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IMPORTANCE: Use of low-value care is common among older adults. It is unclear how to best engage clinicians and older patients to decrease use of low-value services. OBJECTIVE: To test whether the Committing to Choose Wisely behavioral economic intervention could engage primary care clinicians and older patients to reduce low-value care. DESIGN, SETTING, AND PARTICIPANTS: Stepped-wedge cluster randomized clinical trial conducted at 8 primary care clinics of an academic health system and a private group practice between December 12, 2017, and September 4, 2019. Participants were primary care clinicians and older adult patients who had diabetes, insomnia, or anxiety or were eligible for prostate cancer screening. Data analysis was performed from October 2019 to November 2023. INTERVENTION: Clinicians were invited to commit in writing to Choosing Wisely recommendations for older patients to avoid use of hypoglycemic medications to achieve tight glycemic control, sedative-hypnotic medications for insomnia or anxiety, and prostate-specific antigen tests to screen for prostate cancer. Committed clinicians had their photographs displayed on clinic posters and received weekly emails with alternatives to these low-value services. Educational handouts were mailed to applicable patients before scheduled visits and available at the point of care. MAIN OUTCOMES AND MEASURES: Patient-months with a low-value service across conditions (primary outcome) and separately for each condition (secondary outcomes). For patients with diabetes, or insomnia or anxiety, secondary outcomes were patient-months in which targeted medications were decreased or stopped (ie, deintensified). RESULTS: The study included 81 primary care clinicians and 8030 older adult patients (mean [SD] age, 75.1 [7.2] years; 4076 men [50.8%] and 3954 women [49.2%]). Across conditions, a low-value service was used in 7627 of the 37 116 control patient-months (20.5%) and 7416 of the 46 381 intervention patient-months (16.0%) (adjusted odds ratio, 0.79; 95% CI, 0.65-0.97). For each individual condition, there were no significant differences between the control and intervention periods in the odds of patient-months with a low-value service. The intervention increased the odds of deintensification of hypoglycemic medications for diabetes (adjusted odds ratio, 1.85; 95% CI, 1.06-3.24) but not sedative-hypnotic medications for insomnia or anxiety. CONCLUSIONS AND RELEVANCE: In this stepped-wedge cluster randomized clinical trial, the Committing to Choose Wisely behavioral economic intervention reduced low-value care across 3 common clinical situations and increased deintensification of hypoglycemic medications for diabetes. Use of scalable interventions that nudge patients and clinicians to achieve greater value while preserving autonomy in decision-making should be explored more broadly. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03411525

IMPORTANCE: Despite guideline recommendations, clinicians do not systematically use prior screening or health history to guide colorectal cancer (CRC) screening decisions in older adults. OBJECTIVE: To evaluate the effect of a personalized multilevel intervention on screening orders in older adults due for average-risk CRC screening. DESIGN, SETTING, AND PARTICIPANTS: Interventional 2-group parallel unmasked cluster randomized clinical trial conducted from November 2015 to February 2019 at 2 US Department of Veterans Affairs (VA) facilities: 1 academic VA medical center and 1 of its connected outpatient clinics. Randomization at the primary care physician/clinician (PCP) level, stratified by study site and clinical full-time equivalency. Participants were 431 average-risk, screen-due US veterans aged 70 to 75 years attending a primary care visit. Data analysis was performed from August 2018 to August 2023. INTERVENTION: The intervention group received a multilevel intervention including a decision-aid booklet with detailed information on screening benefits and harms, personalized for each participant based on age, sex, prior screening, and comorbidity. The control group received a multilevel intervention including a screening informational booklet. All participants received PCP education and system-level modifications to support personalized screening. MAIN OUTCOMES AND MEASURES: The primary outcome was whether screening was ordered within 2 weeks of clinic visit. Secondary outcomes were concordance between screening orders and screening benefit and screening utilization within 6 months. RESULTS: A total of 436 patients were consented, and 431 were analyzed across 67 PCPs. Patients had a mean (SD) age of 71.5 (1.7) years; 424 were male (98.4%); 374 were White (86.8%); 89 were college graduates (21.5%); and 351 (81.4%) had undergone prior screening. A total of 258 (59.9%) were randomized to intervention, and 173 (40.1%) to control. Screening orders were placed for 162 of 258 intervention patients (62.8%) vs 114 of 173 control patients (65.9%) (adjusted difference, −4.0 percentage points [pp]; 95% CI, −15.4 to 7.4 pp). In a prespecified interaction analysis, the proportion receiving orders was lower in the intervention group than in the control group for those in the lowest benefit quartile (59.4% vs 71.1%). In contrast, the proportion receiving orders was higher in the intervention group than in the control group for those in the highest benefit quartile (67.6% vs 52.2%) (interaction P = .049). Fewer intervention patients (106 of 256 [41.4%]) utilized screening overall at 6 months than controls (96 of 173 [55.9%]) (adjusted difference, −13.4 pp; 95% CI, −25.3 to −1.6 pp). CONCLUSIONS AND RELEVANCE: In this cluster randomized clinical trial, patients who were presented with personalized information about screening benefits and harms in the context of a multilevel intervention were more likely to receive screening orders concordant with benefit and were less likely to utilize screening. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02027545

Genetic researchers’ selection of a database can have scientific, regulatory, and ethical implications. It is important to understand what is driving database selection such that database stewards can be responsive to user needs while balancing the interests of communities in equitably benefiting from advances.

ABSTRACTObjective: We characterised peer support specialists’ self-disclosures related to suicide and recipient responses to inform services for high-risk individuals that may include peer support.Method: We used an inductive approach and thematic analysis to identify themes from audio recordings of initial sessions between peer support specialists trained in suicide-related self-disclosure and 10 study participants who were admitted to inpatient psychiatry units with suicidal ideation or a suicide attempt.Results: The first theme, ‘I’ve been suicidal, but those details are not important', reflects that peers mentioned suicide-related aspects of their histories briefly, often as part of introductions, without participants responding specifically to those aspects. The second theme, ‘Being suicidal is one of the challenges I’ve faced', reflects that in more detailed disclosures by peer specialists and in participant responses, suicide is a part of the mental health challenges and life stressors discussed, not the focus. The third theme ‘Let’s focus on my recovery and what I’ve learned' reflects that peers steered their self-disclosures away from suicide and towards what was helpful in their recovery.Conclusions: Suicide-related self-disclosures embedded within peer specialists’ introduction or overall recovery narrative convey a shared experience while focusing the conversation on mental health challenges other than suicide.

ABSTRACTObjective:To identify modifiers of emergency medical services (EMS) oversight quality, including facilitators and barriers, and inform best practices and policy related to EMS oversight and system performance.Methods:We used a qualitative design, including 4 focus groups and 10 in-depth, 1-on-1 interviews. Primary data were collected from EMS stakeholders in Michigan from June to July 2016. Qualitative data were analyzed using the rapid assessment technique.Results:Emergent themes included organizational structure, oversight and stakeholder leadership, interorganizational communication and relationships, competition or collaboration among MCA stakeholders, quality improvement practices, resources,and needs specific to rural communities.Conclusions:EMS is a critical component of disaster response. This study revealed salient themes and modifiers, including facilitators and barriers, of EMS oversight quality. These findings were evaluated in the context of current evidence and informed state policy to improve the quality of EMS oversight and prehospital care for both routine and disaster settings. Some were particular to geographic regions and communities, whereas others were generalizable.

To describe how and when surgery residents provided primary palliative care and engaged specialty palliative care services.

We evaluated a strategy to increase use of the test (Dix-Hallpike’s test [DHT]) and treatment (canalith repositioning maneuver [CRM]) for benign paroxysmal positional vertigo in emergency department (ED) dizziness visits.

Indwelling urinary and vascular catheters are valuable devices in patient care, but prolonged or unnecessary use increases the risk of infectious and noninfectious catheter harms.

ObjectiveTo determine how a large scale, multicomponent, pharmacy based intervention to reduce proton pump inhibitor (PPI) overuse affected prescribing patterns, healthcare utilization, and clinical outcomes.DesignDifference-in-difference study.SettingUS Veterans Affairs Healthcare System, in which one regional network implemented the overuse intervention and all 17 others served as controls.ParticipantsAll individuals receiving primary care from 2009 to 2019.InterventionLimits on PPI refills for patients without a documented indication for long term use, voiding of PPI prescriptions not recently filled, facilitated electronic prescribing of H2 receptor antagonists, and education for patients and clinicians.Main outcome measuresThe primary outcome was the percentage of patients who filled a PPI prescription per 6 months. Secondary outcomes included percentage of days PPI gastroprotection was prescribed in patients at high risk for upper gastrointestinal bleeding, percentage of patients who filled either a PPI or H2 receptor antagonist prescription, hospital admission for acid peptic disease in older adults appropriate for PPI gastroprotection, primary care visits for an upper gastrointestinal diagnosis, upper endoscopies, and PPI associated clinical conditions.ResultsThe number of patients analyzed per interval ranged from 192 607 to 250 349 in intervention sites and from 3 775 953 to 4 360 868 in control sites, with 26% of patients receiving PPIs before the intervention. The intervention was associated with an absolute reduction of 7.3% (95% confidence interval −7.6% to −7.0%) in patients who filled PPI prescriptions, an absolute reduction of 11.3% (−12.0% to −10.5%) in PPI use among patients appropriate for gastroprotection, and an absolute reduction of 5.72% (−6.08% to −5.36%) in patients who filled a PPI or H2 receptor antagonist prescription. No increases were seen in primary care visits for upper gastrointestinal diagnoses, upper endoscopies, or hospital admissions for acid peptic disease in older patients appropriate for gastroprotection. No clinically significant changes were seen in any PPI associated clinical conditions.ConclusionsThe multicomponent intervention was associated with reduced PPI use overall but also in patients appropriate for gastroprotection, with minimal evidence of either clinical benefits or harms.

ABSTRACTAs citizen-soldiers who maintain military and civilian roles, National Guard service members may experience unique challenges during reintegration. In the current study, 78 Operation Enduring Freedom/Operation Iraqi Freedom National Guard service members completed semistructured interviews on their reintegration experiences. Many soldiers reported smooth reintegration experiences, but others reported challenges. When soldiers reported mental health issues, they usually reported anger problems and alcohol misuse. Help seeking was not frequently reported. The findings highlight the complex interactions among reintegration domains, particularly the influence of family members on help-seeking. Continued efforts are needed to facilitate service delivery and promote smooth reintegration experiences among National Guard service members.

IMPORTANCE Preventing catheter-associated urinary tract infection (CAUTI), a common health care–associated infection, is important for improving the care of hospitalized patients and in meeting the goals for reduction of health care–associated infections set by the US Department of Health and Human Services. OBJECTIVE To identify ways to enhance CAUTI prevention efforts based on the experiences of hospitals participating in the Michigan Health and Hospital Association Keystone Center for Patient Safety statewide program to reduce unnecessary use of urinary catheters (the Bladder Bundle). DESIGN Qualitative assessment of data collected through semistructured telephone interviews with key informants at 12 hospitals and in-person interviews and site visits at 3 of the 12 hospitals. The analysis focused on perceptions and key issues identified by hospitals as influencing implementation of CAUTI prevention practices as recommended by the Bladder Bundle initiative. SETTING Twelve purposefully sampled hospitals in Michigan. PARTICIPANTS Key informants including infection preventionists, clinical personnel, and senior executives. RESULTS Common barriers to Bladder Bundle implementation and appropriate urinary catheter use included (1) difficulty with nurse and physician engagement, (2) patient and family request for indwelling catheters, and (3) catheter insertion practices and customs in the emergency department. Strategies to address these barriers were also identified by several of the participating hospitals, including (1) incorporating urinary management (eg, planned toileting) as part of other patient safety programs, such as a fall reduction program, (2) explicitly discussing the risks of indwelling urinary catheters with patients and families, and (3) engaging with emergency department nurses and physicians to implement a process that ensures that appropriate indications for catheter use are followed. CONCLUSIONS AND RELEVANCE The Bladder Bundle program provides a model for implementing strategies to reduce CAUTI. These findings provide actionable information to inform CAUTI prevention-related activities in hospitals throughout the country.

National Guard soldiers experience high levels of mental health symptoms following deployment to Iraq and Afghanistan, yet many do not seek treatment. We interviewed 30 National Guard soldiers with prior deployments to Iraq or Afghanistan to assess mental health treatment barriers and the role of peers in treatment engagement. Interview transcripts were analyzed by a multidisciplinary research team using techniques drawn from grounded theory. The following themes were identified: (1) personal acceptance of having a mental health problem rather than treatment access is the major barrier to treatment entry; (2) tightly connected, supportive peer networks can decrease stigma related to mental health problems and encourage treatment; however, soldiers in impoverished or conflicted peer networks are less likely to receive these benefits; and (3) soldiers are generally positive about the idea of peer-based programs to improve treatment engagement, although they note the importance of leadership support, peer assignment, and unit specialty in implementing these programs. We conclude that some, but not all, naturally occurring peer networks serve to overcome stigma and encourage mental health treatment seeking by soldiers. Formal peer-based programs may assist soldiers not sufficiently benefitting from natural peer networks, although there are barriers to implementation.

ABSTRACT: While key components of the Patient-Centered Medical Home (PCMH) have been described, improved patient outcomes and efficiencies have yet to be conclusively demonstrated. We describe the rationale, conceptual framework, and progress to date as part of the VA Ann Arbor Patient-Aligned Care Team (PACT) Demonstration Laboratory, a clinical care-research partnership designed to implement and evaluate PCMH programs. Evidence and experience underlying this initiative is presented. Key components of this innovation are: (a) a population-based registry; (b) a navigator system that matches veterans to programs; and (c) a menu of self-management support programs designed to improve between-visit support and leverage the assistance of patient–peers and informal caregivers. This approach integrates PCMH principles with novel implementation tools allowing patients, caregivers, and clinicians to improve disease management and self-care. Making changes within a complex organization and integrating programmatic and research goals represent unique opportunities and challenges for evidence-based healthcare improvements in the VA.

The purpose of this study, conducted in 3 intensive care units (ICUs) at 1 Department of Veterans Affairs Medical Center, was to develop tools and procedures to measure nurse/physician communication in future studies.

Objective.Healthcare-associated infection (HAI) is costly and causes substantial morbidity. We sought to understand why some hospitals were engaged in HAI prevention activities while others were not. Because preliminary data indicated that hospital leadership played an important role, we sought better to understand which behaviors are exhibited by leaders who are successful at implementing HAI prevention practices in US hospitals.Methods.We report phases 2 and 3 of a 3-phase study. In phase 2, 14 purposefully sampled US hospitals were selected from among the 72% of 700 invited hospitals whose lead infection preventionist had completed a quantitative survey on HAI prevention during phase 1. Qualitative data were collected during 38 semistructured phone interviews with key personnel at the 14 hospitals. During phase 3, we conducted 48 interviews during 6 in-person site visits to identify recurrent and unifying themes that characterize behaviors of successful leaders.Results.We found that successful leaders (1) cultivated a culture of clinical excellence and effectively communicated it to staff; (2) focused on overcoming barriers and dealt directly with resistant staff or process issues that impeded prevention of HAI; (3) inspired their employees; and (4) thought strategically while acting locally, which involved politicking before crucial committee votes, leveraging personal prestige to move initiatives forward, and forming partnerships across disciplines. Hospital epidemiologists and infection preventionists often played more important leadership roles in their hospital's patient safety activities than did senior executives.Conclusions.Leadership plays an important role in infection prevention activities. The behaviors of successful leaders could be adopted by others who seek to prevent HAI.

Objective.To determine what practices are used by hospitals to prevent ventilator-associated pneumonia (VAP) and, through qualitative methods, to understand more fully why hospitals use certain practices and not others.Design.Mixed-methods, sequential explanatory study.Methods.We mailed a survey to the lead infection control professionals at 719 US hospitals (119 Department of Veterans Affairs [VA] hospitals and 600 non-VA hospitals), to determine what practices are used to prevent VAP. We then selected 14 hospitals for an in-depth qualitative investigation, to ascertain why certain infection control practices are used and others not, interviewing 86 staff members and visiting 6 hospitals.Results.The survey response rate was 72%; 83% of hospitals reported using semirecumbent positioning, and only 21% reported using subglottic secretion drainage. Multivariable analyses indicated collaborative initiatives were associated with the use of semirecumbent positioning but provided little guidance regarding the use of subglottic secretion drainage. Qualitative analysis, however, revealed 3 themes: (1) collaboratives strongly influence the use of semirecumbent positioning but have little effect on the use of subglottic secretion drainage; (2) nurses play a major role in the use of semirecumbent positioning, but they are only minimally involved with the use of subglottic secretion drainage; and (3) there is considerable debate about the evidence supporting subglottic secretion drainage, despite a meta-analysis of 5 randomized trials of subglottic secretion drainage that generally supported this preventive practice, compared with only 2 published randomized trials of semirecumbent positioning, one of which concluded that it was ineffective at preventing the development of VAP.Conclusion.Semirecumbent positioning is commonly used to prevent VAP, whereas subglottic secretion drainage is used far less often. We need to understand better how evidence related to prevention practices is identified, interpreted, and used to ensure that research findings are reliably translated into clinical practice.

To examine adult–child interactions related to soda consumption in families where 1 inner-city African-American or Latino adult with diabetes is attempting lifestyle changes.

Objective.Although urinary tract infection (UTI) is the most common hospital-acquired infection, there is little information about why hospitals use or do not use a range of available preventive practices. We thus conducted a multicenter study to understand better how US hospitals approach the prevention of hospital-acquired UTI.Methods.This research is part of a larger study employing both quantitative and qualitative methods. The qualitative phase consisted of 38 semistructured phone interviews with key personnel at 14 purposefully sampled US hospitals and 39 in-person interviews at 5 of those 14 hospitals, to identify recurrent and unifying themes that characterize how hospitals have addressed hospital-acquired UTI.Results.Four recurrent themes emerged from our study data. First, although preventing hospital-acquired UTI was a low priority for most hospitals, there was substantial recognition of the value of early removal of a urinary catheter for patients. Second, those hospitals that made UTI prevention a high priority also focused on noninfectious complications and had committed advocates, or “champions,” who facilitated prevention activities. Third, hospital-specific pilot studies were important in deciding whether or not to use devices such as antimicrobial-impregnated catheters. Finally, external forces, such as public reporting, influenced UTI surveillance and infection prevention activities.Conclusions.Clinicians and policy makers can use our findings to develop initiatives that, for example, use a champion to promote the removal of unnecessary urinary catheters or exploit external forces, such public reporting, to enhance patient safety.