VA Population Research Articles

Prognostic impact of common pathologic alterations in pancreatic ductal adenocarcinoma from the veterans health administration.

603 Background: The Veteran Health Administration’s (VHA) National Precision Oncology Program was established to provide comprehensive molecular profiling for US military veterans with advanced cancers. There is an urgent need for precision strategies in pancreatic ductal adenocarcinoma (PDAC), as it is a leading cause of cancer-related mortality. We hypothesized that contributions of molecular alterations in PDAC would fail to stratify overall survival (OS), as current strategies are largely dependent on the activity of cytotoxic chemotherapy. Methods: A retrospective, multicenter cohort of 342 veterans with PDAC were identified from January 2016 to March 2021 who underwent comprehensive next-generation sequencing of tumor using FoundationOne CDx (UW IRB#2020-0696). Subjects were stratified by localized (L) or metastatic (M) disease at the time of diagnosis. Molecular alterations were compared by disease presentation using chi-squared analysis, and the clinical outcomes of overall survival (OS) were evaluated using Student’s t-test. Results: Baseline characteristics were representative of the VA population across 80 independent sites. The cohort was male-dominant (97%) with a median age of 69 years at diagnosis. Of this sample, 55% had M disease (n=189) compared to 45% with L disease (n=153). Median OS for M PDAC was 8.9±10.2 months (mo) v. L PDAC with median OS 22.5±18.0 mo (p<0.00005). Primary driver alterations were representative of PDAC and comparable between L and M on presentation, respectively; these included KRAS (92% v. 91%), TP53 (73% v. 80%), CDKN2A (29% v. 32%), SMAD4 (18% v. 23%), ARID1A (15% v. 16%) and BRCA2 (9% v. 12%). Primary driver alterations did not confer differences in OS across the population when comparing mutant (mt) to wildtype (wt) for KRAS (10.7 v. 11.8 mo, n=312), TP53 (10.3 v. 11.8 mo, n=263), CDKN2A (10.2 v. 10.9 mo, n=105), ARID1A (10.8 v. 10.9 mo, n=53), SMAD4 (11.3 vs 10.7 mo, n=72), and BRCA2 (13.8 v. 10.7 mo, n=37). Conclusions: Using the largest report of molecular profiles in veterans with PDAC to date, current therapeutic strategies fail to differentiate clinical outcomes by common molecular alterations with cytotoxic chemotherapy. The molecular profiles of veterans are representative of PDAC and do not vary significantly between localized and metastatic disease. There remains a persistent unmet need for therapeutic strategies including ongoing investigations of novel metabolic and immune-based therapies.

STEP-KOA knee osteoarthritis programme is cost effective in VA population in the USA

STEP-KOA knee osteoarthritis programme is cost effective in VA population in the USA

Abstract 2830: Effect of tobacco and alcohol intake on the future development of liver metastasis

Abstract While cigarette smoking and drinking of alcohol have been implicated in carcinogenesis, their role in the genesis of liver metastasis (LM) is undefined. Animal studies support a role for alcohol consumption but it appears that alcoholic liver cirrhosis may be protective. Given this conundrum, we prospectively evaluated a VA cohort of patients at high risk of cancer and therefore LM taking into account self- reported and serum-based substance abuse at baseline, documenting future development of cancer and LM correlated with tumor markers. Methods: Patients who completed a questionnaire to assess colorectal cancer (CRC) risk factors and scored positively were enrolled into the study. Data were compared to those in the computerized record and objective clinical data such as serum alcohol and CEA levels were recorded. Cumulative cancer diagnosis was noted on follow-up and LM had to be confirmed by biopsy or imaging. Tumor markers were serum CEA and stool p87 ELISA. Results: 21 patients developed LM (Group A), 529 cancer patients (Group B), and 588 remained cancer free (Group C). Follow up time was similar (A 9.7±5.4; B 9.4±5.4 and C 10.1±6.9 years). Mortality was 83, 42 and 38% in groups A,B,C respectively. In group A the LM were: 3 of each lung, CRC, breast, metastatic hepatocellular cancer and unknown primary; two of each: pancreatic cancer and bladder; and 1 of each B-cell lymphoma, prostate and renal cell carcinoma. These categories were represented in B by 88% of all cancer types. Smoking percentage was highest in the A (63% ;p=0,002 compared to cancer group), 46% in C (p=0.0001 compared to B), and 27% in B. Serum alcohol levels were highest in A 30.7±75.2 vs B 26.6±89.8 and C 25.9±85.8 mg/dL). Percent of active drinkers were lowest in A 12% and highest in C with B intermediate with no significant differences. Serum CEA levels were highest in A (12.24±13.66) vs B (3.59±4.81: p=0.063);B vs C (2.56±2.15 ng/ml: p=0.026). A direct correlation was found between serum alcohol and CEA levels (r=0.996;p=0.059). p87 Stool tests (81, 50 and 47% in A,B,C respectively) correlated with CEA (r=0.999;p<0.011) and ethanol levels (r=0.993,p=0.06). Conclusions: Only 1.8% of this sample developed LM but smoking would appear to be a factor as 62% of the LM were from cancers associated with smoking-risk. The combination of both factors was accordingly highest in A (38%) but significance was found only between groups B and C (24 vs 35% respectively, p=0.004) perhaps reflecting the habits of the entire VA population rather than cancer-associated. In an animal model for LM resistance we also confirmed a direct correlation between CEA and p87 in tissue extracts. Alcohol intake is more difficult to quantify than smoking and the ability to correlate the 2 serum analytes suggests a relevant assumption of the basis proof. CEA has long been recognized as being pro-metastatic in LM and the direct correlation of alcohol with CEA suggests that alcohol is a promoter for LM. Citation Format: Martin Tobi, Fadi Antaki, Mary Ann Rambus, Edi Levi, Harvinder Talwar, Michael Lawson, Benita McVicker. Effect of tobacco and alcohol intake on the future development of liver metastasis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2830.

Gender disparity in breast cancer: A population-based study in the U.S. Department of Veterans Affairs.

e12549 Background: Over the last several decades, the mortality for breast cancer has improved, however, there remains a large gender disparity with male patients having worse overall survival. Recent studies have identified increased mortality in male breast cancer (MBC) despite adjusting for age and other clinical factors necessitating a need to evaluate both screening and treatment patterns for MBC. The survival trends in MBC have not been studied across the VA population. Methods: Male and female breast cancer cases between 2000-2018 were identified in National VA Cancer Cube Registry. A total of 1511 cases of MBC and 8081 cases of female breast cancer (FBC) were identified. IRB approval was obtained. Statistical significance was set to 0.05, with significant results noted with an asterisk (*). Results: Our data showed that the number of new MBC cases per year remained stable over the study period while the FBC cases rose by 13.6* per year. The racial distribution of Caucasian and African American (AA) patients was comparable among the two groups. For FBC, the peak incidence was between ages 50-60, while for MBC, the peak incidence was at age greater than 70 years. Males were more likely to present at a later disease stage (stage III and IV) compared to females, (26.94% vs 13.8%) *. They also had a worse performance status (ECOG 3 or higher) at presentation compared to female patients, (3.72% vs 1.32%) *. The survival characteristics and first course of treatment received are summarized in the table below. Our findings show that males have a worse 5-year survival both in early and late-stage disease and across both Caucasian and AA races. This poor survival difference remains when comparing MBC patients older than 50 years but not when comparing the younger subset in both groups. These findings suggest that the overall poor survival of MBC may be related to late detection, advanced age at presentation and subsequent increased comorbidities and poor performance status. Conclusions: Patients with MBC present at a later disease stage and have a worse overall survival when compared to FBC. This difference in survival remained when stratified by age, race and stage at presentation. These results imply the possible underutilization of screening in males as well as differences in the clinical and pathological behavior of male and female breast cancer.[Table: see text]

Reduction of Opioid Use With Enhanced Recovery Program for Total Knee Arthroplasty.

Adequate pain control after total knee arthroplasty (TKA) is critically important to achieve early mobilization, shorten the length of hospital stay, and reduce postoperative complications. At Veterans Affairs North Texas Health Care System (VANTHCS) in Dallas, we implemented a multidisciplinary enhanced recovery after surgery (ERAS) protocol to deal with increasing length of stay and postoperative pain. We hypothesize that this protocol will reduce the overall opioid burden and decrease inpatient hospital length of stay in our TKA population. A retrospective review of all TKAs performed by a single surgeon at VANTHCS from 2013 to 2018 was conducted. A postoperative ERAS protocol was implemented in 2016. We compared perioperative opioid use and LOS between cohorts before and after protocol implementation. Inpatient length of stay between cohorts was reduced from 66.8 hours for the standard of care (SOC) period to 22.3 hours in the ERAS cohort. Inpatient opioid use measured by total oral morphine equivalent doses averaged 169.5 mg and 66.7 mg for SOC and ERAS cohorts, respectively (P = .0001). Intraoperative use of opioids decreased from 57.4 mg in the SOC cohort to 10.5 mg in the ERAS cohort (P = .0001). Postanesthesia care unit (PACU) opioid use decreased from 13.6 mg (SOC) to 1.3 mg (ERAS) (P = .0002). There was no significant difference in complications between cohorts (P = .09). Initiating a multidisciplinary ERAS protocol for TKA at VANTHCS significantly reduced inpatient length of stay and perioperative opioid use with no deleterious effects on complication rates. The ERAS protocol has major medical and financial implications for our unique VA population and the VA health care system.

Risk Factors for Mortality in an Older Veteran Population With infective Endocarditis.

To determine 30-day and 1-year mortality in patients treated for infective endocarditis (IE) in a VA population. The secondary objective was to identify risk factors for increased risk of mortality in veterans diagnosed with IE. A retrospective cohort study. Veterans Affairs Western New York Healthcare System PARTICIPANTS: Patients who had a diagnosis of IE between the years 2005 and 2016. Patients were identified via International Classification of Diseases (ICD) codes. None. Factors for death and survival were compared using a bivariate analysis. Significant factors were built into a multivariate logistic regression analysis to determine risk factors for death at 30 days and 1 year. Between 2005 and 2016, there were 153 patients with IE. All-cause mortality at 30 days was 14% versus 39% at 1 year. Patients were more likely to die at 1 year with higher Pitt Bacteremia Scores, older age, and lower number of minor criteria according to Duke Criteria. Comorbidities were similar between groups. Older patients with higher Pitt Bacteremia Scores and lower numbers of minor criteria are more likely to experience mortality at one year. Given the high rates of death at one year, close monitoring, even after completion of therapy may be necessary in older patients. Senior care pharmacists are in a unique position to monitor these patients.

Strong for Surgery: Association Between Bundled Risk Factors and Outcomes After Major Elective Surgery in the VA Population.

Strong for Surgery (S4S) is a public health campaign focused on optimizing patient health prior to surgery by identifying evidence-based modifiable risk factors. The potential impact of S4S bundled risk factors on outcomes after major surgery has not been previously studied. This study tested the hypothesis that a higher number of S4S risk factors is associated with an escalating risk of complications and mortality after major elective surgery in the VA population. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) database was queried for patients who underwent major non-emergent general, thoracic, vascular, urologic, and orthopedic surgeries between the years 2008 and 2015. Patients with complete data pertaining to S4S risk factors, specifically preoperative smoking status, HbA1c level, and serum albumin level, were stratified by number of positive risk factors, and perioperative outcomes were compared. A total of 31,285 patients comprised the study group, with 16,630 (53.2%) patients having no S4S risk factors (S4S0), 12,323 (39.4%) having one (S4S1), 2,186 (7.0%) having two (S4S2), and 146 (0.5%) having three (S4S3). In the S4S1 group, 60.3% were actively smoking, 35.2% had HbA1c > 7, and 4.4% had serum albumin < 3. In the S4S2 group, 87.8% were smokers, 84.8% had HbA1c > 7, and 27.4% had albumin < 3. Major complications, reoperations, length of stay, and 30-day mortality increased progressively from S4S0 to S4S3 groups. S4S3 had the greatest adjusted mortality risk (adjusted odds radio [AOR] 2.56, p = 0.04) followed by S4S2 (AOR 1.58, p = 0.02) and S4S1 (AOR 1.34, p = 0.02). In the VA population, patients who had all three S4S risk factors, namely active smoking, suboptimal nutritional status, and poor glycemic control, had the greatest risk of postoperative mortality compared to patients with fewer S4S risk factors.

629. Understanding the Effects of Social Determinants of Health on Outcome When Discharging Veterans on Parenteral Antibiotic Therapy

BackgroundSocial determinants of health are conditions in which people live, including aspects of both social environments and physical environments, and how these conditions affect their health. Examples of social determinants include access to health care, social support, culture, etc. These factors are often considered when discharging a patient on IV antibiotics. The purpose of this study was to determine if social determinants of health are related to outcomes for veterans discharged from the Zablocki VA on outpatient parenteral antibiotic therapy (OPAT).MethodsThis retrospective chart review evaluated veterans discharged home from the Zablocki VA on OPAT between the years of 2013 and 2017. Variables of social determinants of health included: race/ethnicity, co-habitants, mental health diagnosis, employment, use of illicit drugs, use of tobacco, and use of alcohol. The primary outcome analyzed was completion of therapy with or without complication. Complication is defined as antibiotic change/dose adjustment, PICC line complication, or additional clinic/hospital visit.ResultsOverall, 294 veterans’ charts were reviewed. Of these patients, 188 (63.95%) had no complication and 106 (36.05%) had a complication. Univariate analyses of social determinants are summarized in Table 1. Tobacco use was the only factor significantly associated with OPAT complication (p= 0.008).Table 1. ConclusionThis analysis suggests that many social determinants thought to potentially impact OPAT outcomes, such as race/ethnicity, co-inhabitants, mental health diagnosis, employment status, and use of illicit drugs or alcohol were not significant contributions to OPAT complications in the Milwaukee VA population; although, veterans who were current smokers were more likely to have an OPAT complication. These results may speak to the VA’s integral social support provided to veterans upon discharge, and perhaps, the above social determinants should not be as heavily considered when deciding if a veteran can perform OPAT. However, it is important to consider that these results may reflect the careful selection of Milwaukee veterans discharged on OPAT, as questionable cases can be treated as an inpatient.Disclosures All Authors: No reported disclosures

Abstract 14496: Frailty is Associated With Increased Cardiovascular Mortality in 2,837,152 United States Veterans Aged 65 and Older

Introduction: Frailty has been associated with an increased risk of all-cause mortality and CV events. There are limited data from the modern era of CV prevention to examine the relationship between frailty and CV mortality. We hypothesized that frailty would be associated with with increased risk of CV mortality. Methods: All Veterans ≥65 who were regular users of VA care from 2002–2014 were included. Index date was the last visit date in the year of cohort entry. Data were queried biennially, with frailty &amp; outcomes queried each period. Frailty was defined using a 31-item previously validated frailty index, ranging from 0-1. Degrees of frailty were defined as: not frail (FI &lt;0.1), pre-frail (FI &gt;0.1-≤0.2), mild frailty (FI &gt;0.2-≤0.3), moderate frailty (FI &gt;0.3-≤0.4), and severe frailty (FI &gt;0.4). Variables were extracted from national VA administrative data linked to Medicare and Medicaid. The primary outcome was CV mortality. Survival analysis was performed. Models were adjusted for age, sex, race/ethnicity, geographic region, smoking status, hyperlipidemia, statin use, and blood-pressure medication use. Results: There were 2,837,152 Veterans included in the analysis. In 2002 mean age was 74+/- 5.8 years and in 2012 was 76+/- 8.1 years, 98% were male, 88.8% were white. In 2002, the median frailty score was 0.16 (IQR= 0.13). This increased and then stabilized to 0.19 for 2006 to 2012 (IQR= ranging 0.19 to 0.23). Overall frailty became more prevalent over time (prevalence increased from 31.9% in 2002 to 46.5% in 2012). The presence of frailty was associated with increased risk of CVD mortality at every degree of frailty and year, as shown in the Table. Discussion: Frailty is highly prevalent in the VA population, and both the presence and severity of frailty are tightly correlated with CV death. This study is the largest and most contemporary evaluation of the relationship between frailty and CV mortality to date. Further work is needed to understand how this risk can be diminished.

Colorectal cancer under the age of 50 years in U.S. Department of Veterans Affairs: Is there a role of early screening?

4072 Background: While the overall incidence of colorectal cancer (CRC) is decreasing, the rate has increased in population under 50, with higher stages at diagnosis and a greater proportion of African Americans (AA). Hence, there is an ongoing debate about the age of CRC screening. These trends have not been studied in the VA population. Methods: ICD-10 codes C18-C20 were used to identify the cases of colon and rectal cancer in National VA Cancer Cube Registry. 43,544 cases of colon cancer, 1,278 below and 42,254 above age 50, and 19,815 cases of rectal cancer, 862 below and 18,948 above age 50 were identified between 2003-17. Younger age group was defined as patients less than 50 years old. IRB approval was obtained. Results: Our data comprised &gt; 97% of male patients. In younger group, in the 5 year periods, 2003-07, 2008-12 and 2013-17, colon cancer rate increased from 2.59% to 2.79% to 3.59%, while for rectal cancer it increased from 3.5% to 4.3% to 5.3% (p &lt; .0001). Blacks comprise 31.6% cases of colon cancer and 27.15% cases of rectal cancer in under 50 group, compared to 18.5% and 15.9% of cases in above 50 group respectively (p &lt; .0001). For under 50 group, 48.6% cases of colon and 42.2% cases of rectal cancer were diagnosed in stage III or IV compared to 35.7% and 34.05% cases in above 50 group respectively (p &lt; .0001). For colon cancer, 51.87% of patients in the younger group have a &lt; 5 year survival, worse compared to 45.05% in 50-60 group (p &lt; .0001) and similar to 49.3% in 60-70 group (p = .08). For rectal cancer, 5 year survival showed no difference between these groups. Stage specific survival shows no difference for either colon or rectal cancer across &lt; 50, 50-60 and 60-70 age groups. Conclusions: Rate of CRC is rising in &lt; 50 age group with more advanced stage at diagnosis and higher proportion of African Americans. For colon cancer, &lt; 50 group has a worse 5 year survival as compared to 50-60 age group likely due to increased proportion of patients in stage III or IV, as there is no difference in stage specific survival. For rectal cancer, the 5 year survival or stage specific survival shows no difference in &lt; 50, 50-60 and 60-70 groups. These results add to our understanding of the trends of CRC and should be accounted for in the screening guidelines.

1139 High Prevalence of Non-Alcoholic Steatohepatitis in Veterans With Non Alcoholic Fatty Liver Disease Undergoing Sleeve Gastrectomy

INTRODUCTION: Sleeve gastrectomy leads to significant weight loss and improves features of metabolic syndrome. The prevalence of non-alcoholic fatty liver disease (NAFLD) in the general population undergoing bariatric surgery is reported at 84% -95%. Prevalence of Non Alcoholic Steatohepatitis (NASH) in this population is 25%- 50%. Around 10% of these patients have advanced fibrosis at the time of surgery. The prevalence of NAFLD/NASH or advanced fibrosis in the veteran population undergoing sleeve gastrectomy has not been previously reported. NASH may be underrecognized prior to time of surgery, particularly if there are no associated laboratory abnormalities. This study aims to assess the prevalence of NASH and advanced fibrosis in veterans undergoing sleeve gastrectomy. METHODS: This is a retrospective study of 39 patients who underwent sleeve gastrectomy between January 1, 2018- April 30, 2019 at a Veterans Affairs Hospital. Patients with known alcohol use, cirrhosis or without liver biopsy at the time of surgery were excluded. A single pathologist reviewed the liver biopsies and provided a NASH Activity Score (NAS) for each sample. A Fib 4 score and NAFLD fibrosis score were calculated. Summary statistics was used to determine the prevalence of NAFLD at time of surgery. RESULTS: Patients baseline characteristics are outlined in Table 1. Only 13% of patients had an abnormal ALT at the time of surgery. There was no evidence of liver synthetic dysfunction with normal INR, bilirubin and albumin. Median NAFLD fibrosis score was -0.8 and median FIB-4 was 0.9 which rules out advance fibrosis. 59% of patients had NAFLD and 61% of these patients had evidence of NASH on pathologic exam. Advanced fibrosis was seen in 8% of patients. 70% of patients had NAS score of 4 or below. Percentage of steatosis, inflammation, ballooning and fibrosis score have been summarized in Table 2. CONCLUSION: More than half of our NAFLD patients had characteristics features of NASH on biopsy. This is higher than reported in the general population and close to what has been reported in diabetic patients. However, prevalence of diabetes in the NAFLD patients was only 26%, which would not explain the high number of NASH patients. Advanced fibrosis was only seen in 8% of patients at the time of surgery, which is similar to previous studies. This is the first study to our knowledge to report high prevalence of NASH in a VA population undergoing surgery in the absence of high rate of concomitant diabetes.

872-P: Impact of Psychosocial Factors and Nutrition Using a 12-Week Course on Diabetes Management for Veterans

U.S veterans are at considerable risk for complications from diabetes. It affects nearly 25 percent of VA's population. Many veterans report suffering from psychosocial complications particularly lack of management success and symptoms of depression. The Diabetes Empowerment Group (DEG), a 12-week interdisciplinary group for diabetes management. Curriculum includes values assessment, goal setting, biofeedback, problem solving, mindful eating, and other management skills. A registered dietician provides nutritional education and coaching each session. Based on feedback, program changes are implemented to each new group cycle for quality improvement (QI) purposes. Methods: Hemoglobin A1c levels for veterans were measured via on-site laboratory services. They completed Diabetes Empowerment Scale - Short Form and Patient Health Questionnaires-9 at the beginning and end of their respective group session cycles. Scores were used to determine whether group content impacted veterans' HbA1c, depressive symptoms and empowerment in managing their diabetes. Paired sample t-tests were utilized to compare pre- and post-session cycle values. Fifty-nine veterans completed lab work and QI measures. Mean HbA1c levels (t(58) = 2.55, p&amp;lt;0.01) and depressive symptoms scores (t(54) = 3.11, p&amp;lt;0.001) decreased from the beginning (M = 8.11, SD = 3.60; M = 11.31, SD = 43.55) of the group to the end (M = 7.74, SD = 1.97; M = 9.22, SD = 38.77). Mean empowerment scores increased (t(55) = -3.08, p&amp;lt;0.001 from the beginning (M = 3.56, SD = 0.58) of the group to the end (M = 4.02, SD = 1.24). These findings demonstrate the efficacy of DEG in helping veterans manage diabetes. We expect successive improvements toward a more integrative, standardized curriculum will result in increased empowerment and reduced HbA1c levels and depressive symptomatology. Future directions for QI include increasing access to care by initiating access by starting a new cycle of DEG every six weeks. Disclosure N. Farrell: None.

0868 Patients with PTSD and OSA Treated with APAP: Evaluating Compliance Based on Mask Type in the New Mexico VA Population: Quality Improvement Project to Help in Ordering DME Mask Supplies

Approximately 40-50% of patients with PTSD also have OSA. Overall, this population is less compliant with PAP therapy. This is likely multifactorial related to hypervigilance, claustrophobia, nightmares, patient therapy perception, and healthcare response to patients with PTSD. Patients with worse nightmares have poorer PAP compliance. Additionally, REM-rebound can be seen in patient’s initially starting therapy leading to perceived heightened nightmares with PAP use. With better compliance, over time, a decrease in nightmare frequency is associated with better PAP compliance. In the first week of wearing PAP, patients with claustrophobia had a fivefold increase in the odds of using PAP therapy less than 4 hours/night. Current literature supports a bidirectional relationship between PTSD and OSA, such that PTSD is an obstacle in OSA treatment whereas, untreated OSA can be an obstacle in treating PTSD successfully. It was hypothesized that patients using APAP with PTSD would have better compliance with masks that did not obscure the patient’s peripheral vision. The primary evaluation assessed OSA with PTSD, APAP compliance, and mask type. In October 2018 appointments, veterans diagnosed with OSA, concurrent PTSD, and APAP treatment were reviewed on mask selection and compliance of greater than 4 hours of usage for 70% of the time. Mask usage determined by prosthetic inventory. Masks not interfering with patient’s peripheral vision did not elevate around the patient’s nose. Of 34 patients, 17 met this criteria. Less restrictive masks were not associated with improved compliance. Results showed higher compliance to severer OSA regardless of mask usage. My hypothesis was not supported. Multiple identifiable study limitations were present including male veterans only, sleep technologist’s mask preference, and patients’ length of time with APAP usage prior to visit. This short timeframe analysis and only patients seen with an identifiable PAP problem, created a selection bias. An additional study could include a longer time frame, patient’s BMI, the severity of PTSD, and APAP settings. Support (If Any)

Screen of drug use: Diagnostic accuracy for opioid use disorder

AimsOpioid related deaths have more than tripled in recent years. Identifying and referring individuals with opioid use disorder (OUD) to treatment is one of the promising approaches to reduce opioid related deaths. However, using urine toxicology to identify opioid misuse is not reliable. This study validates the Screen of Drug Use (SoDU) to screen for OUD in the primary care setting, and establish its concurrent diagnostic validity among diverse subgroups of patients, including age, gender, race/ethnicity, marital status, educational level, and PTSD status. MethodsWe used data from 1283 primary care patients recruited in the VA in CA. This sample matched patient characteristics general VA population with mean age = 62, and 95% men. A total of 10.4% met DSM-5 criteria for any drug use disorder and 2.7% met criteria for OUD (with or without other drug use disorders). An opioid use abuse or dependence diagnosis based on the Mini International Diagnostic Interview was used as the criterion for having a DSM-5 opioid use disorder. ResultsThe SoDU was 100% sensitive (95% confidence interval [CI], 89.9%–100%), and 86.3% specific (95% CI, 84.3%–88.1%). When tested in subgroups of patients, the SoDU maintained 100% sensitivity in all subgroups. Specificity ranged from 74.5% to 94.2% for diverse subgroups of patients. ConclusionsThe SoDU is an appropriate instrument to screen for opioid use disorder in primary care. It is brief, easy to use, and has good concurrent diagnostic validity for diverse groups of patients.

1822. Veterans Are Special: Clinical Decision Tree Misses ESBL Status in Bacteremic Veterans

BackgroundSevere bacterial infections require appropriate empiric antibiotic choices. The Johns Hopkins Hospital clinical decision tree (JHH-CDT) to detect bacteremia with ESBL+ Enterobacteriaceae performed well at the developer’s institution, but its external validity is not known. We sought to determine the performance of the JHH-CDT to predict bacteremia with ESBL+ Enterobacteriaceae in a VA population and compare the JHH-CDT with standard of care (empiric antibiotics prescribed to the patient, without using the CDT).MethodsElectronic medical records were examined for clinical and microbiological data. The first episodes of mono-microbial bacteremia in patients at the Houston VA with positive blood cultures that grew either E. coli or Klebsiella species during 2016 were included. The JHH-CDT was used to predict whether or not the isolate would be ESBL+. Empiric initial antibiotic selection was also collected.ResultsEighty-seven cases occurred during the study period; 95% were in men. In veterans at the VA in Houston compared with patients at JHH, respectively, the JHH-CDT demonstrated lower sensitivity (35.7% vs. 51%), positive predictive value (83.3% vs. 90.8%), negative predictive value (88.8% vs. 91.9%) but similar specificity (98.6% vs. 99.1%). Of note, of the five questions in the JHH-CDT, only one was applicable to the Veteran population: history of ESBL colonization or infection in the prior 6 months. Two other CDT questions did not apply to the VA population (no Veterans had these conditions): hospitalization for ≥1 day in an ESBL high-burden in the prior 6 months and age <43 years old. Standard of care led to carbapenems being empirically prescribed for 4/14 (28.6%) ESBL+ bloodstream infections and for 3/73 (4.1%) of non-ESBL bloodstream infections.ConclusionIn this VA population, the JHH-CDT had low sensitivity because two decision nodes did not apply to our older population with little international travel. Standard of care empiric choice of antibiotics also had low sensitivity, covering only 28.6% of ESLB infections appropriately. These findings highlight the importance of developing and validating population-specific predictive stewardship tools.Disclosures B. W. Trautner, Paratek: Consultant, Consulting fee. Zambon: Consultant, Consulting fee and Research grant.

Low-Residue Diet Bowel Preparation in a Veteran Population: Satisfaction, Compliance, and Risk Factors for Inadequate Bowel Preparation

Introduction: Bowel preparation with a low-residue diet (LRD) has demonstrated higher patient satisfaction and similar polyp detection rates compared to the conventional clear liquid diet. However, there is very limited experience with LRD in the veteran population, in which conditions associated with poor bowel preparation are more prevalent than in the general population. Our VA facility recently implemented a LRD for bowel preparation. In this study, we examined veteran satisfaction and compliance with the LRD and factors associated with inadequate bowel preparation. Methods: To examine patient satisfaction and compliance, we administered an anonymous questionnaire to patients undergoing outpatient colonoscopy at the Manhattan VA Medical Center from 3/2018-5/2018. Descriptive statistics were calculated. To examine factors associated with inadequate bowel preparation, we conducted a chart review of a subset of outpatient colonoscopies between 2/2017-4/2018. Using a combination of computerized and manual data extraction, we obtained information on demographics, medical risk factors, medications, endoscopic findings, and histologic results. We assessed potential predictors of inadequate bowel preparation using the chi-squared test and t-test. Results: We included 259 patients in the chart review study and 97 patients in the questionnaire study. Questionnaire responses showed high satisfaction with LRD bowel preparation: 87.6% of patients were willing to repeat the bowel preparation, 87.6% found the process easy or acceptable, and 43.2% had no symptoms during preparation (Table 1). Patients also had high self-reported compliance with LRD (89.6%). Patients in the chart review study were 92.3% male with a mean age of 64 years. An adequate Boston Bowel Preparation Scale score ≥2 in each colonic segment was achieved in 92.3% of procedures. The following factors were associated with inadequate bowel preparation: diabetes (p=0.01), higher BMI (p<0.01), and use of opioid medication (p=0.01, Table 2). Older age, race, and smoking status were not significantly associated with poor bowel preparation. Conclusion: In a VA population using the LRD for bowel preparation, there was high satisfaction and compliance. The quality of bowel preparation was high. Diabetes, higher BMI, and use of opioid medication were predictors of inadequate bowel preparation with the LRD. Targeted interventions to improve bowel preparation in these patients should be considered.313_A Figure 1 No Caption available.313_B Figure 2 No Caption available.

Race affects SVR12 in a large and ethnically diverse hepatitis C-infected patient population following treatment with direct-acting antivirals: Analysis of a single-center Department of Veterans Affairs cohort.

Hepatitis C virus (HCV) infection is a major cause of chronic liver disease. HCV cure has been linked to improved patient outcomes. In the era of direct‐acting antivirals (DAAs), HCV cure has become the goal, as defined by sustained virological response 12 weeks (SVR12) after completion of therapy. Historically, African‐Americans have had lower SVR12 rates compared to White people in the interferon era, which had been attributed to the high prevalence of non‐CC interleukin 28B (IL28B) type. Less is known about the association between race/ethnicity and SVR12 in DAA‐treated era. The aim of the study is to evaluate the predictors of SVR12 in a diverse, single‐center Veterans Affairs population. We conducted a retrospective study of patients undergoing HCV therapy with DAAs from 2014 to 2016 at the VA Greater Los Angeles Healthcare System. We performed a multivariable logistic regression analysis to determine predictors of SVR12, adjusting for age, HCV genotype, DAA regimen and duration, human immunodeficiency virus (HIV) status, fibrosis, nonalcoholic fatty liver disease (NAFLD) fibrosis score, homelessness, mental health, and adherence. Our cohort included 1068 patients, out of which 401 (37.5%) were White people and 400 (37.5%) were African‐American. Genotype 1 was the most common genotype (83.9%, N = 896). In the adjusted models, race/ethnicity and the presence of fibrosis were statistically significant predictors of non‐SVR. African‐Americans had 57% lower odds for reaching SVR12 (adj.OR = 0.43, 95% CI = 1.5‐4.1) compared to White people. Advanced fibrosis (adj.OR = 0.40, 95% CI = 0.26‐0.68) was also a significant predictor of non‐SVR. In a single‐center VA population on DAAs, African‐Americans were less likely than White people to reach SVR12 when adjusting for covariates.

178 Low Adherence to Post-Vasectomy Semen Analysis in the VA Population

Post-vasectomy semen analysis (PVSA) is required to confirm the success of vasectomy procedure per established guidelines. We sought to determine the performance of PVSA as well as factors that influenced adherence in veterans who underwent vasectomy over a 10-year period. A retrospective review of men who underwent vasectomy at our Veterans Administration Medical Center between January 2006 and May 2016 was performed. All patients had pre-procedure consultation and counselling at least once. Counselling included emphasis that PVSA was required for definitive confirmation of the procedure's success and other contraceptive methods should be used prior to negative PVSA. Vasectomies were performed under local anesthesia in the outpatient clinic setting or under general anesthesia in the operating room. All specimens were sent for pathologic confirmation of presence or absence of vas with lumen. Post-vasectomy management included follow-up in in 2-4 weeks for wound check with semen analysis performed within 1-3 months after 15-20 post-procedural ejaculations. Standard statistical analysis was performed to assess for factors that predicted adherence to PVSA.

Role of adjuvant chemotherapy following chemoradiation and surgery for locoregionally advanced rectal cancer: A Veterans Health Administration analysis.

741 Background: Adjuvant chemotherapy (AC) following chemoradiation (CRT) and total mesorectal excision (TME) for locoregionally advanced rectal cancer (LARC) is a standard of care in the United States despite limited data. The purpose of this study was to examine the role, optimal regimen, and duration of AC in the mandatory, prospectively collected cancer registry of the largest integrated health system in the US. Methods: Using the VA Central Cancer Registry, stage II-III rectal cancer patients diagnosed between 1/2001-4/2011 were included if they received neoadjuvant CRT followed by TME with or without AC. Adequate chemotherapy was defined as at least 4 months of therapy. Kaplan-Meier and Log-Rank tests were used to assess survival. Propensity score (PS) adjustment was performed to compare survival outcomes while adjusting for baseline characteristics, including AJCC stage, age, gender, race, smoking status, and comorbidity. Results: 649 patients were identified; 323 received AC while 326 did not (OBS). Median follow-up was 66 months. Mean age was 63 years. 85.1% were white; 98.8% were male. 49.2% had stage II disease. Median overall survival (OS) for all patients was 92 months; 6-year OS was 56.8%. Median OS was 72 months for the OBS group and not reached (NR) for the AC group (p &lt; 0.001). OS at 6 years was 49.5% for OBS and 64.1% for AC (p &lt; 0.0001). On PS matched analysis, OS was improved favoring AC (p &lt; 0.0001). Median disease-specific survival (DSS) was NR for the whole group and NR for the OBS and AC groups. 6-year DSS was 73.6% for the whole group and 67.9% for OBS vs. 79.2% for AC (p &lt; 0.001). PS matched analysis for DSS favored AC (p = 0.0004). There was no significant difference in OS (p = 0.554) or DSS (p = 0.680) when comparing single versus multi-agent chemotherapy and no significant difference in OS (p = 0.766) or DSS (p = 0.271) when comparing adequate ( &gt; / = 4 months) versus inadequate chemotherapy ( &lt; 4 months). Conclusions: In this VA population of LARC patients treated with neoadjuvant CRT followed by TME, the addition of AC was found to improve both OS and DSS compared to OBS. There was no improvement in OS or DSS with the addition of a multi-agent over single-agent chemotherapy.

MiraLAX+Bisacodyl Bowel Preparation is an Efficacious and Tolerable Bowel Preparation Regimen for Screening and Surveillance Colonoscopies in a VA Population

MiraLAX+Bisacodyl Bowel Preparation is an Efficacious and Tolerable Bowel Preparation Regimen for Screening and Surveillance Colonoscopies in a VA Population