95% CI, 1.23-1.51), but not with completion of treatment or SVR. Optimum treatment monitoring was associated with a nonsignificant trend toward achieving an SVR (OR, 1.22; 95% CI, 0.95-1.56).Optimum care for HCV infection-particularly the care delivered before treatment-is associated with increased rates of treatment and SVR. These data could be used to guide clinical policy as newer, more-effective treatments become available.

    View details for DOI 10.1016/j.cgh.2012.07.015

    View details for Web of Science ID 000310780200020

    View details for PubMedID 22841970

  • Unhealthy Alcohol and Illicit Drug Use Are Associated With Decreased Quality of HIV Care JAIDS-JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES Korthuis, P. T., Fiellin, D. A., McGinnis, K. A., Skanderson, M., Justice, A. C., Gordon, A. J., Doebler, D. A., Asch, S. M., Fiellin, L. E., Bryant, K., Gibert, C. L., Crystal, S., Goetz, M. B., Rimland, D., Rodriguez-Barradas, M. C., Kraemer, K. L. 2012; 61 (2): 171-178


    HIV-infected patients with substance use experience suboptimal health outcomes, possibly because of variations in care.To assess the association between substance use and the quality of HIV care (QOC) received.Retrospective cohort study.HIV-infected patients enrolled in the Veterans Aging Cohort Study.We collected self-report substance use data and abstracted 9 HIV quality indicators (QIs) from medical records. Independent variables were unhealthy alcohol use (AUDIT-C score ≥4) and illicit drug use (self-report of stimulants, opioids, or injection drug use in past year). Main outcome was the percentage of QIs received, if eligible. We estimated associations between substance use and QOC using multivariable linear regression.The majority of the 3410 patients were male (97.4%) and black (67.0%) with a mean age of 49.1 years (SD = 8.8). Overall, 25.8% reported unhealthy alcohol use, 22% illicit drug use, and participants received 81.5% (SD = 18.9) of QIs. The mean percentage of QIs received was lower for those with unhealthy alcohol use versus not (59.3% vs. 70.0%, P < 0.001) and those using illicit drugs vs. not (57.8% vs. 70.7%, P < 0.001). In multivariable models, unhealthy alcohol use (adjusted β -2.74; 95% confidence interval: -4.23 to -1.25) and illicit drug use (adjusted β -3.51; 95% CI: -4.99 to -2.02) remained inversely associated with the percentage of QIs received.Although the overall QOC for these HIV-infected Veteran patients was high, gaps persist for those with unhealthy alcohol and illicit drug use. Interventions that address substance use in HIV-infected patients may improve the QOC received.

    View details for DOI 10.1097/QAI.0b013e31826741aa

    View details for PubMedID 22820808

  • The Performance of Process Measures in Hepatitis C AMERICAN JOURNAL OF GASTROENTEROLOGY Kanwal, F., Tuyen Hoang, T., Kramer, J., Chrusciel, T., El-Serag, H., Dominitz, J. A., Asch, S. M. 2012; 107 (10): 1512-1521


    Previous evaluations regarding the extent to which standard chronic hepatitis C virus (HCV) care processes are delivered during routine clinical care are scant and have primarily relied on automated data--the validity of which is unknown.We examined adherence to 24 explicit modified Delphi panel-derived HCV-specific process measures in a cohort of 122,744 patients enrolled in the automated Veterans Administration HCV Clinical Case Registry between 2000 and 2006. We reviewed medical charts of 717 patients to compare the agreement between Registry and charts. We also estimated the effect of justifiable exceptions on measured performance in HCV by determining the proportion of patients who failed a measure but met a valid exception (i.e., patient refusal, outside care, or treatment contraindications).The percentage of patients who met the individual measures varied. For example, 74% of patients received HCV genotype testing, 23% received antiviral treatment, 28% received liver biopsy, and 16% received hepatitis A vaccination. We found excellent agreement between the Registry and charts in all measures (agreement coefficients >0.75). However, exceptions to indicated care documented in charts were common for genotype testing, liver biopsy, and antiviral treatment. After accounting for these exceptions, the measure rates increased from 75 to 93% for genotype testing, 31 to 50% for liver biopsy, and from 26 to 64% for antiviral treatment. Treatment contraindications were the most common reasons for not meeting indicated care.Automated data missed several exceptions to care that are documented only in providers' notes, thus underestimating process of care. These results have implications for future quality assessment initiatives-most of which will likely rely on automated data for process-based quality reporting. After accounting for automated data and medical record reviews, vaccinations and antiviral treatment rates in the Veterans Administration left room for improvement.

    View details for DOI 10.1038/ajg.2012.201

    View details for Web of Science ID 000309701000010

    View details for PubMedID 22777337

  • The quality of supportive care among inpatients dying with advanced cancer SUPPORTIVE CARE IN CANCER Walling, A. M., Asch, S. M., Lorenz, K. A., Malin, J., Roth, C. P., Barry, T., Wenger, N. S. 2012; 20 (9): 2189-2194


    Managing symptoms and communicating effectively are essential aspects of providing high-quality cancer care, especially among patients with advanced cancer. The purpose of this study is to apply novel quality indicators to measure the quality of supportive care provided to patients with advanced cancer who died in a large university medical center.Cancer quality ASSIST is a comprehensive quality indicator (QI) set that includes 92 symptom and care planning indicators, of which we piloted 15 applicable to persons with advanced cancer who died in the hospital setting. We evaluated medical records of all adult terminal hospitalizations with lengths of stay ≥3 days at one university medical center between April 2005 and April 2006.Of 496 decedents, 118 had advanced cancer (mean age 60, 54% male). Forty-five percent received chemotherapy or radiation in the month prior to or during admission. During the hospitalization, 56% of the patients spent time in the ICU (median length of stay 8 days), one in five received first-time hemodialysis, and 23% had a ventilator withdrawn anticipating death. The 118 patients triggered 596 quality indicators of which 476 passed (QI level pass rate 80%, range 50-100%). Pain assessment and management were consistently performed; however, other cancer supportive care needed improvement: 26% of patients not receiving cancer therapy who had nausea and vomiting received inadequate follow-up, more than one quarter of patients with dyspnea had this symptom inadequately addressed, and 29% of patients taking long-acting opioids were not prescribed a bowel regimen. Timely discussion of patient preferences upon admission to the ICU or initiation of mechanical ventilation occurred in 64 and 69% of cases, respectively.This set of quality indicators can evaluate the quality of supportive and end-of-life care provided to inpatients dying with advanced cancer and identify aspects of care that need improvement.

    View details for DOI 10.1007/s00520-012-1462-3

    View details for Web of Science ID 000307285800032

    View details for PubMedID 22544290

  • Implementation of Routine Rapid HIV Testing Within the US Department of Veterans Affairs Healthcare System JOURNAL FOR HEALTHCARE QUALITY Anaya, H. D., Bokhour, B., Feld, J., Golden, J. F., Asch, S. M., Knapp, H. 2012; 34 (5): 7-14
  • The Effect of Automated Telephone Appointment Reminders on HIV Primary Care No-Shows by Veterans JANAC-JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE Henry, S. R., Goetz, M. B., Asch, S. M. 2012; 23 (5): 409-418


    Appointment attendance for follow-up care and laboratory monitoring are central components of HIV treatment. In general, appointment reminders are an effective method of reducing outpatient no-shows; however, no single strategy has proven superior. This study tested the effectiveness of adding an automated telephone reminder for laboratory monitoring to the standard set of three appointment reminders to reduce subsequent HIV primary care no-shows. We conducted a quasi-experimental design study in three geographically and administratively affiliated Veterans Administration HIV clinics with one clinic serving as the intervention facility and two others as control facilities. The intervention lasted 6 months. The data show that patients who were not homeless, who were not diagnosed with depression, and who had five or more appointments scheduled in 6 months had significantly fewer no-shows after intervention. The intervention was not effective in reducing no-shows among homeless patients, racial/ethnic minorities, and patients with mental health disorders.

    View details for DOI 10.1016/j.jana.2011.11.001

    View details for Web of Science ID 000321823200005

    View details for PubMedID 22424961

  • National patterns and predictors of liver biopsy use for management of hepatitis C JOURNAL OF HEPATOLOGY Groessl, E. J., Liu, L., Ho, S. B., Kanwal, F., Gifford, A. L., Asch, S. M. 2012; 57 (2): 252-259


    Liver biopsy remains the standard, recommended method for assessing liver damage associated with chronic hepatitis C (HCV) infection. However, there is considerable debate about how liver biopsy should best be used, especially with the advent of more efficacious antiviral therapies. To identify the factors that influence the use of liver biopsy for HCV patients, we describe variations in liver biopsy use at the delivery system and patient level in a national VA sample.We analyzed VA HCV registry data for 171,893 VA patients with confirmed chronic HCV. Delivery system characteristics included geographic region and specialist time. Patient characteristics included antiviral treatment indicators, contraindications, volume of healthcare visits, and demographic variables. Logistic regression was used to explore correlates of biopsy use.Liver biopsy use in the VA system increased from 1997 to 2003 but began declining in 2004. Rates of liver biopsy from 2004 to 2006 varied by VA region, ranging from 5% to 18%. Treatment contraindications and laboratory tests were significantly associated with more biopsies. Demographic variables (higher age, lower BMI, race/ethnicity, and less% service connected disability) were associated with fewer biopsies. Regional variability remained significant independent of volume of care and specialist time.Liver biopsy rates in the VA system have variability that seems unrelated to clinical need. New antiviral therapies and non-invasive assessment techniques may create additional uncertainty for the role of liver biopsy, perhaps explaining its decline in recent years. The availability of more effective antiviral therapies may also affect biopsy rates in the future.

    View details for Web of Science ID 000307685300008

    View details for PubMedID 22521358

  • California Hospitals Serving Large Minority Populations Were More Likely Than Others To Employ Ambulance Diversion HEALTH AFFAIRS Hsia, R. Y., Asch, S. M., Weiss, R. E., Zingmond, D., Liang, L., Han, W., McCreath, H., Sun, B. C. 2012; 31 (8): 1767-1776


    It is well documented that racial and ethnic minority populations disproportionately use hospital emergency departments for safety-net care. But what is not known is whether emergency department crowding is disproportionately affecting minority populations and potentially aggravating existing health care disparities, including poorer outcomes for minorities. We examined ambulance diversion, a proxy measure for crowding, at 202 California hospitals. We found that hospitals serving large minority populations were more likely to divert ambulances than were hospitals with a lower proportion of minorities, even when controlling for hospital ownership, emergency department capacity, and other hospital demographic and structural factors. These findings suggest that establishing more-uniform criteria to regulate diversion may help reduce disparities in access to emergency care.

    View details for DOI 10.1377/hlthaff.2011.1020

    View details for Web of Science ID 000307498200014

    View details for PubMedID 22869655

    View details for PubMedCentralID PMC3618957

  • The Quality of Care Provided to Patients With Cirrhosis and Ascites in the Department of Veterans Affairs GASTROENTEROLOGY Kanwal, F., Kramer, J. R., Buchanan, P., Asch, S. M., Assioun, Y., Bacon, B. R., Li, J., El-Serag, H. B. 2012; 143 (1): 70-77


    Ascites are the most common complication of cirrhosis. Evidence-based guidelines define the criteria and standards of care for patients with cirrhosis and ascites. However, little is known about the extent to which patients with ascites meet these standards.We evaluated the quality of ascites care, measured by 8 explicit Delphi panel-derived quality indicators, in 774 patients with cirrhosis and ascites, seen at 3 Veterans Affairs Medical Centers between 2000 and 2007. We also conducted a structured implicit review of patients' medical charts to determine whether patient refusal, outside care, or other justifiable exceptions to care processes account for nonadherence to the quality indicators.Quality scores (maximum 100%) varied among individual indicators, ranging from 30% for secondary prophylaxis of spontaneous bacterial peritonitis, to 90% for assays for cell number and type in the paracentesis fluid. In general, care targeted at treatment was more likely to meet standards than preventive care. Only 33.2% (95% confidence interval [CI]: 29.9%-32.9%) of patients received all recommended care. Patients with no comorbidity (Deyo index 0 vs >3; odds ratio = 2.21; 95% CI: 1.43-3.43), who saw a gastroenterologist (odds ratio = 1.33; 95% CI, 1.01-1.74), or were seen in a facility with academic affiliation (odds ratio = 1.73; 95% CI: 1.29-2.35) received higher-quality care. Justifiable exceptions to indicated care, documented in charts, were common for patients with paracentesis after diagnosis with ascites, patients that received antibiotics for gastrointestinal bleeding, and patients that required diuretics. However, most patients did not have an explanation documented for nonadherence to recommended care.Health care quality, measured by whether patients received recommended services, was suboptimal for patients with cirrhosis-related ascites. Care that included gastroenterologists was associated with high quality. However, for some of the quality indicators, too many denominator exceptions existed to allow for accurate automated measurement.

    View details for DOI 10.1053/j.gastro.2012.03.038

    View details for Web of Science ID 000305781500030

    View details for PubMedID 22465432

  • A NOVEL CONCEPTUAL MODEL FOR CLINICAL DECISION COMPLEXITY Zulman, D. M., Martins, S. B., Asch, S., Goldstein, M. K. SPRINGER. 2012: S106–S107


    Human immunodeficiency virus (HIV) screening is cost-effective and recommended in populations with low disease prevalence. However, because screening is not cost-saving, its financial feasibility must be understood.We forecast the costs of two Emergency Department-based HIV testing programs in the Veterans Administration: 1) implementing a non-targeted screening program and providing treatment for all patients thusly identified (Rapid Testing); and 2) treating patients identified due to late-stage symptoms (Usual Care); to determine which program was the most financially feasible.Using a dynamic decision-analysis model, we estimated the financial impact of each program over a 7-year period. Costs were driven by patient disease-severity at diagnosis, measured by CD4+ category, and the proportion of patients in each disease-severity category. Cost per CD4+ category was modeled from chart review and database analysis of treatment-naïve HIV-positive patients. Distributions of CD4+ counts differed in patients across the Rapid Testing and Usual Care arms.A non-targeted Rapid Testing program was not significantly more costly than Usual Care. Although Rapid Testing had substantial screening costs, they were offset by lower inpatient expenses associated with earlier identification of disease. Assuming an HIV prevalence of 1% and 80% test acceptance, the cost of Rapid Testing was $1,418,088, vs. $1,320,338 for Usual Care (p=0.5854). Results support implementation of non-targeted rapid HIV screening in integrated systems.This analysis adds a new component of support for HIV screening by demonstrating that rapid, non-targeted testing does not cost significantly more than a diagnostic testing approach.

    View details for DOI 10.1016/j.jemermed.2010.11.038

    View details for Web of Science ID 000305591000019

    View details for PubMedID 21277144

  • Provider Stakeholders' Perceived Benefit from a Nascent Health Information Exchange: A Qualitative Analysis JOURNAL OF MEDICAL SYSTEMS Pevnick, J. M., Claver, M., Dobalian, A., Asch, S. M., Stutman, H. R., Tomines, A., Fu, P. 2012; 36 (2): 601-613


    We sought to better understand the perceived costs and benefits of joining a nascent health information exchange (HIE) from the perspective of potential provider organization participants. We therefore conducted semi-structured interviews with organizational representatives. Interview transcriptions were thematically coded, and coded text was subsequently aggregated to summarize the breadth and depth of responses. Although no respondents expected HIE to result in net financial benefit to their organization, all respondents recognized some potential benefits, and some respondents expected HIE to result in overall organizational benefit. Disproportionate benefit was expected for the poorest, sickest patients. Many respondents had concerns about HIE increasing the risk of data security breaches, and these concerns were most pronounced at larger organizations. We found little evidence of organizational concern regarding loss of patients to other organizations or publication of unfavorable quality data. If HIE's greatest benefactors are indeed the poorest, sickest patients, our current health care financing environment will make it difficult to align HIE costs with benefits. To sustain HIE, state and federal governments may need to consider ongoing subsidies. Furthermore, these governments will need to ensure that policies regulating data exchange have sufficient nationwide coordination and liability limitations that the perceived organizational risks of joining HIEs do not outweigh perceived benefits. HIE founders can address organizational concerns by attempting to coordinate HIE policies with those of their largest founding organizations, particularly for data security policies. Early HIE development and promotional efforts should not only focus on potential benefits, but should also address organizational concerns.

    View details for DOI 10.1007/s10916-010-9524-x

    View details for Web of Science ID 000303825500026

    View details for PubMedID 20703673

  • Evaluation of Human Immunodeficiency Virus and Hepatitis C Telemedicine Clinics AMERICAN JOURNAL OF MANAGED CARE Saifu, H. N., Asch, S. M., Goetz, M. B., Smith, J. P., Graber, C. J., Schaberg, D., Sun, B. C. 2012; 18 (4): 207-212


    Geographical barriers to subspecialty care may prevent optimal care of patients living in rural areas. We assess the impact of human immunodeficiency virus (HIV) and hepatitis C telemedicine consultation on patient-oriented outcomes in a rural Veterans Affairs population.This was a pre- and post-intervention study comparing telemedicine with in-person subspecialty clinic visits for HIV and hepatitis C. Eligible patients resided in 2 rural catchment areas. The primary binary outcome was clinic completion. We estimated a logistic regression model with patient-level fixed effects. This approach controls for the clustering of visits by patient, uses each patient's in-person clinic experience as an internal control group, and eliminates confounding by person-level factors. We also surveyed patients to assess satisfaction and patient-perceived reductions in health visit-related time.There were 43 patients who accounted for 94 telemedicine visits and 128 in-person visits. Clinic completion rates were higher for telemedicine (76%) than for in-person visits (61%). In regression analyses, telemedicine was strongly predictive of clinic completion (OR 2.2; 95% confidence interval [CI]: 1.0-4.7). The adjusted effect of telemedicine on clinic completion rate was 13% (95% CI: 12-13). Of the 30 patients (70%) who completed the survey, more than 95% rated telemedicine at the highest level of satisfaction and preferred telemedicine to in-person clinic visits. Patients reported a significant reduction in health visit-related time (median 340 minutes, interquartile range 250-440), mostly due to decreased travel time.HIV and hepatitis C telemedicine clinics are associated with improved access, high patient satisfaction, and reduction in health visit-related time.

    View details for Web of Science ID 000308443000003

    View details for PubMedID 22554009

  • Translation of Evidence-Based Clinical Standards into a New Prehospital Resuscitation Policy in Los Angeles County HEALTH SERVICES RESEARCH Grudzen, C. R., Richardson, L. D., Koenig, W. J., Hoffman, J. R., Lorenz, K. A., Asch, S. M. 2012; 47 (1): 363-379


    To translate a set of evidence-based clinical standards designed to allow paramedics to forego unnecessary and potentially harmful resuscitation attempts into a feasible new policy.Policy documents, meeting minutes, and personal communications between a large urban Emergency Medical Services (EMS) agency serving all of Los Angeles County (LAC) and a research group were reviewed over 12 months.LAC EMS and University of California, Los Angeles (UCLA) formed a partnership (the EMS-UCLA Collaborative) to develop and translate the standards into new EMS protocols. Clinical indicators considered appropriate and feasible by an expert panel were submitted to the agency for inclusion in the new policy.The Collaborative submitted the results to the LAC EMS Commission and a physician advisory group for review. Of the 41 indicators approved by the expert panel, 22 would have resulted in changes to the current policy. All six involved asking family members about or honoring written and verbal Do Not Attempt Resuscitate requests, but only 4 of the 16 indicators based on clinical characteristics were included in the new policy. Ultimately, 10 of the 22 indicators that would have changed policy were approved and implemented.By collaboration, a large EMS agency and a research team were able to develop and implement a revised resuscitation policy within 1 year.

    View details for DOI 10.1111/j.1475-6773.2011.01341.x

    View details for Web of Science ID 000299041600004

    View details for PubMedID 22091960

  • Methods for improving efficiency in quality measurement: the example of pain screening INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE Bentley, T. G., Malin, J., Longino, S., Asch, S., Dy, S., Lorenz, K. A. 2011; 23 (6): 657-663


    Collecting unnecessary data when assessing quality of care wastes valuable resources. We evaluated three approaches for estimating quality-measure adherence and determined minimum visit data required to achieve accurate estimates.We abstracted medical records for calculating physician-level pain screening rates as: visit-specific, using single-visit data for each patient; visit-level average, using data for all patients and visits; and patient-level average, using data from a subset of patients and visits.VA Greater Los Angeles Health-care System, 2006.One hundred and six patients with Stage IV solid tumors.Pain screening at every medical encounter, measured by a 0-10 numeric rating scale and reported to the national Medicare insurance program under a 'pay-for-reporting' program.Amount of visit data needed to reach the smallest 95% confidence interval (CI) and stable pain screening estimates.Pain screening occurred at 22% (23/106; 95% CI: 14-30%) of initial visits and 50% (8/16; 95% CI: 25-75%) of single visits. Across all visits, screening adherence averaged 34% when estimated at the visit-level precision and 30% at the patient level. Maximum patient-level precision was reached at visit 4 (95% CI: ± 8%) and visit level at visit 14 (95% CI: ± 6%). Using patient-level and visit-level approaches, estimates stabilized at visits 8 and 11, respectively, and reached within 1 percentage point of the steady-state value at visits 4 and 9.To address low-pain screening among cancer patients, an oncology pain screening measure may be most efficiently evaluated with data from a sample of patients and visits. This approach may be valid for visit-level quality measures in other settings.

    View details for DOI 10.1093/intqhc/mzr054

    View details for Web of Science ID 000297067900006

    View details for PubMedID 21846733

  • Access to care for vulnerable veterans with hepatitis C: a hybrid conceptual framework and a case study to guide translation TRANSLATIONAL BEHAVIORAL MEDICINE Rongey, C., Asch, S., Knight, S. J. 2011; 1 (4): 644-651


    The Veterans Health Administration (VHA) is the largest single provider of medical care to people with hepatitis C (HCV) in the USA. Given the advent of promising new HCV therapies, the VHA is now faced with a large number of chronically HCV-infected veterans with concomitant psychiatric or substance use comorbid conditions who will need to either be retreated or newly treated for HCV or will require management for chronic liver disease. There is a critical need in the VHA for behavioral medicine and hepatology specialists, along with infectious disease and primary care providers with an interest in hepatitis C, to provide coordinated care for these complex patients. The VHA Health Services Research and Development Service has advocated for the application of strong implementation science theories and methods to translate new models of healthcare delivery in clinical practice. To inform the delivery and evaluation of integrated behavioral medicine and specialty care for vulnerable patient populations, we sought to develop an enriched framework which incorporates implementation science theory and strong conceptual models for access to care. In this paper, we present a hybrid conceptual framework that accomplishes this goal. To illustrate how this hybrid model could inform the translation of a novel method of healthcare delivery, we provide a case study of a VHA initiative to improve access to integrated behavioral medicine and specialty care among veterans with HCV.

    View details for DOI 10.1007/s13142-011-0098-z

    View details for Web of Science ID 000209412200022

    View details for PubMedCentralID PMC3717662

  • Emergency Medicine Physicians' Perspectives of Providing Palliative Care in an Emergency Department JOURNAL OF PALLIATIVE MEDICINE Stone, S. C., Mohanty, S., Grudzen, C. R., Shoenberger, J., Asch, S., Kubricek, K., Lorenz, K. A. 2011; 14 (12): 1333-1338


    This study describes emergency physicians' perspectives on the challenges and benefits to providing palliative care in an academic, urban, public hospital in Los Angeles. Participants underwent a semi-structured interview on their training and experiences related to palliative care, perceptions of providing palliative care, and their recommendations for education and training in this area. Overall, respondents felt that palliative care is not prioritized appropriately, leading patients to be unaware of their options for end-of-life care. Providing educational materials and courses that have been developed from the ED perspective should be included in ongoing continuing medical education. Having a palliative care team that is responsive to the needs of the ED will further enhance collaboration with the ED. Future research should focus on understanding the range of benefits to having palliative care in the ED.

    View details for DOI 10.1089/jpm.2011.0106

    View details for Web of Science ID 000298145800012

    View details for PubMedID 22136262

  • Patterns and Predictors of Short-Term Death After Emergency Department Discharge ANNALS OF EMERGENCY MEDICINE Gabayan, G. Z., Derose, S. F., Asch, S. M., Yiu, S., Lancaster, E. M., Poon, K. T., Hoffman, J. R., Sun, B. C. 2011; 58 (6): 551-558


    The emergency department (ED) is an inherently high-risk setting. Early death after an ED evaluation is a rare and devastating outcome; understanding it can potentially help improve patient care and outcomes. Using administrative data from an integrated health system, we describe characteristics and predictors of patients who experienced 7-day death after ED discharge.Administrative data from 12 hospitals were used to identify death after discharge in adults aged 18 year or older within 7 days of ED presentation from January 1, 2007, to December 31, 2008. Patients who were nonmembers of the health system, in hospice care, or treated at out-of-network EDs were excluded. Predictors of 7-day postdischarge death were identified with multivariable logistic regression.The study cohort contained a total of 475,829 members, with 728,312 discharges from Kaiser Permanente Southern California EDs in 2007 and 2008. Death within 7 days of discharge occurred in 357 cases (0.05%). Increasing age, male sex, and number of preexisting comorbidities were associated with increased risk of death. The top 3 primary discharge diagnoses predictive of 7-day death after discharge included noninfectious lung disease (odds ratio [OR] 7.1; 95% confidence interval [CI] 2.9 to 17.4), renal disease (OR 5.6; 95% CI 2.2 to 14.2), and ischemic heart disease (OR 3.8; 95% CI 1.0 to 13.6).Our study suggests that 50 in 100,000 patients in the United States die within 7 days of discharge from an ED. To our knowledge, our study is the first to identify potentially "high-risk" discharge diagnoses in patients who experience a short-term death after discharge.

    View details for DOI 10.1016/j.annemergmed.2011.07.001

    View details for Web of Science ID 000298224600012

    View details for PubMedID 21802775

  • Exportability of an intervention to increase HIV testing in the Veterans Health Administration. Joint Commission journal on quality and patient safety / Joint Commission Resources Goetz, M. B., Hoang, T., Knapp, H., Henry, S. R., Anaya, H., Chou, A. F., Gifford, A. L., Asch, S. M. 2011; 37 (12): 553-559


    Exportability, or the dissemination of successful health services interventions from one site to another, must be demonstrated before systemwide implementation.The effectiveness of a previously successful multicomponent intervention to increase rates of HIV testing in Veterans Health Administration (VHA) health care facilities among those without records of previous testing was evaluated in two other VHA facilities. Whereas the principle responsibility for the provider-activation component of the intervention was previously borne by research staff, nonresearch staff now took on these responsibilities.The annual rate of HIV testing among persons with documented risk factors for acquiring HIV infection increased by 5.8% and 16% after the end of the first year of implementation for the sites to which the project was newly exported and where nonresearch staff were responsible for implementation. In contrast, for the original implementation sites, where research staff played a major role in implementation, testing rates increased by 9.3% and 12.4%. There was no change in the rate of testing at a control site. At one site, HIV testing rates increased before implementation of the provider activation aspect of the intervention program.An intervention to increase HIV testing rates, which combines informatics, organizational support, and provider activation, can be successfully exported and implemented by nonresearch staff and may not require an extensive provider activation program. The resultant increases in HIV testing are similar to those seen in facilities where research staff play an active role. This work provides support for further efforts to refine this program to promote non-risk-based testing for HIV infection, as per current VHA policy and to more broadly implement this program.

    View details for PubMedID 22235540

  • Provider and Practice Characteristics Associated with Use of Rapid HIV Testing by General Internists JOURNAL OF GENERAL INTERNAL MEDICINE Bass, M. G., Korthuis, P. T., Cofrancesco, J., Berkenblit, G. V., Sullivan, L. E., Asch, S. M., Bashook, P. G., Edison, M., Sosman, J. M., Cook, R. L. 2011; 26 (11): 1258-1264


    Rapid HIV testing could increase routine HIV testing. Most previous studies of rapid testing were conducted in acute care settings, and few described the primary care providers' perspective.To identify characteristics of general internal medicine physicians with access to rapid HIV testing, and to determine whether such access is associated with differences in HIV-testing practices or perceived HIV-testing barriers.Web-based cross-sectional survey conducted in 2009.A total of 406 physician members of the Society of General Internal Medicine who supervise residents or provide care in outpatient settings.Surveys assessed provider and practice characteristics, HIV-testing types, HIV-testing behavior, and potential barriers to HIV testing.Among respondents, 15% had access to rapid HIV testing. In multivariable analysis, physicians were more likely to report access to rapid testing if they were non-white (OR 0.45, 95% CI 0.22, 0.91), had more years since completing training (OR 1.06, 95% CI 1.02, 1.10), practiced in the northeastern US (OR 2.35; 95% CI 1.28, 4.32), or their practice included a higher percentage of uninsured patients (OR 1.03; 95% CI 1.01, 1.04). Internists with access to rapid testing reported fewer barriers to HIV testing. More respondents with rapid than standard testing reported at least 25% of their patients received HIV testing (51% versus 35%, p = 0.02). However, access to rapid HIV testing was not significantly associated with the estimated proportion of patients receiving HIV testing within the previous 30 days (7.24% vs. 4.58%, p = 0.06).Relatively few internists have access to rapid HIV testing in outpatient settings, with greater availability of rapid testing in community-based clinics and in the northeastern US. Future research may determine whether access to rapid testing in primary care settings will impact routinizing HIV testing.

    View details for DOI 10.1007/s11606-011-1764-z

    View details for Web of Science ID 000295683500009

    View details for PubMedID 21710314

  • Hospital Determinants of Emergency Department Left Without Being Seen Rates ANNALS OF EMERGENCY MEDICINE Hsia, R. Y., Asch, S. M., Weiss, R. E., Zingmond, D., Liang, L., Han, W., McCreath, H., Sun, B. C. 2011; 58 (1): 24-32


    The proportion of patients who leave without being seen in the emergency department (ED) is an outcome-oriented measure of impaired access to emergency care and represents the failure of an emergency care delivery system to meet its goals of providing care to those most in need. Little is known about variation in the amount of left without being seen or about hospital-level determinants. Such knowledge is necessary to target hospital-level interventions to improve access to emergency care. We seek to determine whether hospital-level socioeconomic status case mix or hospital structural characteristics are predictive of ED left without being seen rates.We performed a cross-sectional study of all acute-care, nonfederal hospitals in California that operated an ED in 2007, using data from the California Office of Statewide Health Planning and Development database and the US census. Our outcome of interest was whether a visit to a given hospital ED resulted in left without being seen. The proportion of left without being seen was measured by the number of left without being seen cases out of the total number of visits.We studied 9.2 million ED visits to 262 hospitals in California. The percentage of left without being seen varied greatly over hospitals, ranging from 0% to 20.3%, with a median percentage of 2.6%. In multivariable analyses adjusting for hospital-level socioeconomic status case mix, visitors to EDs with a higher proportion of low-income and poorly insured patients experienced a higher risk of left without being seen. We found that the odds of an ED visit resulting in left without being seen increased by a factor of 1.15 for each 10-percentage-point increase in poorly insured patients, and odds of left without being seen decreased by a factor of 0.86 for each $10,000 increase in household income. When hospital structural characteristics were added to the model, county ownership, trauma center designation, and teaching program affiliation were positively associated with increased probability of left without being seen (odds ratio 2.09; 1.62, and 2.14, respectively), and these factors attenuated the association with insurance status.Visitors to different EDs experience a large variation in their probability of left without being seen, and visitors to hospitals serving a high proportion of low-income and poorly insured patients are at disproportionately higher risk of leaving without being seen. Our findings suggest that there is room for substantial improvement in this outcome, and regional interventions can be targeted toward certain at-risk hospitals to improve access to emergency care.

    View details for DOI 10.1016/j.annemergmed.2011.01.009

    View details for Web of Science ID 000292341100008

    View details for PubMedID 21334761

  • GENERAL INTERNISTS' BELIEFS, BEHAVIORS, AND PERCEIVED BARRIERS TO ROUTINE HIV SCREENING IN PRIMARY CARE AIDS EDUCATION AND PREVENTION Korthuis, P. T., Berkenblit, G. V., Sullivan, L. E., Cofrancesco, J., Cook, R. L., Bass, M., Bashook, P. G., Edison, M., Asch, S. M., Sosman, J. M. 2011; 23 (3): 70-83


    The Centers for Disease Control and Prevention (CDC) recommends routine HIV screening in primary care but little is known about general internists' views of this practice. We conducted a national, cross-sectional, Internet-based survey of 446 general internists in 2009 regarding their HIV screening behaviors, beliefs, and perceived barriers to routine HIV screening in outpatient internal medicine practices. Internists' awareness of revised CDC guidelines was high (88%), but only 52% had increased HIV testing, 61% offered HIV screening regardless of risk, and a median 2% (range 0-67%) of their patients were tested in the past month. Internists practicing in perceived higher risk communities reported greater HIV screening. Consent requirements were a barrier to screening, particularly for VA providers and those practicing in states with HIV consent statutes inconsistent with CDC guidelines. Interventions that promote HIV screening regardless of risk and streamlined consent requirements will likely increase adoption of routine HIV screening in general medicine practices.

    View details for PubMedID 21689038

  • Clinical quality measures for intraoperative and perioperative management in carpal tunnel surgery. Hand (New York, N.Y.) Nuckols, T. K., Maggard Gibbons, M., Harness, N. G., Chang, W. T., Chung, K. C., Asch, S. M. 2011; 6 (2): 119-131


    Previous research documents suboptimal preoperative or postoperative care for patients undergoing surgery. However, few existing quality measures directly address the fundamental element of surgical care: intra-operative care processes. This study sought to develop quality measures for intraoperative, preoperative, and postoperative care for carpal tunnel surgery, a common operation in the USA.We applied a variation of the well-established RAND/UCLA Appropriateness Method. Adherence to measures developed using this method has been associated with improved patient outcomes in several studies. Hand surgeons and quality measurement experts developed draft measures using guidelines and literature. Subsequently, in a two-round modified-Delphi process, a multidisciplinary panel of 11 national experts in carpal tunnel syndrome (including six surgeons) reviewed structured summaries of the evidence and rated the measures for validity (association with improved patient outcomes) and feasibility (ability to be assessed using medical records).Of 25 draft measures, panelists judged 22 (88%) to be valid and feasible. Nine intraoperative measures addressed the location and extent of surgical dissection, release after wrist trauma, endoscopic release, and four procedures sometimes performed during carpal tunnel surgery. Eleven measures covered preoperative and postoperative evaluation and management.We have developed several measures that experts, including surgeons, believe to reflect the quality of care processes occurring during carpal tunnel surgery and be assessable using medical records. Although quality measures like these cannot assess a surgeon's skill in handling the instruments, they can assess many important aspects of intraoperative care. Intraoperative measures should be developed for other procedures.

    View details for DOI 10.1007/s11552-011-9325-9

    View details for PubMedID 21776197

  • Prescription Sharing, Alcohol Use, and Street Drug Use to Manage Pain Among Veterans JOURNAL OF PAIN AND SYMPTOM MANAGEMENT Goebel, J. R., Compton, P., Zubkoff, L., Lanto, A., Asch, S. M., Sherbourne, C. D., Shugarman, L., Lorenz, K. A. 2011; 41 (5): 848-858


    Efforts to promote awareness and management of chronic pain have been accompanied by a troubling increase in prescription medication abuse. At the same time, some patients may misuse substances in an effort to manage chronic pain.This study examines self-reported substance misuse for pain management among veterans and identifies the contributing factors.We analyzed cross-sectional data from the Help Veterans Experience Less Pain study.Of 343 veterans, 35.3% reported an aberrant pain management behavior (24% reported using alcohol, 11.7% reported using street drugs, and 16.3% reported sharing prescriptions to manage pain). Poorer mental health, younger age, substance use disorders (SUDs), number of nonpain symptoms, and greater pain severity and interference were associated with aberrant pain management behaviors. In multivariate analysis, SUDs (odds ratio [OR]: 3.9, 95% confidence interval [CI]: 2.3-6.7, P<0.000) and poorer mental health (OR: 2.3, 95% CI: 1.3-4.3, P=0.006) were associated with using alcohol or street drugs to manage pain; SUDs (OR: 2.4, 95% CI: 1.3-4.4, P=0.006) and pain interference (OR: 1.1, 95% CI: 1.0-1.2, P=0.047) were associated with prescription sharing; and SUDs (OR: 3.6, 95% CI: 2.2-6.1, P<0.000) and number of nonpain symptoms (OR: 6.5, 95% CI: 1.2-35.4, P=0.031) were associated with any aberrant pain management behavior.Veterans with a history of SUDs, greater pain interference, more nonpain symptoms, and mental health concerns should be carefully managed to deter substance misuse for pain management.

    View details for DOI 10.1016/j.jpainsymman.2010.07.009

    View details for Web of Science ID 000290942200008

    View details for PubMedID 21256706

  • Quality of Supportive Care for Patients with Advanced Cancer in a VA Medical Center JOURNAL OF PALLIATIVE MEDICINE Malin, J. L., O'Neill, S. M., Asch, S. M., Dy, S. M., Walling, A. M., Tisnado, D., Antonio, A. L., Lorenz, K. A. 2011; 14 (5): 573-577


    Using the Assessing Symptoms Side Effects and Indicators of Supportive Treatment (ASSIST) quality indicators (QIs), we conducted a comprehensive evaluation of the quality of care provided in our institution to patients diagnosed with advanced cancer in 2006.Patients diagnosed with a Stage IV solid tumor were identified from the hospital's cancer registry. Using data abstracted from medical records, care was assessed using 41 explicit QIs. Mean percent adherence to QIs was calculated overall, as well as across five clinical domains: (1) Pain, (2) Depression and Psychosocial Distress, (3) Dyspnea, (4) Treatment Toxicity, (5) Other Symptoms, and (6) Information and Care Planning.The study cohort (n = 118) was almost all male (2% female) and mean age was 65.9 years (standard deviation [SD] 9.9 years). The most common cancers were lung and head and neck cancer (23% each); 17% had prostate cancer; 13% had colorectal cancer; and the rest (24%) had breast, esophageal, stomach, genitourinary, liver/biliary, or pancreas cancer. Patients received 51% (95% confidence interval [CI] 48%-54%) of recommended care. Adherence to recommended care within domains ranged from 38% (95% CI 35%-42%) for Other Symptoms to 79% (95% CI 73%-86%) for Information and Care Planning.This study suggests that the quality of supportive care for patients with advanced cancer can be greatly improved. Future efforts should use the ASSIST indicators to evaluate the quality of supportive care in larger and more diverse cohorts of advanced cancer patients.

    View details for DOI 10.1089/jpm.2010.0464

    View details for Web of Science ID 000290756700012

    View details for PubMedID 21413885

  • A provider participatory implementation model for HIV testing in an ED AMERICAN JOURNAL OF EMERGENCY MEDICINE Chen, J. C., Goetz, M. B., Feld, J. E., Taylor, A., Anaya, H., Burgess, J., Flores, R. d., Gidwani, R. A., Knapp, H., Ocampo, E. H., Asch, S. M. 2011; 29 (4): 418-426


    The Centers for Disease Control and Prevention recommends routine HIV screening for adults.Community-based participatory research incorporates subjects in the design and conduct of research. We included nurses and physicians in the implementation of HIV rapid test use in the emergency department (ED). We explored the process, facilitators, and barriers.We identified clinical champions and trained staff. Physicians obtained consent and ordered HIV testing; nurses performed rapid testing. Testing rates were tracked by electronic medical record. We conducted regular meetings between staff and researchers. Semistructured qualitative interviews with providers were conducted at 3 months.By week 15, we administered 121 tests. After the eligibility protocol evolved to incorporate ED nursing concerns regarding staffing limitations from a random sampling model to one focused on testing during nonpeak hours, the weekly number of tests increased. Eighteen percent of providers favored nontargeted HIV screening, 27% favored the current model of testing at nonpeak hours, 32% supported diagnostic testing, and 18% favored no testing or "other." Barriers include written consent, electronic documentation, time constraints, and belief that screening is not a core ED duty. Facilitators include ease of test administration, belief that ED patients are at higher risk, and flexibility to tailor screening efforts according to patient volume.The ED-based HIV testing is feasible within a Veterans Hospital Administration setting. Involvement of nursing in a community-based participatory research implementation model may facilitate staff acceptance of nontargeted HIV screening and be a mechanism to initiate administration of clinical preventive services to ED patients with limited primary care contact.

    View details for DOI 10.1016/j.ajem.2009.11.016

    View details for Web of Science ID 000290574600010

    View details for PubMedID 20825814

  • Development of the Hepatitis C Self-Management Program PATIENT EDUCATION AND COUNSELING Groessl, E. J., Weingart, K. R., Gifford, A. L., Asch, S. M., Ho, S. B. 2011; 83 (2): 252-255


    Chronic hepatitis C infection (HCV) is a major health problem that disproportionately affects people with limited resources. Many people with HCV are ineligible or refuse antiviral treatment, but less curative treatment options exist. These options include adhering to follow-up health visits, lifestyle changes, and avoiding hepatotoxins like alcohol. Herein, we describe a recently developed self-management program designed to assist HCV-infected patients with adherence and improve their health-related quality of life (HRQOL).The development of the Hepatitis C Self-Management Program (HCV-SMP) was informed by scientific literature, qualitative interviews with HCV-infected patients, self-management training, and feedback from HCV clinical experts.The Hepatitis C Self-Management Program (HCV-SMP) is a multi-faceted program that employs cognitive-behavioral principles and is designed to provide HCV-infected people with knowledge and skills for improving their HRQOL. The program consists of six 2-h workshop sessions which are held weekly. The sessions consist of a variety of group activities, including disease-specific information dissemination, action planning, and problem-solving.The intervention teaches skills for adhering to challenging treatment recommendations using a validated theoretical model. A randomized trial will test the efficacy of this novel HCV self-management program for improving HRQOL in a difficult to reach population.

    View details for DOI 10.1016/j.pec.2010.06.006

    View details for Web of Science ID 000290929200020

    View details for PubMedID 20638216

  • The hepatitis C self-management programme: a randomized controlled trial JOURNAL OF VIRAL HEPATITIS Groessl, E. J., Weingart, K. R., Stepnowsky, C. J., Gifford, A. L., Asch, S. M., Ho, S. B. 2011; 18 (5): 358-368


    Chronic hepatitis C (HCV) infection afflicts millions of people worldwide. While antiviral treatments are effective for some patients, many either cannot or choose not to receive antiviral treatment. Education about behavioural changes like alcohol avoidance and symptom management, in contrast, is universally recommended, particularly in HCV-infected persons from disadvantaged groups where liver risk factors are most prevalent. Self-management interventions are one option for fostering improved HCV knowledge and health-related quality of life (HRQOL). One hundred and thirty-two patients with VA with HCV (mean age of 54.6, 95% men, 41% ethnic minority, 83% unmarried, 72% unemployed/disabled, 48% homeless in last 5 years) were randomized to either a 6-week self-management workshop or an information-only intervention. The weekly 2-h self-management sessions were based on cognitive-behavioural principles and were adapted from an existing self-management programme that has been efficacious with other chronic diseases. HCV-specific modules were added. Outcomes including HRQOL, HCV knowledge, self-efficacy, depression, energy and health distress were measured at baseline and 6 weeks later. Data were analysed using ANOVA. When compared to the information-only group, participants attending the self-management workshop improved more on HCV knowledge (P < 0.001), HCV self-efficacy (P = 0.011), and SF-36 energy/vitality (P = 0.040). Similar trends were found for SF-36 physical functioning (P = 0.055) and health distress (P = 0.055). Attending the self-management programme improved disease knowledge and HRQOL 6 weeks later in this disadvantaged population. The intervention can improve the health of people with hepatitis C, independent of antiviral therapy. Future research will study longer-term outcomes, effects on antiviral treatment and costs.

    View details for DOI 10.1111/j.1365-2893.2010.01328.x

    View details for Web of Science ID 000289251900007

    View details for PubMedID 20529203

  • A review of quality measures used by state and federal prisons. Journal of correctional health care : the official journal of the National Commission on Correctional Health Care Damberg, C. L., Shaw, R., Teleki, S. S., Hiatt, L., Asch, S. M. 2011; 17 (2): 122-137


    In response to deficiencies in the delivery of health care in prisons, a number of state correctional systems and the Federal Bureau of Prisons (BOP) have established quality of care monitoring systems. In 2009, the California Department of Corrections and Rehabilitation and the federal receiver overseeing the system asked the RAND Corporation to identify existing indicators of quality performance and to recommend a set of indicators applicable to the prison population. An environmental scan of quality measures being used by other state correctional systems and the BOP found substantial variation in the number and type of measures being used and the underlying data systems used to construct measures. Explicit quality measures were being used, as were measures of disease prevalence and standards.

    View details for DOI 10.1177/1078345810397605

    View details for PubMedID 21525116

  • Quality of End-of-Life Care for Patients with Advanced Cancer in an Academic Medical Center JOURNAL OF PALLIATIVE MEDICINE Morss, S., Asch, S. M., Lorenz, K. A., Weeks, K., Sharma, R. K., Wolff, A. C., Malin, J. L. 2011; 14 (4): 451-457


    We assessed key aspects of the quality of end-of-life care using validated explicit process quality measures in an academic medical center (hospital and cancer center) before expanding to a broader palliative care initiative.We evaluated 21 indicators most relevant to end-of-life care from the Cancer Quality-ASSIST supportive oncology indicator set for 238 patients with advanced/metastatic solid tumors who died between 2-15 months after diagnosis. These included outpatient and hospital indicators for cancer symptoms and information and care planning that met criteria for feasibility, reliability, and validity. We abstracted detailed information from medical records to specify the necessary data elements.Overall adherence was 53% (95% confidence interval [CI], 50%-56%); this varied widely among indicators. Adherence was highest for pain indicators; in particular, 97% of eligible subjects' hospitalizations had documented screening for pain, and, after an outpatient pain medication was changed, 97% of patients had a pain assessment at the subsequent visit. For other symptoms, adherence ranged from 0% for documentation of life expectancy for patients starting parenteral or enteral nutrition to 87% for assessment of nausea or vomiting on hospital admission. For information and care planning, results ranged from 6% for documentation of ventilation preferences prior to intubation to 68% for documented communication of risks and benefits or prognosis prior to starting chemotherapy.In conclusion, Cancer Quality-ASSIST indicators are useful for practical quality assessment of cancer end-of-life care in an academic medical center. These results will serve as useful data for targeting areas for quality improvement and measuring progress.

    View details for DOI 10.1089/jpm.2010.0434

    View details for Web of Science ID 000289235100015

    View details for PubMedID 21391819

  • The current state of quality of care measurement in the California Department of Corrections and Rehabilitation. Journal of correctional health care : the official journal of the National Commission on Correctional Health Care Teleki, S. S., Damberg, C. L., Shaw, R., Hiatt, L., Williams, B., Hill, T. E., Asch, S. M. 2011; 17 (2): 100-121


    The quality of health care in prisons is lacking in many states. In particular, the California Department of Corrections and Rehabilitation (CDCR) is in the midst of an extreme legal remedy to address problems related to access to and quality of care; it now operates under the direction of a federally appointed receiver for medical care. To understand the current state of access and quality measurement and to assess strengths and weaknesses of current activities, the RAND Corporation conducted a series of interviews and site visits in the CDCR and related offices as well as document reviews (December 2008 to February 2009). Findings supported RAND's larger project goals to identify measures for use in a sustainable quality measurement system.

    View details for DOI 10.1177/1078345810397498

    View details for PubMedID 21525115

  • Selecting performance indicators for prison health care. Journal of correctional health care : the official journal of the National Commission on Correctional Health Care Asch, S. M., Damberg, C. L., Hiatt, L., Teleki, S. S., Shaw, R., Hill, T. E., Benjamin-Johnson, R., Eisenman, D. P., Kulkarni, S. P., Wang, E., Williams, B., Yesus, A., Grudzen, C. R. 2011; 17 (2): 138-149


    Improving prison health care requires a robust measurement dashboard that addresses multiple domains of care. We sought to identify tested indicators of clinical quality and access that prison health managers could use to ascertain gaps in performance and guide quality improvement. We used the RAND/UCLA modified Delphi method to select the best indicators for correctional health. An expert panel rated 111 indicators on validity and feasibility. They voted to retain 79 indicators in areas such as access, cardiac conditions, geriatrics, infectious diseases, medication monitoring, metabolic diseases, obstetrics/gynecology, screening/prevention, psychiatric disorders/substance abuse, pulmonary conditions, and urgent conditions. Prison health institutions, like all other large health institutions, need robust measurement systems. The indicators presented here provide a basic library for prison health managers developing such systems.

    View details for DOI 10.1177/1078345810397712

    View details for PubMedID 21525117

  • Increasing Prevalence of HCC and Cirrhosis in Patients With Chronic Hepatitis C Virus Infection GASTROENTEROLOGY Kanwal, F., Tuyen Hoang, T., Kramer, J. R., Asch, S. M., Goetz, M. B., Zeringue, A., Richardson, P., El-Serag, H. B. 2011; 140 (4): 1182-?


    Patients with hepatitis C virus (HCV) infection are at risk for developing costly and morbid complications, although the actual prevalence of these complications is unknown. We examined time trends in the prevalence of cirrhosis and its related complications, such as hepatic decompensation and hepatocellular carcinoma (HCC).We calculated the annual prevalence of cirrhosis, decompensated cirrhosis, and HCC in a national sample of veterans diagnosed with HCV between 1996 and 2006. Patients with HCV who had at least one physician visit in a given calendar year were included in the analysis of prevalence for that year. We used direct standardization to adjust the prevalence of cirrhosis and related complications for increasing age of the cohort as well as sex and changes in clinical characteristics.In this cohort, the number of individuals with HCV increased from 17,261 in 1996 to 106,242 in 2006. The prevalence of cirrhosis increased from 9% in 1996 to 18.5% in 2006. The prevalence of patients with decompensated cirrhosis doubled, from 5% in 1996 to 11% in 2006, whereas the prevalence of HCC increased approximately 20-fold (0.07% in 1996 to 1.3% in 2006). After adjustment, the time trend in the prevalence of cirrhosis (and its complications) was lower than the crude trend, although it still increased significantly.The prevalence of cirrhosis and HCC in HCV-infected patients has increased significantly over the past 10 years. An aging cohort of patients with HCV could partly explain our findings. Clinicians and health care systems should develop strategies to provide timely and effective care to this high-risk population of patients.

    View details for DOI 10.1053/j.gastro.2010.12.032

    View details for Web of Science ID 000288789900025

    View details for PubMedID 21184757

  • Communication with Families Facing Life-Threatening Illness: A Research-Based Model for Family Conferences JOURNAL OF PALLIATIVE MEDICINE Fineberg, I. C., Kawashima, M., Asch, S. M. 2011; 14 (4): 421-427


    Communication is an ongoing challenge for clinicians working with people facing life-threatening illnesses and end of life. Family conferences offer patient-focused, family-oriented care that brings together patients, family members, and health care providers.The aim of this study was to develop a research-based model for family conferences to help physicians and other health care providers conduct such conferences effectively and improve communication with patients and families.We prospectively studied family conferences for patients facing life-threatening illness in two inpatient medical centers. We videotape and audiotape recorded real-life conferences and postconference interviews with participants.Twenty-four family conferences were included in the study. Participants consisted of 24 patients, 10 of whom took part in the family conferences, 49 family members, and 85 health care providers.A multidisciplinary team conducted a qualitative analysis of the videotaped and audiotaped materials using thematic analysis. The team used a multistage approach to independently and collectively analyze and integrate three data sources.The resulting theoretical model for family conferences has 4 main components. These include the underlying structural context of conference organization and the key process components of negotiation and personal stance. Emotional engagement by health care providers, emotion work, appears central to the impact of these components on the successful outcome of the conference. In addition to the theoretical model, the authors found that family conference participants place specific value on the "simultaneous presence" of conference attendees that leads to being on the "same page."Physicians and other health care professionals can use the model as a guide for conducting family conferences and strengthening communication with patients, families and colleagues.

    View details for DOI 10.1089/jpm.2010.0436

    View details for Web of Science ID 000289235100011

    View details for PubMedID 21385083

  • Quality Measures for the Diagnosis and Non-Operative Management of Carpal Tunnel Syndrome in Occupational Settings JOURNAL OF OCCUPATIONAL REHABILITATION Nuckols, T., Harber, P., Sandin, K., Benner, D., Weng, H., Shaw, R., Griffin, A., Asch, S. 2011; 21 (1): 100-119


    Providing higher quality medical care to workers with occupationally associated carpal tunnel syndrome (CTS) may reduce disability, facilitate return to work, and lower the associated costs. Although many workers' compensation systems have adopted treatment guidelines to reduce the overuse of unnecessary care, limited attention has been paid to ensuring that the care workers do receive is high quality. Further, guidelines are not designed to enable objective assessments of quality of care. This study sought to develop quality measures for the diagnostic evaluation and non-operative management of CTS, including managing occupational activities and functional limitations.Using a variation of the well-established RAND/UCLA Appropriateness Method, we developed draft quality measures using guidelines and literature reviews. Next, in a two-round modified-Delphi process, a multidisciplinary panel of 11 U.S. experts in CTS rated the measures on validity and feasibility.Of 40 draft measures, experts rated 31 (78%) valid and feasible. Nine measures pertained to diagnostic evaluation, such as assessing symptoms, signs, and risk factors. Eleven pertain to non-operative treatments, such as the use of splints, steroid injections, and medications. Eleven others address assessing the association between symptoms and work, managing occupational activities, and accommodating functional limitations.These measures will complement existing treatment guidelines by enabling providers, payers, policymakers, and researchers to assess quality of care for CTS in an objective, structured manner. Given the characteristics of previous measures developed with these methods, greater adherence to these measures will probably lead to improved patient outcomes at a population level.

    View details for DOI 10.1007/s10926-010-9260-6

    View details for Web of Science ID 000287505100012

    View details for PubMedID 20737200

  • "I Want To Be Taking My Own Last Breath": Patients' Reflections on Illness When Presenting to the Emergency Department at the End of Life JOURNAL OF PALLIATIVE MEDICINE Grudzen, C. R., Stone, S. C., Mohanty, S. A., Asch, S. M., Lorenz, K. A., Torres, J. M., Morrison, M., Ortiz, J. M., Timmermans, S. 2011; 14 (3): 293-296


    To understand perceptions regarding their illness of patients who present to the Emergency Department at the end of life.Semistructured one-on-one interviews were performed with a convenience sample of seriously ill, Emergency Department (ED) patients with advanced illness presenting to an urban, public hospital. A bilingual Latina health promoter used a predetermined discussion guide to conduct all interviews. Non-English- or Non-Spanish-speaking patients and those with uncontrolled symptoms or cognitive deficits were excluded. All interviews were recorded and transcribed, and grounded theory methodology was used to analyze the results.Thirteen patients with advanced illness participated, 8 of whom were Spanish-speaking only. Because of difficulty accessing care and financial concerns, patients with advanced illness present to EDs when their pain or other symptoms are out of control. The majority derive great comfort and strength from their faith in God, who they believe determines their fate. Most listed spending time with family, and not being a burden, as most important at the end of life, and many expressed a preference to die at home surrounded by loved ones. Almost none had spoken to physicians about their care preferences.Patients with advanced illness present to the ED of a safety net hospital when symptoms are out of control. They have many financial concerns, want to spend their remaining days with family, and do not want to be a burden. Most derive immense comfort from faith in God, but do not feel they have control over their own fate.

    View details for DOI 10.1089/jpm.2010.0306

    View details for Web of Science ID 000287915700011

    View details for PubMedID 21288124

  • Improving Adherence to HIV Quality of Care Indicators in Persons With Opioid Dependence: The Role of Buprenorphine JAIDS-JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES Korthuis, P. T., Fiellin, D. A., Fu, R., Lum, P. J., Altice, F. L., Sohler, N., Tozzi, M. J., Asch, S. M., Botsko, M., Fishl, M., Flanigan, T. P., Boverman, J., McCarty, D. 2011; 56: S83-S90


    Opioid-dependent HIV-infected patients are less likely to receive HIV quality of care indicators (QIs) compared with nondependent patients. Buprenorphine/naloxone maintenance therapy (bup/nx) could affect the quality of HIV care for opioid-dependent patients.We abstracted 16 QIs from medical records at nine HIV clinics 12 months before and after initiation of bup/nx versus other treatment for opioid dependence. Summary quality scores (number of QIs received/number eligible × 100) were calculated. We compared change in QIs and summary quality scores in patients receiving bup/nx versus other participants.One hundred ninety-four of 268 participants (72%) received bup/nx and 74 (28%) received other treatment. Mean summary quality scores increased over 12 months for participants receiving bup/nx (45.6% to 51.6%, P < 0.001) but not other treatment (48.6% to 47.8%, P = 0.788). Bup/nx participants experienced improvements in six of 16 HIV QIs versus three of 16 QIs in other participants. Improvements were mostly in preventive and monitoring care domains. In multivariable analysis, bup/nx was associated with improved summary quality score (β 8.55; 95% confidence interval, 2.06-15.0).In this observational cohort study, HIV-infected patients with opioid dependence received approximately half of HIV QIs at baseline. Buprenorphine treatment was associated with improvement in HIV QIs at 12 months. Integration of bup/nx into HIV clinics may increase receipt of high-quality HIV care. Further research is required to assess the effect of improved quality of HIV care on clinical outcomes.

    View details for PubMedID 21317600

  • Quality indicator set for systemic sclerosis CLINICAL AND EXPERIMENTAL RHEUMATOLOGY Khanna, D., Kowal-Bielecka, O., Khanna, P. P., Lapinska, A., Asch, S. M., Wenger, N., Brown, K. K., Clements, P., Getzug, T., Mayes, M. D., Medsger, T. A., Oudiz, R., Simms, R., Steen, V., Maranian, P., Furst, D. E. 2011; 29 (2): S33-S39


    Systemic sclerosis (SSc) is associated with a marked economic burden, high treatment costs and decreased productivity. Although treatment strategies for SSc can have a substantial effect on patients' outcomes, it is not known whether patients with SSc consistently receive such care. Evaluation of process-of-care quality requires specification of quality indicators (QIs), clinically detailed statements of the eligible patients and the care they should receive to achieve a minimal level of quality of care. Our objective was to develop QIs for patients with SSc.We performed a comprehensive literature review of diagnosis and treatment of SSc and proposed QIs that were evaluated by a national Expert Panel (n=9) who were asked to review the supporting literature and individually rank the validity of each QI. These rankings formed the basis of discussion at a face-to-face meeting following the RAND/UCLA method to integrate expert opinion with literature review to identify a set of final QIs. We then presented these QIs to members of the Scleroderma Clinical Trials Consortium (SCTC).Thirty-two QIs for SSc care were judged valid by the Expert Panel. The QI set includes 9 QIs for newly diagnosed with SSc, 12 follow-up QIs for management of SSc, and 11 treatment QIs. The SCTC experts agreed with the validity of each of the 32 QI and agreed that for all but one QI the specified tests, procedures and treatments recommended in the QI were generally available.We have developed 32 QIs for SSc using a rigorous methodology that can be employed to evaluate and improve care for patients with SSc, as well as inform policy decisions supporting appropriate care for SSc patients.

    View details for Web of Science ID 000291117200006

    View details for PubMedID 21586216

  • Systemic Treatment of Cutaneous Lichen Planus: An Update CUTIS Asch, S., Goldenberg, G. 2011; 87 (3): 129-134


    Lichen planus (LP) is a chronic and remitting dermatosis that may be idiopathic or associated with underlying systemic diseases, such as hepatitis C virus. Although numerous cases of LP resolve spontaneously, many cases require systemic treatment. Several therapeutic advances have occurred in the last 10 years: acitretin (30 mg daily for 8 weeks) remains a first-line therapy (level B, controlled clinical trial >20 participants); systemic corticosteroids are second-line therapies (level C, clinical trial <20 participants, or larger trial without appropriate controls); and new data recommend against the use of tetracycline (level C). This article reviews the current status of systemic therapies for cutaneous LP.

    View details for Web of Science ID 000288830000006

    View details for PubMedID 21488570

  • Effectiveness of Collaborative Care for Depression in Human Immunodeficiency Virus Clinics ARCHIVES OF INTERNAL MEDICINE Pyne, J. M., Fortney, J. C., Curran, G. M., Tripathi, S., Atkinson, J. H., Kilbourne, A. M., Hagedorn, H. J., Rimland, D., Rodriguez-Barradas, M. C., Monson, T., Bottonari, K. A., Asch, S. M., Gifford, A. L. 2011; 171 (1): 23-31


    Depression is common among persons with the human immunodeficiency virus (HIV) and is associated with unfavorable outcomes.A single-blind randomized controlled effectiveness trial at 3 Veterans Affairs HIV clinics (HIV Translating Initiatives for Depression Into Effective Solutions [HITIDES]). The HITIDES intervention consisted of an off-site HIV depression care team (a registered nurse depression care manager, pharmacist, and psychiatrist) that delivered up to 12 months of collaborative care backed by a Web-based decision support system. Participants who completed the baseline telephone interview were 249 HIV-infected patients with depression, of whom 123 were randomized to the intervention and 126 to usual care. Participant interview data were collected at baseline and at the 6- and 12-month follow-up visits. The primary outcome was depression severity measured using the 20-item Hopkins Symptom Checklist (SCL-20) and reported as treatment response (≥50% decrease in SCL-20 item score), remission (mean SCL-20 item score, <0.5), and depression-free days. Secondary outcomes were health-related quality of life, health status, HIV symptom severity, and antidepressant or HIV medication regimen adherence.Intervention participants were more likely to report treatment response (33.3% vs 17.5%) (odds ratio, 2.50; 95% confidence interval [CI], 1.37-4.56) and remission (22.0% vs 11.9%) (2.25; 1.11-4.54) at 6 months but not 12 months. Intervention participants reported more depression-free days during the 12 months (β = 19.3; 95% CI, 10.9-27.6; P < .001). Significant intervention effects were observed for lowering HIV symptom severity at 6 months (β = -2.6; 95% CI, -3.5 to -1.8; P < .001) and 12 months (β = -0.82; -1.6 to -0.07; P = .03). Intervention effects were not significant for other secondary outcomes.The HITIDES intervention improved depression and HIV symptom outcomes and may serve as a model for collaborative care interventions in HIV and other specialty physical health care settings where patients find their "medical home." Identifier: NCT00304915.

    View details for Web of Science ID 000286018100005

    View details for PubMedID 21220657

  • Development and implementation of collaborative care for depression in HIV clinics AIDS CARE-PSYCHOLOGICAL AND SOCIO-MEDICAL ASPECTS OF AIDS/HIV Curran, G. M., Pyne, J., Fortney, J. C., Gifford, A., Asch, S. M., Rimland, D., Rodriguez-Barradas, M., Monson, T. P., Kilbourne, A. M., Hagedorn, H., Atkinson, J. H. 2011; 23 (12): 1626-1636


    We sought to develop and implement collaborative depression care in human immunodeficiency virus (HIV) clinics in a project called HIV Translating Initiatives for Depression into Effective Solutions (HITIDES). Here we describe: (i) the formative evaluation (FE) conducted prior to implementation; (ii) the process used to adapt the primary care collaborative care model for depression to specialty HIV clinics; and (iii) the intervention itself. The overall design of HITIDES was a multi-site randomized trial in United States Department of Veterans Affairs (VA) HIV clinics comparing the depression collaborative care intervention to usual depression care. Qualitative methods were used for the FEs and informed the evidence-based quality improvement (EBQI) methods that were used for adapting and implementing the intervention. Baseline assessments were completed by 249 depressed HIV participants. Summaries of respective key informant interviews with eight HIV patients who were receiving depression treatment and 25 HIV or mental health (MH) providers were presented to each site. EBQI methods were used to tailor the HITIDES intervention to each site while maintaining true to the evidence base for depression collaborative care. EBQI methods provided a useful framework for intervention adaptation and implementation. The HITIDES study provides the opportunity to evaluate collaborative depression care in a specialty physical health clinic setting with a population that has a high prevalence of depression and MH comorbidity.

    View details for DOI 10.1080/09540121.2011.579943

    View details for Web of Science ID 000299481400013

    View details for PubMedID 21714689

  • Systematic Review Comparison of the Quality of Medical Care in Veterans Affairs and Non-Veterans Affairs Settings MEDICAL CARE Trivedi, A. N., Matula, S., Miake-Lye, I., Glassman, P. A., Shekelle, P., Asch, S. 2011; 49 (1): 76-88


    The Veterans Health Administration, the nation's largest integrated delivery system, launched an organizational transformation in the mid 1990 s to improve the quality of its care.To synthesize the evidence comparing the quality of medical and other nonsurgical care in Veterans Affairs (VA) and non-VA settings.MEDLINE database and bibliographies of retrieved studies.Studies comparing the technical quality of nonsurgical care in VA and US non-VA settings published between 1990 and August 2009.Two physicians independently reviewed 175 unique studies identified using the search strategy and abstracted data related to 6 domains of study quality.Thirty-six studies met the inclusion criteria. All 9 general comparative studies showed greater adherence to accepted processes of care or better health outcomes in the VA compared with care delivered outside the VA. Five studies of mortality following an acute coronary event found no clear survival differences between VA and non-VA settings. Three studies of care processes after an acute myocardial infarction found greater rates of evidence-based drug therapy in VA, and 1 found lower use of clinically-appropriate angiography in the VA. Three studies of diabetes care processes demonstrated a performance advantage for the VA. Studies of hospital mortality found similar risk-adjusted mortality rates in VA and non-VA hospitals.Most studies used decade-old data, assessed self-reported service use, or included only a few VA or non-VA sites.Studies that assessed recommended processes of care almost always demonstrated that the VA performed better than non-VA comparison groups. Studies that assessed risk-adjusted mortality generally found similar rates for patients in VA and non-VA settings.

    View details for DOI 10.1097/MLR.0b013e3181f53575

    View details for Web of Science ID 000285407100011

    View details for PubMedID 20966778

  • Use of electronic personal health record systems to encourage HIV screening: an exploratory study of patient and provider perspectives. BMC research notes McInnes, D. K., Solomon, J. L., Bokhour, B. G., Asch, S. M., Ross, D., Nazi, K. M., Gifford, A. L. 2011; 4: 295-?


    When detected, HIV can be effectively treated with antiretroviral therapy. Nevertheless in the U.S. approximately 25% of those who are HIV-infected do not know it. Much remains unknown about how to increase HIV testing rates. New Internet outreach methods have the potential to increase disease awareness and screening among patients, especially as electronic personal health records (PHRs) become more widely available. In the US Department of Veterans' Affairs medical care system, 900,000 veterans have indicated an interest in receiving electronic health-related communications through the PHR. Therefore we sought to evaluate the optimal circumstances and conditions for outreach about HIV screening. In an exploratory, qualitative research study we examined patient and provider perceptions of Internet-based outreach to increase HIV screening among veterans who use the Veterans Health Administration (VHA) health care system.We conducted two rounds of focus groups with veterans and healthcare providers at VHA medical centers. The study's first phase elicited general perceptions of an electronic outreach program to increase screening for HIV, diabetes, and high cholesterol. Using phase 1 results, outreach message texts were drafted and then presented to participants in the second phase. Analysis followed modified grounded theory.Patients and providers indicated that electronic outreach through a PHR would provide useful information and would motivate patients to be screened for HIV. Patients believed that electronic information would be more convenient and understandable than information provided verbally. Patients saw little difference between messages about HIV versus about diabetes and cholesterol. Providers, however, felt patients would disapprove of HIV-related messages due to stigma. Providers expected increased workload from the electronic outreach, and thus suggested adding primary care resources and devising methods to smooth the flow of patients getting screened. When provided a choice between unsecured emails versus PHRs as the delivery mechanism for disease screening messages, both patients and providers preferred PHRs.There is considerable potential to use PHR systems for electronic outreach and social marketing to communicate to patients about, and increase rates of, disease screening, including for HIV. Planning for direct-to-patient communications through PHRs should include providers and address provider reservations, especially about workload increases.

    View details for DOI 10.1186/1756-0500-4-295

    View details for PubMedID 21843313

  • Impact of a kiosk educational module on HIV screening rates and patient knowledge JOURNAL OF TELEMEDICINE AND TELECARE Saifu, H. N., Shamouelian, A., Davis, L. G., Santana-Rios, E., Goetz, M. B., Asch, S. M., Sun, B. C. 2011; 17 (8): 446-450


    We assessed the effect of a kiosk educational module on HIV screening rates and patient knowledge about HIV testing. The evaluation was performed in a walk-in clinic offering routine HIV screening. During alternating two-week periods, patients were referred either to view a kiosk-based, educational module prior to receiving usual care, or the kiosk module was turned off and no alterations to care processes were made. The primary outcome was HIV testing rate. The secondary outcome was knowledge about HIV rapid screening, as measured with a questionnaire. There were 71 patients in the kiosk periods and 79 patients in the usual-care periods. The overall HIV testing rate was 41%. The kiosk period was not associated with greater odds of HIV testing (OR 0.7; 95% CI: 0.4-1.4). In 44 patients who completed the knowledge survey, the kiosk group was strongly associated with increased knowledge (predicted increase in knowledge score: 1.3; 95% CI: 036-2.1). The brief kiosk educational module did not improve HIV screening rates, but it increased overall patient knowledge about HIV testing.

    View details for DOI 10.1258/jtt.2011.110415

    View details for Web of Science ID 000298899400009

    View details for PubMedID 21967998

  • Comparisons of Quality of Surgical Care between the US Department of Veterans Affairs and the Private Sector JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Matula, S. R., Trivedi, A. N., Miake-Lye, I., Glassman, P. A., Shekelle, P., Asch, S. 2010; 211 (6): 823-832
  • Nursing Staff, Patient, and Environmental Factors Associated with Accurate Pain Assessment JOURNAL OF PAIN AND SYMPTOM MANAGEMENT Shugarman, L. R., Goebel, J. R., Lanto, A., Asch, S. M., Sherbourne, C. D., Lee, M. L., Rubenstein, L. V., Wen, L., Meredith, L., Lorenz, K. A. 2010; 40 (5): 723-733


    Although pain ranks highly among reasons for seeking care, routine pain assessment is often inaccurate.This study evaluated factors associated with nurses (e.g., registered) and other nursing support staff (e.g., licensed vocational nurses and health technicians) discordance with patients in estimates of pain in a health system where routine pain screening using a 0-10 numeric rating scale (NRS) is mandated.This was a cross-sectional, visit-based, cohort study that included surveys of clinic outpatients (n=465) and nursing staff (n=94) who screened for pain as part of routine vital sign measurement during intake. These data were supplemented by chart review. We compared patient pain levels documented by the nursing staff (N-NRS) with those reported by the patient during the study survey (S-NRS).Pain underestimation (N-NRSS-NRS) in 7% of the cases. Nursing staff used informal pain-screening techniques that did not follow established NRS protocols in half of the encounters. Pain underestimation was positively associated with more years of nursing staff work experience and patient anxiety or post-traumatic stress disorder and negatively associated with better patient-reported health status. Pain overestimation was positively associated with nursing staff's use of the full NRS protocol and with a distracting environment in which patient vitals were taken.Despite a long-standing mandate, pain-screening implementation falls short, and informal screening is common.

    View details for DOI 10.1016/j.jpainsymman.2010.02.024

    View details for Web of Science ID 000284671400009

    View details for PubMedID 20692807

  • Development of National and Multiagency HIV Care Quality Measures CLINICAL INFECTIOUS DISEASES Horberg, M. A., Aberg, J. A., Cheever, L. W., Renner, P., Kaleba, E. O., Asch, S. M. 2010; 51 (6): 732-738


    Human immunodeficiency virus (HIV) is now a complex, chronic disease requiring high quality care. Demonstration of quality HIV care requires uniform, aligned HIV care quality measurement.In September 2007, the National Committee for Quality Assurance, under contract with the Health Resources and Services Administration, the Physician Consortium for Performance Improvement of the American Medical Association, and HIV Medicine Association of the Infectious Disease Society of America jointly sponsored and convened an expert panel as a HIV/AIDS Work Group to draft national HIV/AIDS performance measures for individual patient-level and system-level quality improvement.A total of 17 measures were developed to assess processes and outcomes of HIV/AIDS care for patients established in care, defined as having at least 2 visits in a 12-month period; thus, measures of HIV screening, testing, linkage, and access to care were not included. As a set, the measures assess a wide range of care, including patient retention, screening and prophylaxis for opportunistic infections, immunization, and initiation and monitoring of potent antiretroviral therapy. Since development, the HIV/AIDS measures' specifications have been fully determined and are being beta tested, and a majority have been endorsed by the National Quality Forum and have been adopted and implemented by the sponsoring organizations.HIV care quality measurement should be assessed with greater uniformity. The measures presented offer opportunities for such alignment.

    View details for DOI 10.1086/655893

    View details for Web of Science ID 000281143400015

    View details for PubMedID 20715924

  • Does Screening for Pain Correspond to High Quality Care for Veterans? JOURNAL OF GENERAL INTERNAL MEDICINE Zubkoff, L., Lorenz, K. A., Lanto, A. B., Sherbourne, C. D., Goebel, J. R., Glassman, P. A., Shugarman, L. R., Meredith, L. S., Asch, S. M. 2010; 25 (9): 900-905


    Routine numeric screening for pain is widely recommended, but its association with overall quality of pain care is unclear.To assess adherence to measures of pain management quality and identify associated patient and provider factors.A cross-sectional visit-based study.One hundred and forty adult VA outpatient primary care clinic patients reporting a numeric rating scale (NRS) of moderate to severe pain (four or more on a zero to ten scale). Seventy-seven providers completed a baseline survey regarding general pain management attitudes and a post-visit survey regarding management of 112 participating patients.We used chart review to determine adherence to four validated process quality indicators (QIs) including noting pain presence, pain character, and pain control, and intensifying pharmacological intervention. The average NRS was 6.7. Seventy-three percent of charts noted the presence of pain, 13.9% the character, 23.6% the degree of control, and 15.3% increased pain medication prescription. Charts were more likely to include documentation of pain presence if providers agreed that "patients want me to ask about pain" and "pain can have negative consequences on patient's functioning". Charts were more likely to document character of pain if providers agreed that "patients are able to rate their pain". Patients with musculoskeletal pain were less likely to have chart documentation of character of pain.Despite routine pain screening in VA, providers seldom documented elements considered important to evaluation and treatment of pain. Improving pain care may require attention to all aspects of pain management, not just screening.

    View details for DOI 10.1007/s11606-010-1301-5

    View details for Web of Science ID 000280728300009

    View details for PubMedID 20229139

  • Quality of Care in Patients With Chronic Hepatitis C Virus Infection A Cohort Study ANNALS OF INTERNAL MEDICINE Kanwal, F., Schnitzler, M. S., Bacon, B. R., Hoang, T., Buchanan, P. M., Asch, S. M. 2010; 153 (4): 231-U49


    Medicare has proposed quality-of-care indicators for chronic hepatitis C virus (HCV) infection. The extent to which these standards are met in practice is largely unknown.To evaluate the quality of health care that patients with HCV receive and the factors associated with receipt of quality care.Retrospective cohort study.Nationwide U.S. health insurance company research database.10 385 patients with HCV enrolled in the database between 2003 and 2006. Patients were included if they were eligible for at least 1 quality indicator.Quality of HCV care received by patients, as measured by 7 explicit quality indicators included in Medicare's 2009 Physician Quality Reporting Initiative.Proportions of patients meeting quality indicators varied, ranging from 21.5% for vaccination to 79% for the HCV genotype testing indicator. Overall, 18.5% of patients (95% CI, 18% to 19%) received all recommended care. Older age and presence of comorbid conditions were associated with lower quality, whereas elevated liver enzyme levels, cirrhosis, and HIV infection were associated with higher quality. Patients who saw both generalists and specialists received the best care (odds ratio of receiving care for which a patient is eligible: specialists alone, 0.79 [CI, 0.66 to 0.95]; primary care physician alone, 0.44 [CI, 0.40 to 0.48]).The study had an observational retrospective design, used a convenience sample, and had no information on patient ethnicity. It may be that the indicators or the reporting of the indicators of HCV care--and not the care itself--is suboptimum.Health care quality, based on Medicare criteria, is suboptimum for HCV. Care that included both specialists and generalists is associated with the best quality. Our results support the development of specialist and primary care collaboration to improve the quality of HCV care.Saint Louis University Liver Center.

    View details for Web of Science ID 000280973000003

    View details for PubMedID 20713791

  • Measuring Quality of Care in Patients With Nonvariceal Upper Gastrointestinal Hemorrhage: Development of an Explicit Quality Indicator Set AMERICAN JOURNAL OF GASTROENTEROLOGY Kanwal, F., Barkun, A., Gralnek, I. M., Asch, S. M., Kuipers, E. J., Bardou, M., Sung, J., Enns, R., Agreus, L., Armstrong, D., Spiegel, B. M. 2010; 105 (8): 1710-1718


    With an increasing emphasis on quality in health care and recognition of inconsistencies in the management of patients with nonvariceal upper gastrointestinal hemorrhage (NVUGIH), it is critical to establish a set of explicit quality indicators (QIs) in NVUGIH.We conducted a nine-member, multidisciplinary expert panel and followed modified Delphi methods to systematically identify a set of QIs for NVUGIH. The panel performed independent ratings of each candidate QI using a nine-point RAND appropriateness scale, then met in person and re-voted using an iterative process of discussion. The final set comprised QIs with a median RAND Appropriateness Score >or=7 and no disagreement among experts.Among 116 candidate QIs, the panel rated 26 as valid measures of quality care. The selected QIs cover pre-endoscopy, endoscopy, and post-endoscopy care, including diagnosis, early resuscitation, risk stratification, endoscopic care, Helicobacter pylori management, and proton pump inhibitor therapy.We have developed an explicit set of evidence-based QIs in NVUGIH, providing physicians and institutions with a tool to identify processes amenable to quality improvement. This tool is intended to be applicable in all institutions providing care for NVUGIH patients.

    View details for DOI 10.1038/ajg.2010.180

    View details for Web of Science ID 000280656800001

    View details for PubMedID 20686458

  • An Explicit Quality Indicator Set for Measurement of Quality of Care in Patients With Cirrhosis CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Kanwal, F., Kramer, J., Asch, S. M., El-Serag, H., Spiegel, B. M., Edmundowicz, S., Sanyal, A. J., Dominitz, J. A., Mcquaid, K. R., Martin, P., Keeffe, E. B., Friedman, L. S., Ho, S. B., Durazo, F., Bacon, B. R. 2010; 8 (8): 709-717


    Cirrhosis is a prevalent and expensive condition. With an increasing emphasis on quality in health care and recognition of inconsistencies in the management of patients with cirrhosis, we established a set of explicit quality indicators (QIs) for their treatment.We organized an 11-member, multidisciplinary expert panel and followed modified Delphi methods to systematically identify a set of QIs for cirrhosis. We provided the panel with a report that summarized the results of a comprehensive literature review of data linking candidate QIs to outcomes. The panel performed independent ratings of each candidate QI by using a standard 9-point RAND appropriateness scale (RAS) (ranging from 1 = not appropriate to 9 = most appropriate). The panel members then met, reviewed the ratings, and voted again by using an iterative process of discussion. The final set of QIs was selected; QIs had a median RAS >7, and panel members agreed on those selected.Among 169 candidate QIs, the panel rated 41 QIs as valid measures of quality care. The selected QIs cover 6 domains of care including ascites (13 QIs), variceal bleeding (18 QIs), hepatic encephalopathy (4 QIs), hepatocellular cancer (1 QI), liver transplantation (2 QIs), and general cirrhosis care (3 QIs). Content coverage included prevention, diagnosis, treatment, timeliness, and follow-up.We developed an explicit set of evidence-based QIs for treatment of cirrhosis. These provide physicians and institutions with a tool to identify processes amenable to quality improvement. This tool is intended to be applicable in any setting where care for patients with cirrhosis is provided.

    View details for DOI 10.1016/j.cgh.2010.03.028

    View details for Web of Science ID 000280938200016

    View details for PubMedID 20385251

  • Cost of Rapid HIV Testing at 45 US Hospitals AIDS PATIENT CARE AND STDS Pinkerton, S. D., Bogart, L. M., Howerton, D., Snyder, S., Becker, K., Asch, S. M. 2010; 24 (7): 409-413


    In 2006, the United States Centers for Disease Control and Prevention (CDC) recommended expanded and routine use of single-session rapid HIV tests in all health care settings to increase the proportion of persons who learn their HIV status. Limited empiric information is available regarding the costs of rapid testing and pre- and posttest counseling in health care settings. We surveyed 45 U.S. hospitals during 2005 through 2006 to assess the costs associated with rapid testing and counseling. Cost analyses were conducted from the provider (hospital) perspective, and results were expressed in year 2006 U.S. dollars. The mean per-test cost of rapid HIV testing and counseling was $48.07 for an HIV-negative test and $64.17 for a preliminary-positive test. Pre- and posttest counseling costs accounted for 38.4% of the total cost of rapid testing for HIV-negative patients. Counseling costs were significantly correlated with overall test costs. Many hospitals contained overall test costs by limiting time spent in pre- and posttest counseling or by using lower-paid personnel for counseling activities or both. Counseling costs constituted a significant proportion of the overall costs of rapid testing and counseling activities at study hospitals. Our data provide useful baseline data before implementation of the CDC's 2006 recommendations. Costs can be reduced by limiting time spent in pre- and posttest counseling or by using lower-paid personnel for counseling activities or both.

    View details for DOI 10.1089/apc.2009.0348

    View details for Web of Science ID 000280224500002

    View details for PubMedID 20578906

  • Cancer Quality-ASSIST Supportive Oncology Quality Indicator Set Feasibility, Reliability, and Validity Testing CANCER Dy, S. M., Lorenz, K. A., ONeill, S. M., Asch, S. M., Walling, A. M., Tisnado, D., Antonio, A. L., Malin, J. L. 2010; 116 (13): 3267-3275


    Although measuring the quality of symptom management and end-of-life care could help provide a basis for improving supportive care for advanced cancer, few quality indicators in this area have been rigorously developed or evaluated.The authors conducted a pilot evaluation of a comprehensive set of 92 supportive oncology quality indicators, Cancer Quality-ASSIST, including outpatient and hospital indicators for symptoms commonly related to cancer and its treatment and information and care planning. They operationalized the indicators and developed an electronic abstraction tool and extensive guidelines and training materials. Quality assurance nurses abstracted the medical records for 356 advanced cancer patients in 2 settings: a Veterans Administration hospital and an academic hospital and cancer center. The authors evaluated the indicators' feasibility, inter-rater reliability, and validity.The authors successfully evaluated 78 indicators across the domains; results were similar in the 2 settings. They could not feasibly evaluate 3 indicators because of low prevalence; 22 indicators had significant inter-rater reliability issues, 9 had significant validity issues, and 3 had both reliability and validity issues, leaving a set of 41 indicators most promising for further testing and use in this population, with an overall kappa score of 0.85 for specified care.Of 92 Cancer Quality-ASSIST quality indicators for symptoms, treatment toxicity, and information and care planning, 41 were sufficiently feasible, reliable, and valid to be used for patients with advanced cancer in these settings. This set of indicators shows promise for describing key supportive care processes in advanced cancer.

    View details for DOI 10.1002/cncr.25109

    View details for Web of Science ID 000279208900027

    View details for PubMedID 20564637

  • Indications for Performing Carpal Tunnel Surgery: Clinical Quality Measures PLASTIC AND RECONSTRUCTIVE SURGERY Maggard, M. A., Harness, N. G., Chang, W. T., Parikh, J. A., Asch, S. M., Nuckols, T. K. 2010; 126 (1): 169-179


    Rates of carpal tunnel surgery vary for unclear reasons. In this study, the authors developed measures determining when surgery is necessary (benefits exceed risks), inappropriate (risks outweigh benefits), or optional.Measures were developed using a modified-Delphi panel. Clinical scenarios were defined incorporating symptom severity, symptom duration, clinical probability of carpal tunnel syndrome, electrodiagnostic testing, and nonoperative treatment response. A multidisciplinary panel of 11 carpal tunnel syndrome experts rated appropriateness of surgery for each scenario on a scale ranging from 1 to 9 scale (7 to 9, surgery is necessary; 1 to 3, surgery is inappropriate).Of 90 scenarios (36 for mild, 36 for moderate, and 18 for severe symptoms), panelists judged carpal tunnel surgery as necessary for 16, inappropriate for 37, and optional for 37 scenarios. For mild symptoms, surgery is generally necessary when clinical probability of carpal tunnel syndrome is high, there is a positive electrodiagnostic test, and there has been unsuccessful nonoperative treatment. For moderate symptoms, surgery is generally necessary with a positive electrodiagnostic test involving two or more of the following: high clinical probability, unsuccessful nonoperative treatment, and symptoms lasting longer than 12 months. Surgery is generally inappropriate for mild to moderate symptoms involving two or more of the following: low clinical probability, no electrodiagnostic confirmation, and nonoperative treatment not attempted. For severe symptoms, surgery is generally necessary with a positive electrodiagnostic test or unsuccessful nonoperative treatment.These are the first formal measures assessing appropriateness of carpal tunnel surgery. Applying these measures can identify underuse (failure to provide necessary care) and overuse (providing inappropriate care), giving insight into variations in receipt of this procedure.

    View details for DOI 10.1097/PRS.0b013e3181da8685

    View details for Web of Science ID 000279097500021

    View details for PubMedID 20595866

  • The Quality of Care Provided to Hospitalized Patients at the End of Life 32nd Annual National Meeting of the Society-for-General-Internal-Medicine Walling, A. M., Asch, S. M., Lorenz, K. A., Roth, C. P., Barry, T., Kahn, K. L., Wenger, N. S. AMER MEDICAL ASSOC. 2010: 1057–63


    Patients in American hospitals receive intensive medical treatments. However, when lifesaving treatments are unsuccessful, patients often die in the hospital with distressing symptoms while receiving burdensome care. Systematic measurement of the quality of care planning and symptom palliation is needed.Medical records were abstracted using 16 Assessing Care of Vulnerable Elders quality indicators within the domains of end-of-life care and pain management designed to measure the quality of the dying experience for adult decedents (n = 496) hospitalized for at least 3 days between April 2005 and April 2006 at a university medical center recognized for providing intensive care for the seriously ill.Over half of the patients (mean age, 62 years; 47% were women) were admitted to the hospital with end-stage disease, and 28% were 75 years or older. One-third of the patients required extubation from mechanical ventilation prior to death, and 15% died while receiving cardiopulmonary resuscitation. Overall, patients received recommended care for 70% of applicable indicators (range, 25%-100%). Goals of care were addressed in a timely fashion for patients admitted to the intensive care unit approximately half of the time, whereas pain assessments (94%) and treatments for pain (95%) and dyspnea (87%) were performed with fidelity. Follow-up for distressing symptoms was performed less well than initial assessment, and 29% of patients extubated in anticipation of death had documented dyspnea assessments.A practical, medical chart-based assessment identified discrete deficiencies in care planning and symptom palliation that can be targeted to improve care for patients dying in the hospital.

    View details for Web of Science ID 000279245000012

    View details for PubMedID 20585072

  • Cost-Effectiveness of Strategies to Improve HIV Testing and Receipt of Results: Economic Analysis of a Randomized Controlled Trial JOURNAL OF GENERAL INTERNAL MEDICINE Sanders, G. D., Anaya, H. D., Asch, S., Hoang, T., Golden, J. F., Bayoumi, A. M., Owens, D. K. 2010; 25 (6): 556-563


    The CDC recommends routine voluntary HIV testing of all patients 13-64 years of age. Despite this recommendation, HIV testing rates are low even among those at identifiable risk, and many patients do not return to receive their results.To examine the costs and benefits of strategies to improve HIV testing and receipt of results.Cost-effectiveness analysis based on a Markov model. Acceptance of testing, return rates, and related costs were derived from a randomized trial of 251 patients; long-term costs and health outcomes were derived from the literature. SETTING/TARGET POPULATION: Primary-care patients with unknown HIV status.Comparison of three intervention models for HIV counseling and testing: Model A = traditional HIV counseling and testing; Model B = nurse-initiated routine screening with traditional HIV testing and counseling; Model C = nurse-initiated routine screening with rapid HIV testing and streamlined counseling.Life-years, quality-adjusted life-years (QALYs), costs and incremental cost-effectiveness.Without consideration of the benefit from reduced HIV transmission, Model A resulted in per-patient lifetime discounted costs of $48,650 and benefits of 16.271 QALYs. Model B increased lifetime costs by $53 and benefits by 0.0013 QALYs (corresponding to 0.48 quality-adjusted life days). Model C cost $66 more than Model A with an increase of 0.0018 QALYs (0.66 quality-adjusted life days) and an incremental cost-effectiveness of $36,390/QALY. When we included the benefit from reduced HIV transmission, Model C cost $10,660/QALY relative to Model A. The cost-effectiveness of Model C was robust in sensitivity analyses.In a primary-care population, nurse-initiated routine screening with rapid HIV testing and streamlined counseling increased rates of testing and receipt of test results and was cost-effective compared with traditional HIV testing strategies.

    View details for DOI 10.1007/s11606-010-1265-5

    View details for Web of Science ID 000277712200015

    View details for PubMedID 20204538

    View details for PubMedCentralID PMC2869414

  • The LA story: What happened after a new policy allowing paramedics to forgo resuscitation attempts in prehospital cardiac arrest RESUSCITATION Grudzen, C. R., Hoffman, J. R., Koenig, W. J., Boscardin, J., Lorenz, K. A., Asch, S. M. 2010; 81 (6): 685-690


    Despite potential harm to patients, families, and emergency personnel, a low survival rate, and high costs and intensity of care, attempting resuscitation after prehospital cardiac arrest is the norm, unless there are signs of irreversible death or the presence of a valid, state-issued DNR.To determine whether there was a change in the rate of forgoing resuscitation attempts in prehospital cardiac arrest after implementation of a new policy allowing paramedics to forgo resuscitation based on a verbal family request or the presence of certain arrest characteristics.All prehospital run sheets for cardiac arrest in Los Angeles County were reviewed for the first seven days of each month August 2006-January 2007 (pre-policy) and January-June 2008 (post-policy). Paramedics were more likely to forgo resuscitation attempts after the policy change (13.3% vs. 8.5%, p<0.01). In addition, the percentage of patients with documented signs of irreversible death decreased post-policy, from 50.4% to 35.8%, p<0.01. After adjustment for potential confounders (patient demographics, clinical characteristics and EMS factors), as well as exclusion of patients with signs of irreversible death, paramedics are significantly more likely to forgo a resuscitation, and less likely to attempt resuscitation, after the policy change (OR 1.67 [95% CI 1.07, 2.61], p=0.024).Paramedics are more likely to forgo, and less likely to attempt, resuscitation in victims of cardiac arrest after implementation of a new policy. There was also an associated decrease in the percentage of patients who had signs of irreversible death, which might reflect a change in paramedic behavior.

    View details for DOI 10.1016/j.resuscitation.2010.02.011

    View details for Web of Science ID 000279087900012

    View details for PubMedID 20236748

  • Provider-related Barriers to Rapid HIV Testing in US Urban Non-profit Community Clinics, Community-based Organizations (CBOs) and Hospitals AIDS AND BEHAVIOR Bogart, L. M., Howerton, D., Lange, J., Setodji, C. M., Becker, K., Klein, D. J., Asch, S. M. 2010; 14 (3): 697-707


    We examined provider-reported barriers to rapid HIV testing in U.S. urban non-profit community clinics, community-based organizations (CBOs), and hospitals. 12 primary metropolitan statistical areas (PMSAs; three per region) were sampled randomly, with sampling weights proportional to AIDS case reports. Across PMSAs, all 671 hospitals and a random sample of 738 clinics/CBOs were telephoned for a survey on rapid HIV test availability. Of the 671 hospitals, 172 hospitals were randomly selected for barriers questions, for which 158 laboratory and 136 department staff were eligible and interviewed in 2005. Of the 738 clinics/CBOs, 276 were randomly selected for barriers questions, 206 were reached, and 118 were eligible and interviewed in 2005-2006. In multivariate models, barriers regarding translation of administrative/quality assurance policies into practice were significantly associated with rapid HIV testing availability. For greater rapid testing diffusion, policies are needed to reduce administrative barriers and provide quality assurance training to non-laboratory staff.

    View details for DOI 10.1007/s10461-008-9456-3

    View details for Web of Science ID 000277410500023

    View details for PubMedID 18770022

  • Addressing Patients' Concerns about Pain Management and Addiction Risks PAIN MANAGEMENT NURSING Goebel, J. R., Sherbourne, C. D., Asch, S. M., Meredith, L., Cohen, A. B., Hagenmaier, E., Lanto, A. B., Simon, B., Rubenstein, L. V., Shugarman, L. R., Lorenz, K. A. 2010; 11 (2): 92-98


    Fear of engendering addiction is frequently reported as both a provider and a patient barrier to effective pain management. In this study, a clinical scenario ascertained nursing staff members' usual practice in addressing addiction fears for patients with concerns about the addictive potential of pain medication. One hundred forty-five Veterans Health Administration nursing staff members from eight ambulatory care sites were queried to identify variables associated with proclivity to address patient fears about addiction risks in a population where pain is prevalent and the risk for substance abuse is high. Regarding addressing addiction concerns, 66% of nursing staff were very likely, 16% somewhat likely, 9% unsure, 6% somewhat unlikely, and 2% very unlikely to take action. Health technicians were less likely to address addiction concerns than registered or licensed vocational nurses (odds ratio [OR] 0.116; p=.004). Nursing staff with more years' experience (OR 1.070; p=.005) and higher levels of self-efficacy/confidence (OR 1.380; p=.001) were more likely to engage in discussions related to addiction risks. Targeted efforts to improve pain management activities should focus on retaining experienced nursing staff in initial assessment positions and improving the skills and confidence of less experienced and less skilled staff.

    View details for DOI 10.1016/j.pmn.2009.03.009

    View details for Web of Science ID 000278748700005

    View details for PubMedID 20510839

  • Feasibility of Discussing End-of-Life Care Goals with Inpatients Using a Structured, Conversational Approach: The Go Wish Card Game JOURNAL OF PAIN AND SYMPTOM MANAGEMENT Lankarani-Fard, A., Knapp, H., Lorenz, K. A., Golden, J. F., Taylor, A., Feld, J. E., Shugarman, L. R., Malloy, D., Menkin, E. S., Asch, S. M. 2010; 39 (4): 637-643


    Establishing goals of care is important in advance care planning. However, such discussions require a significant time investment on the part of trained personnel and may be overwhelming for the patient. The Go Wish card game was designed to allow patients to consider the importance of common issues at the end of life in a nonconfrontational setting. By sorting through their values in private, patients may present to their provider ready to have a focused conversation about end-of-life care. We evaluated the feasibility of using the Go Wish card game with seriously ill patients in the hospital. Of 133 inpatients approached, 33 (25%) were able to complete the game. The "top 10" values were scored based on frequency and adjusted for rank. The value selected of highest importance by the most subjects was "to be free from pain." Other highly ranked values concerned spirituality, maintaining a sense of self, symptom management, and establishing a strong relationship with health care professionals. Average time to review the patient's rank list after the patient sorted their values in private was 21.8 minutes (range: 6-45 minutes). The rankings from the Go Wish game are similar to those from other surveys of seriously ill patients. Our results suggest that it is feasible to use the Go Wish card game even in the chaotic inpatient setting to obtain an accurate portrayal of the patient's goals of care in a time-efficient manner.

    View details for DOI 10.1016/j.jpainsymman.2009.08.011

    View details for Web of Science ID 000277372800002

    View details for PubMedID 20413053

  • CLINICAL QUALITY MEASURES FOR ELECTRODIAGNOSIS IN SUSPECTED CARPAL TUNNEL SYNDROME MUSCLE & NERVE Sandin, K. J., Asch, S. M., Jablecki, C. K., Kilmer, D. D., Nuckols, T. K. 2010; 41 (4): 444-452


    Extensive research has documented that medical care in the United States is not of optimal quality, meaning that well-established care processes are not consistently provided to the patients who would benefit from them. To assess and improve quality of care, specific measures are needed. The objective of this study was to develop quality measures for electrodiagnostic testing in suspected carpal tunnel syndrome (CTS). We used a variation of the well-established RAND/UCLA Appropriateness Method to develop the measures. A physiatrist and quality measurement experts developed draft measures based on guidelines and literature. Subsequently, in a two-round, modified-Delphi process, a multidisciplinary panel of 11 national experts in CTS reviewed a summary of the evidence and then rated the measures for validity and feasibility. Seven draft measures were developed. The expert panel combined two, modified the others, and then judged all resulting measures to be valid and feasible. The measures cover compelling indications for testing, essential test components when CTS is suspected, skin temperature measurement and normalization, and the appropriate interpretation of test results. These measures define a minimum standard of care for the use of electrodiagnostic tests in suspected CTS and are consistent with recent guidelines developed by the American Association of Neuromuscular and Electrodiagnostic Medicine. Provider organizations, insurance companies, and professional societies can use these measures in efforts to monitor and improve quality of care for this common and disabling condition.

    View details for DOI 10.1002/mus.21617

    View details for Web of Science ID 000276585800003

    View details for PubMedID 20336661

  • A Review of Quality of Care Evaluation for the Palliation of Dyspnea AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE Mularski, R. A., Campbell, M. L., Asch, S. M., Reeve, B. B., Basch, E., Maxwell, T. L., Hoverman, J. R., Cuny, J., Clauser, S. B., Snyder, C., Seow, H., Wu, A. W., Dy, S. 2010; 181 (6): 534-538


    Assessment and management of dyspnea has emerged as a priority topic for quality evaluation and improvement. Evaluating dyspnea quality of care requires valid, reliable, and responsive measures of the care provided to patients across settings and diseases. As part of an Agency for Healthcare Research and Quality Symposium, we reviewed quality of care measures for dyspnea by compiling quality measures identified in systematic searches and reviews. Systematic reviews identified only three existing quality measurement sets that included quality measures for dyspnea care. The existing dyspnea quality measures reported by retrospective evaluations of care assess only four aspects: dyspnea assessment within 48 hours of hospital admission, use of objective scales to rate dyspnea severity, identification of management plans, and evidence of dyspnea reduction. To begin to improve care, clinicians need to assess and regularly document patient's experiences of dyspnea. There is no consensus on how dyspnea should be characterized for quality measurement, and although over 40 tools exist to assess dyspnea, no rating scale or instrument is ideal for palliative care. The panel recommended that dyspnea assessment should include a measure of intensity and some inquiry into the associated bother or distress experienced by the patient. A simple question into the presence or absence of dyspnea would be unlikely to help guide therapy, as complete relief of dyspnea in advanced disease would not be anticipated. Additional knowledge gaps include standards for clinical dyspnea care, assessment in the cognitively impaired, and evaluation of effectiveness of dyspnea care for patients with advanced disease.

    View details for DOI 10.1164/rccm.200903-0462PP

    View details for PubMedID 20056904

  • Adoption and Use of Stand-Alone Electronic Prescribing in a Health Plan-Sponsored Initiative AMERICAN JOURNAL OF MANAGED CARE Pevnick, J. M., Asch, S. M., Adams, J. L., Mattke, S., Patel, M. H., Ettner, S. L., Bell, D. S. 2010; 16 (3): 182-189


    To quantify rates of stand-alone e-prescribing (SEP) adoption and use among primary care physicians (PCPs) participating in a SEP initiative and to determine which physician and patient characteristics were associated with higher rates of each.Using records from an insurer-led SEP initiative, we compared the characteristics of 297 PCPs who adopted SEP through the initiative with the characteristics of 1892 eligible PCPs who did not. Among 297 adopters, we studied the extent of SEP use.Dependent variables included each physician's adoption of SEP and his or her e-prescribing use ratio (the ratio of electronic prescriptions to pharmacy claims in the same period). Independent variables included characteristics of PCPs (specialty, practice size, and prescribing volume) and their patients (patient age, sex, race/ethnicity, and household income).Solo practitioners, pediatricians, and physicians with more patients from predominantly African American zip codes were underrepresented among SEP adopters. The mean (SD) e-prescribing use ratio among adopters was 0.23 (0.28). Twenty percent of physicians maintained e-prescribing use ratios above 0.50. Available physician characteristics explained little of the variance in use, but physicians in smaller practices had greater use (P = .02).Certain categories of physicians may need more tailored incentives to adopt SEP. On average, adopters used the SEP system for only about one-quarter of their prescriptions. Some adopters achieved high levels of SEP use, and further research is needed to elucidate the factors that enabled this.

    View details for Web of Science ID 000275483400003

    View details for PubMedID 20225913

  • Effect of an education kiosk on patient knowledge about rapid HIV screening JOURNAL OF TELEMEDICINE AND TELECARE Sun, B. C., Knapp, H., Shamouelian, A., Golden, J., Goetz, M. B., Asch, S. M. 2010; 16 (3): 158-161


    Patient education is an important part of routine HIV screening. In a pilot study, we assessed the effect of a computer kiosk education module on patient knowledge about routine HIV screening. A systematic sample of walk-in clinic patients completed a questionnaire before and after using the education module. The primary outcome was a composite nine-point knowledge score. Secondary outcomes included willingness to undergo HIV screening and patient satisfaction. Of 185 patients who were eligible to participate, 100 completed the study. The median duration of kiosk interaction was 3.9 min. The median knowledge score increased from 7 to 8 (P < 0.0001) after viewing the module. There was no significant change in the proportion of patients who were interested in HIV screening. The majority of patients expressed excellent (38%) or very good (39%) satisfaction with the kiosk module. The results suggest that a computer kiosk can deliver brief and targeted education to improve knowledge about HIV screening.

    View details for DOI 10.1258/jtt.2009.090815

    View details for Web of Science ID 000277665600010

    View details for PubMedID 20386037

  • Factors Associated with Clinician Intention to Address Diverse Aspects of Pain in Seriously III Outpatients PAIN MEDICINE Shugarman, L. R., Asch, S. M., Meredith, L. S., Sherbourne, C. D., Hagenmeier, E., Wen, L., Cohen, A., Rubenstein, L. V., Goebel, J., Lanto, A., Lorenz, K. A. 2010; 11 (9): 1365-1372


    Pain is a common, often undertreated problem among patients with palliative needs.To evaluate clinician factors associated with intention to address diverse aspects of pain.Clinicians reviewed a clinical vignette describing a frail elderly patient with advanced hormone-refractory metastatic prostate cancer, depression, and pain not on analgesic therapy. Clinicians were surveyed about their intentions for treatment.All 280 primary care and specialist clinicians working in 19 hospital and community-based primary care, oncology, and cardiology clinics at eight geographically dispersed sites in two large VA hospital systems.Endpoints were clinician intention to deliver guideline-concordant care: prescribe opioids/antidepressants, assess existential wellbeing, and offer mental health referral. Demographic and behavioral measures were evaluated in association with endpoints.Of 208 (74%) responding practitioners, 189 were responsible for prescribing decisions. Of those, 86, 77, 75, and 69 were "very"/"somewhat likely" to prescribe opioids, antidepressants, refer to a mental health specialist, or assess existential wellbeing, respectively. Factors associated with greater intent to prescribe an opioid or antidepressant included female gender, being an attending physician, being a primary care clinician, and greater confidence in pain management skills. Greater trust in the validity of pain ratings was associated with intent to prescribe an antidepressant and assess existential wellbeing. Prescribing opioids was less likely if perceived as an administrative burden. Assessing existential wellbeing was less likely if time constraints were perceived a barrier to evaluating pain. Female gender was the only factor associated with intent to refer to a mental health specialist.Our findings suggest useful targets for improving pain management include bolstering clinician confidence in pain management and their trust in pain ratings.

    View details for Web of Science ID 000281638100008

    View details for PubMedID 20807347

  • Predictors of Short-Term (Seven-Day) Cardiac Outcomes After Emergency Department Visit for Syncope AMERICAN JOURNAL OF CARDIOLOGY Gabayan, G. Z., Derose, S. F., Asch, S. M., Chiu, V. Y., Glenn, S. C., Mangione, C. M., Sun, B. C. 2010; 105 (1): 82-86


    Syncope is a common reason for emergency department (ED) visits, and patients are often admitted to exclude syncope of cardiovascular origin. Population-based data on patterns and predictors of cardiac outcomes may improve decision-making. Our objective was to identify patterns and predictors of short-term cardiac outcomes in ED patients with syncope. Administrative data from an integrated health system of 11 Southern California EDs were used to identify cardiac outcomes after ED presentation for syncope from January 1, 2002, to December 31, 2005. Syncope and cause of death were identified by codes from the International Classification of Disease, Ninth Revision. Cardiac outcomes included cardiac death and hospitalization or procedure consistent with ischemic heart disease, valvular disease, or arrhythmia. Predictors of cardiac outcomes were identified through multivariate logistic regression. There were 35,330 adult subjects who accounted for 39,943 ED visits for syncope. Risk of cardiac outcome sharply decreased following the 7 days after syncope. A 7-day cardiac outcome occurred in 893 cases (3%). Positive predictors of 7-day cardiac outcomes included age > or =60 years, male gender, congestive heart failure, ischemic heart disease, cardiac arrhythmia, and valvular heart disease. Negative predictors included dementia, pacemaker, coronary revascularization, and cerebrovascular disease. There was an age-dependent relation between 7-day cardiac outcomes and arrhythmia and valvular disease, with younger patients (<60 years of age) having greater risk of an event compared to their same-age counterparts. In conclusion, ED decision-making should focus on risk of cardiac event in the first 7 days after syncope and special attention should be given to younger patients with cardiac co-morbidities.

    View details for DOI 10.1016/j.amjcard.2009.08.654

    View details for Web of Science ID 000278136200014

    View details for PubMedID 20102895

  • Program Characteristics Associated With Testing for HIV and Hepatitis C in Veterans Substance Use Disorder Clinics PSYCHIATRIC SERVICES McInnes, D. K., Hyun, J. K., Trafton, J. A., Asch, S. M., Gifford, A. L. 2010; 61 (1): 90-94


    This study examined whether organizational characteristics and quality improvement initiatives were related to HIV and hepatitis C (HCV) testing rates in veterans' substance use disorders programs.Data were collected by surveying 232 program directors at all U.S. Department of Veterans Affairs (VA) substance use disorder programs.Program directors (N=223) reported that, on average, 35% of their patients were tested for HIV (median=10%) and 57% were tested for HCV (median=80%). Of the quality improvement initiatives examined, computerized reminders to clinicians (p=.02) and a designated clinician for screening (p=.01) were positively associated with HCV testing, and computerized templates that guide clinicians through ordering of testing were positively associated with HIV testing (p=.06).Despite national emphasis on HIV testing, rates of testing were lower for HIV than for HCV in programs serving veterans with substance use disorders and at risk of both illnesses. System-level quality improvement initiatives may be effective at increasing rates of infectious disease screening.

    View details for Web of Science ID 000273234800018

    View details for PubMedID 20044426

  • A Low-Literacy Medication Education Tool for Safety-Net Hospital Patients Annual Meeting of the Robert Wood Johnson Clinical Scholars Cordasco, K. M., Asch, S. M., Bell, D. S., Guterman, J. J., Gross-Schulman, S., Ramer, L., Elkayam, U., Franco, I., Leatherwood, C. L., Mangione, C. M. ELSEVIER SCIENCE INC. 2009: S209–S216


    To improve medication adherence in cardiac patients, in partnership with a safety-net provider, this research team developed and evaluated a low-literacy medication education tool.Using principles of community-based participatory research, the team developed a prototype of a low-literacy hospital discharge medication education tool, customizable for each patient, featuring instruction-specific icons and pictures of pills. In 2007, a randomized controlled clinical trial was performed, testing the tool's effect on posthospitalization self-reported medication adherence and knowledge, 2 weeks postdischarge in English- and Spanish-speaking safety-net inpatients. To validate the self-report measure, 4 weeks postdischarge, investigators collected self-reports of the number of pills remaining for each medication in a subsample of participants. Nurses rated tool acceptability.Among the 166/210 eligible participants (79%) completing the Week-2 interview, self-reported medication adherence was 70% (95% CI=62%, 79%) in intervention participants and 78% (95% CI=72%, 84%) in controls (p=0.13). Among the 85 participants (31%) completing the Week-4 interview, self-reported pill counts indicated high adherence (greater than 90%) and did not differ between study arms. Self-reported adherence was correlated with self-reported pill count in intervention participants (R=0.5, p=0.004) but not in controls (R=0.07, p=0.65). There were no differences by study arm in medication knowledge. The nurses rated the tool as highly acceptable.Although the evaluation did not demonstrate the tool to have any effect on self-reported medication adherence, patients who received the schedule self-reported their medication adherence more accurately, perhaps indicating improved understanding of their medication regimen and awareness of non-adherence.

    View details for DOI 10.1016/j.amepre.2009.08.018

    View details for Web of Science ID 000272770000005

    View details for PubMedID 19896021

  • Improving Latino Disaster Preparedness Using Social Networks AMERICAN JOURNAL OF PREVENTIVE MEDICINE Eisenman, D. P., Glik, D., Gonzalez, L., Maranon, R., Zhou, Q., Tseng, C., Asch, S. M. 2009; 37 (6): 512-517


    Culturally targeted, informal social networking approaches to improving disaster preparedness have not been empirically tested.In partnership with community health promoters and the Los Angeles County Department of Public Health, this study tested a disaster preparedness program for Latino households.This study had a community-based, randomized, longitudinal cohort design with two groups and was conducted during February-October 2007. Assessments were made at baseline and 3 months. Analyses were carried out January-October 2008. SETTINGS/PARTICIPANTS: Community-based study of 231 Latinos living in Los Angeles County.Participants were randomly assigned to attending platicas (small-group discussions led by a health promoter/promotora de salud) or receiving "media" (a culturally tailored mailer). A total of 187 (81.0%) completed the 3-month follow-up.A self-reported disaster preparedness checklist was used.Among participants who did not have emergency water pre-intervention, 93.3% of those in the platica arm had it at follow-up, compared to 66.7% in the media arm (p=0.003). Among participants who did not have food pre-intervention, 91.7% in the platica arm reported it at follow-up, compared to 60.6% in the media arm (p=0.013). Finally, among participants who did not have a family communication plan pre-intervention, 70.4% in the platica arm reported one at follow-up, compared to 42.3% in the media arm (p=0.002).Although both arms improved in stockpiling water and food and creating a communication plan, the platica arm showed greater improvement than the media group.

    View details for DOI 10.1016/j.amepre.2009.07.022

    View details for Web of Science ID 000272769700007

    View details for PubMedID 19944917

  • Evaluation of the Sustainability of an Intervention to Increase HIV Testing JOURNAL OF GENERAL INTERNAL MEDICINE Goetz, M. B., Hoang, T., Henry, S. R., Knapp, H., Anaya, H. D., Gifford, A. L., Asch, S. M. 2009; 24 (12): 1275-1280


    Sustainability-the routinization and institutionalization of processes that improve the quality of healthcare-is difficult to achieve and not often studied.To evaluate the sustainability of increased rates of HIV testing after implementation of a multi-component intervention in two Veterans Health Administration healthcare systems.Quasi-experimental implementation study in which the effect of transferring responsibility to conduct the provider education component of the intervention from research to operational staff was assessed.Persons receiving healthcare between 2005 and 2006 (intervention year) and 2006 and 2007 (sustainability year).Monthly HIV testing rate, stratified by frequency of clinic visits.The monthly adjusted testing rate increased from 2% at baseline to 6% at the end intervention year and then declined reaching 4% at the end of the sustainability year. However, the stratified, visit-specific testing rate for persons newly exposed to the intervention (i.e., having their first through third visits during the study period) increased throughout the intervention and sustainability years. Increases in the proportion of visits by patients who remained untested despite multiple, prior exposures to the intervention accounted for the aggregate attenuation of testing during the sustainability year. Overall, the percentage of patients who received an HIV test in the sustainability year was 11.6%, in the intervention year 11.1%, and in the pre-intervention year 5.0%Provider education combined with informatics and organizational support had a sustainable effect on HIV testing rates. The effect was most pronounced during patients' early contacts with the healthcare system.

    View details for DOI 10.1007/s11606-009-1120-8

    View details for Web of Science ID 000272375400003

    View details for PubMedID 19798538

  • Heart Failure: The Hidden Problem of Pain JOURNAL OF PAIN AND SYMPTOM MANAGEMENT Goebel, J. R., Doering, L. V., Shugarman, L. R., Asch, S. M., Sherbourne, C. D., Lanto, A. B., Evangelista, L. S., Nyamathi, A. M., Maliski, S. L., Lorenz, K. A. 2009; 38 (5): 698-707


    Although dyspnea and fatigue are hallmark symptoms of heart failure (HF), the burden of pain may be underrecognized. This study assessed pain in HF and identified contributing factors. As part of a multicenter study, 96 veterans with HF (96% male, 67+/-11 years) completed measures of symptoms, pain (Brief Pain Inventory [BPI]), functional status (Functional Morbidity Index), and psychological state (Patient Health Questionnaire-2 and Generalized Anxiety Disorder-2). Single items from the BPI interference and the quality of life-end of life measured social and spiritual well-being. Demographic and clinical variables were obtained by chart audit. Correlation and linear regression models evaluated physical, emotional, social, and spiritual factors associated with pain. Fifty-three (55.2%) HF patients reported pain, with a majority (36 [37.5%]) rating their pain as moderate to severe (pain>or=4/10). The presence of pain was reported more frequently than dyspnea (67 [71.3%] vs. 58 [61.7%]). Age (P=0.02), psychological (depression: P=0.002; anxiety: P=0.001), social (P<0.001), spiritual (P=0.010), and physical (health status: P=0.001; symptom frequency: P=0.000; functional status: P=0.002) well-being were correlated with pain severity. In the resulting model, 38% of the variance in pain severity was explained (P<0.001); interference with relations (P<0.001) and symptom number (P=0.007) contributed to pain severity. The association of physical, psychological, social, and spiritual domains with pain suggests that multidisciplinary interventions are needed to address the complex nature of pain in HF.

    View details for DOI 10.1016/j.jpainsymman.2009.04.022

    View details for Web of Science ID 000272060600007

    View details for PubMedID 19733032

  • Emergency Department Research in Palliative Care: Challenges in Recruitment JOURNAL OF PALLIATIVE MEDICINE Stone, S. C., Mohanty, S. A., Gruzden, C., Lorenz, K. A., Asch, S. M. 2009; 12 (10): 867-868

    View details for DOI 10.1089/jpm.2009.0139

    View details for Web of Science ID 000270515000007

    View details for PubMedID 19807230

  • Exploring Alternative Approaches to Routine Outpatient Pain Screening PAIN MEDICINE Lorenz, K. A., Krebs, E. E., Bentley, T. G., Sherbourne, C. D., Goebel, J. R., Zubkoff, L., Lanto, A. B., Asch, S. M. 2009; 10 (7): 1291-1299


    To evaluate potential alternatives to the numeric rating scale (NRS) for routine pain screening.Cross-sectional.Nineteen Veterans Affairs outpatient clinics in Southern California at two hospitals and six community sites.Five hundred twenty-eight veterans from primary care, cardiology, and oncology clinics sampled in proportion to the total number of visits made to each clinic during the previous year.Veterans were approached following clinic visits to complete researcher-administered surveys about their clinic experience. Using the Brief Pain Inventory (BPI) interference scale of > or =5 as a reference standard for important unrelieved pain, we evaluated potential alternative pain screening items and item combinations by analyzing sensitivity and specificity, area under the receiver operating curve (AUC), and likelihood ratios.Of the veterans, 43.6% had unrelieved pain as measured by the reference standard. Approximately half had painful musculoskeletal diagnoses and one-third had comorbid mental health or substance use disorders. The fifth vital sign detected pain less accurately than did an NRS with a 1-week timeframe and an item assessing pain-related bother over the past week. AUCs were 0.79, 0.86, and 0.86, respectively. A sequential approach combining the pain-related bother and NRS with a 1-week timeframe items had good discriminatory ability.Alternative single or combined pain screening strategies assessing pain-related bother may improve routine pain detection.

    View details for DOI 10.1111/j.1526-4637.2009.00709.x

    View details for Web of Science ID 000270589100014

    View details for PubMedID 19818039

  • HIV screening among substance-abusing veterans in care JOURNAL OF SUBSTANCE ABUSE TREATMENT Dookeran, N. M., Burgess, J. F., Bowman, C. C., Goetz, M. B., Asch, S. M., Gifford, A. L. 2009; 37 (3): 286-291


    Calls for screening for HIV infection among individuals with substance use disorders, including alcohol use, are increasing. We investigated HIV screening and its predictors in the Veterans Health Administration (VA) system among such individuals in care. Our primary outcome was retrospective evidence of screening for HIV infection, adjusting for patient demographics and important comorbid disease. Of the 371,749 sample patients with histories of substance use disorders using VA services, 20% had evidence of HIV screening. Screening was lowest among those with alcohol use disorders alone (11%) and highest among those treated in substance use programs (28%) or receiving inpatient care (28%). The findings suggest a low recognition of substance use disorders (especially alcohol use) as risk factors for HIV. Quality improvement initiatives to increase risk factor recognition and screening among patients with substance use disorders will yield benefits in the fight against HIV.

    View details for DOI 10.1016/j.jsat.2009.03.003

    View details for Web of Science ID 000270044200008

    View details for PubMedID 19346096

  • Barriers and Facilitators to Routine HIV Testing in VA Primary Care JOURNAL OF GENERAL INTERNAL MEDICINE Bokhour, B. G., Solomon, J. L., Knapp, H., Asch, S. M., Gifford, A. L. 2009; 24 (10): 1109-1114


    Approximately 21% of the 1.1 million HIV-infected persons in the United States are unaware of their HIV status. The Centers for Disease Control (CDC) recommend routine opt-out HIV testing for all patients aged 13-64. Yet little is known about patient and provider perspectives on routine HIV testing.We sought to understand patient and provider perspectives on the adoption of routine HIV testing within the US Department of Veterans Affairs.We conducted four focus groups with patients and two focus groups with primary care providers to explore perceptions of, communication about, and barriers and facilitators to routine HIV testing in primary care.Convenience sample of patients and primary care providers at two geographically diverse Veterans' Affairs Medical Centers.We conducted grounded thematic analyses of transcribed audio-recordings of focus groups to identify major themes, identifying similarities and differences between patient and provider perspectives.Patients and providers concurred that implementation of routine HIV testing, treating HIV like other chronic diseases, and removing requirements for written informed consent and pre-test counseling were of benefit to patients and to public health. Patients, however, wished to have HIV testing routinely offered by providers so that they could decide whether or not to be tested. Veterans also stated that routinizing testing would help destigmatize HIV. Six steps to communicating about routine testing ("the 6 R's") were identified.Patients and providers appear ready for implementation of routine HIV testing. However, providers should use patient-centered communication strategies to ease patients' concerns about confidentiality and stigma associated with HIV disease.

    View details for DOI 10.1007/s11606-009-1078-6

    View details for Web of Science ID 000270814700005

    View details for PubMedID 19690923

  • The Challenge of Measuring Quality of Care From the Electronic Health Record AMERICAN JOURNAL OF MEDICAL QUALITY Roth, C. P., Lim, Y., Pevnick, J. M., Asch, S. M., McGlynn, E. A. 2009; 24 (5): 385-394


    The electronic health record (EHR) is seen by many as an ideal vehicle for measuring quality of health care and monitoring ongoing provider performance. It is anticipated that the availability of EHR-extracted data will allow quality assessment without the expensive and time-consuming process of medical record abstraction. A review of the data requirements for the indicators in the Quality Assessment Tools system suggests that only about a third of the indicators would be readily accessible from EHR data. Other factors involving complexity of required data elements, provider documentation habits, and EHR variability make the task of quality measurement more difficult than may be appreciated. Accurately identifying eligible cases for quality assessment and validly scoring those cases with EHR-extracted data will pose significant challenges but could potentially plummet the cost and therefore expand the use of quality assessment.

    View details for DOI 10.1177/1062860609336627

    View details for Web of Science ID 000269765900002

    View details for PubMedID 19482968

  • Body Mass Index, Neighborhood Fast Food and Restaurant Concentration, and Car Ownership JOURNAL OF URBAN HEALTH-BULLETIN OF THE NEW YORK ACADEMY OF MEDICINE Inagami, S., Cohen, D. A., Brown, A. F., Asch, S. M. 2009; 86 (5): 683-695


    Eating away from home and particularly fast food consumption have been shown to contribute to weight gain. Increased geographic access to fast food outlets and other restaurants may contribute to higher levels of obesity, especially in individuals who rely largely on the local environment for their food purchases. We examined whether fast food and restaurant concentrations are associated with body mass index and whether car ownership might moderate this association. We linked the 2000 US Census data and information on locations of fast food and other restaurants with the Los Angeles Family and Neighborhood Study database, which consists of 2,156 adults sampled from 63 neighborhoods in Los Angeles County. Multilevel modeling was used to estimate associations between body mass index (BMI), fast food and restaurant concentration, and car ownership after adjustment for individual-level factors and socioeconomic characteristics of residential neighborhoods. A high concentration of local restaurants is associated with BMI. Car owners have higher BMIs than non-car owners; however, individuals who do not own cars and reside in areas with a high concentration of fast food outlets have higher BMIs than non-car owners who live in areas with no fast food outlets, approximately 12 lb more (p = 0.02) for an individual with a height of 5 ft. 5 in. Higher restaurant density is associated with higher BMI among local residents. The local fast food environment has a stronger association with BMI for local residents who do not have access to cars.

    View details for DOI 10.1007/s11524-009-9379-y

    View details for Web of Science ID 000269195200004

    View details for PubMedID 19533365

  • Opportunities for improving medication use and monitoring in gout ANNALS OF THE RHEUMATIC DISEASES Singh, J. A., Hodges, J. S., Asch, S. M. 2009; 68 (8): 1265-1270


    To study patterns and predictors of medication use and laboratory monitoring in gout.In a cohort of veterans with a diagnosis of gout prescribed allopurinol, colchicine or probenecid, quality of care was assessed by examining adherence to the following evidence-based recommendations: (1) whether patients starting a new allopurinol prescription (a) received continuous allopurinol, (b) received colchicine prophylaxis, (c) achieved the target uric acid level of

    View details for DOI 10.1136/ard.2008.092619

    View details for Web of Science ID 000268010500006

    View details for PubMedID 18701554

  • Race and Sex Differences in the Receipt of Timely and Appropriate Lung Cancer Treatment MEDICAL CARE Shugarman, L. R., Mack, K., Sorbero, M. E., Tian, H., Jain, A. K., Ashwood, J. S., Asch, S. M. 2009; 47 (7): 774-781


    Previous research suggests that disparities in non-small-cell lung cancer (NSCLC) survival can be explained in part by disparities in the receipt of cancer treatment. Few studies, however, have considered race and sex disparities in the timing and appropriateness of treatment across stages of diagnosis.To evaluate the relationship of sex and race with the receipt of timely and clinically appropriate NSCLC treatment for each stage of diagnosis.Surveillance Epidemiology and End Result data linked to Medicare claims for beneficiaries diagnosed with NSCLC between 1995 and 1999 were used to evaluate the relationship between race and sex with timely and appropriate NSCLC treatment while controlling for other demographic characteristics, comorbidities, socioeconomic status, and provider supply (N = 22,145).Overall adjusted rates of timely and appropriate treatment are 37.2%, 58.1%, and 29.2% for Medicare beneficiaries diagnosed with stage I or II, III, and IV NSCLC, respectively. Among stage I or II patients, women were 25% less likely to receive timely surgical resection relative to men, and blacks were 66% less likely to receive timely and appropriate treatment than whites. Black men were least likely to receive resection (22.2% compared with 43.7% for white men). Blacks were 34% less likely to receive timely surgery, chemotherapy, or radiation for stage III disease and were 51% less likely to receive chemotherapy in a timely fashion for stage IV disease relative to whites.Significant variations in appropriate timely treatment were found within and across stages of diagnosis, confirming that sex and race differences in NSCLC treatment exist.

    View details for Web of Science ID 000267462400009

    View details for PubMedID 19536007

  • Health literacy and English language comprehension among elderly inpatients at an urban safety-net hospital. Journal of health and human services administration Cordasco, K. M., Asch, S. M., Franco, I., Mangione, C. M. 2009; 32 (1): 30-50


    To evaluate the relationship between health literacy and age in chronically-ill inpatients at a safety-net hospital.We recruited 399 English- and Spanish-speaking inpatients being evaluated or treated for Congestive Heart Failure or Coronary Artery Disease at a large, urban safety-net teaching hospital in Southern California.Participants were interviewed to ascertain education, English comprehension, and in-home language use. Health literacy was assessed using The Test of Functional Health Literacy in Adults (TOFHLA). We compared by age (aged 65 or more, 51 to 64 years of age, and less than age 50) levels of health literacy, educational attainment, English comprehension, and language use.Prevalence of inadequate health literacy significantly increased with increasing age (87.2% in > or = 65, 48.9% for 51-64, and 26.3% in < or = 50, p<0.001). The correlation between older age and lower health literacy persisted when controlling for educational achievement, race, ethnicity, gender, and immigration status. Additionally, older patients were more likely to have never learned to read (34.9% in > or = 65, 6.5% for 51-64, and 1.5% in < or = 50, p<0.001), no formal education (27.9% in > or = 65, 9.0% for 51-64, and 0.8% in < or = 50, p<0.001), have limited English comprehension (74.2% in > or = 65, 43.5% for 51-64, and 35.8% in < or = 50, p<0.001), and speak a non-English language at home (82.3% in > or = 65, 70.2% for 51-64, and 62.2% in < or = 50, p=0.015).To prepare to meet the chronic disease needs of a growing older patient population, and ameliorate the negative health effects of associated low literacy, safety-net hospital leaders and providers need to prioritize the development and implementation of low-literacy educational materials, programs, and services.

    View details for PubMedID 19558032

  • Quality Measures for Supportive Cancer Care: The Cancer Quality-ASSIST Project Conference of the Australian-New-Zealand-Health-Services-Association Lorenz, K. A., Dy, S. M., Naeim, A., Walling, A. M., Sanati, H., Smith, P., Shanman, R., Roth, C. P., Asch, S. M. ELSEVIER SCIENCE INC. 2009: 943–64


    Patients and physicians often cite symptom control as one of their most important goals in cancer care. Despite this, a previous systematic review found few tools for evaluating the quality of supportive cancer management. We developed a comprehensive set of quality indicators for evaluating pain and nonpain symptom management as well as care planning needs in cancer patients. Based on the prevalence and quality-of-life data, clinician-researchers prioritized pain, psychosocial distress, dyspnea, nausea and vomiting, fatigue and anorexia, treatment-associated toxicities, and information and care planning for quality-indicator development. Using search terms and selection criteria, we identified English-language documents from Medline (1997-2007) and Internet-based searches. Based on this evidence, clinician-reviewers proposed process quality indicators. We then used the VA Health Services Research and Development (VA HSR & D) appropriateness methods to compile the ratings of a multidisciplinary, international expert panel of the validity and feasibility of each indicator. The panel judged 92 out of 133 (69%) proposed quality indicators valid and feasible (15 out of 23 pain, 5 out of 6 depression, 8 out of 11 dyspnea, 15 out of 19 nausea and vomiting, 13 out of 26 fatigue and anorexia, 23 out of 32 other treatment-associated toxicities, and 13 out of 16 information and care planning). Of the final indicators, 67 are potentially useful for inpatient and 81 for outpatient evaluation, and 26 address screening, 12 diagnostic evaluation, 20 management, and 21 follow-up. These quality indicators provide evidence-explicit tools for measuring processes critical to ensuring high-quality supportive cancer care. Research is needed to characterize adherence to recommended practices and to evaluate the use of these measures in quality improvement efforts.

    View details for DOI 10.1016/j.jpainsymman.2008.05.018

    View details for Web of Science ID 000267183400001

    View details for PubMedID 19359135

  • Paramedic and Emergency Medical Technicians Views on Opportunities and Challenges When Forgoing and Halting Resuscitation in the Field ACADEMIC EMERGENCY MEDICINE Grudzen, C. R., Timmermans, S., Koenig, W. J., Torres, J. M., Hoffman, J. R., Lorenz, K. A., Asch, S. M. 2009; 16 (6): 532-538


    The objective was to assess paramedic and emergency medical technicians (EMT) perspectives and decision-making after a policy change that allows forgoing or halting resuscitation in prehospital atraumatic cardiac arrest.Five semistructured focus groups were conducted with 34 paramedics and 2 EMTs from emergency medical services (EMS) agencies within Los Angeles County (LAC), 6 months after a policy change that allowed paramedics to forgo or halt resuscitation in the field under certain circumstances.Participants had an overwhelmingly positive view of the policy; felt it empowered their decision-making abilities; and thought the benefits to patients, family, EMS, and the public outweighed the risks. Except under certain circumstances, such as when the body was in public view or when family members did not appear emotionally prepared to have the body left on scene, they felt the policy improved care. Assuming that certain patient characteristics were present, decisions by paramedics about implementing the policy in the field involve many factors, including knowledge and comfort with the new policy, family characteristics (e.g., agreement), and logistics regarding the place of arrest (e.g., size of space). Paramedic and EMT experiences with and attitudes toward forgoing resuscitation, as well as group dynamics among EMS leadership, providers, police, and ED staff, also play a role.Participants view the ability to forgo or halt resuscitation in the field as empowering and do not believe it presents harm to patients or families under most circumstances. Factors other than patient clinical characteristics, such as knowledge and attitudes toward the policy, family emotional preparedness, and location of arrest, affect whether paramedics will implement it.

    View details for DOI 10.1111/j.1553-2712.2009.00427.x

    View details for Web of Science ID 000266594600009

    View details for PubMedID 19438412

  • Development and Initial Validation of the PEG, a Three-item Scale Assessing Pain Intensity and Interference JOURNAL OF GENERAL INTERNAL MEDICINE Krebs, E. E., Lorenz, K. A., Bair, M. J., Damush, T. M., Wu, J., Sutherland, J. M., Asch, S. M., Kroenke, K. 2009; 24 (6): 733-738


    Inadequate pain assessment is a barrier to appropriate pain management, but single-item "pain screening" provides limited information about chronic pain. Multidimensional pain measures such as the Brief Pain Inventory (BPI) are widely used in pain specialty and research settings, but are impractical for primary care. A brief and straightforward multidimensional pain measure could potentially improve initial assessment and follow-up of chronic pain in primary care.To develop an ultra-brief pain measure derived from the BPI.Development of a shortened three-item pain measure and initial assessment of its reliability, validity, and responsiveness.We used data from 1) a longitudinal study of 500 primary care patients with chronic pain and 2) a cross-sectional study of 646 veterans recruited from ambulatory care.Selected items assess average pain intensity (P), interference with enjoyment of life (E), and interference with general activity (G). Reliability of the three-item scale (PEG) was alpha = 0.73 and 0.89 in the two study samples. Overall, construct validity of the PEG was good for various pain-specific measures (r = 0.60-0.89 in Study 1 and r = 0.77-0.95 in Study 2), and comparable to that of the BPI. The PEG was sensitive to change and differentiated between patients with and without pain improvement at 6 months.We provide strong initial evidence for reliability, construct validity, and responsiveness of the PEG among primary care and other ambulatory clinic patients. The PEG may be a practical and useful tool to improve assessment and monitoring of chronic pain in primary care.

    View details for DOI 10.1007/s11606-009-0981-1

    View details for Web of Science ID 000266241300007

    View details for PubMedID 19418100

  • Developing a Disaster Preparedness Campaign Targeting Low-Income Latino Immigrants: Focus Group Results for Project PREP JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Eisenman, D. P., Glik, D., Maranon, R., Gonzales, L., Asch, S. 2009; 20 (2): 330-345


    Low-income immigrant Latinos are particularly vulnerable to disasters because they are both ill-prepared and disproportionately affected. Disaster preparedness programs that are culturally appropriate must be developed and tested. To develop such a program, we conducted 12 focus groups with low-income immigrant Latinos to understand their perceptions and understanding of disaster preparedness, and facilitators and obstacles to it. Participants were concerned about remaining calm during an earthquake. Obstacles to storage of disaster supplies in a kit and developing a family communication plan were mentioned frequently. Misunderstandings were voiced about the proper quantity of water to store and about communication plans. Several focus groups spontaneously suggested small group discussions (platicas) as a way to learn about disaster preparedness. They wanted specific help with building their family communication plans. They rated promotoras de salud highly as potential teachers. Results will guide the development of a disaster preparedness program tailored to the needs of low-income Latino immigrants.

    View details for Web of Science ID 000265887100004

    View details for PubMedID 19395833

  • Early Identification of Co-Occurring Pain, Depression and Anxiety JOURNAL OF GENERAL INTERNAL MEDICINE Sherbourne, C. D., Asch, S. M., Shugarman, L. R., Goebel, J. R., Lanto, A. B., Rubenstein, L. V., Wen, L., Zubkoff, L., Lorenz, K. A. 2009; 24 (5): 620-625


    Depression and anxiety frequently co-occur with pain and may affect treatment outcomes. Early identification of these co-occurring psychiatric conditions during routine pain screening may be critical for optimal treatment.To determine aspects of pain related to psychological distress, and, among distressed patients, to determine whether pain factors are related to provider identification of distress.Cross-sectional interview of primary care patients and their providers participating in a Veteran's Administration HELP-Vets study.A total of 528 predominately male VeteransWe measured self-reported pain, including a 0-10 numeric rating scale and interference items from the Brief Pain Inventory. To evaluate distress, brief indicators of depression, anxiety and PTSD were combined. A substantial number of patients had psychological distress (41%), which was even higher (62%) among patients with moderate-severe current pain. Only 29% of those with distress reported talking to their provider about emotional problems during their visit. In multivariate analyses, other pain factors related to distress included interference with enjoyment of life and relationships with others, pain in multiple locations and joint pains. Prior diagnoses of depression and anxiety were also related to current distress. Only prior diagnosis and patient reported headaches and sleep interference because of pain were related to provider identification of distress.VA patients with moderate-severe pain are at high risk for psychological distress, which often goes unrecognized. Providers need to be more vigilant to mental health problems in patients experiencing high pain levels. Targeted screening for co-occurring conditions is warranted.