Department Of Veterans Affairs Research Articles

“Just Food doesn’t Do It”: Understanding Food Insecurity Among Rural Veterans in the United States

ABSTRACT Food security among rural veteran populations is an understudied subject. This study uses qualitative data from 106 semi-structured interviews conducted with staff from programs at the United States Department of Veterans Affairs (VA) and other federal agencies, staff from non-governmental organizations (NGOs), food security researchers, and food insecure veterans to identify the barriers to and facilitators for rural veteran food security. Barriers identified included external, structural barriers that exist in rural areas; internal barriers to using food assistance, such as feeling stigmatized; and barriers related to other social determinants of health, including a lack of education, employment, or housing stability.

A detox dilemma beyond benzodiazepines; clonidine's quandary in alcohol withdrawal management.

Benzodiazepines are the primary method of treatment of alcohol withdrawal, though the American Society of Addiction Medicine guidelines also include alternative agents for consideration. Observations in a Department of Veterans Affairs (VA) psychiatric emergency room noted consistent benzodiazepine use with an overall lack of use of alternative agents, even with low Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scores and in the absence of other concerning symptoms. Due to concerns of potential more-than-necessary benzodiazepine use, we analyzed adjunctive clonidine use for elevated blood pressure/pulse in alcohol withdrawal among this Veteran population. This is a single-site VA retrospective chart review of the psychiatric emergency room from July 1, 2022, to June 30, 2023, focused on patients with alcohol withdrawal managed on a CIWA protocol. Excluding concurrent opioid withdrawal and clonidine as home medication, 167 patient charts were analyzed for this study. Among 167 patients, 99 (59.3%) had comorbid hypertension. A total of 614 medication doses were given for elevated CIWA (373, 60.8%) and elevated blood pressure/pulse (241, 39.2%). Of the 241 doses for elevated blood pressure/pulse, only 2.5% were clonidine. Among all benzodiazepine doses, 75.3% were given to patients with comorbid hypertension. Clonidine was administered to 3.0% of patients, making up 2.5% of total dosing. Alcohol withdrawal management lacks optimization. Integrating adjunctive medications could reduce potential benzodiazepine overuse effectively addressing elevated blood pressure/pulse. This study sheds light on the potential underutilization of clonidine and its potential role in improving alcohol withdrawal syndrome management. By addressing elevated blood pressure/pulse and curbing potential overuse of benzodiazepines, it may contribute to further optimizing patient care.

Strengthening Military Medical Provider Readiness: A Comprehensive Examination of VHA-MHS Partnerships.

Military medical readiness, particularly in surgical specialties, remains a significant concern within the Military Health System (MHS). While initiatives like the U.S. Army Military-Civilian Trauma Team (AMCT3) Program have addressed some readiness gaps, they primarily focus on trauma care, leaving other crucial medical specialties underserved. Leveraging partnerships between the Department of Veterans Affairs (VA) and the Defense Health Agency (DHA) emerges as a strategic approach to address these challenges comprehensively. Further collaboration between the VA and MHS is an opportunity to enhance military medical provider readiness, covering expanded medical specialties and health care personnel. By utilizing resource-sharing agreements (RSAs) and the Joint Incentive Fund (JIF), opportunities for increased collaboration and interoperability between the VA and MHS are explored. Challenges such as maintaining partnerships, addressing billing issues, and navigating local-level politics are identified, with proposed solutions, including establishing a centralized interagency office to monitor and manage specialty care partnerships. A comprehensive approach to enhancing military medical provider readiness through VA-MHS partnerships is crucial. By addressing readiness gaps and optimizing resource utilization, such collaboration would likely improve the overall readiness of the medical force, benefiting both military and veteran patient populations.

Transportation As A Determinant Of Health: Evaluating The Veterans Affairs Rideshare Program For Homeless Patients.

From 2020 to 2023, the Department of Veterans Affairs (VA) conducted a national pilot of a rideshare program to support homeless patients' transportation needs to obtain critical resources and attend medical appointments. This study linked Lyft rideshare data in 2022 to VA administrative data to examine characteristics and changes in service use among VA homeless service users. The results showed that VA homeless service users who used the VA Rideshare program were more likely to have psychiatric diagnoses and urgent care visits than those who did not use the program. When we controlled for past VA service use, use of the VA Rideshare program was associated with greater use of VA outpatient and inpatient services and fewer no-show medical appointments six months after the veterans' index date. VA Rideshare users had three to eight more program visits over the course of six months than non-Rideshare users. These findings indicate benefits associated with providing transportation assistance to vulnerable patients in a nationwide health system.

Implementation of Cognitive Behavioral Therapy for psychosis via telehealth: An expert consultation and clinical service model.

Individuals living with psychosis are often underserved in the United States, partly due to the dearth of providers trained in evidence-based practices for this population. One such practice is Cognitive Behavioral Therapy for psychosis, which the Substance Abuse and Mental Health Services Administration has identified as a standard of care for this population. The explosion of telehealth, in large part due to the COVID-19 pandemic, has led to increased opportunities for virtual psychotherapy. Telehealth offers a number of benefits, such as the ability to address service inequities, including lack of access to a local provider well-trained in the modality of therapy needed. The current article describes the National Psychosis Telehealth Program within the National Expert Consultation and Specialized Services (formerly VA National Telemental Health Center) program, U.S. Department of Veterans Affairs. The goal of this telehealth program is to utilize an expert consultation model and offer a remote individual, time-limited Cognitive Behavioral Therapy for psychosis protocol to Veterans across the nation in order to decrease access disparities to this relatively scarce service. We share our initiation activities and lessons learned as we developed this program in hopes of encouraging others to consider similar efforts at their sites. We also include a typical, complex case that serves to illustrate the challenges and benefits of this approach. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Prospective comparison of risk factors for firearm suicide and non-firearm suicide in a large population-based cohort of current and former US service members: findings from the Millennium Cohort Study

BackgroundSuicide is a leading cause of death among service members and veterans. Among suicide methods, firearms are the most lethal and commonly used method among military populations. Limited research has compared risk factors for the various suicide methods. This study evaluated and compared risk factors for firearm versus non-firearm suicides using data from the Millennium Cohort Study, a large longitudinal military cohort. MethodsUsing a competing risk approach, we identified factors associated with each suicide method. Risk factors included demographics, mental health diagnoses, mental health symptoms, military-specific characteristics, health behaviors, and psychosocial factors. Cause of death was assessed from July 1, 2001, through December 31, 2018. FindingsAmong 201,565 eligible participants with a mean [SD] age of 27.9 [5.2] years, there were 139,789 (69.3%) male, 61,776 (30.7%) female, 15,927 (7.9%) Hispanic, 24,667 (12.3%) non-Hispanic Black, 14,107 (7.0%) Asian, Pacific Islander, American Indian or Multiracial, and 146,736 (72.8%) non-Hispanic White participants. During the study period, 330 died by firearm suicide and 168 died by non-firearm suicide. Overall, effect estimates for risk factors were similar across both methods of suicide. After adjustment, men (HR: 3.69, 95% CI: 2.59, 5.24) and those who screened positive for depression (HR: 1.97, 95% CI: 1.36, 2.87) had an elevated risk for firearm suicide. In contrast, those who self-reported a history of bipolar diagnosis (HR: 3.40, 95% CI: 1.76, 6.55) had significantly increased risk for non-firearm suicide. InterpretationFindings suggest that prevention and intervention strategies overall may not need to be differentiated by specific demographic, military, or health factors. Targeted interventions that consider sex and mental health screens might have relative utility in preventing firearm related suicide risk compared with non-firearm suicide. FundingMilitary Operational Medicine Research Program, Defense Health Program, and Department of Veterans Affairs.

Long-term outcomes after treatment of delirium during critical illness with antipsychotics (MIND-USA): a randomised, placebo-controlled, phase 3 trial

Delirium is common during critical illness and is associated with long-term cognitive impairment and disability. Antipsychotics are frequently used to treat delirium, but their effects on long-term outcomes are unknown. We aimed to investigate the effects of antipsychotic treatment of delirious, critically ill patients on long-term cognitive, functional, psychological, and quality-of-life outcomes. This prespecified, long-term follow-up to the randomised, double-blind, placebo-controlled phase 3 MIND-USA Study was conducted in 16 hospitals throughout the USA. Adults (aged ≥18 years) who had been admitted to an intensive care unit with respiratory failure or septic or cardiogenic shock were eligible for inclusion in the study if they had delirium. Participants were randomly assigned-using a computer-generated, permuted-block randomisation scheme with stratification by trial site and age-in a 1:1:1 ratio to receive intravenous placebo, haloperidol, or ziprasidone for up to 14 days. Investigators and participants were masked to treatment group assignment. 3 months and 12 months after randomisation, we assessed survivors' cognitive, functional, psychological, quality-of-life, and employment outcomes using validated telephone-administered tests and questionnaires. This trial was registered with ClinicalTrials.gov, NCT01211522, and is complete. Between Dec 7, 2011, and Aug 12, 2017, we screened 20 914 individuals, of whom 566 were eligible and consented or had consent provided to participate. Of these 566 patients, 184 were assigned to the placebo group, 192 to the haloperidol group, and 190 to the ziprasidone group. 1-year survival and follow-up rates were similar between groups. Cognitive impairment was common in all three treatment groups, with a third of survivors impaired at both 3-month and 12-month follow-up in all groups. More than half of the surveyed survivors in each group had cognitive or physical limitations (or both) that precluded employment at both 3-month and 12-month follow-up. At both 3 months and 12 months, neither haloperidol (adjusted odds ratio 1·22 [95% CI 0·73-2.04] at 3 months and 1·12 [0·60-2·11] at 12 months) nor ziprasidone (1·07 [0·59-1·96] at 3 months and 0·94 [0·62-1·44] at 12 months) significantly altered cognitive outcomes, as measured by the Telephone Interview for Cognitive Status T score, compared with placebo. We also found no evidence that functional, psychological, quality-of-life, or employment outcomes improved with haloperidol or ziprasidone compared with placebo. In delirious, critically ill patients, neither haloperidol nor ziprasidone had a significant effect on cognitive, functional, psychological, or quality-of-life outcomes among survivors. Our findings, along with insufficient evidence of short-term benefit and frequent inappropriate continuation of antipsychotics at hospital discharge, indicate that antipsychotics should not be used routinely to treat delirium in critically ill adults. National Institutes of Health and the US Department of Veterans Affairs.

Role of homelessness and psychiatric disorders in suicide deaths among veterans: A four-way decomposition analysis

Homelessness and suicide are top priorities in the U.S. Department of Veterans Affairs (VA). This study examined the various pathways involving homelessness, substance use, and mental health disorders in relation to suicide deaths among veterans in the VA healthcare system. A retrospective cohort study was conducted among 6,128,921 veterans—399,125 homeless and 5,729,796 non-homeless—followed-up between 2017 and 2021 using VA/Department of Defense linked databases. Multivariable Cox regression was applied for homelessness and psychiatric disorders as predictor of suicide deaths, sequentially controlling for demographic, clinical, substance use, and mental health characteristics. Four-way decomposition analysis was used to calculate proportions of suicide deaths mediated and/or moderated by homelessness, substance use, and mental health disorders. The relationship between homelessness and suicide-specific mortality risk was reduced from 40 % greater risk in unadjusted to 9 % greater risk in fully-adjusted models. Nearly 26 % of the total effect of homelessness on suicide-specific mortality risk was mediated by substance use disorders, whereas 49 % was mediated and 36 % was moderated by mental health disorders. In conclusion, excess suicide-specific mortality risk in homeless veterans is partly explained by substance use and mental health disorders, highlighting the importance of wrap-around health and social services for homeless veterans in mitigating suicide risk.

Motivators, Barriers, and Facilitators to Choosing Care in VA Facilities Versus VA-Purchased Care.

Many Veterans receive Department of Veterans Affairs (VA)-purchased care from non-VA facilities but little is known about factors that Veterans consider for this choice. Between May 2020 and August 2021, we surveyed VA-purchased care-eligible VA patients about barriers and facilitators to choosing where to receive care. We examined the association between travel time to their VA facility and their choice of VA-purchased care (VA-paid health care received in non-VA settings) versus VA facility and whether this association was modified by distrust. We received 1,662 responses and 692 (42%) chose a VA facility. Eighty percent reported quality care was in their top three factors that influenced their decision. Respondents with the highest distrust and who lived >1 hr from the nearest VA facility had the lowest predicted probability (PP) of choosing VA (PP 15%; 95% confidence interval: 10%-20%). Veterans value quality of care. VA and other health care systems should consider patient-centered ways to improve and publicize quality and reduce distrust.

Chronic opioid prescription in veterans with spinal cord injury: Prevalence and associated factors

Objective Chronic opioid use presents long-term health risks for individuals with spinal cord injury (SCI). The purpose of the study was to characterize patterns and correlates of the chronic prescription of opioids among individuals with SCI in a population of Veterans receiving care though the Veteran’s Health Administration. Design A retrospective, longitudinal cohort study examined the US Department of Veterans Affairs electronic medical record data of veterans with SCI. The annual prevalence of prescription opioid use by type (any, acute, chronic, incident chronic) was calculated for each study year (2015–2017). Multivariable models examined associations with demographics and pre-existing medical comorbidities. Setting US Department of Veterans Affairs, Veteran’s Health Administration. Participants National sample of Veterans with SCI (N = 10,811). Main Outcome Measure Chronic prescription opioid use (≥90 days). Results All types of prescription opioid use declined across the three study years (chronic opioid use prevalence = 33.2%, 31.7%, and 29.7%, respectively). Past history of depression, COPD, diabetes, pain condition, opioid use and tobacco use disorders were associated with a greater likelihood of current chronic prescription opioid use. Non-white race, hyperlipidemia, dementia, and tetraplegia were associated with a lower likelihood of current chronic prescription opioid use. When added to the multivariable model, prior chronic opioid prescription use was robustly associated with current chronic prescription opioid use, but most other factors were no longer significantly associated with current opioid use. Conclusions This study demonstrates opioid reduction over time from 2015 to 2017, however, chronic prescription opioid use remains common among a substantial minority of Veterans with SCI. Several demographics and comorbidities may provide clinicians with important insights into factors associated with chronic prescription opioid use, with past chronic prescription opioid use being the most important.

Predictors of recurrent stroke and subsequent mortality among patients experiencing housing instability

BackgroundThe experience of homelessness has been linked with developing poor health outcomes. Little is known about the risk of recurrent stroke among these individuals. This study investigated the correlates of developing recurrent stroke and subsequent mortality among Veterans with housing instability. MethodsUsing a national sample of Veterans from the U.S. Department of Veterans Affairs who had an indicator of housing instability between 2014–2018 (n=659,987), we identified 15,566 Veterans who experienced incident stroke. We compared characteristics of Veterans who experienced incident stroke and did and did not experience recurrent stroke and conducted logistic regressions using a discrete-time survival framework to assess two outcomes: recurrent stroke and all-cause mortality. ResultsAmong our cohort, 91.3% did not experience recurrent stroke while 8.7% did during the observation period. The receipt of any level of primary care outpatient visits was associated with a reduction in the odds of recurrent stroke. Several medical diagnoses were also associated with increased odds of recurrent stroke, including hypertension (aOR 1.35, 95% CI 1.15-1.59), diabetes (aOR 1.21, 95% CI 1.07-1.36), and renal disease (aOR 1.17, 95% CI 1.02, 1.35). Veterans who used any level of VA Homeless Programs had reduced odds of all-cause mortality (high level: aOR 0.65, 95% CI 0.60-0.71; low level: aOR 0.66, 95% CI 0.60-0.73). ConclusionOur study found several predictors of developing recurrent stroke and subsequent death in a population of Veterans experiencing housing instability. Implications include the need to monitor closely high-risk patients who have experienced incident stroke and have other co-occurring needs.

Receipt of Gender-Affirming Surgeries Among Transgender and Gender Diverse Veterans.

Gender-affirming surgery (GAS) can be an important part of comprehensive care for transgender and gender diverse (TGD) individuals, but this care is not provided by the Department of Veterans Affairs (VA) because of an exclusion in the medical benefits package. To describe the receipt of GAS by veterans and assess the associations between key sociodemographic characteristics and receipt of chest ("top") and genital ("bottom") surgeries. Cross-sectional national survey (the GendeR Affirming Care Evaluation (GRACE)), among TGD Veterans conducted between September 2022 and July 2023. A total of 6653 Veterans (54% response rate) completed the survey. Self-reported "top" and "bottom" GAS were key outcomes. Covariates included gender identity, sex assigned at birth, age, race, ethnicity, income, employment status, education, relationship status, sexual orientation, and geographic region. Among all respondents, 39% had ≥ 1 GAS. Among the 4430 veterans interested in top surgery, 38% received it; 23% of 3911 veterans interested in bottom surgery had received it. In multivariable models, older age (50 + vs. 18-39) was associated with higher receipt of top and bottom surgery while nonbinary gender identity (vs. binary gender identity), lower household income (< $50,000 vs. > $75,000), less education (less than a college graduate vs. Master's degree or more), sexual orientations other than heterosexual, and residing in a region other than the Pacific were associated with lower receipt of top and bottom surgery. Individuals assigned male (vs. assigned female) at birth had lower receipt of top surgery and higher receipt of bottom surgery. GAS receipt was low and there were important disparities by gender, sex, income, education, sexual orientation, and region. By removing the exclusion to providing GAS, VA could reduce barriers to accessing GAS and decrease disparities among TGD veterans.

Leadership and the high reliability transformation: A qualitative study at Truman VA medical center.

The Department of Veterans Affairs (VA) has committed to becoming a High Reliability Organization (HRO). The Truman VA Medical Center (VAMC) successfully implemented and sustained foundational HRO elements over a period with several changes in facility executive leadership. We interviewed current and past leaders at Truman to understand how they retained fidelity to the HRO transformation. We conducted 16 interviews with 14 leaders involved in the HRO transformation and identified three themes related to the Truman HRO transformation: (1) Leadership visibly drove culture change through intentional communication and modeling HRO principles; (2) Leadership deferred to frontline expertise and empowered staff to make changes and to fail; (3) Hiring the right team members for the organizational culture and investing in training can support HRO principles and values. Our findings highlight key actions for leaders in the context of HROs: regularly communicate the significance of HRO, demonstrate behavior consistent with what they hope to see from staff, celebrate failure, allocate time and resources to the creation of hiring frameworks that identify employee skillsets conducive to HRO principles, and substantial and recurring investments in employee development. Importantly, successive executive leaders at Truman VAMC modeled these skills to promote and sustain the HRO transformation.

Linking implementation science and policy: Process and tools for congressionally mandated implementation, evaluation, and reporting.

To describe a process model for assisting partners in addressing requirements of legislation and review policy analysis, planning, and evaluation design processes and tools. Throughout its 25-year history, the United States Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) program has been a forerunner in partnering with organizational leaders to improve health care. The Foundations of Evidence-based Policymaking Act of 2018 provided new opportunities for QUERI and other implementation scientists to support federal agency leaders in implementing, evaluating, and reporting on congressionally mandated programs. Although implementation scientists have the skills to support partnered implementation and evaluation, these skills must be adapted for congressionally mandated projects as many scientists have limited experience in policy analysis and the intersection of data informing organizational policy, programs, and practices (i.e., evidence-based policy). During the conduct of four congressionally mandated projects, our national VA QUERI team developed processes and tools to achieve the goals and aims of our VHA partners and to ensure our collective work and reporting met legislative requirements. Our process model, program planning, and analysis tools were informed by an iterative process of refining and adapting the tools over a period of six years, spanning the years 2017 to 2023. Work to support our partners was conducted across three phases: preparation and planning, conducting implementation and evaluation, and developing the congressionally mandated report. The processes and tools we developed within the context of mutually respectful and honest partnerships have been critical to our QUERI center's success in this area. Lessons we learned may help other scientists partnering in VA or other federal agencies to plan, conduct, and report on congressionally mandated projects.

Benzodiazepine Prescription Patterns After Mild Traumatic Brain Injury inU.S. Military Service Members.

Clinical practice guidelines (CPGs) and clinical recommendations (CRs) are developed to aide and guide providers in treating a variety of conditions, including traumatic brain injury (TBI). There is little knowledge on the impact that CPGs and CRs have on provider practice. One TBI recommendation that was able to be tracked in medical record codes was the use of benzodiazepines (BZD). Because of potential for misuse, diversion, addiction, cognitive impairment, and brain healing interference, the DoD and Department of Veterans Affairs (VA) jointly discourage prescribing BZD after TBI. As part of an effort to look at translation of CPG guidance into clinical practice, our objective was to examine the issuance of BZD prescriptions, including dose, type, and prescribing provider, prescribing setting, and primary diagnosis at issuance among U.S. service members with mild Traumatic Brian Injury (mTBI). Using DoD data sourced from the Comprehensive Ambulatory/Professional Encounter Record (CAPER) databases of the Military Health System (MHS) Medical Data Repository (MDR), we identified all U.S. service members with a first lifetime diagnosis of mTBI from October 1, 2015 to September 30, 2016. Data on prescriptions issued to this group during a period of active treatment for a mTBI were obtained from the Pharmacy Detail Transaction Service (PDTS) databases of the MDR and identified BZD prescriptions based on the American Hospital Formulary Service (AHFS) therapeutic classification system. We validated coding assumptions through structured review of the clinical record contained within the Armed Forces Health Longitudinal Technology Application (AHLTA) of 30 randomly selected cohort members. Among U.S. service members, 4.5% filled a BZD prescription while under active medical treatment for a recent mTBI. These service members were more likely female and older when compared to their counterparts not prescribed BZD. Among service members under active treatment for mTBI during the study period, 52.6% (n = 7,935) filled a prescription; of these, 8.5% (n = 676) filled a BZD prescription. Of U.S. service members filing a BZD prescription while undergoing active treatment for an mTBI, 64.6% (n = 437) filled prescriptions for BZD and antidepressants, 54.9% (n = 371) filled prescriptions for both BZD and NSAIDS, and 42.2% (n = 285) concurrently filled prescriptions for BZD and opioids. This effort to examine the translation of CPG recommendations into practice through evaluation of medical record data indicates that providers are prescribing BZD to patients under active treatment for an acute mTBI. The mTBI CPG recommends that the BZD class of medications be avoided in patients healing from brain injury. However, the team recognizes there are confounding factors that may impact the medications that are prescribed for patients with mTBI. Additional work to understand how CPGs and CRs are received and utilized by providers may elucidate opportunities to close the gap between clinical practice guidance and clinical practice.

Email recruitment for chronic pain clinical trials: results from the LAMP trial

BackgroundRecruitment for clinical trials and large-scale studies is challenging, especially for patients with complex conditions like chronic pain. Email recruitment has the potential to increase efficiency, to reduce costs, and to improve access for underrepresented patient populations. The objective of this study was to examine the effectiveness, efficiency, and equitability of email versus postal mail recruitment for the Learning to Apply Mindfulness to Pain (LAMP) study, a three-site clinical trial of mindfulness-based interventions for chronic pain.MethodsPatients with chronic pain diagnoses were recruited from three United States Department of Veterans Affairs (VA) facilities using the VA electronic health record (EHR). Recruitment materials were sent using either postal mail (n = 7986) or email (n = 19,333). Patients in the email recruitment group were also mailed introductory postcards before any emails. Mailing addresses and email addresses were obtained from the EHR. Effectiveness was measured by the response rate of patients who logged into the secure LAMP study website. Efficiency was measured by the number of days from when the recruitment materials were sent to when patients logged into the LAMP portal as well as the estimated costs of each recruitment approach. To assess equitability, we examined whether email recruitment was less effective for underrepresented populations, based on demographic information from the EHR.ResultsEffectiveness—unadjusted response rates were greater for email versus postal-mail recruitment (18.9% versus 6.3%), and adjusted response rates were over three times greater for email recruitment (RR = 3.5, 95% CI 3.1–3.8) based on a multivariable analysis controlling for age, gender, race, ethnicity, rurality, and site. Efficiency—email recruitment had a significantly lower mean response time (1 day versus 8 days) and a lower cost. Equity—email recruitment led to higher response rates for all subpopulations, including older, non-White, Hispanic, rural, and female Veterans.ConclusionsEmail recruitment is an effective, efficient, and equitable way to recruit VA patients to large-scale, chronic pain clinical trials.Trial registrationClinical Trial Registration Number: NCT04526158. Patient enrollment began on December 4, 2020.

Accuracy, thoroughness, and quality of outpatient primary care documentation in the U.S. Department of Veterans Affairs

BackgroundElectronic health records (EHRs) can accelerate documentation and may enhance details of notes, or complicate documentation and introduce errors. Comprehensive assessment of documentation quality requires comparing documentation to what transpires during the clinical encounter itself. We assessed outpatient primary care notes and corresponding recorded encounters to determine accuracy, thoroughness, and several additional key measures of documentation quality.MethodsPatients and primary care clinicians across five midwestern primary care clinics of the US Department of Veterans Affairs were recruited into a prospective observational study. Clinical encounters were video-recorded and transcribed verbatim. Using the Physician Documentation Quality Instrument (PDQI-9) added to other measures, reviewers scored quality of the documentation by comparing transcripts to corresponding encounter notes. PDQI-9 items were scored from 1 to 5, with higher scores indicating higher quality.ResultsEncounters (N = 49) among 11 clinicians were analyzed. Most issues that patients initiated in discussion were omitted from notes, and nearly half of notes referred to information or observations that could not be verified. Four notes lacked concluding assessments and plans; nine lacked information about when patients should return. Except for thoroughness, PDQI-9 items that were assessed achieved quality scores exceeding 4 of 5 points.ConclusionsAmong outpatient primary care electronic records examined, most issues that patients initiated in discussion were absent from notes, and nearly half of notes referred to information or observations absent from transcripts. EHRs may contribute to certain kinds of errors. Approaches to improving documentation should consider the roles of the EHR, patient, and clinician together.

Psychology Recognition Week: A Blueprint for Recognizing and Promoting the Contributions of Psychology at Academic Health Centers.

It is important to recognize and celebrate the contributions of psychologists at Academic Health Centers (AHCs). Recognition events can help attract, retain, and honor professionals who play essential roles in healthcare. This case study describes the establishment of a national Psychology Recognition Week in the Department of Veterans Affairs and offers a model for other AHCs looking to implement a similar initiative. This case study outlines several factors that contributed to the success of developing a recognition week, including the involvement of leadership at all levels, forming a planning committee, setting milestones, building infrastructure, and fostering partnerships.

Postacute Sequelae of SARS-CoV-2 Infection in the Pre-Delta, Delta, and Omicron Eras

BackgroundPostacute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PASC) can affect many organ systems. However, temporal changes during the coronavirus disease 2019 (Covid-19) pandemic, including the evolution of SARS-CoV-2, may have affected the risk and burden of PASC. Whether the risk and burden of PASC have changed over the course of the pandemic is unclear.MethodsWe used health records of the Department of Veterans Affairs to build a study population of 441,583 veterans with SARS-CoV-2 infection between March 1, 2020, and January 31, 2022, and 4,748,504 noninfected contemporaneous controls. We estimated the cumulative incidence of PASC at 1 year after SARS-CoV-2 infection during the pre-delta, delta, and omicron eras of the Covid-19 pandemic.ResultsAmong unvaccinated persons infected with SARS-CoV-2, the cumulative incidence of PASC during the first year after infection was 10.42 events per 100 persons (95% confidence interval [CI], 10.22 to 10.64) in the pre-delta era, 9.51 events per 100 persons (95% CI, 9.26 to 9.75) in the delta era, and 7.76 events per 100 persons (95% CI, 7.57 to 7.98) in the omicron era (difference between the omicron and pre-delta eras, −2.66 events per 100 persons [95% CI, −2.93 to −2.36]; difference between the omicron and delta eras, −1.75 events per 100 persons [95% CI, −2.08 to −1.42]). Among vaccinated persons, the cumulative incidence of PASC at 1 year was 5.34 events per 100 persons (95% CI, 5.10 to 5.58) during the delta era and 3.50 events per 100 persons (95% CI, 3.31 to 3.71) during the omicron era (difference between the omicron and delta eras, −1.83 events per 100 persons; 95% CI, −2.14 to −1.52). Vaccinated persons had a lower cumulative incidence of PASC at 1 year than unvaccinated persons (difference during the delta era, −4.18 events per 100 persons [95% CI, −4.47 to −3.88]; difference during the omicron era, −4.26 events per 100 persons [95% CI, −4.49 to −4.05]). Decomposition analyses showed 5.23 (95% CI, 4.97 to 5.47) fewer PASC events per 100 persons at 1 year during the omicron era than during the pre-delta and delta eras combined; 28.11% of the decrease (95% CI, 25.57 to 30.50) was attributable to era-related effects (changes in the virus and other temporal effects), and 71.89% (95% CI, 69.50 to 74.43) was attributable to vaccines.ConclusionsThe cumulative incidence of PASC during the first year after SARS-CoV-2 infection decreased over the course of the pandemic, but the risk of PASC remained substantial even among vaccinated persons who had SARS-CoV-2 infection in the omicron era. (Supported by the Department of Veterans Affairs.)

Summary and Roadmap of Breast Cancer Research in the Veterans Affairs.

Women are the largest growing population of Veterans within the U.S. Department of Veterans Affairs (VA) Health Care System. Among women Veterans, breast cancer is the most common malignancy (30% of all cancers), yet little is known about the unique needs of women Veterans with cancer and how to provide them with high quality care. The VA health care system has initiated multiple system-wide systemic efforts, including launching the Breast and Gynecologic Cancer System of Excellence (BGSOE) to address this knowledge gap. This report summarizes the outcomes of the inaugural 2023 VA Women's Cancer Research Conference, which assembled 37 multidisciplinary clinicians, scientists, the VA and civilian partners with a shared goal of advancing VA breast cancer research. Conference objectives were to build a collective vision for improving: (1) referral patterns for breast cancer treatment and patient-level outcomes and (2) molecular and genetic testing patterns across the breast cancer continuum among women Veterans. The meeting hosted 15 speakers at the Houston VA Medical Center. Future research priorities for women Veterans with cancer were identified from discussions and a post-conference survey. We then administered a 13-question post-conference survey to conference attendees. Respondents ranked the research priorities. The survey results show that the cross-cutting cancer research priorities designed to transform cancer care for women Veterans at the VA fit into 5 broad areas of study, including (1) care quality for treatment, (2) improving treatment, (3) care quality of molecular and genetic testing, (4) risk reduction through risk assessment and germline genetic testing, and (5) establishing strategic partnerships. Our data elucidate areas for further investigation to improve the delivery of cancer care.