United States Veterans Affairs Research Articles

Veterans in Northern Ireland: Evaluation of chronic pain experience, service type, and physical and mental health functioning.

Chronic pain is common and associated with disruptions in quality of life (QoL) and psychosocial functioning. These issues are particularly pronounced in veterans, although data in this regard primarily come from the United States Veterans Affairs System, meaning less is known regarding veterans of other countries and regions. The present study evaluated veterans living in Northern Ireland (NI), a region with historic high rates of both chronic pain and psychosocial difficulties associated with the decades-long period of civil and military conflict preceding the 1999 armistice (the Good Friday Agreement). Unique to the Northern Ireland military operation was the initiation of Home Service battalions comprised of local recruits, a role with increased risk due to the conflict's nature and the fact that they were serving as a military and security presence in their home region. A cross-sectional assessment of veterans living in Northern Ireland (N = 722) provided details of service type (Home Service vs other service), current health conditions (including chronic pain), and current psychosocial functioning (including physical and mental health QoL, anxiety, depression, and post-traumatic stress disorder [PTSD] symptoms). Findings indicated that those with chronic pain had worse QoL, anxiety, depression, and PTSD. Those with chronic pain were also more likely to have served in the Home Services, be unemployed, and be receiving disability payment. Contrary to hypotheses, there was no interaction between chronic pain and service type. These results extend previous work with veterans to the unique circumstances of a post-conflict military that engaged in operations within its own country and underscore the need for coordinated, efficacious interventions for co-morbid chronic pain and anxiety, depression, and PTSD.

50563 Anatomical Locations of Keratinocyte Carcinomas Among United States Veterans Affairs Healthcare System Patients in Minnesota

50563 Anatomical Locations of Keratinocyte Carcinomas Among United States Veterans Affairs Healthcare System Patients in Minnesota

Exploring Colorectal Cancer Screening Reach Among United States Veterans: Analyzing Clinical, Sociodemographic, and Social Determinants of Health-Based Patient Factors Across Screening Methods: Analyzing Clinical, Sociodemographic, and Social Determinants of Health-based Patient Factors Across Screening Methods.

Mailed fecal immunochemical testing (mFIT), in-clinic FIT (cFIT), and colonoscopy are believed to reach distinct patient populations. This study aims to evaluate this belief. Sociodemographic, clinical, and social determinants of health (SDOH) characteristics of 201 patients completing mFIT, 203 patients completing cFIT, and 74 patients completing colonoscopy at a Northeastern United States Veterans Affairs center from August 2023 to January 2024 were compared using descriptive statistics, χ2, and ANOVA tests. Patients completing mFIT (P=0.003) and cFIT (P=0.001) were older than those completing colonoscopy. mFIT patients had more private health insurance as compared with cFIT (P<0.0001) patients. Patients completing colonoscopy had higher average disability ratings as compared with cFIT patients (P<0.0001). mFIT (P<0.0001) and colonoscopy (P<0.0001) patients had more time elapsed since their last primary care visit as compared with cFIT patients. mFIT patients had lower rates of mental health disorders as compared with colonoscopy (P<0.0001) and cFIT (P<0.0001) patients. cFIT patients had higher rates of past stool test use as compared with mFIT (P<0.0001) and colonoscopy (P<0.0001) patients. mFIT patients had lower rates of past colonoscopy completion as compared with cFIT (P<0.0001) and colonoscopy (P<0.0001) patients. There were no significant differences in SDOH domains among patients completing each of the screening methods. While each of the screening methods reaches a different patient population, mFIT does not reach a substantially more vulnerable population compared with cFIT and colonoscopy, highlighting the need for improvements in mFIT outreach.

Challenges and Opportunities in Developing an Oncology Clinical Trial Network in the United States Veterans Affairs Health Care System: The VA STARPORT Experience.

The United States Veterans Affairs (VA) Health Care System has a strong history of conducting impactful oncology randomized clinical trials (RCTs). We developed a phase II/III RCT to test the use of metastasis-directed therapy in Veterans with oligometastatic prostate cancer (OMPC)-the first VA RCT in OMPC that leverages novel imaging and advanced radiotherapy techniques. To accomplish this, we developed a clinical trial network to conduct the study. In this manuscript, we describe several challenges we encountered in study development/conduct and our strategies to address them, with the goal of helping investigators establish robust study networks to conduct clinical trials. In the study start-up, we encountered challenges in timely site activation, and leveraged project management to maximize efficiency. Additionally, there were several changes in the clinical paradigms in imaging and treatment that led to protocol amendments to ensure maximum equipoise, recruitment, and impact of the study. Specifically, we amended the trial to add de novo OMPC patients (from initially only recurrent OMPC) and expanded the study to allow up to 10 metastases (from initially five). Finally, in order to maintain local study team engagement, we developed initiatives to maximize collaboration and add value to the overall clinical program through study participation.

Increasing goals of care conversations in primary care: Study protocol for a cluster randomized, pragmatic, sequential multiple assignment randomized trial

BackgroundGoals of care conversations explore seriously ill patients' values to guide medical decision making and often inform decisions about life sustaining treatments. Ideally, conversations occur before a health crisis between patients and clinicians in the outpatient setting. In the United States Veterans Affairs (VA) healthcare system, most conversations still occur in the inpatient setting. Strategies are needed to improve implementation of outpatient, primary care goals of care conversations. MethodsWe plan a cluster randomized (clinician-level) sequential, multiple assignment randomized trial to evaluate the effectiveness of patient implementation strategies on the outcome of goals of care conversation documentation when delivered in combination with clinician implementation strategies. Across three VA healthcare system sites, we will enroll primary care clinicians with low rates of goals of care conversations and their patients with serious medical illness in the top 10th percentile of risk of hospitalization or death. We will compare the effectiveness of sequences of implementation strategies and explore how patient and site factors modify implementation strategy effects. Finally, we will conduct a mixed-methods evaluation to understand implementation strategy success or failure. The design includes two key innovations: (1) strategies that target both clinicians and patients and (2) sequential strategies with increased intensity for non-responders. ConclusionThis study aims to determine the effect of different sequences and combinations of implementation strategies on primary care documentation of goals of care conversations. Study partners, including the VA National Center for Ethics in Health Care and Office of Primary Care, can consider policies based on study findings.

National rollout of a medication safety dashboard to improve testing for latent infections among biologic and targeted synthetic disease-modifying agent users within the Veterans Health Administration.

To develop, deploy, and evaluate a national, electronic health record (EHR)-based dashboard to support safe prescribing of biologic and targeted synthetic disease-modifying agents (b/tsDMARDs) in the United States Veterans Affairs Healthcare System (VA). We extracted and displayed hepatitis B (HBV), hepatitis C (HCV), and tuberculosis (TB) screening data from the EHR for users of b/tsDMARDs using PowerBI (Microsoft) and deployed the dashboard to VA facilities across the United States in 2022; we observed facilities for 44 weeks post-deployment. We examined the association between dashboard engagement by healthcare personnel and the percentage of patients with all screenings complete (HBV, HCV, and TB) at the facility level using an interrupted time series. Based on frequency of sessions, facilities were grouped into high- and low/none-engagement categories. We modeled changes in complete screening pre- and post-deployment of the dashboard. All VA facilities were eligible for inclusion; excluded facilities participated in design of the dashboard or had <20 patients receiving b/tsDMARDs. Session counts from facility personnel were captured using PowerBI audit log data. Outcomes were assessed weekly based on EHR data extracted via the dashboard itself. Totally 117 facilities (serving a total of 41,224 Veterans prescribed b/tsDMARDs) were included. Before dashboard deployment, across all facilities, 61.5% of patients had all screenings complete, which improved to 66.3% over the course of the study period. The largest improvement (15 percentage points, 60.3%-75.3%) occurred among facilities with high engagement (post-intervention difference in outcome between high and low/none-engagement groups was 0.17 percentage points (pp) per week, 95% confidence interval (0.04 pp, 0.30 pp); p = 0.01). We observed significant improvements in screening for latent infections among facilities with high engagement with the dashboard, compared with those with fewer sessions.

Prospective randomized controlled trial of water exchange plus cap versus water exchange colonoscopy in unsedated veterans

Background and AimsWater exchange (WE) and cap-assisted colonoscopy (CAC) separately reduced pain during insertion in unsedated patients. We hypothesized that compared with WE, WECAC could significantly lower real-time maximum insertion pain (RTMIP). MethodsVeterans without escort were recruited, randomized, blinded, and examined at three United States Veterans Affairs sites. The primary outcome was RTMIP, highest segmental pain (0 = no pain, 10 = most severe pain) during insertion. ResultsRandomization [WECAC (n = 143) and WE (n = 137)] produced even distribution of a racially diverse group of males and females of low socioeconomic status. Intention-to-treat analysis reported results of WECAC (listed first) and WE (listed second): cecal intubation [93%, 94.2%]; mean (SD) of RTMIP [2.9 (2.5), 2.6 (2.4)]; the proportion with no pain (28.7%, 27.7%); the insertion time [18.6 (15.6), 18.8 (15.9) min]; overall ADR (55.2%, 62.8%), all P values were > 0.05. When RTMIP was binarized as "no pain" (0) vs. "some pain" (1-10), or "low pain" (0-7) vs. "high pain" (8-10), different significant predictors (see text) of RTMIP were identified. ConclusionsUnsedated colonoscopy was appropriate for unescorted Veterans. WE alone was sufficient. Adding a cap did not reduce RTMIP. Patient specific factors and application of WE with insertion suction of infused water contributed to high and low RTMIP, respectively. For unesorted patients, selecting those with low anxiety, avoiding low body mass index, history of depression or self-reported poor health and adhering to the steps of WE can minimize RTMIP to ensure success of unsedated colonoscopy.

Epidemiology, treatment patterns, and clinical outcomes in de novo oligometastatic hormone-sensitive prostate cancer.

This study was conducted to better characterize the epidemiology, clinical outcomes, and current treatment patterns of de novo oligometastatic hormone-sensitive prostate cancer (omHSPC) in the United States Veterans Affairs Health Care System. In this observational retrospective cohort study, 400 de novo metastatic hormone-sensitive PC (mHSPC) patients diagnosed from January 2015 to December 2020 (follow-up through December 2021) were randomly selected. omHSPC was defined as five or less total metastases (excluding liver) by conventional imaging. Kaplan-Meier methods estimated overall survival (OS) and castration-resistant prostate cancer (CRPC)-free survival from mHSPC diagnosis date and a log-rank test compared these outcomes by oligometastatic status. Twenty percent (79 of 400) of de novo mHSPC patients were oligometastatic. Most baseline characteristics were similar by oligometastatic status; however, men with non-omHSPC had higher median prostate-specific antigen at diagnosis (151.7) than omHSPC (44.1). First-line (1L) novel hormonal therapy was similar between groups (20%); 1L chemotherapy was lower in omHSPC (5%) versus non-omHSPC (14%). More omHSPC patients received metastasis-directed therapy/prostate radiation therapy (14%) versus non-omHSPC (2%). Median OS and CRPC-free survival (in months) were higher in omHSPC versus non-omHSPC (44.4; 95% confidence interval [CI], 33.9-not estimated vs. 26.2; 95% CI, 20.5-32.5, p=.0089 and 27.6; 95% CI, 22.1-37.2 vs. 15.3; 95% CI, 12.8-17.9, p=.0049), respectively. Approximately 20% of de novo mHSPC were oligometastatic, and OS was significantly longer in omHSPC versus non-omHSPC. Although potentially "curative" therapy use was higher in omHSPC versus non-omHSPC, the percentages were still relatively low. Future studies are warranted given potential for prolonged responses with multimodal therapy inclusive of systemic and local therapies.

CO211 Gout Epidemiology, Pharmacotherapy, Healthcare Utilization, and Outcomes for United States Veterans Affairs Patients From 2016 to 2022

CO211 Gout Epidemiology, Pharmacotherapy, Healthcare Utilization, and Outcomes for United States Veterans Affairs Patients From 2016 to 2022

Survival and multidisciplinary amyotrophic lateral sclerosis clinic care at a United States Veterans Affairs medical center

Introduction/Aims: The purpose of this work was to investigate survival outcomes in patients with amyotrophic lateral sclerosis (ALS) at our Veteran’s Affairs Medical Center multidisciplinary ALS clinic and compare this to relevant data from several European studies.&#x0D; Methods: Our sample consisted of 56 total Veterans (n=56; 54 males, 2 females) that had been seen between June 24, 2013 and February 1, 2021 at our multidisciplinary ALS clinic.&#x0D; Results: The median survival time of our Veterans from symptom onset was 40.96 months (95% CI of 32.17, 76.07), and the median survival time from diagnosis was 23.77 months (95% CI of 18.64, 38.58). This was consistent with the literature. Further consistent with the literature is that multidisciplinary clinics, including ours, have survival advantage over general neurology clinics. Analyzing factors that contributed to this survival, we found significant protective effect on survival from Edaravone use (HR = 0.32, p = 0.036). Otherwise, there was no significant effect on survival noted from use of percutaneous endoscopic gastrostomy (PEG), non-invasive ventilation (NIV), or Riluzole.&#x0D; Conclusion: We found no significant difference in survival rates between our U.S. Veterans in our multidisciplinary ALS clinic and European multidisciplinary ALS clinics, and both are better than general neurology clinics. We also found that Edaravone use may provide some benefit to survival in this patient population.

Ten-year atherosclerotic cardiovascular disease risk trajectories among women veteran cancer patients

Despite a higher risk of cardiovascular disease (CVD) events in women cancer survivors than their male counterparts, importance of female sex has been underestimated due to under-representation of women in clinical research and male dominant CVD risk models. This study examined ten-year Atherosclerosis Cardiovascular Disease (ASCVD) risk trajectories in women veterans diagnosed with the ten most common cancers—bladder, breast, colorectal, endometrial/uterine/cervix, leukemia, liver, lung and bronchium, Non-Hodgkin’s lymphoma, melanoma, and thyroid cancer—using United States (US) Veterans Affairs (VA) Electronic Health Records data. The study included 78,556 women veterans aged between 30 and 80 years from diverse backgrounds treated at VA hospitals with ≥2 complete outpatient visit records in the VA health care system between January 01, 2007 and December 31, 2017. A steep rise in ASCVD risk score trajectories post-cancer diagnosis was observed among women diagnosed with bladder, breast, liver, lung and thyroid cancer, melanoma, and Non-Hodgkin’s lymphoma, compared to pre-cancer diagnosis periods, as well as significantly elevated pre-cancer ASCVD risk among all patients with cancer, other than thyroid cancer, compared to the no cancer group (p < 0.0001). ASCVD risk monitoring is highly recommended to reduce adverse cardiovascular events for women diagnosed with cancer, survivors, and for women at risk of future cancer incidences.

Unrealized opportunities for cardiovascular risk reduction with optimized statin and ezetimibe in veterans with coronary artery disease

Abstract Background Many patients with coronary artery disease (CAD) do not achieve guideline-directed low-density lipoprotein cholesterol (LDL-C) goals (1,2). Purpose To quantify unrealized opportunities to improve clinical outcomes of Veterans with CAD through optimized oral lipid-lowering therapy (LLT) with statins and ezetimibe within the United States Veterans Affairs healthcare system. Methods Veterans with CAD by coronary angiography between 2015 and 2020 were identified, the observed LLT and LDL-C were described, and the observed rates of death, myocardial infarction, stroke, and coronary revascularization were determined. Potential reductions in these events with optimized statin alone or with ezetimibe were modelled based on expected further LDL-C reductions (3). Results The analysis cohort comprised 111,954 Veterans (59.7% statin-treated at baseline angiography) observed for median 3.4 (IQR 2.1-4.0) years. At 6 months, statin prescription increased to 68.7%, but high-intensity statin regimens were prescribed in only 52.9%, ezetimibe use was low (1.1%), and LDL-C remained ≥70 mg/dL in 52.1% of patients. At 4 years, observed incidences (95% CI) of death, myocardial infarction, stroke, and coronary revascularization were 21.6% (21.3-21.8), 5.0% (4.9-5.2), 2.2% (2.1-2.3), and 15.4% (15.2-15.7), respectively (Figure 1). With optimized statin, projected absolute reductions in these incidences were 1.3% (0.9-1.7), 0.8% (0.7-1.0), 0.2% (0.1-0.3), and 2.3% (2.0-2.7). With optimized statin and ezetimibe, projected absolute reductions were 1.8% (1.2-2.4), 1.1% (0.9-1.3), 0.3% (0.2-0.4) and 3.1% (2.6-3.6). Conclusions Suboptimal LLT was prevalent among Veterans with CAD. Meaningful improvements in their cardiovascular outcomes could be achieved with optimized statin alone. Despite lesser lipid-lowering efficacy of ezetimibe, its widespread use on a population level could contribute substantially to cardiovascular risk reduction from intensified oral LLT.Figure 1Figure 2

Rule-Based Identification of Individuals with Mild Cognitive Impairment or Alzheimer's Disease Using Clinical Notes from the United States Veterans Affairs Healthcare System.

Early identification of individuals with mild cognitive impairment (MCI) and Alzheimer's disease (AD) is a clinical and research imperative. Use of diagnostic codes for MCI and AD identification has limitations. We used clinical notes to supplement diagnostic codes in the Veterans Affairs Healthcare System (VAHS) electronic health records (EHR) to identify and establish cohorts of Veterans recorded with MCI or AD. Targeted keyword searches for MCI ("Mild cognitive impairment;" "MCI") and AD ("Alz*") were used to extract clinical notes from the VAHS EHR from fiscal year (FY) 2010 through FY 2019. Iterative steps of inclusion and exclusion were applied until searches achieved a positive predictive value ≥ 80%. MCI and AD cohorts were identified via clinical notes and/or diagnostic codes (i.e., including Veterans recorded by "Notes Only," "Notes + Code," or "Codes Only"). A total of 2,134,661 clinical notes from 339,007 Veterans met the iterative search criteria for MCI due to any cause and 4,231,933 notes from 572,063 Veterans met the iterative search criteria for AD. Over the 10-year study period, the number of clinical notes recording AD was generally stable, whereas the number for MCI more than doubled. More Veterans were identified for the MCI or AD cohorts via clinical notes than by diagnostic codes, particularly in the AD cohort. Among Veterans identified by having "Notes + Code" for MCI, the number first recorded by a code was lower than the number first recorded by a note until FY 2015 and then gradually became comparable after FY 2015. Among Veterans identified by having "Notes + Code" for AD, the number first recorded by a note was more than double the number first recorded by a code AD in each of the FYs. Clinical note-based identification captured more Veterans recorded with MCI and AD than diagnostic code-based identification.

The Impact of a Narrative Medicine Life Story Pilot Program on Press Ganey™ Scores in an Outpatient Cancer Center

ABSTRACT Oncology patients face challenges beyond those directly affecting their cancer management. Guided personal narrative programs have been shown to help patients with chronic conditions and life-framing events. Few such narrative programs have been reported for cancer patients or analyzed for their impact on patient experience. We established our Life Story Narrative Program, modeled on the United States Veterans Affairs’ “My Life, My Story” for outpatient oncology patients in our hospital’s cancer center. Press Ganey™ patient experience scores from program participants were compared retrospectively with scores from patients who were not participants. Over an eight-month period, we invited 30 cancer center outpatients to participate. Twenty-seven individuals accepted, and 18 had their stories edited, approved, and scanned into their electronic health record. Cohort matching yielded a control arm consisting of 255 responses from 48 surveys, while the intervention arm consisted of 68 responses from 12 surveys. 78.4% of responses from the control arm were rated 5 compared with 100% in the intervention arm. The mean Press Ganey™ score response in the control arm was 4.71 compared with 5.00 from the intervention arm. Wilcoxon U value was 10,540 with p < .001. An outpatient narrative medicine program for cancer patients to tell their life stories can easily be organized. Patients were willing to participate, enrollment was brisk, and the use of resources was limited. Although our sample size was small, participation in our Life Story Narrative Pilot Program resulted in a statistically significant improvement in Press Ganey™ scores.

Liver Disease Is a Risk Factor for Recurrent Hyperkalemia: A Retrospective Cohort Study.

Liver disease is often associated with dysfunctional potassium homeostasis but is not a well-established risk factor for hyperkalemia. This retrospective cohort study examined the potential relationship between liver disease and recurrent hyperkalemia. Patients with ≥1 serum potassium measurement between January 2004 and December 2018 who experienced hyperkalemia (serum potassium >5.0 mmol/L) were identified from the United States Veterans Affairs database. A competing risk regression model was used to analyze the relationship between patient characteristics and recurrent hyperkalemia. Of 1,493,539 patients with incident hyperkalemia, 71,790 (4.8%) had liver disease (one inpatient or two outpatient records) within 1 year before the index hyperkalemia event. Recurrent hyperkalemia within 1 year after the index event occurred in 234,807 patients (15.7%) overall, 19,518 (27.2%) with liver disease, and 215,289 (15.1%) without liver disease. The risk of recurrent hyperkalemia was significantly increased in patients with liver disease versus those without (subhazard ratio, 1.34; 95% confidence interval, 1.32-1.37; p < 0.0001). Aside from vasodilator therapy, the risk of recurrent hyperkalemia was not increased with concomitant medication. In this cohort study, liver disease was an independent risk factor strongly associated with recurrent hyperkalemia within 1 year, independent of concomitant renin-angiotensin-aldosterone system inhibitor or potassium-sparing diuretic use.

Decreasing Antibiotic Resistance Trends Nationally in Gram-Negative Bacteria Across United States Veterans Affairs Medical Centers, 2011-2020.

Gram-negative resistance is a well-acknowledged public health threat. Surveillance data can be used to monitor resistance trends and identify strategies to mitigate their threat. The objective of this study was to assess antibiotic resistance trends in Gram-negative bacteria. The first cultures of Pseudomonas aeruginosa, Citrobacter, Escherichia coli, Enterobacter, Klebsiella, Morganella morganii, Proteus mirabilis, and Serratia marcescens per hospitalized patient per month collected from 125 Veterans Affairs Medical Centers (VAMCs) between 2011 to 2020 were included. Time trends of resistance phenotypes (carbapenem, fluoroquinolone, extended-spectrum cephalosporin, multi-drug, and difficult-to-treat) were analyzed with Joinpoint regression to estimate average annual percent changes (AAPC) with 95% confidence intervals and p values. A 2020 antibiogram of reported antibiotic percent susceptibilities was also created to evaluate resistance rates at the beginning of the COVID-19 pandemic. Among 40 antimicrobial resistance phenotype trends assessed in 494,593 Gram-negative isolates, there were no noted increases; significant decreases were observed in 87.5% (n = 35), including in all P. aeruginosa, Citrobacter, Klebsiella, M. morganii, and S. marcescens phenotypes (p < 0.05). The largest decreases were seen in carbapenem-resistant phenotypes of P. mirabilis, Klebsiella, and M. morganii (AAPCs: - 22.9%, - 20.7%, and - 20.6%, respectively). In 2020, percent susceptibility was over 80% for all organisms tested against aminoglycosides, cefepime, ertapenem, meropenem, ceftazidime-avibactam, ceftolozane-tazobactam, and meropenem-vaborbactam. We observed significant decreases in antibiotic resistance for P. aeruginosa and Enterobacteralesover the past decade. According to the 2020 antibiogram, in vitro antimicrobial activity was observed for most treatment options. These results may be related to the robust infection control and antimicrobial stewardship programs instituted nationally among VAMCs.

Utilization of imaging reports for management of suspected lumbar spinal stenosis in the Veterans Administration

Background and PurposeThe interprofessional gap between neurosurgeons and neuroradiologists has been increasing steadily since the implementation of electronic health record systems and remote radiology readings. Our aim was to survey and report the current practices employed by neurosurgeons in utilizing neuroradiology reports for management of patients with lumbar spinal stenosis. Materials and MethodsA voluntary survey was distributed among a group of neurosurgeons affiliated with the United States Veterans Affairs Health System. Survey questions were aimed at assessing the trends and the subsequent practice patterns in neurosurgical utilization of neuroradiology reports in patients with LSS. Results20 out of 43 respondents across all surveyed VAHS centers completed the survey, achieving a 46.5% response rate. 95% (19/20) of respondents had an on-site radiologist, while 80% (16/20) had access to a neuroradiologist. 95% (19/20) of respondents report having imaging routinely read by a neuroradiologist. 40% (8/20) of the neurosurgeons read the ordered radiology reports less than 50% of the time. Only 20% of respondents always read the neuroradiology report. 60% (12/20) of the surveyed neurosurgeons frequently reported major discrepancies between imaging interpretation among neuroradiologists and the surveyed neurosurgeons, with only 45% (9/20) neurosurgeons contacting the neuroradiologist to discuss discrepancies. Furthermore, a majority of neurosurgeons do not routinely participate in conferences where imaging is discussed. ConclusionsOur results suggest that the increase in teleradiology and remote readings may cause neurosurgeons to largely ignore radiology reports and major discrepancies in imaging interpretation when treating suspected LSS. Whether such practices lead to altered surgical outcomes and affect healthcare costs warrants further investigation.

Blood count derangements after sepsis and association with post-hospital outcomes.

Predicting long-term outcomes in sepsis survivors remains a difficult task. Persistent inflammation post-sepsis is associated with increased risk for rehospitalization and death. As surrogate markers of inflammation, complete blood count parameters measured at hospital discharge may have prognostic value for sepsis survivors. To determine the incremental value of complete blood count parameters over clinical characteristics for predicting 90-day outcomes in sepsis survivors. Electronic health record data was used to identify sepsis hospitalizations at United States Veterans Affairs hospitals with live discharge and relevant laboratory data (2013 to 2018). We measured the association of eight complete blood count parameters with 90-day outcomes (mortality, rehospitalization, cause-specific rehospitalizations) using multivariable logistic regression models. We identified 155,988 eligible hospitalizations for sepsis. Anemia (93.6%, N=142,162) and lymphopenia (28.1%, N=29,365) were the most common blood count abnormalities at discharge. In multivariable models, all parameters were associated with the primary outcome of 90-day mortality or rehospitalization and improved model discrimination above clinical characteristics alone (likelihood ratio test, p<0.02 for all). A model including all eight parameters significantly improved discrimination (AUROC, 0.6929 v. 0.6756) and reduced calibration error for the primary outcome. Hemoglobin had the greatest prognostic separation with a 1.5 fold increased incidence of the primary outcome in the lowest quintile (7.2-8.9 g/dL) versus highest quintile (12.70-15.80 g/dL). Hemoglobin and neutrophil lymphocyte ratio provided the most added value in predicting the primary outcome and 90-day mortality alone, respectively. Absolute lymphocyte count added little value in predicting 90-day outcomes. The incorporation of discharge complete blood count parameters into prognostic scoring systems could improve prediction of 90-day outcomes. Hemoglobin had the greatest prognostic value for the primary composite outcome of 90-day rehospitalization or mortality. Absolute lymphocyte count provided little added value in multivariable model comparisons, including for infection- or sepsis-related rehospitalization.

Epidemiology, treatment patterns, and clinical outcomes in de novo oligometastatic hormone-sensitive prostate cancer.

92 Background: Oligometastatic hormone-sensitive prostate cancer (omHSPC) represents an advanced prostate cancer subset where metastasis-directed therapy (MDT) and prostate radiation therapy (RT) may improve clinical response and outcomes; however, there is a lack of published data on the epidemiology, clinical outcomes, and current treatment patterns. As such, we conducted a study to better characterize de novo omHSPC in the United States Veterans Affairs Health Care System (VA). Methods: This observational retrospective cohort study utilized chart abstracted data from the VA electronic medical record, as well as data from the VA Corporate Data Warehouse, a central repository of VA patient medical records. We randomly selected 400 men diagnosed with de novo mHSPC from 1/2015-12/2020. omHSPC was defined as up to 5 bone, lymph node, and/or visceral (excluding liver) metastases in total, identified by conventional imaging (bone scan, CT, and/or MRI). We estimated prevalence, described treatment patterns and used Kaplan-Meier methods to estimate overall survival (OS) and time to castration resistance from date of mHSPC diagnosis. The log rank test was used to compare differences in outcomes between omHSPC and non-omHSPC groups. Results: Of the 400 men with de novo mHSPC, 76 (19%) had omHSPC by conventional imaging. Men with omHSPC and non-omHSPC were similar in age, race, Gleason grade group, comorbidities, and metastatic site (bone and lymph node being most common). Men with non-omHSPC had a higher median PSA at mHSPC diagnosis (147.0) than omHSPC (38.3). The percentage of men on first-line (1L) novel hormonal therapy (NHT) use (most commonly abiraterone or enzalutamide) was similar between groups in the 1L setting (22.4% (omHSPC) vs 20.4% (non-omHSPC)), but the percentage of men on a 1L chemotherapy regimen was lower in omHSPC (5.3%) vs. non-omHSPC (13.6%). Overall, there was a higher percentage of men treated with MDT or prostate RT in omHSPC (13.2%) vs non-omHSPC cases (2.5%). Median OS in months (mos) was higher in men with omHSPC (55.3 mos, 95% CI 35.9-79.0) vs. non-omHSPC (25.9 mos, 95% CI 20.5-31.7, p=0.002). Median time to castration resistance was also longer in omHSPC (not reached [NR], 95% CI 42.2-NR) vs. non-omHSPC (29.3 mos, 95% CI 23.7-36.1, p=0.0014). Conclusions: Our study provides real-world insight into the prevalence, treatment patterns and clinical outcomes for omHSPC using a nationally representative VA sample. Approximately 1 in 5 men with de novo mHSPC were oligometastatic, and OS in men with omHSPC was more than double that of non-omHSPC. Although more men with omHSPC compared to non-omHSPC received potential curative therapy, the percentage was still relatively low. Future studies are warranted as several clinical trials are investigating the potential for prolonged responses with aggressive, multimodal therapy inclusive of systemic and local therapies.

Concordance and discordance in disease severity classification between clinician judgments and cognitive testing scores for Alzheimer’s disease in the United States Veterans Affairs Healthcare System

AbstractBackgroundThe current standard of practice for assessment of Alzheimer’s disease (AD) severity in the Department of Veterans Affairs (VA) Healthcare System is primarily based on clinical examination and cognitive testing. We aimed to assess the consistency between clinician judgements of AD severity compared with that classified by cognitive test scores in the VA system.MethodWe identified medical notes for patients with mild, moderate, or severe AD from the VA electronic healthcare records (EHR) database between March 2008 and October 2021, using the natural language processing technology. Mini‐Mental Status Exam (MMSE) and Montreal Cognitive Assessment (MoCA) scores from the corresponding medical notes with physician judgments were classified and used for comparisons of severity levels. A binary variable was coded to indicate concordance or discordance for each paired comparison.ResultWe screened clinical notes from 51,809 AD patients and analyzed 8,888 clinical notes that had either an MMSE or MoCA test score from 5,150 AD patients (3.5% female; average age at 78.1±9.4 years). Clinician judgements and test‐score‐based classification of AD severity were concordant in 53.2% of comparisons (weighted Kappa = 0.39, 95% CI:0.38‐0.41, p = 0.009); whereas clinician judgments were less severe in 25.7% and more severe in 21.1% comparisons, relative to the test‐score‐based severity level. Clinician judgments were concordant with 54.1%, 51.8%, and 53.0% cognitive test‐score‐based classifications, of mild, moderate, and severe AD, respectively. Concordance was observed in 55.9% clinician judgments involving internist, 53.0% involving psychiatrist or neurologist, and 51.7% involving psychologist specialties, and in 50.4% involving nurse practitioners. Among discordant severity classifications, clinician judgments tended to be less severe than test scores (Figure).ConclusionExamination of VA EHR reveals that nearly one half of clinician judgments of AD severity are discordant with severity classification based on the MMSE or MoCA test scores. Discordance is more pronounced in the moderate relative to mild and severe AD categories but does not vary substantially over clinicians’ specialty background. Research will aim to find plausible explanations for the variation of concordance vs discordance by further examining the relative contributions of patient, clinician, and system characteristics in the process of AD clinical assessments.