Department Of Veterans Affairs Research Articles

Association of deployment characteristics and exposures with persistent ill health among 1990-1991 Gulf War veterans in the VA Million Veteran Program

BackgroundVeterans of the 1990–1991 Gulf War have experienced excess health problems, most prominently the multisymptom condition Gulf War illness (GWI). The Department of Veterans Affairs (VA) Cooperative Studies Program #2006 “Genomics of Gulf War Illness in Veterans” project was established to address important questions concerning pathobiological and genetic aspects of GWI. The current study evaluated patterns of chronic ill health/GWI in the VA Million Veteran Program (MVP) Gulf War veteran cohort in relation to wartime exposures and key features of deployment, 27–30 years after Gulf War service.MethodsMVP participants who served in the 1990–1991 Gulf War completed the MVP Gulf War Era Survey in 2018–2020. Survey responses provided detailed information on veterans’ health, Gulf War exposures, and deployment time periods and locations. Analyses determined associations of three defined GWI/ill health outcomes with Gulf War deployment characteristics and exposures.ResultsThe final cohort included 14,103 veterans; demographic and military characteristics of the sample were similar to the full population of U.S. 1990–1991 Gulf War veterans. Overall, a substantial number of veterans experienced chronic ill health, as indicated by three defined outcomes: 49% reported their health as fair or poor, 31% met Centers for Disease Control and Prevention criteria for severe GWI, and 20% had been diagnosed with GWI by a healthcare provider. Health outcomes varied consistently with veterans’ demographic and military characteristics, and with exposures during deployment. All outcomes were most prevalent among youngest veterans (< 50 years), Army and Marine Corps veterans, enlisted personnel (vs. officers), veterans located in Iraq and/or Kuwait for at least 7 days, and veterans who remained in theater from January/February 1991 through the summer of 1991. In multivariable models, GWI/ill health was most strongly associated with three exposures: chemical/biological warfare agents, taking pyridostigmine bromide pills, and use of skin pesticides.ConclusionsResults from this large cohort indicate that GWI/chronic ill health continues to affect a large proportion of Gulf War veterans in patterns associated with 1990-1991 Gulf War deployment and exposures. Findings establish a foundation for comprehensive evaluation of genetic factors and deployment exposures in relation to GWI risk and pathobiology.

VA's EHR transition and health professions trainee programs: Findings and impacts of a multistakeholder learning community

AbstractIntroductionThe Department of Veterans Affairs (VA) is undergoing an unprecedented electronic health record (EHR) transition, switching from its homegrown EHR to a commercial system. The transition affects nearly every clinical employee but is particularly disruptive to health professions trainees (HPTs)—an often‐overlooked population in EHR transitions. To better understand and address trainee challenges with the EHR transition, we formed a multistakeholder learning community. In this study, we describe the findings of this learning community and the practices and policies developed in response.MethodsIn the qualitative study designed and executed by our learning community, we conducted 51 interviews with HPTs, program leaders, and preceptors before and multiple times after an EHR transition site's go‐live (February 16, 2022 to April 7, 2023). We merged interview transcripts with 125 survey free‐text responses from a survey conducted with preceptors 2 months post‐go‐live and conducted thematic analysis to identify key themes. To complement qualitative findings, we also include a quantitative survey finding, and, where applicable, we note policy and practice responses spurred by our learning community.ResultsInterviews yielded six key themes: (1) High satisfaction with HPT programs, despite negative impacts of the EHR transition; (2) early delays, then substantial improvements, in HPTs' EHR access; (3) persistent challenges with HPTs' EHR training and support, mitigated by local and national efforts; (4) the challenge of learning to use a rapidly evolving EHR during clinical training; (5) reduced visit volume as a continuing barrier to education; and (6) an impression that HPTs' relative lack of exposure to the prior EHR facilitated their proficiency with the new EHR.ConclusionsFindings highlighted challenges for HPT programs related to the EHR transition, which spurred important changes including the creation of a national VA council to represent the needs of HPTs in the EHR transition, and improvements to HPTs' EHR training and access.

Incidence of Self-Reported Bothersome Tinnitus Versus Tinnitus Diagnosis Among U.S. Army Soldiers.

U.S. Army Soldiers undergo annual audiometric surveillance to facilitate prevention of auditory injury. Soldiers are screened for bothersome tinnitus and subsequently referred for a clinical audiological evaluation as warranted. Presumably, most Soldiers seen in the clinic for bothersome tinnitus receive a tinnitus diagnosis. The incidence of self-reported bothersome tinnitus at the time of annual audiometric surveillance and subsequent diagnosis of tinnitus in the medical record has not been examined to date. This study estimated the incidence of tinnitus diagnosis in a population of Soldiers who reported new onset bothersome tinnitus and explored trends associated with tinnitus diagnosis to refine hearing health education. A subset of hearing conservation records retrieved for a previous study were selected based on change in self-reporting of bothersome tinnitus. Corresponding medical records were retrieved for this sample of Active Duty (AD) Soldiers. The data were retrospectively examined, and analyses were conducted to identify statistically significant differences between Soldiers with and Soldiers without a tinnitus diagnosis. In addition, trend patterns of bothersome tinnitus and significant threshold shift (STS) were examined. Of the sample of 730,350 AD Soldiers, 16.7% self-reported new onset bothersome tinnitus and 7.1% of those recorded as having bothersome tinnitus had a diagnosis of tinnitus in their medical record. Soldiers with a tinnitus diagnosis were older and had higher pure-tone averages than Soldiers without a tinnitus diagnosis. Counterintuitively, overall trend percentages of bothersome tinnitus increased per calendar year, while the percentages of STS decreased throughout the study period. The rate of tinnitus diagnosis in the medical record is vastly lower than the prevalence of bothersome tinnitus recorded in the annual surveillance system. Steps should be taken to screen, refer, and diagnose tinnitus more consistently. Based on the outcome of the study analysis, we recommend that screening for bothersome tinnitus more closely follows procedure recommendations from the Department of Veterans Affairs and Department of Defense (VA/DOD) Tinnitus Working Group, which may reduce the rate at which Soldiers report bothersome tinnitus.

Hearing Loss, Incident Parkinson Disease, and Treatment With Hearing Aids

The risk of developing Parkinson disease (PD) after objective hearing loss is unknown. PD studies using self-reported hearing loss are insensitive, and objective data are lacking. To examine the association of hearing loss with incident PD in US veterans and its effect modification by well-established prodromal conditions and hearing aids. This cohort study analyzed electronic health record data from the US Department of Veterans Affairs for veterans who had an audiogram from January 1, 1999, to December 30, 2022. Individuals with data missing or a preexisting PD diagnosis were excluded. Audiogram-confirmed hearing loss. Cumulative incidence of PD was calculated with adjustment for competing risk of death. Among 7 296 051 veterans with an audiogram, 3 596 365 were included. They were mostly male (n = 3 452 898 [96%]) and had a mean (SD) age of 67 (10.3) years. A total of 750 010 individuals (20.8%) had normal hearing at the time of audiometry examination; among those with hearing loss, 1 080 651 (30.0%), 1 039 785 (28.9%), 568 296 (15.8%), and 157 623 (4.3%) individuals had mild (20-<35 dB), moderate (35-<50 dB), moderate to severe (50-<65 dB), and severe to profound (65-120 dB) hearing loss, respectively. Age, gender, and smoking history were balanced between all exposed and unexposed groups with further adjustment for race, ethnicity, and frailty. At 10 years after the baseline audiogram, the numbers of additional cases of PD were 6.1 (95% CI, 4.5-7.79, 15.8 (95% CI, 12.8-18.8), 16.2 (95% CI, 11.9-20.6), and 12.1 (95% CI, 4.5-19.6) among veterans with mild, moderate, moderate to severe, and severe to profound hearing loss, respectively, compared with those with normal hearing. When combined with established prodromal conditions, hearing loss was associated with 5.7 (95% CI, 2.2-9.2) additional cases of PD at 10 years compared with either condition alone. With prompt hearing aid dispensation, incident cases of PD decreased by 21.6 cases (95% CI, 19.5-23.6) at 10 years. Hearing loss appears to be an independent risk factor for later development of PD. Hearing aids attenuate this risk, and therefore widespread screening for hearing loss and appropriate use of hearing aids may reduce the incidence of PD. Additional studies are needed to examine the mechanisms underlying the association between hearing loss and PD.

Lessons from the Department of Veterans Affairs: A continuum of age-friendly care for older adults.

With almost 90% of Americans expressing a desire to age in place in their home, many health systems and communities are challenged to provide the right resources, at the right time, to support What Matters to older adults. In the Department of Veterans Affairs (VA), approximately 50% of Veterans enrolled in VA health care are aged 65 and older, driving an imperative to provide timely, Age-Friendly care through a broad continuum of services. VA has taken a multifaceted approach to shift Long-Term Services and Supports to promote aging in place through innovation pilots, expansion of Home and Community Based Services (HCBS) and adoption of Age-Friendly Health Systems (AFHS) practices [or "framework"]. VA is spreading geriatrics knowledge throughout the clinician and trainee workforce, improving skills and practices across all disciplines and care settings. The framework of AFHS creates a shared language to support transitions across ambulatory, hospital, emergency department, home care, and nursing home settings. Through these efforts, VA is reimagining geriatrics, providing an example of the type of care all older adults want and deserve. Since March 2020, 375 care settings across 132/139 (95%) VA parent facilities have earned AFHS recognition. By incorporating AFHS into the infrastructure of the healthcare system, clinicians are prepared to address What Matters across clinical settings and address common geriatric syndromes. Leaders in a variety of health systems can learn from VA efforts to provide a continuum of Age-Friendly programs and services that promote independence, function, well-being and aging in place.

Ten Years of Bipolar Telehealth: Program Evaluation of a Team-Based Telemental Health Clinic.

Objectives: Telemental health via videoconferencing (TMH-V) can overcome many of the barriers to accessing quality mental health care. Toward this end, in 2011, the U.S. Department of Veterans Affairs (VA) established the National Bipolar Disorders TeleHealth (BDTH) Program to provide expert mental health consultation and treatment to Veterans with bipolar spectrum disorders. Methods: Initial analyses of BDTH services suggested that participants had positive changes in quality-of-care indices and clinical outcomes; however, that evaluation was based on a limited sample of both participants and VA medical centers. We were able to confirm and expand upon those early results by using nearly eight times the number of participants and more than twice as many medical centers. Results: For the 2,456 Veterans who completed the intake to our program, there were significant improvements in some of the quality metrics (e.g., lithium use) and a 54% reduction in positive suicide screens (p < 0.05). The Veterans who completed the initial and postprogram assessments (n = 815) reported a 16.6% reduction in manic symptoms (p < 0.001), a 29.3% reduction in depressive symptoms (p < 0.001), and a 21.2% reduction in mood episodes (p < 0.001). Additionally, these Veterans demonstrated significant improvements (p < 0.001) in mental health-related quality of life between the two assessments. Conclusions: These analyses provide further support for the general effectiveness and safety of telemental health via videoconferencing. Future research should examine the generalizability of these findings across various subgroups (e.g., minority patients, patients in rural areas), populations, and health care systems.

Drug overdose deaths among homeless veterans in the United States Department of Veterans Affairs healthcare system.

With an epidemic of drug overdoses, contemporary research is needed to examine drug overdose deaths among homeless populations. This study measured rates, types and correlates of drug overdose deaths occurring over a 5-year study period among veterans experiencing homelessness (VEH) and non-homeless veterans (NHV) in the US Department of Veterans Affairs (VA) healthcare system. Retrospective cohort study. USA. A total of 6 128 921 veterans. We followed 399 125 VEH and 5 729 796 NHV between 2017 and 2021 using linked administrative VA and National Death Index data. Multivariable Cox regression models were constructed to estimate hazard ratios (HRs) for homelessness as a predictor of time-to-occurrence of overdose deaths with 95% confidence interval (CIs), sequentially controlling for demographic, medical, substance use and mental health characteristics. Among overdose deaths, 8653 [93.7%, 95% confidence interval (CI) = 93.2-94.2%] were unintentional and 5378 (57.8%, 95% CI = 56.8-58.8%) involved opioids. The overdose-specific mortality rate (per 100 000 person-years) was 227.3 among VEH and 23.2 among NHV (HR = 9.76, 95% CI = 9.36, 10.16), with rates 7-14 times higher among VEH than NHV, depending on the drug involved. In fully adjusted models, homelessness was associated with greater risk of drug overdose death (HR = 3.33, 95% CI = 3.18, 3.49), with the greatest risk involving psychostimulants (HR = 4.19), followed by antiepileptic/sedative/hypnotic drugs (HR = 3.69), synthetic opioids (HR = 3.50) and natural and semi-synthetic opioids (HR = 2.79). US veterans experiencing homelessness appear to have three times the risk for drug overdose deaths than non-homeless veterans. There may be specific risks associated with psychostimulant, antiepileptic, sedative and hypnotic drugs in this population that deserve greater attention.

Schizophrenia, Off-Label Antipsychotics, and Dementia Risk in People with HIV.

Comorbidities such as schizophrenia and medication such as antipsychotics may influence the risk of dementia among people living with HIV (PLWH). The objective of this paper is to assess the associations among HIV patients with schizophrenia, off-label antipsychotics, and dementia risk. US Department of Veterans Affairs healthcare facilities from 2000 to September 2023. Retrospective cohort study of PLWH treated by the U.S. Department of Veterans Affairs with prior history of schizophrenia, off-label antipsychotic use and neither schizophrenia nor antipsychotic use. Propensity score matched non-HIV controls were included for the respective HIV groups. The hazard of dementia is estimated using Cox proportional hazards models. PLWH and schizophrenia, were found to have a 2.49 higher hazard of dementia compared to HIV patients with no history of schizophrenia or antipsychotic medication use (HR=2.49, 95%CI=(1.85-3.35)). PLWH and off-label antipsychotic use were found to have a 1.77-fold higher hazard of dementia compared to HIV patients with no history of schizophrenia or antipsychotic medication use (HR=1.77, 95% CI=(1.37-2.28)). Propensity score matched analysis reveals that, among schizophrenia patientis, those with HIV had a 1.65-fold higher hazard of dementia (HR=1.65, 95%CI=(1.12-2.44)). Among patients with no schizophrenia or antipsychotic medication, those with HIV had a 1.47 fold higher hazard of dementia (HR=1.47, 95%CI=(1.33-1.63)). This study demonstrates that among PLWH, history of schizophrenia or off-label antipsychotic medication use are associated with substantial increases in dementia incidence. Furthermore, propensity-matched control analysis reveals that HIV infection itself is independently and significantly associated with elevated dementia risk.

"It's Really About Those Social Determinants of Health that Drive It": Addressing Food Insecurity in Rural Veterans.

The Department of Veterans Affairs (VA) employs numerous strategies to address food insecurity among rural veterans. This manuscript discusses findings from a quality improvement project examining factors impacting food insecurity among rural veterans. Qualitative interviews were conducted with VA expert informants (n = 30) who worked in national program offices addressing veteran food insecurity, site visit participants (n = 57) at three VA Medical Centers (VAMCs), and rural veterans who screened positive for food insecurity at the VAMC sites (n = 10). Interviews were analyzed with analysis matrices. Current VA programming includes a national food insecurity screening initiative and connecting veterans with local community resources. Veteran participants provided suggestions for addressing veteran food insecurity, including outreach and education. In addition, these interviews demonstrate that rural veteran food insecurity is intrinsically interwoven with other social determinants of health. Addressing rural veteran food insecurity must include strategies for understanding and supporting interconnected veteran needs.

Effectiveness of telehealth-delivered massed trauma-focused psychotherapy among veterans with posttraumatic stress disorder.

Trauma-focused psychotherapies can be effectively delivered using a massed delivery format. Telehealth treatment for posttraumatic stress disorder (PTSD) using evidence-based interventions has been shown to be as effective as in-person treatment. However, the effectiveness of evidence-based treatments for PTSD over telehealth using the massed delivery format requires further examination. To examine the effectiveness of telehealth massed PTSD treatment, we report on a quality improvement study of 33 veterans (75.8% male; MAge = 42.3, SD = 11.0) who participated in a virtual 4-week massed PTSD program at a Department of Veterans Affairs (VA) medical center. Twenty-seven (81.8%) veterans completed the treatment and reported large reductions in PTSD (d = 1.48) and depressive symptoms (d = 1.08) at Week 4 and at 1-month follow-up (PTSD, d = 1.34; depression, d = 0.70). Results suggested that evidence-based treatment for PTSD can be effectively delivered in a massed format over telehealth in a VA medical setting. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Hepatitis Delta Coinfection Rates and All-Cause Mortality Among Hepatitis B-Infected Veterans in the USA.

Screening for hepatitis D virus (HDV) is recommended for all individuals with hepatitis B virus (HBV) infection. Coinfected individuals experience more severe liver-related outcomes. We determined the HDV testing and coinfection rates and all-cause mortality among those infected with HBV. We used the US Department of Veterans Affairs (VA) healthcare system's national databases to identify individuals with HBV infection. We determined the proportion of individuals referred to gastroenterologists/hepatologists, or infectious diseases providers, and the proportion screened and tested positive for HDV. We calculated the HBV treatment rates, defined as ≥ 3 months of continuous prescription with an approved drug. Finally, we calculated all-cause mortality stratified by HDV coinfection and HBV treatment status. Among 44,951 individuals with at least one positive HBsAg, HBeAg or HBV DNA test, 5964 (13.3%) were screened for HDV (180 [3.0%] tested positive), and 28,291 (62.9%) were referred to gastroenterology/hepatology or infectious diseases. Treatment for HBV was prescribed for 73 (40.5%) of HDV-coinfected and 2425 (41.9%) HDV-uninfected individuals. All-cause mortality rate per 100 person-years was lower among those without HDV coinfection (2.98 for untreated HBV, 2.53 for treated HBV; p < 0.001) compared with those with HDV coinfection (5.14 for untreated HBV, 3.0 for treated HBV; p = 0.02). Kaplan-Meier curves demonstrated a significantly higher mortality among HDV-coinfected individuals who were not treated for HBV (log-rank p < 0.0001). Screening rates for HDV among HBV-infected individuals are suboptimal. While HDV coinfection is associated with higher all-cause mortality, HBV treatment may confer a survival benefit.

Clinicians' use of Health Information Exchange technologies for medication reconciliation in the U.S. Department of Veterans Affairs: a qualitative analysis.

Medication reconciliation is essential for optimizing medication use. In part to promote effective medication reconciliation, the Department of Veterans Affairs (VA) invested substantial resources in health information exchange (HIE) technologies. The objectives of this qualitative study were to characterize VA clinicians' use of HIE tools for medication reconciliation in their clinical practice and to identify facilitators and barriers. We recruited inpatient and outpatient prescribers (physicians, nurse practitioners, physician assistants) and pharmacists at four geographically distinct VA medical centers for observations and interviews. Participants were observed as they interacted with HIE or medication reconciliation tools during routine work. Participants were interviewed about clinical decision-making pertaining to medication reconciliation and use of HIE tools, and about barriers and facilitators to use of the tools. Qualitative data were analyzed via inductive and deductive approaches using a priori codes. A total of 63 clinicians participated. Over half (58%) were female, and the mean duration of VA clinical experience was 7 (range 0-32) years. Underlying motivators for clinicians seeking data external to their VA medical center were having new patients, current patients receiving care from an external institution, and clinicians' concerns about possible medication discrepancies among institutions. Facilitators for using HIE software were clinicians' familiarity with the HIE software, clinicians' belief that medication information would be available within HIE, and their confidence in the ability to find HIE medication-related data of interest quickly. Six overarching barriers to HIE software use for medication coordination included visual clutter and information overload within the HIE display; challenges with HIE interface navigation; lack of integration between HIE and other electronic health record interfaces, necessitating multiple logins and application switching; concerns with the dependability of HIE medication information; unfamiliarity with HIE tools; and a lack of HIE data from non-VA facilities. This study is believed to be the first to qualitatively characterize clinicians' HIE use with respect to medication reconciliation. Results inform recommendations to optimize HIE use for medication management activities. We expect that healthcare organizations and software vendors will be able to apply the findings to develop more effective and usable HIE information displays.

A landmark federal interagency collaboration to promote data science in health care: Million Veteran Program-Computational Health Analytics for Medical Precision to Improve Outcomes Now.

In 2016, the Department of Veterans Affairs (VA) and the Department of Energy (DOE) established an Interagency Agreement (IAA), the Million Veteran Program-Computational Health Analytics for Medical Precision to Improve Outcomes Now (MVP-CHAMPION) research collaboration. Oversight fell under the VA Office of Research Development (VA ORD) and DOE headquarters. An Executive Committee and 2 senior scientific liaisons work with VA and DOE leadership to optimize efforts in the service of shared scientific goals. The program supported centralized data management and genomic analysis including creation of a scalable approach to cataloging phenotypes. Cross-cutting methods including natural language processing, image processing, and reusable code were developed. The 79.6 million dollar collaboration has supported centralized data management and genomic analysis including a scalable approach to cataloging phenotypes and launched over 10 collaborative scientific projects in health conditions highly prevalent in veterans. A ground-breaking analysis on the Summit and Andes supercomputers at the Oak Ridge National Laboratory (ORNL) of the genetic underpinnings of over 2000 health conditions across 44 million genetic variants which resulted in the identification of 38270 independent genetic variants associating with one or more health traits. Of these, over 2000 identified associations were unique to non-European ancestry. Cross-cutting methods have advanced state-of-the-art artificial intelligence (AI) including large language natural language processing and a system biology study focused on opioid addiction awarded the 2018 Gordon Bell Prize for outstanding achievement in high-performance computing. The collaboration has completed work in prostate cancer, suicide prevention, and cardiovascular disease, and cross-cutting data science. Predictive models developed in these projects are being tested for application in clinical management. Eight new projects were launched in 2023, taking advantage of the momentum generated by the previous collaboration. A major challenge has been limitations in the scope of appropriated funds at DOE which cannot currently be used for health research. Extensive multidisciplinary interactions take time to establish and are essential to continued progress. New funding models for maintaining high-performance computing infrastructure at the ORNL and for supporting continued collaboration by joint VA-DOE research teams are needed.

Provision of Home & Community Based Services to Veterans by Race, Rurality, and Neighborhood Deprivation Index.

Home and community-based services (HCBS) enable frail patients to remain at home. We examined whether there were neighborhood-deprivation, racial, or rural disparities in HCBS utilization provided to Veterans by the Department of Veterans Affairs (VA) or Medicare by comparing the adjusted utilization rate of a historically disadvantaged group with the predicted utilization rate had it been treated as the historically dominant group. Among the 2.7 million VA patients over 66 years old in 2019, 11.0% were Black, 39.2% lived in rural settings, 15.3%/29.2%/30.9%/24.7% lived in least/mild/moderate/most-deprived neighborhoods. On average, 11.2% received VA or Medicare HCBS. Veterans residing in more deprived neighborhoods had 0.11-0.95% higher adjusted probability of receiving HCBS than expected had they resided in the least deprived neighborhoods. Veterans residing in rural areas had 0-0.7% lower HCBS rates than expected had they been treated like urban Veterans. Black Veterans were 0.8-1.2% more likely to receive HCBS than expected had they been treated like White Veterans. Findings indicate that VA resources were equitably employed, aligning with probable HCBS needs, suggesting that VA's substantial and long-standing investment in HCBS for care of frail Veterans could serve as a model for other payers and providers in the U.S.

The translation-to-policy learning cycle to improve public health.

Learning Health Systems (LHSs) have not directly informed evidence-based policymaking. The Translation-to-Policy (T2P) Learning Cycle aligns scientists, end-users, and policymakers to support a repeatable roadmap of innovation and quality improvement to optimize effective policies toward a common public health goal. We describe T2P learning cycle components and provide examples of their application. The T2P Learning Cycle is based on the U.S. Department of Veterans Affairs (VA) Office of Research and Development and Quality Enhancement Research Initiative (QUERI), which supports research and quality improvement addressing national public health priorities to inform policy and ensure programs are evidence-based and work for end-users. Incorporating LHS infrastructure, the T2P Learning Cycle is responsive to the Foundations for Evidence-based Policymaking Act, which requires U.S. government agencies to justify budgets using evidence. The learning community (patients, providers, clinical/policy leaders, and investigators) drives the T2P Learning Cycle, working toward one or more specific, shared priority goals, and supports a repeatable cycle of evidence-building and evaluation. Core T2P Learning Cycle functions observed in the examples from housing/economic security, precision oncology, and aging include governance and standard operating procedures to promote effective priority-setting; complementary research and quality improvement initiatives, which inform ongoing data curation at the learning system level; and sustainment of continuous improvement and evidence-based policymaking. The T2P Learning Cycle integrates research translation with evidence-based policymaking, ensuring that scientific innovations address public health priorities and serve end-users through a repeatable process of research and quality improvement that ensures policies are scientifically based, effective, and sustainable.

Barriers to accessing home and community-based services among family caregivers of Veterans.

The Department of Veterans Affairs (VA) has long recognized the importance of having a rich complement of home and community-based resources for the Veteran population. For Veterans experiencing disability-related impairments, home- and community-based services (HCBS) facilitate aging in place and alleviate family caregivers' burden. However, even in the enriched VA context, HCBS are underutilized. Our objective was to understand unmet needs and barriers to accessing HCBS from the perspectives of Veterans' family caregivers. This multi-method study recruited family caregivers of Veterans seen within a major VA Health Care System. Eligible caregivers provided care for at least 8 h/week in the prior 6 months, to a Veteran with 1+ impairments in instrumental activities of daily living. Recruitment was conducted via flyers, physician referrals, registries, and chart reviews. Participants completed 1-h semi-structured interviews to assess unmet psychosocial needs and barriers to accessing VA and non-VA HCBS. Interviews were analyzed using a thematic analysis approach. A total of 23 caregivers (62.9 + 13.5 years; 74% women; 52.2% White; 26.1% Black; 95.2% pre-9/11) provided 8.4 ± 6.3 h of daily care. Most had provided care for more than 1 year; nine had cared for their Veteran for 5+ years. The following themes were identified: (1) need for clear, accurate, timely information about HCBS; (2) lack of time, amplified by COVID-19 restrictions; (3) need for respite to manage their own health and other caregiving responsibilities; and (4) perceived difference in care needs that can strain caregivers' relationship with the care recipient. In addition to known barriers including lack of timely knowledge, service delays, and caregiver stress, Veteran-caregiver disagreements emerged as a novel barrier to using HCBS. A multi-pronged approach that addresses these barriers may increase timely access to HCBS.

Using Natural Language Processing to develop risk-tier specific suicide prediction models for Veterans Affairs patients

Suicide is a leading cause of death. Suicide rates are particularly elevated among Department of Veterans Affairs (VA) patients. While VA has made impactful suicide prevention advances, efforts primarily target high-risk patients with documented suicide risk. This high-risk population accounts for less than 10% of VA patient suicide deaths. We previously evaluated epidemiological patterns among VA patients that had lower classified suicide risk and derived moderate- and low-risk groupings. Expanding upon VA's leading suicide prediction model, this study uses national VA data to refine high-, moderate-, and low-risk specific suicide prediction methods. We selected all VA patients who died by suicide in 2017 or 2018 (n = 4584), matching each case with five controls who remained alive during treatment year and shared suicide risk percentiles. We extracted all sample unstructured electronic health record notes, analyzed them using natural language processing, and applied machine-learning classification algorithms to develop risk-tier-specific predictive models. We calculated area under the curve (AUC) and suicide risk concentration to evaluate predictive accuracy and analyzed derived words. ResultsOur high-risk model (AUC = 0.621 (95% CI: 0.55–0.68)), moderate-risk (AUC = 0.669 (95% CI: 0.64–0.71)), and low-risk (AUC = 0.673 (95% CI: 0.63–0.72)) models offered significant predictive accuracy over VA's leading suicide prediction algorithm. Derived words varied considerably, the high-risk model including chronic condition service words, moderate-risk model including outpatient care, and low-risk model including acute condition care.Study suggests benefit of leveraging unstructured electronic health records and expands prediction resources for non-high-risk suicide decedents, an historically underserved population.

Training satisfaction and future employment consideration among physician and nursing trainees at rural Veterans Affairs facilities in the United States during COVID-19: a time-series before and after study

The coronavirus disease 2019 (COVID-19) pandemic limited healthcare professional education and training opportunities in rural communities. Because the US Department of Veterans Affairs (VA) has robust programs to train clinicians in the United States, this study examined VA trainee perspectives regarding pandemic-related training in rural and urban areas and interest in future employment with the VA. Survey responses were collected nationally from VA physicians and nursing trainees before and after COVID-19 (2018 to 2021). Logistic regression models were used to test the association between pandemic timing (pre-pandemic or pandemic), trainee program (physician or nurse), and the interaction of trainee pandemic timing and program on VA trainee satisfaction and trainee likelihood to consider future VA employment in rural and urban areas. While physician trainees at urban facilities reported decreases in overall training satisfaction and corresponding decreases in the likelihood of considering future VA employment from pre-pandemic to pandemic, rural physician trainees showed no changes in either outcome. In contrast, while nursing trainees at both urban and rural sites had decreases in training satisfaction associated with the pandemic, there was no corresponding effect on the likelihood of future employment by nurses at either urban or rural VA sites. The study’s findings suggest differences in the training experiences of physicians and nurses at rural sites, as well as between physician trainees at urban and rural sites. Understanding these nuances can inform the development of targeted approaches to address the ongoing provider shortages that rural communities in the United States are facing.

Review of foreign experience of professional adaptation of war veterans

Problem setting. After the end of the war, most of the veterans will be an economically active stratum of the population, who will need active support from the state when reintegrating into civilian life, but in return will be able to benefit the country by remaining active subjects of the national economy. The preservation and development of this potential is critically important both for the post-war recovery of Ukraine and for the establishment of social justice in relation to defenders. The study of foreign experiences is an important step in order to learn effective practices that can be adapted and applied to the Ukrainian context. Despite the fact that the experience of other countries does not always fully correspond to Ukrainian realities, it contains useful lessons and methods that can be modified to solve the specific challenges that Ukraine faces. Analysis of recent researches and publications. Such domestic researchers as V.P. Kokhan, A.S. Kolisnyk, O.V. Shapovalova, V.I. Sheverdina, T. Zakharina, V.K. Malolitneva, R.A. Jabrailov. M. Bazaeva studied foreign experience using the example of the USA. At the same time, there is no comprehensive overview of foreign policy regarding the support of veterans and their reintegration into civilian life in domestic works. Purpose of research is to carry out a general review of foreign experience in issues of support for veterans using the example of the USA, EU, Germany, France and Great Britain. Article`s main body. The article examines the issue of professional adaptation of veterans as a key element in the successful reintegration of military personnel into civilian life. It outlines the experiences of the United States, the European Union, Germany, France, and the United Kingdom to identify effective veteran support practices that could be adapted to the Ukrainian context. The focus is on the legal and organizational aspects of veteran policies, including legislative support and the involvement of both governmental and non-governmental organizations in the outlined area. The article concludes that the United States has a well-developed system of veteran support, primarily driven by the Department of Veterans Affairs (VA). Special attention is given to the functioning of the U.S. Court of Appeals for Veterans Claims (CAVC). It is suggested that the establishment of a similar specialized judicial body could be an important step for Ukraine to effectively protect veterans’ rights in the post-war period. The article highlights the absence of unified legislation on veterans within the European Union. Nevertheless, it emphasizes the role of pan-European non-governmental organizations in this field, such as the European Confederation of Veterans. The legal and institutional framework for veteran policies in specific EU member states, particularly Germany and France, is also discussed. Special attention is given to the experience of the United Kingdom, which aspires to have the most advanced veteran support system. It is noted that the strategic approach to veteran policy, particularly through the Veterans’ Strategy Action Plan 2022-2024, provides long-term legal certainty for veterans and enhances the effectiveness of state policy. Conclusions and prospects for the development. The article underlines that professional adaptation of veterans is a critical precondition for successful post-war recovery in Ukraine and the preservation of veterans’ economic activity. The use of foreign experience, particularly the creation of specialized judicial bodies, the development of national veteran support strategies, and the active involvement of non-governmental organizations, could become a subject of further discussion aimed at finding the optimal path for building an effective veteran support system in Ukraine.

Developing Evidence to Support Policy: Protocol for the StrAtegic PoLicy EvIdence-Based Evaluation CeNTer (SALIENT).

All federal agencies are required to support appropriation requests with evidence and evaluation (US Public Law 115-435; the Evidence Act). The StrAtegic PoLicy EvIdence-Based Evaluation CeNTer (SALIENT) is 1 of 6 centers that help the Department of Veterans Affairs (VA) meet this requirement. Working with the existing VA evaluation structure, SALIENT evaluations will contribute to (1) optimize policies and programs for veteran populations; (2) improve outcomes regarding health, equity, cost, and provider well-being; (3) advance the science of dissemination and knowledge translation; and (4) expand the implementation and dissemination science workforce. We leverage the Lean Sprint methodology (iterative, incremental, rule-governed approach to clearly defined, and time-boxed work) and 3 cores to develop our evaluation plans collaboratively with operational partners and key stakeholders including veterans, policy experts, and clinicians. The Operations Core will work with evaluation teams to develop timelines, facilitate work, monitor progress, and guide quality improvement within SALIENT. The Methods Core will work with evaluation teams to identify the most appropriate qualitative, quantitative, and mixed methods approaches to address each evaluation, ensure that the analyses are conducted appropriately, and troubleshoot when problems with data acquisition and analysis arise. The Knowledge Translation (KT) Core will target key partners and decision makers using a needs-based market segmentation approach to ensure that needs are incorporated in the dissemination of knowledge. The KT Core will create communications briefs, playbooks, and other materials targeted at these market segments to facilitate implementation of evidence-based practices and maximize the impact of evaluation results. The SALIENT team has developed a center infrastructure to support high-priority evaluations, often to be responsive to shifting operational needs and priorities. Our team has engaged in our core missions and operations to rapidly evaluate a high-priority areas, develop a comprehensive Lean Sprint systems redesign approach to training, and accelerate rapid knowledge translation. With an array of interdisciplinary expertise, operational partnerships, and integrated resources, SALIENT has an established and evolving infrastructure to rapidly develop and implement high-impact evaluations. Projects are developed with sustained efficiency approaches that can pivot to new priorities as needed and effectively translate knowledge for key stakeholders and policy makers, while creating a learning health system infrastructure to foster the next generation of evaluation and implementation scientists. PRR1-10.2196/59830.