Does Mental Health Care Integration Affect Primary Care Clinician Burnout? Results from a Longitudinal Veterans Affairs Survey.

Background: Burnout among primary care clinicians (PCPs) is associated with negative health and productivity consequences. The Veterans Health Administration (VA) embedded mental health specialists and care managers in primary care to manage common psychiatric diseases. While challenging to implement, mental health integration is a team-based care model thought to improve clinician well-being.

Do Collaborative Care Managers and Technology Enhance Primary Care Satisfaction with Care from Embedded Mental Health Providers?

Background: To improve mental health care access, the Veterans Health Administration (VA) implemented Primary Care-Mental Health Integration (PC-MHI) in clinics nationally. Primary care clinical leader satisfaction can inform model implementation and may be facilitated by collaborative care managers and technology supporting cross-specialty collaboration.

Objective: (1) To determine primary care clinical leaders' overall satisfaction with care from embedded mental health providers for a range of conditions and (2) to examine the association between overall satisfaction and two program features (care managers, technology).

Assessing fidelity to evidence-based quality improvement as an implementation strategy for patient-centered medical home transformation in the Veterans Health Administration.

Background: Effective implementation strategies might facilitate patient-centered medical home (PCMH) uptake and spread by targeting barriers to change. Evidence-based quality improvement (EBQI) is a multi-faceted implementation strategy that is based on a clinical-researcher partnership. It promotes organizational change by fostering innovation and the spread of those innovations that are successful.

Regional Adoption of Primary Care-Mental Health Integration in Veterans Health Administration Patient-Centered Medical Homes.

Introduction: Behavioral health integration is important, yet difficult to implement, in patient-centered medical homes. The Veterans Health Administration (VA) mandated evidence-based collaborative care models through Primary Care-Mental Health Integration (PC-MHI) in large PC clinics. This study characterized PC-MHI programs among all PC clinics, including small sites exempt from program implementation, in one VA region.

Communication Among Team Members Within the Patient-centered Medical Home and Patient Satisfaction With Providers: The Mediating Role of Patient-Provider Communication.

Background: The Patient-centered Medical Home (PCMH) uses team-based care to improve patient outcomes, including satisfaction. The quality of patients' communication with their primary care providers (PCPs) is a key determinant of patient satisfaction. A shift to team-based care could disrupt the therapeutic relationship between patients and their PCPs and reduce patient satisfaction if communication and coordination among primary care team members is poor.

A real-time assessment of factors influencing medication events.

Reducing medical error is critical to improving the safety and quality of healthcare. Physician stress, fatigue, and excessive workload are performance-shaping factors (PSFs) that may influence medical events (actual administration errors and near misses), but direct relationships between these factors and patient safety have not been clearly defined. This study assessed the real-time influence of emotional stress, workload, and sleep deprivation on self-reported medication events by physicians in academic hospitals.

Development of a hand-held computer platform for real-time behavioral assessment of physicians and nurses.

We developed a hand-held data collection tool to facilitate real-time collection of data on the factors that affect hospital staff performance. To assure high-yield of data from busy clinicians, the design objectives included low response burden, the ability to collect complex real-time data in dynamic work environments, and automated data integration. Iterative user-centered design of custom interfaces resulted in a dynamic intuitive platform where branching logic was applied to present a series of survey questions dependent on the participant's responses.

Intern to attending: assessing stress among physicians.

Purpose: Organizations have raised concerns regarding stress in the medical work environment and effects on health care worker performance. This study's objective was to assess workplace stress among interns, residents, and attending physicians using Ecological Momentary Assessment technology, the gold-standard method for real-time measurement of psychological characteristics.

Method: The authors deployed handheld computers with customized software to 185 physicians on the medicine and pediatric wards of four major teaching hospitals.

Use of a handheld computer application for voluntary medication event reporting by inpatient nurses and physicians.

Objective: To determine the feasibility of capturing self-reported medication events using a handheld computer-based Medication Event Reporting Tool (MERT).

Design And Participants: Handheld computers operating the MERT software application were deployed among volunteer physician (n = 185) and nurse (n = 119) participants on the medical wards of four university-affiliated teaching hospitals. Participants were encouraged to complete confidential reports on the handheld computers for medication events observed during the study period.

Direct and indirect links between childhood maltreatment, posttraumatic stress disorder, and women's health.

The authors evaluated the relationships among childhood maltreatment, sexual trauma in adulthood, posttraumatic stress disorder (PTSD), and health functioning in women. Female Veterans' Affairs (VA) primary care patients (N = 200) completed self-report measures of childhood maltreatment, adult sexual trauma, PTSD symptoms, and current health functioning. The authors used structural equation modeling to test models of the relationship among these variables.

Effect of age at onset on the course of major depressive disorder.

Objective: This report assesses whether age at onset defines a specific subgroup of major depressive disorder in 4,041 participants who entered the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study.

Method: The study enrolled outpatients 18-75 years of age with nonpsychotic major depressive disorder from both primary care and psychiatric care practices. At study entry, participants estimated the age at which they experienced the onset of their first major depressive episode.

Relationships among childhood maltreatment, PTSD, and health in female veterans in primary care.

Objective: Women with histories of childhood maltreatment (CM) have higher rates of physical health problems and greater medical utilization compared to women without abuse histories. This study examined whether current post-traumatic stress disorder (PTSD) symptoms mediate the relationship between CM and indicators of physical health and medical utilization in female veterans.

Method: Respondents were 221 female veterans (56% of the potential sample), who received medical care from the San Diego VA Healthcare System during a 12-month period.

Mental health and satisfaction with primary health care in female patients.

Purpose And Objectives: Patient satisfaction is an important outcome in patient care and is increasingly being used as an indicator of quality of care within large health systems. This study examined whether consideration of specific mental health factors, including posttraumatic stress disorder (PTSD), can improve our understanding of patient satisfaction in primary care settings.

Methods: Questionnaires were mailed to all women who used the VA San Diego Healthcare System primary care clinic in 1998.

Mental health treatment preferences of older and younger primary care patients.

Objective: To compare mental health treatment history and preferences in older and younger primary care patients.

Method: We surveyed 77 older (60+) and 312 younger adult primary care patients from four outpatient medical clinics about their mental health treatment history and preferences.

Results: Older adults were less likely than younger adults to report a history of mental health treatment (29% vs.

An evaluation of vignettes for predicting variation in the quality of preventive care.

Objective: Clinical vignettes offer an inexpensive and convenient alternative to the benchmark method of chart audits for assessing quality of care. We examined whether vignettes accurately measure and predict variation in the quality of preventive care.

Design: We developed scoring criteria based on national guidelines for 11 prevention items, categorized as vaccine, vascular-related, cancer screening, and personal behaviors.

The impact of individual forms of childhood maltreatment on health behavior.

Objective: This study examines the unique contribution of five types of maltreatment (sexual abuse, physical abuse, emotional abuse, physical neglect, emotional neglect) to adult health behaviors as well as the additive impact of exposure to different types of childhood maltreatment.

Method: Two hundred and twenty-one women recruited from a VA primary care clinic completed questionnaires assessing exposure to childhood trauma and adult health behaviors. Regression models were used to test the relationship between childhood maltreatment and adult health behaviors.

Relationship of sexual assault history to somatic symptoms and health anxiety in women.

Prior reports have pointed to a link between traumatic experiences and health consequences in women. The objective of this study was to determine whether there is an association between sexual assault history and measures of somatic symptoms and illness attitudes in a sample of female Veterans Affairs primary care patients, a group in whom high rates of sexual trauma have been reported. We conducted a cross-sectional study of a representative sample of 219 women in a Veteran's Affairs primary care outpatient clinic.

Sexual trauma, posttraumatic stress disorder, and health behavior.

The authors tested whether sexual traumatization is associated with poorer health behavior and also evaluated the role of posttraumatic stress disorder (PTSD) in this relationship. They mailed questionnaires to 419 women who had visited a San Diego Veterans Administration primary care clinic in 1998 and received 221 responses, a 56% return rate. They found that a history of sexual assault was associated with increased substance use, risky sexual behaviors, less vigorous exercise, and increased preventive healthcare.

Sensitivity and specificity of the PTSD checklist in detecting PTSD in female veterans in primary care.

PTSD affects a substantial number of women in medical settings and is associated with significant distress and impairment. There are effective methods of treating trauma-related distress, but a minority seek such care. Thus, primary care is an important setting in which to identify individuals with PTSD.