For high-mortality procedures that veterans frequently obtain in the private sector, like CABG, directing care to high-performance hospitals may be an effective way to improve outcomes for veterans.

Although process elements that define community-based participatory research (CBPR) are well articulated and provide guidance for bringing together researchers and communities, additional models to implement CBPR are needed. One potential model for implementing and monitoring CBPR is Action Learning Collaboratives (ALCs); short term, team-based learning processes that are grounded in quality improvement. Since 2010, the Prevention Research Center at Dartmouth (PRCD) has used ALCs with three communities as a platform to design, implement and evaluate CBPR. The first ALC provided an opportunity for academia and community leadership to strengthen their relationships and knowledge of respective assets through design and evaluation of community-based QI projects. Building on this work, we jointly designed and are implementing a second ALC, a cross-community research project focused on obesity prevention in vulnerable populations. An enhanced community capacity now exists to support CBPR activities with a high degree of sophistication and decreased reliance on external facilitation.

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Objective. To determine whether patients' use of the Veterans Health Administration health care system (VHA) is an independent risk factor for mortality following coronary artery bypass grafting (CABG) in the private sector in New York. Data Sources. VHA administrative and New York Department of Health Cardiac Surgery Reporting System (CSRS) databases for surgeries performed in 1999 and 2000. Study Design. Prospective cohort study comparing observed, expected, and risk‐adjusted mortality rates following private sector CABG for 2,326 male New York State residents aged 45 years and older who used the VHA (VHA users) and 21,607 who did not (non‐VHA users). Data Collection Methods. We linked VHA administrative databases to New York's CSRS to identify VHA users who obtained CABG in the private sector in New York in 1999 and 2000. Using CSRS risk factors and previously validated risk‐adjustment model, we compared patient characteristics and expected and risk‐adjusted mortality rates of VHA users to non‐VHA users. Principal Findings. Compared with non‐VHA users, patients undergoing private sector CABG who had used the VHA were older, had more severe cardiac disease, and were more likely to have the following comorbidities associated with increased risk of mortality: diabetes, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, and history of stroke (p<.001 for all); a calcified aorta (p=.009); and a high creatinine level (p=.003). Observed (2.28 versus 1.80 percent) and expected (2.48 versus 1.78 percent) mortality rates were higher for VHA users than for non‐VHA users. The risk‐adjusted mortality rate for VHA users (1.70 percent; 95 percent confidence interval [CI]: 1.27–2.22) was not statistically different than that for the non‐VHA users (1.87 percent; 95 percent CI: 1.69–2.06). Use of the VHA was not an independent risk factor for mortality in the risk‐adjustment model. Conclusions. Although VHA users had a greater illness burden, use of the VHA was not found to be an independent risk factor for mortality following private sector CABG in New York. The New York Department of Health risk adjustment model adequately applies to veterans who obtain CABG in the private sector in New York.

BackgroundAlthough global efforts to support routine immunization (RI) system strengthening have resulted in higher immunization rates, the World Health Organization (WHO) estimates that the proportion of children receiving recommended DPT3 vaccines has stagnated at 80% for the past 3 years (WHO Fact sheet—Immunization coverage 2014, WHO, 2014). Meeting the WHO goal of 90% national DPT3 coverage may require locally based strategies to support conventional approaches. The Africa Routine Immunization Systems Essentials-System Innovation (ARISE-SI) initiative is a proof-of-concept study to assess the application of the Microsystems Quality Improvement Approach for generating local solutions to strengthen RI systems and reach those unreached by current efforts in Masaka District, Uganda.MethodsThe ARISE-SI intervention had three components: health unit (HU) advance preparations, an action learning collaborative, and coaching of improvement teams. The intervention was informed and assessed using qualitative and quantitative methods. Data collection focused on changes and outcomes of improvement efforts among five HUs and one district-level team during the intervention (June 2011–February 2012) and five follow-up months.ResultsWorkshops and team meetings had a 95% attendance rate. All teams gained RI system knowledge and implemented changes to address locally identified problems. Specific changes included: RI register implementation and expanded use, Child Health Card provision and monitoring, staff cross-training, staffing pattern changes, predictable outreach schedules, and health system leader—community leader meetings. Several RI system barriers prevalent across Masaka District (e.g., lack of backup HU gas cylinders, inadequate outreach transportation, and village health team underutilization) were successfully addressed. Three of five HUs significantly increased the vaccines administered. All improvements were sustained 5 months post-intervention. External evaluation validated the findings of high levels of participant engagement, empowerment to make change, and willingness to sustain improvements.ConclusionsThe Microsystems Quality Improvement Approach is a comprehensive approach, grounded in systems thinking, and coupled with intensive coaching. It provides a robust framework for engaging teams in the development of unique local solutions that strengthen RI systems in resource poor settings. The sustained improvements in local RI systems from this study provide evidence that this approach may be an effective framework for enhancing the WHO’s Reaching Every District (RED) immunization strategy.