US Veterans Affairs Health Care Research Articles

Effectiveness of BNT162b2 XBB vaccine in the US Veterans Affairs Healthcare System

Data evaluating effectiveness of XBB.1.5-adapted vaccines against JN.1-related endpoints are scarce. This nationwide test-negative case-control study within the US Veterans Affairs Healthcare System aims to estimate vaccine effectiveness (VE) of BNT162b2 XBB.1.5-adapted vaccine compared to not receiving an XBB vaccine of any kind against COVID-19 hospitalization, emergency department or urgent care visits (ED/UC), and outpatient visits. Between September 25, 2023 and January 31, 2024, effectiveness was 24–35% during a period of JN.1 predominance and 50–61% during XBB predominance across all outcomes. VE within 60 days of vaccination during the likely JN.1 period was 32% (95% confidence interval 3–52%) against hospitalization, 41% (23–54%) against ED/UC visits, and 31% (1–52%) against outpatient visits. Corresponding VE during the likely XBB period was 62% (44–74%), 52% (37–63%), and 50% (25–66%) by setting, respectively. Here, we show the importance of strain match to maximize the public health impact of COVID-19 vaccination.

Trends in infection incidence and antimicrobial resistance in the US Veterans Affairs Healthcare System: a nationwide retrospective cohort study (2007–22)

Antimicrobial resistance poses a major threat to public health. There are few comprehensive nationwide studies that quantify long-term trends in infection incidence and antimicrobial resistance for multiple pathogens. We aimed to analyse trends in inpatient infection incidence and antimicrobial resistance for nine pathogens over the past 15 years across the USA. In this US nationwide retrospective cohort study, we analysed clinical microbiology data from electronic health records from all patients admitted to all 138 Veterans Affairs (VA) Medical Centers with acute care wards across the USA from Feb 1, 2007, to March 31, 2022. We quantified inpatient antibiotic use as days of therapy (DOT) per 1000 patient-days and antimicrobial resistance by resistance proportion (proportion of incident isolates identified as resistant) and phenotypic incidence (incidence of infections per 1000 admissions classified as resistant, susceptible, or missing). To analyse trends before the COVID-19 pandemic and during the COVID-19 pandemic, we used generalised estimating equation models and reported average annual percentage changes (AAPC). We collected 991 527 30-day incident isolates from 507 760 patients in 138 VA Medical Centers and 50 states in the USA. Between Feb 1, 2007, and Dec 31, 2019, infection incidence and antimicrobial resistance declined for many pathogens and pathogen-drug combinations. The proportion of methicillin resistance in Staphylococcus aureus decreased from 57·7% (11 876 of 20 584 incident isolates) to 44·6% (5916 of 13 257) over these 13 years (AAPC -1·8%; 95% CI -2·4 to -1·2; p<0·0001), and vancomycin-resistant Enterococcus faecium infections decreased from 77·8% (2555 of 3285) to 65·1% (893 of 1371; AAPC -1·2%; 95% CI -2·5 to 0·0; p=0·052). Fluoroquinolone resistance declined in both proportion and incidence for most pathogens. These trends correlated with substantial reductions in fluoroquinolone use, from 125 DOT per 1000 patient-days to 20 DOT per 1000 patient-days. Third generation cephalosporin resistance increased steeply in Escherichia coli infections from 6·7% (942 of 14 042) in 2007 to 15·3% (2153 of 14 053) in 2019 (AAPC 8·5%; 95% CI 6·2 to 10·7; p<0·0001). Carbapenem resistance proportion increased in Enterobacter cloacae infections from 1·1% (30 of 2852) in 2007 to 7·3% (212 of 2919) in 2019 (AAPC 19·8%; 95% CI 13·7 to 26·2; p<0·0001), but remained low for Klebsiella pneumoniae and E coli. During the COVID-19 pandemic between Jan 1, 2020, and March 31, 2022, several pathogen-drug combinations increased in both incidence and resistance for hospital-associated infections. For some pathogen-drug combinations, trends in incidence of resistant and susceptible infections were divergent, whereas for other combinations, these trends were in the same direction. Significant reductions in methicillin resistance in S aureus, vancomycin-resistant E faecium, and fluoroquinolone resistance across multiple pathogens suggest that control efforts have had an effect on resistance. The rise in extended-spectrum β-lactamases-producing Enterobacterales and recent surge in hospital-associated infections emphasise the need for ongoing surveillance and interventions. Our study highlights how coupling the analysis of phenotypic incidence with resistance proportion can enhance interpretation of antimicrobial resistance data. US Centers for Disease Control and Prevention.

Antidepressant exposure and long-term dementia risk in a nationwide retrospective study on US veterans with midlife major depressive disorder.

The use of antidepressants in major depressive disorder (MDD) has been reported to influence long-term risk of Alzheimer's disease (AD) and AD-related dementias (AD/ADRD), but studies are conflicting. We used inverse probability weighted (IPW) Cox models with time-varying covariates in a retrospective cohort study among midlife veterans with MDD within the US Veterans Affairs healthcare system from January 1, 2000 to June 1, 2022. A total of 35,200 patients with MDD were identified. No associations were seen regarding the effect of being exposed to any antidepressant versus no exposure on AD/ADRD risk (events=1,056, hazard ratio=0.94, 95% confidence interval: 0.81 to 1.09) or the exposure to specific antidepressant classes versus no exposure. A risk reduction was observed for female patients in a stratified analysis; however, the number of cases was small. Our study suggests that antidepressant exposure has no effect on AD/ADRD risk. The association in female patients should be interpreted with caution and requires further attention. We studied whether antidepressant use was associated with future dementia risk. We specifically focused on patients after their first-ever diagnosis of depression. We used IPW Cox models with time-varying covariates and a large observation window. Our study did not identify an effect of antidepressant use on dementia risk. A risk reduction was observed in female patients, but the number of cases was small.

Racial disparities in stage at bladder cancer diagnosis in the US Veterans Affairs healthcare system.

To describe patient characteristics and pathological stage at bladder cancer (BCa) diagnosis in a diverse population within a national, equal-access healthcare system. This retrospective cohort study identified 15 966 men diagnosed with BCa in the Veterans Affairs (VA) healthcare system from 2000 to 2020. The primary outcome was pathological stage at diagnosis, determined by index transurethral resection of bladder tumour. Logistic regression was used to assess the relationship between race and stage. Competing risk models tested the association between race and BCa-specific mortality with cumulative incidence estimates. Of 15 966 BCa patients, 12 868 (81%), 1726 (11%), 493 (3%) and 879 (6%) were White, Black, Hispanic and Other race, respectively. Black patients had significantly higher muscle-invasive bladder cancer (MIBC) rates than White patients (35% vs 32%; P = 0.009). In multivariable analysis, the odds of presenting with MIBC did not differ significantly between Black and White patients (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.98-1.22) or between Hispanic patients (OR 0.82, 95% CI 0.67-1.01) and White patients. Compared to White patients, Black patients had a similar risk of BCa-specific mortality (hazard ratio [HR] 0.89, 95% CI 0.75-1.06), whereas Hispanic patients had a lower risk (HR 0.56, 95% CI 0.38-0.82). Black patients presented with the highest rates of de novo MIBC. However, in a large, equal-access healthcare system, this did not result in a difference in BCa-specific mortality. In contrast, Hispanic patients had lower risks of MIBC and BCa-specific mortality.

Clinician Burnout and Effectiveness of Guideline-Recommended Psychotherapies

Clinician burnout has been associated with clinician outcomes, but the association with patient outcomes remains unclear. To evaluate the association between clinician burnout and the outcomes of patients receiving of guideline-recommended trauma-focused psychotherapies for posttraumatic stress disorder (PTSD). This cohort study was set at the US Veterans Affairs Health Care System and included licensed therapists who provided trauma-focused psychotherapies and responded to an online survey between May 2 and October 8, 2019, and their patients who initiated a trauma-focused therapy during the following year. Patient data were collected through December 31, 2020. Data were analyzed from May to September 2023. Therapists completing the survey reported burnout with a 5-point validated measure taken from the Physician Worklife Study. Burnout was defined as scores of 3 or more. The primary outcome was patients' clinically meaningful improvement in PTSD symptoms according to the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Patient dropout, therapist adherence, and session spacing was assessed through electronic health records. Multivariable random-effects logistic regression examined the association of therapist burnout and clinically meaningful improvement, adjusted for case-mix. In this study, 165 of 180 (91.7%) therapists (89 [53.9%] female) completed the burnout measure and provided trauma-focused psychotherapies to 1268 patients (961 [75.8%] male) with outcome data. Fifty-eight (35.2%) therapists endorsed burnout. One third of patients (431 [34.0%]) met criterion for clinically meaningful improvement. Clinically meaningful improvement in PTSD symptoms was experienced by 120 (28.3%) of the 424 patients seen by therapists who reported burnout and 311 (36.8%) of the 844 patients seen by therapists without burnout. Burnout was associated with lower odds of clinically meaningful improvement (adjusted odds ratio [OR],0.63; 95% CI, 0.48-0.85). The odds of clinically meaningful improvement were reduced for patients who dropped out (OR, 0.15; 95% CI, 0.11-0.20) and had greater session spacing (OR, 0.80; 95% CI, 0.70-0.92). Therapist adherence was not associated with therapy effectiveness. Adjusting for dropout or session spacing did not meaningfully alter the magnitude of the association between burnout and clinically meaningful improvement. In this prospective cohort study, therapist burnout was associated with reduced effectiveness of trauma-focused psychotherapies. Studying when and how burnout affects patient outcomes may inform workplace interventions.

2478. Trends in antibiotic resistance for nine pathogens in the US Veterans Affairs Healthcare System from 2007 to 2022

Abstract Background Antibiotic-resistant infections are a major public health concern. To better understand the burden of these infections, we analyzed incidence and antibiotic resistance trends for nine important organisms in the US Veterans Affairs (VA) Healthcare System from February 2007 to March 2022. Example plot of reporting resistance burden. The bar blot represents the proportion of isolates resistant to the respective drug that includes the number of missing test results in the denominator. Green points represent the incidence of isolates susceptible to the drug (S). Red points represent the incidence isolates resistant to the drug (R). Grey points represent the incidence of isolates with missing susceptibility test results (NA). Solid lines and grey bands represent smoothing curves using the loess method and the 95% confidence intervals, respectively. Methods We collected microbiology data from all patients admitted to acute-care wards in 158 VA Medical Centers in the US. For nine bacterial pathogens, we evaluated two types of metrics: 1) incidence of resistant or susceptible clinical isolates per 1,000 admissions, and 2) proportion of 30-day incident isolates resistant to a given drug class. Inpatient antibiotic use was calculated as the days of therapy (DOT) divided by 1,000 patient days. Results Trends in resistance proportions for beta-lactam antibiotics varied by species and beta-lactam class. The proportion resistant to 3rd and 4th generation cephalosporins increased in Escherichia coli isolates (from 7.5% to 18% and 4% to 10%, respectively) but remained stable for Klebsiella pneumoniae (∼ 15% and ∼ 8%, respectively). Carbapenem resistance remained low for both pathogens. In contrast, resistance to anti-pseudomonal beta-lactams in Pseudomonas aeruginosa and methicillin resistance in Staphylococcus aureus declined from 29.5% to 21.1% and from 58% to 41%, respectively. Most species demonstrated trends of decreasing resistance proportion for fluoroquinolones. The decline was associated with an increase in incidence of susceptible isolates for E. cloacae, E. faecalis, E. coli, and P. aeruginosa. Trends in inpatient antibiotic use included substantial decreases in fluoroquinolone use (from 125 to 20 DOT per 1,000 patient days), smaller changes in the use of beta-lactam and glycopeptide drugs, and an increase in the use of 3rd and 4th generation cephalosporins (from 48 to 79 and from 19 to 43 DOT per 1,000 patient days). Fluoroquinolone resistance burden for all nine species from 2007 to 2022. Dark bar plots represent the proportion of isolates resistant to fluoroquinolones where missing values were included in the denominator (right axis). Points represent the incidence rate of the respective fluoroquinolone susceptibility test results. Green points represent the quarterly incidence of isolates susceptible to fluoroquinolones. Red points represent the quarterly incidence isolates resistant to fluoroquinolones. Grey points represent the quarterly incidence of isolates with missing susceptibility test results. Solid lines and grey bands represent smoothing curves using the loess method and the 95% confidence intervals, respectively. Inpatient antibiotic utilization from patients admitted to Veterans Affairs Medical Centers from 2007 till 2022. Inpatient antibiotic utilization from patients admitted to Veterans Affairs Medical Centers from 2007 till 2022. Points are days of therapy per 1,000 patient days in each year. Dashed lines are linear interpolations between the points. Solid lines are smoothed curves using the loess method and grey bands represent the respective 95% confidence interval. Conclusion The proportion of fluoroquinolone resistant isolates declined for multiple species and is associated with a decline in inpatient fluoroquinolone use, whereas the proportion of beta-lactam resistant isolates varied by class of beta-lactam and by pathogen. Our study highlights the need for continued surveillance and more research to understand these trends. Disclosures Marc Lipsitch, PhD, Janssen: Advisor/Consultant|Pfizer: Grant/Research Support Yonatan H. Grad, MD, PhD, Day Zero Diagnostics: Board Member|GSK: Advisor/Consultant

More intensive therapy has a better effect for frail parents with multiple myeloma

AbstractAlthough randomized controlled trial data suggest that the more intensive triplet bortezomib-lenalidomide-dexamethasone (VRd) is superior to the less intensive doublet lenalidomide-dexamethasone (Rd) in patients newly diagnosed with multiple myeloma (MM), guidelines have historically recommended Rd over VRd for patients who are frail and may not tolerate a triplet. We identified 2573 patients (median age, 69.7 years) newly diagnosed with MM who were initiated on VRd (990) or Rd (1583) in the national US Veterans Affairs health care System from 2004 to 2020. We measured frailty using the Veterans Affairs Frailty Index. To reduce imbalance in confounding, we matched patients for MM stage and 1:1 based on a propensity score. Patients who were moderate-severely frail had a higher prevalence of stage III MM and myeloma-related frailty deficits than patients who were not frail. VRd vs Rd was associated with lower mortality (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.70-0.94) in the overall matched population. Patients who were moderate-severely frail demonstrated the strongest association (HR 0.74; 95% CI, 0.56-0.97), whereas the association weakened in those who were mildly frail (HR, 0.80; 95% CI, 0.61-1.05) and nonfrail (HR, 0.86; 95% CI, 0.67-1.10). VRd vs Rd was associated with a modestly higher incidence of hospitalizations in the overall population, but this association weakened in patients who were moderate-severely frail. Our findings confirm the benefit of VRd over Rd in US veterans and further suggest that this benefit is strongest in patients with the highest levels of frailty, arguing that more intensive treatment of myeloma may be more effective treatment of frailty itself.

Myocardial Infarction Across COVID-19 Pandemic Phases: Insights From the Veterans Health Affairs System.

Background Cardiovascular procedural treatments were deferred at scale during the COVID-19 pandemic, with unclear impact on patients presenting with non-ST-segment-elevation myocardial infarction (NSTEMI). Methods and Results In a retrospective cohort study of all patients diagnosed with NSTEMI in the US Veterans Affairs Healthcare System from January 1, 2019 to October 30, 2022 (n=67 125), procedural treatments and outcomes were compared between the prepandemic period and 6 unique pandemic phases: (1) acute phase, (2) community spread, (3) first peak, (4) post vaccine, (5) second peak, and (6) recovery. Multivariable regression analysis was performed to assess the association between pandemic phases and 30-day mortality. NSTEMI volumes dropped significantly with the pandemic onset (62.7% of prepandemic peak) and did not revert to prepandemic levels in subsequent phases, even after vaccine availability. Percutaneous coronary intervention and coronary artery bypass grafting volumes declined proportionally. Compared with the prepandemic period, patients with NSTEMI experienced higher 30-day mortality during Phases 2 and 3, even after adjustment for COVID-19-positive status, demographics, baseline comorbidities, and receipt of procedural treatment (adjusted odds ratio for Phases 2 and 3 combined, 1.26 [95% CI, 1.13-1.43], P<0.01). Patients receiving Veterans Affairs-paid community care had a higher adjusted risk of 30-day mortality compared with those at Veterans Affairs hospitals across all 6 pandemic phases. Conclusions Higher mortality after NSTEMI occurred during the initial spread and first peak of the pandemic but resolved before the second, higher peak-suggesting effective adaptation of care delivery but a costly delay to implementation. Investigation into the vulnerabilities of the early pandemic spread are vital to informing future resource-constrained practices.

Clinical and Scientific Challenges to Effectiveness Studies Under Coverage with Evidence Development in Alzheimer's Disease.

The Centers for Medicare and Medicaid Services (CMS) has recently issued a national coverage determination for US Food and Drug Administration (FDA)-approved anti-amyloid monoclonal antibodies (mAbs) for the treatment of Alzheimer's disease (AD) under coverage with evidence development (CED). CED schemes are complex, costly, and challenging, and often fail to achieve intended objectives because of administrative and implementation issues. AD is a heterogeneous, progressive neurodegenerative disorder with complex care pathway that additionally presents scientific challenges related to the choice of study design and methods used in evaluating CED schemes. These challenges are herein discussed. Clinical findings from the US Veterans Affairs healthcare system help inform our discussion of specific challenges to CED-required effectiveness studies in AD.

COUNTERPOINT: Pulmonary Vascular Resistance 2.0— Shedding Light or Casting Shadows?

COUNTERPOINT: Pulmonary Vascular Resistance 2.0— Shedding Light or Casting Shadows?

Fitting a Hearing Aid on the Better Ear, Worse Ear, or Both: Associations of Hearing-aid Fitting Laterality with Outcomes in a Large Sample of US Veterans.

Longitudinal electronic health records from a large sample of new hearing-aid (HA) recipients in the US Veterans Affairs healthcare system were used to evaluate associations of fitting laterality with long-term HA use persistence as measured by battery order records, as well as with short-term HA use and satisfaction as assessed using the International Outcome Inventory for Hearing Aids (IOI-HA), completed within 180 days of HA fitting. The large size of our dataset allowed us to address two aspects of fitting laterality that have not received much attention, namely the degree of hearing asymmetry and the question of which ear to fit if fitting unilaterally. The key findings were that long-term HA use persistence was considerably lower for unilateral fittings for symmetric hearing loss (HL) and for unilateral worse-ear fittings for asymmetric HL, as compared to bilateral and unilateral better-ear fittings. In contrast, no differences across laterality categories were observed for short-term self-reported HA usage. Total IOI-HA score was poorer for unilateral fittings of symmetric HL and for unilateral better-ear fittings compared to bilateral for asymmetric HL. We thus conclude that bilateral fittings yield the best short- and long-term outcomes, and while unilateral and bilateral fittings can result in similar outcomes on some measures, we did not identify any HL configuration for which a bilateral fitting would lead to poorer outcomes. However, if a single HA is to be fitted, then our results indicate that a better-ear fitting has a higher probability of long-term HA use persistence than a worse-ear fitting.

Dementia and hearing-aid use: a two-way street.

Hearing-aid use may reduce risk of dementia, but cognitive impairment makes use more challenging. An observed association between reduced hearing-aid use and incident dementia could reflect either or both of these causal paths. The objective was to examine the effects of each path while minimising contamination between paths. Health records data from 380,794 Veterans who obtained hearing aids from the US Veterans Affairs healthcare system were analysed. Analysis 1 (n = 72,180) used multivariable logistic regression to model the likelihood of incident dementia 3.5-5years post hearing-aid fitting for patients free of dementia and mild cognitive impairment (MCI). Analysis 2 (n = 272,748) modelled the likelihood of being a persistent hearing-aid user at 3years 2months after fitting, contrasting subgroups by level of cognitive function at the time of fitting. Analysis time windows were optimized relative to dataset constraints. Models were controlled for available relevant predictors. The adjusted OR for incident dementia was 0.73 (95% CI 0.66-0.81) for persistent (versus non-persistent) hearing-aid users. The adjusted OR for hearing-aid use persistence was 0.46 (95% CI 0.43-0.48) in those with pre-existing dementia (versus those remaining free of MCI and dementia). Substantial independent associations are observed in both directions, suggesting that hearing-aid use decreases risk of dementia and that better cognitive function predisposes towards persistent use. Research studying protective effects of hearing-aid use against dementia needs to account for cognitive status. Clinically, hearing devices and hearing care processes must be accessible and usable for all, regardless of their cognitive status.

Penetrance and Pleiotropy of Polygenic Risk Scores for Schizophrenia, Bipolar Disorder, and Depression Among Adults in the US Veterans Affairs Health Care System

Serious mental illnesses, including schizophrenia, bipolar disorder, and depression, are heritable, highly multifactorial disorders and major causes of disability worldwide. To benchmark the penetrance of current neuropsychiatric polygenic risk scores (PRSs) in the Veterans Health Administration health care system and to explore associations between PRS and broad categories of human disease via phenome-wide association studies. Extensive Veterans Health Administration's electronic health records were assessed from October 1999 to January 2021, and an embedded cohort of 9378 individuals with confirmed diagnoses of schizophrenia or bipolar 1 disorder were found. The performance of schizophrenia, bipolar disorder, and major depression PRSs were compared in participants of African or European ancestry in the Million Veteran Program (approximately 400 000 individuals), and associations between PRSs and 1650 disease categories based on ICD-9/10 billing codes were explored. Last, genomic structural equation modeling was applied to derive novel PRSs indexing common and disorder-specific genetic factors. Analysis took place from January 2021 to January 2022. Diagnoses based on in-person structured clinical interviews were compared with ICD-9/10 billing codes. PRSs were constructed using summary statistics from genome-wide association studies of schizophrenia, bipolar disorder, and major depression. Of 707 299 enrolled study participants, 459 667 were genotyped at the time of writing; 84 806 were of broadly African ancestry (mean [SD] age, 58 [12.1] years) and 314 909 were of broadly European ancestry (mean [SD] age, 66.4 [13.5] years). Among 9378 individuals with confirmed diagnoses of schizophrenia or bipolar 1 disorder, 8962 (95.6%) were correctly identified using ICD-9/10 codes (2 or more). Among those of European ancestry, PRSs were robustly associated with having received a diagnosis of schizophrenia (odds ratio [OR], 1.81 [95% CI, 1.76-1.87]; P < 10-257) or bipolar disorder (OR, 1.42 [95% CI, 1.39-1.44]; P < 10-295). Corresponding effect sizes in participants of African ancestry were considerably smaller for schizophrenia (OR, 1.35 [95% CI, 1.29-1.42]; P < 10-38) and bipolar disorder (OR, 1.16 [95% CI, 1.11-1.12]; P < 10-10). Neuropsychiatric PRSs were associated with increased risk for a range of psychiatric and physical health problems. Using diagnoses confirmed by in-person structured clinical interviews and current neuropsychiatric PRSs, the validity of an electronic health records-based phenotyping approach in US veterans was demonstrated, highlighting the potential of PRSs for disentangling biological and mediated pleiotropy.

Barriers to dermatologic ultrasound: A national survey of dermatologists in the US Veterans Affairs health care system

To the Editor: Dermatologic ultrasound (DUS) can aid in the management of several skin conditions, including evaluation of benign neoplasms, presurgical planning of skin cancers, evaluation and treatment of scarring conditions, staging of inflammatory disorders, and evaluation of cosmetic fillers.1,2 In 2016, the Dermatologic Ultrasound group, an international collaboration of physicians, published guidelines to standardize the performance and quality of DUS exams.3 Though guidelines have been published, how dermatologists currently use DUS around the world is unknown.

Abstract P165: Glycemic Response To Initial Treatment In Data-driven Diabetes Clusters In A Real-world Sample Of Adults With Newly Diagnosed Diabetes

Diabetes patient heterogeneity is well recognized. Statistical clustering methods are gaining popularity as a precision medicine tool for identifying diabetes subgroups. We evaluated data-driven clusters among individuals with newly diagnosed diabetes and examined associations with glycemic response to initial treatment in real-world care. We studied individuals in the US Veterans Affairs Health Care System with newly diagnosed diabetes based on diagnosis codes and medications who were initially treated with a single diabetes medication from 2005-2013. We performed k -means clustering as previously described based on age, body mass index (BMI), and hemoglobin A1c (HbA1c) at the time of diabetes diagnosis. We compared 5-year glycemic response by initial medication class (metformin, sulfonylurea, or insulin) in each cluster using linear mixed effects models, adjusted for age, race, sex, BMI, glomerular filtration rate, and HbA1c, and including a medication*time term to assess medication-specific HbA1c trends. Four clusters best fit the data for the 325,250 individuals studied (mean age 63.5 years, BMI 32.7 kg/m 2 , HbA1c 7.5%). Clusters corresponded to those identified previously in other studies with three characterized by extreme values of clustering variables: Cluster 1 with mean HbA1c 11.3% (N=35,071), Cluster 2 with mean BMI 41.1 kg/m 2 (N=70,909), Cluster 3 with mean age 76.8 years (N=92,363), and Cluster 4 with intermediate values for all the three variables (N=126,907). HbA1c trends differed by medication class in all four clusters (p&lt;0.0001 for all). However, differences in HbA1c trends by medication class were clinically small in all 4 clusters (Figure). Mean HbA1c trend was lowest among metformin users, intermediate among sulfonylurea users, and highest among insulin users in all clusters. Conclusion: Data-driven clustering of individuals with newly diagnosed diabetes using routinely collected clinical variables may not help guide initial diabetes treatment choice with regard to glycemic control.

Disulfiram use is associated with lower risk of COVID-19: A retrospective cohort study.

Effective, low-cost therapeutics are needed to prevent and treat COVID-19. Severe COVID-19 disease is linked to excessive inflammation. Disulfiram is an approved oral drug used to treat alcohol use disorder that is a potent anti-inflammatory agent and an inhibitor of the viral proteases. We investigated the potential effects of disulfiram on SARS-CoV-2 infection and disease severity in an observational study using a large database of clinical records from the national US Veterans Affairs healthcare system. A multivariable Cox regression adjusted for demographic information and diagnosis of alcohol use disorder revealed a reduced risk of SARS-CoV-2 infection with disulfiram use at a hazard ratio of 0.66 (34% lower risk, 95% confidence interval 24–43%). There were no COVID-19 related deaths among the 188 SARS-CoV-2 positive patients treated with disulfiram, in contrast to 5–6 statistically expected deaths based on the untreated population (P = 0.03). Our epidemiological results suggest that disulfiram may contribute to the reduced incidence and severity of COVID-19. These results support carefully planned clinical trials to assess the potential therapeutic effects of disulfiram in COVID-19.

The Effect of Telehealth Services on Provider Productivity.

Telehealth services historically have played a small role in the provision of health care in the United States. However during the coronavirus disease 2019 (COVID-19) pandemic, public and private insurers rapidly expanded access to telehealth in order to reduce exposure and avoid transmission. It is unknown whether telehealth will become a more regular substitute for in-person care beyond the pandemic. Our objective was to provide evidence on the value of telehealth by comparing the productivity of physicians and other specialized clinicians who provide telehealth with the productivity of those who do not. We conducted a retrospective data analysis of 17,705 unique providers in the areas of internal medicine, cardiology, dermatology, psychiatry, psychology, and optometry practicing in the US veterans affairs health care system during the period 2015 to 2018. For each year, we measured individual providers productivity by the total number of relative value units (RVUs) per full-time equivalent (FTE). We estimated the impact of providing telehealth on RVUs/FTE using fixed effects regression models estimated on a panel dataset of 58,873 provider-year observations and controlling for provider and patient characteristics. Overall provider productivity increased in veterans affairs over the period, particularly in cardiology and dermatology. Providers of telehealth had above average productivity by 124 RVUs/FTE, or ∼4% of average total provider productivity. For the highest quartile of telehealth providers, average productivity was 188 RVUs/FTE higher than productivity of other providers. Strategies that encourage long-term integration of telehealth into provider practices may contribute to overall health care value.

Antibiotic Use and Presumptive Pathogens in the Veterans Affairs Healthcare System.

Empirical antibiotic use is common in the hospital. Here, we characterize patterns of antibiotic use, infectious diagnoses, and microbiological laboratory results among hospitalized patients and aim to quantify the proportion of antibiotic use that is potentially attributable to specific bacterial pathogens. We conducted an observational study using electronic health records from acute care facilities in the US Veterans Affairs Healthcare System. From October 2017 to September 2018, 482 381 hospitalizations for 332 657 unique patients that met all criteria were included. At least 1 antibiotic was administered at 202 037 (41.9%) of included hospital stays. We measured frequency of antibiotic use, microbiological specimen collection, and bacterial isolation by diagnosis category and antibiotic group. A tiered system based on specimen collection sites and diagnoses was used to attribute antibiotic use to presumptive causative organisms. Specimens were collected at 130 012 (64.4%) hospitalizations with any antibiotic use, and at least 1 bacterial organism was isolated at 35.1% of these stays. Frequency of bacterial isolation varied widely by diagnosis category and antibiotic group. Under increasingly lenient criteria, 10.2%-31.4% of 974 733 antibiotic days of therapy could be linked to a potential bacterial pathogen. Overall, the vast majority of antibiotic use could be linked to either an infectious diagnosis or microbiological specimen. Nearly one-half of antibiotic use occurred when there was a specimen collected but no bacterial organism identified, underscoring the need for rapid and improved diagnostics to optimize antibiotic use.

Prevalence and Outcome of COVID-19 Infection in Cancer Patients: A National Veterans Affairs Study.

BackgroundEmerging data suggest variability in susceptibility and outcome to coronavirus disease 2019 (COVID-19) infection. Identifying risk factors associated with infection and outcomes in cancer patients is necessary to develop healthcare recommendations.MethodsWe analyzed electronic health records of the US Veterans Affairs Healthcare System and assessed the prevalence of COVID-19 infection in cancer patients. We evaluated the proportion of cancer patients tested for COVID-19 who were positive, as well as outcome attributable to COVID-19, and stratified by clinical characteristics including demographics, comorbidities, cancer treatment, and cancer type. All statistical tests are 2-sided.ResultsOf 22 914 cancer patients tested for COVID-19, 1794 (7.8%) were positive. The prevalence of COVID-19 was similar across age. Higher prevalence was observed in African American (15.0%) compared with White (5.5%; P < .001) and in patients with hematologic malignancy compared with those with solid tumors (10.9% vs 7.8%; P < .001). Conversely, prevalence was lower in current smokers and patients who recently received cancer therapy (<6 months). The COVID-19–attributable mortality was 10.9%. Higher attributable mortality rates were observed in older patients, those with higher Charlson comorbidity score, and in certain cancer types. Recent (<6 months) or past treatment did not influence attributable mortality. Importantly, African American patients had 3.5-fold higher COVID-19–attributable hospitalization; however, they had similar attributable mortality as White patients.ConclusionPreexistence of cancer affects both susceptibility to COVID-19 infection and eventual outcome. The overall COVID-19–attributable mortality in cancer patients is affected by age, comorbidity, and specific cancer types; however, race or recent treatment including immunotherapy do not impact outcome.

Assessment of Health Information Technology–Related Outpatient Diagnostic Delays in the US Veterans Affairs Health Care System

Diagnostic delay in the outpatient setting is an emerging safety priority that health information technology (HIT) should help address. However, diagnostic delays have persisted, and new safety concerns associated with the use of HIT have emerged. To analyze HIT-related outpatient diagnostic delays within a large, integrated health care system. This cohort study involved qualitative content analysis of safety concerns identified in aggregated root cause analysis (RCA) data related to HIT and outpatient diagnostic delays. The setting was the US Department of Veterans Affairs using all RCAs submitted to the Veterans Affairs (VA) National Center for Patient Safety from January 1, 2013, to July 31, 2018. Common themes associated with the role of HIT-related safety concerns were identified and categorized according to the Health IT Safety framework for measuring, monitoring, and improving HIT safety. This framework includes 3 related domains (ie, safe HIT, safe use of HIT, and using HIT to improve safety) situated within an 8-dimensional sociotechnical model accounting for interacting technical and nontechnical variables associated with safety. Hence, themes identified enhanced understanding of the sociotechnical context and domain of HIT safety involved. Of 214 RCAs categorized by the terms delay and outpatient submitted during the study period, 88 were identified as involving diagnostic delays and HIT, from which 172 unique HIT-related safety concerns were extracted (mean [SD], 1.97 [1.53] per RCA). Most safety concerns (82.6% [142 of 172]) involved problems with safe use of HIT, predominantly sociotechnical factors associated with people, workflow and communication, and a poorly designed human-computer interface. Fewer safety concerns involved problems with safe HIT (14.5% [25 of 172]) or using HIT to improve safety (0.3% [5 of 172]). The following 5 key high-risk areas for diagnostic delays emerged: managing electronic health record inbox notifications and communication, clinicians gathering key diagnostic information, technical problems, data entry problems, and failure of a system to track test results. This qualitative study of a national RCA data set suggests that interventions to reduce outpatient diagnostic delays could aim to improve test result management, interoperability, data visualization, and order entry, as well as to decrease information overload.