Public-Academic Partnerships: The Continuous Improvement for Veterans in Care: Mood Disorders (CIVIC-MD) Study, a VA-Academic Partnership

CIVIC-MD began as a collaboration of administrators and providers from the VA Pittsburgh Medical Center's Highland Drive Campus and academic investigators from the University of Pittsburgh's Department of Medicine and Department of Psychiatry. Designed as a naturalistic, longitudinal cohort study, the goal of CIVIC-MD was to identify the patient factors associated with processes and outcomes of care among VA patients receiving care for bipolar disorder. The study involved a baseline and follow-up survey of clinical status, behaviors, access to care, vulnerability (homelessness), adherence, and treatment perceptions. Medical charts were reviewed for comorbidity, patient preferences, provider decision making, and quality of care. Administrative data on patient utilization were also ascertained from local data warehouses, including pharmacotherapy, laboratories, and visits. VA administrators were initially supportive of CIVIC-MD because the principal investigator was part of a VA Center of Excellence that was affiliated with the university's medical school. The principal investigator was a full-time VA employee and had implemented similar health services research studies in the VA's general medical clinic.

We focused on bipolar disorder because it is associated with substantial morbidity, mortality, and health care costs ( 7 ). The alternating episodes of mania and depression and the comorbidities associated with this illness make research with this patient population particularly difficult. Bipolar disorder was considered a priority condition by VA Highland Drive administrators and providers primarily because patient outcomes for this illness remained suboptimal despite the availability of efficacious treatments ( 7 ). Moreover, there were no active studies on bipolar disorder at Highland Drive.

Through this partnership, we enrolled a substantial number of individuals with bipolar disorder. The nature of bipolar disorder renders this population challenging to engage and to follow over time. A total of 468 patients were enrolled in CIVIC-MD between July 2004 and July 2006, or 76% of eligible patients at the VA. The primary reason for study refusal was lack of time to complete the survey (for example, because of a pending outpatient appointment). Of the 468 patients enrolled, 435 (93%) completed the survey, and of those, the mean± SD age was 49±10.6 years (range 21–78 years), with 62 (14%) women and 58 (13%) African Americans. CIVIC-MD patients reflected the underlying bipolar patient population at Highland Drive (12% women and 13% African American overall). The sample included a substantial number of vulnerable patients: 12% (N=53) were homeless, 28% (N=123) had substance use disorders, and 78% (N=340) were unemployed.

Some challenges in implementing CIVIC-MD, although unique to this VA facility, may reflect challenges experienced in forging academic-community partnerships elsewhere. Foremost was balancing comprehensive data collection with participant and provider burden. Mental health clinics within VA medical centers are often busy because they serve large catchment areas and many patients are referred from smaller primary care clinics in more rural areas. Hence research may be secondary to the clinic's priority of caring for veterans. In some cases providers did not have enough time in their schedule to refer patients to CIVIC-MD. The recruitment period was therefore extended to two years. We also regularly held working lunches to update providers on the study and disseminate preliminary findings.

Some VA data from electronic medical records were not available or were recorded inconsistently. A few years before CIVIC-MD began, Highland Drive ceased transcription services; providers were responsible for entering their progress notes into the electronic medical record. As a result, busy clinic schedules precluded many providers from entering detailed information on patient clinical status that would be useful for research purposes (such as symptoms and treatment preferences). Therefore, the patient surveys were crucial because they were used to collect clinical, utilization, and health behavior information not available from these other sources.

The key to successful implementation of CIVIC-MD was the ability to both obtain and incorporate input from VA administrators and providers. Another factor was fostering the relationship between the principal investigator and the VA mental health program staff. This partnership facilitated patient recruitment. To address concerns about time required for recruitment, the recruiter's office was located in the mood disorders clinic adjacent to the providers' offices. This access facilitated communication between the provider and survey coordinator.

The strength of the partnership and the use of provider input led to a more innovative project that captured data on patient factors that had not been widely available in previous bipolar disorder research studies (including access to medical care, therapeutic alliance, use of complementary and alternative medicine, and vulnerability).

Furthermore, CIVIC-MD could not be successful without an understanding of the VA's mission and focus on providing comprehensive care for veterans. CIVIC-MD was not a replication of a university-based research protocol but rather a study designed to address crucial questions regarding the health care and outcomes of veterans. Moreover, the principal investigator's full-time affiliation with the VA, familiarity with the VA system, and commitment to a VA research career were other factors contributing to the project's success. Specifically, the principal investigator felt that fostering this VA-academic partnership would facilitate the development of a mood disorders research program that reflected VA priorities, both locally and nationally, and focused on improving the care of veterans through implementing research findings into clinical practice.

CIVIC-MD also provided an opportunity for VA providers to learn about the behaviors, clinical status, and outcomes of their overall patient population. VA providers received newsletters that summarized study findings. Study participants responded to satisfaction surveys to provide input on the process. Moreover, CIVIC-MD served as a patient registry to implement an intervention to improve medical care for patients with bipolar disorder ( 8 ).

The current research-to-practice gap in mental health care can be reduced by engaging providers in settings outside of academia to treat more diverse, vulnerable patient populations. Although many VAs have established academic partnerships in psychiatric research, some still face challenges in establishing successful academic partnerships that are common in community-based practices. For such partnerships to be successful, researchers need to actively solicit and incorporate input on study design and operationalization from administrators and providers. Incorporating the interests and priorities of VA administrators and providers up-front, adapting surveys and recruitment protocols to be appropriate for veterans and VA settings, and rapid dissemination and application of study findings were critical elements to the success of CIVIC-MD.

This research was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

The authors report no competing interests.

Dr. Kilbourne is affiliated with the Department of Veterans Affairs National Serious Mental Illness Treatment Research and Evaluation Center (VA SMITREC), Ann Arbor, Michigan, and the Department of Psychiatry, University of Michigan, Ann Arbor. Ms. Lasky, Dr. Good, Ms. Cooley, Ms. Basavaraju, Ms. Greenwald, and Dr. Fine are with the VA Pittsburgh Healthcare System. Dr. Pincus is with Columbia University College of Physicians and Surgeons, New York City. Dr. Bauer is with the VA Boston Healthcare System and the Harvard South Shore Psychiatry Residency Training Program, Harvard Medical School, Boston. Send correspondence to Dr. Kilbourne at VA Ann Arbor SMITREC (11H), 2215 Fuller Rd., Ann Arbor, MI 48105 (e-mail: [email protected]). Lisa B. Dixon, M.D., M.P.H., and Anthony F. Lehman, M.D., M.S.P.H., are editors of this column.