Veterans Affairs primary care organizational characteristics associated with better diabetes control

Health Services Research & Development Center of Excellence for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, 27705, USA.
The American journal of managed care (Impact Factor: 2.26). 04/2005; 11(4):225-37.
Source: PubMed

ABSTRACT To examine organizational features of Veterans Affairs (VA) primary care programs hypothesized to be associated with better diabetes control, as indicated by hemoglobin A1C (HbA1C) levels.
Cross-sectional cohort.
We established a cohort of 224 221 diabetic patients using the VA Diabetes Registry and Dataset and VA corporate databases. The 1999 VHA (Veterans Health Administration) Survey of Primary Care Practices results were combined with individual patient data. A 2-level hierarchical model was used to determine the relationship between organizational characteristics and HbA1C levels in 177 clinics with 82 428 cohort members.
The following attributes were associated with lower (better) HbA1C and were statistically significant at P < .05: greater authority to establish or implement clinical policies (lower by 0.21%), greater staffing authority (0.28%), computerized diabetes reminders (0.17%), notifying all patients of their assigned provider (0.21%), hiring needed new staff during fiscal year 1999 (0.18%), having nurses that report only to the program (0.16%), and being a large academic practice (0.27%). Associated with higher (worse) HbA1C were programs reporting that patients almost always see their assigned provider (greater by 0.18%), having a quality improvement program involving all nurses without all physicians (0.38%), having general internal medicine physicians report only to the program (0.20%), and being located at an acute care hospital (0.20%).
Programs that are associated with better diabetes control simultaneously have teams that actively involve physicians in quality improvement, use electronic health information systems, have authority to respond to staffing and programmatic issues, and engage patients in care.

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Available from: Elizabeth M Yano, Sep 28, 2015
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    • "We did not expect to find that none of the facility level characteristics from the CPOS-COS survey were associated with time to implementation of automated eGFR reporting. Intrinsic to our study design, we used the CPOS-COS survey for facility-level organizational variables because other similar studies demonstrated variable performance and practice patterns among VHA facilities that are related to facility- and clinic-level organizational characteristics [10,16-21]. We further justified use of the CPOS-COS survey because general QI characteristics can affect implementation of new innovations in individual facilities [22]. "
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    ABSTRACT: Automated reporting of estimated glomerular filtration rate (eGFR) is a recent advance in laboratory information technology (IT) that generates a measure of kidney function with chemistry laboratory results to aid early detection of chronic kidney disease (CKD). Because accurate diagnosis of CKD is critical to optimal medical decision-making, several clinical practice guidelines have recommended the use of automated eGFR reporting. Since its introduction, automated eGFR reporting has not been uniformly implemented by U. S. laboratories despite the growing prevalence of CKD. CKD is highly prevalent within the Veterans Health Administration (VHA), and implementation of automated eGFR reporting within this integrated healthcare system has the potential to improve care. In July 2004, the VHA adopted automated eGFR reporting through a system-wide mandate for software implementation by individual VHA laboratories. This study examines the timing of software implementation by individual VHA laboratories and factors associated with implementation. We performed a retrospective observational study of laboratories in VHA facilities from July 2004 to September 2009. Using laboratory data, we identified the status of implementation of automated eGFR reporting for each facility and the time to actual implementation from the date the VHA adopted its policy for automated eGFR reporting. Using survey and administrative data, we assessed facility organizational characteristics associated with implementation of automated eGFR reporting via bivariate analyses. Of 104 VHA laboratories, 88% implemented automated eGFR reporting in existing laboratory IT systems by the end of the study period. Time to initial implementation ranged from 0.2 to 4.0 years with a median of 1.8 years. All VHA facilities with on-site dialysis units implemented the eGFR software (52%, p<0.001). Other organizational characteristics were not statistically significant. The VHA did not have uniform implementation of automated eGFR reporting across its facilities. Facility-level organizational characteristics were not associated with implementation, and this suggests that decisions for implementation of this software are not related to facility-level quality improvement measures. Additional studies on implementation of laboratory IT, such as automated eGFR reporting, could identify factors that are related to more timely implementation and lead to better healthcare delivery.
    BMC Medical Informatics and Decision Making 07/2012; 12(1):69. DOI:10.1186/1472-6947-12-69 · 1.83 Impact Factor
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    • "An emphasis on QI capability is an important component of organizational structure [43,64,65]. For example, experience with QI programs in VHA clinics [9,40] and by physician organizations has been linked to increased use of longitudinal care management processes [32]. Formal screening and use of clinical reminders was also associated with a greater probability of ongoing care for depression [32]. "
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    ABSTRACT: Evidence-based quality improvement models for depression have not been fully implemented in routine primary care settings. To date, few studies have examined the organizational factors associated with depression management in real-world primary care practice. To successfully implement quality improvement models for depression, there must be a better understanding of the relevant organizational structure and processes of the primary care setting. The objective of this study is to describe these organizational features of routine primary care practice, and the organization of depression care, using survey questions derived from an evidence-based framework. We used this framework to implement a survey of 27 practices comprised of 49 unique offices within a large primary care practice network in western Pennsylvania. Survey questions addressed practice structure (e.g., human resources, leadership, information technology (IT) infrastructure, and external incentives) and process features (e.g., staff performance, degree of integrated depression care, and IT performance). The results of our survey demonstrated substantial variation across the practice network of organizational factors pertinent to implementation of evidence-based depression management. Notably, quality improvement capability and IT infrastructure were widespread, but specific application to depression care differed between practices, as did coordination and communication tasks surrounding depression treatment. The primary care practices in the network that we surveyed are at differing stages in their organization and implementation of evidence-based depression management. Practical surveys such as this may serve to better direct implementation of these quality improvement strategies for depression by improving understanding of the organizational barriers and facilitators that exist within both practices and practice networks. In addition, survey information can inform efforts of individual primary care practices in customizing intervention strategies to improve depression management.
    Implementation Science 12/2009; 4(1):84. DOI:10.1186/1748-5908-4-84 · 4.12 Impact Factor
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    • "Studies by McBride, et al and Carey, et al do provide some guidance, but an overall framework and details for such recruitment remain to be elaborated [6,7]. Understanding how to recruit complete group practices has become increasingly important as studies of how to improve the quality of care have shifted their focus from the behavior of individual physicians to the environment in which they work [8-13]. In fact, this kind of recruitment has become such a necessity for good implementation science that many of these studies can't be done effectively without involvement of a representative cross-section of entire eligible medical practices. "
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    ABSTRACT: In order to conduct good implementation science research, it will be necessary to recruit and obtain good cooperation and comprehensive information from complete medical practice organizations. The goal of this paper is to report an effective example of such a recruitment effort for a study of the organizational aspects of depression care quality. There were 41 medical groups in the Minnesota region that were eligible for participation in the study because they had sufficient numbers of patients with depression. We documented the steps required to both recruit their participation in this study and obtain their completion of two questionnaire surveys and two telephone interviews. All 41 medical groups agreed to participate and consented to our use of confidential data about their care quality. In addition, all 82 medical directors and quality improvement coordinators completed the necessary questionnaires and interviews. The key factors explaining this success can be summarized as the seven R's: Relationships, Reputation, Requirements, Rewards, Reciprocity, Resolution, and Respect. While all studies will not have all of these factors in such good alignment, attention to them may be important to other efforts to add to our knowledge of implementation science.
    Implementation Science 02/2006; 1:25. DOI:10.1186/1748-5908-1-25 · 4.12 Impact Factor
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