Family involvement, medication adherence, and depression outcomes among patients in veterans affairs primary care.

OBJECTIVE Family involvement and social support are associated with recovery from mental disorders. This project explored how family involvement in health care and social support among depressed veterans in primary care related to medication adherence and depression outcomes. METHODS During a longitudinal telephone survey, 761 Veterans Affairs (VA) primary care patients (mean age=60 years) with probable major depression were asked about depression symptoms, self-reported health, medication adherence, social support, family involvement with care, and satisfaction with clinicians' efforts to involve the patients' families in their care.

Help-seeking from clergy and spiritual counselors among veterans with depression and PTSD in primary care.

Little is known about the prevalence or predictors of seeking help for depression and PTSD from spiritual counselors and clergy. We describe openness to and actual help-seeking from spiritual counselors among primary care patients with depression. We screened consecutive VA primary care patients for depression; 761 Veterans with probable major depression participated in telephone surveys (at baseline, 7 months, and 18 months).

Implementing collaborative care for depression treatment in primary care: a cluster randomized evaluation of a quality improvement practice redesign.

Background: Meta-analyses show collaborative care models (CCMs) with nurse care management are effective for improving primary care for depression. This study aimed to develop CCM approaches that could be sustained and spread within Veterans Affairs (VA). Evidence-based quality improvement (EBQI) uses QI approaches within a research/clinical partnership to redesign care.

Gender differences in smoking and smoking cessation treatment: an examination of the organizational features related to care.

Objectives: Veterans experience a particularly heavy burden with smoking rates higher than the general population, and the smoking prevalence for women Veterans has increased in recent years. We examined differences in smoking prevalence and treatment by gender for Veterans receiving at least some of their care at a VA facility, and examined the degree to which organizational factors may be associated with reductions in gender disparities in smoking cessation treatment.

Methods: We merged national organizational-level data focused on primary care (sites = 225) and women's health (sites = 195) with patient-level survey data (n = 15,033 smokers).

Prescription sharing, alcohol use, and street drug use to manage pain among veterans.

Context: 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.

Objectives: This study examines self-reported substance misuse for pain management among veterans and identifies the contributing factors.

Factors associated with clinician intention to address diverse aspects of pain in seriously ill outpatients.

Background: Pain is a common, often undertreated problem among patients with palliative needs.

Objectives: To evaluate clinician factors associated with intention to address diverse aspects of pain.

Design: Clinicians reviewed a clinical vignette describing a frail elderly patient with advanced hormone-refractory metastatic prostate cancer, depression, and pain not on analgesic therapy.

Using evidence-based quality improvement methods for translating depression collaborative care research into practice.

Objective: Translating Initiatives in Depression into Effective Solution (TIDES) aimed to translate research-based collaborative care for depression into an approach for the Veterans Health Administration (VA). SITES: Three multistate administrative regions and seven of their medium-sized primary care practices.

Intervention: Researchers assisted regional leaders in adapting research-based depression care models using evidence-based quality improvement (EBQI) methods.

Nursing staff, patient, and environmental factors associated with accurate pain assessment.

Context: Although pain ranks highly among reasons for seeking care, routine pain assessment is often inaccurate.

Objectives: This study evaluated factors associated with nurses (e.g.

Addressing patients' concerns about pain management and addiction risks.

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.

Does screening for pain correspond to high quality care for veterans?

Background: Routine numeric screening for pain is widely recommended, but its association with overall quality of pain care is unclear.

Objective: To assess adherence to measures of pain management quality and identify associated patient and provider factors.

Design: A cross-sectional visit-based study.

Exploring alternative approaches to routine outpatient pain screening.

Objective: To evaluate potential alternatives to the numeric rating scale (NRS) for routine pain screening.

Design: Cross-sectional.

Setting: Nineteen Veterans Affairs outpatient clinics in Southern California at two hospitals and six community sites.

Heart failure: the hidden problem of pain.

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).

How reliable is pain as the fifth vital sign?

Background: Although many health care organizations require routine pain screening (eg, "5th vital sign") with the 0 to 10 numeric rating scale (NRS), its accuracy has been questioned; here we evaluated its accuracy and potential causes for error.

Methods: We randomly surveyed veterans and reviewed their charts after outpatient encounters at 2 hospitals and 6 affiliated community sites. Using correlation and receiver operating characteristic analysis, we compared the routinely measured "5th vital sign" (nurse-recorded NRS) with a research-administered NRS (research-recorded NRS) and the Brief Pain Inventory (BPI).

Early identification of co-occurring pain, depression and anxiety.

Background: 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.

Objective: 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.

A comparative study of pain in heart failure and non-heart failure veterans.

Background: Progress has been made in addressing pain in specific diseases such as cancer, but less attention has focused on understanding pain in nonmalignant states, including heart failure (HF).

Methods And Results: From March 2006 to June 2007, 672 veterans were surveyed and scores for the Brief Pain Inventory, pain distress, clinically significant pain levels (moderate to severe pain), and pain locations were compared using univariate and multivariate models. Fifteen percent of the final sample had HF (95/634).

Availability of gynecologic services in the department of veterans affairs.

Purpose: The optimum approach to providing the Congressionally mandated gender-specific services for which women veterans are eligible is unknown. We evaluated onsite availability of gynecologic services, clinic type and staffing arrangements, and the impact of having a gynecology clinic (GYN) and/or an obstetrician gynecologist (OBGYN) routinely available.

Methods: We analyzed data from the 2001 national VHA Survey of Women Veterans Health Programs and Practices (n = 136 sites; response rate, 83%).

Effectiveness of an on-call counselor at increasing smoking treatment.

Background: Smoking cessation programs are very effective, but little is known about how to get smokers to attend these programs.

Objective: To evaluate whether an "on-call" counselor increased smoking cessation program referrals and attendance.

Design: We randomly assigned 1 of 2 primary care teams at the Sepulveda VA Ambulatory Care Center to intervention and the other to usual care.

Perceived barriers to weight management in primary care--perspectives of patients and providers.

Background: Despite the consequences of overweight and obesity, effective weight management is not occurring in primary care.

Objective: To identify beliefs about obesity that act as barriers to weight management in primary care by surveying both patients and providers and comparing their responses.

Design: Anonymous, cross-sectional, self-administered survey of patients and providers of a Veteran's Administration Primary Care Clinic, distributed at the clinic site.

Assessing the structure of smoking cessation care in the Veterans Health Administration.

Purpose: National smoking cessation practice guidelines offer recommendations regarding the processes and structure of care. Facilities routinely measure the processes of care but not the structure of care. This pilot study assessed the structure of smoking cessation care at Veterans Health Administration facilities.

Ethnic disparities in the use of nicotine replacement therapy for smoking cessation in an equal access health care system.

Purpose: To examine ethnic variations in the use of nicotine replacement therapy (NRT) in an equal access health care system.

Design: Cross-sectional survey.

Setting: Eighteen Veterans Affairs medical and ambulatory care centers.

Smokers' interest in quitting and services received: using practice information to plan quality improvement and policy for smoking cessation.

Given the prevalence of smoking, its impact, and the benefits of cessation, helping smokers quit should be a top priority for health care organizations. To restructure health care delivery and guide future policy, the authors used baseline survey data from an 18-site Veterans Health Administration group randomized trial to assess the level of interest in quitting smoking for a practice population and determine what smoking cessation services they reported receiving. Among 1941 current smokers, 55% did not intend to quit in the next 6 months, and the remainder intended to quit in the next month (13%) to 6 months (32%).

Smoking cessation care received by veterans with chronic obstructive pulmonary disease.

Smoking is the main cause of chronic obstructive pulmonary disease (COPD), and smoking cessation is the only effective intervention to slow its progression. We examined whether smokers with COPD received more cessation services than smokers without COPD. Current smokers from 18 Veterans Health Administration primary care clinics completed baseline and 12 month follow-up surveys (baseline n = 1,941; 12 month n = 1,080), composed of validated questions on smoking habits, history, and attitudes; health/functional status; and sociodemographics.