e 

FORUM translating research 

into quality health car

for veterans

A publication of the VA Office of Research 

& Development, Health Services Research 

& Development Service, Center for 

Information Dissemination and Education 

Resources, in conjunction with AcademyHealth 

November 2004 VA Health Services Research & Development Service 

Contents 

Director’s Letter 2 

Response to Commentary 3 

VA Initiative 4 

Research Highlights 5 

What Does Patient-Centered Care Mean for the VA? 

By Gerald M. Cross, M.D., National Director, Primary Care 

Patient-centered care means partnering with Several new initiatives support patient-centered 

patients. It means arranging health care in care, including the directive on panel size 

such a way that patients routinely participate in released earlier this year to ensure that resource

decisions about their own treatment. It means match demand. The directive sets a panel siz

creating an atmosphere where staff naturally standard and identifies quantitative adjustsolicit patients’ input and accept that input ments based on factors such as the number of 

with respect. It means building a system that exam rooms and the number of support perdoesn’t waste patients’ time, offers easy access sonnel. As described in this directive, continu

to care, and meets patients’ needs for informa­ ity of care, enrollment to panels, and adjusttion, education, and preventive care. Most ments to panel size serve as a structural founimportantly, patient-centered care means better dation for patient-centered care, even though 

outcomes for patients —and rewards for staff these things are largely invisible to patients. 

in knowing that they provide excellent care. 

Ultimately, however, patient-centered care 

Patient-centered care also means hard work — thrives where innovative leaders and dedicated 

otherwise, we would see more of it. staff members join forces to care for veterans. 

Each time a patient calls for an appointment, 

At VA, patient-centered care has become contacts a nurse advice line, or visits one of 

increasingly important as we’ve shifted our our clinics, we have an opportunity to exceed 

focus from inpatient to outpatient care. that veteran’s expectations. Each staff membe

Although we maintain a large number of who encounters a patient should understand 

robust medical centers — more than 150 — and practice the fundamentals of patientVA now operates more than 800 community- centered care. 

based outpatient clinics. This is all part of a 

strategic move to establish primary care near Patient-centered care is largely determined by 

where our veterans live. To make this strategy the rules that define the health care environwork, we need a more effective approach to ment. All medical facilities have rules. Rules 

patient encounters, and that’s where patient- determine what patients may or may not do, 

centered care comes in. from the moment they enter the parking lot 

until they leave. And while the rules differ, 

The Employee Education System and the they probably have one thing in common: 

Primary Care Central Office promote patient- They were made by the facility staff, with little 

centered care within VA through our national input from the patients themselves. Rules 

meetings, conference calls, and educational may either serve as a source of patient dissatis

presentations. Advanced Clinic Access coaches faction or they may form a solid foundation fo

support patient-centered care through a variety patient-centered care. 

of meetings and their soon-to-be-released 

handbook. continued on page 
2 ■ Forum/November 2004 

Case in point: A new medical center director heard from his staff how they had 

solved a persistent problem, that of patients 

showing up late for their appointments. 

The solution seemed simple. The staff 

made a rule to have the front desk clerks 

tell any patient who showed up as little as 

five minutes late that he or she would not 

be seen and must re-schedule. 

The director later attended a meeting that 

included many patients. There he heard a 

very different story. The patients told him 

how long they had to wait for appointments. 

When they finally arrived for the appointment, the nearest parking space was blocks 

away. When they entered the hospital, they 

found no one to give them directions. And 

of course when they finally got to the clinic, 

the clerk told them they were late, their 

appointment was canceled, and they should 

return home and call for another appointment. 

At the next staff meeting, the director 

explained that the rule had to be changed. 

Staff members, wanting to accommodate 

the new director, recommended that the 

grace period be extended to 10 minutes. 

The director knew that the battle for patient 

loyalty was often won or lost at a clinic’s 

front desk. He told staff they should never 

create a situation where patients would 

automatically be turned away. Whether the 

patient was 30 minutes late or a day late, the 

response should always be: “We are glad to 

see you. Sorry you missed your appointment. Let’s see if we can work you in, but 

if we can’t, I’ll help you get another 

appointment.” 

He then enlisted a group of volunteers, 

gave them red jackets to wear and assigned 

some to drive golf carts to distant parking 

lots to pick up patients — a job the volunteers loved. (Some innovative VA medical 

centers have created valet parking services 

to help ensure that their patients arrive on 

time). Other red jacket volunteers were 

assigned the task of providing directions to 

patients entering the lobby. Then the 

director developed a customer service train

ing program for the entire staff and began 

to deal with the access problem. 

This is just one example of how to create a 

patient-centered environment. 

As we care for service members returning 

from their missions across the globe, we 

should review our rules and how they are 

perceived by today’s veterans, who may 

have different needs and preferences than 

our established veterans. For example, 

continued on page 

Resources on Patient-Centered
 

Care
 

The Advanced Clinic Access Handbook, 

now under development, will be an excellent source of information for VA staff. 

VHA Information Letter 99-02 promoted 

shared decision-making, a component of 

patient-centered care. The Institute of 

Medicine report Crossing the Quality 

Chasm: A New System for the 21st Century 

(National Academy Press, 2001) advocated 

patient-centered care while providing a 

broad view of our nation’s health care. 

For information about ongoing HSR&D 

studies focused on patient-centered care, 

check the studies database on the HSR&D 

web at www. hsrd.research.va.gov/research/. 

Director’s Letter 

The past year has been one of transition 

in organization and leadership within 

HSR&D, the Office of Research and 

Development, and VHA as a whole. 

In HSR&D, we wished a happy retirement 

to John Demakis, M.D., who guided the 

Service during a period of unprecedented 

growth. John left us with an exceptionally 

strong program nationally and an excellent 

team in Central Office. I am particularly 

pleased to have Joe Francis, M.D., as the 

new Associate Director for QUERI/ 

Implementation. Our programs remain 

strong due to our capacity in the field, a 

vigorous and established health services 

research tradition, and enhanced partnerships among our research and clinical 

leaders. 

We had hoped to have a new HSR&D 

Director by the time John retired, and a 

search yielded some excellent candidates. 

However, because of the rapidly changing 

environment in Central Office and the 

imminent turnover in leadership at several 

levels, the position will not be filled at this 

time. We anticipate that the search will be 

reopened in the near future. 

Meanwhile, I am privileged to serve for 

the third time as Acting Director of 

HSR&D. I expect this next year to yield 

both challenges and opportunities. We 

have expanded our capacity to meet growing demand among managers and clinicians for answers to questions they face 

in caring for patients, and for enhancing 

evidence-based practice and management. 

We have implemented a new system of 

program and portfolio management, 

which we hope will enhance program 

effectiveness and responsiveness. As 

described in this issue of FORUM, meeting the needs of patients remains the 

focus of our attention. 

Shirley Meehan, M.B.A., Ph.D. 

Acting Director, HSR&D 

“Each time a patient calls for 

an appointment, contacts a nurse 

advice line, or visits one of our 

clinics, we have an opportunity 

to exceed that veteran’s 

expectations.” 
Forum/November 2004 ■ 

Response to Commentary
 

Patient-Centered Care in the VA: A Research 

Perspective 

By Lisa V. Rubenstein, M.D., M.S.P.H., Edmund F. Chaney, Ph.D., HSR&D Centers of 

Excellence, Sepulveda and Seattle, respectively; Jeffrey L. Smith, Ph.D., Candidate, HSR&D 

Mental Health QUERI 

Increasing the patient-centered focus of Traditional research designs such as rancare potentially holds great promise for domized controlled trials may need to be 

improving the quality of health care deliv­ enhanced to allow greater consideration of 

ered to veterans. Making care more patient- patient and clinician treatment preferences 

centered involves encouraging an increas­ and to more closely reflect routine clinical 

ingly diverse veteran population to take an practice. Clinicians have often criticized 

active role in partnering with their health the traditional research enterprise as taking 

care team. These changes have implica­ too long to produce relevant clinical findings. 

tions both for VA clinical managers and In helping to make effective care more 

staff and for health services researchers. patient-centered, investigating and dissemiJust as patients and clinicians work best nating results quickly will be an even 

together, teams made up of VA clinical greater challenge. 

managers, staff, and researchers will be in 

the best position to evaluate whether orga­ Chronic care is an important issue for many 

nizational redesign, structural enhancements, veterans. Research is needed to identify 

and other accommodations intended to and implement effective strategies to help 

facilitate the provision of patient-centered patients with chronic illness be informed 

care— such as those described in Dr. Cross’ and activate health care consumers and to 

commentary— produce desired results. help them improve their ability to selfmanage their care, consistent with the 

Clinical staff in a patient-centered VA chronic care model. With its Computerized 

health care system will actively seek to elicit Patient Record System, the VA may be an 

patient preferences about health care deci­ ideal health care system for researchers to 

sions, and will demonstrate that patients develop and test innovative informatics 

are valued by responding to stated prefer­ tools to help support patient self-management 

ences when an alternative course of care is of chronic illness. For instance, the Office 

not clearly indicated. Indeed, evidence has of Care Coordination has a specific focus on 

suggested that patients may experience evaluating technology that will improve the 

more favorable outcomes when they receive ability of patients and clinicians to commuthe care they prefer; and quality improve­ nicate important care information quickly 

ment interventions that support patient and easily between the patient in his home 

choice have been shown to improve the and the physician in her office. 

likelihood of patients receiving preferred 

treatments. More fundamentally, developing a health 

care system that is truly patient-centered 

To help ensure that patient preferences will likely require VA researchers to increasreflect informed decisions about care alter­ ingly incorporate participatory research 

natives, researchers will need to partner methods into their work, where veterans are 

with patients and clinicians to develop provided the opportunity to have a more 

effective patient education tools and strate­ active voice in setting the research agenda, 

gies to enhance patient awareness of the defining the specific issue(s) to be addressed 

most effective evidence-based treatments. in quality improvement research initiatives, 

and in proposing and suggesting refinement

to intervention tools and strategies that may 

help improve the quality of care. Participatory research requires different approach

es than more traditional health services 

research, and increased use of participatory 

methods may require some researchers to 

develop new skills and knowledge. 

Researchers within the VA Quality Enhance

ment Research Initiative (QUERI) are 

becoming increasingly adept at using partic

ipatory research strategies to implement 

evidence-based practices in VA health care 

settings. More information on QUERI 

research strategies and tools is available in 

the on-line QUERI Guide to Implementation 

Research at www.hsrd.research.va.gov/queri/ 

implementation. Also, the Agency for 

Healthcare Research and Quality (AHRQ) 

recently released a systematic review of the 

evidence concerning participatory research in 

the community, which VA may find useful in 

its efforts to partner effectively with veterans i

projects to improve patient care and outcomes

Finally, as noted in Dr. Cross’ commentary, 

many VA facilities and clinicians are alread

providing high-quality patient-centered care

Researchers should work actively with 

administrators, clinical leaders, and patient

in these facilities to learn about key determ

nants and best practices that facilitate their 

provision of patient-centered care. They 

should then seek to transfer such knowledge and innovative practices to other VA 

facilities through novel intervention strategies. In essence, researchers should play the 

role of both student and teacher of innovation 

within the VA health care system. In that way

researchers may enhance their capacity to 

play an active and critical role in helping th

VA realize its purpose to make care for veterans increasingly patient-centered. ■ 

References 

1.Dwight-Johnson M, Unutzer J, Sherbourne C, 

Tang L, Wells KB. Can quality improvement pro

grams for depression in primary care address 

patient preferences for treatment? Medical Care 

continued on page 
4 ■ Forum/November 2004 

VA Initiative
 

Measuring the Patient’s Experience of VA Health 

Care 

By Charles Humble, Ph.D., Jim Schaefer, M.S.P.H., Director of Analyses, and 

Barbara Fleming, M.D., Ph.D., VA Office of Quality and Performance 

Until the mid-1990s, patient satisfaction 

surveying in the VA was essentially the 

responsibility of local facilities. Though 

these local surveys may have been adequate 

for quality improvement purposes, they 

were usually a side duty of staff inexperienced in survey methods and statistical 

analysis. Without a standard system-wide 

process, it wasn’t possible to develop 

national data and compare facility scores 

across the system. 

In the early 1990s, the Picker Institute 

used national focus groups with patients 

and close collaboration with health care 

providers to identify “dimensions” of the 

patient experience that resonated with 

providers. In 1993, VA’s Office of Quality 

Management (predecessor of today’s Office 

of Quality and Performance or OQP) partnered with the Picker Institute to develop a 

national program of patient satisfaction surveys for veterans. 

We conducted our own focus groups with 

veterans around the country and produced 

separate questionnaires for Inpatients and 

Outpatients. These questionnaires are based 

on the Picker dimensions (called “standards” 

in VA surveys; see accompanying chart) but 

include extra dimensions and questions for 

aspects of care important to VA patients. 

After a pilot survey in 1994, VA conducted 

the first national surveys of inpatients and 

outpatients in 1995. In 2002, OQP further 

expanded the questionnaires by including 

items on health status (SF-12V), sources of 

care (VA versus non-VA), availability of 

health insurance, healthy behaviors, and 

body mass. These expanded surveys are 

referred to as the Survey of Health 

Experiences of Patients (SHEP). Since 

2002, questions on immunizations, complaint resolution, women’s issues, and spiritual needs have been included by request 

from other VA offices. 

The SHEP serves both quality improvement 

and performance measurement functions. 

The standard scores serve as high-level flags 

that providers and administrators can use to 

identify areas that need attention. When a 

given standard falls substantially below 

national benchmarks in a particular bed section or clinic, process action teams can 

examine the question scores to identify specific barriers to patient service. 

Similarly, question scores for specific programs, such as immunization use, have 

been used to identify subgroups of veterans 

who are underusing VA services. This information can then be used to develop outreach programs to address the disparities. 

The surveys also help VA facilities meet the 

requirements of the Joint Commission on 

Accreditation of Healthcare Organizations. 

Finally, five VA Performance Standards are 

based on specific SHEP questions regarding 

overall ratings of care and access to care. 

Survey management in OQP relies heavily 

on input from the SHEP Advisory Group, 

with half of its membership drawn from 

field-based colleagues. 

Since SHEP was created, weighted samplin

and analyses have been used to counterbalance the greater probability of selection 

in smaller bed sections and clinics in our 

earlier surveys. To provide data more frequently and more rapidly, we concentrated 

survey efforts on monthly samples and 

web-based results reporting. 

Recently, we have conducted pilot tests to 

test the importance of various components 

of the Dillman Method, the industry standard for collecting data via mailed surveys. 

The goal is to identify which mailings migh

be eliminated to speed the survey cycle and 

reduce costs without affecting accuracy. ■ 

Access to SHEP data is available by filing a 

Data Use Agreement to OQP through Dr. 

Steven M. Wright, Steven.Wright@va.gov. 

Reference 

Cleary PD, Edgman-Levitan S. Health care quali

ty: Incorporating customer perspectives. Journa

of the American Medical Association 1997; 

278(19):1608-12. 

Veteran Health Care Service Standards 

■ Provide timely access to health care 

■ Treat patients with courtesy and respect 

■ Support patient’s emotional needs 

■ Provide information and education about condition, treatments and tests 

■ Have one provider or team in charge of care 

■ Coordinate both visit specific and overall health care needs 

■ Insure patient involvement in decisions about care 

■ Meet physical comfort needs 

■ Provide timely and appropriate pharmacy services 

■ Provide a smooth transition between inpatient and outpatient care 

■ Overall rating of VA health care 
Forum/November 2004 ■ 

Research Highlights
 

New Study Finds Teamwork Culture Linked to 

Higher Patient Satisfaction in VA Hospitals 

By Mark Meterko, Ph.D., Center for Organization, Leadership, Management and Research 

Increasingly, organization culture is being ture that represent competing values or priorrecognized as an important factor in the ities for organizations: 

performance and adaptability of health care ■ teamwork (emphasis on collaboration organizations. A number of studies have among departments and employees) pointed to the importance of teamwork or 

employee collaboration in particular as ■ entrepreneurial (emphasis on calculated 

being associated with such positive outcomes risk-taking and innovation) 

as the implementation of quality improve­ ■ bureaucratic (emphasis on formal poli­ ment processes and lower nurse turnover. cies and chain of command) However, we could find no studies that 

examined the relation between teamwork ■ rational (emphasis on task completion 

culture and one key health care outcome: and production) 

patient satisfaction. This is a potentially 

important area of inquiry for VA where The NQIS survey questionnaire was mailed 

patient satisfaction is used as a measure of to as many as 150 employees at each VHA 

performance. Why might teamwork culture hospital, based on a stratified random samaffect patient satisfaction? We believed that pling procedure. A total of 16,405 employees 

the connections could be both direct and were surveyed; 8,454 (52 percent) responded. 

indirect. On one hand, a culture emphasizing teamwork may help cultivate effective We obtained data on patient satisfaction from 

coordination among health care providers, the VHA national database created and 

which several studies have shown to be pos­ maintained by the Office of Quality and 

itively associated with quality of care. More Performance. For this study, we used the 

indirectly, social exchange theory and inpatient and outpatient satisfaction data colresearch on “service climate” suggest that lected in 2000, the year for which the orgathe exchange of support among employees nization culture data were also available. 

who collaborate to serve customers will 

strengthen employee motivation to provide Ultimately, we collected complete data for 

excellent service, which in turn could lead 125 acute-care facilities. Among the four 

to higher customer satisfaction. types of culture, bureaucratic received the 

highest score (mean = 44.1), followed by 

We set out to test the hypothesis that a rational (23.7), teamwork (18.6), and entreteamwork-oriented culture in hospitals was preneurial (13.2). Thus, the bureaucratic 

positively associated with patient satisfaction dimension was most prevalent across VA 

using the extensive and unique national hospitals and entrepreneurial the least. The 

databases available in VA. Specifically, mean hospital-level score for inpatient satisorganizational culture data were obtained faction was 73.6 and the mean hospital-level 

from a survey of VHA employees that we score for outpatient satisfaction was 79.2. 

conducted in 2000 as part of the National 

Quality Improvement Survey (NQIS). A Our analysis showed that two of the four 

component of that survey, yields scores on culture dimensions were statistically signifia 0-100 scale for four dimensions of cul­ cant in the inpatient models. Specifically, 

teamwork culture was positively associated 

with inpatient satisfaction and bureaucratic 

culture was negatively associated with inpa

tient satisfaction. 

We found that teamwork culture had the 

strongest relation to patient satisfaction. In 

the study sample, organizations with relatively high scores on teamwork culture had 

significantly better inpatient satisfaction 

scores. The research literature suggests 

that a relation between teamwork culture 

and inpatient satisfaction may be mediated

at least in part, through more effective coor

dination among employees and through 

greater cohesion among employees workin

toward the same goal. 

The relation between bureaucratic culture 

and inpatient satisfaction was somewhat 

smaller but negative: the greater the 

emphasis on bureaucracy, the lower the 

level of inpatient satisfaction. Certainly, in 

a hospital setting, adherence to rules and 

regulations is necessary to ensure quality 

control in the delivery of patient care. 

However, a high emphasis on bureaucratic 

culture may deter employees from finding 

new ways of improving patient care that 

contribute to better patient satisfaction. 

Outpatient satisfaction was not related to 

any of the culture dimensions. This finding might reflect in part the relatively limit

ed amount of time that some patients have 

with their hospital and its employees when 

receiving outpatient care. 

This study extends a growing line of research 

demonstrating the importance of teamwork 

culture to the performance of health care 

organizations. Our investigation is the first 

we are aware of to examine the relation 

between independent measures of organizational culture and patient satisfaction. ■ 

For detailed results, see: Meterko M, Mohr DC, 

Young G.J, Teamwork culture and patient satisfaction in hospitals. Medical Care 2004; 42(5): 492-8
6 ■ Forum/November 2004 

Research Highlights
 

Seriously Ill Patients Care More About 

Outcomes of Care Than Treatment Burdens in 

End-of-Life Decision-Making 

By Terri Fried, M.D., VA Connecticut Healthcare System 

Grounding treatment decision-making in 

patients’ preferences is at the core of 

patient-centered care. Yet incorporating 

preferences into end-of-life decision-making 

poses considerable challenges. Several 

studies supported by HSR&D have helped 

to elucidate these challenges and provide 

the data and tools necessary to overcome 

them. 

In order to make patient preferences a part 

of everyday treatment, we must first find a 

way to elicit those preferences in a way that 

is meaningful to patients. Other research 

has shown the importance of treatment 

outcomes to decision-making among the 

elderly. We developed a novel instrument to 

elicit preferences based on a comprehensive 

assessment of patients’ attitudes toward 

treatment burden weighted against the likelihood of desired versus undesirable outcomes. 

The instrument pairs descriptions of lowburden and high-burden therapies with a 

range of possible outcomes, such as physical 

and cognitive impairment. It first asks the 

patient whether he or she would want therapy 

if the outcome were known with certainty 

and then as the likelihood of the outcome 

varies. Using visual aides, the instrument 

allows patients to consider the complex concept of uncertainty in their preferences. 

We administered this instrument among 

226 older persons with advanced congestive 

heart failure, chronic lung disease, and cancer to illustrate the central role that health 

outcomes play in the preferences of elderly 

people. We found that many more patients 

chose not to have therapy on the basis of a 

poor outcome than on the basis of the burdens imposed by the therapy. In addition, a 

large majority of patients were unwilling to 

risk an outcome of severe physical or cognitive impairment. 

This study and the work of other VA investigators help shift the framework for eliciting 

preferences, from one based on preferences 

for specific treatment interventions, such as 

resuscitation, to one based on preferences 

for the outcomes of those interventions. 

“The outcomes patients desire for 

themselves frequently differ from 

the outcomes that caregivers 

desire for the patient.” 

A second challenge to ensuring patiententered end-of-life care involves communiation between patients and caregivers, who 

requently are called upon to make decisions 

n behalf of seriously ill patients. Examining 

atient-caregiver pairs in this same study 

roup, we found that large proportions of 

oth patients and caregivers desired greater 

ommunication with one another. 

nfortunately, these desires were frequently 

ismatched. Among the pairs in which 

aregivers desired more communication, 83 

ercent of patients did not. And among the 

airs in which patients desired more comunication, 67 percent of caregivers did not. 

In addition, caregivers who desired greater 

c

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f

o

p

g

b

c

U

m

c

p

p

m

communication had significantly higher 

caregiver burden scores than caregivers 

who did not, suggesting that enhancing 

caregiver-patient communication may 

decrease caregiver burden. This lack of 

communication likely underlies the finding 

that the outcomes patients desire for themselves frequently differ from the outcomes 

that caregivers desire for the patient. 

Improving patient-physician communication 

is a third challenge to eliciting and honoring patients’ preferences. Communication 

about prognosis, a critical determinant of 

preferences, is particularly problematic. In 

this study, patients and caregivers alike frequently disagreed with their clinicians as to 

whether communication on prognosis had 

actually occurred. Even among physicians 

who reported having discussed the possibil

ity of death with their patients— certainly a 

fundamental question—69 percent of 

patients said they had not. 

Patient-centered care for seriously ill 

patients means that patients’ preferences 

should guide treatment decision-making. 

Eliciting and understanding those preferences will depend on improving patientphysician and patient-caregiver communication, with a focus on patients’ valuations 

of the outcomes of care. ■ 

References 

1. Fried TR, Bradley EH, Towle VR. Assessment 

of patient preferences: Integrating treatments 

and outcomes. Journals of Gerontology Series B: 

Psychological Sciences and Social Sciences 2002; 57

S348-354. 

2. Fried TR, Bradley EH, Towle VR, Allore H. 

Understanding the treatment preferences of seri

ously ill patients. New England Journal of Medicin

2002; 346: 1061-6. 

3. Fried TR, Bradley EH, O’Leary J. Prognosis 

communication in serious illness: perceptions of 

older patients, caregivers, and clinicians. Journal 

of the American Geriatric Society 2003; 51: 1398­

403. 

For complete references, please contact terri.fried@ 

med.va.gov. 
Forum/November 2004 ■ 

HSR&D Study Identifies Barriers to Shared 

Decision-Making Among Newly Diagnosed Prostate 

Cancer Patients 

By Charles L. Bennett, M.D., Ph.D., and E. Allison Lyons, B.A. 

Midwest Center for Health Services and Policy Research 

More than 220,000 men are diagnosed with These impairments could easily prevent patient

prostate cancer each year. Upon diagnosis, from actively participating in shared decisioneach man faces a choice of five treatments: making. Considering that more than 60 perradical retropubic prostatectomy (RRP), exter­ cent of our geriatric patients had at least one 

nal beam radiation therapy (XRT), brachythera­ impairment, we conclude that older age can 

py, hormonal therapy, or watchful waiting have serious effects on the patient’s ability to 

(WW). With the exception of watchful waiting, participate in a shared decision-making process

each of these treatments is associated with several side effects, such as sexual functioning Race is another factor often cited as a barrier to 

and incontinence with RRP, bowel function screening, access to care, and treatment. In 

with XRT, and hot flashes and impotence with our study, we found that low literacy may be a

hormonal therapy. even more significant barrier than race in the 

case of prostate cancer patients. We found that 

Because of these considerations, physicians African American men had higher PSA levels 

have begun to work with prostate cancer (median of 9.8 versus 6.3 ng/ml) and were 

patients to choose the treatment that would more likely to have literacy skills below a sevwork the best for the patient. This process is enth-grade level (25.3 percent versus 9.7 pertermed shared-decision making. In our cur­ cent) than white men. But after adjusting for 

rent study of newly diagnosed prostate cancer age, annual income, marital status, and site of 

patients at four sites in the Chicago area, care, individuals with low health literacy skills 

including two VA hospitals, we have found two were 2.1 times as likely to have high PSA level

barriers that may affect shared decision-mak­ at the time of diagnosis, while the odds of preing: older age and low literacy skills. senting with an elevated PSA were similar for 

African American versus white men. This 

Of the 258 patients participating in our information is significant because patients pre

study, 134 were over age 65. These geriatric senting with higher PSA levels and low health 

patients were assessed for impairment using literacy may have greater difficulty understand

several validated tools, including the Mini-Cog, ing educational materials about their treatmen

Mini Nutritional Assessment Short Form, and options and gaining access to health care systhe Vulnerable Elderly Survey. Impairments tems, including the VA. 

dentified included: no social support 

(33 percent); cognitive impairment (33 per­ The availability of different treatments for 

cent); increased risk of decline in activities of prostate cancer enables each patient to work 

daily living and death (13 percent); mobility with his physician to choose a treatment that i

(11 percent); undernutrition (19 percent); sen­ most appropriate and will provide the best 

sory impairment (36 percent); depressive quality of life for him. It is important for 

mood (7 percent); and lack of social support (6 physicians to recognize and address barriers to 

percent). shared decision-making, such as older age and 

low health literacy. ■ 

2005 HSR&D 

National Meeting 

The Veterans Health Administration 

faces many challenges, including 

the aging of and increasing prevalence of significant medical comorbidities among the veteran patient 

population. The 2005 HSR&D 

National Meeting will address 

these challenges with the theme 

“Improving Care for Veterans with 

Chronic Illnesses.” The conference will be held February 16-18, 

2005 in Washington, DC. VA 

health services researchers will 

come together to present a broad 

array of their research methodologies and results with particular 

emphasis placed on productive 

patient/provider interactions, 

specifically improvements in 

care that are evidence-based, 

population-based, or patientcentered. 
Cross continued from page 2 

we’re seeing increasing numbers of women We’re also seeing more veterans who enjoy 

veterans. Rather than make assumptions, using computers. They may rely on the 

we should ask them how they would like Internet for medical advice. One innovative 

their health care environment arranged. VA medical center, recognizing the imporSeveral small studies have indicated that tance of Internet access for this generation 

women veterans have mixed opinions of veterans, created a special room where 

about enrollment to separate “women-only” patients could surf the Internet during their 

clinics. However, we do know that privacy inpatient stay. 

is paramount to them. Remember that 

simple things can make a big difference — Finally, let’s recognize that having the patient 

to all patients. For example: come to see us is not always the best answer. 

Patients respond well to phone follow-up ■ Always knock before entering the exam for some conditions. And as we figure out room if the patient is already there (and how to meet the requirements of the Health wait for a reply!). Insurance Portability and Accountability 

Act, more providers will stay in touch with ■ Ask for permission before allowing any­ their patients via email. As technology one else to enter the room or participate in advances, more and more health care moni­ any part of the exam. toring will be performed in the comfort of 

■ Ensure that privacy curtain is used and the patient’s own home, or in the workplace. 

arrange the room for maximum privacy 

during gynecological exams. Many VA facilities are already providing 

patient-centered care, even if they have not 

Many of today’s returning veterans are put that label on it. But many improveyoung, and they may be accompanied by ments can be made. Research can help us 

small children. How will our patient- become more patient-centered by identifycentered medical facilities accommodate ing best practices for meeting the needs of 

them? Some medical facilities, recognizing our changing veteran population. 

the difficulty and expense of arranging 

for child care, allow patients to bring their So, let us take pride in our progress, underchild into the exam room during the par­ standing all the while that there is always 

ent’s routine visit. more to be done. ■ 

Response continued from page 3 

2001; 39: 934-44.
 

2.Wagner EH, Glasgow RE, Davis C, Bonomi A

Provost L, McCulloch D, et al. Quality improvement in chronic illness care: A collaborative
 

approach. Joint Commission Journal on Quality
 

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For complete references, email Edmund.Chaney@ 

med.va.gov. 

FORUM 

Geraldine McGlynn, Editor-in-Chief 

Mary Darby, Editor 

Advisory Committee 

Martin P. Charns, D.B.A., VA HSR&D Center of 

Excellence, Boston 

Joe Francis, M.D., Director, HSR&D QUERI 

Rodney A. Hayward, M.D., VA HSR&D Center of 

Excellence, Ann Arbor 

Shirley Meehan, M.B.A., Ph.D., Acting Director, 

VA HSR&D 

Michael Miller, M.D., Ph.D., VA Network #1, 

Bedford, MA 

Laura Miller, Deputy Under Secretary for Health 

for Operations and Management, Washington, DC 

Eugene Oddone, M.D., M.H.Sc., VA HSR&D 

Center of Excellence, Durham, NC 

Alan S. Perry, M.H.A., FACHE, Director, 

VA Medical Center, Fresno, CA