Ill Veterans Research Articles

Barriers Facing Primary Care Leaders in Implementing Goals of Care Conversations with Seriously Ill Veterans

Barriers Facing Primary Care Leaders in Implementing Goals of Care Conversations with Seriously Ill Veterans

Mental Health Scores but not Sleep Quality are Lower in Veterans with Gulf War Illness that have Low Physical Function

PURPOSE: Gulf War Illness (GWI) is a poorly understood illness that impacts about a third of Veterans who were deployed to the Gulf Region during the 1990-1991 Gulf War (GW). GW Veterans have twice the odds of having depression compared to non-deployed Veterans. Depression and sleep quality are associated with impaired physical function, which is notable since physical activity is a modifiable health behavior that can be an effective method to reduce mild to moderate depressive symptoms and improve sleep. We hypothesize that Veterans categorized with GWI and with high physical function scores will have fewer depressive symptoms and better sleep quality compared to those with low physical function. Evaluating the connection between physical and mental health in Veterans with GWI could support behavioral health interventions intended to improve symptom management. Methods: GW Veterans were enrolled in an ongoing VA multi-site remote clinical research study and completed web-based questionnaires: the Modified Kansas questionnaire, short-form 36 (SF-36), Patient Reported Outcomes Measurement Information System (PROMIS)-Emotional Distress Anxiety and Depression, and the Pittsburgh Sleep Quality Index (PSQI). The modified Kansas was used to designate GWI based on 6 self-reported symptom domains. Symptom onset was also required within 5 years of deployment. The SF-36 assessed eight functional domains, including physical functioning measuring mobility disability. GW Ill Veterans were grouped based on the SF-36 physical function score such that those with ≤70 were considered in the poor physical function group (low) and >70 were in the high physical function group (high). The PROMIS Anxiety assessed anxiety and PROMIS Depression assessed negative mood and decreased positive affect. The PSQI global score assessed sleep quality over a one-month period and ranges from 0-21 where a greater score reflects poorer sleep quality. Data were analyzed using student t-tests and linear regressions using Graphpad Prism 9. RESULTS: 63 Veterans (low group: 12 females/35 males, 60±4 years old; high group: 3 females/13 males, 59±5 years old) completed the web-based questionnaires. Anxiety and depression scores were greater in the low vs high group (Anxiety= low: 70.0±29; high: 45.4±14.0, P=0.001; Depression= low: 64.2.0±34.5; high: 41.3±14.7, P=0.01). Sleep quality (low: 12.8±4.0; high: 11.9±4.7, P=0.44) was not different between the groups. Anxiety scores (R2=0.19, P=0.0004) and depression scores (R2=0.11, P=0.007) were related to physical function, thus greater physical function was associated with lower (better) mental health scores. Sleep quality (R2=0.07, P=0.03) was related to physical function, so greater physical function was associated with better sleep quality. CONCLUSIONS: Gulf War Illness is a chronic multi-symptom condition that can be debilitating. Insight about physical function, depression and sleep symptoms could guide therapeutic approaches. The SF-36 is recommended as a core data element in GWI research and as such can provide information on the physical aspects of health. These findings suggest that depression and anxiety differ in those with low versus high physical function and that physical function is related to mental health and sleep quality. Future research should examine how GW Veterans are able to maintain their physical function to improve overall health. VA CSR&D. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

USING PROCESS EVALUATION TO IMPROVE DOCUMENTATION OF LIFE-SUSTAINING TREATMENTS FOR VETERANS

Abstract The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) intervention began in 2021 to support United States Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) clinicians in completing life-sustaining treatment (LST) templates for Veterans. In PERSIVED, HBPC clinicians partner with the PERSIVED team for 15 months, with clinicians routinely receiving coaching from the PERSIVED team. To assess participation in PERSIVED and to inform coaching sessions, the PERSIVED team conducted process evaluation interviews from August-November 2022 with N=24 clinicians across the country from seven HBPC sites. Interviews were conducted between months six-seven of PERSIVED implementation. Two PERSIVED team members conducted interviews, one acting as interviewer and the other as notetaker. Following interviews, the notetaker cleaned up the notes and the interviewer reviewed them, with the two reaching consensus on summaries on individual interviews and ultimately summarizing interview data by site. Two PERSIVED coaches then reviewed the summaries to brainstorm how to adapt coaching based on process evaluation findings. Coaches noted site-specific barriers and facilitators to improving LST template completion rates; positives of PERSIVED coaching; suggestions to improve PERSIVED; and goals for the remaining nine months of the PERSIVED intervention. Strategies suggested based on the process evaluation analyses included how to integrate checking for the LST template into existing processes, adapting note templates, discussing LST templates during team meetings, and improving education around LST template completion. The rapid integration of process evaluation findings into PERSIVED coaching sessions proved beneficial for participating HBPC teams.

Strategies to Improve Perioperative Palliative Care Integration for Seriously Ill Veterans.

Seriously ill patients are at higher risk for adverse surgical outcomes. Palliative care (PC) interventions for seriously ill surgical patients are associated with improved quality of patient care and patient-centered outcomes, yet, they are underutilized perioperatively. To identify strategies for improving perioperative PC integration for seriously ill Veterans from the perspectives of PC providers and surgeons. We conducted semistructured, in-depth individual and group interviews with Veteran Health Administration PC team members and surgeons between July 2020 and April 2021. Participants were purposively sampled from high- and low-collaboration sites based on the proportion of received perioperative palliative consults. We performed a team-based thematic analysis with dual coding (inter-rater reliability above 0.8). Interviews with 20 interdisciplinary PC providers and 13 surgeons at geographically distributed Veteran Affairs sites converged on four strategies for improving palliative care integration and goals of care conversations in the perioperative period: 1) develop and maintain collaborative, trusting relationships between palliative care providers and surgeons; 2) establish risk assessment processes to identify patients who may benefit from a PC consult; 3) involve both PC providers and surgeons at the appropriate time in the perioperative workflow; 4) provide sufficient resources to allow for an interdisciplinary sharing of care. The study demonstrates that individual, programmatic, and organizational efforts could facilitate interservice collaboration between PC clinicians and surgeons.

Barriers and facilitators to goals of care conversations with Veteran residents of community nursing homes.

Despite evidence that structured goals of care conversations (GoCCs) and documentation of life-sustaining treatment (LST) preferences improve the delivery of goal-concordant care for seriously ill patients, rates of completion remain low among nursing home residents. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program aims to improve the consistent documentation of LST preferences among Veterans receiving care in veterans affairs (VA)-paid community nursing homes (CNH); however, the barriers and facilitators of completing and documenting GoCCs in this unique context of care have not been described. We conducted semi-structured, qualitative interviews with key stakeholders of the VA CNH programs located at six VA Medical Centers between July 2021 and July 2022. With a rapid approach to analysis, interview transcripts were reduced into memo templates using the Tailored Implementation for Chronic Disease Checklist and coded and analyzed using qualitative data analysis software. The 40 participants consisted of nurses (n = 13), social workers (n = 25), and VA physicians (n = 2). Most participants felt confident about conducting GoCC; however, several barriers were identified. At the staff level, our results indicated inconsistent completion of GoCC and documentation due to a lack of training, confusion about roles and responsibilities, and challenging communication within the VA as well as with CNH. At the organizational level, there was a lack of standardization across sites for how LST preferences were documented. At the patient level, we found key barriers related to patient and family readiness and issues finding surrogate decision makers. While COVID-19 brought end-of-life issues to the forefront, lockdowns hindered communication about the goals of care. Findings from this pre-implementation evaluation revealed multi-level barriers in conducting and documenting GoCCs with Veterans receiving VA-paid CNH care, as well as several facilitators that can be used to inform strategies for improvement.

Applying the Tailored Implementation in Chronic Diseases framework to inform implementation of the Preferences Elicited and Respected for Seriously Ill Veterans through enhanced decision-making program in the United States Veterans Health Administration.

In 2017, the National Center for Ethics in Health Care for the United States Department of Veterans Affairs (VA) commenced national roll-out of the Life-Sustaining Treatment Decisions Initiative. This national VA initiative aimed to promote personalized, proactive, patient-driven care for seriously ill Veterans by documenting Veterans' goals and preferences for life-sustaining treatments in a durable electronic health record note template known as the life-sustaining treatment template. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) quality improvement program was created to address the high variation in life-sustaining treatment template completion in VA Home Based Primary Care (HBPC) and Community Nursing Home programs. This manuscript describes the program that focuses on improving life sustaining treatment template completion rates amongst HBPC programs. To increase life-sustaining treatment template completion for Veterans receiving care from HBPC programs, the PERSIVED team applies two implementation strategies: audit with feedback and implementation facilitation. The PERSIVED team conducts semi-structured interviews, needs assessments, and process mapping with HBPC programs in order to identify barriers and facilitators to life-sustaining treatment template completion to inform tailored facilitation. Our interview data is analyzed using the Tailored Implementation in Chronic Diseases (TICD) framework, which identifies 57 determinants that might influence practice or implementation of interventions. To quickly synthesize and use baseline data to inform the tailored implementation plan, we adapted a rapid analysis process for our purposes. This paper describes a six-step process for conducting and analyzing baseline interviews through applying the TICD that can be applied and adapted by implementation scientists to rapidly inform tailoring of implementation facilitation.

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration

BackgroundEmpirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings.MethodsPERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations.DiscussionThe PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.

60. Evaluation of Outcomes Associated with Intermittent Versus Extended Infusion of Piperacillin/tazobactam in Acutely Ill Veterans

BackgroundAntibiotic dosing optimization is a key principle of antimicrobial stewardship. This study evaluated the impact of an extended infusion piperacillin/tazobactam dosing protocol on clinical outcomes in acutely ill veterans treated for infections at VA San Diego.MethodsThis retrospective cohort study looked at veterans admitted to the medical-surgical unit who were treated with piperacillin/tazobactam for at least 48 hours. The control group included patients who received treatment between 12/14/2017 to 7/22/2018, and the “protocol” or after protocol implementation group included patients who received treatment between 7/23/2018 to 2/28/2019. Excluded from the study were veterans with microbiological cultures showing intermediate sensitivity or resistance to piperacillin/tazobactam, those who experienced interruption in therapy, or those who required dialysis. Primary clinical outcomes included in-hospital mortality rate, 30-day mortality rate, hospital length of stay (LOS), and 30-day readmission rates. Rates of adverse effects such as elevated liver enzymes, thrombocytopenia, acute kidney impairment (AKI), and Clostridium difficile infection were also collected. χ 2, Fisher’s exact, and Mann-Whitney U tests were used for statistical analysis.Results260 veterans were included in the final analysis: 96% male, mean age 65 years, mean BMI 29, 84 met SIRS criteria for sepsis, and 55% received at least 48 hours of concomitant vancomycin. Groups had similar outcomes for median LOS, in-hospital mortality, and 30-day mortality. The incidence of AKI was significantly lower in the protocol group (39.2% vs. 56.9%, p=0.004), in veterans on concomitant vancomycin (42.3% vs. 63.2%, p=0.011), and in veterans with obesity (36.4% vs. 70.8%, p=0.001). Rates of liver enzyme elevation, thrombocytopenia, and C. difficile infection were lower in the protocol group though these were not significant.ConclusionThere was a significantly lower rate of AKI with EI dosing which supports enhanced patient safety. This may be the preferred method of administration for obese patients and/or those receiving vancomycin concurrently. This is the first study to demonstrate that EI piperacillin/tazobactam dosing significantly reduces rates of AKI in patients on concomitant vancomycin.Disclosures All Authors: No reported disclosures

An Exploratory Study of Goals of Care Conversations Initiated with Seriously Ill Veterans in the Emergency Room.

Background: Emergency department (ED) visits are common for older patients with chronic, life-limiting illnesses and may offer a valuable opportunity for clinicians to initiate proactive goals of care conversations (GoCC) to ensure end-of-life care that aligns with the patients' values, goals, and preferences. Objectives: The purpose of this study is to assess whether GoCC are occurring with patients in Department of Veteran Affairs (VA) EDs, to characterize these patients' goals of care and life-sustaining treatment (LST) decisions, and to examine the extent to which palliative or hospice consultations occur following the ED visit. Design: We conducted a cross-sectional retrospective study using health record data. Settings/Subjects: A total of 10,780 patients receiving care in VA, whose first GoCC occurred during an ED visit. Results: Of the patients in the study, approximately half were at least 70 years of age, three-quarters were white, and half had multiple serious disease comorbidities. The percentage of patients who desired cardiopulmonary resuscitation was lower among the highest risk (i.e., of hospitalization and death) patients (64% vs. 51%). The percentage of patients wanting other LSTs (e.g., mechanical ventilation) was higher among the lowest risk patients; and the percentage of patients requesting limits to LSTs was highest among higher risk patients. Eighteen percent of patients had a palliative or hospice care consult within three months of their ED visit. Conclusions: In this study, we verified that GoCC are being initiated in the ED with Veterans at differing stages in their illness trajectory and that higher proportions of higher risk patients preferred to limit LSTs.

Psychiatric Multimorbidity in a Specialized Program for Severely Mentally Ill Veterans.

It has been suggested that psychiatric multimorbidity may better characterize severely impaired psychiatric patients than individual severe mental illness (SMI) diagnoses, and that these patients may be better served by centers offering integrated co-located, psychiatric and social services than in conventional clinics providing one-to-one care. We tested the hypothesis that multimorbidity is a critical characteristic of Veterans treated at a co-located multi-service Veteran's Health Administration (VHA) program originally established to treat Veterans living with SMI. Administrative data from the VA Connecticut Health Care System from fiscal year 2012 were used to compare veterans using diverse mental health and social services at the Errera Community Care Center (ECCC), an integrated "one-stop shop" for SMI veterans, and those seen exclusively at standard outpatient mental health clinics. Bivariate and multiple logistic regression analyses were used to compare groups on demographic characteristics, psychiatric and medical diagnoses, service utilization, and psychotropic medication fills. Results: Of the 11,092 veterans included in the study, 2281 (20.6%) had been treated at the ECCC and 8811 (79.4%) had not. Multivariable analysis highlighted the association of treatment in the ECCC and younger age, lower income, homelessness, and especially multimorbidity including both multiple substance use and multiple psychiatric diagnoses. Programs originally designed to address the diverse needs of patients living with SMI and homelessness may be usefully characterized as treating patients with psychiatric multimorbidity, a term of greater clinical relevance. Effectiveness research is needed to evaluate the one-stop shop approach to their treatment.

Assessment and Management of Delirium in Critically Ill Veterans.

Delirium is a complex syndrome prevalent in the intensive care unit. It has been associated with significant morbidity including distress, longer hospital stays, prolonged cognitive impairment, and increased mortality. To describe a nurse-led interdisciplinary quality improvement initiative to increase nurses' knowledge of delirium, documentation of delirium assessment, and patient mobility. Sixty-seven nurses in medical and surgical intensive care units were required to attend an interactive education program on delirium assessment and management. Scores on tests taken before and after the education program were used to evaluate knowledge. Medical records and bedside rounds were used to validate Confusion Assessment Method for the Intensive Care Unit documentation and interventions. Descriptive statistics were used to describe changes over time. A delirium resource team composed of nurses, physicians, and therapists provided didactic education paired with simulation training and bedside coaching. Mobility screening tests and computer templates guided assessments and interventions. Documentation of the Confusion Assessment Method improved from less than 50% to consistently 99%. Mobilization in the surgical intensive care unit increased from 90% to 98% after intervention. Days of delirium significantly decreased from 51% before intervention to 31% after intervention (χ12=7.01, P = .008). The success of this quality improvement project to enhance recognition of delirium and increase mobility (critical components of the pain assessment, breathing, sedation choice, delirium, early mobility, and family education bundle) was contingent on nursing leaders hip, interdisciplinary team collaboration, and interactive education.

A National Pilot of Goals of Care Conversations for Seriously Ill Veterans: Patient and Site Variation and Associations with Bereaved Family Survey Outcomes (TH323D)

•Describe patient characteristics from four VA pilot sites that are associated with having a Goals of Care Conversation (GoCC) documented on the standardized Life Sustaining Treatment (LST) Progress Note template.•Determine whether the occurrence of a documented GoCC predicts higher Bereaved Family Survey (BFS) perceptions of a positive patient care experience. Prior to national implementation, VA piloted the Life Sustaining Treatment Decision Initiative (LSTDI), including practice standards requiring Goals of Care Conversations (GoCC) for seriously ill Veterans, at four geographically diverse sites. We examined patient characteristics associated with GoCC and the association of GoCC with Bereaved Family Survey (BFS) data on end-of-life quality. To assess a pilot of an initiative to ensure GoCC for high risk patients, including to: 1) describe characteristics of patients with GoCC; association with the BFS; and how implementation and quality varied across diverse sites. We examined Veteran characteristics in association with documentation of a GoCC. We evaluated the first occurrence of GoCC (n=6,664) among Veterans who received care at the sites (N=221,383). Among decedents (n=15,177), we examined whether GoCC was associated with higher BFS outcomes versus propensity-score matched controls by site. Veteran's with widower [OR=1.68(1.53,1.86), p<0.001] and urban status [OR=1.79(1.43,2.24), p <0.001] were more likely to have a GoCC. Patients >=65 years were twice as likely to have a GoCC [OR=2.65(2.46,2.86), p<0.001], and patients with more serious health conditions were more likely to receive a GoCC compared to frail patients. Findings were similar among Veterans with a higher risk index. Of Veterans with BFS data, we identified 353 GoCC and non-GoCC patient pairs. Comparing across sites, a GoCC was not significantly associated with a higher BFS Overall Score [OR=1.29(0.84,1.99), p=0.24], Communication Score [OR=1.32(0.81,2.16), p=0.27], or Support Score [OR=1.54(0.97,2.47), p=0.07]. Individually analyzed, GoCC was associated with a higher Support Score [OR=1.31(1.09,1.57), p=0.003] at one site. Despite site differences, recipients of GoCC generally had higher illnesses burden and prognostic risk. Site-level heterogeneity in outcomes suggest the need for deeper understanding of implementation and communication fidelity. These issues are critical to achieve expected benefits from widespread efforts to implement GoCC.

Ensuring the Safety of Chronically Ill Veterans Enrolled in Home-Based Primary Care.

Ensuring the Safety of Chronically Ill Veterans Enrolled in Home-Based Primary Care.

The Impact of Integrating Physical Health into a Brief CBT Approach for Medically Ill Veterans.

The current study explored the use and preliminary outcomes of physical health treatment elements integrated into a traditional brief cognitive behavioral therapy (bCBT) approach for medically ill veterans with depression and/or anxiety. Data were collected as part of a pragmatic randomized trial examining patient outcomes of bCBT versus an enhanced usual care condition. bCBT was delivered to participants by Veterans Health Administration (VA) mental health providers in the primary care setting. Using a skill-based approach, providers and participants selected modules from a list of intervention strategies. Modules included Taking Control of Your Physical Health, Using Thoughts to Improve Wellness, Increasing Pleasant Activities, and Learning How to Relax. Skill module use and impact on treatment completion and clinical outcomes were explored for participants randomized to bCBT who received at least one skill module (n = 127). Utilization data showed that participants and providers most commonly selected the physical health module for the first skill session. Receiving the "physical health" and "thoughts" modules earlier in treatment were associated with a higher likelihood of treatment completion (defined as four or more sessions). Preliminary outcome data suggest that the physical health skill module was equally effective or superior to other bCBT skill modules. Results suggest that incorporating physical health elements with a bCBT approach hold the potential to positively impact treatment engagement/completion and may result in improved outcomes for medically ill patient populations.

‘Definitely Wrong’? The Ministry of Pensions’ Treatment of Mentally Ill Great War Veterans in Interwar British and Irish Society

Shell-shock has been well examined in literary and wartime works although marginalized in post-war studies into the experience of British Army veterans of the Great War. Attention to the history of the Ministry of Pensions, the British governmental department created to provide for disabled British ex-servicemen, complicates previous criticisms of the department and its supposed inactivity in rehabilitating the mentally ill veteran. Initial attempts to treat the mentally ill veteran were progressive and innovative. However, financial stringency imposed by the British Treasury undermined the Ministry of Pensions’ efforts to cure the shell-shocked veteran as did wider societal attitudes which stigmatized the mentally ill.

Including Family Caregivers In Seriously Ill Veterans' Care: A Mixed-Methods Study.

Family caregivers often serve as unpaid members of the home and community-based care workforce for people with serious illness; as key partners in the home-clinic continuum, they should be included in health care teams. The Campaign for Inclusive Care is an initiative within the Veterans Affairs health care system to improve provider practices for including caregivers of military members in treatment planning and decisions. We defined inclusive care using a literature review, provider interviews, and a caregiver survey. We found that inclusive care involves clear definition of the caregiver role, system policies for inclusion, assessment of caregivers' capacity, explicit involvement of caregivers, and mutuality in caregiver-provider communication. We recommend solutions based on this definition that can inform development of a national caregiver strategy, required of the Department of Health and Human Services by the Recognize, Assist, Include, Support, and Engage Family Caregivers Act of 2018.

Characterizing Life-Sustaining Treatment Decisions of Seriously Ill Veterans During Pilot Testing of the Veterans Health Administration’s Life-Sustaining Treatment Decisions Initiative (QI742)

Characterizing Life-Sustaining Treatment Decisions of Seriously Ill Veterans During Pilot Testing of the Veterans Health Administration’s Life-Sustaining Treatment Decisions Initiative (QI742)

Older, Seriously Ill Veterans' Views on the Role of Religion and Spirituality in Health-Care Delivery.

To describe older Veteran's perspectives on the current delivery of religious or spiritual (R/S) care. Semi-structured interviews with older veterans with advanced stage cancer, heart failure, or pulmonary disease to elicit views on when, how, and by whom religious and spiritual care is preferred. The sample (n = 17) was largely male (94%), non-Hispanic white (52.9%), Christian (82.3%), and most had at least some college education (64.7%). Participants shared diagnoses of cancer (47%), heart failure (35.2%), or chronic obstructive pulmonary disease (17.6%). As a group, participants had moderate religiosity. Themes relevant to the study goal of improving VA care delivery are as follows: (1) process of R/S engagement, (2) timing of R/S engagement, and (3) awareness of services. Veterans discussed the need for VA providers to accommodate diverse spiritual beliefs, importance of screening for spiritual needs, inclusion of family spiritual support, need for higher visibility of services, use of nonchaplains for R/S support, and times when R/S is important. Veterans recognize the diversity of their fellow veterans and note the opportunities and challenges in providing R/S support in the VA care setting. The findings have implications for quality improvement in VA care including efforts focused on enhanced outreach to veterans, bolstered education for staff, and more nuanced approaches to R/S support.

Factors Associated With High Frequency of Suicidal Ideation in Medically Ill Veterans

Suicide is a leading cause of death, and rates are especially high among medically ill, older individuals. Health-related psychosocial correlates of suicidal ideation (SI) may be particularly important for medically ill older adults as they may clarify who may benefit from interventions to reduce SI. This study examined whether demographic, physical health, and/or health-related psychosocial factors were associated with high frequency of SI in older, medically ill Veterans experiencing elevated anxiety or depression. This cross-sectional study included 302 Veterans with (1) a cardiopulmonary condition and functional impairment and (2) elevated symptoms of depression and/or anxiety. Participants were classified as having either no, low, or high SI, based on self-reported ideation, from the Patient Health Questionnaire-9. SI was reported in 26.8% of the full sample and high SI was reported by 12.6% of participants. Logistic regression analyses predicting high versus no SI found the odds of high SI increased 4.7 times (95% confidence interval, 2.6-8.3) for each 1-unit increase in maladaptive coping and 4.1 times (95% confidence interval, 1.2-14.3) for each 1-unit increase in physical health severity/functional limitations. Older, medically ill Veterans with comorbid depression and/or anxiety frequently reported SI and were at greater risk of experiencing a high frequency of SI if they engaged in maladaptive coping strategies and/or had high levels of functional impairment. Effective interventions to reduce SI for this population should focus on reducing maladaptive coping and minimizing negative behavioral, cognitive, and emotional reactions to functional limitations.

Towards a Biopsychosocial Model of Gulf War Illness?

Towards a Biopsychosocial Model of Gulf War Illness?