VA Office Research Articles

Medical training program size and clinical staff productivity and turnover.

The objective of this analysis was to evaluate the effect of resident program training size on clinician productivity and turnover in the Veterans Health Administration (VHA), the largest education and training platform for medical professionals in the United States. We retrieved administrative data on training programs and training facilities from the VA Office of Academic Affiliations and the VHA Corporate Data Warehouse. Data on primary care physician shortage areas were retrieved from the Health Resources and Services Administration. We used a quasi-experimental instrumental variables 2SLS design and constructed an exogenous predicted training allocation treatment variable as a function of the total national training program allocation. The outcome was clinical staff productivity and turnover. Secondary analyses stratified results using Health Professional Shortage Areas data (HPSA). Data were obtained for a national dataset of 141 VHA medical facilities and 26 specialties that hosted training programs across 11 years from 2011 to 2021 (N = 132,177). Instrumental variables results showed that on average, an increase of one training slot in a specialty leads to a decrease of 0.039 visits per standardized clinic day (p < 0.001) and a 0.02 percentage point increase in turnover (p < 0.001). The direction of this association varied by specialty: while psychiatry and psychology specialties saw a decline in productivity, fields such as primary care and cardiology experienced an increase in productivity. HPSA stratified results indicate that negative effects on productivity and turnover are driven by areas with little to no primary care physician shortage, whereas shortage areas experienced a small increase in productivity and no effect on turnover. This quasi-experimental evaluation indicates that resident training program size is associated with reduced productivity and increased turnover in specialties such as psychiatry and in facilities with high baseline productivity. However, in specialties like primary care and cardiology, as well as areas with shortages of primary care, larger training programs are associated with increased productivity.

The effects of the Veterans Health Administration's Referral Coordination Initiative on referral patterns and waiting times for specialty care.

To investigate whether the Veterans Health Administration's (VA) 2019 Referral Coordination Initiative (RCI) was associated with changes in the proportion of VA specialty referrals completed by community-based care (CC) providers and mean appointment waiting times for VA and CC providers. Monthly facility level VA data for 3,097,366 specialty care referrals for eight high-volume specialties (cardiology, dermatology, gastroenterology, neurology, ophthalmology, orthopedics, physical therapy, and podiatry) from October 1, 2019 to May 30, 2022. We employed a staggered difference-in-differences approach to evaluate RCI's effects on referral patterns and wait times. Our unit of analysis was facility-month. We dichotomized facilities into high and low RCI use based on the proportion of total referrals for a specialty. We stratified our analysis by specialty and the staffing model that high RCI users adopted: centralized, decentralized, and hybrid. Administrative data on referrals and waiting times were extracted from the VA's corporate data warehouse. Data on staffing models were provided by the VA's Office of Integrated Veteran Care. We did not reject the null hypotheses that high RCI use do not change CC referral rates or waiting times in any of the care settings for most specialties. For example, high RCI use for physical therapy-the highest volume specialty studied-was associated with -0.054 (95% confidence interval [CI]: -0.114 to 0.006) and 2.0 days (95% CI: -4.8 to 8.8) change in CC referral rate and waiting time at CC providers, respectively, among centralized staffing model adopters. In the initial years of the RCI program, RCI does not have a measurable effect on waiting times or CC referral rates. Our findings do not support concerns that RCI might be impeding Veterans' access to CC providers. Future evaluations should examine whether RCI facilitates Veterans' ability to receive care in their preferred setting.

Implementation of Virtual, Livestream Yoga Classes for Veterans at Home During the COVID-19 Pandemic: A Mixed-Methods Pilot Program Evaluation.

The COVID-19 pandemic and shut down of in-person complementary and integrative (CIH) wellness services at the San Francisco Veterans' Affairs Healthcare System (SFVAHCS) required implementation of virtual program delivery. In May 2020, VA in-person group yoga classes pivoted to virtual classes for existing attendees. In October 2020, we partnered with SFVAHCS Integrative Health and the VA Office of Rural Health to formalize the TeleYoga Program to expand yoga access to Veterans in SFVAHCS' geographically dispersed area. This pilot study evaluated Veterans' experiences and self-reported health outcomes after participating in at-home tele-yoga groups during the COVID-19 pandemic. The RE-AIM framework guided program delivery evaluation. Reach was assessed with medical record data. Adoption was assessed by the number of new facilities providing referrals to tele-yoga. Implementation, satisfaction, and patient-reported outcomes, were evaluated through structured interviews with Likert scale and open-ended responses. We offered 4-6 weekly livestreamed classes between October 2020-September 2021. The program reached 70 Veterans, including 40 new participants, with 1208 total unique encounters. Referrals increased from 2 to 6 SFVAHCS facilities. Fourteen participants completed structured interviews. Over half rated highly the convenience and overall experience of tele-yoga classes and reported improvement with pain, stress management, exercise, and flexibility. Open-ended responses indicated opportunities for social connection, maintaining mental health, cultivating resilience, improving function, and managing pain. Suggestions for improvement focused on technological aspects, including audiovisual quality. During the COVID-19 pandemic, we successfully transitioned and expanded virtual group yoga delivery to Veterans from all geographic locations within SFVAHCS. We attribute this success to existing infrastructure for telehealth and CIH services and a virtual program orientation for new participants. The results of this pilot study suggest in-person group yoga may be successfully implemented virtually, serving as a viable modality that contributes to holistic wellbeing for Veterans.

Sustainment of the TeleSleep program for rural veterans.

In fiscal year 2021, the Veterans Health Administration (VHA) provided care for sleep disorders to 599,966 Veterans, including 189,932 rural Veterans. To further improve rural access, the VA Office of Rural Health developed the TeleSleep Enterprise-Wide Initiative (EWI). TeleSleep's telemedicine strategies include tests for sleep apnea at the Veteran's home rather than in a sleep lab; Clinical Video Telehealth applications; and other forms of virtual care. In 2017 and 2020, VHA provided 3-year start-up funding to launch new TeleSleep programs at rural-serving VA medical facilities. In early 2022, we surveyed leaders of 24 sites that received TeleSleep funding to identify successes, failures, facilitators, and barriers relevant to sustaining TeleSleep implementations upon expiration of startup funding. We tabulated frequencies on the multiple choice questions in the survey, and, using the survey's critical incident framework, summarized the responses to open-ended questions. TeleSleep program leaders discussed the responses and synthesized recommendations for improvement. 18 sites reported sustainment, while six were "on track." Sustainment involved medical centers or regional entities incorporating TeleSleep into their budgets. Facilitators included: demonstrating value; aligning with local priorities; and collaborating with spoke sites serving rural Veterans. Barriers included: misalignment with local priorities; and hiring delays. COVID was a facilitator, as it stimulated adoption of telehealth practices; and also a barrier, as it consumed attention and resources. Recommendations included: longer startup funding; dedicated funding for human resources to accelerate hiring; funders communicating with local facility leaders regarding how TeleSleep aligns with organizational priorities; hiring into job classifications aligned with market pay; and obtaining, from finance departments, projections and outcomes for the return on investment in TeleSleep.

0936 Characteristics and predictors of prescription sleep medication use in a national sample of Veterans with chronic pain

Abstract Introduction Insomnia and other sleep problems commonly occur in patients with chronic pain. While behavioral approaches are recommended first-line treatments for conditions such as insomnia, patients with sleep complaints often receive sleep medications. Thus, we aim to understand patterns of prescription sleep medication use in Veterans with chronic pain receiving care at the Veterans Health Administration (VHA). Methods We reviewed electronic medical records to identify patients with moderate/severe chronic pain receiving care at a VA hospital between FY2019—2021. Multivariate logistic regressions examined associations between 14 patient demographic and clinical variables on sleep medication prescription. Short-term prescriptions associated with upcoming procedures were excluded. Results Of the 1,706,214 moderate/severe patients with chronic pain (88% male, 66% White), 14% had comorbid diagnosis of insomnia, 30% sleep disordered breathing, and 19% were prescribed sleep medications. Trazodone (40%), melatonin (23%), and benzodiazepines (14%) were most commonly prescribed. Although 14% of patients without insomnia or sleep apnea diagnostic codes were prescribed medication, patients with insomnia were four times more likely to use sleep medication (odds ratio (OR) = 4.05, 95% CI [4.01-4.09]). Strongest predictors of medication use were insomnia (adjusted OR = 2.84, 95% CI [2.81-2.86]), PTSD (adjusted OR = 2.77, 95% CI [2.75-2.79]), depression (adjusted OR = 1.89, 95% CI [1.87-1.91]), bipolar disorder (adjusted OR = 1.84, 95% CI [1.81-1.87]), and ongoing opioid use (adjusted OR = 1.82, 95% CI [1.80-1.84]). Prevalence of medication use was similar across gender, age, and racial/ethnic groups. Conclusion Sleep medication use is common in Veterans with chronic pain, with highest rates among patients with insomnia diagnoses. Additionally, a large number of patients without a sleep disorder diagnosis also receive medications. Findings highlight need to connect chronic pain patients with behavioral sleep interventions. Notably, we observed a wide variety of medications without strong patterns across demographic characteristics. Support (if any) This work was conducted as a non-research quality improvement effort supported by Quality Enhancement Research Initiative (PEC 13-001) and the VA Office of Patient Centered Care and Cultural Transformation. YIL is supported by a VA MIRT Fellowship. JAC is supported by a VA HSR&amp;D CDA (IK2 HX002866). LMD is supported by a VA HSR&amp;D CDA (CDA 18-187).

0399 Examining Insomnia Treatment Adherence and Outcomes in Black Women Veterans

Abstract Introduction Black identified women and veterans consistently experience disproportionately higher rates of insomnia. Cognitive behavioral therapy for insomnia (CBT-I) improves sleep outcomes, although higher rates of attrition and sub-optimal adherence in these groups can limit symptom improvement. Few studies have examined CBT-I treatment adherence and outcomes in women veterans, particularly among those who identify as black. . The current study examined differences in adherence and treatment outcomes in Black identified women veterans compared to white identified women veterans who engaged in CBT-I. Methods As part of a larger clinical trial (NCT02076165), 26 black and 25 white women veterans with insomnia disorder completed a 5-session CBT-I program. Insomnia Severity Index (ISI) and sleep diaries were completed at baseline, post-treatment, and 3-month follow-up. Multiple and fractional regression models were used to evaluate the association between race and change in ISI, change in sleep diary sleep efficiency (SE), and adherence to bedtime and rise time during CBT-I. Results Mean change from baseline to 3-month follow-up in ISI score for black and white women were -7.31 and -7.97 and mean change in diary SE was +14.9% and +10.8%, respectively. Race did not impact change-scores for ISI or SE (1.09 &amp;lt; F &amp;lt; 1.8, p&amp;gt;.05); however, in the fractional regression model, (Χ2=6.9, p=.008; pseudo R2=.058) race was a significant predictor (OR=.27, p=.009) of adherence to prescribed bedtime in the second week of CBT-I, with black women less likely to adhere to prescribed bedtime than women. Race was not a significant predictor of wake time adherence. Conclusion Both black and white women veterans benefitted from CBT-I; however, early adherence to the recommended sleep schedule was lower in black women. Future research could expand on these findings by examining potential barriers in early adherence to recommendations, and how to improve early adherence to ensure that therapy meets the needs of all patients. Support (if any) VA/HSR&amp;D IIR-HX002300 (PI: Martin), NIH/NHLBI K24HL143055 and VA HSR&amp;D RCS 20-191. Dr. May supported by the VA Office of Academic Affiliations.

0414 Pain in Your Day? Get Sleep Treatment Anyway! The Benefits of Behavioral Treatments for Insomnia Despite Pain Symptoms

Abstract Introduction Sleep-related problems and pain affect millions of U.S. adults. Sleep-focused interventions improve both sleep and pain-related outcomes. However, pain can be a barrier to insomnia care due to perceptions that insomnia treatment may not be as effective in the presence of ongoing pain. This study evaluated whether pain severity and pain interference in daily life moderate the effects of behavioral treatments for insomnia on sleep outcomes (e.g., insomnia symptoms, perceived sleep quality, sleep effort, daytime sleepiness). Methods Secondary data analysis was conducted on a sample of 149 women veterans with insomnia disorder who completed either Cognitive Behavior Therapy for insomnia (CBT-I) or Acceptance and Behavioral Changes to treat Insomnia (ABC-I) treatment, both of which showed overall benefit in treating insomnia in women veterans. In the original study, sleep outcomes (ISI, PSQI, GSES, ESS), pain factors (BPI), and other outcomes were measured at baseline, posttreatment, and at 3-months follow-up. Linear and quadratic mixed effects models with random intercepts (subject-level) were conducted to examine the influence of treatment phase, pain-related severity and interference, and their interaction on sleep outcomes. Results All models were statistically significant (92.13≤Χ2≤519.55). No significant interactions were present between treatment phase and pain severity or interference in relation to sleep outcomes. Across analyses, treatment phase, both from baseline to posttreatment (-2.22≤b≤-8.31, p&amp;lt;.001) and from baseline to 3-month follow-up (-2.67≤b≤-8.17, p&amp;lt;.001), illustrated significant improvement of sleep quality outcomes. Conclusion Neither pain severity nor pain interference had a significant impact on outcomes of behavioral treatments for insomnia in women veterans. Findings have clinical implications in that they support the encouragement of individuals with co-morbid chronic pain and insomnia symptoms to engage in non-pharmacological interventions for insomnia disorder. Future research could expand on this study by including pain-related interventions concurrent with behavioral interventions for insomnia disorder. Support (if any) Data used was from an original project funded by VA/HSR&amp;D IIR-HX002300 (PI: Martin), NIH/NHLBI K24HL143055 (PI: Martin). Dr. Erickson was supported by the VA Office of Academic Affiliations through the Advanced Fellowship Program in Geriatrics. Support was also provided by the VA Greater Los Angeles Geriatric Research, Education and Clinical Center.

0446 Sleep Disordered Breathing Treatment is Associated with Improved Mental Health Symptoms and Quality of Life in Women Veterans

Abstract Introduction Sleep disordered breathing (SDB) is associated with poor mental health and lower overall quality of life (QOL); however, research examining these outcomes after positive airway pressure (PAP) therapy for SDB in women is limited. We studied a 6-session PAP adherence program that included behavioral sleep improvement strategies plus concepts of Acceptance and Commitment Therapy (ACT) to promote sustained PAP use, and evaluated the impact of this ACT-based program on daytime and mental health symptoms and quality of life in a sample of women veterans with SDB who were prescribed PAP. Methods Women veterans with SDB (n=90, mean = 53.2 years [range 26-80]) receiving care in an urban VA healthcare system were randomly assigned to a “control” SDB/PAP education program or the “Acceptance and Behavioral Changes to treat Sleep Apnea” (ABC-SA) program. All received PAP therapy. Measures included: Epworth Sleepiness Scale (ESS), Flinders Fatigue Scale (FFS), Patient-Health Questionnaire 9-item (PHQ-9), Generalized Anxiety Disorder Questionnaire 7-item (GAD), and The World Health Organization Quality of Life Scale, Brief (WHOQOL BREF). Mixed-effect models assessed the main effect of time across groups and between-group changes in these measures at post-treatment and 3 month-follow up compared to baseline. Results For the main effect of time, participants in both groups had significant improvements at post-treatment and 3-month follow-up in sleepiness, fatigue, depression, anxiety, and QOL (all p&amp;lt; 0.05). Compared to controls, women who received ABC-SA reported greater improvements in daytime sleepiness (ESS) at post treatment (p=0.04) and in fatigue (FFS) at 3-month follow-up (p=0.008). Conclusion PAP treatment in women with SDB was associated with improvements in measures of mental health and QOL. There was some evidence of even greater benefits with ABC-SA. Further work is needed to understand the relationship between SDB treatment and improved mental health outcomes in women and other underrepresented populations. Support (if any) VA HSR&amp;D IIR 16-244 and RCS 20-191; NIH/NHLBI K24 HL143055, HRS&amp;D COIN; VAGLAHS GRECC and VA Office of Academic Affiliations

Effect of Mechanical Stretch on Sex-Dependent Gene Expression by RNA Sequencing in Mouse Renal Endothelial Cells

Increased mechanical endothelial cell stretch contributes to the development of numerous cardiovascular and renal pathologies by orchestration of immune cell activation. While endothelial cells are not recognized as professional antigen presenting cells, they can express both major histocompatibility complexes (MHC) I and II. MHCs are essential to form part of the immunological synapse during antigen presentation to adaptive immune cells. The mechanisms by which increased endothelial cell stretch regulates renal endothelial antigen processing and presentation is unknown. We hypothesized that increased mechanical endothelial stretch promotes upregulation of key antigen processing and presentation genes in mouse renal endothelial cells (MRECs) in a sex-dependent manner. MRECs derived from both sexes underwent 5%, 10%, and 15% (1 Hz) uniaxial cyclical stretch for 48 hours. After stretch, RNA sequencing was performed and bioinformatic and pathway analysis was executed to determine potential inflammatory mechanisms of action. We found that 10% stretch induced downregulation in MHC and costimulatory genes ( H2-Da, H2-K1, H2-T23, H2-T24) and upregulation of antigen processing associated genes ( tap1, psmb2, psmb4, and psmb8) in male MRECs. Females undergoing 10% stretch exhibited inverse gene expression profiles with upregulation of MHC genes and downregulation of antigen processing and presentation genes. At 15% stretch, the sex-specific gene expression tendencies were inverse from 10% stretch. To understand the function of differential gene expression we performed gene ontology enrichment pathway analysis. Male MRECs undergoing 10% stretch exhibited an enrichment for renal and cardiovascular development processes and inflammatory processes including chemokine-mediated signaling and cytokine-mediated signaling. When we compared female MRECs at 10% stretch, we found enrichment for renal and cardiovascular development processes including endothelial cell migration, angiogenesis and glomerular vascular, kidney, and artery development. Interestingly, 10% mechanical stretch enriched pro-inflammatory processes including positive regulation of cell migration and leukocyte migration. These data provide novel insight into how mechanical stretch regulates key antigen processing and presentation pathways in renal endothelial cells in a stretch and sex-dependent manner. This work was funded by MUSC Core Centers for Clinical Research Project Award to JPVB and Biomedical Laboratory Research and Development Service of the VA office of Research and Development Awards IK2BX003922 to KYDP and IK2BX005605 to JPVB. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Seizure Rates Across Pathologically-Confirmed Dementia Subtypes (P3-6.005)

<h3>Objective:</h3> Taking advantage of a large autopsy series of uniformly pathologically-characterized persons with dementia (PWD), our goal was to determine the seizure occurrence rate for different types of pathologically confirmed dementia subtypes. <h3>Background:</h3> The incidence of seizures in PWD is higher than in persons without dementia. However, evidence of this is based on studies that included clinically-diagnosed all-cause dementia, pathologically-diagnosed Alzheimer’s Disease (AD), or clinically-diagnosed subtypes of dementia without pathological confirmation. <h3>Design/Methods:</h3> Retrospective review of clinical and autopsy records among all veterans who died while in a VA-based Special Dementia Care Unit and whose families consented to brain autopsy was conducted. <h3>Results:</h3> Of the 335 veterans, the majority (n = 327, 97.61%) were male with an average age of 78 years at death (SD=7.62). The average age at first reported symptom was 71 (SD=8.28). Overall, 57 (17%) veterans had evidence of new-onset seizures after the date of their dementia diagnosis and were thus considered to have dementia-related seizures. Of those with AD-only neuropathology (n=121), 26 (21.5%) had developed seizures and accounted for 45.6% of all the dementia-related seizure cases. In addition, most of the remaining cases of dementia-related seizures (n=26, 45.6%) showed evidence of AD pathology and in addition to another comorbid pathology. The remaining five (8.8%) were diagnosed with Frontotemporal Dementia and/or Traumatic Brain Injury. <h3>Conclusions:</h3> Dementia-related seizures are common and are associated with AD pathology. Even among pathologically mixed dementias, seizure prevalence was driven by AD pathology. Diagnosis of seizures in patients with dementia may reflect underlying AD pathology, regardless of clinical presentation. The development of dementia-related seizures should raise the possibility of underlying AD pathology and thus could have implications for treatment response. <b>Disclosure:</b> An immediate family member of Dr. Moo has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Taylor and Francis. Dr. Moo has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Smith Mirabella Blake. Dr. Moo has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Cambridge Medical Experts. The institution of Dr. Moo has received research support from VA HSR&amp;D. The institution of Dr. Moo has received research support from VA Office of Rural Health. Prof. Shirk has received personal compensation for serving as an employee of Hologic. The institution of Prof. Shirk has received research support from Alzheimer’s Association. The institution of Prof. Shirk has received research support from VA. The institution of Prof. Shirk has received research support from NIA. Dr. Baumann has nothing to disclose. Dr. Sullivan has nothing to disclose.

Practice Implications of Patterns of Healthcare Utilization before and after Alzheimer’s Disease diagnosis (P2-6.005)

<h3>Objective:</h3> To describe patterns of dementia-related healthcare utilization before and after initial diagnosis code for Alzheimer’s Disease (AD). <h3>Background:</h3> Clinical guidelines and common practices indicate appropriate responses to dementia warning signs, for diagnostic work-up and medical management of AD. It is not clear, however, to what extent these practice patterns are followed and what consequences they may have for AD patients. <h3>Design/Methods:</h3> Structured electronic health records from the Department of Veterans Affairs healthcare system (VA), the largest integrated healthcare system in the United States, were examined to identify first recorded AD diagnosis (ICD) code in patients with at least two visits with AD codes. Use of related diagnostic and therapeutic services was compared in the year preceding and following first AD diagnosis. 2018 was studied to limit Covid-19 driven changes in practice. <h3>Results:</h3> A first AD code was found in 2018 for 6,046 patients (mean age of 80.5 years; 97% men). Most (53.1%) had a prior diagnosis code of dementia not-otherwise-specified and 29.4% had a prior code for mild cognitive impairment, with first codes appearing an average of three prior. Services increased from the year before to the year after first AD diagnosis: neuroimaging (31.3% to 32.2%), neuropsychological assessment (25.7% to 32.3%), specialist visit (neurologist, geriatric psychiatrist or geriatrician) (51.1% to 73.2%), prescribed dementia-specific medications (30.2% to 60.5%), inpatient care (11.4% to 25.9%), and home healthcare services (45.8% to 63.6%) (p&lt;0.01 for all except neuroimaging). <h3>Conclusions:</h3> Use of dementia and aging-related services increased after first AD diagnosis code. For many, dementia-targeted treatment began years before AD coding and diagnostic procedures continued afterward. These service and treatment patterns may reflect the complexity of AD diagnostic and care processes in clinical practice, including variability regarding when to attribute dementia to a specific underlying etiology. <b>Disclosure:</b> An immediate family member of Dr. Moo has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Taylor and Francis. Dr. Moo has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Smith Mirabella Blake. Dr. Moo has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Cambridge Medical Experts. The institution of Dr. Moo has received research support from VA HSR&amp;D. The institution of Dr. Moo has received research support from VA Office of Rural Health. The institution of Dr. Davila has received research support from Department of Veterans Affairs. Dr. Jasuja has nothing to disclose. Mrs. Palnati has received personal compensation for serving as an employee of Optum. Mrs. Palnati has received personal compensation in the range of $50,000-$99,999 for serving as a Research Analyst with Veterans Administration. Qing Shao has nothing to disclose. Ms. Dinesh has nothing to disclose. The institution of Dr. Palacios has received research support from Eisai, Inc. The institution of Dr. Palacios has received research support from NIH. The institution of Dr. Palacios has received research support from Department of Veterans Affairs. Dr. Palacios has a non-compensated relationship as a Grant Reviewer with National Institutes of Health that is relevant to AAN interests or activities. Dr. Palacios has a non-compensated relationship as a Associate Editor with Journal of Alzheimer’s Disease that is relevant to AAN interests or activities. Dr. Palacios has a non-compensated relationship as a Researcher with Department of Veterans Affairs that is relevant to AAN interests or activities. Ms. McDannold has nothing to disclose. Weiming Xia has nothing to disclose. Dr. Zhang has received personal compensation for serving as an employee of Eisai. Amir Tahami has received personal compensation for serving as an employee of Eisai. Dr. Miller has nothing to disclose.

What is the impact of veterans affairs rotations in oral and maxillofacial surgery residency?

Oral and maxillofacial surgery (OMS) residencies commonly affiliate with Veterans Affairs Medical Centers (VAMC) to extend care for veterans. This study quantifies the surgical experience of residents at the Corporal Michael J. Crescenz (CMC) VAMC in Philadelphia, Pennsylvania and determines the number of programs affiliated with VA Medical Centers, to enumerate the educational benefits and improve veteran healthcare. The dental project manager logs from 2012 through 2021 of the CMC VAMC operating room were analyzed, and cases were categorized into 12 groups. The implant cases from 2012 through 2021 were quantified. Program affiliations were determined using a VA Office of Academic Affiliation report. There were 1359 procedures (760 cases) performed. Dentoalveolar (n=967) was the most common category, and extractions (n=384) were the most common procedure. The least cases and procedures were performed in 2012 (n=14; n=23). The most cases were performed in 2019 (n=137), and the most procedures were performed in 2019 and 2021 (n=255). There were 3133 implants placed. There are 40 OMS programs affiliated with VA Medical Centers; more dual degree (n=24) than single degree (n=16) programs having an affiliation. The CMC VAMC offers robust dentoalveolar experience and is increasing in surgical volume, representing the expected needs of an aging veteran population. An increasing budget and millions of eligible veterans indicates VA medical centers nationally will continue to provide valuable surgical experiences.

Clinical trial facilitators: A novel approach to support the execution of clinical research at the study site level

In the summer of 2020, multiple efforts were undertaken to establish safe and effective vaccines to combat the spread of the coronavirus disease (COVID-19). In the United States (U.S.), Operation Warp Speed (OWS) was the program designated to coordinate such efforts. OWS was a partnership between the Department of Health and Human Services (HHS), the Department of Defense (DOD), and the private sector, that aimed to help accelerate control of the COVID-19 pandemic by advancing development, manufacturing, and distribution of vaccines, therapeutics, and diagnostics. The U.S. Department of Veterans Affairs’ (VA) was identified as a potential collaborator in several large-scale OWS Phase III clinical trial efforts designed to evaluate the safety and efficacy of various vaccines that were in development. Given the global importance of these trials, it was recognized that there would be a need for a coordinated, centralized effort within VA to ensure that its medical centers (sites) would be ready and able to efficiently initiate, recruit, and enroll into these trials.The manuscript outlines the partnership and start-up activities led by two key divisions of the VA's Office of Research and Development's clinical research enterprise. These efforts focused on site and enterprise-level requirements for multiple trials, with one trial serving as the most prominently featured of these studies within the VA. As a result, several best practices arose that included designating clinical trial facilitators to study sites to support study initiation activities and successful study enrollment at these locations in an efficient and timely fashion.

Utilizing Telehealth to Meet the Needs of Rural Veterans: Introduction the VA's Clinical Resource Hubs Geriatric Mental Health Programs

The Department of Veterans Affairs Clinical Resource Hubs (CRHs) offer a variety of telehealth initiatives designed to expand access to care. Each VA Integrated Service Network (VISN) or region has its own CRH to provide telehealth services to veterans residing in that region. Many older veterans receiving services through the telemental health programs reside in rural areas, with limited access to specialty care. Several CRHs offer geriatric mental health consults to expand older veterans’ access to specialty mental health treatment. By utilizing telehealth consultations, older veterans are able to receive high quality mental health care in their homes or at small local clinics.At this time, the CRHs serving VISN 9 (Tennessee and Kentucky), VISN 23 (North Dakota, South Dakota, Nebraska, Iowa, and Minnesota), VISN 1 (New England), VISN 20 (Washington, Oregon, Idaho and Alaska), and VISN 4 (Pennsylvania) offer specialized geriatric mental health services. All of these CRHs offer consultative care with exception of VISN 20, which offers fully virtual continuity clinics to highly underserviced areas within that region. VISN 23 was the first region to offer such a program and has been in operation through the CRH since 2018 (although its geriatric psychiatrist was providing consultative telehealth services prior to that). VISN 9, VISN 20, and VISN 1 began program development and services in 2021. The programs receive additional support from the VA Office of Rural Health, which has also funded a program evaluation team.Each region's geriatric mental health program has a geriatric psychiatrist as well as additional team members with geriatric specialty experience in various fields such as psychology, pharmacy, neuropsychology, internal medicine, and nursing. Care is provided through a range of modalities, including electronic consultations (e-consults), direct to home video visits, video visits at local clinics and inpatient/residential settings, and telephone evaluations. A range of diagnosis and concerns are addressed including, but not limited to, dementia diagnosis and management, caregiver support, treatment of complex psychiatric conditions in late life, and capacity. Veterans residing in outpatient, inpatient, and VHA residential/long term care settings are all eligible for care through CRH programs. Although these programs share a common goal to expand access to geriatric mental health treatment, each program operates uniquely, with different models of care based on the needs of their region's specific population. Our session will start by highlighting the care offered by CRHs and the VA Office of Rural Health's program evaluation research. The geriatric psychiatrist from VISN 9, VISN 23, and VISN 1 will present the specifics of their program, focusing on program development, types of care provided, and population served.

Office of inspector general-An atypical job for a psychologist.

This article outlines the career of Dr. Dana Moore, who began her federal career as a clinical psychologist at the VA Medical Center in Nashville, TN. Following her husband's transfer to Washington, DC, she moved into VA Central Office training and management positions, which eventually led her to become a Senior Executive in VA's Office of Inspector General. She encourages readers to consider making career choices that open up new opportunities for their future. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Qualitative Evaluation: GRECC Connect as a Method of Delivering Health Care to Rural Older Veterans

The VA Office of Rural Health-funded GRECC Connect program uses telehealth modalities to provide geriatric specialty care to rural older veterans and education to clinicians in VA Community-based outpatient clinics (CBOCs). Qualitative evaluation of GRECC Connect has included interviews with three stakeholder groups: geriatrics specialty teams at 15 hub medical centers, rural CBOC staff, and patients/family caregivers. CBOC staff interviews included 50 individuals from 13 different CBOCs. Staff roles included clinic managers, social workers, psychologists, physicians, nurses, and telehealth technicians. Older veterans who had recently been involved in a GRECC Connect video visit were also invited to share their views on the visit. By including multiple perspectives on the program, we are better positioned to increase reach, access, and improve care for older rural veterans.

Support From the Top: Diverse Leadership Partners for Sustained STAR-VA Implementation

The STAR-VA program was an initiative out of what is now called the VA Office of Mental Health and Suicide Prevention, partnering with the national Offices of Geriatrics and Extended Care and Nursing Services. Ongoing collaboration with these national, as well as regional and medical-center-level leaders, has been critical for informing program implementation and dissemination strategies. We will discuss several key partnered strategies, including (1) linking STAR-VA to national CLC systematic quality improvement efforts; (2) engaging national inter-office program leaders in decisions about outreach to and inclusion of facilities in STAR-VA training and implementation; (3) training local STAR-VA champions on strategies for engaging local leadership support; (4) briefing leaders across the system with program updates; and (5) using national VA data to inform STAR-VA sustained implementation. Discussion will address challenges and opportunities for engaging leadership stakeholders in facilitating sustained implementation of evidence-based programs.

Veteran Experiences with Telehealth

Research ObjectiveIn FY18‐19, VA Office of Rural Health initiated a pilot program to increase access to services in underserved areas by funding 13 telehealth hubs. Understanding Veterans' experiences with telehealth hubs is essential to its delivery, especially in its scale‐up nationally and in response to the pandemic in FY20. We examine characteristics and ratings of care among Veterans with telehealth hub visits compared to usual primary care (PC) during the pilot program.Our objectives are to: Understand Veteran experiences with access, care coordination, comprehensiveness and primary care provider (PCP) communication during a telehealth pilot program. Examine Veteran characteristics associated with telehealth hub visits during a pilot program. Study DesignRegression analysis of a cross‐sectional data: VA Survey of Healthcare Experiences of Patients – Patient‐Centered Medical Home (SHEP‐PCMH), which uses Consumer Assessment of Healthcare Providers and Systems (CAHPS) questionnaires to survey Veterans on their healthcare experiences. We derived dichotomous outcomes from SHEP‐PCMH composite indices, indicating optimal experiences with access, care coordination, PCP communication, comprehensiveness (based on the percentages of responses that fall in the top category (Always or Yes) and PCP rating (9 or 10 out of 10). Key predictors were telehealth hub v. usual care index visit and proportion of telehealth hub visits in 6 months prior to the index visit. Other covariates included age, gender, race/ethnicity, education, number of PC visits in past year, self‐rated overall and mental health, and year of visit. We conducted multivariate logistic regression analyses to predict optimal care experiences, controlling for demographics, healthcare use, health status and year.Population StudiedVeterans receiving care at VA PC clinics offering telehealth hub visits during FY2018‐2019.Principal FindingsIn FY2018‐2019, 3201 out of 57,793 Veterans had a telehealth hub index visit. Telehealth hub utilization 6 months prior to index visit: 0.25% usual care v. 83% telehealth. Compared to usual care, the telehealth hub group was significantly older (age ≥ 65: 60% telehealth, 50.5% usual care), had fewer PC visits (0–1 visits: 69% telehealth, 56% usual care). In multivariate models, we failed to detect statistically significant difference between telehealth hub and usual care groups for the composite measures of Veteran experiences. Adjusted Odds Ratio (AOR) (95% CI): 0.68 (0.12–3.81), 0.3 (0.07–1.35), 1.55 (0.48–4.95), 0.47 (0.18–1.22), and 0.66 (0.18–2.49) for access, coordination, PCP communication, comprehensiveness, and PCP rating, respectively. Older age and greater number of PC visits were associated with greater likelihood of optimal care ratings; fair/poor overall and mental health were associated with lower likelihood of optimal experiences.ConclusionsCompared to usual care, telehealth hub users did not differ in likelihood ratings of optimal care experience although they are distinct in their demographics and healthcare utilization. Further study is needed, since the population of telehealth hub users is quite different from usual care population during pilot program.Implications for Policy or PracticeTelehealth hub visits were not associated with decrements in care experience. Our findings suggest that Veterans' experiences with tele‐health during the COVID‐19 pandemic might be similar to usual care. This is of importance since the Covid‐19 pandemic necessitates expanded use of virtual care to ensure patient safety.Primary Funding SourceDepartment of Veterans Affairs.

Implementation of documented and written informed consent for clinical trials of communicable diseases: Lessons learned, barriers, solutions, future directions identified during the conduct of a COVID-19 clinical trial

Background and objectiveThe communicable nature of many infectious diseases, including SARS-CoV-2, creates challenges for implementing and obtaining regulatory-compliant written informed consent. The goal of this project was to identify and evaluate processes that address these barriers while maintaining clinical and research staff safety. MethodsWe reviewed Federal Drug Administration (FDA), World Health Organization (WHO), and VA Office of Research and Development (ORD) guidance about informed consent during the COVID-19 pandemic, and identified and pilot-tested several mechanisms for obtaining regulatory-compliant consent during our COVID-19 therapeutics clinical trial. ResultsSeveral processes were identified. These included a standard face-to-face consent with a plan for maintaining a paper copy of the signed consent form, a phone or video chat consent process that included taking a picture of the signed consent form or a screen shot of the signed document during a video chat, integration of the consent forms into software embedded within the electronic health record, and secure software programs with electronic signature. These processes are FDA-compliant but time-intensive, often requiring four or more hours of coordination between the clinical team, research staff, patients, and legally authorized representatives. ConclusionsFuture studies could evaluate how to improve efficiency, and whether some elements of the consenting process, such as the requirement for documented written signed consent, rather than a witnessed oral consent, is an acceptable standard for research participants with communicable diseases.

471 Identifying gaps in evaluation, treatment, and treatment adherence in women Veterans with sleep disordered breathing risk factors

Abstract Introduction In our recent national survey study, 13% of women Veterans reported a diagnosis of Sleep Disordered Breathing (SDB), of whom 65% used positive airway pressure (PAP) treatment. We also found many women Veterans at high risk for SDB were undiagnosed (43%). The current study builds upon this survey research to identify rates of evaluation, diagnosis, treatment, and treatment adherence among women Veterans with risk factors for SDB. Methods We analyzed telephone screening data from an ongoing SDB treatment adherence intervention study for women Veterans in Los Angeles county. A total of 173 women Veterans, identified by retrospective chart review as having at least one risk factor for SDB (i.e. high blood pressure, diabetes, obesity, depression, or &amp;gt; 50 years old), completed the screener. Screening questions included 1) previous diagnostic testing for SDB, 2) SDB diagnosis 3) SDB treatment type, and 4) past week SDB treatment use. Descriptive statistics regarding evaluation and treatment of SDB are reported. Results In total, 31% of respondents endorsed having previously completed diagnostic testing, of whom, 54% reported an SDB diagnosis. Of those with diagnosed SDB, 82.8% were prescribed treatment (PAP [72.4%], oral appliance [6.9%], surgery [3.5%]), and 17.2% did not report being prescribed any SDB treatment. Of the 21 (72.4%) women Veterans diagnosed with SDB that were prescribed PAP, only 33% reported using treatment in the past week. Of the 2 women Veterans (6.9%) prescribed an oral appliance, 0% reported past week use. Conclusion Less than 1/3 of women Veterans with at least one risk factor for SDB had previously been evaluated for SDB; however, over 1/2 of women Veterans who were evaluated tested positive for SDB. Additionally, most women Veterans had not used PAP or oral appliance therapy in the past week. Greater clinical attention is needed to identify, evaluate, and diagnose SDB in women Veterans. Moreover, further research is needed to evaluate and inform interventions to address SDB treatment adherence barriers in women Veterans. Support (if any) VA HSR&amp;D IIR 16–244 and RCS 20–191; NIH/NHLBI K24 HL143055, VAGLAHS GRECC and VA Office of Academic Affiliations.