Gwen Lapham Curriculum Vitae Personal information Gwen Lapham, PhD, MPH, MSW Cell: 206-940-5048 lapham.g@ghc.org Education Eastern Washington University, Cheney, WA, Bachelor of Science in Biochemistry, June 1992 University of Washington, Seattle, WA, Master of Social Work, June 2002 University of Washington, Seattle, WA, Master of Public Health, August 2003 University of Washington, Seattle WA, Doctorate in Health Services, Public Health, June 2012 Professional Positions Crisis Intervention Specialist, King County Crisis Clinic, Seattle, WA June 1998 August 2001 Intervention Coordinator, Healthy Neighbors Pilot Project, Fred Hutchinson Cancer Research Center, Graduate Research Assistantship, Seattle, WA August 2001- June 2002 Medical Social Worker, University of Washington Medical Center, Seattle, WA June 2002 December 2003 Research Health Science Specialist, Nurse Staffing and Patient Outcomes in VA study, VA Puget Sound Health Care System Health Services Research & Development, Seattle, WA October 2002 December 2006 Project Manager, Ischemic Heart Disease Quality Enhancement Research Initiative, VA Puget Sound Health Care System Health Services Research & Development, Seattle, WA March 2004-December 2006 Senior Project Director and Data Analyst, Alcohol Misuse Work Group, VA Puget Sound Health Care System Health Services Research & Development, Seattle, WA January 2007 December 2012 Research Associate II, Group Health Research Institute, Seattle, WA January 2013 - Present Honors, Awards and Scholarships President s Scholarship Award, EWU 1988-89 Magna Cum Laude, EWU 1992 University Honors, EWU 1988-1992 Rickey Fellowship Award, UW School of Social Work, 2001 Addiction Health Services Research Conference Junior Investigator Travel Award, 2008
Addiction Health Services Research Conference Junior Investigator Travel Award, 2010 Outstanding Graduate Student Award, UW School of Public Health, Health Services, 2012 Professional Societies and Public Advisory Committees 2010 present Member, Research Society on Alcoholism 2013 HSERV Professional Development Group Conferences and Symposiums 2003 Sales AE, Sharp ND, Li Y, Greiner GT. Nurse Staffing and Patient Outcomes in VA. Oral presentation at the Nursing Leadership Conference, Orlando FL. 2003 Sales AE, Sharp ND, Li Y, Greiner GT. Organization of nursing services in the Veterans Health Administration. Oral presentation at the AcademyHealth Annual Research Meeting. 2004 Sales AE, Sharp ND, Li Y, Greiner GT. Nurse Staffing and Patient Outcomes in VA Study: VA Puget Sound Health Care System. Oral presentation to VISN 1 Nurse Managers Conference, April. 2004 Sales AE, Sharp ND, Li Y, Greiner GT.. Nurse Staffing and Patient Outcomes in VA. Oral presentation at AcademyHealth Annual Research Meeting, San Diego, CA. 2004 Sharp ND., Greiner GT, Li Y, Sales AE. Organization of Nursing Services in the Veterans Health Administration: Effects of Reorganization on Nursing Management. Poster presentation at the AcademyHealth Annual Research Meeting, San Diego, CA. 2004 Li Y, Sales AE, Sharp ND, Greiner GT. Reported Job Satisfaction by VHA Nursing Personnel and the Impact of Response Rate. Poster presentation at the AcademyHealth Annual Research Meeting, San Diego, CA. 2004 Greiner GT, Li Y, Sharp ND and Sales AE. RN Characteristics and Staffing Patterns: A Comparison of VHA and Non-VHA Hospital RNs in the United States. Oral presentation at the AcademyHealth Annual Research Meeting, San Diego, CA. 2004 Sharp ND., Greiner GT, Li Y, Sales AE.. Effects of Organizational Change on Nursing Services in VHA Hospitals. Oral presentation at the VA Health Services Research & Development Service Annual Research Meeting, Washington DC. 2004 Sales AE, Sharp ND, Li Y, Greiner GT, Lowy E. Nursing Work Environment, Job Outcomes, and Quality: A Comparison of Acute Medical/Surgical, Acute Psychiatric, and Long-term Care Nursing in Veterans Health Administration Hospitals. SOTA Conference on Implementing the Evidence: Transforming Practices, Systems, and Organizations, Washington DC. 2004 Greiner GT, Li Y, Lowy E, Almenoff P, Sales AE. The State of Emergency Medicine in VHA: Results of the 2003 VHA Emergency Department Survey. Poster presentation at the Annual VA Health Services Research and Development Service National Meeting, Washington DC. 2005 Sales AE, Sharp ND, Greiner GT, Li Y, Lowy E. Nursing Factors and Patient Outcomes in the Veterans Health Administration. Poster presentation at AcademyHealth Annual Research Meeting, Boston, MA.
2005 Sharp ND, Sales AE, Greiner GT, Li Y, Lowy E, Mitchell PH, Sochalski J. Nurses in VHA Hospitals: Results from the Nurse Staffing and Patient Outcomes in VA Nursing Staff Survey. Poster presentation at AcademyHealth Annual Research Meeting, Boston, MA. 2005 Li Y, Sales AE, Sharp ND, Greiner GT, Lowy E. Survey of Nursing Work Environment: A Confirmatory Factor Analysis of the Nursing Work Index-Revised. Poster presentation at AcademyHealth Annual Research Meeting, Boston, MA 2005 Lowy E, Sales AE, Sharp ND, Greiner GT, Li Y. Nursing Factors and Surgical Outcomes in the Veterans Health Administration. Oral presentation at AcademyHealth Annual Research Meeting, Boston, MA. 2006 Sales AE, Sharp ND, Greiner GT, Li Y, Lowy E, Liu C, Sochalski J, Mitchell P, Needleman J. Association between nurse staffing and education and inpatient mortality in VHA. Poster presentation at the VA Health Services Research & Development Service Annual Research Meeting, Washington DC. 2006 Sales AE, Li Y, Greiner GT, Sharp ND, Lowy E, Liu C. Association of Unit-level Perceptions of Work Environment with Patient Mortality in VHA Acute Care Units. Poster presentation at AcademyHealth Annual Research Meeting. 2006 Lowy E, Li Y, Greiner GT, Sharp ND, Sales AE. Nurse Staffing and Patient Mortality: Unit Level, Non-Linear Effects. Poster presentation at AcademyHealth Annual Research Meeting. 2006 Li Y, Sharp ND, Greiner GT, Lowy E, Sales AE. The Relationship Between Patient Satisfaction and Inpatient Nursing Care. Poster presentation at AcademyHealth Annual Research Meeting. 2006 Sales AE, Sharp ND, Greiner GT, Lowy E, Li Y. Association Between Nurse Staffing and Education and Inpatient Mortality in VHA. Paper Presentation. 17 th International Nursing Research Congress Focusing on Evidence-Based Practice. Montréal, Québec, Canada. 2006 Greiner GT, Lowy E, Maynard C, Rumsfeld J, Sales AE, Fihn SD. A comparison of four AMI mortality risk adjustment models. Poster Presentatoin. 24 th VA Annual Health Services Research and Development Service National Meeting. 2006 Greiner GT, Li Y, Sharp ND, Lowy E, Sales AE. Organizational factors and ICU patient outcomes in Veterans Health Administration. Poster Presentation. 24 th VA Annual Health Services Research and Development Service National Meeting. 2006. Greiner GT, Lowy E, Maynard C, Rumsfeld J, Sales AE, Fihn SD. Comparison of six mortality risk adjustment models for acute myocardial infarction. 7th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke, American Heart Association. 2006 Greiner GT, Li Y, Sharp ND, Lowy E, Sales AE. Organizational factors and ICU patient outcomes in Veterans Health Administration. Poster Presentation. Annual Research Meeting, AcademyHealth, June 2006. 2008 Bradley KA, Williams EC, Greiner G, Achtmeyer CE, Volpp B, Hawkins E, Kivlahan DR. Use of Electronic Reminders and a Performance Measure to Increase BI in the VA. Research Society on Alcoholism. July 2008, oral presentation, Washington, DC.
2008 Bradley KA, Williams EC, Greiner G, Achtmeyer CE, Volpp B, Hawkins E, Kivlahan DR. Use of Electronic Reminders and a Performance Measure to Increase BI in the VA. Research Society on Alcoholism. July 2008, oral presentation, Washington, DC. 2008 Greiner G, Williams EC, Achtmeyer C, Kivlahan D, Bradley KA. Alcohol screening and monitoring with the AUDIT-C: How stable are patients alcohol screening scores? Addiction Health Services Research Conference. October 2008, oral presentation. Boston, MA. 2008 Williams, EC, Greiner G, Achtmeyer CE, Volpp B, Kivlahan D, Bradley KA. Use of an electronic clinical reminder for brief alcohol counseling is associated with resolution of alcohol misuse. Addiction Health Services Research Conference. October 2008, oral presentation. Boston, MA. 2009 Delaney KE, Lapham GT, Kivlahan DR, Bradley KA. Limitations of using AUDIT-C or AUDIT scores alone in developing feedback for web-based SBI. Addiction Health Services Research Conference, San Francisco, CA, October 2009. Poster presentation. 2009 Williams EC, Lapham GT, Hawkins EJ, Kivlahan DR, Rubinsky AD, Bradley KA. Referral and Treatment Initiation Practices in the Veterans Affairs Health Care System Prior to a Performance Measure for Brief Alcohol Counseling. Addiction Health Services Research Conference, San Francisco, CA, October 2009. Poster presentation. 2009 Lapham GT, Achtmeyer CE, Williams EC, Hawkins EJ, Kivlahan DR, Bradley KA. Increased Brief Intervention for Alcohol Misuse after National Implementation of a Performance Measure and Electronic Clinical Reminder. Addiction Health Services Research Conference, San Francisco, CA, October 2009. Poster presentation. 2009 Bradley KA, Lapham GT, Kivlahan DR. Implications of Varying Alcohol Screening Instruments and Thresholds for a Performance Measure of Brief Alcohol Counseling. Addiction Health Services Research Conference, San Francisco, CA, October 2009. Symposium presentation. 2010 Bradley KA, Lapham GT, Williams EC, Achtmeyer CA, Hawking EJ, Kivlahan DR. Implementation of Alcohol Screening and Brief Intervention (SBI) in VA Health Care System: Successes and Challenges. ASAM. April 2010, Oral presentation, San Francisco, CA. 2010 Rubinsky AD, Lapham GT, Kivlahan DR, Williams EC, Hawkins EJ, Bradley KA. Prevalence of Previously Recognized Alcohol and Other Substance Use Disorders among VA Patients who Screen Positive for Alcohol Misuse. Academy Health Annual Research Meeting. Boston, MA. June 2010 2010 Bradley KA, Lapham GT, Williams EC, Achtmeyer CE, Hawkins E, Saitz R, Kivlahan DR. Effects of the Proportion Screening Positive on a Performance Measure for Brief Alcohol Intervention. Presented at the Biannual Congress of the International Society on Biomedical Research on Alcoholism. Paris, France. September 2010. 2010 Williams EC, Lapham GT, Johnson ML, Bradley KA. Strategies to Implement Alcohol Screening and Brief Intervention: A Structured Literature Review. Presented at the Biannual Congress of the International Society on Biomedical Research on Alcoholism. Paris, France. September 2010. 2010 Johnson ML, Williams EC, Lapham GT, Bradley KA. The Association between Alcohol Screening Scores and Alcohol-Related Risks among Female Veterans Affairs
Patients. Addiction Health Services Research Conference, Lexington, KY, October 2010. Poster presentation. 2010 Lapham GT, Hawkins EJ, Johnson ML, Williams EC, Thomas R, Ludman E, Achtmeyer CA, Kivlahan DR, Hunt S, Kypri K, Bradley KA. Returning Veterans reflections on drinking: Lessons learned about adapting a web-based alcohol screening and brief intervention. Addiction Health Services Research Conference, Lexington, KY, October 2010. Poster presentation 2011 Williams EC, Lapham GT, Hawkins EJ, Rubinsky AD, Morales L, Young B, Bradley KA. Difference in management of unhealthy alcohol consumption across race/ethnicity in the Department of Veterans Affairs Healthcare System. Poster presented at the NIDAsponsored From Disparities Research to Disparities Interventions: Lessons Learned and Opportunities for the Future of Behavioral Health Services Conference. Arlington, VA, April 2011. 2011 Williams EC, Achtmeyer CE, Grossbard JR, Lapham GT, Thomas RM, Johnson ML, Bradley KA. Barriers and facilitators to implementing alcohol screening with a clinical reminder in the VA: A qualitative study. Poster presented at the annual conference of the Research Society on Alcoholism, Atlanta, GA, June 2011. 2011 Williams EC, Johnson ML, Lapham GT, Rubinsky AD, Bradley KA. Race and receipt of alcohol-related advice in the VA: Association before and after implementation of a brief alcohol counseling performance measure. Poster presented at the annual conference of the Research Society on Alcoholism, Atlanta, GA, June 2011. 2011 Williams EC, Achtmeyer CE, Thomas RT, Grossbard JR, Lapham GT, Johnson ML, Ludman E, Berger DB, Bradley KA. Limitations to Implementing Alcohol Screening with an Electronic Clinical Reminder in the Veterans Affairs Healthcare System: A Qualitative Study. Annual conference of the International Network on Brief Interventions for Alcohol Problems (INEBRIA) Conference, Boston, MA September 2011. Accepted for oral presentation. 2012 Chavez LJ, Williams EC, Lapham GT, Rubinsky AD, Bradley KA. Gender Differences in the Prevalence of Patient-Reported Alcohol-Related Advice Following a National Performance Measure. Poster presented at the Academy Health Annual Research Meeting, Orland, FL, June 2012. 2012 Lapham GT, Rubinsky AD, Williams EC, Maynard C, Heagerty P, Kivlahan DR, Au DH, Bradley KA. Factors Associated with Repeated Negative alcohol Screens: Is Annual Alcohol Screening Unnecessary for Some VA Patients? Poster presentation at the 35 th Annual Research Society on Alcoholism Scientific Meeting, San Francisco, June 2012. 2012 Grossbard JR, Hawkins EJ, Lapham GT, Williams EC, Rubinsky AD, Chavez LJ, Bradley KA. Rates of Alcohol Misuse and Follow-Up Care among OEF/OIF Veterans in VA: Associations with Substance Use Disorders and PTSD. Poster presentation at the 35 th Annual Research Society on Alcoholism Scientific Meeting, San Francisco, June 2012 2012 Williams EC, Lapham GT, Rubinsky AD, Ritmueller S, Chavez LJ, Bradley KA. Impact of a Performance Measure for Brief Alcohol Intervention on Gender Differences in Alcohol-related Care in the Veterans Affairs Health Care System. Poster presentation
at the annual conference of the Research Society on Alcoholism, San Francisco, June 2012. 2012 Bradley KA, Rubinsky AD, Lapham GT, Williams EC, Au DH, Blough DK, Berger D, Chavez LJ; Hawkins E. Changes in AUDIT-C Scores Reflect Changes in Drinking - Results of a Biomarker Study. Poster presentation at the annual conference of the Research Society on Alcoholism, San Francisco, June 2012. 2012 KA Bradley, Lapham GT, LJ Chavez, EC Williams, AD Rubinsky, and DR Kivlahan. A Majority of Brief Alcohol Interventions Documented in the Medical Record are Reported By VA Patients. Oral presentation at the July 2012 VA HSR&D/QUERI National Conference. 2012 Grossbard JR, Hawkins EJ, Lapham GT, Williams EC, Rubinsky AD, Chavez LJ, Bradley KA. Rates of Alcohol Misuse and Follow-Up Care among OEF/OIF Veterans in VA: Associations with Substance Use Disorders and PTSD. Poster presentation at the July 2012 VA HSR&D/QUERI National Conference. 2012 Chavez LJ, Lapham GT, Williams EC, Kivlahan DR, Bradley KA. Prevalence of Patient-Reported Alcohol-Related Advice Following Performance Measure Implementation. Poster presentation at the July 2012 VA HSR&D/QUERI National Conference. 2012 Williams EC, Achtmeyer CE, Thomas RM, Grossbard JR, Lapham GT, Chavez LJ, Ludman E, Berger D, Bradley KA. Implementing Alcohol Screening and Brief Intervention with Clinical Reminders: Barriers and Facilitators. Oral presentation at the July 2012 VA HSR&D/QUERI National Conference. 2012 Lapham GT, Rubinsky AD, Williams EC, Hawkins EJ, Kivlahan DR, Maynard C, Bradley KA. The Assocation between a Positive Screen for Alcohol Misuse and Prior Negative Screen Scores. Oral presentation at the October 2012 Addiction Health Services Research Conference, New York, NY. 2013 Lapham GT, Rubinsky AD, Hawkins EJ, Williams EC, Kivlahan DR, Bradley KA. Annual Alcohol Screening May Not Be Necessary for Nondrinkers with Multiple Prior Negative Screens. Presented as part of a symposium for the 2013 RSA Annual Meeting. Bibliography 1. Sales, AE; Sharp, ND; Li, Y-F; Greiner, GT; Lowy, E; Mitchell, P; Sochalski, JA; Cournoyer, P. Nurse Staffing and Patient Outcomes in Veterans Affairs Hospitals J Nurs Adm. 2005 Oct;35(10):459-66.. 2. Sharp ND, Greiner GT, Li YF, Mitchell PH, Sochalski JA, Cournoyer PR, Sales AE.. Nurse executive and staff nurse perceptions of the effects of reorganization in Veterans Health Administration hospitals J Nurs Adm. 2006 Oct;36(10):471-8 3. Li YF, Lake ET, Sales AE, Sharp ND, Greiner GT, Lowy E, Liu CF, Mitchell PH, Sochalski JA. Measuring nurses' practice environments with the revised nursing work index: evidence from registered nurses in the Veterans Health Administration Res Nurs Health. 2007 Feb;30(1):31-44.
4. Plomondon ME, Ho MP, Wang LI, Greiner GT, Shore JH, Sakai JT, Fihn SD, Rumsfeld JS. Severe Mental Illness and Mortality of Hospitalized Acute Coronary Syndrome Patients in the Veteran Healthcare Administration. BMC Health Services Research. 2007 Sep 18;7:146. 5. Sales, AE, Sharp N, Li YF, Lowy E, Greiner GT, Liu CF, Alt-White A, Rick C, Sochalski J, Mitchell PH, Rosenthal G, Stetler C, Cournoyer P, Needleman J. The association between nursing factors and patient mortality in the Veterans Health Administration: The view from the nursing unit level. Medical Care. 2008 46;9:938-45. 6. Williams EC, Lapham G, Achtmeyer CE, Volpp B, Kivlahan DR, Bradley KA. Use of an Electronic Clinical Reminder for Brief Alcohol Counseling is Associated with Resolution of Alcohol Misuse. J Gen Intern Med. 2010; 25(1):11-8 7. Hawkins EJ, Lapham GT, Kivlahan DR, Bradley KA. Recognition and Management of Alcohol Misuse in OEF/OIF and Other Veterans in the VA: A Cross-Sectional Study. Drug Alcohol Depend. 2010 Feb 16. [Epub ahead of print]. 8. Lapham GT, Achtmeyer CE, Williams EC, Hawkins EJ, Kivlahan DR, Bradley KA. Increased Documented Brief Alcohol Interventions with a Performance Measure and Electronic Decision Support. Medical Care. 50(2):179-187, February 2012. 9. Bradley KA, Lapham GT, Hawkins EJ, Achtmeyer CE, Williams EC, Thomas RM, Kivlahan DR. Quality Concerns When Implementing Routine Alcohol Screening. J Gen Intern Med. 2011 Mar;26(3):299-306. 10. Williams EC, Johnson ML, Lapham GT, Caldeiro R, Chew L, Fletcher G, McCormick KA, Weppner W, Bradley KB. Strategies to Implement Alcohol Screening and Brief Intervention: A Structured Literature Review. Psychology of Addictive Behaviors. 2011 Apr 25. [Epub ahead of print] 11. Sales AE. Lapham GT, Squires J, Hutchinson A, Almenoff P, Sharp ND, Lowy E, Li Y. Organizational factors associated with decreased mortality among VA patients with an ICU stay. Computers, Informatics, Nursing. 2011 Sep;29(9):496-501 12. Williams EC, Lapham GT, Hawkins EJ, Rubinsky AD, Morales L, Young BA, Bradley KA. Differences in Documented Care for Unhealthy Alcohol Consumption across Race/Ethnicity in the Department of Veterans Affairs Healthcare System. Alcohol Clin Exp Res 2012. [Epub ahead of print] 13. Johnson ML, Williams EC, Lapham GT, Bradley KA. The Association between Alcohol Screening Scores and Alcohol-Related Risks among Female Veterans Affairs Patients. J Stud Alcohol Drugs. 2012 May;73(3):391-400. 14. Lapham GT, Hawkins EJ, Johnson ML, Achtmeyer CA, Williams EC, Thomas R, Ludman E, Kypri K, Hunt S, Bradley KA. Feedback from Recently Returned Veterans on an Anonymous Web-based Brief Alcohol Intervention. Addiction Science and Clinical Practice. 2012, 7:17 15. Bradley KA, Chavez L, Lapham GT, Williams EC, Achtmeyer CA, Hawkins EJ, Thomas RM, Kivlahan DJ. When Quality Measures undermine Quality: Bias in a Quality Measure for Follow-up for Alcohol Misuse. Psychiatric Services in Advance, July 15, 2013.
16. Grossbard JR, Hawkins EJ, Lapham GT, Williams EC, Rubinsky AD, Simpson T, Seale KH, Kivlahan DJ, Bradley KA. Follow-Up Care for Alcohol Misuse among OEF/OIF Veterans with and without AUD and PTSD. In Press J Stud Alcohol Drugs. 17. Lapham GT, Rubinsky AD, Heagerty PJ, Williams EC, Hawkins EJ, Maynard C, Kivlahan DK, Bradley KA. Annual alcohol screening for alcohol misuse: Diminishing returns for some patient subgroups. Med Care. 2013 Oct;51(10):914-21. 18. Lapham GT, Rubinsky AD, Heagerty PJ, Achtmeyer CA, Williams EC, Hawkins EJ, Maynard C, Kivlahan DK, Au D, Bradley KA. Probability and Predictors of Patients Converting from Negative to Positive Screens for Alcohol Misuse.[Published online ahead of print October 7 2013] Alcohol Clin Exp Res. 2013 DOI: 10.1111 Submitted: 1. Delaney KE, Lee A, Lapham GT, Rubinsky AD, Chavez LJ, Bradley KA. Inconsistencies between Reported Alcohol Consumption on Individual AUDIT-C Questions and Screening Results based on AUDIT-C Scores: Prevalence in Two National U.S. Samples. Revisions requested Addiction Science and Clinical Practice 2. Williams EC, Rubinsky AD, Chavez LJ, Lapham GT, Rittmueller S, Achtmeyer CE, Bradley KA. No Association between Documented Brief Intervention and Resolution of Unhealthy Alcohol Use: Results of an Early Implementation Evaluation in the Veterans Health Administration. Revisions requested Addiction 3. Williams EC, Rubinsky AD, Lapham GT, Hawkins EJ, Chavez LJ, Bradley KA. Previously Recognized Alcohol and Other Substance Use Disorders among Female and Male VA Outpatients who Screen Positive for Unhealthy Alcohol Use. Revisions requested DAD In preparation: 1. Williams EC, Achtmeyer CE, Thomas RT, Grossbard JG, Lapham GT, Chavez LJ, Ludman E, Berger DB, Bradley KA. Challenges to Implementing Alcohol Screening with Electronic Clinical Decision Support: Results of a Qualitative Observation Study at 9 Veterans Affairs Primary Care Clinics. In preparation. 2. Chavez L, Lapham GT, Williams EC, Bradley KA. Prevalence of Patient-Reported Alcohol Related Advice Following Performance Measure Implementation. In preparation. 3. Chavez L, Fishman PA, Lapham GT, Bradley KA. Comparing the Costs of Various Alcohol Screening Strategies in Primary Care. In preparation 4. Lapham GT, Rubinsky AD, Hawkins EJ, Williams EC, Chavez LJ, Grossbard J, Kivlahan DR, Bradley KA. Decreasing sensitivity of clinical alcohol screening with the AUDIT-C after repeated negative screens in VA clinics. In preparation. 5. Williams EC, Lapham GT, Rubinsky AD, Rittmueller SE, Chavez LJ, Bradley KA. Impact of a Performance Measure for Brief Alcohol Counseling on Gender Differences in Alcohol-Related Care in the Veterans Affairs Healthcare System. In preparation. 6. Williams EC, Achtmeyer CE, Rittmueller SE, Lapham GT, Lee A, Ludman E, Berger DB, Bradley KA. Local Implementation of Preventive Alcohol Care after National
Performance Measures: Results from Key-informant Interviews at Five VA Primary Care Clinics. In preparation.