VA Primary Care Research Articles

Expanding Naloxone Coprescribing at a Regional VA Medical Center.

Veterans are disproportionately affected by chronic pain and are more likely to be prescribed opioids. As a means of risk mitigation, the Centers for Disease Control and Prevention and Department of Defense recommend naloxone for patients on opioids with risk factors, including use of ≥50 morphine milligram equivalents daily, concurrent benzodiazepine/sedative use, and pulmonary or liver disease. An interprofessional quality improvement team consisting of 6 residents, a pharmacist, a nurse educator, and a faculty mentor was formed to increase naloxone coprescriptions at a regional VA medical center Continuity of Care Clinic. Primary intervention identified eligible patients via the VA Primary Care Almanac's Opioid Therapy Risk Report and alerted providers by email and secure messaging. Naloxone coprescription rates increased from 42% initially in June 2022 to 82% by June 2023 (29/69 to 41/50 patients, P < 0.0001). This project demonstrates that notifying providers of high-risk patients can significantly increase naloxone coprescriptions.

Optimizing Utilization of SGLT2 Inhibitors in Patients With Type 2 Diabetes Mellitus and Chronic Kidney Disease in a VA Primary Care Clinic: An Interdisciplinary Quality Improvement Project.

Optimizing Utilization of SGLT2 Inhibitors in Patients With Type 2 Diabetes Mellitus and Chronic Kidney Disease in a VA Primary Care Clinic: An Interdisciplinary Quality Improvement Project.

Trends in Veteran hospitalizations and associated readmissions and emergency department visits during the MISSION Act era.

To examine changes in hospitalization trends and healthcare utilization among Veterans following Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act implementation. VA Corporate Data Warehouse and Centers for Medicare and Medicaid Services datasets. Retrospective cohort study to compare 7- and 30-day rates for unplanned readmission and emergency department visits following index hospital stays based on payor type (VHA facility stay, VA-funded stay in community facility [CC], or Medicare-funded community stay [CMS]). Segmented regression models were used to compare payors and estimate changes in outcome levels and slopes following MISSION Act implementation. Veterans with active VA primary care utilization and ≥1 acute hospitalization between January 1, 2016 and December 31, 2021. Monthly index stays increased for all payors until MISSION Act implementation, when VHA and CMS admissions declined while CC admissions accelerated and overtook VHA admissions. In December 2021, CC admissions accounted for 54% of index admissions, up from 25% in January 2016. From adjusted models, just prior to implementation (May 2019), Veterans with CC admissions had 47% greater risk of 7-day readmission (risk ratio [RR]: 1.47, 95% confidence interval [CI]: 1.43, 1.51) and 20% greater risk of 30-day readmission (RR: 1.20, 95% CI: 1.19, 1.22) compared with those with VHA admissions; both effects persisted post-implementation. Pre-implementation CC admissions were also associated with higher 7- and 30-day ED visits, but both risks were substantially lower by study termination (RR: 0.90, 95% CI: 0.88, 0.91) and (RR: 0.89, 95% CI: 0.87, 0.90), respectively. MISSION Act implementation was associated with substantial shifts in treatment site and federal payor for Veteran hospitalizations. Post-implementation readmission risk was estimated to be higher for those with CC and CMS index admissions, while post-implementation risk of ED utilization following CC admissions was estimated to be lower compared with VHA index admissions. Reasons for this divergence require further investigation.

Evaluation of regional variation in racial and ethnic differences in patient experience among Veterans Health Administration primary care users.

To evaluate racial and ethnic differences in patient experience among VA primary care users at the Veterans Integrated Service Network (VISN) level. We performed a secondary analysis of the VA Survey of Healthcare Experiences of Patients-Patient Centered Medical Home for fiscal years 2016-2019. We compared 28 patient experience measures (six each in the domains of access and care coordination, 16 in the domain of person-centered care) between minoritized racial and ethnic groups (American Indian or Alaska Native [AIAN], Asian, Black, Hispanic, Multi-Race, Native Hawaiian or Other Pacific Islander [NHOPI]) and White Veterans. We used weighted logistic regression to test differences between minoritized and White Veterans, controlling for age and gender. We defined meaningful difference as both statistically significant at two-tailed p < 0.05 with a relative difference ≥10% or ≤-10%. Within VISNs, we included tests of group differences with adequate power to detect meaningful relative differences from a minimum of five comparisons (domain agnostic) per VISN, and separately for a minimum of two for access and care coordination and four for person-centered care domains. We report differences as disparities/large disparities (relative difference ≥10%/≥ 25%), advantages (experience worse or better, respectively, than White patients), or equivalence. Our analytic sample included 1,038,212 Veterans (0.6% AIAN, 1.4% Asian, 16.9% Black, 7.4% Hispanic, 0.8% Multi-Race, 0.8% NHOPI, 67.7% White). Across VISNs, the greatest proportion of comparisons indicated disparities for three of seven eligible VISNs for AIAN, 6/10 for Asian, 3/4 for Multi-Race, and 2/6 for NHOPI Veterans. The plurality of comparisons indicated advantages or equivalence for 17/18 eligible VISNs for Black and 12/14 for Hispanic Veterans. AIAN, Asian, Multi-Race, and NHOPI groups had more comparisons indicating disparities by VISN in the access domain than person-centered care and care coordination. We found meaningful differences in patient experience measures across VISNs for minoritized compared to White groups, especially for groups with lower population representation.

Diagnostic Accuracy of the Primary Care PTSD for DSM-5 Screen (PC-PTSD-5) in Demographic and Diagnostic Subgroups of Veterans

BackgroundThe Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) is a screening instrument designed to identify patients with probable PTSD and is mandated to be used in VA primary care settings. However, validation of the diagnostic accuracy of the instrument is lacking in various demographic and diagnostic groups.ObjectiveTo evaluate the diagnostic accuracy of the PC-PTSD-5 in demographically and diagnostically stratified groups of VA primary care patients.Design, Setting, and ParticipantsBased on a sample of 519 VA primary care patients (40.61% response rate), the PC-PTSD-5 was evaluated against a criterion measure, examining its sensitivity, specificity, and other diagnostic properties. Evaluations were conducted in demographically stratified patient groups, including gender, age, race/ethnicity, marital status, and education, as well as diagnostically stratified groups, in patients with and without a depression, alcohol use, and drug use disorder.Main MeasuresThe MINI-International Neuropsychiatric Interview was the criterion measure against which the PC-PTSD-5 was evaluated.Key ResultsAmong the 10 demographically stratified groups of patients, the PC-PTSD-5 demonstrated a sensitivity between 81.25% (95% C.I.: 54.35 – 05.95) and 100% (95% C.I.: 63.06 – 1000) and its specificity ranged from 80.54% (95% C.I.: 74.70 – 85.55) to 88.31% (95% C.I.: 83.45 – 92.15). Among the 6 diagnostically stratified groups of patients (with and without depression, alcohol use, and drug use disorders), the PC-PTSD-5 exhibited a sensitivity between 88.89% (95% C.I.: 65.29 – 98.62) and 95.92% (95% C.I.: 86.02 – 99.50), and its specificity varied from 60.00% (95% C.I.: 40.60 – 77.34) to 88.14% (95% C.I.: 84.50 – 91.19).ConclusionsThe PC-PTSD-5, suitable for a diverse range of VA primary care patients, shows satisfactory sensitivity and specificity across various demographic and diagnostic groups. Healthcare providers should be cautious of false positives in patients with depression or substance use disorders, given the potential symptom overlap with PTSD.

Disparities in Video-Based Primary Care Use Among Veterans with Cardiovascular Disease

BackgroundCardiovascular disease (CVD) is prevalent among Veterans, and video care enhances access to CVD care. However, it is unknown which patients with CVD conditions receive video care in primary care clinics, where a large proportion of CVD services is delivered.ObjectiveCharacterize use of VA video primary care for Veterans with two common CVDs, heart failure and hypertension.DesignRetrospective cohort study.PatientsVeterans seen in VA primary care with diagnoses of heart failure and/or hypertension in the year prior to the COVID-19 pandemic and for the first two pandemic-years.Main MeasuresThe primary outcome was use of any video-based primary care visits. Using multilevel regressions, we examined the association between video care use and patient sociodemographic and clinical characteristics, controlling for time and adjusting for patient- and site-level clustering.Key ResultsOf 3.8M Veterans with 51.9M primary care visits, 456,901 Veterans had heart failure and hypertension, 50,753 had heart failure only, and 3,300,166 had hypertension only. Veterans with heart failure and hypertension had an average age of 71.6 years. 2.9% were female, and 34.8% lived in rural settings. Patients who were male, aged 75 or older, or rural-dwelling had lower odds of using video care than female patients, 18–44-year-olds, and urban-dwellers, respectively (male patients’ adjusted odds ratio [AOR] 0.73, 95% confidence interval [CI] 0.72–0.74; 75 years or older, AOR 0.38, 95% CI 0.37–0.38; rural-dwellers, AOR 0.71, 95% CI 0.70–0.71). Veterans with heart failure had higher odds of video care use than those with hypertension only (AOR 1.05, 95% CI 1.04–1.06).ConclusionsGiven lower odds of video primary care use among some patient groups, continued expansion of video care could make CVD services increasingly inequitable. These insights can inform equitable triage of patients, for example by identifying patients who may benefit from additional support to use virtual care.

Integrating stakeholder feedback into the design of a peer-delivered primary care wellness program: A rapid qualitative study

BackgroundIndividuals seen in Primary Care with behavioral health concerns who decline behavioral health treatment may benefit from the support of peers (consumers in recovery from behavioral health concerns employed to support other consumers). Whole Health STEPS is a new intervention for Veterans in Primary Care with behavioral health concerns which combines essential elements of peers’ role and the Whole Health model using a stepped-care design. We incorporated stakeholder feedback in the Whole Health STEPS design to improve fit with Veterans, peers, and primary care settings.MethodsWe conducted semi-structured qualitative interviews with VA staff using questions derived from the Consolidated Framework for Implementation Research (CFIR). Participants were recruited via a maximum variation strategy across a national sample and interviewed between January 2021-April 2021. The analytic design was a rapid qualitative analysis. Interviews addressed design decisions and potential barriers and facilitators to future implementation. Then, we made adaptations to Whole Health STEPS and catalogued changes using the Framework for Adaptations and Modifications-Enhanced (FRAME). A VA peer conducted the interviews, participated in analyses, assisted with design modifications, and co-wrote this paper.ResultsSixteen staff members from 9 VA primary care peer programs participated (8 peers and 8 supervisors/administrators). Feedback themes included: capitalizing on peer skills (e.g., navigation), ensuring patient-centered and flexible design, and making it easy and efficient (e.g., reducing session length). Understanding the structure of primary care peers’ roles and their interactions with other programs helped us identify role conflicts (e.g., overlap with Whole Health Coaches and Health Behavior Coordinators), which led to design modifications to carve out a unique role for Whole Health STEPS. Staff also made recommendations about marketing materials and training tools to support Whole Health STEPS roll out.ConclusionsFeedback from frontline staff, including peers, in the design process was crucial to identifying essential modifications that would not have been possible after initial trials without re-evaluating efficacy due to the extent of the changes. Whole Health STEPS was adapted to fit within a range of program structures, emphasize peers’ unique contributions, and streamline delivery. Lessons learned can be applied to other interventions.

Demographic Characteristics and Treatment Patterns in Veterans with Multiple Myeloma: A Comprehensive Analysis from the Veterans Affairs Database (2000-2020)

BACKGROUND: Multiple Myeloma (MM) is the 2nd most common hematologic malignancy, accounting for 32,270 new cases diagnosed in the United States each year with over 12,830 deaths and a 57% overall 5 -year survival rate. Increased incidence is seen in patients aged &amp;gt;60, African American (AA) race and Male population. Despite significant advancements in therapies with novel agents and immunotherapy, MM remains a challenging disease to manage due to its heterogeneity, resistance to treatment, and the risk of relapse. In this study, we aim to determine the demographics, comorbidities and trends in treatment patterns of MM patients, over time in the VA database. METHODS: Patients diagnosed with MM from 2000-2020 in the VA's nationwide electronic health records were identified using the VA Corporate Data Warehouse (VA CDW) and VINCI to host and analyze the data. Patients were identified using International Classification of Diseases codes for MM. Patient demographics, including drugs and therapies used, were identified through structured data in the VA CDW. We included all veterans 1) over the age of 18, 2) diagnosed with MM with 3 coded visits on different days and received 1 agent other than steroids after diagnosis date. We excluded all patients who did not have at least two VA primary care visits, or one primary care visit and one VA pharmacy refill in the one year prior to MM diagnosis. We analyzed demographic details, comorbidity burden, treatment regimens for induction and attrition rates. RESULTS: A total of 12,196 patients were identified, with a median age at diagnosis of 68 years (range, 28-96 years), of which 97.8% were males, 59% (n=7187) were White, 23% (n=2903) were Black, Other (Asian/Pacific Islanders) made up 1.9% the cohort (n=233) and for 15% cohort (n=1867), race was either unknown or missing. Comorbidities at diagnosis were the following: 4164 patients had diabetes mellitus; 1329 patients had CHF ,2159 patients had pre-existing renal disease. 10,156 patients received at least one line of therapy, with the following distribution: 215 pts - RVD, 20 - DRD, 344 - CyBORD , 1930 - oral Melphalan, 3368- Thalidomide, 2692 -Revlimid/Dexamethasone, 1555 - Velcade/Dexamethasone and 2040 patients received an induction regimen not specified in Table 2. The breakdown of first line therapy utilization in respect to race is shown in Table 2. 4228 patients received two distinct lines of therapy (LOT), 1718 patients received 3 distinct LOT and 419 patients received 4 LOT. Transitioning from 1st st to 2nd LOT, attrition rates of approximately 50.3% for Black and 56.5% for White patients were observed, and from two to three lines, rates were around 52.4% for Black and 57.8% for White patients, indicating substantial drop-offs in treatment progression. The Cox proportional hazard model analysis reveals significant predictors for overall survival. Notably, age (70 or older) and renal disease was associated with increased mortality with hazard ratios (HR) of 1.731 and 1.275 (p &amp;lt; .0001 for both), respectively. Conversely, Black and White races, and receiving three or more therapy lines, was associated with increased OS, with HRs of 0.545, 0.607, and 0.825 (p &amp;lt; .0001 for all). CONCLUSIONS: This comprehensive overview of veterans with MM in the VA system over a 20-year period reveals heterogeneity in treatment utilization as expected with the changing landscape of MM treatment. A detailed analysis on the nature of subsequent lines of therapies, including stem cell transplant utilization, access to clinical trials is ongoing and will be submitted as a full manuscript publication. Additionally, the data on the staging and cytogenetics is also being obtained.

Burnout, employee engagement, and changing organizational contexts in VA primary care during the early COVID-19 pandemic

BackgroundThe COVID-19 pandemic involved a rapid change to the working conditions of all healthcare workers (HCW), including those in primary care. Organizational responses to the pandemic, including a shift to virtual care, changes in staffing, and reassignments to testing-related work, may have shifted more burden to these HCWs, increasing their burnout and turnover intent, despite their engagement to their organization. Our objectives were (1) to examine changes in burnout and intent to leave rates in VA primary care from 2017–2020 (before and during the pandemic), and (2) to analyze how individual protective factors and organizational context affected burnout and turnover intent among VA primary care HCWs during the early months of the pandemic.MethodsWe analyzed individual- and healthcare system-level data from 19,894 primary care HCWs in 139 healthcare systems in 2020. We modeled potential relationships between individual-level burnout and turnover intent as outcomes, and individual-level employee engagement, perceptions of workload, leadership, and workgroups. At healthcare system-level, we assessed prior-year levels of burnout and turnover intent, COVID-19 burden (number of tests and deaths), and the extent of virtual care use as potential determinants. We conducted multivariable analyses using logistic regression with standard errors clustered by healthcare system controlled for individual-level demographics and healthcare system complexity.ResultsIn 2020, 37% of primary care HCWs reported burnout, and 31% reported turnover intent. Highly engaged employees were less burned out (OR = 0.57; 95% CI 0.52–0.63) and had lower turnover intent (OR = 0.62; 95% CI 0.57–0.68). Pre-pandemic healthcare system-level burnout was a major predictor of individual-level pandemic burnout (p = 0.014). Perceptions of reasonable workload, trustworthy leadership, and strong workgroups were also related to lower burnout and turnover intent (p < 0.05 for all). COVID-19 burden, virtual care use, and prior year turnover were not associated with either outcome.ConclusionsEmployee engagement was associated with a lower likelihood of primary care HCW burnout and turnover intent during the pandemic, suggesting it may have a protective effect during stressful times. COVID-19 burden and virtual care use were not related to either outcome. Future research should focus on understanding the relationship between engagement and burnout and improving well-being in primary care.

Pain and Hazardous Alcohol Use in Veterans in Primary Care: The Role of Affective Pain Interference and Alcohol Pain-Coping Perceptions

Chronic pain and unhealthy alcohol use commonly co-occur and are associated with negative health outcomes. Veterans may be particularly vulnerable to these conditions, yet limited research has examined factors involved in their co-occurrence. This cross-sectional study aimed to examine the role of affective pain interference and alcohol pain-coping perceptions in the relationship between pain and hazardous alcohol use. As informed by the catastrophizing, anxiety, negative urgency, and expectancy model, we hypothesized that the relationship between pain and hazardous alcohol consumption is mediated by affective pain interference and stronger among those with greater perceptions that alcohol helps cope with pain. Participants were 254 VA primary care patients (87.8% male, Mage = 64.03, 76.4% White) with a history of chronic musculoskeletal pain, past-year alcohol use, and past-week pain. Veterans completed a mailed survey including measures of pain, affective pain interference, alcohol pain-coping perceptions, and hazardous alcohol use. Hypotheses were tested with regression models and PROCESS macros. As hypothesized, affective pain interference mediated the pain-hazardous alcohol use association. Contrary to hypotheses, results showed no moderating effect of alcohol pain-coping perceptions. Findings partially support relationships among theorized constructs and suggest that for Veterans with co-occurring pain and alcohol use it may be important to target pain-related affective interference and perceptions that alcohol helps cope with pain. PerspectiveThis article presents a test of factors involved in the pain and alcohol relationship, as informed by the CANUE model. Findings suggest that for Veterans with co-occurring pain and past-year alcohol use, it may be important to target pain-related affective interference and perceptions that alcohol helps cope with pain.

Using Nudges to Reduce Missed Appointments in Primary Care and Mental Health: a Pragmatic Trial

BackgroundMissed appointments (“no-shows”) are a persistent and costly problem in healthcare. Appointment reminders are widely used but usually do not include messages specifically designed to nudge patients to attend appointments.ObjectiveTo determine the effect of incorporating nudges into appointment reminder letters on measures of appointment attendance.DesignCluster randomized controlled pragmatic trial.PatientsThere were 27,540 patients with 49,598 primary care appointments, and 9420 patients with 38,945 mental health appointments, between October 15, 2020, and October 14, 2021, at one VA medical center and its satellite clinics that were eligible for analysis.InterventionsPrimary care (n = 231) and mental health (n = 215) providers were randomized to one of five study arms (four nudge arms and usual care as a control) using equal allocation. The nudge arms included varying combinations of brief messages developed with veteran input and based on concepts in behavioral science, including social norms, specific behavioral instructions, and consequences of missing appointments.Main MeasuresPrimary and secondary outcomes were missed appointments and canceled appointments, respectively.Statistical AnalysisResults are based on logistic regression models adjusting for demographic and clinical characteristics, and clustering for clinics and patients.Key ResultsMissed appointment rates in study arms ranged from 10.5 to 12.1% in primary care clinics and 18.0 to 21.9% in mental health clinics. There was no effect of nudges on missed appointment rate in primary care (OR = 1.14, 95%CI = 0.96–1.36, p = 0.15) or mental health (OR = 1.20, 95%CI = 0.90–1.60, p = 0.21) clinics, when comparing the nudge arms to the control arm. When comparing individual nudge arms, no differences in missed appointment rates nor cancellation rates were observed.ConclusionsAppointment reminder letters incorporating brief behavioral nudges were ineffective in improving appointment attendance in VA primary care or mental health clinics. More complex or intensive interventions may be necessary to significantly reduce missed appointments below their current rates.Trial NumberClinicalTrials.gov, Trial number NCT03850431.

1050-P: Implementation of Professional Continuous Glucose Monitoring in VA Primary Care Clinics

Background: Professional continuous glucose monitoring (proCGM) can be used sporadically for patients who do not meet criteria for Personal CGM. The interdisciplinary nature of primary care teams from Veterans Affairs Community Based Outpatient Clinics (CBOCs) represents a good opportunity for implementation of proCGM technology to improve glycemic control. Objectives: To assess treatment changes prompted by proCGM implementation. Methods: Veterans with suboptimal glycemic control (A1c &amp;gt;7.5% or hypoglycemia) who did not qualify for a personal CGM had a proCGM placed during office visit. Two weeks later, the proCGM was downloaded during a follow-up visit and changes were implemented as needed. Results: Thirty-eight sensors were placed in 36 patients (two patients repeat after sensor fell off) seen by clinical pharmacists from 5 CBOCs from North Florida/South Georgia VA Health System. Baseline A1c was 8.1% (SD 1.3), proCGM data was available in 91% of patients. Mean duration of sensors was 13 days (SD 3.3). In 36% of patients, there was insulin de-intensification, mainly because of hypoglycemic events. In 6% of patients, an oral agent was discontinued because their time in range was above 90% and side effect profile (weight gain). About 18% of veterans needed insulin intensification, either adding short acting insulin or increasing basal insulin. Overall, significant treatments changes were implemented in 60% of patients, thus, avoiding clinical inertia. High glucose variability (% coefficient of variation &amp;gt;33%) was present in 45% of veterans and two thirds of them required de-intensification of their insulin regimen due to hypoglycemia. Conclusions: Implementation of proCGM in primary care clinics led to treatment changes in 60% of patients. This improvement project demonstrated feasibility of deploying new diabetes technologies in primary care setting. Disclosure K.Saren: None. A.L.Raulerson: None. S.Finch: None. J.A.Leey: None. Funding U.S. Department of Veterans Affairs Office of Rural Health

505 Use of Implementation Science to Identify Implementation Determinants of Chronic Obstructive Pulmonary Disease Practice Guidelines

OBJECTIVES/GOALS: COPD is a progressive airways disease that results in death or disability. There is poor uptake of clinical guidelines (CPG) to manage COPD and studies to bridge this implementation gap have shown inconsistent results. Using implementation science principles we aim to understand COPD-CPG implementation determinants from providers’perspective. METHODS/STUDY POPULATION: The study is being conducted in ten VA Primary Care Clinics. Guided by the Consolidated Framework for Implementation Research (CFIR), a conceptual framework developed to guide systematic assessment of multilevel implementation contexts, we are using semi-structured guides to conduct key informant qualitative interviews (physicians, physician extenders and nurses), to support a formative evaluation. CFIR domains relevant to the study were determined by a multidisciplinary team. Informants are identified through online outreach and voluntary participation. Sampling adequacy will be assessed by achievement of code saturation. A qualitative template analysis will be used to summarize the barriers and facilitators of each component of COPD-CPG organized by CFIR-domain. RESULTS/ANTICIPATED RESULTS: We anticipate a list of modifiable and non-modifiable contextual, recipient (provider and patient), and COPD CPG content (innovation) barriers to implementation. Many settings do not have critical elements of these CPG, such as a standardized inhaler education/assessment pathway, patient education material, or pulmonary rehabilitation referral pathway. Existing literature indicate reasons behind the insufficient uptake of COPD CPG include low familiarity with guidelines, perception of minimal value of guidelines by physicians, and time constraints; we will present contextual, recipient and innovation determinants specific to our setting. DISCUSSION/SIGNIFICANCE: This comprehensive assessment of barriers and facilitators to COPD-CPG will inform tool development and implementation strategies identification to improve COPD CPG uptake. COPD is the most common veteran lung disease. Improvement in COPD care has enormous potential for benefit for local veterans, as well as potential for wider dissemination.

A Randomized Clinical Trial of Clinician-Supported PTSD Coach in VA Primary Care Patients.

Posttraumatic stress disorder (PTSD) is common in primary care patients; however, evidence-based treatments are typically only available in specialty mental healthcare settings and often not accessed. To test the effectiveness of a brief primary care-based treatment, Clinician-Supported PTSD Coach (CS PTSD Coach) was compared with Primary Care Mental Health Integration-Treatment as Usual (PCMHI-TAU) in (1) reducing PTSD severity, (2) engaging veterans in specialty mental health care, and (3) patient satisfaction with care. Multi-site randomized pragmatic clinical trial. A total of 234 veterans with PTSD symptoms who were not currently accessing PTSD treatment. CS PTSD Coach was designed to be implemented in Veterans Affairs PCMHI and combines mental health clinician support with the "PTSD Coach" mobile app. Four 30-min sessions encourage daily use of symptom management strategies. PTSD severity was measured by clinician-rated interviews pre- and post-treatment (8weeks). Self-report measures assessed PTSD, depression, and quality of life at pretreatment, posttreatment, and 16- and 24-week follow-ups, and patient satisfaction at post-treatment. Mental healthcare utilization was extracted from medical records. Clinician-rated PTSD severity did not differ by condition at post-treatment. CS PTSD Coach participants improved more on patient-reported PTSD severity at post-treatment than TAU participants (D = .28, p = .021). Coach participants who continued to have problematic PTSD symptoms at post-treatment were not more likely to engage in 2 sessions of specialty mental health treatment than TAU participants. Coach participants engaged in 74% more sessions in the intervention and reported higher treatment satisfaction than TAU participants (p < .001). A structured 4-session intervention designed to align with patient preferences for care resulted in more patient-reported PTSD symptom relief, greater utilization of mental health treatment, and overall treatment satisfaction than TAU, but not more clinician-rated PTSD symptom relief or engagement in specialty mental health.

Development and cross-validation of a veterans mental health risk factor screen.

VA primary care patients are routinely screened for current symptoms of PTSD, depression, and alcohol disorders, but many who screen positive do not engage in care. In addition to stigma about mental disorders and a high value on autonomy, some veterans may not seek care because of uncertainty about whether they need treatment to recover. A screen for mental health risk could provide an alternative motivation for patients to engage in care. Data from samples of veterans and traumatic injury survivors were analyzed to identify mental health risk factors that are characteristics of individuals or stressors or of post-trauma, post-deployment, or post-military service resources, experiences, or responses. Twelve risk factors were strongly related to PTSD (r > .50): current PTSD, depression, dissociation, negative thinking, and emotional lability symptoms, life stress, relationship stress, social constraints, and deployment experiences of a difficult environment, concerns about life and family, perceived threat, and moral injury. Items assessing each of these risk factors were selected and their validity to prospectively predict PTSD and/or depression 6 months later was assessed in a new sample of 232 VA primary care patients. Twelve items assessing dissociation, emotional lability, life stress, and moral injury correctly classified 86% of those who later had elevated PTSD and/or depression symptoms (sensitivity) and 75% of those whose later symptoms were not elevated (specificity). Performance was also very good for 110 veterans who identified as members of ethnic/racial minorities. Mental health status was prospectively predicted in VA primary care patients with high accuracy using a screen that is brief, easy to administer, score, and interpret, and fits well into VA's integrated primary care. When care is readily accessible, appealing to veterans, and not perceived as stigmatizing, information about mental health risk may result in higher rates of engagement than information about current mental disorder status.

Social Work Staffing and Use of Palliative Care Among Recently Hospitalized Veterans

Palliative care improves quality of life for patients and families but may be underused. To assess the association of an intervention to increase social work staffing in Veterans Health Administration primary care teams with use of palliative care among veterans with a recent hospitalization. This cohort study used differences-in-differences analyses of the change in palliative care use associated with implementation of the Social Work Patient Aligned Care Team (PACT) staffing program, conducted from October 1, 2016, to September 30, 2019. The study included 71 VA primary care sites serving rural veterans. Participants were adult veterans who received primary care services from a site enrolled in the program and who received inpatient hospital care. Data were analyzed from January 2020 to August 2022. The PACT staffing program was a clinic-level intervention that provided 3-year seed funding to Veterans Health Administration medical centers to hire 1 or more additional social workers in primary care teams. Staggered timing of the intervention enabled comparison of mean outcomes across sites before and after the intervention. The primary outcome was the number of individuals per 1000 veterans who had any palliative care use in 30 days after an inpatient hospital stay. The analytic sample included 43 200 veterans (mean [SD] age, 65.34 [13.95] years; 37 259 [86.25%] men) and a total of 91 675 episodes of inpatient hospital care. Among the total cohort, 8611 veterans (9.39%) were Black, 77 069 veterans (84.07%) were White, and 2679 veterans (2.92%) were another race (including American Indian or Alaskan Native, Asian, and Native Hawaiian or other Pacific Islander). A mean of 14.5 individuals per 1000 veterans (1329 individuals in all) used palliative care after a hospital stay. After the intervention, there was an increase of 15.6 (95% CI, 9.2-22.3) individuals per 1000 veterans using palliative or hospice care after a hospital stay, controlling for national time trends and veteran characteristics-a 2-fold difference relative to the mean. This cohort study found significant increases in use of palliative care for recently hospitalized veterans whose primary care team had additional social work staffing. These findings suggest that social workers may increase access to and/or use of palliative care. Future work should assess the mechanism for this association and whether the increase in palliative care is associated with other health or health care outcomes.

Patient Perspectives on Population-Based Suicide Risk Screening in VA Primary Care; Mixed Methods Study

Patient Perspectives on Population-Based Suicide Risk Screening in VA Primary Care; Mixed Methods Study

Long drives and red tape: mapping rural veteran access to primary care using causal-loop diagramming

BackgroundRural veterans experience more challenges than their urban peers in accessing primary care services, which can negatively impact their health and wellbeing. The factors driving this disparity are complex and involve patient, clinic, health system, community and policy influences. Federal policies over the last decade have relaxed requirements for some veterans to receive primary care services from community providers through their VA benefits, known as community care.MethodsWe used a participatory systems mapping approach involving causal-loop diagramming to identify interrelationships between variables underlying challenges to veteran access to primary care and potential opportunities for change—known as leverage points in systems science. Our methods involved a secondary analysis of semi-structured qualitative interviews with rural veterans, VA staff, non-VA clinic staff and providers who serve rural veterans, and veteran service officers (VSOs) in the Northwest region of the US, followed by a two-part participatory modeling session with a study advisory board. We then applied Meadows’s leverage point framework to identify and categorize potential interventions to improve rural veteran access to primary care.ResultsThe final model illustrated challenges at the veteran, clinic, and system levels as experienced by stakeholders. Main components of the diagram pertained to the choice of VA or non-VA primary care, veteran satisfaction with the VA, enrollment in VA benefits and other insurance, community care authorization, reimbursement of non-VA care, referrals to specialty care, record sharing and communication between VA and non-VA providers, institutional stability of the VA, and staffing challenges. Fourteen interventions, including administrative and communications changes, were identified by analyzing the model using the leverage points framework.ConclusionsOur findings illustrate how challenges rural veterans face accessing health care are interconnected and persist despite recent changes to federal law pertaining to the VA health care system in recent years. Systems mapping and modeling approaches such as causal-loop diagramming have potential for engaging stakeholders and supporting intervention and implementation planning.

Depression Care Quality Among Cancer Patients Screened for Depression in VA Primary Care Clinics (RP509)

Depression Care Quality Among Cancer Patients Screened for Depression in VA Primary Care Clinics (RP509)

Behavioral health treatment barriers and preferences of primary care patients with chronic pain and alcohol use.

Although chronic pain and high-risk alcohol use are prevalent in primary care and associated with more severe pain and functional impairment, current approaches address them separately and often neglect risky alcohol use among those with chronic pain. Treatments tailored to patient preferences increase utilization, yet little is known about patient treatment preferences for chronic pain and high-risk alcohol use. Describe treatment barriers and preferences of primary care patients with chronic musculoskeletal pain and past-year alcohol use and test for differences based on alcohol use (no risk, low risk, high risk). Chart review and patient survey. VA primary care clinics. Inclusion criteria: ≥ 18 years old, past year VA primary care visit, chronic musculoskeletal condition, past year alcohol use. Exclusion criteria: psychotic or neurocognitive disorder diagnosis. Eligible participants were identified via chart review and mailed a survey packet. Participants (N = 371) were primarily White (74.7%) male (88.4%) veterans. Readiness to change, alcohol treatment barriers, pain-alcohol beliefs, attitudes toward behavioral health and medical treatment, and treatment preferences were assessed. Chi-square tests revealed statistically significant preferences for: face-to-face (70.3% preferred), individual (68.7% preferred), VA primary care, (69.2% preferred), and chronic pain focus (38.4% preferred). Patients with high-risk alcohol use reported more readiness to change alcohol use, stronger pain-alcohol beliefs, and more favorable attitudes toward behavioral health treatment than those with low- or no-risk alcohol use. Primary care patients with chronic musculoskeletal pain and alcohol use showed clear preferences for individual, face-to-face behavioral health treatment focused on chronic pain in a VA primary care clinic. Those with co-occurring high-risk alcohol use may experience differences in treatment barriers that may impede treatment engagement (i.e., stronger pain-alcohol beliefs), and in other cases, may facilitate treatment engagement (i.e., more readiness to change, more favorable treatment attitudes) compared to those with low- or no-risk alcohol use. Incorporating patient perspectives may help clinicians provide optimal behavioral health treatment for chronic pain and/or hazardous alcohol use in primary care.