Showing papers by "Thomas K. Houston published in 2011"

The attributable risk of smoking on surgical complications

Abstract: Objective: This study aimed to assess the attributable risk and potential benefit of smoking cessation on surgical outcomes. Summary Background Data: Risk reduction with the implementation of surgical care improvement project process measures has been the primary focus for improving surgical outcomes. Little emphasis has been placed on preoperative risk factor recognition and intervention. Methods: A retrospective cohort analysis of elective operations from 2002 to 2008 in the Veterans Affairs Surgical Quality Improvement Program for all surgical specialties was performed. Patients were stratified by current, prior, and never smokers. Adjusted risk of complication and death was calculated using multilevel, multivariable logistic regression. Results: Of 393,794 patients, 135,741 (34.5%) were current, 71,421 (18.1%) prior, and 186,632 (47.4%) never smokers. A total of 6225 pneumonias, 11,431 deep and superficial surgical-site infections, 2040 thromboembolic events, 1338 myocardial infarctions, and 4792 deaths occurred within 30 days of surgery. Compared with both never and prior smokers individually and controlled for patient and procedure risk factors, current smokers had significantly more postoperative pneumonia, surgical-site infection, and deaths (P < 0.001 for all). There was a dose-dependent increase in pulmonary complications based on pack-year exposure with greater than 20 pack years leading to a significant increase in smoking-related surgical complications. Conclusions: This is the first study to assess the risk of current versus prior smoking on surgical outcomes. Despite being younger and healthier, current smokers had more adverse perioperative events, particularly respiratory complications. Smoking cessation interventions could potentially reduce the occurrence and costs of adverse perioperative events.

Culturally appropriate storytelling to improve blood pressure: a randomized trial

Abstract: Background Storytelling is emerging as a powerful tool for health promotion in vulnerable populations. However, these interventions remain largely untested in rigorous studies. Objective To test an interactive storytelling intervention involving DVDs. Design Randomized, controlled trial in which comparison patients received an attention control DVD. Separate random assignments were performed for patients with controlled or uncontrolled hypertension. (ClinicalTrials.gov registration number: NCT00875225) Setting An inner-city safety-net clinic in the southern United States. Patients 230 African Americans with hypertension. Intervention 3 DVDs that contained patient stories. Storytellers were drawn from the patient population. Measurements The outcomes were differential change in blood pressure for patients in the intervention versus the comparison group at baseline, 3 months, and 6 to 9 months. Results 299 African American patients were randomly assigned between December 2007 and May 2008 and 76.9% were retained throughout the study. Most patients (71.4%) were women, and the mean age was 53.7 years. Baseline mean systolic and diastolic pressures were similar in both groups. Among patients with baseline uncontrolled hypertension, reduction favored the intervention group at 3 months for both systolic (11.21 mm Hg [95% CI, 2.51 to 19.9 mm Hg]; P = 0.012) and diastolic (6.43 mm Hg [CI, 1.49 to 11.45 mm Hg]; P = 0.012) blood pressures. Patients with baseline controlled hypertension did not significantly differ over time between study groups. Blood pressure subsequently increased for both groups, but between-group differences remained relatively constant. Limitation This was a single-site study with 23% loss to follow-up and only 6 months of follow-up. Conclusion The storytelling intervention produced substantial and significant improvements in blood pressure for patients with baseline uncontrolled hypertension. Primary funding source Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation.

Smoking as a risk factor for short-term outcomes following primary total hip and total knee replacement in veterans.

Abstract: Objective To assess the effect of smoking on postoperative complications following elective primary total hip replacement (THR) or primary total knee replacement (TKR). Methods We used data from the national Veterans Affairs Surgical Quality Improvement Program to examine the association of smoking status at surgery with 30-day postoperative complication rates (including surgical site and other infections, pneumonia, stroke, myocardial infarction, mortality, and other complications) in veterans undergoing primary elective THR or TKR. Multilevel multivariable-adjusted logistic regression models, adjusted for age, race/ethnicity, work relative value units, American Society of Anesthesiology classification, and year of surgery, with additional adjustment for wound classification for surgical site infections, were used. Results A total of 33,336 patients, 95% men and 80% white with a mean age of 64 years, underwent elective primary THR/TKR between October 2001 and September 2008. Fifty-seven percent never smoked, 19% were prior smokers, and 24% were current smokers. Current smokers undergoing THR/TKR were significantly more likely than never smokers to have surgical site infections (odds ratio [OR] 1.41, 95% CI 1.16–1.72), pneumonia (OR 1.53, 95% CI 1.10–2.14), stroke (OR 2.61, 95% CI 1.26–5.41), and 1-year mortality (OR 1.63, 95% CI 1.31–2.02). Prior smokers were significantly more likely than nonsmokers to have pneumonia, (OR 1.34, 95% CI 1.00–1.80), stroke (OR 2.14, 95% CI 1.12–4.10), and urinary tract infection (OR 1.26, 95% CI 1.02–1.55). Conclusion Current smoking at the time of elective THR or TKR is associated with increased postarthroplasty complications, especially surgical site infections and pneumonia. Preoperative smoking cessation programs should be considered in patients undergoing elective THR or TKR.

Alcohol Screening and Risk of Postoperative Complications in Male VA Patients Undergoing Major Non-cardiac Surgery

Abstract: Patients who misuse alcohol are at increased risk for surgical complications. Four weeks of preoperative abstinence decreases the risk of complications, but practical approaches for early preoperative identification of alcohol misuse are needed. To evaluate whether results of alcohol screening with the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire—up to a year before surgery—were associated with the risk of postoperative complications. This is a cohort study. Male Veterans Affairs (VA) patients were eligible if they had major noncardiac surgery assessed by the VA’s Surgical Quality Improvement Program (VASQIP) in fiscal years 2004-2006, and completed the AUDIT-C alcohol screening questionnaire (0-12 points) on a mailed survey within 1 year before surgery. One or more postoperative complication(s) within 30 days of surgery based on VASQIP nurse medical record reviews. Among 9,176 eligible men, 16.3% screened positive for alcohol misuse with AUDIT-C scores ≥ 5, and 7.8% had postoperative complications. Patients with AUDIT-C scores ≥ 5 were at significantly increased risk for postoperative complications, compared to patients who drank less. In analyses adjusted for age, smoking, and days from screening to surgery, the estimated prevalence of postoperative complications increased from 5.6% (95% CI 4.8–6.6%) in patients with AUDIT-C scores 1–4, to 7.9% (6.3–9.7%) in patients with AUDIT-Cs 5–8, 9.7% (6.6–14.1%) in patients with AUDIT-Cs 9–10 and 14.0% (8.9–21.3%) in patients with AUDIT-Cs 11–12. In fully-adjusted analyses that included preoperative covariates potentially in the causal pathway between alcohol misuse and complications, the estimated prevalence of postoperative complications increased significantly from 4.8% (4.1–5.7%) in patients with AUDIT-C scores 1–4, to 6.9% (5.5–8.7%) in patients with AUDIT-Cs 5-8 and 7.5% (5.0–11.3%) among those with AUDIT-Cs 9–10. AUDIT-C scores of 5 or more up to a year before surgery were associated with increased postoperative complications.

The art and science of patient storytelling-harnessing narrative communication for behavioral interventions: the ACCE project.

Abstract: Narrative communication is an emerging form of persuasive communication used in health education to solicit actual patient stories. Eliciting a narrative is an open-ended process and may or may not map to desired intervention objectives or underlying behavioral constructs. In addition, incorporating actual, unscripted narratives into multimedia interventions is challenging. The authors evaluated a protocol of editing narratives for a multimedia intervention to promote smoking cessation in the African American community that maintains fidelity to the original message and was related to behavioral constructs from social cognitive theory. The authors used four steps: (a) narrative collection (videotaping), (b) narrative review (rating of content), (c) narrative editing (documentary style), and (d) pilot testing (usability and assessment of transportation). The authors videotaped 50 personal smoking cessation narratives. After coding for presence of theoretical constructs, perceived risks of smoking (present in 53% of narratives) was the most common related behavioral construct. Four narratives were chosen for inclusion in the DVD. Pilot testing showed viewers reported high level of transportation into the narrative. The authors found that some behavioral constructs were rare and difficult to solicit in this population but that the final product was engaging to the viewers. Lessons learned may be useful for other video-based behavioral interventions that incorporate personal narratives.

What should we include in a cultural competence curriculum? An emerging formative evaluation process to foster curriculum development.

Abstract: PurposeTo identify, prioritize, and organize components of a cultural competence curriculum to address disparities in cardiovascular disease.MethodIn 2006, four separate nominal group technique sessions were conducted with medical students, residents, community physicians, and academic physi

Promoting Access Through Complementary eHealth Technologies: Recommendations for VA’s Home Telehealth and Personal Health Record Programs

Abstract: BACKGROUND Many healthcare organizations have embraced eHealth technologies in their efforts to promote patient-centered care, increase access to services, and improve outcomes.

Development of an interactive, Web-delivered system to increase provider-patient engagement in smoking cessation

Abstract: Background: Patient self-management interventions for smoking cessation are effective but underused. Health care providers do not routinely refer smokers to these interventions. Objective: The objective of our study was to uncover barriers and facilitators to the use of an e-referral system that will be evaluated in a community-based randomized trial. The e-referral system will allow providers to refer smokers to an online smoking intervention during routine clinical care. Methods: We devised a four-step development and pilot testing process: (1) system conceptualization using Delphi to identify key functionalities that would overcome barriers in provider referrals for smoking cessation, (2) Web system programming using agile software development and best programming practices with usability refinement using think-aloud testing, (3) implementation planning using the nominal group technique for the effective integration of the system into the workflow of practices, and (4) pilot testing to identify practice recruitment and system-use barriers in real-world settings. Results: Our Delphi process (step 1) conceptualized three key e-referral functions: (1) Refer Your Smokers, allowing providers to e-refer patients at the point of care by entering their emails directly into the system, (2) practice reports, providing feedback regarding referrals and impact of smoking-cessation counseling, and (3) secure messaging, facilitating provider–patient communication. Usability testing (step 2) suggested the system was easy to use, but implementation planning (step 3) suggested several important approaches to encourage use (eg, proactive email cues to encourage practices to participate). Pilot testing (step 4) in 5 practices had limited success, with only 2 patients referred; we uncovered important recruitment and system-use barriers (eg, lack of study champion, training, and motivation, registration difficulties, and forgetting to refer). Conclusions: Implementing a system to be used in a clinical setting is complex, as several issues can affect system use. In our ongoing large randomized trial, preliminary analysis with the first 50 practices using the system for 3 months demonstrated that our rigorous preimplementation evaluation helped us successfully identify and overcome these barriers before the main trial. Trial: Clinicaltrials.gov NCT00797628; http://clinicaltrials.gov/ct2/show/NCT00797628 (Archived by WebCite at http://www.webcitation.org/61feCfjCy) [J Med Internet Res 2011;13(4):e87]

A web-based diabetes intervention for physician: a cluster-randomized effectiveness trial

Abstract: Objective. To determine the effectiveness of a provider-based education and implementation intervention for improving diabetes control. Design. Cluster-randomized trial with baseline and follow-up cross sections of diabetes patients in each participating phys- ician's practice. Primary Outcome Measures. 'Acceptable control' (hemoglobin A1c � 9%, blood pressure (BP) ,140/90 mmHg, low- density lipoprotein cholesterol (LDL) ,130 mg/dl) and 'optimal control' (A1c ,7%, BP ,130/80 mmHg, LDL ,100 mg/dl). Results. Of 364 physicians attempting to register, 205 were randomized to the intervention (n ¼ 102) or control arms (n ¼ 103). Baseline and follow-up data were provided by 95 physicians (2127 patients). The proportion of patients with A1c � 9% was similar at baseline and follow-up in both the control (adjusted odds ratio (AOR): 0.94; 95% confidence interval (CI): 0.61, 1.47) and intervention arms (AOR: 1.16 (95% CI: 0.80, 1.69)); BP ,140/90 mmHg and LDL ,130 mg/dl were also similar at both measurement points (P ¼ 0.66, P ¼ 0.46; respectively). We observed no significant effect on diabetes control attributable to the intervention for any of the primary outcome measures. Intervention physicians engaged with the Website over a median of 64.7 weeks (interquartile range (IQR): 45.4 - 81.8) for a median total of 37 min (IQR: 16 - 66). Conclusions. A wide-reach, low-intensity, Web-based interactive multi-component intervention did not improve control of glucose, BP or lipids for patients with diabetes of physicians practicing in the rural Southeastern US.

Stories to Communicate Risks about Tobacco: Development of a Brief Scale to Measure Transportation into a Video Story--The ACCE Project.

Abstract: Objective: To evaluate the construct and criterion validity of the Video Transportation Scale (VTS).Setting: Inpatient service of a safety net hospital in Birmingham, Alabama, USA.Method: We administered the VTS in the context of a randomized controlled trial of a DVD-delivered narrative-based intervention (stories) designed to encourage smoking cessation among hospitalized patients.Results: Factor analysis yielded a two-factor solution relating to engagement and attentional focus. Patients receiving the stories-based intervention had a higher score for engagement than control but stories patients and controls did not differ in reported attentional focus. The engagement factor demonstrated predictive validity in that patients with higher scores were more likely to report quitting smoking at two weeks.Conclusion: The VTS provides a rapid assessment of transportation that can be used in applied settings using video-based narratives.

Culturally Appropriate Storytelling to Improve Blood Pressure

Abstract: Many patients with hypertension do not achieve adequate blood pressure control. This randomized trial assigned 299 African Americans with hypertension to receive usual care or to view 3 interactive...

Defining core issues in utilizing information technology to improve access: evaluation and research agenda.

Abstract: The Department of Veterans Affairs (VA) has been at the vanguard of information technology (IT) and use of comprehensive electronic health records Despite the widespread use of health IT in the VA, there are still a variety of key questions that need to be answered in order to maximize the utility of IT to improve patient access to quality services This paper summarizes the potential of IT to enhance healthcare access, key gaps in current evidence linking IT and access, and methodologic challenges for related research We also highlight four key issues to be addressed when implementing and evaluating the impact of IT interventions on improving access to quality care: 1) Understanding broader needs/perceptions of the Veteran population and their caregivers regarding use of IT to access healthcare services and related information 2) Understanding individual provider/clinician needs/perceptions regarding use of IT for patient access to healthcare 3) System/Organizational issues within the VA and other organizations related to the use of IT to improve access 4) IT integration and information flow with non-VA entities While the VA is used as an example, the issues are salient for healthcare systems that are beginning to take advantage of IT solutions

Improving care after myocardial infarction using a 2-year internet-delivered intervention: the Department of Veterans Affairs myocardial infarction-plus cluster-randomized trial

Abstract: Background Cardiovascular risk reduction in ambulatory patients who survive myocardial infarction (MI) is effective but underused. We sought to evaluate a provider-directed, Internet-delivered intervention to improve cardiovascular management for post-MI outpatients. Methods The Department of Veterans Affairs (VA) MI-Plus study was a cluster-randomized trial involving 168 community-based primary care clinics and 847 providers in 26 states, the Virgin Islands, and Puerto Rico, from January 1, 2002, through December 31, 2008, with the clinic as the randomization unit. We collected administrative data for 15 847 post-MI patients and medical record data for 10 452 of these. A multicomponent, Internet-delivered intervention included quarterly educational modules, practice guidelines, monthly literature summaries, and automated e-mail reminders delivered to providers for 27 months. Main outcome measures included percentage of patients who achieved each of 7 clinical indicators, a composite score of the 7 clinical indicators, and mean low-density lipoprotein cholesterol and hemoglobin A1c levels. Results Clinics had a median of 3 providers (interquartile range, 2-6), with a median of 50.0% of providers (33.3%-66.7%) participating in the study. Patients in intervention clinics had greater improvements (from 70.0% to 85.5%) in the percentages prescribed β-blockers than patients in control clinics (71.9% to 84.0%; adjusted improvement gain for intervention vs control, 2.6%; 95% CI, 0.1%-4.1%). We found nonsignificant differences in improvements favoring patients in intervention clinics for 5 of 6 remaining clinical indicators and levels of low-density lipoprotein cholesterol and hemoglobin A1c. Conclusion A longitudinal, Internet-delivered intervention improved only 1 of 7 clinical indicators of cardiovascular management in ambulatory post-MI patients.

Marketing to increase participation in a Web-based continuing medical education cultural competence curriculum.

Abstract: Introduction—CME providers may be interested in identifying effective marketing strategies to direct users to specific content. The use of online advertisements to recruit participants for clinical trials, public health programs, and Continuing Medical Education (CME) has been shown to be

Physician and Patient Influences on Provider Performance β-Blockers in Postmyocardial Infarction Management in the MI-Plus Study

Abstract: Background—Efforts to improve the quality of care for patients with cardiovascular disease frequently target the decrease of physician-level performance variability. We assessed how variability in providing β-blockers to ambulatory postmyocardial infarction (MI) patients was influenced by physician and patient level characteristics. Methods and Results—β-Blocker prescription and patient characteristics were abstracted from charts of post-MI patients treated by 133 primary care physicians between 2003 and 2007 and linked to physician and practice characteristics. Associations of β-blocker prescription with physician- and patient-level characteristics were examined using mixed-effects models, with physician-level effects as random. Mean physician-specific predicted probabilities and the intraclass correlations, which assessed the proportion of variance explainable at the physician level, were estimated. Of 1901 patients without major contraindication, 69.1% (range across physicians, 20% to 100%) were prescr...

Cognitive Mapping Tobacco Control Advice for Dentistry: A Dental PBRN Study.

Abstract: OBJECTIVE To identify facilitative strategies that could be used in developing a tobacco cessation program for community dental practices METHODS Nominal group technique (NGT) meetings and a card-sort task were used to obtain formative data A cognitive mapping approach involving multidimensional scaling and hierarchical cluster analysis was used for data analysis RESULTS Three NGT meetings conducted with 23 dental professionals yielded 27 nonredundant facilitative strategies A 2-dimensional 4-cluster cognitive map provided an organizational framework for understanding these strategies CONCLUSION Views of the target population solicited in a structured format provided clear direction for designing a tobacco cessation intervention

Patient Complexity and Diabetes Quality of Care in Rural Settings

Abstract: Purpose Even though pay-for-performance programs are being rapidly implemented, little is known about how patient complexity affects practice-level performance assessment in rural settings. We sought to determine the association between patient complexity and practice-level performance in the rural United States. Basic procedures: Using baseline data from a trial aimed at improving diabetes care, we determined factors associated with a practice's proportion of patients having controlled diabetes (hemoglobin A 1 c 1 c controlled for these factors. We compared practice rankings using observed and expected performance and classified practices into hypothetical pay-for-performance categories. Main Findings: Rural primary care practices (n = 135) in 11 southeastern states provided information for 1641 patients with diabetes. For practices in the best quartile of observed control, 76.1% of patients had controlled diabetes vs 19.3% of patients in the worst quartile. After controlling for other variables, proportions of diabetes control were 10% lower in those practices whose patients had the greatest difficulty with either self testing or appointment keeping (p proportion of A 1 c control showed only moderate agreement in pay-for-performance categories (K = 0.47; 95% confidence interval, 0.32-0.56; p Principal Conclusions: Basing public reporting and resource allocation on quality assessment that does not account for patient characteristics may further harm this vulnerable group of patients and physicians.

Translating preoperative smoking cessation interventions into routine clinical care of veterans: provider beliefs

Abstract: Smoking among veterans undergoing surgery is estimated to be 36%. Smoking has been linked to postoperative surgical complications including ischemia and cardiac arrhythmias, pneumonia, deep venous thrombosis, pulmonary embolism, and surgical site infection. Preoperative smoking cessation interventions, in which smokers quit at least 6 weeks prior to surgery, have been shown to be effective both in smoking cessation and reduction of postoperative complications; however, little is known about physician beliefs regarding the optimal location and the responsible provider for intervention, or whether surgery should be postponed or delayed based on smoking status. Within the routine coordination from medical to surgical care, how should cessation interventions best be implemented? To better inform the translation of preoperative best practices for smoking cessation into clinical care in VA, a survey regarding preoperative smoking cessation beliefs and practices was administered to primary care physicians, surgeons, and anesthesia providers. Chi-square tests were used to examine differences in proportions by provider type. Most providers agreed that the primary care clinic is the best location for intervention, with preoperative and surgical clinics ranked by few as the optimal location (13% and 11%, respectively); most respondents (82%) reported that they would refuse or delay surgery in some cases based on smoking status. There were no differences in either beliefs on location or delay based on provider type. Primary care providers were most likely to advise (86.7%) and assess (80.0%) while anesthesia providers were least likely (59.1% and 22.7%, respectively). Taking time to counsel and the belief that dedicated resources would improve quit rates were associated with advising patients to quit smoking, while being uncomfortable with counseling, the belief that acute health takes precedence and the belief that there is not always time to counsel were identified as barriers to assessing patients for smoking cessation intervention. Primary care providers were more optimistic (100%) that patients would quit if counseled, more often (73.3%) reported having time to counsel, and were less likely to report that acute health takes precedence. Most providers believe that smoking cessation would reduce postoperative complications, with the ideal location for the intervention being the primary care clinic, and that some surgical cases should be delayed for this intervention.

Recruitment activities for a nationwide, population-based, group-randomized trial: the VA MI-Plus study

Abstract: The Veterans Health Administration (VHA) oversees the largest integrated healthcare system in the United States. The feasibility of a large-scale, nationwide, group-randomized implementation trial of VHA outpatient practices has not been reported. We describe the recruitment and enrollment of such a trial testing a clinician-directed, Internet-delivered intervention for improving the care of postmyocardial infarction patients with multiple comorbidities. With a recruitment goal of 200 eligible community-based outpatient clinics, parent VHA facilities (medical centers) were recruited because they oversee their affiliated clinics and the research conducted there. Eligible facilities had at least four VHA-owned and -operated primary care clinics, an affiliated Institutional Review Board (IRB), and no ongoing, potentially overlapping, quality-improvement study. Between December 2003 and December 2005, in two consecutive phases, we used initial and then intensified recruitment strategies. Overall, 48 of 66 (73%) eligible facilities were recruited. Of the 219 clinics and 957 clinicians associated with the 48 facilities, 168 (78%) clinics and 401 (42%) clinicians participated. The median time from initial facility contact to clinic enrollment was 222 days, which decreased by over one-third from the first to the second recruitment phase (medians: 323 and 195 days, respectively; p < .001), when more structured recruitment with physician recruiters was implemented and a dedicated IRB manager was added to the coordinating center staff. Large group-randomized trials benefit from having dedicated physician investigators and IRB personnel involved in recruitment. A large-scale, nationally representative, group-randomized trial of community-based clinics is feasible within the VHA or a similar national healthcare system.

Use of Ecological Momentary Assessment to Guide Curricular Change in Graduate Medical Education

Abstract: Purpose To assess whether a novel evaluation tool could guide curricular change in an internal medicine residency program. Method The authors developed an 8-item Ecological Momentary Assessment tool and collected daily evaluations from residents of the relative educational value of 3 differing ambulatory morning report formats (scale: 8 = best, 0 = worst). From the evaluations, they made a targeted curricular change and used the tool to assess its impact. Results Residents completed 1388 evaluation cards for 223 sessions over 32 months, with a response rate of 75.3%. At baseline, there was a decline in perceived educational value with advancing postgraduate (PGY) year for the overall mean score (PGY-1, 7.4; PGY-2, 7.2; PGY-3, 7.0; P < .01) and for percentage reporting greater than 2 new things learned (PGY-1, 77%; PGY-2, 66%; PGY-3, 50%; P < .001). The authors replaced the format of a lower scoring session with one of higher cognitive content to target upper-level residents. The new sessio...