Health Administration Research Articles

A pilot study of a scalable training programme for coaches delivering webSTAIR

ABSTRACT Background: Accessible, low-cost digital programmes are emerging as a means by which to address high rates of mental health problems. However, the development and assessment of scalable training programmes for effective use of digital interventions has lagged. This is particularly important, as coach-supported digital interventions provide benefits that substantially and consistently exceed those of programmes that are entirely self-guided. Objectives: This report describes the evaluation of a brief coach training programme consisting of a two-hour workshop and six 1-hour consultation sessions for delivery of webSTAIR, a 10-module transdiagnostic web-based programme for trauma-exposed populations. Method: The training was provided to 68 mental health counsellors at Veteran Health Administration Readjustment Counselling Services, who delivered the treatment to 99 veteran clients. Results: A total of 51% of the coaches completed the programme. Client outcomes were encouraging. Veterans enrolled in the programme demonstrated significant and clinically meaningful improvements in functioning (Cohen’s d = 0.88), emotion regulation (Cohen’s d = 0.97), posttraumatic stress disorder (PCL-5 Cohen’s d = 0.61; ITQ Cohen’s d = 0.60), and depression (Cohen’s d = 0.53). Conclusions: The study contributes much needed information regarding evidence for the effectiveness of ‘light-touch’ training strategies. The data support the integration and testing of brief training programmes in the implementation and dissemination of evidence-based digital interventions. Strategies for improving training completion rates among busy providers and resource-burdened clinical services need to be considered.

Association Between Racial Marginalization with Direct Healthcare Expenditure, Time at Home and Rehabilitation Access Following Moderate to Severe Traumatic Brain Injury

Objective: To determine the association between residence in racialized neighborhoods with direct healthcare expenditure and days at home (DAH) after moderate to severe traumatic brain injury (TBI). Summary Background Data: Differences in ethno-racial background have been associated with health outcome disparities. Much of this prior research was conducted in settings without universal healthcare coverage. The influence of ethno-racial background on health outcomes after TBI in universal healthcare settings remains unclear. Methods: This retrospective multicenter cohort study utilized linked administrative health data to identify adults sustaining moderate to severe TBI between 2009-2021. The primary exposure was an area-level index corresponding to the degree of racialized and immigrant populations within neighborhoods of residence (Q1-least racialized; Q5-most racialized). Co-primary outcomes were direct healthcare expenditure and DAH365days after injury. Secondary outcomes included discharge to rehabilitation and functional independence measure (FIM) scores at rehabilitation discharge. Results: 6,188 patients met inclusion criteria. Patients in the most racialized neighborhoods incurred higher crude and adjusted direct healthcare costs compared to those in the least racialized neighborhoods. This effect was driven predominantly by physician claims and acute care costs. There were no significant differences in crude or adjusted DAH across quintiles. Access to rehabilitation and discharge FIM scores were comparable for patients residing different racialized neighborhood quintiles. Conclusions: Despite differences in healthcare expenditure, this study found similar home time, access to rehab and discharge FIM scores for TBI patients according to racialized neighborhood residence. Recognizing the limitations of area-level indices, our findings suggest equitable care delivery in a publicly funded universal care environment.

Impact of the COVID-19 pandemic on hospital-based heart failure care in New South Wales, Australia: a linked data cohort study

BackgroundHealthcare policy implemented during the COVID-19 pandemic may have impacted the health of patients with heart failure. Australian data provide a unique opportunity to examine service disruption independent of significant COVID-19 burden. This study aimed to examine heart failure care during the pandemic in New South Wales (NSW).MethodsAnalysis of hospital utilisation among patients aged ≥ 18 years with a primary diagnosis of heart failure conducted using linked administrative health records from hospital admission, emergency department, non-admitted services, and mortality data collections. Health service utilisation and outcomes were compared “Pre-pandemic” (PP): 16th March 2018 – 28th August 2019 and “During pandemic” (DP): 16th March 2020 – 28th August 2021. Mortality data were available until December 2021.ResultsHeart failure-related ED presentations and hospital admissions were similar between the periods (PP = 15,324 vs DP = 15,023 ED presentations, PP = 24,072 vs DP = 23,145 hospital admissions), though rates of admission from ED were lower DP (PP = 12,783/15,324 (83.4% [95% CI 82.8-84.0]) vs DP = 12,230/15,023 (81.4% [95% CI 80.8-82.0%]). There was no difference according to age, sex, rurality, or socioeconomic status. Outpatient volume reduced DP (PP = 44,447 vs DP = 35,801 occasions of service), but telehealth visits increased nearly threefold (PP = 5,978/44,447 (13.4% [95% CI 13.1-13.8%]) vs DP = 15,901/35,801 (44.4% [95% CI 43.9-44.9%]) with highest uptake among the wealthy and those in major cities. Time to heart failure-related ED presentation, hospitalisation or all-cause mortality following index admission was longer DP (PP = 273 [IQR 259, 290] days, DP = 323 [IQR 300, 342] days, HR 0.91 [95% CI 0.88, 0.95]).ConclusionsPolicies implemented DP had minimal impact on volumes of inpatient heart failure care in NSW hospitals, but there were fewer admissions from ED and reduced volumes of publicly funded outpatient care. A rapid shift from patient-facing to remotely delivered care enabled compliance with restrictions and was associated with increased time to heart failure-related adverse events, but access was not afforded equally across the socio-demographic spectrum.

Equity of access to pathological diagnosis and bronchoscopy for lung cancer in Aotearoa New Zealand

background: Māori are less likely to survive their lung cancer once diagnosed, but it remains unclear whether this is partially driven by poorer access to best-practice diagnostic services. methods: We examined all lung cancer registrations in Aotearoa New Zealand between 2007–2019 (n=27,869) linked to national administrative health datasets and further stratified by ethnicity, tumour type and stage of disease. Using descriptive and regression analyses, we compared ethnic groups in terms of the basis of diagnosis (e.g., histology, cytology), receipt of bronchoscopy and travel distance and time to access bronchoscopy. results: We found no differences in access to a pathological diagnosis between ethnic groups regardless of cancer type or stage. We found that Māori within the cohort were marginally more likely to access bronchoscopy than the majority European group; however, we also found that Māori had a lower odds of living close to the location of their bronchoscopy, and a correspondingly higher odds of living 100–200km (adjusted odds ratio [adj. OR] 1.46, 95% confidence interval [CI] 1.26–1.69) or more than 200km away (1.36, 95% CI 1.15–1.61) than Europeans. conclusion: Interventions that aim to further support Māori to overcome the systematic and cumulative disadvantages in access to cancer care should be broadly supported and resourced.

Beyond videoconferencing: enhancing remote home assessments with 3D modeling technology

Purpose: Occupational therapists in the Veterans Health Administration have transitioned from in-person to videoconferencing for home assessments, benefiting Veterans living in remote and rural areas. However, videoconferencing has limitations, including restricted field of view and poor video quality, affecting hazard identification accuracy. This study aims to introduce and evaluate a three-dimensional (3D) model as an alternative technology for remote home assessments. Materials and methods: We created 3D models using a 360-degree camera and mobile app. Five occupational therapists individually completed virtual training and practice sessions to familiarize themselves with using the 3D model. Each participant then conducted a remote home assessment using the 3D model and completed questionnaires, System Usability Scale (SUS), and semi-structured interviews. Results: Participants spent an average of 10 min training and practicing with the 3D model, and most reported either maintaining or gaining confidence in using it compared to before. All participants successfully completed the assessments, which took an average of 17 min. They rated the 3D model as easy to use, with an average SUS score of 78.5. Participants preferred the 3D model over videoconferencing, noting that it effectively addressed current challenges, and expressed their willingness to integrate it into clinical practice. Conclusion: This study demonstrates that 3D models offer a promising option for remote home assessments. With minimal training, occupational therapists could conduct more effective assessments. It is recommended to use 3D models for an initial understanding of the home environment before videoconferencing-based assessments to enhance the remote assessment experience for occupational therapists and clients.

Leadership best practices for improving engagement and burnout in health facilities: A positive deviance approach from the Veterans Health Administration.

Leadership best practices for improving engagement and burnout in health facilities: A positive deviance approach from the Veterans Health Administration.

Educational outcomes of children with major congenital anomalies: Study protocol for a population-based cohort study using linked hospital and education data from England

Background Major congenital anomalies (CAs) affect around 2% of live births and are a primary cause of infant mortality, childhood morbidity and long-term disability, often requiring hospitalisation and/or surgery. Children with CAs are at greater risk of lower educational attainment compared with their peers, which could be due to learning disabilities, higher rates of ill-health and school absences, or lack of adequate educational support. Our study will compare the educational attainment of children with CAs to those of their peers up to age 11 in England, using linked administrative health and education data. Methods We will analyse data from the ECHILD (Education and Child Health Insights from Linked Data) database. Children born in NHS-funded hospitals from 1st September 2003 to 31st August 2008 whose hospital records were linked to their educational records at three Key Stages (ages 4/5, 6/7 and 10/11 years) will be included. Children with different CAs, indicated by recorded hospital diagnosis codes, will be compared to children without CAs. We will compare the proportions of enrolled children who take the assessment, the proportions who reached national expected levels of attainment, and the mean standardised attainment scores for Maths and English at each Key Stage. We will describe variations in outcome by sex, ethnic minority background, region, and neighbourhood deprivation, and perform regression modelling to compare the attainment trajectories of children with and without CAs, controlling for sociodemographic factors. Ethics and dissemination Ethics approval has been obtained for the analyses of the ECHILD database. Our findings will provide information for parents regarding their children’s expected academic potential, and also enable the development of interventions to support those at risk of not doing well. We will disseminate our findings to academics, policy makers, service users and providers through seminars, peer-reviewed publications, conference abstracts and other media (lay summaries and infographics).

Clinic-Level Predictors of Psychotherapy Dosage in the Military Health System.

This study aimed to describe the demand for, supply of, and clinic processes associated with behavioral health care delivery in the Military Health System and to examine the clinic-level factors associated with receipt of a minimally adequate dosage of psychotherapy. This retrospective study used administrative behavioral health data from eight military treatment facilities (N=25,433 patients; N=241,028 encounters) that were participating in a larger implementation study of evidence-based psychotherapy for posttraumatic stress disorder. Minimally adequate dosage of psychotherapy was defined in two ways: at least three sessions within a 90-day period and at least six sessions within a 90-day period. The authors then used a path model to examine clinic-level factors hypothesized to predict psychotherapy dosage, including care demand, supply, and processes. Patients had an average of 2.5 psychotherapy appointments per quarter. Wait times for intake, between intake and the first psychotherapy session, and between follow-up sessions all averaged 17 days or longer. Path modeling showed that a higher patient-to-encounter ratio was associated with a longer wait time between follow-up psychotherapy appointments. In turn, a longer wait time between appointments was associated with a lower probability of receiving an adequate dosage of psychotherapy. However, a greater proportion of care delivered in groups was associated with a greater probability of receiving at least six sessions of psychotherapy. Receipt of a minimally adequate dosage of psychotherapy in the Military Health System is hindered by clinic staffing and workflows that increase wait times between follow-up psychotherapy appointments.

Virtual Mental Health Care and Suicide-Related Events

The rising suicide rates in the US emphasize the need for effective prevention. While telehealth has transformed access to mental health care, the impact of telehealth on suicide outcomes is unknown. To evaluate the association of virtual mental health services with individual-level suicide-related events (SREs). This retrospective cohort study using broadband access as an instrumental variable assessed a national sample of Veterans Health Administration patients who received mental health care between March 1, 2020, and December 31, 2021. Participants were recently separated (ie, discharged or released from active duty) veterans who completed their active duty service between March 1, 2019, and December 31, 2020, and who received at least 2 outpatient or inpatient diagnoses related to major depressive disorder, substance use disorder, or posttraumatic stress disorder within the year before their most recent separation date. Data were analyzed May 1 to October 31, 2023. Percentage of a patient's total mental health visits that were conducted virtually by psychiatrists, psychologists, or social workers within a calendar month. Binary measure indicating whether the patient had experienced an SRE (defined as a nonfatal suicide attempt, intentional self-harm, or suicide death) in a specific month and year as evaluated an instrumental variable probit model. The sample included 66 387 data points from 16 236 unique recently separated veterans. Among these entries, 44 766 were for male veterans (67.4%), the mean (SD) age across the sample was 32.9 (8.9) years, and the sample was representative of the US veteran population. There were 929 SREs (1.4%). Virtual mental health visits comprised a mean (SD) of 44.6% (46.1%) of all mental health visits. In instrumental variable probit analyses accounting for factors simultaneously associated with use of virtual mental health care and SRE risk, a 1% increase in the probability of virtual mental health visits was associated with a 2.5% decrease in SREs. Findings from this cohort study using a retrospective quasi-experimental design found that an increase in virtual mental health visits relative to total visits was associated with a statistically significant decrease in SREs, suggesting that providing virtual mental health services may reduce suicide-related outcomes.

Food Insecurity Among LGBQ+ Veterans

Food insecurity is associated with numerous adverse health outcomes. Little is known about the prevalence of and risks for food insecurity among veterans identifying as lesbian, gay, bisexual, queer, and similar (LGBQ+), a population facing unique social barriers and medical comorbidities. To examine food insecurity and potential risk factors among LGBQ+ veterans. This retrospective, cross-sectional study used administrative data from all US Veterans Health Administration (VHA) facilities nationally. Participants included veterans screened for food insecurity between March 1, 2021, and August 31, 2023. Positive response to food insecurity screening administered in VHA facilities as part of routine clinical care. Prevalence of and sociodemographic, clinical, and psychosocial factors associated with food insecurity among veterans identifying as LGBQ+ or heterosexual and those with "don't know" responses regarding their sexual orientation. Of 3 580 148 veterans screened, the mean (SD) age was 61.6 (0.4) years; 3 192 507 (89.2%) were assigned male sex at birth. A total of 83 292 veterans (2.3%) identified as LGBQ+, and 10 183 (0.3%) had "don't know" responses. LGBQ+ veterans (5352 [6.4%]) and veterans with "don't know" responses (635 [6.2%]) were more than twice as likely as heterosexual veterans (90 426 [2.6%]) to have positive screen results for food insecurity. While risk factors for food insecurity were similar for veterans across sexual orientation groups, LGBQ+ veterans had higher rates of several risk factors compared with heterosexual veterans, including age younger than 45 years (45.3% vs 19.5%), female sex assigned at birth (44.1% vs 10.0%), being in a minoritized racial or ethnic group (34.7% vs 29.8%), unmarried or unpartnered status (69.1% vs 39.7%), low income (16.4% vs 14.9%), homelessness or housing instability (10.3% vs 5.4%), anxiety (7.7% vs 4.3%), depression (31.1% vs 19.3%), suicidality (3.6% vs 1.4%), posttraumatic stress disorder (42.2% vs 30.2%), substance use disorder (13.1% vs 9.0%), military sexual trauma (24.0% vs 5.4%), and recent intimate partner violence (2.6% vs 1.4%). In this cohort study of veterans screened for food insecurity, LGBQ+ veterans and those with "don't know" responses for sexual orientation experienced food insecurity at nearly 2.5 times the rate of heterosexual veterans. While risk factors for food insecurity were similar across groups, LGBQ+ veterans faced a higher prevalence of particular risks, including homelessness and several mental health and trauma-related comorbidities. Future work should examine targeted screening and interventions tailored to identifying and addressing food insecurity in this population, given their increased vulnerability and burden of food insecurity.

Spatiotemporal patterns and factors contributing to neonatal mortality in Ethiopia: Data from EDHS 2000 to 2019.

Although Ethiopia has substantial improvements in various health indicators such as maternal and child mortality, the burden of neonatal mortality remains high. Between 2016 and 2019, neonatal mortality increased from 29 deaths per 1,000 live births to 33 deaths per 1,000 live births. This study aimed to explore the spatial patterns and factors contributing to neonatal mortality in Ethiopia. Data from the Ethiopian Demographic and Health Surveys (EDHS) for the years 2000, 2005, 2011, 2016, and 2019 were analyzed. The EDHS sampling design uses a two-stage cluster sampling technique, considering census enumeration areas as primary sampling units and households as secondary sampling units. We used the Spatial Scan analysis in SaTScan and Getis-Ord Gi* statistic in Geographic Information System (GIS), to analyse the spatiotemporal patterns of neonatal mortality. Maternal, newborn and health service-related factors contributing to neonatal mortality were also analyzed using a multilevel logistic regression model. Adjusted Odds Rios (AOR) with corresponding 95% CI were presented as a measure of association and a P-value of 0.05 was used to declare statistical significance. During the initial three consecutive surveys, there was a consistent pattern of hot spot clusters in the Amhara and Benshangul Gumuz regions, along with certain parts of the Oromia region. However, in later surveys, these clusters shifted to the eastern parts of the country, notably including the Somali region. Early initiation of breast feeding was associated with reduced chances of neonatal death (Adjusted Odds Ratio [AOR]) = 0.27; 95% Confidence Interval [CI]: 0.23, 0.32). Neonates born at home (AOR = 1.46; 95% CI: 1.16, 1.82) and male babies had a higher likelihood of mortality during the neonatal period compared to their counterparts (AOR = 1.36; 95% CI: 1.24, 1.51). The odds of neonatal mortality increased with the number of children a mother had ever given birth to (AOR = 1.36; 95% CI: 1.24, 1.51). In contrast, longer birth intervals were associated with a reduced risk of neonatal mortality (AOR = 0.76; 95% CI: 0.68, 0.83). The central southern, central-western, north-western, and northern parts of Ethiopia had most of the neonatal death clusters in the first three rounds of DHS while eastern Ethiopia had the highest neonatal mortality clusters in the latest two surveys. Our results underscore the importance for policymakers and health administrators to reassess intervention approaches and reallocate resources to regions identified as hot spots for neonatal mortality. Enhancing the initiation of breastfeeding within the first hour of birth would improve newborn survival rates. Special attention and care need to be given to babies born of smaller sizes.

Behaviorally Informed Text Message Nudges to Schedule COVID-19 Vaccinations: A Randomized Controlled Trial.

Vaccine hesitancy, especially related to COVID-19 vaccinations among Veterans, may limit uptake. Behaviorally informed text-based messages have the potential to improve uptake of COVID-19 vaccinations. To evaluate the impact of two different behaviorally informed text message nudges on COVID-19 vaccine scheduling and completion, compared to standard control message. Prospective, three-arm patient-level randomized quality improvement trial. Between March and May 2021, 20,523 Veterans were eligible for the initial series of COVID-19 vaccination, enrolled at two large Veterans Health Administration sites. Arm 1 (Control): standard scheduling message; Arm 2 (Social Good): standard message plus behaviorally informed text message "When you get a vaccine now, you help protect yourself, your family, and your community"; and Arm 3 (Scarcity): standard plus behaviorally informed text message "Only a limited number of vaccine appointments are available." Outcomes were vaccine scheduling and/or completion rate within 7 days of receipt of text message (primary), and within 14 days and 30 days after receipt of text message (secondary). Veterans had an overall rate of 19% of scheduling or receiving a vaccination in 7 days. In our adjusted intention-to-treat analysis, we found no difference between intervention social good or scarcity (aOR 0.98, 95% CI, 0.88-1.09, for both arms) compared to standard scheduling message. We found no statistical differences in our secondary outcomes. During the initial phases of vaccine roll-out, two behaviorally informed text messages did not increase COVID-19 vaccination rates among Veterans compared to a standard scheduling message.

Tuberculosis and increased incidence of cardiovascular disease: Cohort study using US and UK health records.

Limited evidence suggests elevated risks of cardiovascular disease (CVD) among people diagnosed with tuberculosis (TB) disease, though studies have not adjusted for pre-existing CVD risk. We carried out a cohort study using two separate datasets, estimating CVD incidence in people with TB versus those without. Using data from the United States (Veterans Health Administration) and the United Kingdom (Clinical Practice Research Datalink) for 2000-2020 we matched adults with incident TB disease and no CVD history 2-years before TB diagnosis (US n=2,121; UK n=15,820) with up to 10 people without TB on the basis of age, sex, race/ethnicity and healthcare practice. Participants were followed beginning 2-years before TB diagnosis and for 2-years subsequently. The acute period was defined as 3-months before/after TB diagnosis. TB, CVD and covariates were identified from electronic routinely collected data (primary and secondary care; mortality). Poisson models estimated incident rate ratios (IRR) for CVD events in people with TB compared to those without. CVD incidence was consistently higher in people with TB, including during the baseline period (pre-TB) and particularly in the acute period: IRRs were US 3.5 (95% Confidence Interval 2.7-4.4), UK 2.7 (2.2-3.3). Rate Ratios remained high after adjusting for differences in pre-existing CVD risk: US 3.2 (2.2-4.4), UK 1.6 (1.2-2.1). Increased CVD incidence was observed in people with TB versus those without, especially within months of TB diagnosis, persistent after adjustment for differences in pre-existing risk. Enhancing CVD screening and risk management may improve long-term outcomes in people with TB.

Geographical variation in osteoporosis in Australian women: a longitudinal analysis over 23years.

To determine whether the prevalence of osteoporosis, fractures, and dual-X-ray absorptiometry (DXA) differs between Australian women living in rural compared with urban areas. The Australian Longitudinal Study on Women's Health, a prospective longitudinal study of Australian women, includes a cohort of women born 1946-1951, surveyed nine times from 1996-2019. Data from administrative health records were linked to survey data. Geographic area was classified as major city, inner regional, outer regional, or remote. Generalised estimating equations (GEE) explored outcomes of osteoporosis, fracture, and DXA rates. Univariable and multivariable regression were performed and bootstrapping with 100 repetitions at 95% sampling of the original dataset to ensure robust results. A total of 13,712 women were included: 5000 (36.5%) living in major cities, 5214 (38.0%) inner regional, 2798 (20.41%) outer regional, and 700 (5.1%) remote areas. Baseline age, 47.6 (1.46) years (mean (SD)), was similar; but education, marital status, country of birth, smoking, BMI, and comorbidities varied between areas. Over 23years, 2956 (21.6%) were diagnosed with osteoporosis, 3185 (23.2%) had an incident fracture, and 8151 (59.4%) had a DXA. On univariable analysis, women living outside major cities had lower risk of osteoporosis (inner regional OR 0.92; 95% CI 0.84, 0.99; outer regional 0.70; 0.63, 0.79; remote 0.43; 0.34, 0.53), and lower risk of fractures (inner regional area OR 0.92, 95% CI 0.84, 0.99; outer regional 0.81; 0.73, 0.90; remote 0.54; 0.42, 0.67), than women living in major cities. These differences were no longer significant on multivariable analysis, suggesting differences might be related to the distribution of risk factors. Women living in inner regional and outer regional areas were significantly less likely to have a DXA, than those living in a major city (OR 0.75, 95% CI 0.70, 0.81; OR 0.72; 95% CI 0.64, 0.77, respectively), and this remained significant on multivariable analysis. Osteoporosis or fracture affected one-third of older Australian women, and women living outside major cities had lower rates of osteoporosis, fractures, and DXA completion.

Implementation of a High-Reliability Organization Framework in a Large Integrated Health Care System: A Pre-Post Quasi-Experimental Quality Improvement Project.

The purpose of this quality improvement (QI) project was to evaluate outcomes across Veterans Health Administration (VHA) hospital facilities engaged in an enterprise-wide implementation of a high-reliability organization (HRO) framework. This QI project relied on primary data drawn from 139 facilities nationwide from 2019 to 2023. Data sources included the All Employee Survey Patient Safety Culture (PSC) Module and patient safety reporting data derived from the Joint Patient Safety Reporting system. The project design applied a pre-post quasi-experimental design that examined within-cohort changes at pre-intervention, intervention, and 2 post-intervention follow-up timepoints. HRO interventions included a combination of training, leadership coaching, site assessments, and experiential learning. HRO interventions were initiated at 18 facilities beginning in 2019 (Cohort 1), 54 facilities in 2020 (Cohort 2), and 67 facilities in 2021 (Cohort 3). For between-cohort analyses, the relative degree of change within Cohort 1 sites was compared with all other sites. There were broad positive within-group trends for PSC scores across all sites, and domain-specific between-group differences in PSC Dimension 2-Risk Identification and Just Culture-and Dimension 4-Error Transparency and Risk Mitigation. For patient safety reporting, total events reported, and close calls increased for Cohort 1. The ratio of close calls to adverse events also increased for both Cohort 1 and all other VHA sites at post-intervention year 2. The results of this QI project will inform further refinements to VHA's efforts to implement HRO principles and practices in the nation's largest integrated health system. In addition, the implementation practices may inform other large-scale, multi-level efforts to improve quality and patient safety.

Distinct comorbidity phenotypes among post-9/11 Veterans with epilepsy are linked to diverging outcomes and mortality risks.

To investigate phenotypes of comorbidity before and after an epilepsy diagnosis in a national cohort of post-9/11 Service Members and Veterans and explore phenotypic associations with mortality. Among a longitudinal cohort of Service Members and Veterans receiving care in the Veterans Health Administration (VHA) from 2002 to 2018, annual diagnoses for 26 conditions associated with epilepsy were collected over 5 years, ranging from 2 years prior to 2 years after the year of first epilepsy diagnosis. Latent class analysis (LCA) was used to identify probabilistic comorbidity phenotypes with distinct health trajectories. Descriptive statistics were used to describe the characteristics of each phenotype. Fine and Gray cause-specific survival models were used to measure mortality outcomes for each phenotype up to 2021. Six distinct phenotypes were identified: (1) relatively healthy, (2) post-traumatic stress disorder, (3) anxiety and depression, (4) chronic disease, (5) bipolar/substance use disorder, and (6) polytrauma. Accidents were the most common cause of death overall, followed by suicide/mental health and cancer, respectively. Each phenotype exhibited unique associations with mortality and cause of death, highlighting the differential impact of comorbidity patterns on patient outcomes. By delineating clinically meaningful epilepsy comorbidity phenotypes, this study offers a framework for clinicians to tailor interventions. Moreover, these data support systems of care that facilitate treatment of epilepsy and comorbidities within an interdisciplinary health team that allows continuity of care. Targeting treatment toward patients with epilepsy who present with specific heightened risks could help mitigate adverse outcomes and enhance overall patient care.

IPDLN Workshop: Opportunities for Cross-Country Comparisons of Linked Administrative Education and Health Data

ObjectivesTo understand how we can better initiate and run international collaborations to deliver tangible and impactful findings using population-wide linked health and education data. ApproachRepresentatives from 14 countries (America, Australia, Canada, Chile, Denmark, England, Finland, Germany, New Zealand, Northern Ireland, Norway, Scotland, Sweden, Wales) summarised the potential for research using their linked administrative health and education data. The scope for collaboration and comparison of research findings across countries was explored. ResultsSeveral substantive research themes emerged, including the quantifying of differences in educational outcomes by health conditions and other early life factors, using health data to better identify and explore the special educational needs identified in educational records, using linked health and education data to identify and explore reasons for absenteeism from school. ConclusionsThe workshop showcased the primary themes for research and the data assets available within each country for comparative work. Further work is required to more robustly document the available detail within these datasets, collaboratively develop protocol templates for comparative studies, and develop pilot, proof of concept, studies.

Medicare Advantage Plans With High Numbers Of Veterans: Enrollment, Utilization, And Potential Wasteful Spending.

Medicare Advantage (MA) plans are increasingly enrolling veterans. Because MA plans receive full capitated payments regardless of whether or not veterans use Medicare services, the federal government can incur substantial duplicative, wasteful spending if veterans in MA plans predominantly seek care through the Veterans Health Administration (VHA) system. The recent growth of MA plans that disproportionately enroll veterans could further exacerbate such wasteful spending. Using national data, we found that veterans increasingly enrolled in MA between 2016 and 2022, including in a growing number of MA plans in which 20percent or more of the enrollees were veterans. Notably, about one in five VHA enrollees in these high-veteran MA plans did not incur any Medicare services paid by MA within a given year-a rate 2.5 times that of VHA enrollees in other MA plans and 5.7 times that of the general MA population. Meanwhile, VHA enrollees in high-veteran MA plans were significantly more likely to receive VHA-funded care. In 2020, the Centers for Medicare and Medicaid Services paid more than $1.32billion to MA plans for VHA enrollees who did not use any Medicare services, with 19.1percent going to high-veteran MA plans.

Perspectives on pain management from the veterans health administration and the defense health agency

Perspectives on pain management from the veterans health administration and the defense health agency

Trends in All-cause Mortality among U.S. Veterans with Sarcoidosis, 2004–2022

BACKGROUNDSarcoidosis is an idiopathic multiorgan disease with variable clinical outcomes. Comprehensive analysis of sarcoidosis mortality in U.S. Veterans is lacking. RESEARCH QUESTIONSWhat are the trends in all-cause mortality among U.S. Veterans with sarcoidosis, and how are these trends influenced by demographics, Black vs. White racial disparities, and geographic variability in relation to mortality? STUDY DESIGN AND METHODSUsing Veterans Health Administration (VHA) electronic health records (EHR), we conducted a population-based, retrospective cohort study of adjusted all-cause mortality 2004–2022 among Veterans diagnosed with sarcoidosis who received care through the VHA. Demographics, region of residence, service branch, tobacco use, and comorbidities were extracted from EHR. Annual trends in all-cause mortality and patient-level characteristics associated with mortality were examined with multivariable ungrouped Poisson regression. We visualized trends and analyzed state-by-state mortality using the marginal means procedure. In subgroup analysis (2015–2022), we considered the impact of neighborhood-level socioeconomic disparities using the area deprivation index (ADI). RESULTSIn all, 23,745 Veterans were diagnosed with sarcoidosis between 2004 and 2019 and followed through 2022. After adjustment, including age and sex, all-cause mortality increased annually by 4.7% (P<0.0001) and was 6.4% higher in Black than White Veterans (mortality rate ratio=1.064, P=0.02). A subgroup analysis comparing models with and without ADI adjustment showed no meaningful change in mortality trends. Risk factors for increased all-cause mortality included older age, male sex, Black race, and Northeast residence, and lower risk with “Other” service branches. Despite distinct geographical variations in mortality rates, no clear patterns emerged. INTERPRETATIONMortality among Veterans with sarcoidosis is rising. Differences identified by service branch and higher risk among male Veterans raise questions about differences in environmental exposures. The narrower racial disparities and smaller impact of ADI than in other studies may highlight the role of universal healthcare access in achieving equitable outcomes.