US Veterans Affairs Medical Centers Research Articles

Cardiorespiratory fitness and risk of heart failure with preserved ejection fraction.

Preventive strategies for heart failure with preserved ejection fraction (HFpEF) include pharmacotherapies and lifestyle modifications. However, the association between cardiorespiratory fitness (CRF) assessed objectively by a standardized exercise treadmill test (ETT) and the risk of HFpEF has not been evaluated. Thus, we evaluated the association between CRF and HFpEF incidence. We assessed CRF in US Veterans (624 551 men; mean age 61.2 ± 9.7 years and 43 179 women; mean age 55.0 ± 8.9 years) by a standardized ETT performed between 1999 and 2020 across US Veterans Affairs Medical Centers. All had no evidence of heart failure or myocardial infarction prior to completion of the ETT. We assigned participants to one of five age- and gender-specific CRF categories (quintiles) based on peak metabolic equivalents (METs) achieved during the ETT and four categories based on CRF changes in those with two ETT evaluations (n = 139 434) ≥1.0 year apart. During a median follow-up of 10.1 years (interquartile range 6.0-14.3 years), providing 6 879 229 person-years, there were 16 493 HFpEF events with an average annual rate of 2.4 events per 1000 person-years. The adjusted risk of HFpEF decreased across CRF categories as CRF increased, independent of comorbidities. For fit individuals (≥10.5 METs) the hazard ratio (HR) was 0.48 (95% confidence interval [CI] 0.46-0.51) compared with least fit (≤4.9 METs; referent). Being unfit carried the highest risk (HR 2.88, 95% CI 2.67-3.11) of any other comorbidity. The risk of unfit individuals who became fit was 37% lower (HR 0.63, 95% CI 0.57-0.71), compared to those who remained unfit. Higher CRF levels are independently associated with lower HFpEF in a dose-response manner. Changes in CRF reflected proportional changes in HFpEF risk, suggesting that the HFpEF risk was modulated by CRF.

Outcomes Associated with Concomitant Lower-Limb Amputation in Persons with Major Upper-Limb Amputation: Results of a National Study

ABSTRACT Introduction The challenges faced by persons with amputations are amplified for those with multiple limb loss, compared with single limb loss. However, there is limited research describing the functional outcomes of mixed upper and lower limb loss or the long-term psychosocial and health-related quality of life (HRQoL) outcomes among this group. Materials and Methods A cross-sectional, national telephone survey of 808 US veterans with major upper-limb amputation (ULA) with and without concomitant lower-limb amputation (LLA) who received care at US Veterans Affairs Medical Centers between 2010 and 2015 was conducted. T-tests and χ2 tests identified any significant differences in characteristics and outcomes of groups with and without LLA. Linear regressions examined the association between amputation laterality and outcomes. Results In comparison to those with no LLA, respondents with concomitant LLA were slightly younger (60.0 vs. 63.7) and had similar mean time in years from initial amputation (31.5 vs. 31.4). Transfemoral was the most common level of LLA (67.7%), and there was no significant difference in the distribution of ULA levels between the 2 groups. Phantom pain was less common among those with concomitant LLA compared with ULA only (64.4% vs. 74.5%, P < 0.05). No significant differences were found in prevalence of residual limb, neck, or back pain; measures of disability (QuickDASH); HRQoL; or need for activities of daily living help across the two groups. Conclusions In veterans with concomitant LLA and ULA, transfemoral amputation was the most common level of LLA. Those with concomitant LLA were less likely to report phantom limb pain. No statistically significant differences were found by group in need for ADL help, disability, or HRQoL. Clinical Relevance These results provide clinicians with a greater appreciation of the similarities and differences between the two groups in relation to amputation characteristics, pain, prosthesis utilization, prosthesis satisfaction, and functional outcomes.

1000-P: The Economic Impact of Reducing Hospitalizations and Amputations in Patients with Diabetic Foot Ulcers

The purpose of this real-word evidence (RWE) cohort study was to evaluate whether utilization of Cyclical Pressurized Topical Oxygen (TWO2) therapy had any impact on the incidence of Diabetic Foot Ulcer related hospitalizations and amputations over a 12-month period in patients with hard to heal Diabetic foot Ulcers (DFU). An IRB approved retrospective review of deidentified DFU patient medical records was conducted at 2 US Veterans Affairs Medical Centers in Illinois and Virginia, which included demographic information on wound characteristics, clinical characteristics, neuropathy, cardiovascular disease (CVD), peripheral vascular disease (PVD), pain levels and kidney disease etc. Within the unmatched cohorts of the 202 DFU patients (91 TWO2, 111 NO TWO2)there was an 88% reduction in hospitalizations and a 71% reduction in amputations over a 12-month period for the patients treated with TWO2 therapy compared to those that did not receive TWO2 therapy. Propensity score matching was conducted showing similar outcomes and a regression analysis as preformed along with a budget impact model which demonstrated significant cost saving to the payor system. This large RWE study demonstrates the TWO2 therapy positively impacts patients quality of life and the costs associated with treating their DFU by forcing them into remission, resulting in significantly reduced rates of hospitalizations, amputations and cost outlay. Disclosure M.G.Garoufalis: Consultant; Uluru, Employee; AOT Inc., Speaker's Bureau; 3M/KCI, Horizon Therapeutics plc.

History of Suicide Attempt and Clozapine Treatment in Veterans With Schizophrenia or Schizoaffective Disorder.

Objective: To evaluate whether a history of suicide attempt increases the odds of receiving clozapine treatment in veterans with schizophrenia or schizoaffective disorder. Methods: Electronic health record data were obtained for veterans with schizophrenia or schizoaffective disorder treated at any US Veterans Affairs Medical Center between January 1, 2000, and January 31, 2021 (N = 134,692). Logistic regression (adjusted and unadjusted) was applied to estimate odds ratios (ORs) for clozapine treatment in suicide attempters relative to nonattempters. Results: 3,407 patients had a documented history of suicide attempt, while 6,867 patients had received clozapine treatment. Also, 9.4% (n = 321) of suicide attempters versus 5.0% (n = 6546) of nonattempters had received clozapine treatment. The odds of being treated with clozapine was approximately 2-fold in patients with a history of suicide attempt in unadjusted (OR = 1.98, 95% CI, 1.76–2.22) and adjusted (OR = 1.91, 95% CI, 1.67–2.15) analyses. Conclusions: Despite the higher odds of clozapine treatment in suicide attempters with schizophrenia or schizoaffective disorder, clozapine was underutilized in the current sample of veterans. Concerted efforts should be made to expand the use of clozapine in patients with schizophrenia or schizoaffective disorder, especially those with a history of suicide attempt.

127-OR: Diabetic Foot Ulcers in Remission: Cyclical-Pressure Topical Wound Oxygen Therapy Significantly Reduces DFU Related Hospitalizations and Amputations over a 12-Month Period

Purpose: The purpose of this real-world evidence (RWE) cohort study was to evaluate whether utilization of Cyclical-Pressure Topical Wound Oxygen (TWO2) therapy had any impact on the incidence of Diabetic Foot Ulcer (DFU) related hospitalizations and amputations over a 12-month period in patients with hard to heal Diabetic Foot Ulcers (DFU) Methods: An IRB approved retrospective review of deidentified DFU patient medical records was conducted at 2 US Veterans Affairs Medical Centers in Illinois and Virginia, which included demographic information on wound characteristics, clinical characteristics, neuropathy, cardiovascular disease (CVD) , peripheral vascular disease (PVD) , pain level and kidney disease etc. Results: Within the unmatched cohorts of 202 DFU patients (91 TWO2, 1NO TWO2) there was an 88% reduction in hospitalizations and 71% reduction in amputations over the 12-month period for the patients treated with TWO2 therapy compared to those that did not receive TWO2 therapy. After propensity score matching was conducted, which minimizes the effects of confounding by achieving more balanced covariates in the absence of a randomized study, resulting in matched cohorts of 140 DFU patients (70 TWO2, 70 NO TWO2) , 82% fewer TWO2 patients were hospitalized) and 73% fewer TWO2 patients had amputations, compared to those who did not receive TWO2 therapy (p < 0.0001, p = 0.00 respectively) . Conclusions: This large RWE study demonstrates that TWO2 therapy positively impacts patient’s quality-of-life and the costs associated with treating their DFU by forcing them into remission, resulting in significantly reduced rates of amputations and hospitalizations. Disclosure M.G.Garoufalis: None.

Trends in Illness Severity, Hospitalization, and Mortality for Community-Onset Pneumonia at 118 US Veterans Affairs Medical Centers.

BackgroundDeaths from pneumonia were decreasing globally prior to the COVID-19 pandemic, but it is unclear whether this was due to changes in patient populations, illness severity, diagnosis, hospitalization thresholds, or treatment. Using clinical data from the electronic health record among a national cohort of patients initially diagnosed with pneumonia, we examined temporal trends in severity of illness, hospitalization, and short- and long-term deaths.DesignRetrospective cohortParticipantsAll patients >18 years presenting to emergency departments (EDs) at 118 VA Medical Centers between 1/1/2006 and 12/31/2016 with an initial clinical diagnosis of pneumonia and confirmed by chest imaging report.ExposuresYear of encounter.Main MeasuresHospitalization and 30-day and 90-day mortality. Illness severity was defined as the probability of each outcome predicted by machine learning predictive models using age, sex, comorbidities, vital signs, and laboratory data from encounters during years 2006–2007, and similar models trained on encounters from years 2015 to 2016. We estimated the changes in hospitalizations and 30-day and 90-day mortality between the first and the last 2 years of the study period accounted for by illness severity using time covariate decompositions with model estimates.ResultsAmong 196,899 encounters across the study period, hospitalization decreased from 71 to 63%, 30-day mortality 10 to 7%, 90-day mortality 16 to 12%, and 1-year mortality 29 to 24%. Comorbidity risk increased, but illness severity decreased. Decreases in illness severity accounted for 21–31% of the decrease in hospitalizations, and 45–47%, 32–24%, and 17–19% of the decrease in 30-day, 90-day, and 1-year mortality. Findings were similar among underrepresented patients and those with only hospital discharge diagnosis codes.ConclusionsOutcomes for community-onset pneumonia have improved across the VA healthcare system after accounting for illness severity, despite an increase in cases and comorbidity burden.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-022-07413-8.

Strategies prescribers and pharmacists use to identify and mitigate adverse drug reactions in inpatient and outpatient care: a cognitive task analysis at a US Veterans Affairs Medical Center

ObjectiveTo develop a descriptive model of the cognitive processes used to identify and resolve adverse drug reactions (ADRs) from the perspective of healthcare providers in order to inform future informatics...

Antibiotic exposure and acquisition of antibiotic-resistant gram-negative bacteria among outpatients at a US Veterans Affairs medical center.

To assess the prevalence of antibiotic-resistant gram-negative bacteria (R-GNB) among patients without recent hospitalization and to examine the influence of outpatient antibiotic exposure on the risk of acquiring R-GNB in this population. 2-year retrospective cohort study. Regional Veterans Affairs healthcare system. Outpatients at 13 community-based clinics. We examined the rate of acquisition of R-GNB within 90 days following an outpatient visit from 2018 to 2019. We used clinical and administrative databases to determine and summarize prescriptions for systemic antibiotics, associated infectious diagnoses, and subsequent R-GNB acquisition among patients without recent hospitalizations. We also calculated the odds ratio of R-GNB acquisition following antibiotic exposure. During the 2-year study period, 7,215 patients had outpatient visits with microbiological cultures obtained within 90 days. Of these patients, 206 (2.9%) acquired an R-GNB. Among patients receiving antibiotics at the visit, 4.6% acquired a R-GNB compared to 2.7% among patients who did not receive antibiotics, yielding an unadjusted odds ratio of 1.75 (95% confidence interval, 1.18-2.52) for a R-GNB following an outpatient visit with versus without an antibiotic exposure. Regardless of R-GNB occurrence, >50% of antibiotic prescriptions were issued at visits without an infectious disease diagnosis or issued without documentation of an in-person or telehealth clinical encounter. Although the rate of R-GNBs was low (2.9%), the 1.75-fold increased odds of acquiring a R-GNB following an outpatient antibiotic highlights the importance of antimicrobial stewardship efforts in outpatient settings. Specific opportunities include reducing antibiotics prescribed without an infectious diagnosis or a clinical visit.

Association Between Operative Autonomy of Surgical Residents and Patient Outcomes

Resident operative autonomy has been steadily decreasing. Whether this reduction in autonomy has been associated with changes in patient outcomes is unclear. To assess whether surgical procedures performed by residents without an attending surgeon scrubbed are associated with differences in patient outcomes compared with procedures performed by attending surgeons alone or by residents with the assistance of attending surgeons. This retrospective propensity score-matched cohort study analyzed 30-day outcomes among patients who received operations at US Veterans Affairs (VA) medical centers and were recorded within the VA Surgical Quality Improvement Program (VASQIP) database from July 1, 2004, to September 30, 2019. Among 1 797 056 operations recorded in the VASQIP during that period, 1 319 020 were eligible for inclusion. Operations performed by a surgical resident without an attending surgeon scrubbed (resident primary) were propensity score matched on a 1:1 ratio (based on year of procedure and patient age, race, sex, American Society of Anesthesiologists physical status classification, functional status, emergency status, inpatient status, presence of multiple comorbidities, and Current Procedural Terminology code) to operations performed by an attending surgeon only (surgeon primary) and operations performed by a resident with assistance from an attending surgeon (resident plus surgeon). Level of resident involvement. Thirty-day adjusted all-cause mortality. Among 1 319 020 surgical procedures included, 138 750 were performed by residents only, 308 724 were performed by surgeons only, and 871 546 were performed by residents and surgeons. For the 1 319 020 total cases, patients' mean (SD) age was 61.6 (12.9) years; 1 223 051 patients (92.7%) were male; and 212 315 (16.1%) were Black or African American, 63 817 (4.9%) were Hispanic, 830 704 (63.0%) were White, and 212 814 (16.1%) were of other or unknown race and ethnicity. Propensity score matching produced 101 130 pairs of resident-primary and surgeon-primary procedures and 137 749 pairs of resident-primary and resident plus surgeon procedures. Patient all-cause mortality and morbidity were no different among those who received surgeon-primary procedures (mortality: odds ratio [OR], 1.03 [95% CI, 0.95-1.12]; morbidity: OR, 1.01 [95% CI, 0.97-1.05]) vs resident plus surgeon procedures (mortality: OR, 1.03 [95% CI, 0.97-1.11]; all-cause morbidity: OR, 0.97 [95% CI, 0.95-1.00]). Resident-primary procedures had longer operative times than surgeon-primary procedures (median, 80 minutes [IQR, 50-123 minutes] vs 70 minutes [IQR, 41-114 minutes], respectively; P < .001) but shorter operative times than resident plus surgeon procedures (median, 71 minutes [IQR, 43-113 minutes] vs 73 minutes [IQR, 45-115 minutes]; P < .001). Hospital length of stay was unchanged among resident-primary vs surgeon-primary procedures (median, 4 days [IQR, 2-10 days] vs 4 days [IQR, 2-9 days]; P = .08) and statistically significantly shorter than resident plus surgeon procedures (median, 4 days [IQR, 1-9 days] vs 4 days [IQR, 2-10 days]; P < .001). In this cohort study, surgical procedures performed by residents alone were not associated with any changes in all-cause mortality or composite morbidity compared with those performed by attending surgeons alone or by residents with the assistance of attending surgeons. Given these findings and the importance of operative autonomy to prepare surgical residents for independent practice, efforts to increase autonomy are both safe and needed.

Effect of 7 vs 14 Days of Antibiotic Therapy on Resolution of Symptoms Among Afebrile Men With Urinary Tract Infection

Determination of optimal treatment durations for common infectious diseases is an important strategy to preserve antibiotic effectiveness. To determine whether 7 days of treatment is noninferior to 14 days when using ciprofloxacin or trimethoprim/sulfamethoxazole to treat urinary tract infection (UTI) in afebrile men. Randomized, double-blind, placebo-controlled noninferiority trial of afebrile men with presumed symptomatic UTI treated with ciprofloxacin or trimethoprim/sulfamethoxazole at 2 US Veterans Affairs medical centers (enrollment, April 2014 through December 2019; final follow-up, January 28, 2020). Of 1058 eligible men, 272 were randomized. Participants continued the antibiotic prescribed by their treating clinician for 7 days of treatment and were randomized to receive continued antibiotic therapy (n = 136) or placebo (n = 136) for days 8 to 14 of treatment. The prespecified primary outcome was resolution of UTI symptoms by 14 days after completion of active antibiotic treatment. A noninferiority margin of 10% was selected. The as-treated population (participants who took ≥26 of 28 doses and missed no more than 2 consecutive doses) was used for the primary analysis, and a secondary analysis included all patients as randomized, regardless of treatment adherence. Secondary outcomes included recurrence of UTI symptoms and/or adverse events within 28 days of stopping study medication. Among 272 patients (median [interquartile range] age, 69 [62-73] years) who were randomized, 100% completed the trial and 254 (93.4%) were included in the primary as-treated analysis. Symptom resolution occurred in 122/131 (93.1%) participants in the 7-day group vs 111/123 (90.2%) in the 14-day group (difference, 2.9% [1-sided 97.5% CI, -5.2% to ∞]), meeting the noninferiority criterion. In the secondary as-randomized analysis, symptom resolution occurred in 125/136 (91.9%) participants in the 7-day group vs 123/136 (90.4%) in the 14-day group (difference, 1.5% [1-sided 97.5% CI, -5.8% to ∞]) Recurrence of UTI symptoms occurred in 13/131 (9.9%) participants in the 7-day group vs 15/123 (12.9%) in the 14-day group (difference, -3.0% [95% CI, -10.8% to 6.2%]; P = .70). Adverse events occurred in 28/136 (20.6%) participants in the 7-day group vs 33/136 (24.3%) in the 14-day group. Among afebrile men with suspected UTI, treatment with ciprofloxacin or trimethoprim/sulfamethoxazole for 7 days was noninferior to 14 days of treatment with regard to resolution of UTI symptoms by 14 days after antibiotic therapy. The findings support the use of a 7-day course of ciprofloxacin or trimethoprim/sulfamethoxazole as an alternative to a 14-day course for treatment of afebrile men with UTI. ClinicalTrials.gov identifier: NCT01994538.

A Prospective Cross-Sectional Analysis of Construct Validity for the PALMPASS, A Brief Patient-Reported Outcome Measure for Psoriasis

Background: While the Psoriasis Area and Severity Index (PASI) represents the most commonly used assessment tool for psoriasis severity, it has been criticized for its complexity in clinical practice. Objective: To validate a simplified 2-item patient-administered limited measure psoriasis area and severity score (PALMPASS) compared to standardized measure of psoriasis. Materials and Methods: This was a prospective observational survey of adult patients with psoriasis and psoriatic arthritis in Veterans Affairs Medical Center (VAMC) dermatology and rheumatology clinics participating in the Program to Understand the Longterm outcomes in SpondyloARthritis registry between January and June 2016 (n = 885). Patients at 7 US VAMCs (n = 363) completed a 2-item, 11-point PALMPASS questionnaire, assessing (1) how psoriasis affected the patient and (2) the degree of surface area involvement. Results from the PALMPASS were then compared to the PASI, the Psoriasis Symptom Inventory (PSI) and the Dermatology Life Quality Index (DLQI). Data were analyzed using Lin concordance, intraclass correlations, Spearman correlations, and linear regression. Results: Strong correlations existed between PALMPASS and PASI (Spearman ρ = 0.74, P &lt; .001), PSI (Spearman ρ = 0.71, P = .001), and DLQI (Spearman ρ = 0.77, P &lt; .001). Results were comparable in analyses based on intraclass correlations. Elevated C-reactive protein concentrations correlated with higher PALMPASS. Conclusion: The PALMPASS is a patient-reported instrument that demonstrates validity and serves as a reliable and simplified tool to guide evidence-based management.

Facilitators and Barriers to Implementation of a Peer Support Intervention for Patients with Chronic Pain: A Qualitative Study.

Pain self-management information and support, delivered by peers, are a potentially useful approach to help patients who are struggling to manage their chronic pain. Before implementation into clinical settings, it is important to understand factors that may influence the success of implementation. The purpose of this study was to explore facilitators and barriers to implementation of peer support for chronic pain. Semistructured interviews were conducted with clinicians who provide care to patients with chronic pain, regarding their perceptions of the proposed peer support intervention. A single US Veterans Affairs Medical Center. Using maximum variation sampling, 15 providers were interviewed (11 women, four men). Clinicians' disciplines included primary care, physical therapy, nursing, clinical psychology, social work, and pharmacy. Findings indicated that clinicians 1) had an overall positive perception of the intervention; 2) had specific intervention outcomes they wanted for patients; 3) anticipated that the intervention could positively influence their role; 4) anticipated barriers to intervention participation and maintenance; and 5) had concerns regarding peer coach selection. Findings are discussed in the context of the Consolidated Framework for Implementation Research. Understanding clinician perceptions of a peer support intervention is critical for successful implementation. The feedback collected in this study will facilitate implementation of the intervention on a broader scale, allowing more patients to benefit.

1875. How Many Different Antimicrobial Regimens Are There and Which Are Emerging and Declining?

BackgroundAntimicrobial regimens evolve with changing recommendations and emerging practice patterns. We sought to explore the diversity of these patterns and to identify which inpatient regimens may be emerging in US Veterans Affairs medical centers (VAMC).MethodsWe extracted antimicrobial use and admission data from all acute care VA medical centers between 2005 and 2016. A regimen was defined as all unique antimicrobials and their routes given in a day to a single patient. We applied smoothing to account for intended discontinuation and intermittent dosing due to clearance. We described the distribution of regimens among VAMCs using the Gini index (a Gini index of 0 would mean all regimens were equally frequent and 1 would mean that one regimen dominated all others). We calculated the rank percentile of all regimens. We also used the absolute change in rank percentile between years 2005 and 2016 of the regimen used to describe emerging and declining regimens.ResultsThere were 55,767 distinct regimens. Table 1 describes the Gini index and its decomposition among VAMCs. Overlap accounts for most of the inequality present because regimens are shared between VAMCs. Approximately 20% of the inequality present can be accounted for by variation between VAMCs. Table 2 describes the top 10 rising and the top 10 declining regimens. ConclusionWhile there was a large number of distinct regimens, there was a relative handful of antimicrobial regimens dominated—most of which were commonly present among VAMCs (as manifest by the Gini “overlap” percent). Most regimens in the top 10 were broad-spectrum IV agents, with PO levofloxacin and doxycycline being notable standouts. IV vancomycin, which was the single most common regimen in 2005, decreased markedly. Linezolid and mixed PO metronidazole agents appear to be on the decline.Disclosures V. Stevens, Pfizer, Inc.: Grant Investigator, Research grant.

1825. Electronic Measure of Unnecessary Antimicrobial Use in US Veterans Affairs Medical Centers

BackgroundAntimicrobial inappropriateness is highly contextual and dynamic, depending not only on the patient’s disease condition but also the information available at the time. To estimate the extent to which antimicrobials could theoretically be decreased with antimicrobial stewardship, we sought to capture unnecessary inpatient antimicrobial use in context over time as manifested in the electronic health record in Veterans Affairs (VA).MethodsWe extracted antimicrobial use, administrative, admission, and laboratory data from all acute care VA medical centers between 2010 and 2016. Information present during Choice (hospital day [HD] 1–3), Change (HD 4–5), Completion (HD 6–7), and Post-completion (thereafter) was used to determine context. All antimicrobial use without any documented infection was considered unnecessary (admission, discharge, or otherwise). Choice Anti-MRSA agents were considered unnecessary in cellulitis without history of or current positive culture for MRSA. Choice HOMDR agents were unnecessary in cellulitis without history of positive culture for ceftriaxone-resistant Gram-negative rods. Also unnecessary were broad-spectrum antimicrobials (anti-methicillin-resistant Staphylococcus aureus [MRSA] and hospital-onset multidrug-resistant [HOMDR] organisms antimicrobials as defined by the National Healthcare Safety Network) administered without evidence of multidrug-resistant organisms existed during Change and Completion time frames.ResultsFigure 1 demonstrates the distribution of facility proportions of unnecessary antimicrobials of different classes over time. Table 1 illustrates the percentage of unnecessary antimicrobials administered during choice, change, completion, and post-completion time-frames. ConclusionBy this measure, unnecessary anti-MRSA and HOMDR use has been decreasing in VA over time. The bulk of unnecessary use is empiric but there is a substantial proportion that is used for longer stays, during which time more information was likely present. More research is necessary to determine how well these simple rules correlate with clinical determinations of appropriateness. Also ICD-10-CM was implemented in October 2015, which may have introduced an ascertainment bias.Disclosures V. Stevens, Pfizer, Inc.: Grant Investigator, Research grant.

A qualitative study of clinical champions in context: Clinical champions across three levels of acute care.

Objectives:To compare activities and field descriptions of clinical champions across three levels of stroke centers.Methods:A cross-sectional qualitative study using quota sampling was conducted. The setting for this study was 38 acute stroke centers based in US Veterans Affairs Medical Centers with 8 designated as Primary, 24 as Limited Hours, and 6 as Stroke Support Centers. Key informants involved in stroke care were interviewed using a semi-structured approach. A cross-case synthesis approach was used to conduct a qualitative analysis of clinical champions’ behaviors and characteristics. Clinical champion behaviors were described and categorized across three dimensions: enthusiasm, persistence, and involving the right people.Results:Clinical champions at Primary Stroke Centers represented diverse medical disciplines and departments (education, quality management); directed implementation of acute stroke care processes; coordinated processes across service lines; and benefited from supportive contexts for implementation. Clinical champions at Limited Hours Stroke Centers varied in steering implementation efforts, building collaboration across disciplines, and engaging in other clinical champion activities. Clinical champions at Stroke Support Centers were implementing limited changes to stroke care and exhibited few behaviors fitting the three clinical champion dimensions. Other clinical champion behaviors included educating colleagues, problem-solving, implementing new care pathways, monitoring progress, and standardizing processes.Conclusion:These data demonstrate clinical champion behaviors for implementing changes to complex care processes such as acute stroke care. Changes to complex care processes involved coordination among clinicians from multiple services lines, persistence facing obstacles to change, and enthusiasm for targeted practice changes.

Hysterectomy risk in premenopausal-aged military veterans: associations with sexual assault and gynecologic symptoms

Several gynecological conditions associated with hysterectomy, including abnormal bleeding and pelvic pain, have been observed at increased rates in women who have experienced sexual assault. Previous findings have suggested that one of the unique health care needs for female military veterans may be an increased prevalence of hysterectomy and that this increase may partially be due to their higher risk of sexual assault history and posttraumatic stress disorder (PTSD). Although associations between trauma, PTSD, and gynecological symptoms have been identified, little work has been done to date to directly examine the relationship between sexual assault, PTSD, and hysterectomy within the rapidly growing female veteran population. The objective of the study was to assess the prevalence of hysterectomy in premenopausal-aged female veterans, compare with general population prevalence, and examine associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms in this veteran population. We performed a computer-assisted telephone interview between July 2005 and August 2008 of 1004 female Veterans Affairs (VA)-enrolled veterans ≤ 52 years old from 2 Midwestern US Veterans Affairs medical centers and associated community-based outreach clinics. Within the veteran study population, associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms were assessed with bivariate analyses using χ(2), Wilcoxon-Mann-Whitney, and Student t tests; multivariate logistic regression analyses were used to look for independent associations. Hysterectomy prevalence and ages were compared with large civilian populations represented in the Behavioral Risk Factor Surveillance System and American College of Surgeons National Surgical Quality Improvement Program databases from similar timeframes using χ(2) and Student t tests. Prevalence of hysterectomy was significantly higher (16.8% vs 13.3%, P = .0002), and mean age at hysterectomy was significantly lower (35 vs 43 years old, P < .0001) in this VA-enrolled sample of female veterans compared with civilian population-based data sets. Sixty-two percent of subjects had experienced attempted or completed sexual assault in their lifetimes. A history of completed lifetime sexual assault with vaginal penetration (LSA-V) was a significant risk factor for hysterectomy (age-adjusted odds ratio, 1.85), with those experiencing their first LSA-V in childhood or in military at particular risk. A history of PTSD was also associated with hysterectomy (age-adjusted odds ratio, 1.83), even when controlling for LSA-V. These associations were no longer significant when controlling for the increased rates of gynecological pain, abnormal gynecological bleeding, and pelvic inflammatory disease seen in those veterans with a history of LSA-V. Premenopausal-aged veterans may be at higher overall risk for hysterectomy, and for hysterectomy at younger ages, than their civilian counterparts. Veterans who have experienced completed sexual assault with vaginal penetration in childhood or in military and those with a history of PTSD may be at particularly high risk for hysterectomy, potentially related to their higher risk of gynecological symptoms. If confirmed in future studies, these findings have important implications for women's health care providers and policy makers within both the VA and civilian health care systems related to primary and secondary prevention, costs, and the potential for increased chronic disease and mortality.

Efficacy of Cranial Electrotherapy Stimulation for Anxiety, PTSD, Insomnia and Depression: Military Service Members and Veterans Self Reports

Key Inclusion Criteria Service Members and Veterans who obtained an Alpha-Stim CES device through the US Department of Defense or US Veterans Affairs Medical Centers from 2006-2011. Protocol Summery Participants either voluntarily chose to respond or not to respond to the questionnaire. One hundred fifty-two (N=152) responses to the questionnaire were received, yielding a response rate of 10%. The questionnaire contained 27 questions that covered the following areas: demographic information, prescription medication use, current exercise activity, and questions asking respondents to rate the effectiveness of Alpha-Stim CES technology for treating anxiety, PTSD, insomnia and depression.

Patient perceptions of proactive medication discontinuation

ObjectiveWhile many patients prefer fewer medications, decisions about medication discontinuation involve collaboration between patients and providers. We sought to identify patient perspectives on intentional medication discontinuation in order to optimize medication use. MethodsWe conducted 20 interviews and two focus groups with a convenience sample of patients (22 men, 5 women; mean age 66 years) at two US Veterans Affairs Medical Centers. We queried patients’ experiences with and attitudes toward taking multiple medications, preferences about taking fewer medications, and communication with their providers about stopping a medicine. Transcripts were analyzed qualitatively. ResultsThree main themes emerged to create a conceptual model of medication discontinuation from the patient perspective: (1) conflicting views of medication, encompassing the sub-themes of desire for fewer medications, adherence, and specific versus general; (2) importance of patient–provider relationships, encompassing the sub-themes of trust, relying on expertise, shared decision making, and balancing multiple providers; and (3) limited experience with medication discontinuation. ConclusionMany patients who have a preference to take fewer medicines do not share their beliefs with providers and recall few instances of provider-initiated medication discontinuation. Practice implicationsStrengthening patient–provider relationships and eliciting patient attitudes about taking fewer medications may enable appropriate discontinuation of unnecessary medications.

Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the US Multi-Society Task Force on Colorectal Cancer.

Optimizing Adequacy of Bowel Cleansing for Colonoscopy: Recommendations From the US Multi-Society Task Force on Colorectal Cancer

Implications for patient safety in the use of safe patient handling equipment: A national survey

BackgroundThe prevalence of musculoskeletal injuries among nursing staff has been high due to patient handling and movement. Internationally, healthcare organizations are integrating technological equipment into patient handling and movement to improve safety. Although evidence shows that safe patient handling programs reduce work-related musculoskeletal injuries in nursing staff, it is not clear how safe these new programs are for patients. ObjectivesThe objective of this study was to explore adverse patient events associated with safe patient handling programs and preventive approaches in US Veterans Affairs medical centers. MethodsThe study surveyed a convenience sample of safe patient handling program managers from 51 US Department of Veterans Affairs medical centers to collect data on skin-related and fall-related adverse patient events. ResultsBoth skin- and fall-related adverse patient events associated with safe patient handling occurred at VA Medical centers. Skin-related events included abrasions, contusions, pressure ulcers and lacerations. Fall-related events included sprains and strains, fractures, concussions and bleeding. Program managers described contextual factors in these adverse events and ways of preventing the events. ConclusionsThe use of safe patient handling equipment can pose risks for patients. This study found that organizational factors, human factors and technology factors were associated with patient adverse events. The findings have implications for how nursing professionals can implement safe patient handling programs in ways that are safe for both staff and patients.