Current Veterans Health Administration Research Articles

Examining the Utility of Veterans Health Administration (VHA) Traumatic Brain Injury Screening among Women Veterans: Recommendations for Expansion to Include Interpersonal Violence.

Women veterans (WVs) are more likely than men veterans to experience traumatic brain injury (TBI) from causes unrelated to deployment. Yet, current Veterans Health Administration (VHA) TBI screening focuses on deployment. This study examines the utility of the VHA TBI screening tool for WVs. Using the Boston Assessment for TBI-Lifetime (BAT-L) as the gold standard, sensitivity and specificity of the VHA screen were identified for deployment and non-deployment injuries. Injuries missed by the screen were thematically described. Sensitivity and specificity were compared by context (research, clinical). Ninety WVs were included; fifty-three (60.9%) met TBI criteria per the BAT-L. For TBIs occurring during deployment, sensitivity was higher in research (89.1%) compared to clinics (61.7%); specificity was lower in research (60.7%) compared to clinics (93.0%). The BAT-L identified 27 non-deployment TBIs not captured by the VHA screen, most frequently from physical assault or sports. The VHA screen does not include non-deployment events; thus, non-deployment sensitivity and specificity could not be calculated. For lifetime TBIs (deployment + non-deployment etiologies), sensitivity was higher in research (73.5%) compared to clinics (48.9%). Specificity was lower in research (60.0%) compared to clinics (100.0%). Findings can inform improvements to TBI screening among WVs, including expansion for interpersonal violence.

"You want people to listen to you": Patient experiences of women's healthcare within the Veterans Health Administration.

To identify constructs that are critical in shaping Veterans' experiences with Veterans Health Administration (VA) women's healthcare, including any which have been underexplored or are not included in current VA surveys of patient experience. From June 2022 to January 2023, we conducted 28 semi-structured interviews with a diverse, national sample of Veterans who use VA women's healthcare. Using VA data, we divided Veteran VA-users identified as female into four groups stratified by age (dichotomized at age 45) and race/ethnicity (non-Hispanic White vs. all other). We enrolled Veterans continuously from each recruitment strata until thematic saturation was reached. For this qualitative study, we asked Veterans about past VA healthcare experiences. Interview questions were guided by a priori domains identified from review of the literature, including trust, safety, respect, privacy, communication and discrimination. Analysis occurred concurrently with interviews, using inductive and deductive content analysis. We identified five themes influencing Veterans' experiences of VA women's healthcare: feeling valued and supported, bodily autonomy, discrimination, past military experiences and trauma, and accessible care. Each emergent theme was associated with multiple of the a priori domains we asked about in the interview guide. Our findings underscore the need for a measure of patient experience tailored to VA women's healthcare. Existing patient experience measures used within VA fail to address several aspects of experience highlighted by our study, including bodily autonomy, the influence of past military experiences and trauma on healthcare, and discrimination. Understanding distinct factors that influence women and gender-diverse Veterans' experiences with VA care is critical to advance efforts by VA to measure and improve the quality and equity of care for all Veterans.

Inclination to pursue Veterans Health Administration for primary care practice: survey of medical residents.

Health systems like the Veterans Health Administration (VA) face challenges in recruiting and retaining a primary care physician workforce. This cross-sectional study of recent or current VA medical residents sought to identify determinants of intent to pursue primary care practice in VA after residency training. Residents were identified from administrative data between 2020 and 2021 and recruited via an emailed self-administered survey. Multivariable logistic regression, accounting for survey non-response, was applied to examine the association between intent to pursue VA practice and two sets of measures: VA training experiences and individual preferences for work conditions. Of 268 responses received, 141 (56%) of the sample reported inclination to consider VA employment post-residency. Experiences with training in VA were rated more positively in the VA-inclined group compared to the not-inclined group. In the multivariable model, intent to practice primary care was the strongest predictor (OR 4.04, p < 0001). Preceptors' modeling of work-life balance (OR 3.23, p = 0.009) and perceptions of quality of clinical staff and services (OR 2.64, p = 0.004), ability to get patients the care they need (OR 2.51, p = 0.017), and quality of patient care (OR 2.30, p = 0.075) were independent predictors of being in the VA inclined group. Overall, we found that intent to practice primary care and the quality of VA training experiences are important determinants of inclination to consider VA for employment. These results provide an important perspective relevant to medical education, the hiring and retention of the United States (U.S). primary care workforce.

Research Priorities to Support Women Veterans' Reproductive Health and Health Care Within a Learning Health Care System.

Research Priorities to Support Women Veterans' Reproductive Health and Health Care Within a Learning Health Care System.

Are x-waiver trainings enough? Facilitators and barriers to buprenorphine prescribing after x-waiver trainings.

In the United States, an x-waiver credential is necessary to prescribe buprenorphine medication treatment for opioid use disorder (B-MOUD). Historically, this process has required certified training, which could be a barrier to obtaining an x-waiver and subsequently prescribing. To address this barrier, the US recently removed the training requirement for some clinicians. We sought to determine if clinicians who attended x-waiver training went on to obtain an x-waiver and prescribe B-MOUD, and to examine what facilitated or impeded B-MOUD prescribing. In September 2020, we conducted a cross-sectional, electronic survey of attendees of 15 in-person x-waiver pieces of training from June 2018 to January 2020 within the Veterans Health Administration (VHA). Of the attendees (n = 321), we surveyed current VHA clinicians who recalled taking the training. The survey assessed whether clinicians obtained the x-waiver, had prescribed B-MOUD, and barriers or facilitators that influenced B-MOUD prescribing. Of 251 eligible participants, 62 (24.7%) responded to the survey, including 27 (43.5%) physicians, 16 (25.8%) advanced practice clinicians, and 12 (19.4%) pharmacists. Of the 43 clinicians who could prescribe, 29 (67.4%) had obtained their x-waiver and 16 (37.2%) had reported prescribing B-MOUD. Prominent barriers to prescribing B-MOUD included a lack of supporting clinical staff and competing demands on time. The primary facilitator to prescribing was leadership support. Nine months after x-waiver training, two-thirds of clinicians with prescribing credentials had obtained their x-waiver and one-third were prescribing B-MOUD. Removing the x-waiver training may not have the intended policy effect as other barriers to B-MOUD prescribing persist.

Recovery-oriented acute inpatient mental health care: Operationalization and measurement.

The current article describes efforts to develop and test a measure of recovery-oriented inpatient care. The Recovery-oriented Acute INpatient (RAIN) scale was based on prior literature and current Veterans Health Administration (VHA) policy and resources and further revised based on data collection from 34 VHA acute inpatient units. A final scale of 23, behaviorally anchored items demonstrated a four-factor structure including the following factors: inpatient treatment planning, outpatient treatment planning, group programming, and milieu. While several items require additional revision to address psychometric concerns, the scale demonstrated adequate model fit and was consistent with prior literature on recovery-oriented inpatient care. Conclusions and Implementations for Practice: The RAIN scale represents an important tool for future implementation and empirical study of recovery-oriented inpatient care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Female Veterans' Willingness to Seek Veterans Health Administration and Non-Veterans Health Administration Services for Suicidal Thoughts and Mental Health Concerns.

The extent to which female veterans are willing to seek Veterans Health Administration (VHA) and non-VHA care when they are suicidal or experiencing mental health (MH) concerns is unknown. The objectives of this study were to: (1) examine whether current, past, and never VHA using female veterans' willingness to seek VHA care differs from their willingness to seek non-VHA care if suicidal or experiencing MH symptoms; (2) examine if VHA use, military sexual trauma, and suicidal ideation and attempt are associated with female veterans' willingness to use VHA and non-VHA care when experiencing suicidal thoughts or MH symptoms. A cross-sectional anonymous survey. Four hundred thirty nine female veterans, including current, past, and never VHA users were included. General Help-Seeking Questionnaire, Self-Injurious Thoughts and Behaviors Interview, and the VA Military Sexual Trauma Screening Questions. Current VHA users reported more willingness to use VHA than non-VHA care; conversely, past and never VHA users reported less willingness to use VHA care relative to non-VHA care. Military sexual assault and none or past VHA use were associated with lower willingness to use VHA care if suicidal or experiencing MH symptoms. In contrast, those with none or past VHA use reported greater willingness to use non-VHA care if suicidal or experiencing MH symptoms, while prior suicide attempt was associated with lower willingness. Ensuring that acceptable and effective suicide prevention services are available to female veterans in both VHA and community settings is critical. Increasing help-seeking intentions among female veterans who have attempted suicide or experienced military sexual assault is also essential.

Suicidal ideation, suicide attempt, and non-suicidal self-injury among female veterans: Prevalence, timing, and onset

BackgroundSuicide rates among female veterans have continued to increase, particularly among those not using Veterans Health Administration (VHA) care. Nonetheless, suicide research has rarely focused on female veterans, particularly non-VHA users. The present study examined the prevalence and onset of suicidal ideation (SI), suicide attempt (SA), and non-suicidal self-injury (NSSI) in relation to military service among female veterans. Additionally, current, past, and never VHA users were compared in regard to SI, SA, and NSSI prevalence. MethodsFemale veterans (n = 439) participated in a national, cross-sectional survey. ResultsLifetime prevalence of SI (47.9%), SA (17.7%), and NSSI (13.2%) were high. Participants were more likely to report experiencing SI and SA following separation, compared to preceding (SI, SA) or during (SI only) military service, controlling for time at risk. However, onset was more likely to occur prior to military service, compared to after separation, for SI, SA, and NSSI. In age-adjusted analyses, current and past users of VHA care were more likely to report experiencing lifetime SI, compared to those who never used VHA care. However, when adjusting for service era, past and never VHA users did not significantly differ. LimitationsCross-sectional design, retrospective recall, and convenience sample. ConclusionsFor female veterans, onset of SI, SA, and NSSI appears to most commonly occur before military service. However, SI and SA prevalence are highest following separation, suggesting a period warranting additional support and intervention. Results underscore the need for continued suicide surveillance, prevention, and intervention efforts for female veterans, especially current VHA users.

The VA Transplant Program: A rebuttal to criticism and a look to the future.

The Department of Veterans Affairs (VA) Transplant Program was established decades ago, is well resourced, and provides timely and high quality solid organ transplant care and services to a Nation of Veterans. In the past few years, the VA Transplant Program has received criticism that can be characterized as follows: the location of VA Transplant Centers (VATCs) requires Veterans to travel considerable distances for transplant care and services; the National Surgery Office (NSO) that provides oversight limits the number of active VATCs; Veterans Health Administration (VHA) policy limits referral of Veterans to non-VA transplant centers (community care); and the VA Transplant Program does not provide living donor transplant procedures. The MISSION Act of 2018 (Public Law 115-182) was enacted in part to address these themes by promoting community care and living donation. This article provides perspective regarding the VA Transplant Program and rebuttal to stated criticism: Travel to a transplant center is not isolated to the VA; the NSO does not limit VATC activation; current VHA policy authorizes community care; and the VA Transplant Program currently performs living donor procedures. The MISSION Act, as intended, has the potential to decrease referrals to the VA Transplant Program by 30%.

Determining Best Practices for Management of Bacteriuria in Spinal Cord Injury: Protocol for a Mixed-Methods Study.

BackgroundBacteriuria, either asymptomatic (ASB) or symptomatic, urinary tract infection (UTI), is common in persons with spinal cord injury (SCI). Current Veterans Health Administration (VHA) guidelines recommend a screening urinalysis and urine culture for every veteran with SCI during annual evaluation, even when asymptomatic, which is contrary to other national guidelines. Our preliminary data suggest that a positive urine culture (even without signs or symptoms of infection) drives antibiotic use.ObjectiveThrough a series of innovative studies utilizing mixed methods, administrative databases, and focus groups, we will gain further knowledge about the attitudes driving current urine testing practices during the annual exam, as well as quantitative data on the clinical outcomes of these practices.MethodsAim 1 will identify patient, provider, and facility factors driving bacteriuria testing and subsequent antibiotic use after the SCI annual evaluation through qualitative interviews and quantitative surveys. Aim 2 will use national VHA databases to identify the predictors of urine testing and subsequent antibiotic use during the annual examination and compare the clinical outcomes of those who received antibiotics with those who did not. Aim 3 will use the information gathered from the previous 2 aims to develop the Test Smart, Treat Smart intervention, a combination of patient and provider education and resources that will help stakeholders have informed conversations about urine testing and antibiotic use; feasibility will be tested at a single site.ResultsThis protocol received institutional review board and VHA Research and Development approval in July 2017, and Veterans Affairs Health Services Research and Development funding started on November 2017. As of submission of this manuscript, 10/15 (67%) of the target goal of provider interviews were complete, and 77/100 (77%) of the goal of surveys. With regard to patients, 5/15 (33%) of the target goal of interviews were complete, and 20/100 (20%) of the target goal of surveys had been completed. Preliminary analyses are ongoing; the study team plans to present these results in April 2019. Database analyses for aim 2 will begin in January 2019.ConclusionsThe negative consequences of antibiotic overuse and antibiotic resistance are well-documented and have national and even global implications. This study will develop an intervention aimed to educate stakeholders on evidence-based management of ASB and UTI and guide antibiotic stewardship in this high-risk population. The next step will be to refine the intervention and test its feasibility and effectiveness at multiple sites as well as reform policy for management of this common but burdensome condition.International Registered Report Identifier (IRRID)DERR1-10.2196/12272

Veterans' Preferences for Remote Management of Chronic Conditions.

The Veterans Health Administration (VA) is investing considerable resources into providing remote management care to patients for disease prevention and management. Remote management includes online patient portals, e-mails between patients and providers, follow-up phone calls, and home health devices to monitor health status. However, little is known about patients' attitudes and preferences for this type of care. This qualitative study was conducted to better understand patient preferences for receiving remote care. Ten focus groups were held comprising 77 patients with hypertension or tobacco use history at two VA medical centers. Discussion questions focused on experience with current VA remote management efforts and preferences for receiving additional care between outpatient visits. Most participants were receptive to remote management for referrals, appointment reminders, resource information, and motivational and emotional support between visits, but described challenges with some technological tools. Participants reported that remote management should be personalized and tailored to individual needs. They expressed preferences for frequency, scope, continuity of provider, and mode of communication between visits. Most participants were open to nonclinicians contacting them as long as they had direct connection to their medical team. Some participants expressed a preference for a licensed medical professional. All groups raised concerns around confidentiality and privacy of healthcare information. Female Veterans expressed a desire for gender-sensitive care and an interest in complementary and alternative medicine. The findings and specific recommendations from this study can improve existing remote management programs and inform the design of future efforts.

A study to reduce readmissions after surgery in the Veterans Health Administration: design and methodology

BackgroundHospital readmissions are associated with higher resource utilization and worse patient outcomes. Causes of unplanned readmission to the hospital are multiple with some being better targets for intervention than others. To understand risk factors for surgical readmission and their incremental contribution to current Veterans Health Administration (VA) surgical quality assessment, the study, Improving Surgical Quality: Readmission (ISQ-R), is being conducted to develop a readmission risk prediction tool, explore predisposing and enabling factors, and identify and rank reasons for readmission in terms of salience and mutability.MethodsHarnessing the rich VA enterprise data, predictive readmission models are being developed in data from patients who underwent surgical procedures within the VA 2007–2012. Prospective assessment of psychosocial determinants of readmission including patient self-efficacy, cognitive, affective and caregiver status are being obtained from a cohort having colorectal, thoracic or vascular procedures at four VA hospitals in 2015–2017. Using these two data sources, ISQ-R will develop readmission categories and validate the readmission risk prediction model. A modified Delphi process will convene surgeons, non-surgeon clinicians and quality improvement nurses to rank proposed readmission categories vis-à-vis potential preventability.DiscussionISQ-R will identify promising avenues for interventions to facilitate improvements in surgical quality, informing specifications for surgical workflow managers seeking to improve care and reduce cost. ISQ-R will work with Veterans Affairs Surgical Quality Improvement Program (VASQIP) to recommend potential new elements VASQIP might collect to monitor surgical complications and readmissions which might be preventable and ultimately improve surgical care.

Community Veterans' Decision to Use VA Services: A Multimethod Veteran Health Partnership Study.

Ensuring veterans' access to healthcare is a national priority. Prior studies of veterans' use of Veterans Health Administration (VA) healthcare have had limited success in evaluating barriers to access for certain vulnerable veteran subpopulations. Our coalition of researchers and veteran community members sought to understand factors affecting use of VA, particularly for those less likely to participate in traditional survey studies. We recruited 858 veterans to complete a collaboratively designed survey at community events or via social media. We compared our results regarding VA use with the 2010 National Survey of Veterans (NSV) using chi-square tests, multiple logistic regression to identify predictors of VA use, and content analysis for open-ended descriptions of barriers to VA use. Veterans in our study were more likely than NSV respondents to report using VA healthcare ever (76% vs. 28%; p<0.0001). Within this group, more veterans in our sample were current VA users (83% vs. 68%; p<0.0001). In multivariable analysis, VA use was predicted by self-reported physical problems (comparing "a lot" vs. "none" for each variable, adjusted odds ratio [OR], 8.35), thinking problems (OR, 1.14), need for smoking cessation (OR, 1.54), need for pain management (OR, 1.65), and need for other mental health services (OR, 3.04). We identified 15 themes summarizing veterans' perceived barriers to VA use. Persistent actual and perceived barriers prevent some veterans from using VA services. The VA can better understand and address these issues through community-academic partnerships with veterans' organizations.

Unclaimed health care benefits: a mixed-method analysis of rural veterans.

Rural areas contribute a disproportionate number of US military recruits compared to urban areas. However, few studies have examined why many rural veterans do not enroll in the Veterans Health Administration (VHA) for health care. Our objective was to elicit reasons rural veterans chose not to use VHA. This mixed-methods study included quantitative survey and qualitative interview data. Surveys were mailed to 4,176 households with a registered voter in a rural Midwestern county to reach the estimated 1,100 veterans, of whom 600 were not enrolled in VHA. Surveys were designed to assess demographics and basic eligibility requirements for VHA. Themes were derived deductively from survey responses and inductively as they emerged through analysis of interview transcripts. A total of 180 veterans completed the survey and 165 were eligible based on an approximation of enrollment criteria. Of those, 74 (45%) were current VHA users, and 91 (55%) were nonusers of VHA but appeared to be eligible. The most common reason selected by these potentially eligible veterans for not using VHA was they did not think they were eligible (41%). Interviews revealed the issue of distance was superseded by the perception that enrollees must be poor and have experienced combat, injury, or disability during service. Most reported they had never been told about VHA health care benefits. Results suggest that lack of awareness of VHA health care benefits may be the biggest barrier identified by rural veterans. Targeted outreach and education efforts related to eligibility for rural veterans are warranted.

Pathways and Barriers to Care for LGBT Veterans in the U.S. Department of Veterans Affairs (VA)

To assess the perceived needs of lesbian, gay, bisexual, and transgender (LGBT) Veterans when they engage in counseling services through the Veterans’ Health Administration (VHA), psychologists working in VHA were reached through an online survey as well as an open-ended question that asked psychologists to offer their thoughts about the needs of LGBT Veterans in VHA and current VHA resources. Their answers were content analyzed to determine what lessons can be learned from their experiences with LGBT Veterans in the VHA system. Four major themes emerged: Concern about the current culture of the medical facilities as a whole (Veterans, staff, environment), concern for the safeguarding of privacy and dignity of clients through the electronic medical record when writing counseling progress notes, need for training of counselors, and need for resources for counselors and Veterans.

Understanding Health-Care Needs of Sexual and Gender Minority Veterans: How Targeted Research and Policy Can Improve Health.

Given the size of the patient population of the Veterans Health Administration (VHA), it is likely the largest single provider of health care for sexual and gender minority (SGM) individuals in the United States, including lesbian, gay, bisexual, and transgender persons. However, current VHA demographic data-collection strategies limit the understanding of how many SGM veterans there are, thereby making a population-based understanding of the health needs of SGM veterans receiving care in VHA difficult. In this article, we summarize the emergent research findings about SGM veterans and the first initiatives that have been implemented by VHA to promote quality care. Though the research on SGM veterans is in its infancy, it suggests that SGM veterans share some of the health risks noted in veterans generally and also risks associated with SGM status. Some promising resiliency factors have also been identified. These findings have implications for both VHA and non-VHA systems in the treatment of SGM veterans. However, more research on the unique needs of SGM veterans is needed to fully understand their health risks and resiliencies in addition to health-care utilization patterns.

Exportability of an Intervention to Increase HIV Testing in the Veterans Health Administration

Exportability, or the dissemination of successful health services interventions from one site to another, must be demonstrated before systemwide implementation. The effectiveness of a previously successful multicomponent intervention to increase rates of HIV testing in Veterans Health Administration (VHA) health care facilities among those without records of previous testing was evaluated in two other VHA facilities. Whereas the principle responsibility for the provider-activation component of the intervention was previously borne by research staff, nonresearch staff now took on these responsibilities. The annual rate of HIV testing among persons with documented risk factors for acquiring HIV infection increased by 5.8% and 16% after the end of the first year of implementation for the sites to which the project was newly exported and where nonresearch staff were responsible for implementation. In contrast, for the original implementation sites, where research staff played a major role in implementation, testing rates increased by 9.3% and 12.4%. There was no change in the rate of testing at a control site. At one site, HIV testing rates increased before implementation of the provider activation aspect of the intervention program. An intervention to increase HIV testing rates, which combines informatics, organizational support, and provider activation, can be successfully exported and implemented by nonresearch staff and may not require an extensive provider activation program. The resultant increases in HIV testing are similar to those seen in facilities where research staff play an active role. This work provides support for further efforts to refine this program to promote non-risk-based testing for HIV infection, as per current VHA policy and to more broadly implement this program.

Cost-effectiveness of adding decolonization to a surveillance strategy of screening and isolation for methicillin-resistant Staphylococcus aureus carriers

We compared the cost-effectiveness of a methicillin-resistant Staphylococcus aureus (MRSA) programme of active surveillance plus decolonization with the current Veterans Health Administration (VHA) strategy of active surveillance alone, as well as a common strategy of no surveillance. A decision-analytical model was developed for an inpatient stay time horizon, using the VHA's perspective. Model inputs were taken from published literature where available, and supplemented with expert opinion when necessary. Effectiveness outcomes were hospital-acquired MRSA infections and deaths avoided. One-way and two-way sensitivity analyses and Monte Carlo simulations were performed. In the base-case analysis, the strategy of active surveillance plus decolonization dominated (i.e. lower cost and greater effectiveness) both the comparison strategies of active surveillance and no surveillance. In addition, the active surveillance strategy dominated the strategy of no surveillance. One-way and two-way sensitivity analyses demonstrated that at low levels of direct benefit of decolonization (1–4%), the strategy of active surveillance plus decolonization would no longer be dominant. In the probabilistic sensitivity analysis, active surveillance plus decolonization dominated both the other two strategies, and the active surveillance strategy dominated no surveillance in all of 1000 Monte Carlo simulations. These results provide a strong economic argument for adding an MRSA decolonization protocol to the current VHA active surveillance strategy.

Department of Veterans Affairs' Quality Enhancement Research Initiative for Diabetes Mellitus.

Diabetes is a common disease, which frequently leads to serious, high-cost complications. Estimates show that in fiscal year 1994 (FY94), 12.5% of outpatients in the Veterans Health Administration (VHA) received diabetes-specific medications, accounted for almost 25% of all VHA pharmacy costs, had a hospitalization rate 1.6 times that of veterans without diabetes, and made 3.6 million outpatient visits to VA clinics. Research demonstrates that much of the mortality and morbidity associated with diabetes can be prevented, and rigorous evidence-based guidelines have been developed. The short-term objectives of the Quality Enhancement Research Initiative for Diabetes Mellitus (QUERI-DM) are to (1) gather baseline information on how current VHA diabetes care differs from the VHA guidelines, (2) develop an efficient, validated system for monitoring key diabetes quality standards in the VHA, (3) evaluate the effectiveness of current approaches to diabetes care and the success of guideline implementation initiatives, and (4) initiate 2 to 4 large-scale quality improvement projects to enhance adherence to practice guidelines and evaluate their impact on patient outcomes, including quality of life.