Veterans Affairs Health System Research Articles

Determinants of appropriate antibiotic and NSAID prescribing in unscheduled outpatient settings in the veterans health administration

BackgroundDespite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration.MethodsWe conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process.ResultsWe conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal.ConclusionsThe diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.

Factors Associated with Acute Telemental Health Consultations in Older Veterans.

The United States Veterans Health Administration is a leader in the use of telemental health (TMH) to enhance access to mental healthcare amidst a nationwide shortage of mental health professionals. The Tennessee Valley Veterans Affairs (VA) Health System piloted TMH in its emergency department (ED) and urgent care clinic (UCC) in 2019, with full 24/7 availability beginning March 1, 2020. Following implementation, preliminary data demonstrated that veterans ≥65years old were less likely to receive TMH than younger patients. We sought to examine factors associated with older veterans receiving TMH consultations in acute, unscheduled, outpatient settings to identify limitations in the current process. This was a retrospective cohort study conducted within the Tennessee Valley VA Health System. We included veterans ≥55years who received a mental health consultation in the ED or UCC from April 1, 2020-September 30, 2022. Telemental health was administered by a mental health clinician (attending physician, resident physician, nurse practitioner, or physician assistant) via iPad, whereas in-person evaluations were performed in the ED. We examined the influence of patient demographics, visit timing, chief complaint, and psychiatric history on TMH, using multivariable logistic regression. Of the 254 patients included in this analysis, 177 (69.7%) received TMH. Veterans with high-risk chief complaints (suicidal ideation, homicidal ideation, or agitation) were less likely to receive TMH consultation (adjusted odds ratio [AOR]: 0.47, 95% confidence interval [CI] 0.24-0.95). Compared to attending physicians, nurse practitioners and physician assistants were associated with increased TMH use (AOR 4.81, 95% CI 2.04-11.36), whereas consultation by resident physicians was associated with decreased TMH use (AOR 0.04, 95% CI 0.00-0.59). The UCC used TMH for all but one encounter. Patient characteristics including their visit timing, gender, additional medical complaints, comorbidity burden, and number of psychoactive medications did not influence use of TMH. High-risk chief complaints, location, and type of mental health clinician may be key determinants of telemental health use in older adults. This may help expand mental healthcare access to areas with a shortage of mental health professionals and prevent potentially avoidable transfers in low-acuity situations. Further studies and interventions may optimize TMH for older patients to ensure safe, equitable mental health care.

Addressing racial disparities in prostate cancer pathology prediction models: external validation and comparison of four models of pathological outcome prediction before radical prostatectomy in the multiethnic SEARCH cohort.

Certain widely used pathological outcome prediction models that were developed in tertiary centers tend to overpredict outcomes in the community setting; thus, the Michigan Urological-Surgery Improvement Collaborative (MUSIC) model was developed in general urology practice to address this issue. Additionally, the development of these models involved a relatively small proportion of Black men, potentially compromising the accuracy of predictions in this patient group. We tested the validity of the MUSIC and three widely used nomograms to compare their overall and race-stratified predictive performance. We extracted data from 4139 (1138 Black) men from the Shared Equal Access Regional Cancer Hospital (SEARCH) database of the Veterans Affairs health system. The predictive performance of the MUSIC model was compared to the Memorial-Sloan Kettering (MSK), Briganti-2012, and Partin-2017 models for predicting lymph-node invasion (LNI), extra-prostatic extension (EPE), and seminal vesicle invasion (SVI). The median PSA of Black men was higher than White men (7.8 vs. 6.8 ng/ml), although they were younger by a median of three years and presented at a lower-stage disease. MUSIC model showed comparable discriminatory capacity (AUC:77.0%) compared to MSK (79.2%), Partin-2017 (74.6%), and Briganti-2012 (76.3%), with better calibration for LNI. AUCs for EPE and SVI were 72.7% and 76.9%, respectively, all comparable to the MSK and Partin models. LNI AUCs for Black and White men were 69.6% and 79.6%, respectively, while EPE and SVI AUCs were comparable between races. EPE and LNI had worse calibration in Black men. Decision curve analysis showed MUSIC superiority over the MSK model in predicting LNI, especially among Black men. Although the discriminatory performance of all models was comparable for each outcome, the MUSIC model exhibited superior net benefit to the MSK model in predicting LNI outcomes among Black men in the SEARCH population.

Clinical Pharmacy Specialist Collaborative Management and Prescription of Diabetes Medications with Cardiovascular Benefit.

Background: Involvement of Clinical Pharmacy Specialists (CPS) in the care of patients with diabetes mellitus (DM) has been demonstrated to be beneficial. Whether this positive impact applies to increased use of cardiovascular risk-reducing medications is less well established. Objective: To determine the association of CPS co-management on the prescription of diabetes medications with proven cardiovascular benefits for patients with DM and established cardiovascular disease in the primary care setting. Methods: This retrospective cohort study evaluated patients in a Veterans Affairs health-system in primary care settings from February 1, 2019, through January 31, 2020. Patients were included if they had type 2 DM treated with at least one medication and had CVD. Patients were grouped into two cohorts for comparison, those with CPS co-management and those without. The primary outcome was the proportion of patients in each group with new prescriptions for empagliflozin or liraglutide initiated during the study timeframe. Results: In total, 8058 patients were found eligible for inclusion in the study. Clinical co-management by a CPS was provided to 2099 patients. Study medications were prescribed, approved, and initiated in 596 patients during the study period, including 391 (18.6%) in the CPS group and 205 (3.4%) in the non-CPS group (P < .001). Conclusion: This study showed CPS involvement is associated with increased prescribing of diabetes medications with proven cardiovascular benefits.

Men with adrenal-permissive HSD3B1 genotype and prostate cancer mortality: Results from the Veterans Affairs Health System Million Veteran Program.

Men with adrenal-permissive <i>HSD3B1</i> genotype and prostate cancer mortality: Results from the Veterans Affairs Health System Million Veteran Program.

Patient Focus: Sodium-Glucose Cotransporter-2 Inhibitor Rates for Patients with Heart Failure in the Veterans Affairs Health System: We Need to Move the Needle! An Explanation of Uptake of Sodium-Glucose Cotransporter-2 Inhibitors in Patients Hospitalized due to Heart Failure: Insights from the Veterans Affairs Healthcare System

Patient Focus: Sodium-Glucose Cotransporter-2 Inhibitor Rates for Patients with Heart Failure in the Veterans Affairs Health System: We Need to Move the Needle! An Explanation of Uptake of Sodium-Glucose Cotransporter-2 Inhibitors in Patients Hospitalized due to Heart Failure: Insights from the Veterans Affairs Healthcare System

PATIENT PRIORITIES CARE FOR VETERANS

Abstract People receiving care in the Veterans Affairs (VA) health system are older, have greater socioeconomic disadvantage, and more chronic conditions than those receiving healthcare outside of VA. PPC is well-suited for older adults with multiple chronic conditions and aligns with the VA’s Whole Health movement. A small VA PPC pilot study demonstrated that those receiving PPC compared to usual care had fewer medications added and more home and community services aligned with priorities. VA primary care is a cornerstone and hub for veteran care utilizing a team-based approach. A two-site randomized controlled trial exploring the implementation of PPC in VA primary care is currently recruiting veterans. The early phase of the project involved semi-structured formative assessment interviews with key stakeholders to obtain feedback and perspectives on PPC implementation in VA primary care. Interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis. Concerns elicited were time constraints, follow up and documentation of changes in priorities over time, managing patient expectation, communication between primary care and specialty care, as well as how PPC would impact quality metrics. In response to these findings, the patient priorities note template was shortened and streamlined, and the study communications workflow was adapted to align with clinician preferences. Succinct templated language for care alignment was crafted and shared with study providers. Education for clinicians highlighted ways in which priorities could be used to optimize communication. Study procedures were added to identify quality metric exclusions. The study will explore how PPC impacts veteran care and experience.

Housing Status, Cancer Care, and Associated Outcomes Among US Veterans

Cancer is a leading cause of death among older people experiencing homelessness. However, the association of housing status with cancer outcomes is not well described. To characterize the diagnosis, treatment, surgical outcomes, and mortality by housing status of patients who receive care from the US Department of Veterans Affairs (VA) health system for colorectal, breast, or lung cancer. This retrospective cohort study identified all US veterans diagnosed with lung, colorectal, or breast cancer who received VA care between October 1, 2011, and September 30, 2020. Data analysis was performed from February 13 to May 9, 2023. Veterans were classified as experiencing homelessness if they had any indicators of homelessness in outpatient visits, clinic reminders, diagnosis codes, or the Homeless Operations Management Evaluation System in the 12 months preceding diagnosis, with no subsequent evidence of stable housing. The major outcomes, by cancer type, were as follows: (1) treatment course (eg, stage at diagnosis, time to treatment initiation), (2) surgical outcomes (eg, length of stay, major complications), (3) overall survival by cancer type, and (4) hazard ratios for overall survival in a model adjusted for age at diagnosis, sex, stage at diagnosis, race, ethnicity, marital status, facility location, and comorbidities. This study included 109 485 veterans, with a mean (SD) age of 68.5 (9.7) years. Men comprised 92% of the cohort. In terms of race and ethnicity, 18% of veterans were Black, 4% were Hispanic, and 79% were White. A total of 68% of participants had lung cancer, 26% had colorectal cancer, and 6% had breast cancer. There were 5356 veterans (5%) experiencing homelessness, and these individuals more commonly presented with stage IV colorectal cancer than veterans with housing (22% vs 19%; P = .02). Patients experiencing homelessness had longer postoperative lengths of stay for all cancer types, but no differences in other treatment or surgical outcomes were observed. These patients also demonstrated higher rates of all-cause mortality 3 months after diagnosis for lung and colorectal cancers, with adjusted hazard ratios of 1.1 (95% CI, 1.1-1.2) and 1.3 (95% CI, 1.2-1.4) (both P < .001), respectively. In this large retrospective study of US veterans with cancer, homelessness was associated with later stages at diagnosis for colorectal cancer. Differences in lung and colorectal cancer survival between patients with housing and those experiencing homelessness were present but smaller than observed in other settings. These findings suggest that there may be important systems in the VA that could inform policy to improve oncologic outcomes for patients experiencing homelessness.

Abstract A063: Critical factors influencing clinical trial enrollment and autologous stem cell transplantation in African-American patients with multiple myeloma: A retrospective, interview-based analysis

Abstract Purpose: The backbone of multiple myeloma (MM) therapy include chemotherapy, targeted therapies, autologous stem cell transplantation (ASCT), amongst others. Patient enrollment in clinical trials and uptake of complex interventions such as ASCT is crucial for these advancements and to improve patient outcomes. Furthermore, MM is more than twice as common in Black/African-American (B/AA) persons, yet many B/AA people decline to enroll in clinical trials or undergo transplant. However, at the Cleveland Clinic, many B/AA patients do elect to undergo ASCT and enroll in clinical trials. We interview these patients to understand the conditions under which B/AA patients elect trial/transplant. Experimental Procedures: To study differences in access to care, which have the potential to lead to differences in survival and disease progression, we conduct semi-structured interviews with patients to better understand the breadth of their complex decision making about electing trial/transplant. We gather rich descriptive patient perceptions about their experiences on and with other novel therapies including understanding how these interventions were described by their healthcare teams and the factors that were most influential in rendering their decisions. The study includes two arms: patients who elected trial/transplant and a second cohort of B/AA patients comprised of patients matched for disease state and socioeconomic attributes who did not elect to undergo these interventions. In concert with these qualitative evaluations, we collect and analyze quantitative and categorical data regarding disease response, survival, post-protocol therapies where applicable, and patient reported outcomes including healthcare associated quality of life. We also analyze follow up surveys and a range of patient reported outcomes data collected throughout the patient’s treatment. Data Summary: We examine the impact of critical social and disease-related factors, including income, health insurance status, access to caregiving, understanding of the disease process, initial point of access to the healthcare system, health literacy, and perception of the intervention on the decision to enroll or decline enrollment in clinical trials or undergo ASCT. Conclusion: Our findings examine the mechanisms behind patient enrollment in clinical trials/transplant. B/AA patients comprise only 4% of enrollees in large MM trials worldwide. Many studies have also demonstrated that B/AA patients are less likely to undergo ASCT and are more likely to do so later in their disease course. Furthermore, a study conducted in the Veterans Affairs health system showed that with equal access to care for MM, B/AA patients actually have superior overall survival as compared to their white counterparts. We focus on patient’s complex decision making process, to provide better care and expand diverse research on MM. Study implications include improving equity in MM care for B/AA patients. Citation Format: Louis Williams, Heathe M. Hurwitz, Tiffany Onger, Diana Basali. Critical factors influencing clinical trial enrollment and autologous stem cell transplantation in African-American patients with multiple myeloma: A retrospective, interview-based analysis [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A063.

911. Burden of Herpes Zoster among Employed Adults in the Department of Veterans Affairs Health System

Abstract Background Herpes zoster (HZ) is characterized by a painful dermatomal rash and is associated with increased healthcare costs. Research quantifying work productivity loss and activity impairment associated with HZ is limited and outdated. This study aimed to describe severity of HZ related pain, health related quality of life, activity impairment, and work productivity among employed adults diagnosed with HZ in the Department of Veterans Affairs (VA) Health System. Methods This cross-sectional study utilized a self-reported survey among adults in the VA health system. Eligibility was assessed biweekly from electronic health record data, and adults with an incident International Classification of Diseases, 10th Revision (ICD-10) HZ diagnosis were invited to complete an online survey. Respondents were indexed on their HZ diagnosis and included if aged 18-70 years, reported working for pay at index, and had 6 months of baseline continuous enrollment. Respondents were excluded if they had a baseline HZ vaccine, did not complete the survey within 30 days after index, or reported not having HZ or experiencing a rash &amp;gt; 14 days prior to index. Questions used to assess outcomes were based on validated survey instruments (Table 1). Work productivity was described among respondents employed at survey completion. Data were collected from 05/04/2021 to 07/07/2022. Descriptive statistics were used to summarize survey responses. Results Among 231 respondents completing the survey, mean (standard deviation [SD]) age was 49 (10) years and 79% were male. Overall, 70% reported experiencing pain in the last 7 days. Mean (SD) [minimum, maximum] “average-pain” severity and EQ-5D-3L scores were 4.0 (2.8) [0, 10] and 0.69 (0.22) [-0.04, 1.00], respectively. Mean (SD) activity impairment was 42% (33%). Mean (SD) absenteeism, presenteeism, and overall work impairment were 17% (27%), 35% (30%), and 43% (35%) out of 202, 192, and 202 respondents, respectively. Conclusion Burden associated with HZ is substantial, with a significant proportion experiencing pain, activity impairment, and work productivity loss. These results provide updated context on the impact of HZ in this population of employed adults in the VA health system. Funding: GlaxoSmithKline Biologicals SA (GSK study identifiers: 208907/HO-16-16967). Disclosures Shaloo Gupta, MS; ORCID: 0000-0002-2535-2892, Cerner Enviza: Salary|GSK: Funding to employer to conduct and support this study Nai-Chung N. Chang, PhD; ORCID: 0000-0002-4541-8967, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Kantar Health: Grant/Research Support|Myriad Genetic Laboratories, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support Nikita Stempniewicz, MSc, GSK: Salary|GSK: Ownership Interest Chenchu Bhavani K. Tirupati, MS, MBA, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Kantar Health: Grant/Research Support|Myriad Genetic Laboratories, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support Gregorio Coronado, MBA, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Kantar Health: Grant/Research Support|Myriad Genetic Laboratories, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support Julie A. Lynch, PhD, RN, MBA; ORCID: 0000-0003-0108-2127, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support Cosmina Hogea, PhD; ORCID: 0000-0002-0686-2395, Gilead Sciences: Ownership Interest|GSK: Salary at the time of the submitted work|GSK: Ownership Interest Emily Mulvihill, MBA; ORCID: 0000-0002-1430-8837, Cerner Enviza: Salary|GSK: Funding to employer to conduct and support this study Scott L. DuVall, PhD, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support

Patients' Experience of Specialty Care Coordination: Survey Development and Validation.

Specialty care coordination relies on information flowing bidirectionally between all three participants in the "specialty care triad" - patients, primary care providers (PCPs), and specialists. Measures of coordination should strive to account for the perspectives of each. As we previously developed two surveys to measure coordination of specialty care as experienced by PCPs and specialists, this study aimed to develop and evaluate the psychometric properties of a related survey of specialty care coordination as experienced by the patient, thereby completing the suite of surveys among the triad. We developed a draft survey based on literature review, patient interviews, adaptation of existing measures, and development of new items. Survey responses were collected via mail and online in two waves, August 2019-November 2019 and September 2020-May 2021, among patients (N=939) receiving medical specialty care and primary care in the Veterans Affairs health system. Exploratory and confirmatory factor analysis were used to assess scale structure. Multiple linear regression was used to examine the relationship of the final coordination scales to patients' overall experience of specialty care coordination. A 38-item measure representing 10 factors that assess the patient's experience of coordination in specialty care among the patient, PCP, and specialist was finalized. Scales demonstrated good internal consistency reliability and, together, explained 59% of the variance in overall coordination. Analyses revealed an unexpected construct describing organization of care between patient and specialist that accounted for patient goals and preferences; this 10-item scale was named Patient-Centered Care Coordination. The final survey, Coordination of Specialty Care - Patient, or CSC-Patient for short, is a reliable instrument that can be used alone or with its companions (CSC-PCP, CSC-Specialist) to provide a detailed assessment of specialty care coordination and identify targets for coordination improvement.

Prostate cancer patient stratification by molecular signatures in the Veterans Precision Oncology Data Commons.

Veterans are at an increased risk for prostate cancer, a disease with extraordinary clinical and molecular heterogeneity, compared with the general population. However, little is known about the underlying molecular heterogeneity within the veteran population and its impact on patient management and treatment. Using clinical and targeted tumor sequencing data from the National Veterans Affairs health system, we conducted a retrospective cohort study on 45 patients with advanced prostate cancer in the Veterans Precision Oncology Data Commons (VPODC), most of whom were metastatic castration-resistant. We characterized the mutational burden in this cohort and conducted unsupervised clustering analysis to stratify patients by molecular alterations. Veterans with prostate cancer exhibited a mutational landscape broadly similar to prior studies, including KMT2A and NOTCH1 mutations associated with neuroendocrine prostate cancer phenotype, previously reported to be enriched in veterans. We also identified several potential novel mutations in PTEN, MSH6, VHL, SMO, and ABL1 Hierarchical clustering analysis revealed two subgroups containing therapeutically targetable molecular features with novel mutational signatures distinct from those reported in the Catalogue of Somatic Mutations in Cancer database. The clustering approach presented in this study can potentially be used to clinically stratify patients based on their distinct mutational profiles and identify actionable somatic mutations for precision oncology.

Abstract 15893: A Quality Improvement Project of Increasing Utilization of SGLT2i in Patients With Heart Failure Within a Veterans Affairs Health System Through an Interdisciplinary Approach in the Primary Care Setting

Introduction: Given the astounding beneficial effects of SGLT2i in patients with heart failure, they continue to be underutilized especially in the outpatient setting. Our project looked at increasing empagliflozin usage in patients with heart failure, preserved and reduced ejection fraction, at James A Haley VA Hospital (JAHVA). Methods: Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a multidisciplinary team was created to identify ways to increase utilization of empagliflozin in patients with heart failure. We created an actionable database using ICD codes for heart failure to identify eligible heart failure patients who were not on SGLT2i categorized by local primary care clinics at the JAHVA. We split up the responsibilities between clinic pharmacists and primary care physicians to safely start patients on SGLT2i from February to April 2023. Primary care physicians focused on patients scheduled for clinic during this period while pharmacists were responsible for patients not scheduled for clinic. Results: Our initial data showed only 19% of the 3,352 patients were on SGLT2i at JAHVA. From February to April 2023, we started 224 patients on empagliflozin with heart failure (preserved and reduced ejection fraction). We increased utilization by 13% in three months from 19% to 32% at JAHVA. Primary care physicians accounted for 46% of drug initiation while pharmacists accounted for 20% of new prescriptions. Cardiology providers prescribed 27% of all SGLT2i with 7% started by endocrinology or nephrology. Some of the characteristics of our sample included patients with an average age of 70 years old, 35% without diabetes, 50% with preserved heart failure. Conclusion: Our multi-disciplinary team approach involving pharmacists increased the utilization of SGLT2i in patients with heart failure through an actionable dashboard. Next steps for this project include improving the database to include other GDMT to further optimize medications.

Abstract 12799: Geographic Variation in Cardiac Amyloidosis in U.S. Veterans From 2012 to 2021

Background: Prior studies suggest variability in cardiac amyloidosis (CA) detection across the U.S. with underdiagnosis in some regions. Research Question: It is unknown whether geographic variation exists in the occurrence of CA amongst U.S. Veterans in a contemporary cohort. Method: This is a retrospective observational cohort study. CA was defined as ≥ 1 heart failure (ICD9/10) and ≥ 1 amyloidosis diagnosis. For geographic mapping the location was the state of the diagnosing Veterans Affairs (VA) facility. The population at risk was patients in each state with ≥1 VA encounter during the year. The outcomes were incidence and prevalence rates of CA at the state and U.S. Census regional level (per 100,000 patients). The data source was the VA Corporate Data Warehouse (MDClone ADAMS platform). Results: The incidence and prevalence rates of CA by region are shown in the Table, and by state in the Figure. There was an increase in incidence and prevalence in all regions in 2012 and 2021. In both years, incidence and prevalence were highest in the Northeast and lowest in the South. Conclusion: Despite increasing recognition of CA in the VA Health System, there is regional variation in incidence and prevalence in 2012 and 2021. VA facilities in the Midwest, West and especially the South may have differences in CA detection relative to those in the Northeast region. Further research into health system, provider, and patient factors leading to this variation is needed to ensure health equity and quality of care for patients with CA.

Engaging early experiential learners to improve quality at a VA medical center - a cross-sectional analysis.

An innovative population health-based introductory pharmacy practice experience (IPPE) leveraging a Veterans Affairs (VA) and college of pharmacy collaboration was implemented in fall 2019. All second-year pharmacy students from the college actively engage in the evaluation of the medical records of veterans identified using population health management tools as needing additional care or experiencing a gap in care. This study examines the clinical impact of the experience on the care of patients at the partnering VA medical center. Course and patient records were reviewed to enumerate the number and types of interventions performed as part of the IPPE from fall 2019 to spring 2021. Descriptive statistics were used to report clinical impact. Where relevant, t test analysis was used to compare pre- and postintervention clinical values. A total of 1,794 medical records were reviewed. An average of 2.67 interventions were completed for each of the 615 veterans receiving an intervention. A total of 155 patients were identified as needing routine laboratory tests (eg, glycated hemoglobin), with 48.4% of patients receiving recommended laboratory tests within 3 months. Thirty-three veterans were eligible for prescription renewals, resulting in 43 medication orders. Thirty-six veterans were recommended to take a statin medication, and statin therapy was initiated in 11, resulting in a significant decrease in the mean (SD) low-density lipoprotein cholesterol concentration (-42.4 [30.3] mg/dL, P < 0.05). Eight hundred immunizations were recommended for 632 veterans, and 286 recommendations were verbally accepted. This study demonstrates that a population health-based IPPE can provide significant clinical support to the care of patients within the VA health system.

Using Research to Transform Electronic Health Record Modernization: Advancing a VA Partnered Research Agenda to Increase Research Impacts.

The U.S. Department of Veterans Affairs (VA) is undergoing an enterprise-wide transition from a homegrown electronic health record (EHR) system to a commercial off-the-shelf product. Because of the far-reaching effects of the EHR transformation through all aspects of the healthcare system, VA Health Services Research and Development identified a need to develop a research agenda that aligned with health system priorities so that work may inform evidence-based improvements in implementation processes and outcomes. The purpose of this paper is to report on the development of a research agenda designed to optimize the EHR transition processes and implementation outcomes in a large, national integrated delivery system. We used a sequential mixed-methods approach (portfolio assessment, literature review) combined with multi-level stakeholder engagement approach that included research, informatics, and healthcare operations experts in EHR transitions in and outside the VA. Data from each stage were integrated iteratively to identify and prioritize key research areas within and across all stakeholder groups. VA informatics researchers, regional VA health system leaders, national VA program office leaders, and external informatics experts with EHR transition experience. Through three rounds of stakeholder engagement, priority research topics were identified that focused on operations, user experience, patient safety, clinical outcomes, value realization, and informatics innovations. The resulting EHR-focused research agenda was designed to guide development and conduct of rigorous research evidence aimed at providing actionable results to address the needs of operations partners, clinicians, clinical staff, patients, and other stakeholders. Continued investment in research and evaluation from both research and operations divisions of VA will be critical to executing the research agenda, ensuring its salience and value to the health system and its end users, and ultimately realizing the promise of this EHR transition.

Outcomes of resident physician-performed cataract surgery in a diverse veterans affairs health system population.

To evaluate visual acuity (VA) outcomes and complications from resident physician-performed cataract surgery in a diverse Veterans Affairs Hospital population. A retrospective chart review was conducted for patients who underwent cataract surgery performed by resident physicians from 01/01/2013 to 12/31/2015 at the Veterans Affairs Medical Center. Intraoperative and postoperative clinical information, best-corrected VA (BCVA) (1 day, months 1, 2-3, and 6), and surgery complications were extracted. Univariable and multivariable linear regression models were performed for risk factors of BCVA change. This study included 1183 patients, with mean (SD) age of 70.8 (9.3) years. 1154 (97.5%) were males, 493 (41.7%) African-American, and 681 (57.6%) Caucasian. The mean (SD) VA in logMAR was 0.69 (0.74) at baseline, improved to 0.19 (0.36) at 1 month, 0.16 (0.34) at 2-3 months, and 0.14 (0.36) at 6 months. 1080 (91.3%) patients experienced VA improvement from baseline and 1023 (86.5%) patients achieved at least 20/40 BCVA at 1 month. There were 86 (7.3%) complications, most commonly including 47 (4.0%) posterior capsular tears and 64 (5.4%) vitreous loss. In multivariable analysis, younger age (P < 0.0001), worse baseline VA (P < 0.0001), and absence of iris prolapse (P < 0.001) were significantly associated with greater improvement in VA at 1 month. In a diverse VAMC, resident-performed cataract surgeries achieved significant improvement in VA with a cumulative complication rate lower than previously reported. Resident physician education may benefit from specific focus on prevention of iris prolapse and better incision construction during surgery as these intraoperative events often led to delayed stabilization of visual outcome beyond 1 month.

Changes in Patterns of Use of Advanced Therapies Following Emerging Data About Adverse Events in Patients With Rheumatoid Arthritis From the Veterans Affairs Health System.

To determine whether prescribing practices for Janus kinase inhibitors (JAKi), tumor necrosis factor inhibitors (TNFi), and non-TNFi biologic agents changed after the results of the Oral Rheumatoid Arthritis Trial (ORAL) Surveillance trial were released in January 2021. This is a retrospective study in adult patients with rheumatoid arthritis (RA) receiving advanced therapies within the Veterans Affairs Health System from January 2012 through September 2022. Eligible patients were required to have at least one diagnosis code for RA and to have received a biologic disease-modifying antirheumatic drug or JAKi. Treatment courses were defined from pharmacy dispensing data and the number of new courses of each advanced therapy was quantified over time. We assessed changes in the use of each therapy before and after the release of safety data (January 2021). A total of 88,253 individual drug courses (in 34,656 unique patients) were included in the study. There was a consistent increase in the number and proportion of new courses of JAKi leading up to January 2021, which was followed by a significant net decrease in JAKi use through September 2022. There was significantly less tofacitinib use after the release of safety data, with a significant difference in the slope of change in use with time. In contrast, whereas TNFi use declined leading up to 2021, its use significantly increased after January 2021. Changes in prescribing in response to new evidence emphasize the impact that safety trials have on prescribing practices. Ongoing study in this area, with attention to specific patient characteristics and risk profiles, will help characterize these changes in practice.

40668 Barriers to Use of Dermatologic Ultrasound: A National Survey of Dermatologists in the Veterans Affairs Health System

40668 Barriers to Use of Dermatologic Ultrasound: A National Survey of Dermatologists in the Veterans Affairs Health System

Exposure to Agent Orange and Risk of Bladder Cancer Among US Veterans

To date, limited data exist regarding the association between Agent Orange and bladder cancer, and the Institute of Medicine concluded that the association between exposure to Agent Orange and bladder cancer outcomes is an area of needed research. To examine the association between bladder cancer risk and exposure to Agent Orange among male Vietnam veterans. This nationwide Veterans Affairs (VA) retrospective cohort study assesses the association between exposure to Agent Orange and bladder cancer risk among 2 517 926 male Vietnam veterans treated in the VA Health System nationwide from January 1, 2001, to December 31, 2019. Statistical analysis was performed from December 14, 2021, to May 3, 2023. Agent Orange. Veterans exposed to Agent Orange were matched in a 1:3 ratio to unexposed veterans on age, race and ethnicity, military branch, and year of service entry. Risk of bladder cancer was measured by incidence. Aggressiveness of bladder cancer was measured by muscle-invasion status using natural language processing. Among the 2 517 926 male veterans (median age at VA entry, 60.0 years [IQR, 56.0-64.0 years]) who met inclusion criteria, there were 629 907 veterans (25.0%) with Agent Orange exposure and 1 888 019 matched veterans (75.0%) without Agent Orange exposure. Agent Orange exposure was associated with a significantly increased risk of bladder cancer, although the association was very slight (hazard ratio [HR], 1.04; 95% CI, 1.02-1.06). When stratified by median age at VA entry, Agent Orange was not associated with bladder cancer risk among veterans older than the median age but was associated with increased bladder cancer risk among veterans younger than the median age (HR, 1.07; 95% CI, 1.04-1.10). Among veterans with a diagnosis of bladder cancer, Agent Orange was associated with lower odds of muscle-invasive bladder cancer (odds ratio [OR], 0.91; 95% CI, 0.85-0.98). In this cohort study among male Vietnam veterans, there was a modestly increased risk of bladder cancer-but not aggressiveness of bladder cancer-among those exposed to Agent Orange. These findings suggest an association between Agent Orange exposure and bladder cancer, although the clinical relevance of this was unclear.