BackgroundVaccine hesitancy, especially related to COVID-19 vaccinations among Veterans, may limit uptake. Behaviorally informed text-based messages have the potential to improve uptake of COVID-19 vaccinations.ObjectiveTo evaluate the impact of two different behaviorally informed text message nudges on COVID-19 vaccine scheduling and completion, compared to standard control message.DesignProspective, three-arm patient-level randomized quality improvement trial.ParticipantsBetween March and May 2021, 20,523 Veterans were eligible for the initial series of COVID-19 vaccination, enrolled at two large Veterans Health Administration sites.InterventionArm 1 (Control): standard scheduling message; Arm 2 (Social Good): standard message plus behaviorally informed text message "When you get a vaccine now, you help protect yourself, your family, and your community"; and Arm 3 (Scarcity): standard plus behaviorally informed text message "Only a limited number of vaccine appointments are available."Main MeasuresOutcomes were vaccine scheduling and/or completion rate within 7 days of receipt of text message (primary), and within 14 days and 30 days after receipt of text message (secondary).Key ResultsVeterans had an overall rate of 19% of scheduling or receiving a vaccination in 7 days. In our adjusted intention-to-treat analysis, we found no difference between intervention social good or scarcity (aOR 0.98, 95% CI, 0.88-1.09, for both arms) compared to standard scheduling message. We found no statistical differences in our secondary outcomes.ConclusionsDuring the initial phases of vaccine roll-out, two behaviorally informed text messages did not increase COVID-19 vaccination rates among Veterans compared to a standard scheduling message.

Background: The Veterans Affairs (VHA) is working to establish a population-based colorectal cancer screening program for average-risk patients using mailed fecal immunochemical testing (FIT). However, low response rates to mailed FIT may hinder success. Key features of mailed FIT programs, including the use of reminders, differ among various national programs, with limited evidence among veterans.Objective: We sought to test whether using reminders, either via telephone call or text message, was effective in improving mailed FIT response rates.Design: We conducted a prospective, randomized quality improvement trial (ClinicalTrials.gov NCT05012007). Veterans who had not returned a FIT within 2 weeks of receiving the kit were randomized to one of three groups: (1) control (no reminder); (2) an automated telephone call reminder; or (3) an automated text message reminder.Participants: A total of 2658 veterans enrolled at VA Puget Sound Health Care System who were aged 45-75 and had an average risk of colorectal cancer.Interventions: A single automated telephone call or text message reminder prompting veterans to return the FIT kit.Main Measures: Our primary outcome was FIT return at 90 days and our secondary outcome was FIT return at 180 days.Key Results: Participant average age was 62 years, 88% were men, and 66% White. At 90 days, both the phone and text reminder interventions had higher FIT return rates compared to control (intention-to-treat results (ITT): control 28%, phone 39%, text 38%; p<0.001). At 180 days, FIT kit return remained higher in the reminder interventions (ITT: control 32%, phone 42%, text 40%; p<0.001).Conclusions: Automated reminders increased colorectal cancer screening completion among average-risk veterans. An automated phone call or text message was equally effective. VHA facilities seeking to implement a mailed FIT program should consider using phone or text reminders, depending on available resources.

Telehealth services, specifically telemedicine audio-video and audio-only patient encounters, expanded dramatically during the COVID-19 pandemic through temporary waivers and flexibilities tied to the public health emergency. Early studies demonstrate significant potential to advance the quintuple aim (patient experience, health outcomes, cost, clinician well-being, and equity). Supported well, telemedicine can particularly improve patient satisfaction, health outcomes, and equity. Implemented poorly, telemedicine can facilitate unsafe care, worsen disparities, and waste resources. Without further action from lawmakers and agencies, payment will end for many telemedicine services currently used by millions of Americans at the end of 2024. Policymakers, health systems, clinicians, and educators must decide how to support, implement, and sustain telemedicine, and long-term studies and clinical practice guidelines are emerging to provide direction. In this position statement, we use clinical vignettes to review relevant literature and highlight where key actions are needed. These include areas where telemedicine must be expanded (e.g., to support chronic disease management) and where guidelines are needed (e.g., to prevent inequitable offering of telemedicine services and prevent unsafe or low-value care). We provide policy, clinical practice, and education recommendations for telemedicine on behalf of the Society of General Internal Medicine. Policy recommendations include ending geographic and site restrictions, expanding the definition of telemedicine to include audio-only services, establishing appropriate telemedicine service codes, and expanding broadband access to all Americans. Clinical practice recommendations include ensuring appropriate telemedicine use (for limited acute care situations or in conjunction with in-person services to extend longitudinal care relationships), that the choice of modality be done through patient-clinician shared decision-making, and that health systems design telemedicine services through community partnerships to ensure equitable implementation. Education recommendations include developing telemedicine-specific educational strategies for trainees that align with accreditation body competencies and providing educators with protected time and faculty development resources.

Adverse events can take an emotional toll on physicians, which, left unprocessed, can have negative impacts on well-being, including burnout and depression. Peer support can help mitigate these negative effects. Structured programs train physicians to aid colleagues in processing work-related experiences and emotions such as guilt and self-doubt. Although such programs are common for faculty, peer support for resident physicians has not been adequately addressed, and few programs have been described in the literature. Residency is a vulnerable time of professional identity formation, and providing support has specific challenges. The power dynamics and distance between lived experiences limit the utility of faculty peer support programs. Some institutions have trained residents to provide peer support, but widespread implementation may be difficult because of limited resident time and comfort in providing support. Chief residents (CRs), however, are close to residents in training yet experienced enough to afford perspective and are uniquely situated to provide "near-peer" support. We describe the implementation of a CR near-peer support program in which an established peer support framework was adapted to add elements specific to resident stressors and CR-resident relationships. One faculty member and two outgoing CRs lead a 2-hour workshop that is built into existing CR onboarding to ensure sustainability. The workshop combines large-group didactics and small-group breakouts, using clinical vignettes and simulated near-peer support conversations. To date, 36 CRs have been trained. CR near-peer support can serve as a model for programs in which true resident peer support is not feasible.

Jessica L. Ryan, PhD; Stephanie M. Franklin, MPS; Melanie Canterberry, PhD; Charron L. Long, PharmD; Andy Bowe, MPH; Brandy D. Roy, MD; Danielle Hessler, PhD; Benjamin Aceves, PhD; Laura M. Gottlieb, MD

BackgroundThe COVID-19 pandemic necessitated increased synchronous distance education (SDE) in graduate medical education, presenting challenges for Quality Improvement and Patient Safety (QIPS) best practices, which call for integration with daily clinical care and investigation of real patient safety events.ObjectiveTo evaluate educational outcomes for QIPS training after conversion of a mature, in-person curriculum to SDE.Methods68 postgraduate year (PGY)-1 residents were surveyed before and after the SDE Culture of Patient Safety training in June 2020, and 59 PGY-2s were administered the Quality Improvement Knowledge Application Tool-Revised (QIKAT-R) before and after the SDE QIPS seminar series in July–August 2020. Values before and after training were compared using sign tests for matched pairs (PGY-1) and Wilcoxon signed-rank tests (PGY-2).Results100% (68 of 68) of PGY-1s and 46% (27 of 59) of PGY-2s completed precourse and postcourse surveys. Before the course, 55 PGY-1s (81%) strongly agreed that submitting patient safety event reports are a physician’s responsibility, and 63 (93%) did so after (15% increase, p=0.004). For PGY-2s, the median composite QIKAT-R score was 17 (IQR 14.5–20) before and 22.5 (IQR 20–24.5) after the seminars, with a median difference of 4.5 (IQR 1.5–7), a 32% increase in QIPS competency (p=0.001).ConclusionsPatient safety attitudes and quality improvement knowledge increased after SDE QIPS training at comparable levels to previously published results for in-person training, supporting SDE use in future hybrid curricula to optimise educational value and reach.

Background Mailed fecal immunochemical testing (FIT) programs are increasingly utilized for population-based colorectal cancer (CRC) screening. Advanced notifications (primers) are one behavioral designed feature of many mailed FIT programs, but few have tested this feature among Veterans. Objective To determine if an advanced notification, a primer postcard, increases completion of FIT among Veterans. Design This is a prospective, randomized quality improvement trial to evaluate a postcard primer prior to a mailed FIT versus mailed FIT alone. Participants A total of 2404 Veterans enrolled for care at a large VA site that were due for average-risk CRC screening. Intervention A written postcard sent 2 weeks in advance of a mailed FIT kit that contained information on CRC screening and completing a FIT. Main Measures Our primary outcome was FIT completion at 90 days, and our secondary outcome was FIT completion at 180 days. Key Results Overall, unadjusted mailed FIT return rates were similar among control vs. primer arms at 90 days (27% vs. 29%, p = 0.11). Our adjusted analysis found a primer postcard did not increase FIT completion compared to mailed FIT alone (OR 1.14 (0.94, 1.37)). Conclusions Though primers are often a standard part of mailed FIT programs, we did not find an increase in FIT completion with mailed postcard primers among Veterans. Given the overall low mailed FIT return rates, testing different ways to improve return rates is essential to improving CRC screening.

Medical EducationVolume 56, Issue 11 p. 1142-1143 REALLY GOOD STUFF An equity timeout in quality improvement medical education A. Vincent Raikhel, Corresponding Author A. Vincent Raikhel vraikhel@uw.edu orcid.org/0000-0003-1630-7106 Correspondence A. Vincent Raikhel, Department of Medicine, University of Washington School of Medicine, Chief Resident for Quality and Safety at the VA Puget Sound Healthcare System, 1660 South Columbian Way, Seattle, WA 98108 USA. Email: vraikhel@uw.eduSearch for more papers by this authorHannah Oren, Hannah OrenSearch for more papers by this authorChenwei Wu, Chenwei WuSearch for more papers by this authorAnders Chen, Anders Chen orcid.org/0000-0002-1376-0629 Search for more papers by this author A. Vincent Raikhel, Corresponding Author A. Vincent Raikhel vraikhel@uw.edu orcid.org/0000-0003-1630-7106 Correspondence A. Vincent Raikhel, Department of Medicine, University of Washington School of Medicine, Chief Resident for Quality and Safety at the VA Puget Sound Healthcare System, 1660 South Columbian Way, Seattle, WA 98108 USA. Email: vraikhel@uw.eduSearch for more papers by this authorHannah Oren, Hannah OrenSearch for more papers by this authorChenwei Wu, Chenwei WuSearch for more papers by this authorAnders Chen, Anders Chen orcid.org/0000-0002-1376-0629 Search for more papers by this author First published: 29 August 2022 https://doi.org/10.1111/medu.14930Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume56, Issue11November 2022Pages 1142-1143 RelatedInformation

The Affordable Care Act (2010) and Medicare Access and CHIP Reauthorization Act (2015) ushered in a new era of Medicare value-based payment programs. Five major mandatory pay-for-performance programs have been implemented since 2012 with increasing positive and negative payment adjustments over time. A growing body of evidence indicates that these programs are inequitable and financially penalize safety-net systems and systems that care for a higher proportion of racial and ethnic minority patients. Payments from penalized systems are often redistributed to those with higher performance scores, which are predominantly better-financed, large, urban systems that serve less vulnerable patient populations — a “Reverse Robin Hood” effect. This inequity may be diminished by adjusting for social risk factors in payment policy. In this position statement, we review the literature evaluating equity across Medicare value-based payment programs, major policy reports evaluating the use of social risk data, and provide recommendations on behalf of the Society of General Internal Medicine regarding how to address social risk and unmet health-related social needs in these programs. Immediate recommendations include implementing peer grouping (stratification of healthcare systems by proportion of dual eligible Medicare/Medicaid patients served, and evaluation of performance and subsequent payment adjustments within strata) until optimal methods for accounting for social risk are defined. Short-term recommendations include using census-based, area-level indices to account for neighborhood-level social risk, and developing standardized approaches to collecting individual socioeconomic data in a robust but sensitive way. Long-term recommendations include implementing a research agenda to evaluate best practices for accounting for social risk, developing validated health equity specific measures of care, and creating policies to better integrate healthcare and social services.

Background Screening for colorectal cancer (CRC) with faecal immunochemical test (FIT) is effective at reducing CRC mortality. Unfortunately, the COVID-19 pandemic has been associated with deferred care, especially screening for CRC. Aim We sought to develop a mailed FIT programme (MFP) to increase CRC screening and make recommendations for adoption across the Veterans Health Administration (VHA) and for other large healthcare systems. Setting 2 regional VA medical centres in California and Washington state. Participants 5667 average risk veterans aged 50–75 overdue or due within 90 days for CRC screening. Programme description A multidisciplinary implementation team collaborated to mail an FIT kit to eligible veterans. Both sites mailed a primer postcard, and one site added an automated reminder call. Programme evaluation We monitored FIT return and positivity rate, as well as impact of the programme on clinical staff. 34% of FIT kits were returned within 90 days and 7.8% were abnormal. Discussion We successfully implemented a population-based MFP at multiple regional VA sites and recommend that these efforts be spread across VA. Our model of regional leadership, facility champions and using centralised resources can be adaptable to other large healthcare systems. MFPs support catch-up from disrupted care by addressing access to CRC screening, unburden primary care visits and conserve limited procedural resources.

INTRODUCTION:Early or mid-career physicians have few opportunities to participate in career development programs in health policy and advocacy with experiential and mentored training that can be incorporated into their busy lives.AIM:The Society of General Internal Medicine (SGIM) created the Leadership in Health Policy (LEAHP) program, a year-long career development program, to prepare participants with a sufficient depth of knowledge, skills, attitudes, and behaviors to continue to build mastery and effectiveness as leaders, advocates, and educators in health policy. We sought to evaluate the program's impact on participants' self-efficacy in the core skills targeted in the curriculum.SETTING/PARTICIPANTS:Fifty-five junior faculty and trainees across three scholar cohorts from 2017 to 2021.PROGRAM DESCRIPTION:Activities included workshops and exercises at an annual meeting, one-on-one mentorship, monthly webinars and journal clubs, interaction with policy makers, and completion of capstone projects.PROGRAM EVALUATION:Self-administered, electronic surveys conducted before and following the year-long program showed a significant improvement in mean self-efficacy scores for the total score and for each of the six domains in general knowledge, teaching, research, and advocacy in health policy. Compared to the baseline scores, after the program the total mean score increased from 3.1 to 4.1, an increase of 1.1 points on a 5-point Likert scale (95% CI: 0.9-1.3; Cohen's D: 1.7), with 61.4% of respondents increasing their mean score by at least 1 point. Responses to open-ended questions indicated that the program met scholars' stated needs to improve their knowledge base in health policy and advocacy skills.DISCUSSION:The LEAHP program provides an opportunity for mentored, experiential training in health policy and advocacy, can build the knowledge and amplify the scale of physicians engaged in health policy, and help move physicians from individual patient advocacy in the clinic to that of populations.