Uncertainty as a Key Influence in the Decision To Admit Patients with Transient Ischemic Attack

Background Patients with transient ischemic attacks (TIA) are at high risk of subsequent vascular events. Hospitalization improves quality of care, yet admission rates for TIA patients vary considerably. Objectives We sought to identify factors associated with the decision to admit patents with TIA. Design We conducted a secondary analysis of a prior study’s data including semi-structured interviews, administrative data, and chart review. Participants We interviewed multidisciplinary clinical staff involved with TIA care. Administrative data included information for TIA patients in emergency departments or inpatient settings at VA medical centers (VAMCs) for fiscal years (FY) 2011 and 2014. Chart reviews were conducted on a subset of patients from 12 VAMCs in FY 2011. Approach For the qualitative data, we focused on interviewees’ responses to the prompt: “Tell me what influences you in the decision to or not to admit TIA patients.” We used administrative data to identify admission rates and chart review data to identify ABCD2 scores (a tool to classify stroke risk after TIA). Key Results Providers’ decisions to admit TIA patients were related to uncertainty in several domains: lack of a facility TIA-specific policy, inconsistent use of ABCD2 score, and concerns about facilities’ ability to complete a timely workup. There was a disconnect between staff perceptions about TIA admission and facility admission rates. According to chart review data, staff at facilities with higher admission rates in FY 2011 reported consistent reliance on ABCD2 scores and related guidelines in admission decision-making. Conclusions Many factors contributed to decisions regarding admitting a patient with TIA; however, clinicians’ uncertainty appeared to be a key driver. Further quality improvement interventions for TIA care should focus on facility adoption of TIA protocols to address uncertainty in TIA admission decision-making and to standardize timely evaluation of TIA patients and delivery of secondary prevention strategies

Implementation Evaluation of a Complex Intervention to Improve Timeliness of Care for Veterans with Transient Ischemic Attack

Background: The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was designed to address systemic barriers to providing timely guideline-concordant care for patients with transient ischemic attack (TIA). Objective: We evaluated an implementation bundle used to promote local adaptation and adoption of a multi-component, complex quality improvement (QI) intervention to improve the quality of TIA care Bravata et al. (BMC Neurology 19:294, 2019). Design: A stepped-wedge implementation trial with six geographically diverse sites. Participants: The six facility QI teams were multi-disciplinary, clinical staff. Interventions: PREVENT employed a bundle of key implementation strategies: team activation; external facilitation; and a community of practice. This strategy bundle had direct ties to four constructs from the Consolidated Framework for Implementation Research (CFIR): Champions, Reflecting & Evaluating, Planning, and Goals & Feedback. Main measures: Using a mixed-methods approach guided by the CFIR and data matrix analyses, we evaluated the degree to which implementation success and clinical improvement were associated with implementation strategies. The primary outcomes were the number of completed implementation activities, the level of team organization and > 15 points improvement in the Without Fail Rate (WFR) over 1 year. Key results: Facility QI teams actively engaged in the implementation strategies with high utilization. Facilities with the greatest implementation success were those with central champions whose teams engaged in planning and goal setting, and regularly reflected upon their quality data and evaluated their progress against their QI plan. The strong presence of effective champions acted as a pre-condition for the strong presence of Reflecting & Evaluating, Goals & Feedback, and Planning (rather than the other way around), helping to explain how champions at the +2 level influenced ongoing implementation. Conclusions: The CFIR-guided bundle of implementation strategies facilitated the local implementation of the PREVENT QI program and was associated with clinical improvement in the national VA healthcare system

The protocol-guided rapid evaluation of veterans experiencing new transient neurological symptoms (PREVENT) quality improvement program: rationale and methods

Abstract Background Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) developed, implemented, and evaluated a TIA quality improvement (QI) intervention aligned with Learning Healthcare System principles. Methods This stepped-wedge trial developed, implemented and evaluated a provider-facing, multi-component intervention to improve TIA care at six facilities. The unit of analysis was the medical center. The intervention was developed based on benchmarking data, staff interviews, literature, and electronic quality measures and included: performance data, clinical protocols, professional education, electronic health record tools, and QI support. The effectiveness outcome was the without-fail rate: the proportion of patients who receive all processes of care for which they are eligible among seven processes. The implementation outcomes were the number of implementation activities completed and final team organization level. The intervention effects on the without-fail rate were analyzed using generalized mixed-effects models with multilevel hierarchical random effects. Mixed methods were used to assess implementation, user satisfaction, and sustainability. Discussion PREVENT advanced three aspects of a Learning Healthcare System. Learning from Data: teams examined and interacted with their performance data to explore hypotheses, plan QI activities, and evaluate change over time. Learning from Each Other: Teams participated in monthly virtual collaborative calls. Sharing Best Practices: Teams shared tools and best practices. The approach used to design and implement PREVENT may be generalizable to other clinical conditions where time-sensitive care spans clinical settings and medical disciplines. Trial registration clinicaltrials.gov: NCT02769338 [May 11, 2016].https://deepblue.lib.umich.edu/bitstream/2027.42/152210/1/12883_2019_Article_1517.pd

STATUS ASSESSMENT OF ELEOCHARIS WOLFII (CYPERACEAE) IN THE UNITED STATES

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Ungulate impacts on herbaceous-layer plant communities in even-aged and uneven-aged managed forests

Forest management and ungulate herbivory are extant drivers of herbaceous-layer community composition and diversity. We conducted a white-tailed deer (Odocoileus virginianus) exclosure experiment across a managed landscape to determine how deer impacts interact with the type of forest management system in influencing herb-layer (all vascular plants \u3c 0.5 m tall) species richness and composition. Our study took place 3 yr after harvest in a deciduous forest landscape being managed through even-aged (∼4.1 ha openings) and uneven-aged (∼1.4 ha openings) silvicultural systems. We expected the severity of deer impacts on herb layer species richness and composition to vary according to opening position, opening size, and the spatial scale of inference. At forest stand and landscape scales, species richness within silvicultural openings was greater outside compared to inside deer exclosures, and did not differ according to deer access in edges or the forest matrix. However, greater levels of species richness associated with deer access were driven by infrequently occurring forbs, and overall species composition did not differ. Notably, these species were not exotics or ferns. Deer reduced the density of large saplings and blackberry (Rubus spp.) shrubs in the smaller openings characteristic of uneven-aged management stands, but had no effect on sapling density in the larger openings characteristic of even-aged management stands. This result extends the forage maturation hypothesis to silvicultural systems, and is consistent with predictions that plant tolerance and avoidance of herbivory increase with resource availability. Deer may have facilitated the establishment of forbs in recently created silvicultural openings by temporarily slowing sapling regeneration, creating establishment sites through physical disturbance, and seed dispersal via epizoochory and endozoochory. This outcome is contingent upon declining deer visitation rates as woody vegetation matures as well as distance from source populations of exotic species. We conclude that ecological context, such as local ungulate abundance, disturbance, and landscape factors, influence how ungulates interact with forest management systems