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Statistical modeling methods are widely used in clinical science, epidemiology, and health services research to analyze data that has been collected in clinical trials as well as observational studies of existing data sources, such as claims files and electronic health records. Diagnostic and prognostic inferences from statistical models are critical to researchers advancing science, clinical practitioners making patient care decisions, and administrators and policy makers impacting the health care system to improve quality and reduce costs. The veracity of such inferences relies not only on the quality and completeness of the collected data, but also statistical model validity. A key component of establishing model validity is determining when a model is not correctly specified and therefore incapable of adequately representing the Data Generating Process (DGP). In this article, model validity is first described and methods designed for assessing model fit, specification, and selection are reviewed. Second, data transformations that improve the model's ability to represent the DGP are addressed. Third, model search and validation methods are discussed. Finally, methods for evaluating predictive and classification performance are presented. Together, these methods provide a practical framework with recommendations to guide the development and evaluation of statistical models that provide valid statistical inferences.

BACKGROUND: The nursing profession is exploring how academic-practice partnerships should be structured to maximize the potential benefits for each partner. As part of an evaluation of the U.S. Department of Veterans Affairs Nursing Academy (VANA) program, we sought to identify indicators of successful partnerships during the crucial first year. METHODS: We conducted a qualitative analysis of 142 individual interviews and 23 focus groups with stakeholders from 15 partnerships across the nation. Interview respondents typically included the nursing school Dean, the VA chief nurse, both VANA Program Directors (VA-based and nursing school-based), and select VANA faculty members. The focus groups included a total of 222 VANA students and the nursing unit managers and staff from units where VANA students were placed. An ethnographic approach was utilized to identify emergent themes from these data that underscored indicators of and influences on Launch Year achievement. RESULTS: We emphasize five key themes: the criticality of inter-organizational collaboration; challenges arising from blending different cultures; challenges associated with recruiting nurses to take on faculty roles; the importance of structuring the partnership to promote evidence-based practice and simulation-based learning in the clinical setting; and recognizing that stable relationships must be based on long-term commitments rather than short-term changes in the demand for nursing care. CONCLUSIONS: Developing an academic-clinical partnership requires identifying how organizations with different leadership and management structures, different responsibilities, goals and priorities, different cultures, and different financial models and accountability systems can bridge these differences to develop joint programs integrating activities across the organizations. The experience of the VANA sites in implementing academic-clinical partnerships provides a broad set of experiences from which to learn about how such partnerships can be effectively implemented, the barriers and challenges that will be encountered, and strategies and factors to overcome challenges and build an effective, sustainable partnership. This framework provides actionable guidelines for structuring and implementing effective academic-practice partnerships that support undergraduate nursing education.

OBJECTIVE: To assess how changes in curriculum, accreditation standards, and certification and licensure competencies impacted how medical students and physician residents value interprofessional team and patient-centered care. PRIMARY DATA SOURCE: The Department of Veterans Affairs Learners' Perceptions Survey (2003-2013). The nationally administered survey asked a representative sample of 56,569 U.S. medical students and physician residents, with a comparison group of 78,038 nonphysician trainees, to rate satisfaction with 28 elements, in two overall domains, describing their clinical learning experiences at VA medical centers. STUDY DESIGN: Value preferences were scored as independent adjusted associations between an element (interprofessional team, patient-centered preceptor) and the respective overall domain (clinical learning environment, faculty, and preceptors) relative to a referent element (quality of clinical care, quality of preceptor). PRINCIPAL FINDINGS: Physician trainees valued interprofessional (14 percent vs. 37 percent, p < .001) and patient-centered learning (21 percent vs. 36 percent, p < .001) less than their nonphysician counterparts. Physician preferences for interprofessional learning showed modest increases over time (2.5 percent/year, p < .001), driven mostly by internal medicine and surgery residents. Preferences did not increase with trainees' academic progress. CONCLUSIONS: Despite changes in medical education, physician trainees continue to lag behind their nonphysician counterparts in valuing experience with interprofessional team and patient-centered care.

Transition to interprofessional team-based care is a quickly progressing healthcare model and requires changes in medical training approaches. The Department of Veteran Affairs (VA) has taken a lead role in creating such training experiences, one of which is the establishment of multiple Centers of Excellence in Primary Care Education (CoEPCE). These sites are tasked with developing teaching innovations to better facilitate interprofessional team-based care. The patient-aligned care team interprofessional care update (PACT-ICU) is an interprofessional workplace learning activity with the goals of simultaneously addressing educational and patient care needs. Participants of the PACT-ICU included trainees and faculty of a variety of medical disciplines (e.g., internal medicine, psychology, and pharmacy) involved in a training primary care clinic. Two medically complex patients were presented at each PACT-ICU conference with the purpose of creating a plan of care that maintained an interprofessional team-based approach. Following implementation of the PACT-ICU conference intervention, two primary outcomes were assessed. First, self-assessment of PACT-ICU attendee learner outcomes was measured using a brief questionnaire surveying knowledge gain as it related to increase in knowledge of other professions' capabilities, roles, and responsibilities. Secondly, trainee provider behavior change was evaluated by measuring number of "within PACT" consults before and after participating in PACT-ICU. There was a significant positive change in self-assessed knowledge along with an indication of trainee behavioral change, as measured by electronic medical record consult patterns. This study demonstrates that interprofessional case conferences involving trainees and staff from multiple professions can increase awareness of other professions roles in patient care as well as facilitate interprofessional collaboration.

BACKGROUND: Traditional approaches to subgroup analyses that test each moderating factor as a separate hypothesis can lead to erroneous conclusions due to the problems of multiple comparisons, model misspecification, and multicollinearity. OBJECTIVE: To demonstrate a novel, systematic approach to subgroup analyses that avoids these pitfalls. METHODS: A Best Approximating Model (BAM) approach that identifies multiple moderators and estimates their simultaneous impact on treatment effect sizes was applied to a randomized, controlled, 11-week, double-blind efficacy trial on smoking cessation of adult smokers with attention-deficit/hyperactivity disorder (ADHD), randomized to either OROS-methylphenidate (n = 127) or placebo (n = 128), and treated with nicotine patch. Binary outcomes measures were prolonged smoking abstinence and point prevalence smoking abstinence. RESULTS: Although the original clinical trial data analysis showed no treatment effect on smoking cessation, the BAM analysis showed significant subgroup effects for the primary outcome of prolonged smoking abstinence: (1) lifetime history of substance use disorders (adjusted odds ratio [AOR] 0.27; 95% confidence interval [CI] 0.10-0.74), and (2) more severe ADHD symptoms (baseline score >36; AOR 2.64; 95% CI 1.17-5.96). A significant subgroup effect was also shown for the secondary outcome of point prevalence smoking abstinence--age 18 to 29 years (AOR 0.23; 95% CI 0.07-0.76). CONCLUSIONS: The BAM analysis resulted in different conclusions about subgroup effects compared to a hypothesis-driven approach. By examining moderator independence and avoiding multiple testing, BAMs have the potential to better identify and explain how treatment effects vary across subgroups in heterogeneous patient populations, thus providing better guidance to more effectively match individual patients with specific treatments.

RATIONALE, AIMS AND OBJECTIVES: Healthcare professionals need a new skill set to ensure the success of quality improvement in healthcare. The Department of Veterans Affairs (VA) initiated the VA National Quality Scholars fellowship in 1998; its mission is to improve the quality of care, ensure safety, accelerate healthcare re-design, and advance the improvement science by educating the next generation of leaders in quality and safety. We describe the critical need for leadership in quality and safety and interprofessional education, illustrate the curriculum, provide lessons learned by fellows, summarize key lessons learned from the implementation of an interprofessional education approach, and present most recent accomplishments. METHODS: Narrative review. RESULTS: As of 2011, 106 program alumni are embedded in the health care delivery system across the United States. Since 2009, when nurse fellows joined the program, of the first nine graduating interdisciplinary fellows, the tailored curriculum has resulted in five advanced academic degrees, 42 projects, 29 teaching activities, 44 presentations, 36 publications, six grants funded or submitted, and two awards. CONCLUSIONS: The VA National Quality Scholars program continues to nurture and develop leaders for the new millennium focusing on interprofessional education. The nations' health care systems need strong interdisciplinary leaders in advanced quality improvement science who are dedicated to improving the overall quality of health and health care.

BACKGROUND: Graduate medical education is centered in hospitals despite a care system where patients mostly receive their care in an outpatient setting. Such gaps may exist because of inadequate funding for residency positions in community and hospital-based clinics. OBJECTIVE: Determine if physician residents' contribution to outpatient workload offsets their costs for supervision, salary, and fringe benefits as residents acquire skills to become independent practitioners. RESEARCH DESIGN: VA's electronic patient records from 2005 through 2018 were analyzed using generalized linear mixed models to estimate resident and staff contributions to workload in relative value units. MEASURES: Resident participation rate is resident contributed workload net of supervision as a percent of total clinic workload. Productivity is per diem resident workload as a percent of per diem staff workload. Efficiency is per dollar resident workload as a percent of per dollar staff workload. Progressive independence is annual rate of change in resident productivity. RESULTS: Average participation rates varied by specialty from 6% to 22%, with 11% (primary care) and 13% (psychiatry). Productivity rates ranged from 21% to 94%, with 57% (primary care) and 61% (psychiatry). Efficiency rates varied from 0.63 to 3.81, with 1.69 (primary care), 1.89 (psychiatry). Progressive independence rates varied from 2.7%/year (psychiatry) to 39.7%/year (specialty care). CONCLUSIONS: Although residents rotating through most VA clinics generate revenue to cover their direct costs as they learn, some federal subsidies may be necessary to encourage hospital- and community-based clinics to accept residents from the less profitable primary care and mental health specialties.

Increasing use of Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) for hospital performance measurement intensifies the need to critically assess their validity. Our study examined the extent to which variation in PSI composite score is related to differences in hospital organizational structures or processes (i.e., criterion validity). In site visits to three Veterans Health Administration hospitals with high and three with low PSI composite scores ("low performers" and "high performers," respectively), we interviewed a cross-section of hospital staff. We then coded interview transcripts for evidence in 13 safety-related domains and assessed variation across high and low performers. Evidence of leadership and coordination of work/communication (organizational process domains) was predominantly favorable for high performers only. Evidence in the other domains was either mixed, or there were insufficient data to rate the domains. While we found some evidence of criterion validity, the extent to which variation in PSI rates is related to differences in hospitals' organizational structures/processes needs further study.

INTRODUCTION: The Freedom Commission's recommendations, Substance Abuse and Mental Health Services Administration's framework, and policy directives on recovery-oriented services have fueled the recovery transformation. Mental health recovery services have been implemented in a broad range of outpatient settings. However, psychiatric inpatient units remained embedded in the traditional model of care. AIMS: The purpose of this article is to describe an ongoing quality improvement implementation of recovery services in a Veterans Health Administration acute psychiatric inpatient unit. METHOD: An interprofessional Partnership for Wellness delivered 4 to 6 hours per day of evidence-based recovery and holistic population-specific health programs. Veteran, system, and program indicators were measured. RESULTS: Preliminary indicators over a 2-year period suggest that Veterans rated group content and relevance high, pre-post psychiatric rehospitalization rates decreased by 46%, and fidelity to recommended strategies was high. CONCLUSIONS: The project success reflects strong leadership, a partnership of committed staff, effective training, and an organizational culture exemplifying excellence in Veteran services and innovation.

Health care professionals in the United States are expected to engage in quality improvement (QI) as part of their daily practice. This has created the need for QI training at all levels of health professional education. A reported barrier to increasing QI-trained health care professionals is the lack of QI-trained faculty at health care institutions and the limited availability of practitioners, given their daily clinical demands. E-learning is a potential solution. E-learning allows learning outside the traditional classroom setting, where instructors can flexibly deliver practical QI curricula to an interprofessional audience in multiple practice locations. The 11 principles presented in this article are derived from established evidence and experience and provide QI educators with practical principles for course design, implementation, and learner feedback of an e-learning course in QI.

BACKGROUND: Adoption of electronic health care records (EHRs) has proliferated since 2000. While EHR transitions are widely understood to be disruptive, little attention has been paid to their effect on health professions trainees' (HPTs) ability to learn and conduct work. Veterans Health Administration's (VA) massive transition from its homegrown EHR (CPRS/Vista) to the commercial Oracle Cerner presents an unparalleled-in-scope opportunity to gain insight on trainee work functions and their ability to obtain requisite experience during transitions. OBJECTIVE: To identify how an organizational EHR transition affected HPT work and learning at the third VA go-live site. DESIGN: A formative mixed-method evaluation of HPT experiences with VHA's EHR transition including interviews with HPTs and supervisors at Chalmers P. Wylie VA Outpatient Clinic in Columbus, OH, before (~60 min), during (15-30 min), and after (~60 min) go-live (December 2021-July 2022). We also conducted pre- (March 2022-April 2022) and post-go live (May 2022-June 2022) HPT and employee surveys. PARTICIPANTS: We conducted 24 interviews with HPTs (n=4), site leaders (n=2), and academic affiliates (n=2) using snowball sampling. We recruited HPTs in pre- (n=13) and post-go-live (n=10) surveys and employees in pre- (n=408) and post-go-live (n=458) surveys. APPROACH: We conducted interviews using a semi-structured guide and grounded prompts. We coded interviews and survey free text data using a priori and emergent codes, subsequently conducting thematic analysis. We conducted descriptive statistical analysis of survey responses and merged interview and survey data streams. KEY RESULTS: Our preliminary findings indicate that the EHR transition comprehensively affected HPT experiences, disrupting processes from onboarding and training to clinical care contributions and training-to-career retention. CONCLUSIONS: Understanding HPTs' challenges during EHR transitions is critical to effective training. Mitigating the identified barriers to HPT training and providing patient care may lessen their dissatisfaction and ensure quality patient care during EHR transitions.

Since 2002, the Department of Veterans Affairs (VA) has provided a unique training opportunity in palliative care at six VA medical centers. The VA Interprofessional Fellowship in Palliative Care has trained chaplains, nurses, pharmacists, physicians, psychologists, and social workers to provide clinical palliative care and to develop as leaders in the profession. This article describes the program's origin, mission, outcomes, and lessons learned.

Abstract Total knee arthroplasty (TKA) risks persistent pain and long-term opioid use (LTO). The role of social determinants of health (SDoH) in LTO is not well established. We hypothesized that SDoH would be associated with postsurgical LTO after controlling for relevant demographic and clinical variables. This study utilized data from the Veterans Affairs Surgical Quality Improvement Program, VA Corporate Data Warehouse, and Centers for Medicare and Medicaid Services, including Veterans aged ≥ 65 who underwent elective TKA between 2013 and 2019 with no postsurgical complications or history of significant opioid use. LTO was defined as &gt; 90 days of opioid use beginning within 90 days postsurgery. SDoH variables included the Area Deprivation Index, rurality, and housing instability in the last 12 months identified via medical record screener or International Classification of Diseases, Tenth Revision codes. Multivariable risk adjustment models controlled for demographic and clinical characteristics. Of the 9,064 Veterans, 97% were male, 84.2% white, mean age was 70.6 years, 46.3% rural, 11.2% living in highly deprived areas, and 0.9% with a history of homelessness/housing instability. Only 3.7% (n = 336) developed LTO following TKA. In a logistic regression model of only SDoH variables, housing instability (odds ratio [OR] = 2.38, 95% confidence interval [CI]: 1.09–5.22) and rurality conferred significant risk for LTO. After adjusting for demographic and clinical variables, LTO was only associated with increasing days of opioid supply in the year prior to surgery (OR = 1.52, 95% CI: 1.43–1.63 per 30 days) and the initial opioid fill (OR = 1.07; 95% CI: 1.06–1.08 per day). Our primary hypothesis was not supported; however, our findings do suggest that patients with housing instability may present unique challenges for postoperative pain management and be at higher risk for LTO.

When testing the effects of a femoral component on cortical bone following total hip arthroplasty, the patient's implanted femur is often compared with his/her contralateral nonimplanted femur, with differences attributed to the femoral component. However, if normal anatomical differences exist between bilateral femurs, they need to be quantified in order to validate whether the differences between implanted and nonimplanted bilateral femurs are due to the implant or possibility due to intrinsic differences before implantation. This study quantified the geometric properties of cortical bone shape between seven pairs of bilateral, cadaveric, human femurs. The null hypothesis tested stated that the bilateral femurs would not be significantly different in cortical bone geometry. Digitized images of cortical bone cross-sections taken at percent biomechanical lengths (levels 1-8) were used to calculate bone geometry measurements. The paired t-test showed that the only significant difference was in the location of principal axes at the most proximal location, level 1 (p = 0.015). All other measurements and levels were not significant with percent differences less than 6.6%. In conclusion, the data supports attributing cortical bone shape differences between implanted and contralateral nonimplanted femurs in levels 2-8 to the presence of the implant when the significant differences are greater than 6.6%.

Background: The US Department of Veterans Affairs designated education officer (DEO) is a unique facility-based leadership role responsible for training of > 40 health professions in cooperation with affiliated academic institutions. Methods: We conducted mixed methods analyses of data from a DEO needs assessment. Quantitative analysis identified differences between DEOs who are physicians and DEOs who are other professions on role characteristics and self-perceived task effectiveness. Qualitative analysis using rapid analysis procedures was applied to open-ended responses on facilitators and barriers. Results: < .001-.03). DEOs identified multiple facilitators that assist their individual effectiveness (eg, training, mentorship, communication) and common barriers (eg, not enough staff). Conclusions: Our findings are supportive of individuals from various health disciplines serving in the DEO role with responsibilities that span multiple health profession training programs. Future quantitative and qualitative work should include additional measures of individual and organizational characteristics, and actual measures of educational effectiveness.

It is projected that by 2045, racial/ethnic minorities in the U.S. will become the majority. Unfortunately, the numbers of racial/ethnic minority psychologists have not kept up with population trends. This discrepancy poses challenges for many psychology training sites, including the Department of Veterans Affairs (VA). There is a lack of data on what factors are important for psychology applicants, including racial/ethnic minority trainees when they are considering internship and postdoctoral training sites. This quality improvement project surveyed 237 VA psychology trainees (59% psychology interns, 32.5% psychology postdoctoral fellows, 69.6% White, 9.3% multiracial, 6.8% Asian American or Pacific Islander, 5.1% Black/African American, 4.2% Latinx American, 0.8% Native American, 0.8% Middle Eastern) to study what factors are important when considering training sites. Results indicated that overall, racial/ethnic minority and White trainees endorsed similar primary factors when considering training programs. Site related factors (e.g., perceived workload, training opportunities) and future work related factors (e.g., ease of licensure, obtaining a first job) were top considerations regardless of race/ethnicity. The groups diverged in secondary factors with racial/ethnic minorities desiring infusion of diversity in training more than White applicants and White applicants considering quality of life factors such as extracurricular opportunities and convenience of daily living more important than racial/ethnic minority applicants. Qualitative data indicated applicants perceived VA training sites to be more welcoming and offer more opportunities for learning about diversity than non-VA sites. Recommendations for recruiting psychology trainees in general, and then specifically for racial/ethnic minority applicants are discussed.

OBJECTIVE: The authors evaluated the distribution of psychiatry residency positions funded by the Department of Veterans Affairs between 2014 and 2020 with respect to geographic location and hospital patient population rurality. METHODS: The authors collected data on psychiatry residency positions from the Veterans Affairs' Office of Academic Affiliations Support Center and data on hospital-level patient rurality from the Veterans Health Administration Support Service Center. They examined the chronological and geospatial relationships between the number of residency positions deployed and the size of the rural patient populations served. RESULTS: Between 2014 and 2020, the Department of Veterans Affairs has substantially increased the number of rural hospitals hosting psychiatry residency programs, as well as the number of residency positions at those hospitals. However, several geographic regions serve high numbers of rural veterans with few or no psychiatry resident positions. CONCLUSIONS: While the VA efforts to increase psychiatry residency positions in rural areas have been partially successful, additional progress can be made increasing support for psychiatry trainees at Veterans Affairs hospitals and community-based outpatient clinics that serve large portions of the rural veteran population.

The U.S. Department of Veterans Affairs Veterans Health Administration (VA) is an important source of health care in rural locations. The Veterans Access Choice and Accountability Act of 2014 authorized 1500 new graduate medical education positions in high need specialties and locations. Program implementation necessitated supporting clinicians representing multiple professions with the skills to build and sustain an interprofessional healthcare workforce training program. The VA Office of Academic Affiliations and the Office of Rural Health partnered to create the Rural Interprofessional Faculty Development Initiative (RIFDI), a curriculum focused on interprofessional education and practice, designed to prepare rural educators to create or enhance small, typically rural, geographically diverse training sites. Eighty-four health care providers, representing eight professions are enrolled or have completed the program. President Biden has characterized the initiative as innovative and directed the VA to launch a new joint initiative with the Department of Health and Human Services (HHS) to add non-VA clinicians to the program in 2022.

Introduction: The Department of Veterans Affairs (VA) is undergoing an unprecedented electronic health record (EHR) transition, switching from its homegrown EHR to a commercial system. The transition affects nearly every clinical employee but is particularly disruptive to health professions trainees (HPTs)-an often-overlooked population in EHR transitions. To better understand and address trainee challenges with the EHR transition, we formed a multistakeholder learning community. In this study, we describe the findings of this learning community and the practices and policies developed in response. Methods: In the qualitative study designed and executed by our learning community, we conducted 51 interviews with HPTs, program leaders, and preceptors before and multiple times after an EHR transition site's go-live (February 16, 2022 to April 7, 2023). We merged interview transcripts with 125 survey free-text responses from a survey conducted with preceptors 2 months post-go-live and conducted thematic analysis to identify key themes. To complement qualitative findings, we also include a quantitative survey finding, and, where applicable, we note policy and practice responses spurred by our learning community. Results: Interviews yielded six key themes: (1) High satisfaction with HPT programs, despite negative impacts of the EHR transition; (2) early delays, then substantial improvements, in HPTs' EHR access; (3) persistent challenges with HPTs' EHR training and support, mitigated by local and national efforts; (4) the challenge of learning to use a rapidly evolving EHR during clinical training; (5) reduced visit volume as a continuing barrier to education; and (6) an impression that HPTs' relative lack of exposure to the prior EHR facilitated their proficiency with the new EHR. Conclusions: Findings highlighted challenges for HPT programs related to the EHR transition, which spurred important changes including the creation of a national VA council to represent the needs of HPTs in the EHR transition, and improvements to HPTs' EHR training and access.

In the last few years, US policymakers and health care stakeholders have become increasingly concerned with the rise of opioid-related morbidity and deaths. They have enacted many health policies a...