Health Administration Research Articles

Satisfaction Amongst Drug-dependent Population with Methadone Maintenance Treatment Services, A Comparison between Public and Private Clinics: Implications for Private Sector Engagement in the Delivery of Methadone Maintenance Programs Across Vietnam.

In Vietnam, the public sector has largely been responsible for delivering methadone maintenance treatment (MMT) services. However, with foreign aid anticipated to decline in the coming years, the involvement of the private sector in delivering MMT services is critical to ensure the continued sustainability of MMT programs across Vietnam. This study aims to evaluate patient satisfaction and identify correlated factors among Vietnamese drug users undergoing MMT in both public and private methadone clinics. A cross-sectional study was conducted in one private and two public methadone facilities in Nam Dinh, a province in the North of Vietnam. A convenience sampling technique was applied to recruit 395 participants. Data was collected through 20-minute face-to-face interviews using a structured questionnaire. Multivariate Tobit regression was utilized to measure associated factors with patient satisfaction. Results showed that patients were highly satisfied with MMT services in both public and private; however, they expected a higher degree of comprehensive care services. Compared with public facilities, the satisfaction level of patients in private facilities was significantly lower in the following aspects: health administration and professional capacity of health workers. However, there were insignificant differences in regard to infrastructure, equipment, and availability of medical services resources, supporting a promising role of the private sector in supporting the expansion of the MMT programs in Vietnam. Integrating MMT with other physical and mental healthcare services, along with strategies for improving administrative procedures and health workers' capacity in private clinics, are critical implications of this study.

Age-Related Variation in Ecological Resources Among Veterans Seeking Treatment Related to Military Sexual Trauma.

Approximately 16% of Veterans experience military sexual trauma (MST), defined as sexual assault or harassment experienced during military service. Veterans across life stages may possess differing resources and face unique stressors that impact their ability to engage in mental health treatment or require additional liaison to services. The present study sought to characterize age-related differences in the socioecological contexts of Veterans seeking mental health treatment following MST in the domains of economic sufficiency, housing, spiritual coping, supportive relationships, and interpersonal violence. From 2009 to 2019, Veterans (N = 640) seeking mental health services following exposure to MST attended evaluation and treatment planning sessions at a Midwestern Veterans Health Administration posttraumatic stress disorder specialty clinic. Veterans completed semistructured interviews that included surveys and diagnostic screenings to assess psychosocial needs and resources. ANOVA and ordinal regressions were used to evaluate potential disparities in socioecological resources by age. No age-related differences in economic sufficiency and stable housing emerged, though most Veterans (57%) endorsed financial difficulties. Veterans who endorsed spiritual beliefs were significantly older than those who did not. Veterans who reported having a support system were significantly younger than Veterans who denied having a support system. Less than half (46%) of Veteran reported having peer relationships. Veterans who endorsed frequent interaction with their peers were significantly older than those who did not. Veterans who reported past-year exposure to interpersonal violence were significantly younger. Greater clarity about age-related differences in the socioecological contexts of Veterans can support clinicians in providing responsive mental health treatment and connecting Veterans to additional Veterans Health Administration resources following MST.

Incidence of Pulmonary Hypertension in the Echocardiography Referral Population.

Incidence rates for pulmonary hypertension using diagnostic data in patients with cardiopulmonary disease are not known. To determine incidence rates of, risk factors for, and mortality hazard associated with pulmonary hypertension among patients referred for transthoracic echocardiography Methods: Retrospective cohort study using data from the Veterans Health Administration (1999-2020) and Vanderbilt University Medical Center (1994-2020). Pulmonary hypertension was defined as pulmonary artery systolic pressure >35mmHg with prevalent cases excluded. Heart failure and chronic obstructive pulmonary disease were the primary exposures of interest. The primary outcome was incident pulmonary hypertension. Secondarily, we examined mortality rate following incident diagnosis. We identified 245,067 VA patients (94% male, 20% Black) and 117,526 Vanderbilt patients (46% male, 11% Black) without pulmonary hypertension, of whom 38,882 VA patients and 8,061 Vanderbilt patients developed pulmonary hypertension. Only 18-19% of patients with echo-based pulmonary hypertension also had a diagnostic code. Hazard of pulmonary hypertension was 4-fold higher in patients with heart failure and chronic obstructive pulmonary disease compared to patients without either. Mortality rates increased from pulmonary artery systolic pressure of 35mmHg to 45mmHg then plateaued. Independent risk factors for incident pulmonary hypertension included older age, male sex, black race, and cardiometabolic comorbidities. Pulmonary hypertension incidence rates estimated by diagnostic data are higher than code-based rates. Heart failure and chronic obstructive pulmonary disease strongly associate with incident pulmonary hypertension. Pulmonary artery systolic pressure >45mmHg at diagnosis is associated with high mortality. New pulmonary hypertension on echocardiography is an important prognostic sign.

Training Needs for School Staff Supporting Students Returning to School After a Psychiatric Hospitalization

AbstractSupporting students returning to school after a mental health crisis often involves more training than many school staff members receive. With the increase in youth mental health diagnoses, there has also been an increase in the number of youth requiring psychiatric emergency department visits and hospitalizations. As such, this study employed a basic qualitative design to gather the perspectives of school staff who support students’ mental health about their experiences and training needs related to supporting youth returning to school after psychiatric hospitalization. Semi-structured interviews were conducted with 10 school mental health professionals or administrators. Thematic analysis was used to analyze the data. Three themes were identified: (1) most participants received minimal formal training in graduate school on hospital-to-school transition, (2) most participants learned about hospital-to-school transition on the job, and (3) participants made recommendations and identified specific training needs. Implications for training are discussed including a need for variety (e.g., some practitioners need basic training while others need more advanced training) and different format preferences (in-person may be preferred but online asynchronous is more convenient).

Core Mechanisms in Mediating eHealth Implementation and Uptake: A Case Study of Eastern Uganda

Researchers agree that, globally, in both developing and developed countries, healthcare management is faced with acute challenges: expanding areas of health needs, operationalizing health management, constrained budget allocations, as well as resource limitations. Hence, there is an imminent drive to find solutions to stimulate health system transformation through health system innovation. Therefore, effective national operational strategies to minimize resource wastage and contain the costs of health service delivery are critical. The study adopted a methodology that incorporated different research approaches and strategies. Deductive and inductive approaches were used; the strategies were surveys and case studies. A sample of 178 health professionals and administrators in three Health care facilities in Eastern Uganda, were determined and surveyed. Eligible respondents were stratified and selected through simple random sampling. Self-administered questionnaires and interview guides were used to gather the data. The captured data was analysed using Stata version 17. Regression analysis was used to determine the impact of eHealth Implementation core mechanisms on Quality Health Service Delivery. From the results of regression analysis, the core mechanisms variable had a p-value of 0.049 which was significant. For eHealth Implementation Core Mechanisms, the respondents have less control over them since they are dependent on several environmental factors, such as government funding or grants, Government regulations, and policies among others.

Accounting for Red Cell Distribution Width Improves Risk Stratification by Commonly Used Mortality/Deterioration Risk Scores in Adult Patients Hospitalized Due to COVID-19.

Higher red blood cell distribution width (RDW) levels have gained attention in the prognostication of many chronic metabolic and malignant diseases, as well as coronavirus disease 2019 (COVID-19). We aimed to evaluate whether accounting for RDW might contribute to risk stratification when added to commonly used risk scoring systems in adult COVID-19 patients. We retrospectively analyzed a cohort of 3212 non-critical COVID-19 patients hospitalized in a tertiary-level institution from March 2020 to June 2021. Admission RDW values were considered normal if they were ≤14.5% in males or ≤16.1% in females. The Modified Early Warning Score (MEWS), International Severe Acute Respiratory and Emerging Infections Consortium Coronavirus Clinical Characterisation Consortium score (ISARIC 4C), and Veterans Health Administration COVID-19 (VACO) index were evaluated as prognostic scores. RDW exceeded the upper limit in 628 (19.6%) of the patients. When RDW was accounted for, risks of the predicted outcomes were considerably different within the same MEWS, 4C score, and VACO index levels. The same patterns applied equally to patients who started, and those who did not start, remdesivir before deterioration. RDW may be a useful tool for stratifying risk when considered on top of commonly used prognostic scores in non-critical COVID-19 patients.

8139 Examining the Association of GLP1-RA or DPP4i with Bullous Skin Diseases in Veterans

Abstract Disclosure: S. Saad-Omer: None. M. Kinaan: None. N. Sami: None. I. Mansi: None. Introduction: Pemphigus vulgaris (PV) and bullous pemphigoid (BP) are Autoimmune Blistering Disorders (AIBDs). GLP-1 Receptor Agonists (GLP1-RA) and Dipeptidyl peptidase 4 inhibitors (DPP4i) have been noted in various case reports and case control studies to be linked with certain AIBDs; however, their overall role in these diseases is not completely understood, despite the exponential increase in use of these medications. This study aims to be the first study to investigate the association of DPP-4 inhibitors and GLP-1 agonists with incidence of AIBD, PV, and BP in a large cohort of American veterans. Methods: This retrospective cohort study of veterans enrolled in the Veterans Health Administration (VHA) used Corporate Data Warehouse (CDW). We extracted data of patients from fiscal years (FY) 2006 to end of FY 2021 who filled either GLP1-RA or DPP4i prescriptions. CDW is a comprehensive data source that encompasses vital status, demographic data, inpatient and outpatient diagnoses and procedure codes, vital signs, laboratory data, and pharmacy fill data. The study groups included: 1) GLP1-RA group: patients who initiated GLP1-RA; and 2) DPP4i group: patients who initiated DPP4i. Our primary outcome was the incidence of AIBDs. We compared baseline characteristics of patients who experienced the outcome and those who did not among GLP1-RA or DDP4i users. We, thereafter, examined factors associated with incidence of AIBD, PV, and BP among GLP1-RA users and DPP4i users. Results: The initial cohort of GLP1-RA or DPP4i users comprised a total of 415,895 patients, from which we excluded 397 (0.095%) patients with prior bullous skin diseases before starting GLP1-RA or DPP4i medications. Overall, a total of 154 patients developed PV/BP disease after initiation of either DPP4i or GLP1-RA. Of these 154 patients, 123 of these patients were on DPP4i and 31 of these patients were on GLP1-RA. The mean age (SD) of PV/BP patients was 72 (11) years compared to an average age of 66 (10) years in patients who did not develop PV/BP. Patients were also found to be predominately white (77.9%). Factors associated with increased risk of BP were use of DPP4i (Odds Ratio [OR] 1.90, 95% confidence interval [95% CI: 1.14-3.47, p=<0.01), and older age (OR: 1.07, 95%CI: 1.04-1.09, p<0.01). Use of GLP1-RA or DPP4i was not associated with PV incidence. (OR: 1.31, 95% CI: 0.65-2.62, p=<0.45). Conclusion: In conclusion, our study supports existing literature that DPP4i use is associated with an increased risk of developing BP. Our data does not find association with GLP-1 agonists nor DPP4 inhibitors in increasing the risk of PV. Presentation: 6/3/2024

Interhospital transfer among US veterans admitted to community and veterans affairs hospitals for acute myocardial infarction and ischemic stroke before and during the COVID-19 pandemic.

Veterans Health Administration (VHA) enrollees may use community hospitals for inpatient care and sometimes require transfer to larger community or VHA hospitals. Little is known about interhospital transfer patterns among veterans using community and VHA hospitals or how coronavirus disease 2019 (COVID-19) case surges affected transfer. Retrospective cohort study among veterans age 65+ admitted to community and VHA hospitals for acute myocardial infarction (AMI) or acute ischemic stroke (AIS) during 2018-2021. We examined associations between COVID-19 case density in regional hospital referral networks and the likelihood of transfer. A total of 8373 (23.6%) veterans with AMI and 4630 (13.1%) with AIS were transferred in the prepandemic period. Transfer was especially common for rural veterans (36% with AMI, 20% with AIS). Most transfers (88%) were between community hospitals and 6% from community to VHA. Among AMI patients, transfer was less likely among patients age >90 (relative to age 65-69), those with non-White race/ethnicity, and females. Transfer was more common among patients initially seen in rural hospitals (AMI, odds ratio [OR] = 2.73, 95% confidence interval [CI], 2.90-3.74; AIS, OR = 2.43; 95% CI, 2.24-2.65). During 2020-2021, transfer among AMI patients was less likely during COVID-19 case density surges affecting the admitting hospital's referral network (OR = 0.86; 95% CI, 0.78-0.96 for highest compared with lowest quartile of COVID-19 cases). Interhospital transfer was common for veterans with AMI and AIS, especially among rural veterans. Few transfers were to VHA hospitals. COVID-19 case surges were associated with decreased transfer for veterans with AMI, potentially limiting access to needed care.

6851 Rapidly Increasing Use of Anti-Obesity Medications among Veterans in the Veterans Health Administration (VA)

Abstract Disclosure: V. Vimalananda: None. S. Qian: None. R. Bolton: None. A. Hung: None. V. Smith: None. M. Maciejewski: None. Introduction: Obesity is a prevalent and costly chronic disease that compromises quality of life; increases risks of cardiometabolic disease, osteoarthritis, and several cancers; and accounts for 28% of U.S. health care costs. Anti-obesity medications (AOMs) may fill the treatment gap given the low uptake of bariatric surgery and limited effectiveness of behavioral interventions, and are guideline-recommended as part of a comprehensive obesity treatment plan. The landscape for obesity treatment has changed with introduction of the highly effective and in-demand glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and dual GLP-1 + GIP receptor agonists (GIP/GLP-1 RAs). Given limited knowledge of use patterns, we describe use of AOMs among patients receiving care in the Veterans Health Administration (VA), which is the largest integrated health system in the United States. Methods: In a retrospective cohort study of VA patients from 7/1/2021-6/30/2023, we examined data from the VHA Corporate Data Warehouse separately for patients on AOMs without and with diagnosed diabetes, since the newer AOMs can be used at lower doses for the diabetes indication. Results: There were 31,106 patients without diabetes and at least one AOM prescription in the two year study period, who were 60% male and 62% White. AOM prescriptions from Year 1 to Year 2 among this group increased 215%. Overall, prescriptions were: semaglutide 34%, liraglutide 18%, orlistat 18%, phentermine/topiramate 14%, bupropion/naltrexone 12%, phentermine 4% and tirzepatide 0.03%. Prescribers were physicians 60%, LIPs 25%, and pharmacists 13%. There were 188,017 patients with diagnosed diabetes and at least one AOM prescription, and they were 92% male and 67% white. AOM prescriptions from Year 1 to Year 2 among this group increased 14% and were primarily (87%) for semaglutide. Prescribers were physicians 63%, licensed independent practitioners (LIPs) 23%, and pharmacists 10%. Conclusions AOM use is increasing in VA across all AOM classes, particularly among patients without diabetes, indicating growing interest in medical treatment of obesity. As AOM use spreads, real-world evidence on weight loss and clinical outcomes is needed among patients like those in VA who tend to be older and less healthy than the highly selected patients included in randomized clinical trials. Data is especially needed to guide practice among patients with obesity and without diabetes, given the dramatic increase in use among that group over the past 2 years. Presentation: 6/1/2024

Suicide Rates by Age and Time Among American Indian and Alaskan Native Veterans

Objective: Although recent work has highlighted high rates of suicide among American Indian and Alaska Native individuals who served in the US military, to date, a comprehensive evaluation of age-specific suicide rates, over time, has yet to be conducted. Methods: Population-based retrospective cohort study. Average annual suicide rates (2005–2020) were computed. The cohort included 207,955 Native Veterans who were alive as of January 1, 2005, and separated from military service on or before December 31, 2020. Suicide was identified via National Death Index codes. Results: Between 2005 and 2020, average annual, age-specific suicide rates among Native Veterans ranged from 16.32/100,000 (55+ y) to 64.49/100,000 (18–34 y). Compared with other age-related cohorts, the rate among those in the youngest age cohort (18–34y) was the highest between 2005 and 2018. The 2019–2020 average annual rate for 18- to 34-year-olds (41.86/100,000) dropped below that of the middle-aged cohort (35–45 y; 44.66/100,000). Across all age cohorts, firearms were the most used method of suicide [57.2% (18–34 and 35–54 y) to 66.17% (55+y)]; however, a notable percentage of Veterans died by suffocation, 16.54% (55 y and older), 26.71% (35–54 y), and 33.21% (18–34 y). Conclusions: Findings highlight differences in suicide rates by age groups overtime for Native Veterans irrespective of Veterans Health Administration use and across service eras, as well as means of suicide, which also differed across groups. Increased efforts are needed to identify culturally and age-relevant intervention strategies, as well as factors associated with risk, to reduce deaths among Native Veterans.

Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate the written exposure therapy training program in the Veterans Health Administration.

The Veterans Health Administration (VHA) has rolled out evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD); however, reach has remained low, and there is a need for briefer interventions. The National Center for PTSD conducted a facilitated learning collaborative to train clinicians and support VHA PTSD teams in their adoption of an emerging best practice, written exposure therapy (WET). Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) evaluation framework, the present study utilized longitudinal data from 178 clinicians and 556 patients across seven training cohorts to evaluate key clinical and implementation outcomes and whether clinic (i.e., implementation climate) or clinician factors (i.e., treatment attitudes) were associated with effectiveness and implementation. Intent-to-treat analyses indicated WET was effective in reducing PTSD (d = 0.54) and depression symptoms (d = 0.39). Data indicated that 87.60% of clinicians reported using WET 6 months postconsultation. Clinic-wide reach was modest after training (14.53% of individuals with PTSD); however, WET-trained clinicians continued to offer WET to an average of 87.38% of their patients. Fidelity remained high after training, with essential session elements most often being offered "always" (M = 6.65 on a scale from 1 to 7). More positive postconsultation clinician treatment attitudes predicted higher posttraining rates of having patients engaged in WET. Clinician treatment attitudes and implementation climate did not predict any other implementation or effectiveness outcomes examined. Results suggest that WET implementation is advancing in VHA, with good clinical outcomes. Data provide evidence that a facilitated learning collaborative can be used to support and scale EBPs. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

An Automated Electronic Health Record Score to Estimate Length of Stay and Readmission in Patients Undergoing Radical Cystectomy for Bladder Cancer.

Patients treated with radical cystectomy experience a high rate of postoperative complications and frequent hospital readmissions. We sought to explore the utility of the Care Assessment Need (CAN) score, derived from electronic health data, to estimate the risk of these adverse clinical outcomes, thereby aiding patient counseling and informed treatment decision-making. We retrospectively examined data from 982 patients with bladder cancer who underwent radical cystectomy between 2013 and 2018 within the national Veterans Health Administration system. We tested for associations between the preoperative CAN score and length of stay, discharge location, and readmission rates. We observed a correlation between higher CAN scores and longer hospital stays (adjusted relative risk = 1.03 [95% CI: 1.02-1.05]). An increased CAN score was also linked to greater odds of discharge to a skilled nursing facility or death (adjusted odds ratio = 1.16 [95% CI: 1.06-1.26]). Furthermore, the score was associated with hospital readmission at both 30 and 90 days postdischarge (adjusted HR = 1.03 [95% CI: 1.00-1.07] and 1.04 [95% CI: 1.00-1.07], respectively). The CAN score is associated with length of hospital stay, discharge to a skilled nursing facility, and readmission within 30 and 90 days after radical cystectomy. These findings highlight the potential of health care systems leveraging electronic health records for automatically calculating multidimensional tools, such as the CAN score, to identify patients at risk of adverse clinical outcomes after radical cystectomy.

Spending by the Veterans Health Administration for Medicare Advantage Dual Enrollees, 2011-2020

This study assesses veterans’ dual enrollment in the Veterans Health Administration (VHA) and Medicare Advantage and VHA spending from 2011 through 2020.

“We just need to create as many avenues for access as we possibly can”: Clinician and administrator attitudes toward telehealth medication abortion in the U.S. South

ObjectivesThere is currently a gap in literature on the perspectives of sexual and reproductive health clinicians and administrators in the South toward telehealth abortion services. This research seeks to explore these perspectives to understand clinician and administrator attitudes toward importance and priority of telehealth abortion to contribute to the development of a richer understanding of telehealth abortion in the South. Study DesignThis study conducts a secondary analysis of data from the Provider Readiness for Virtual Implementation and Delivery of Medication Abortion Services (PROVIDA) study. We collected qualitative data regarding perspectives of 13 clinicians and 7 administrators toward importance and priority of telehealth abortion during a series of in-depth interviews that took place from June 2021-2022 and analyzed data using MAXQDA. ResultsWe identified four main themes: telehealth abortion is important for patient benefit in mitigating physical, administrative, financial, and privacy-related barriers; telehealth abortion is important for clinic benefit in improving clinic flow and sustainability; the political climate affects personal prioritization of telehealth abortion; and staff hesitance affects clinic prioritization of telehealth abortion. ConclusionsOur analysis revealed telehealth abortion to be particularly important in mitigating physical access barriers for patients and for clinic sustainability. We found the political climate to be the most notable factor influencing personal prioritization of telehealth abortion, with most participants noting it made telehealth abortion less of a priority. Additionally, our analysis found participant perception of staff hesitation to implement telehealth abortion to be the most notable factor affecting clinic prioritization. Future research should utilize these findings to inform studies examining the implementation climate of telehealth abortion in the South.

The impact of regulatory workplace safety inspections on workers' compensation claim rates.

Studies on the impact of workplace safety inspections on work injuries have found mixed effectiveness. Most studies are from the United States, examining Occupational Health and Safety Administration (OSHA) regulatory inspections in manufacturing firms with more than 10 employees. This study examines whether regulatory inspections in Alberta, Canada, result in reductions in workers' compensation claims rates for inspected firms relative to comparable non-inspected firms. Firm and claim-level data from the Workers' Compensation Board of Alberta were linked with regulatory enforcement data from the Government of Alberta for construction, manufacturing, and transportation firms with at least one full-time employee for 37 consecutive months. A matched difference-in-differences study design was used to estimate changes in lost-time claim rates for work-related injuries and musculoskeletal diseases of inspected and comparable non-inspected firms between the year pre-inspection and 2 years, post-inspection, controlling for firm-level characteristics. Inspections were not effective in reducing firm-level claim rates, with the exception of transportation firms with more than one inspection experiencing a 28% decrease in their claim rate in the second year post-inspection, relative to the change in non-inspected firms. In construction, inspected firms experienced a 12% increase in their claim rate in the first year post-inspection. No effect was observed in the manufacturing sector. Regulatory workplace safety inspections in Alberta generally do not result in greater reductions in firm-level claim rates in the construction, manufacturing, and transportation sectors. Inspections alone may not be sufficient to induce compliance or hazard management changes that lead to reductions in firm-level injuries.

COVID-19 in Perspective: A Witness Seminar1.

In June 2023, we brought together leaders who responded to the emergency phase COVID-19 pandemic in Ontario as part of a "Witness Seminar." This approach to studying history was developed by the Institute of Contemporary British History. It has been extensively used in the history of science and medicine by the Wellcome Trust History of Twentieth Century Medicine. A witness seminar provides a collective oral history, in which participants can express diverse perspectives, build on each other's thoughts, and create a documentary record for policy makers and future historians. The published transcript provides an intimate look at how the pandemic played out in the eyes of some of key responders and raises many questions about the history of public health funding and administration in the province of Ontario, the failures in long-term care, and the need to improve pandemic communication. This article documents the success of the pandemic response.

Factors Associated with Influenza Vaccination in a National Veteran Cohort

IntroductionOnly 53% of American adults receive influenza vaccination, and disparities in vaccination exist amongst particular racial and ethnic groups. This study determines how race, ethnicity, sex, and rurality are associated with influenza vaccination adherence in a national Veteran Health Affairs Administration (VHA) cohort. MethodsWe examined differences in documented influenza vaccinations for the 2019-2020 influenza season among VHA patients in a retrospective cohort study using VHA administrative electronic health record data. We used logistic regression to model receipt of influenza vaccination in association with race, ethnicity, sex, and rurality while controlling for clinical diagnoses, demographics, and ambulatory care utilization. We also stratified the models by sex and rurality. ResultsAmong 5,943,918 veterans, 48.6% received influenza vaccination. Unadjusted comparisons showed those who were vaccinated were more likely to be white, male sex, and older. Similar proportions of unvaccinated and unvaccinated veterans were from rural settings. In adjusted models, Black race was most strongly associated with decreased vaccination (AOR=0.69, [0.69-0.70]), and American Indian/Alaskan Native race also had reduced odds of vaccination (AOR=0.94 [0.92-0.95]) compared to White race. Female veterans had increased odds of vaccination (AOR=1.20; [1.19-1.20]) compared to men. Rurality (AOR=0.97 [0.96-0.97]) was associated with a small decreased odds of vaccination compared to urban. In stratified models, Black veterans were less likely to receive influenza vaccination regardless of sex and rurality compared to White veterans. American Indian/Alaska Native female veterans had equal odds of vaccination as compared to White female veterans, while American Indian/Alaska Native male veterans had reduced odds of vaccination compared to White male veterans. ConclusionsDuring the 2019-2020 influenza season, Black and American Indian/Alaskan Native veterans had lower odds of vaccination. Despite the VHA's universal approach to healthcare, racial disparities still exist in preventive care.

Women's Health Care Delivery and Coordination After Transitioning From One Electronic Health Record to Another: Perspectives From Staff in the Veterans Health Administration

ObjectivesThe Veterans Health Administration (VA) is transitioning its 1,300 health care facilities from one electronic health record (EHR) to another. The transition aims to improve care delivery and interoperability; however, specific effects on women veterans, who comprise only 7.5% of the patient population, may be obscured without focused evaluation. We aimed to characterize the perspectives of VA staff regarding the impact of transitioning EHRs on women's health care delivery. MethodsWe conducted semistructured interviews with VA staff members involved in delivering or coordinating care for women at three sites that had transitioned EHRs within the past year. Interviews were audio-recorded and transcribed. We used a rapid, templated qualitative analytic approach to identify salient themes in the data. ResultsWe interviewed 16 staff members across VA departments and roles. Although some participants felt the new EHR held promise, most identified challenges with the EHR rollout and implementation (e.g., insufficient training) and the EHR product (e.g., system inefficiencies and latency). Participants highlighted several ways the EHR transition disproportionately affected care delivery for women veterans, including via backlogs of community care referrals, insufficient opportunities for providers to gain proficiency with sex-specific workflows in the new EHR, and outdated listings for veterans who have changed their names. Participants reported that these issues affected their morale and contributed to decreases in productivity and delayed care. ConclusionsMany of our findings reflect challenges that affect VA staff broadly, whereas others may be compounded among women veterans and the VA staff who serve them. To achieve the goal of delivering timely, equitable, high-quality, comprehensive health care services to women veterans, continued efforts to monitor and address the impacts of the EHR transition on this population are needed.

Variation in Urology Care after Urinary Stone Surgery among Veterans at High-risk for Recurrence

ObjectiveTo determine rates of urology follow-up and implementation of stone prevention measures after stone surgery and to assess variation in care delivery within a large, integrated healthcare system. Materials and MethodsWe used nationwide data from the United States Veterans Health Administration to identify patients who had stone surgery between 2016 and 2018 and who were at higher risk for recurrence. Our cohort included 13,444 Veterans across 90 facilities. We examined the proportion of patients who had a post-operative urology visit or who received a prevention measure (24-hour urine test, serum parathyroid hormone measurement, or prescription of a stone-related medication) within 6 months of stone surgery. We calculated the median odds ratio to quantify facility-level variation in urology care after stone surgery, adjusting for patient- and facility-level characteristics. ResultsWithin 6 months of stone surgery, 94.2% Veterans had a urology visit, yet only 8.8% completed 24-hour urine testing, 8.4% had a parathyroid hormone measurement, and 31.0% were prescribed a stone-related medication. Implementation of prevention measures varied widely across facilities with the median odds ratio ranging between 1.18 for medication prescriptions and 1.77 for 24-hour urine testing. ConclusionsWhile most patients have a urology visit after stone surgery, stone prevention measures were implemented infrequently and inconsistently for patients at higher risk for recurrence, indicating an opportunity for quality improvement.

Assessing 1-year sodium-glucose co-transporter-2 inhibitor tolerance in older adults.

Evidence concerning tolerability of sodium-glucose co-transporter-2 (SGLT2) inhibitors in older adults is limited due to under-representation in clinical trials. Our study aimed to determine the extent to which SGLT2 inhibitor intolerance increases with age and explore additional factors associated with intolerance. This retrospective observational study included patients in the Veterans Health Administration who initiated an SGLT2 inhibitor between 1 January 2013 and 31 December 2021. One-year discontinuation served as a proxy for intolerance. Relative risk (RR) for 1-year discontinuation was contrasted across age groups using log-binomial regression to adjust for confounding. Of 232 495 patients who initiated an SGLT2 inhibitor, 60 582 (26.1%) discontinued within one year. A difference was observed across age groups, <65, 65-74, 75-84 and ≥85years, where 25.8%, 25.3%, 28.5% and 34.9% of patients discontinued, respectively (P < .001). After adjustment for confounding factors, patients 75-84 and ≥85years were at 8% (RR = 1.08; 95% CI: 1.05, 1.10) and 21% increased risk (RR = 1.21; 95% CI: 1.15, 1.26) for discontinuation, respectively, relative to patients <65years. Additional risk factors were identified: female (RR = 1.41; 95% CI: 1.37, 1.45), estimated glomerular filtration rate stage 4 (RR = 1.49; 95% CI: 1.39, 1.60), underweight (RR = 1.15; 95% CI: 1.03, 1.29), urinary tract infection history (RR = 1.25; 95% CI: 1.21, 1.30) and yeast infection history (RR = 1.39; 95% CI: 1.27, 1.51). No clinically meaningful differences in SGLT2 inhibitor intolerance were observed in patients up to 84years. Our findings support having closer follow-up when initiating in patients 85years and older.