Integrated Service Network Research Articles

Implications of Electronic Consultations for Clinician Communication and Relationships: A Qualitative Study.

Strong relationships and effective communication between clinicians support care coordination and contribute to care quality. As a new mechanism of clinician communication, electronic consultations (e-consults) may have downstream effects on care provision and coordination. The objective of this study was to understand primary care providers' and specialists' perspectives on how e-consults affect communication and relationships between clinicians. Qualitative study using thematic analysis of semistructured interviews. Six of 8 sites in the VISN 1 (Veterans Integrated Service Network) in New England were chosen, based on variation in organization and received e-consult volume. Seventy-three respondents, including 60 clinicians in primary care and 3 high-volume specialties (cardiology, pulmonology, and neurology) and 13 clinical leaders at the site and VISN level, were recruited. Participants' perspectives on the role and impact of e-consults on communication and relationships between clinicians. Clinicians identified 3 types of e-consults' social affordances: (1) e-consults were praised for allowing specialist advice to be more grounded in patient data and well-documented, but concerns about potential legal liability and increased transparency of communication to patients and others were also noted; (2) e-consults were perceived as an imperfect modality for iterative communication, especially for complex conversations requiring shared deliberation; (3) e-consults were understood as a factor influencing clinician relationships, but clinicians disagreed on whether e-consults promote or undermine relationship building. Clinicians have diverse concerns about the implications of e-consults for communication and relationships. Our findings may inform efforts to expand and improve the use of e-consults in diverse health care settings.

Partnership Forum: The Role of Research in the Transformation of Veterans Affairs Community Care.

Partnership Forum: The Role of Research in the Transformation of Veterans Affairs Community Care.

Integrating mental health services into primary health care – a review of challenges and outcomes in the international setting

IntroductionMental illness accounts for about one-third of the world’s disability, a burden that many health systems cannot adequately respond to. Up to 70% of mental health (MH) patients are followed-up in primary health care (PHC) settings. To bridge the treatment gap, the World Health Organization developed mhGAP, a guidance package for integrated management of priority MH disorders in lower-income countries. Other countries have developed their own evidence-based interventions.ObjectivesOverviewing countries’ strategies towards integrating MH services into PHC, their outcomes and challenges.MethodsReview of literature using PubMed search terms “mental health primary care”, MeSH terms “Primary Health Care”, “Mental Health Care” and “organization and administration”, published in the last 5 years, in English.Results25 of 602 articles were selected. The mhGAP programme has seen successful integration in pilot district-level programs, but wider implementation has stalled due to stigma and lack of clinical engagement, resources, MH specialists, and policy support. The Quebec MH reform promoted integrated service networks, improving accessibility and quality of care (QoC). A Norwegian-Russian long-standing collaboration initiative has significantly improved treatment for anxiety and depression (A&D), with 58% reliable recovery rate. A Danish collaborative care intervention provided high-quality treatment of moderate A&D. In Peru, a similar initiative allowed early detection, referral, and treatment of MH patients attending PHC services.ConclusionsComprehensive, integrated and responsive collaborative care models are a cost-efficient strategy to improve QoC for many MH conditions across diverse populations. MH-PHC integration initiatives have seen varying degrees of success. However, several barriers impact wider implementation and scale-up.

The Use of Readily Available Longitudinal Data to Predict the Likelihood of Surgery in Crohn Disease.

BackgroundAlthough imaging, endoscopy, and inflammatory biomarkers are associated with future Crohn disease (CD) outcomes, common laboratory studies may also provide prognostic opportunities. We evaluated machine learning models incorporating routinely collected laboratory studies to predict surgical outcomes in U.S. Veterans with CD.MethodsAdults with CD from a Veterans Health Administration, Veterans Integrated Service Networks (VISN) 10 cohort examined between 2001 and 2015 were used for analysis. Patient demographics, medication use, and longitudinal laboratory values were used to model future surgical outcomes within 1 year. Specifically, data at the time of prediction combined with historical laboratory data characteristics, described as slope, distribution statistics, fluctuation, and linear trend of laboratory values, were considered and principal component analysis transformations were performed to reduce the dimensionality. Lasso regularized logistic regression was used to select features and construct prediction models, with performance assessed by area under the receiver operating characteristic using 10-fold cross-validation.ResultsWe included 4950 observations from 2809 unique patients, among whom 256 had surgery, for modeling. Our optimized model achieved a mean area under the receiver operating characteristic of 0.78 (SD, 0.002). Anti-tumor necrosis factor use was associated with a lower probability of surgery within 1 year and was the most influential predictor in the model, and corticosteroid use was associated with a higher probability of surgery. Among the laboratory variables, high platelet counts, high mean cell hemoglobin concentrations, low albumin levels, and low blood urea nitrogen values were identified as having an elevated influence and association with future surgery.ConclusionsUsing machine learning methods that incorporate current and historical data can predict the future risk of CD surgery.

Access to Lung Cancer Screening in the Veterans Health Administration: Does Geographic Distribution Match Need in the Population?

Studies show uneven access to Medicare-approved lung cancer screening (LCS) programs across the United States. The Veterans Health Administration (VA), the largest national US integrated health system, is potentially well positioned to coordinate LCS services across regional units to ensure that access matches distribution of need nationally. To what extent does LCS access (considering both VA and partner sites) and use match the distribution of eligible Veterans at state and regional levels? In this retrospective analysis, we identified LCS examinations in VA facilities between 2013 and 2019 from the VA Corporate Data Warehouse and plotted VA facilities with LCS geographically. We compared estimated LCS rates (unique Veterans screened per LCS-eligible population) across states and VA regional units. Finally, we assessed whether the VA's new partnership with the GO2 Foundation for Lung Cancer (which includes more than 750 LCS centers) closes geographic gaps in LCS access. We identified 71,898 LCS examinations in 96 of 139 (69.1%) VA facilities in 44 states between 2013 and 2019, with substantial variation across states (0-8 VA LCS facilities per state). Screening rates among eligible Veterans in the population varied more than 30-fold across regional networks (rate ratio, 33.6; 95%CI, 30.8-36.7 for VA New England vsVeterans Integrated Service Network 4), with weak correlation between eligible populations and LCS rates (coefficient, -0.30). Partnering with the GO2 Foundation for Lung Cancer expands capacity and access (eg, all states now have≥ 1 VA or partner LCS site), but 9 of the 12 states with the highest proportions of rural Veterans still have≤ 3 total LCS facilities. Disparities in LCS access exist based on where Veterans live, particularly for rural Veterans, even after partnering with the GO2 Foundation for Lung Cancer. The nationally integrated VA system has an opportunity to leverage regional resources to distribute and coordinate LCS services better to ensure equitable access.

Increased risk of dementia in older female US veterans with alcohol use disorder.

To determine whether alcohol use disorder (AUD) is associated with increased dementia risk among older women veterans. Cohort study. United States. Women veterans with AUD aged≥55years (n=2207), receiving care from Veterans Health Administration medical centers from October 2004 to September 2015 with one or more follow-up visit and an age-matched sample of women veterans without AUD (n=2207). Women at baseline with prevalent dementia or AUD in remission were excluded. AUD, substance use disorder (SUD), smoking, psychiatric (depression, anxiety, post-traumatic stress disorder, anxiety) and medical comorbidities (diabetes, hypertension, stroke, chronic obstructive pulmonary disorder, traumatic brain disorder) and dementia determined by the International Classification of Diseases, 9th revision, Clinical Modification codes. Cox proportional hazards models were used to determine the association between AUD and dementia risk during follow-up. Sensitivity analyses were performed by excluding women (n=349) with comorbid SUD and by excluding women (n=1568) currently smoking. Veteran women had a mean [standard deviation (SD)] age of 65.0 (5.6) years at baseline. During follow-up (median 4years, interquartile range: 2-6) 3.7% of women (n=82) with AUD developed dementia compared with 1.1% (n=24) without AUD (P<0.001). After adjustment for demographics, medical and psychiatric conditions and accounting for different Veteran's Integrated Service Networks, the adjusted hazard ratio (aHR) for dementia was 3.12 (95% CI=1.90-5.12) for women with AUD compared with women without AUD. After removing women with SUD (aHR=3.53, 95% CI=2.13-5.85) and women currently smoking (aHR=3.80, 95% CI=2.11-6.84), results were similar. Alcohol use disorder among female US veterans aged more than 55years appears to be associated with a more than threefold increase of dementia.

Veterans Health Administration's Whole Health System of Care: Supporting the Health, Well-Being, and Resiliency of Employees.

The Veterans Health Administration (VHA) is implementing a Whole Health System (WHS) of care that empowers and equips Veterans to take charge of their health and well-being and live their lives to the fullest, and increasingly leaders recognize the need and value in implementing a similar approach to support the health and well-being of employees. The purpose of this paper is to do the following: 1) provide an overview of the WHS of care in VHA and applicability in addressing employee resiliency; 2) provide a brief history of employee well-being efforts in VHA to date; 3) share new priorities from VHA leadership as they relate to Employee Whole Health strategy and implementation; and 4) provide a summary of the impacts of WHS of care delivery on employees. The WHS of care utilizes all therapeutic, evidence-based approaches to support self-care goals and personal health planning. Extending these approaches to employees builds upon 10 years of foundational work supporting employee health and well-being in VHA. In 2017, one facility in each of the 18 Veterans Integrated Service Networks (VISNs) in VHA was selected to participate in piloting the WHS of care with subsequent evaluation by VA’s Center for Evaluating Patient-Centered Care (EPCC). Early outcomes, from an employee perspective, suggest involvement in the delivery of the WHS of care and personal use of the whole health approach have a meaningful impact on the well-being of employees and how they experience the workplace. During the COVID-19 pandemic, VHA has continued to support employees through virtual resources to support well-being and resiliency. VHA's shift to this patient-centered model is supporting not only Veteran care but also employee health and well-being at a time when increased support is needed.

Prolonged Physical Inactivity in Older Adult Couples: A Dyadic Analysis Using Actigraphy.

Background and ObjectivesMany older adults remain inactive despite the known positive health implications of physical activity (improved mood, reduced mortality risk). Physical inactivity is an interdependent phenomenon in couples, but most research examines physical inactivity at the individual level. We estimated the average amount of prolonged physical inactivity for older adult couples and, using dyadic analysis, identified physical and mental health determinants thereof.Research Design and MethodsForty-six heterosexual older adult couples (age = 70.61 ± 6.56) from the Veterans Integrated Service Network 20 cohort of the Collaborative Aging Research using Technology (CART) initiative were included. The average number per day of prolonged inactive periods (no step counts or sleep activity for ≥30 min) was estimated using actigraphy data collected over a month.ResultsMultilevel modeling revealed that, within couples, there was no significant difference between partners in the average amount of inactive periods (p = .28). On average across couples, males and females had an average of 6.90 ± 2.02 and 6.56 ± 1.93 inactive periods per day, respectively. For males, older age was the only variable associated with more inactive periods (β = 0.15, p = .002). For females, having more depressive symptoms in both dyad members was associated with fewer inactive periods (female: β = −0.30, p = .03; male: β = −0.41, p < .001), and more dependence in completing their own instrumental activities of daily living predicted more inactive periods (β = 2.58, p < .001).Discussion and ImplicationsViewing couples’ activity as an interdependent phenomenon, rather than individual, provides a novel approach to identifying pathways to reduce inactivity in older adults, especially when focusing on the mental health and level of independence within the couple.

Physical Inactivity in Older Adult Couples: A Dyadic Analysis Using Continuous In-Home Monitoring

Many older adults remain inactive despite the known positive health implications of physical activity (e.g. improved mood, reduced mortality risk). Physical inactivity is a known interdependent phenomenon in couples, but the majority of research identifies determinants of physical inactivity at the individual level. We estimated the average amount of physical inactivity for older adult couples and, using dyadic analysis, identified physical and mental health determinants thereof. Forty-eight heterosexual older adult couples (mean age=70.6, SD=6.63) from the Veterans Integrated Service Network 20 cohort of the Collaborative Aging Research using Technology (CART) initiative were included in this study. Both dyad members wore actigraph devices for a month. The average number per day of inactive periods (defined as no movement or sleep activity for ≥ 30 minutes) was estimated. Multilevel modeling revealed that, within couples, there was no difference between partners in the average number of inactive periods, but on average across couples, males had more inactive periods per day (13.4, SD=4.43) than females (12.3, SD=4.87). For males, older age was the only variable associated with more inactive periods (β=0.13, p=.013). For females, more depressive symptoms in men were associated with fewer inactive periods (β=-0.37, p=.002), and more dependence in completing their own IADLs predicted more inactive periods (β=2.80, p<.001). All models were adjusted for covariates. Viewing couples’ activity as a unit, rather than as separate individuals, provides a novel approach to identifying pathways to reduce inactivity in older adults, especially when focusing on mental health issues and decreased independence within the couple.

Implementing an Interdisciplinary Committee to Reduce Psychotropic Drug and Increase Behavioral Intervention Use

In Fiscal Year (FY) 2018, the Butler VA Health Care System’s Psychotropic Medication and Behavior Management Committee was identified as a Veterans Integrated Service Network 4 Best Practice. The goal of this committee is to reduce unnecessary psychotropic medication use and polypharmacy and to increase behavioral intervention implementation among Community Living Center (CLC) Veterans. This committee meets quarterly to review Psychotropic Drug Safety Initiative data, behaviors and behavior care plans, and all psychotropic medications prescribed to Veterans. Psychiatric diagnoses, changes to psychotropic medications, and appropriate behavioral interventions are discussed. Committee members take responsibility for action items in accordance with their discipline; documentation of recommendations are made in quarterly behavioral health assessments in CPRS; and follow-up on action items is completed at twice weekly interdisciplinary treatment team meetings, weekly behavior rounds, and/or as needed. From the first quarter (Q1) of FY16 to Q1 FY20, the Butler VA CLC has seen decreased prescriptions of 2 or more anticholinergics (6.6% to 0.80%), antihistamines (12.5% to 5.9%), benzodiazepines (24.7% to 11.0%), and benzodiazepines or sedative hypnotics (23.2% to 9.0%). While prescription of antipsychotic use has increased (Q1 FY20 = 23.8%), the committee will follow Long Term Care Institute guidelines for gradual dose reductions, behavioral interventions, and as needed psychotropic medication PRN use. This committee provides an interdisciplinary forum to discuss and implement beneficial changes to pharmacological and non-pharmacological interventions among all CLC Veterans. The committee is a valuable process for monitoring and reinforcing best practices that may be easily replicated across VA CLCs nationwide.

Evaluation of Metabolic Monitoring and Diabetes Incidence in the First Year for Veterans Newly Started on an Atypical Antipsychotic.

This retrospective chart review is an evaluation of patient and health care provider adherence to a metabolic monitoring protocol as well as progression to type 2 diabetes mellitus (T2DM) in the first year after atypical antipsychotic initiation. Patient (N = 1,651) data from February 2014 to February 2019 were collected from the US Department of Veterans Affairs (VA) Corporate Data Warehouse for 8 VA medical centers within Veterans Integrated Service Network (VISN) 21. Collected data included patient demographic, laboratory results, and medication history. In the final cohort, 6% of patients were found to have progressed to T2DM. Adherence to appropriate metabolic monitoring was found to be overall suboptimal. The findings of this project demonstrate that patients in VISN 21 who were previously antipsychotic-naïve and nondiabetic may be at increased risk of progression to T2DM when compared with the general population. To effectively manage patient risk, health care providers and patients should improve adherence to metabolic monitoring.

Implementation of VA's Life-Sustaining Treatment Decisions Initiative: Facilitators and Barriers to Early Implementation Across Seven VA Medical Centers

ContextIn 2017, Veterans Health Administration (VHA) National Center for Ethics in Health Care began system-wide implementation of the Life-Sustaining Treatment Decisions Initiative (LSTDI). The LSTDI is a national VHA policy and practice to promote conducting goals of care conversations and documenting veterans' preferences for life-sustaining treatments (LSTs). ObjectivesThe aim of this article is to describe facilitators and barriers to early implementation of the LSTDI within one VHA Veterans Integrated Service Network. MethodsFrom September 2016 to December 2018, we conducted site visits and semistructured phone interviews with implementation coordinators who championed the LSTDI rollout at seven VHA medical centers. We applied the Consolidated Framework for Implementation Research (CFIR) to assess facilitators and barriers to implementing the LSTDI and assigning interview data to specific CFIR constructs and CFIR valence ratings. We simultaneously benchmarked VHA medical centers' implementation progress as outlined by the National Center for Ethics in Health Care implementation guidebook. ResultsWe divided sites into three descriptive groups based on implementation progress: successfully implemented (n = 2); moving forward, but delayed (n = 3); and implementation stalled (n = 2). Five CFIR constructs emerged as facilitators or barriers to implementation of the LSTDI: 1) self-efficacy of implementation coordinators; 2) leadership engagement; 3) compatibility with pre-existing workflows; 4) available resources; and 5) overall implementation climate. ConclusionAlthough self-efficacy proved key to overcoming obstacles, degree of perceived workflow compatibility of the LSTDI policy, available resources, and leadership engagement must be adequate for successful implementation within the implementation time line. Without these components, successful implementation was hindered or delayed.

Screening and Recognition of Chronic Kidney Disease in VA Health Care System Primary Care Clinics.

The successful implementation of interventions targeted to improve kidney health requires early identification of CKD which involves screening at-risk populations as well as recognizing CKD. We aim to determine CKD screening and recognition rates, factors associated with these rates, and evaluate the effect of CKD awareness on delivery of care. A retrospective cohort study of veterans enrolled with Veterans Integrated Service Network 17 who had hypertension (HTN) and/or diabetes (DM) and were seen at least twice in primary care clinics within 18 months. The final cohort of 270,170 patients (52% HTN, 5% DM, and 44% both) was examined for serum creatinine/eGFR, urine protein/albumin, International Classification of Diseases (ICD) codes for CKD, and nephrology referral. CKD was defined as eGFR <60 ml/min per 1.73 m2 and/or urine albumin-creatinine ratio (uACR) >30 mg/g at least twice 90 days apart. Clinical covariates, HTN control, and prescription rates of renal prudent medications and nonsteroidal anti-inflammatory drugs (NSAIDs) were assessed. Overall, 254,831 (94%) patients had either eGFR, urine protein/albumin, or both. However, screening for protein/albuminuria was low (56%), particularly in patients with isolated HTN (35%). Of 254,831 patients, 92,900 (36%) had laboratory evidence of CKD and, of these, 40,586 (44%) were recognized to have CKD by ICD code and/or nephrology referral. CKD due to presence of uACR criteria alone had the lowest recognition (19%) as compared with CKD due to eGFR criteria (44%) or both (67%). Frequency of emergency room visits, hospitalization, and cardiac and endovascular procedures requiring contrast had the highest odds and races other than white had the lower odds of screening. In contrast, CKD recognition was high in races other than white and increased with worsening eGFR and increasing uACR. In screened and recognized CKD, prescription was higher for angiotensin inhibitors, statins, and diuretics, and was lower for NSAIDs. Although overall CKD screening rate was high, screening of protein/albuminuria in isolated HTN and overall recognition of CKD was low in at-risk veterans. Increased recognition was associated with a favorable prescription rate for renal prudent medications.

Argentinian Digital Health Strategy.

Digital Health is one of the three pillars for the effective implementation of Universal Health Coverage in Argentina. The Ministry of Health published the National Digital Health Strategy 2018-2024 in order to establish the conceptual guidelines for the design and development of interoperable health information systems as a state policy. The World Health Organization "National eHealth Strategy Toolkit", "Global Strategy on Digital Health" and other international and local evidence and expert recommendations were taken into account. The path to better healthcare involves adopting systems at the point of care, allowing for the primary recording of information and enabling information exchange through real interoperability. In that way, people, technology and processes will synergize to enhance integrated health service networks. In this paper, we describe the plan and the first two years of implementation of the strategy.

457 Teledermatology service quality improvement at the Southeast Veterans’ Integrated Service Network

The Southeast Veterans’ Integrated Service Network (VISN7) has a robust teledermatology program providing services to community outpatient centers in Georgia, South Carolina and Alabama. Despite rapid growth of teledermatology across the Veterans Health Administration, there has not been standardization in teledermatology practices. To provide optimal, standardized consult readings among dermatologists at the VISN7, we examined adherence to 5 mutually agreed upon best practices. Quarterly from July 2018-August 2019, each physician was assigned a month to randomly review teledermatology consult cases and to evaluate if they adhered to the best practices. Evaluators commented on at least 3 of the 5 practices for each physician, marking “yes” or “no” for adherence. Overall, adherence to best practices was high among 7 dermatologists with an average adherence of 92.0% (Q1), 88.8% (Q2), and 93.0% (Q3). Between the first and last evaluation, 2 physicians improved adherence, 2 worsened adherence and 3 were consistently 100% adherent to all practices. Average adherence to each individual practice throughout the year was as follows: 1) Attendings should sign notes within 10 business days (100%); 2) Patients with cysts and keloids should be referred to general dermatology clinic initially (91%); 3) Primary care provider biopsy clinics should be utilized when available (80%); 4) The teledermatology nurse should be instructed to call patients prescribed oral corticosteroids and/or mid-to-high potency topical corticosteroids for follow-up, and to call patients prescribed topical fluorouracil or retinoids for education (91%); 5) Patients with cosmetic diagnoses should be aware of the VA non-cosmetic policy (64%). This study was limited to a 13-month review at a single facility and only examined 5 specific practices. We found high level of adherence to pre-specified practices and identified areas of improvement for dermatologists at the VISN7. Further studies are needed to examine whether adherence to these 5 practices improve patient outcomes.

Results of the Use of the Teleconsultation Platform After 2 Months of Implementation.

The Ministry of Health (MoH) set the National Digital Health Strategy 2018-2024 as a state policy. It included a National TeleHealth Plan to enhance access and quality of healthcare in a wide territory like Argentina, leveraging more than 20 years of national telemedicine experiences and coordinating it with the territorial integrated health service networks proposed by the Universal Health Coverage strategy. In collaboration with the Ministry of Modernisation, the MoH developed and implemented a new TeleHealth Web Platform to perform eReferrals and eConsultations nationwide. This poster describes the first 2 months of usage.

Outcomes of Paraesophageal Hernia Repair: Analysis of the Veterans Affairs Surgical Quality Improvement Program Database

BackgroundWhile there have been many outcome studies on paraesophageal hernia repair in the civilian population, there is sparse recent data on the veteran population. This study analyzes the mortality and morbidities of veterans who underwent paraesophageal hernia repair in the Veterans Affairs Surgical Quality Improvement Program database. MethodsVeterans who underwent paraesophageal hernia repair from 2010 to 2017 were identified using Current Procedural Terminology codes. Multivariable analysis was used to compare laparoscopic and open, including abdominal and thoracic approaches, groups. The outcomes were postoperative complications and mortality. ResultsThere were 1607 patients in the laparoscopic group and 366 in the open group, with 84.1% men and mean age of 61 years. Gender and body mass index did not influence the type of surgical approach. The mortality rates at 30 and 180 days were 0.5% and 0.7%, respectively. Postoperative complications, including reintubation (2.2%), pneumonia (2.0%), intubation > 48 h (2.0%), and sepsis (2.0%) were higher in the open group (15.9% versus 7.2%, p < 0.001). The laparoscopic group had a significantly shorter length of stay (4.3 versus 9.6 days, p < 0.001) and a lower percentage of return to surgery within 30 days (3.9% versus 8.2%, p < 0.001) than the open group. The ratio of open versus laparoscopic paraesophageal hernia repairs varied significantly by different Veterans Integrated Services Network regions. ConclusionsVeterans undergoing laparoscopic paraesophageal hernia repair experience similar outcomes as patients in the private sector. Veterans who underwent laparoscopic paraesophageal hernia repair had significantly less complications compared to an open approach even after adjusting for patient comorbidities and demographics. The difference in open versus laparoscopic practices between various regions requires further investigation.

Social determinants and emergency department utilization: Findings from the Veterans Health Administration

BackgroundSocial determinants of health (SDH) are strong predictors of morbidity and mortality but health care systems struggle to integrate documentation of SDH into health records in ways that can be used for health services research. Given the impact of social factors on health, it is important to examine the relationship with emergency department (ED) utilization. ObjectiveTo examine the association between seven indicators of SDH and ED utilization using electronic health record (EHR) data from the Veterans Health Administration (VHA). MethodsThis cross-sectional analysis included data from all patients who had at least one health care visit in the Veterans Integrated Service Network region 4 from October 1, 2015 through September 30, 2016 (n=293,872). Seven categories of adverse SDH included violence, housing instability, employment or financial problems, legal problems, social or family problems, lack of access to care or transportation, and non-specific psychosocial needs identified through structured coding in EHR. Negative binomial regression was used to examine the association of the count of adverse SDH (0–7) with the count of ED visits, adjusting for socio-demographic and health-related factors. ResultsApproximately 18% of patients visited the ED during the observation period. After adjusting for covariates, adverse SDH were positively associated with VHA ED utilization. Each of the SDH indicators, other than legal issues, was positively associated with increased ED utilization. ConclusionEven after accounting for several demographic and health-related factors, adverse SDH demonstrated strong positive associations with VHA ED utilization.

The shift in therapies for the treatment of chronic lymphocytic leukemia (CLL) patients in the US Veterans Health Administration (VHA) from 2013-2018.

e19339 Background: The first novel agent for use in CLL was approved in 2014; however, the extent of novel agent uptake in the VHA is largely unknown. Objective: This study described the pharmacoepidemiology of three novel agents (ibrutinib, idelalisib, venetoclax), and traditional chemotherapies/chemoimmunotherapies (CT/CIT) in the VHA. Methods: This was a retrospective study of 26,879 adults with CLL in the VHA from 10/01/2013 to 5/31/2018. All were followed for at least 6 months. Data were extracted from the VHA electronic health record. Patients came from all 18 Veterans Integrated Service Networks, spanning all 50 states and US territories. Descriptive statistics were used to summarize baseline characteristics, CLL treatments, next therapies, and secondary complications. Results: A total of 3670 patients received at least one of 12 CLL therapies of interest. Patients had a median age of 69 years (47% were 65+ and 26% were 75+), a median age-adjusted Charlson comorbidity score of 6, and 6% had a history of exposure to Agent Orange. Ibrutinib accounted for 89% of the novel agent use. Ibrutinib use across all lines of therapy (LOTs) increased sevenfold over the study period (Table). Venetoclax (42%) and idelalisib (30%) were the most common therapies for the next LOT after ibrutinib. Across all LOTs, traditional CT/CIT use declined steadily over the study period. However, in fiscal year (FY) 2018, there were still 17% of patients receiving CT/CIT. Ibrutinib was the most common therapy for the next LOT in these patients (43–74%). Incidence of diffuse large B cell lymphoma post-index was 2–6 times higher in patients on CT/CIT than those on ibrutinib. Other secondary complications were similar between ibrutinib and CT/CIT. Conclusions: To our knowledge, this is the largest study looking at CLL treatment patterns among VHA patients in the real world. There has been a major shift in the treatment of CLL, with fast adoption of novel agents in the VHA from 2013 to 2018. The impact of this shift on healthcare resource use and cost burden in the VHA will need to be examined. [Table: see text]

Trends in overall mortality among US veterans with intermediate (Int)/high-risk primary myelofibrosis (PMF).

e19534 Background: PMF is a heterogeneous disorder with variable outcomes and differential effects on overall survival (OS) based on risk. Data on the OS of veterans with MF are limited and represent a unique opportunity given the stability of longitudinal retrospective follow up in patients (pts) with multiple comorbid conditions. In phase 3 trials, ruxolitinib (RUX; Janus kinase [JAK]1/JAK2 inhibitor) improved OS in pts with MF [int2/high DIPSS] leading to FDA-approval in 2011. In this study, we investigated mortality trends among US veterans with PMF pre- and post-RUX approval. Methods: De-identified PMF pt-level data obtained from Veterans Integrated Service Networks using PMF diagnosis codes (ICD-9: 238.76, ICD-10: D47.1) were collected from 2 Veterans Health Administration (VHA) data periods (01JAN2006–31DEC2010 and 01JAN2014–30SEP2018) reflecting years pre- and post-RUX approval. The first PMF diagnosis in the identification periods (pre-RUX, 01JAN2007–31DEC2010; post-RUX, 01JAN2015–30SEP2018) was the index date. Pts were required to be continuously enrolled in the VHA plan from 1 calendar year prior to 6 mo after the index date. Pts also must have had int/high-risk PMF defined as ≥1 risk factor at diagnosis (age &gt; 65 y, hemoglobin [Hb] &lt; 10 g/dL, white blood cells [WBCs] &gt; 25 × 109/L). Demographic and clinical characteristics were recorded. All-cause 1-y, 2-y, and overall mortality rates and time to death from index until end of data availability were estimated using Kaplan-Meier (KM) methodology; univariate Cox regression was used to examine the hazard ratio (HR) for all-cause mortality for the pre- and post-RUX cohorts. Results: 244 and 1005 pts with PMF were included in the pre-and post-RUX cohorts, respectively. Most pts were age ≥65 y (84% vs 95%), male (99% vs 99%), and white (64% vs 77%). 64% vs 32% of pts had Hb &lt; 10 g/dL at PMF diagnosis and 20% vs 14% had WBCs &gt; 25 × 109/L for pre- and post-RUX cohorts, respectively. Based on KM analysis, the 1-y, 2-y, and overall mortality rates for pre- vs post-RUX periods were 45%, 63%, and 89% vs 27%, 37%, and 57%, respectively. Time from index PMF diagnosis to death was significantly longer for the post- vs pre-RUX cohort (median [95% CI], 1091 [989‒NR] vs 430 [347‒568] d; P&lt; 0.001), and risk of death was 47% lower in the post- vs pre-RUX period (HR, 0.53; P&lt; 0.001). Conclusions: In this retrospective analysis, patients with PMF had a high mortality rate; a 47% lower risk of mortality was observed post-RUX approval. Multiple factors may have influenced the lower mortality observed, which will be further explored.