Veterans Health Administration Research Articles

Transitioning an implementation research intervention to a sustained clinical service: Telehealth primary care mental health integration implementation in Veterans Health Administration.

Often in implementation science efforts, an intervention originated by research funding does not continue in clinical practice after funding ends, or if it does, the process by which it was sustained remains known only to the implementation research or clinical teams. From 2018 to 2020, we implemented a complex telehealth interdisciplinary behavioral health program supported by research funding. The intervention was Primary Care Mental Health Integration (PCMHI) delivered via televideo from a large parent medical facility to rural satellite clinics (tele-PCMHI) within the Veterans Health Administration. Two implementation facilitators worked closely with clinical leaders and staff to plan, launch, and sustain tele-PCMHI across four sites. The intervention is still maintained by the clinical service and has spread to eight sites. Based on ethnographic and qualitative data collected weekly over 2 years, we categorized sustainment strategies across distinct time periods for this complex program, theoretically grounded in the Dynamic Sustainability Framework, emphasizing changes to adapt intervention fit to rapidly changing context. To contextualize, we identified barriers and strengths, such as difficulty training staff to use new equipment, restructuring clinic workflow, and determining suicide risk management remotely. New barriers arose, and, thus, new strategies were needed to continue implementing at the onset of the COVID-19 pandemic in 2020. Different strategies at different stages of implementation allowed sustainment to be a dynamic and evolving process. Plus, proactive and persistent planning for sustainment early in the effort, along with alignment with performance metrics and national policy, supported continued delivery in real-world organized care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Contact resolution among Veterans Crisis Line phone andtext contacts regarding Veterans Health Administration enrollees.

To expand access to suicide prevention and support services, the Veteran Crisis Line (VCL) added text capabilities in 2011. It is unknown whether the likelihood of a contact being terminated by the user varies by contact type. We aimed to assess whether contact resolution varies by contact type after accounting for Veterans' sociodemographic and clinical characteristics, contact risk, and reasons for contact. A retrospective cohort study of VCL phone and text contacts regarding identified VHA enrollees between 2016 and 2021 was performed. To examine differences in contact resolution between contact types, inverse probability of treatment weights were used to balance characteristics of text and phone contacts. Relative to phone contacts, text contacts were associated with 3.39 percentage point (PP) (95% CI, 3.27-3.50; p < 0.001) lower likelihood of receiving an emergency dispatch/welfare check, 2.65 PP (95% CI, 2.55-2.76; p < 0.001) lower likelihood of requiring arrangement for same-day care, and 9.47 (95% CI, 9.34-9.59; p < 0.001) PP higher likelihood of being terminated by the user. VCL text contact was associated with an increased likelihood of being terminated by the user. Further investigation is needed to understand the reasons for terminating contact for those who texted VCL.

Neurosurgical Residency Training at Veterans Affairs Medical Centers, the Resident Perspective.

Department of Veteran's Affairs (VA) Medical Centers play a crucial role in training neurosurgery residents. Although previous studies have examined the impact of VA rotations from the attending perspective, the resident experience remains unexplored. We present a national survey of neurosurgery residents to assess their perceptions of VA rotations, focusing on operative experience, call burden, longitudinal patient care experiences, and overall strengths and limitations. A 33-question survey was distributed by email to all neurosurgery residents who had previously completed a VA rotation within the past 7 years. Responses were received from 77 residents, representing 36 out of 40 neurosurgical residency programs with an active VA rotation. Most residents (79.2%) found their VA rotations adequate in length, having spent a median of 5 months at the VA. Residents completed an average of 11.7 (SD 7.2) cases per month while at the VA, including 8.9 (SD 5.5) spine, 1.7 (SD 2.0) cranial, and 1.4 (SD 1.6) peripheral nerve cases. Many residents reported completing a greater proportion of spine and peripheral nerve cases at the VA compared with their primary clinical sites. Across all postgraduate years, residents felt that the VA offered increased operative autonomy (79.0% agreement) at the expense of total operative volume (98.7% agreement) and complexity (81.9% agreement). Importantly, 94.8% of residents participated in longitudinal patient care experiences, and 59.7% followed all patients longitudinally. The resident experience at the VA varies, presenting both strengths and limitations. Addressing these factors could enhance the overall effectiveness of VA rotations in neurosurgical training programs in the future.

Conventional Machine Learning and Ensemble Learning Techniques in Cardiovascular Disease Prediction and Analysis

Cardiovascular diseases, which significantly affect the heart and blood vessels, are one of the leading causes of death worldwide. Early diagnosis and treatment of these diseases, which cause approximately 19.1 million deaths, are essential. Many problems, such as coronary artery disease, blood vessel disease, irregular heartbeat, heart muscle disease, heart valve problems, and congenital heart defects, are included in this disease definition. Today, researchers in the field of cardiovascular disease are using approaches based on diagnosis-oriented machine learning. In this study, feature extraction is performed for the detection of cardiovascular disease, and classification processes are performed with a Support Vector Machine, Naive Bayes, Decision Tree, K-Nearest Neighbor, Bagging Classifier, Random Forest, Gradient Boosting, Logistic Regression, AdaBoost, Linear Discriminant Analysis and Artificial Neural Networks methods. A total of 918 observations from Cleveland, Hungarian Institute of Cardiology, University Hospitals of Switzerland, and Zurich, VA Medical Center were included in the study. Principal Component Analysis, a dimensionality reduction method, was used to reduce the number of features in the dataset. In the experimental findings, feature increase with artificial variables was also performed and used in the classifiers in addition to feature reduction. Support Vector Machines, Decision Trees, Grid Search Cross Validation, and existing various Bagging and Boosting techniques have been used to improve algorithm performance in disease classification. Gaussian Naïve Bayes was the highest-performing algorithm among the compared methods, with 91.0% accuracy on a weighted average basis as a result of a 3.0% improvement.

The association of azole antifungals with overall survival in patients with non-small cell lung cancer receiving immune checkpoint inhibitors.

Preclinical data suggest antifungal azole derivatives have antitumor efficacy that may modulate response to immune checkpoint inhibitors (ICIs). We aimed to evaluate the association of azole drugs with overall survival (OS) in a population of patients with non-small cell lung cancer (NSCLC) treated with ICI within the Veterans Health Administration (VHA). In this retrospective study, the VA Corporate Data Warehouse was queried for patients diagnosed with NSCLC and treated with ICI from 2010 to 2018. Concomitant oral azole use was defined as dispensation by a VA pharmacy within 90 days of the first ICI infusion. Patients who received azole after 30 days were excluded from the analysis to mitigate immortal time bias. OS was measured from the start of ICI. Cox regression and propensity score matching were used to adjust for confounders. We identified 3413 patients with NSCLC receiving ICI; 324 (9.5%) were exposed to concomitant azoles. As a group, azole use was not associated with OS (hazard ratio [HR] = 0.96; 95% CI, 0.84-1.09; P = .51). After stratification by azole type, clotrimazole had an association with better OS on univariable (HR = 0.75; 95% CI, 0.59-0.96; P = .024) and multivariable analysis (HR = 0.71; 95% CI, 0.56-0.91; P = .007). Propensity score matching of patients who received clotrimazole vs no azole yielded 101 patients per matched cohort. Clotrimazole was associated with improved OS, although this did not meet the threshold for statistical significance (HR = 0.74; 0.54-1.01; P = .058). This observational study demonstrated an association between clotrimazole and OS among patients with advanced NSCLC receiving ICI. These findings build upon preclinical evidence and support further investigation into the potential for clotrimazole as a repurposed FDA drug to improve cancer outcomes.

Skilled Nursing Facility Rehabilitation Intensity and Successful Discharge in Persons with Dementia

ObjectivesSkilled therapies (STs), including audiology, speech-language therapy, occupational therapy, and physical therapy, can address functional deficits in dementia. This study aims to quantify the association between ST and successful discharge after heart failure (HF) hospitalization in persons living with dementia. DesignRetrospective cohort study. Setting and ParticipantsWe included veterans with dementia (VwD) hospitalized for HF in Veterans Affairs (VA) medical centers and then admitted to non-VA skilled nursing facilities (SNFs) from January 2011 to June 2019. MethodsFollow-up continued 120 days after SNF admission. We measured ST hours per week using MDS admission assessments. We defined successful discharge as SNF discharge occurring within 90 days of SNF admission with MDS discharge status not hospital or institutional setting, and 30 days’ survival after discharge without Medicare or VA-paid rehospitalization or reinstitutionalization. We estimated relative risk using multiple variable regression to adjust for measured sources of confounding. ResultsOur final sample included 8255 VwD. The mean (SD) age was 80 (10) years, and 8074 (98%) were male. Successful discharge occurred in 2776 (34%) of the sample. The median (IQR) weekly hours of ST was 10.4 (7.1–12.1). Sextile 1 received less than 5.2 hours per week of ST. The adjusted relative risk (95% CI) for sextiles 2–6 compared with sextile 1 were, respectively, 2.20 (1.85–2.62), 2.48 (2.09–2.94), 2.52 (2.12–2.99), 2.62 (2.21–3.11), and 2.69 (2.27–3.19). DiscussionDuring SNF care after HF hospitalization, 5.3 or more hours of STs per week was associated with a higher rate of successful discharge, in a roughly dose-dependent fashion, up to a 170% increase in the highest sextile of ST hours. Conclusions and ImplicationsHigher ST hours are associated with successful discharge from SNF after HF hospitalization.

A mobile telehealth program for behavioral treatment of urinary incontinence in women Veterans: Qualitative evaluation of MyHealtheBladder

Women Veterans constitute a distinctive cohort whose exposure to military service can contribute to development of bladder conditions, such as urinary incontinence (UI), as they age. Behavioral therapies are recommended as first-line treatment for incontinence, yet many VA Medical Centers do not have staff trained to administer them. The purpose of this research study was to conduct a qualitative program evaluation of MyHealtheBladder, a mobile telehealth version of an evidence-based eight‐week behavioral treatment program designed for women Veterans with incontinence. MyHealtheBladder uses mobile telehealth technology to teach pelvic floor muscle exercises, bladder control strategies, fluid management, risk factor reduction, and self‐monitoring. Eighteen women Veterans who completed a pilot study of MyHealtheBladder participated in semi-structured telephone interviews exploring their experience with the program. A directed content analysis was conducted of the transcribed interview data. Participants described ease of accessing MyHealtheBladder using smart phones and other mobile devices, emphasizing the flexibility of using the program at home, work, or while traveling. Most participants described program content as understandable, relevant, and easy to follow. They discussed how the program increased knowledge of UI, promoted consistency in practicing behavioral therapy, strengthened pelvic floor muscles, reduced urine leakage, and improved psychosocial wellbeing. Suggestions for improvement included more interaction with staff, more individualized tailoring of content to UI type, incorporating in-person clinic visits, and including supplementary material. Participants uniformly endorsed the program and recommended it for other women Veterans, as well as for those in active duty to prevent or treat UI earlier in the life course.

Improving Cancer Care for Women Seeking Services in the Veterans Health Administration Through the Breast and Gynecological Oncology System of Excellence.

Women are the fastest growing population among Veterans and have substantial risk factors that increase their likelihood for developing cancer. To ensure that the Department of Veterans Affairs Veterans Health Administration (VHA) offers the best possible cancer care to women Veterans, it established the Breast and Gynecologic Oncology System of Excellence (BGSoE) in 2021. The BGSoE offers telehealth oncology services and a comprehensive cancer navigation program. Veterans are identified through physician referral or through the BGSoE dashboard which integrates ICD-10 codes and text mining from VA electronic health records to identify eligible Veterans with breast or gynecological cancers. Descriptive statistics, including Veteran demographics and geographical location, were derived from BGSoE dashboard data. From January 1, 2021 to March 15, 2024, the BGSoE identified a total of 7,187 incident cases of breast or gynecological cancer among living Veterans. Most cancers were breast (78%) versus gynecological cancers (22%) and 10% of Veterans with breast cancer were identified as male. The average age at diagnosis was 59 for Veterans with breast cancer and 56 for those Veterans with gynecological cancers. Among Veterans in the BGSoE, 28% identified as Black and 6% identified as Hispanic. As the prevalence of women Veterans requiring cancer-related care continues to rise, it will be essential for VHA to evaluate the equitable reach, quality, and acceptability of women-focused cancer health services. The BGSoE focuses on providing high-quality and coordinated clinical cancer care. Veterans Health Administration also established the Center for Oncology Outcomes Review and Gender (COURAGE) to evaluate the BGSoE and continue to strengthen cancer care services in VHA. Initial evaluation objectives include establishing an evidence base regarding Veterans with breast and gynecological cancers, including their experiences with cancer care in the VHA. Eventually, COURAGE will provide ongoing monitoring and evaluation to continue to grow and improve cancer care in the VHA.

Patient-Directed Education to Promote Deprescribing

Patient-directed educational materials are a promising implementation strategy to expand deprescribing reach and adoption, but little is known about the impact across medication groups with potentially different perceived risks. To examine the impact of a patient-directed education intervention on clinician deprescribing of potentially low-benefit (proton pump inhibitors) or high-risk medications (high-dose gabapentin, diabetes agents with hypoglycemia risks). This pragmatic multisite nonrandomized clinical trial took place at 3 geographically distinct US Veterans Affairs (VA) medical centers from April 2021 to October 2022. The total study sample was composed of the intervention cohort and the historical control cohort cared for by 103 primary care practitioners (PCPs). The primary intervention component was a medication-specific brochure, mailed during the intervention time frame to all eligible patients 2 to 3 weeks prior to upcoming primary care appointments. Patients seen by the same PCPs at the same sites 1 year prior to the study intervention served as controls. The primary binary outcome variable was deprescribing 6 months after the intervention, defined as complete cessation or any dose reduction of the target medication using VA pharmacy dispensing data. The total study sample included 5071 patients. The overall rate of deprescribing among the intervention cohort (n = 2539) was 29.5% compared with 25.8% among the controls (n = 2532). In an unadjusted model, the intervention cohort was statistically significantly more likely to have deprescribing (odds ratio [OR], 1.17 [95% CI, 1.03-1.33]; P = .02). In a multivariable logistic regression model nesting patients within PCPs within sites and controlling for patient and PCP characteristics, the odds of deprescribing in the intervention cohort were 1.21 times that of the control cohort (95% CI, 1.05-1.38; P = .008). The difference in deprescribing prevalence between the intervention and control cohorts (proton pump inhibitors: 29.4% vs 25.4%; gabapentin: 40.2% vs 36.2%; hypoglycemia risk: 27.3% vs 25.1%) did not statistically significantly differ by medication group (P = .90). This nonrandomized clinical trial found that patient-directed educational materials provided prior to scheduled primary care appointments can effectively promote deprescribing for potentially low-benefit and high-risk medication groups. ClinicalTrials.gov Identifier: NCT0429490.

Abstract A061: The impact of race and obesity on the prostate tumor microenvironment

Abstract Black Americans have the highest prostate cancer incidence and are twice as likely to die from their disease compared to Non-Hispanic White men, making this one of the largest cancer disparities between these two racial groups in the United States. While access to health care is one of the strongest contributors to this disparity, studies suggest biological distinctions exist between tumors from Black and Non-Hispanic White men. Furthermore, obesity is associated with worse prostate cancer outcomes, and research showing a stronger association between obesity and prostate cancer risk among Black men compared to Non-Hispanic White men suggests obesity and Black race may work in combination to create aggressive disease. Hence, we sought to thoroughly and precisely characterize tumors from Black men, with and without obesity, to identify tumor behavior and potential therapeutic options for this population, which to date, has not been done mostly because of the lack of racially diverse cohorts of prostate cancer. Also, we sought to determine the impact of obesity on the composition of the prostate tumor microenvironment, which to date remains unknown. Given that in the US obesity rates are over 40% and the pressing need to better address high-risk populations, it is critical to better understand how obesity and race impact disease biology. We hypothesized obesity and Black race, individually and combined, increase tumor immune infiltration, creating a distinct tumor microenvironment. Specifically, we hypothesized this microenvironment will be characterized by higher overall inflammation, but also will enable us to identify therapeutic targets that in time can lead to the creation of personalized treatments for this population. To test this hypothesis, we used a large and racially diverse patient cohort from men who underwent radical prostatectomy at the Veterans Affairs Medical Center in Durham, North Carolina. To analyze the tumor microenvironment at the single cell level and define spatial organization, we used imaging mass cytometry in tissue microarrays of tumor and normal prostate samples from patients similar in tumor stage. We created a customized marker panel to determine cell phenotype and expression of immune checkpoints. We detected 25 cell phenotypes in the prostate microenvironment and determined differential phenotypic abundance and interactions by race and obesity. Next, we will expand our study to include a larger number of samples and associate tumor microenvironment characteristics with patient recurrence, metastasis, and survival. In this study, we generated new insights into disease drivers in an understudied and disproportionately affected population and lay important groundwork for future research identifying novel therapeutic targets for high-risk populations, such as men with African descent and obesity. Citation Format: Gloria Cecilia Galvan, Simeon Mahov, Sungyong You, Simon Knott, Michael Freeman, Akil Merchant, Stephen J Freedland. The impact of race and obesity on the prostate tumor microenvironment [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A061.

Implementation of a clinical pathway for the evaluation of asymptomatic hypertension in the emergency department

IntroductionAccording to the guidelines of the American Heart Association and American College of Emergency Physicians, respectively, there is no indication for immediate lowering of asymptomatic hypertension in the Emergency Department (ED), and no requirement for routine diagnostic testing in these patients. Despite this, asymptomatic hypertension represents a recurring source of referrals for ED evaluation from other healthcare settings, or from patient self-referral, with significant practice variation in the evaluation and treatment of this complaint. MethodsThis is a pre-post study of a pathway to standardize care of patients presenting to a tertiary academic Veteran's Health Administration ED with asymptomatic hypertension. Inclusion criteria were patients with ICD10 codes of hypertension who were confirmed via chart review to have sought care for a complaint of elevated blood pressure readings from 2018 to 2022, with the pathway having been implementing in 2022. Patients were excluded if they had symptoms of possible end organ pathology due to hypertension, such as chest pain, headache, or shortness of breath, or if they were reproductive age women who had not undergone a sterilization procedure. The primary outcome was major adverse cardiovascular event within 30 days of ED visit. Secondary outcomes included: diagnostic tests performed, administration of antihypertensives in the ED, and length of stay. Descriptive statistics and statistical analysis were performed. ResultsThere were a total of 295 unique patients and 324 patient encounters that met the inclusion/exclusion criteria, with 46 encounters that took place after pathway implementation. There were no major adverse cardiovascular events either before or after pathway implementation. Chest radiographs were reduced from 10 % to 0 % (p = 0.005) after pathway respectively. There were also declines in laboratory testing, EKGs, and administration of oral antihypertensives, but these differences were not statistically significant. At no point did any diagnostic testing identify any previously undiagnosed medical conditions. There were no instances of intravenous hypertensives being given after pathway implementation. Despite the reductions in diagnostic testing, there was no change in ED length of stay for patients with asymptomatic hypertension. ConclusionOur findings redemonstrate that patients presenting to the ED with asymptomatic hypertension are at low risk for short-term complications of hypertension, and that diagnostic testing is low yield in this population. While we were able to achieve reductions in unnecessary testing, further work is needed to educate clinicians and improve adherence to evidence based principles when caring for these patients.

Abstract A062: Glycemic control and risk of total and advanced prostate cancer in Veterans with diabetes: analysis of disparities by race/ethnicity

Abstract Introduction Access to quality healthcare is considered a key driver in the multifactorial process giving rise to racial inequities in two of the most common complex diseases in adult men in the US - prostate cancer and diabetes. Whether inequities in diabetes treatment and outcomes, and/or related metabolic and hormone signaling pathways contribute to racial differences in prostate cancer outcomes in an equal access setting is unknown. Our objective is to determine if associations between glycemic control assessed by routine clinically measured hemoglobin A1c (A1c), among men with diabetes and risk of total and advanced prostate are similar in Black and White men receiving care from the Veterans Health Administration (VHA). Methods We used clinical data from the VHA to construct a longitudinal cohort of male Veterans &amp;gt;=45 years of age with diagnosed diabetes free of any cancer from 01/01/2010 to 12/31/2019. We classified men with total prostate cancer if the date of prostate cancer diagnosis preceded any other cancer diagnosis. Advanced prostate cancer was classified as prostate cancer diagnosis with Gleason score &amp;gt;=8, or PSA &amp;gt;=100 ng/mL, or metastasis, or death from prostate cancer. We used Cox regression to estimate hazard ratios (HRs) and 95% confidence intervals (CI) for time-updated annual mean A1c (&amp;lt;7% [ref]; 7-8%; &amp;gt;8%) and total and advanced prostate cancer risk adjusted for age; marital status; rurality, smoking; annual primary care visits; service-connected disability; comorbidities; statin use; and oral diabetes medication use for non-Hispanic Black (NHB) and non-Hispanic White (NHW) men separately. Results Among 736,964 Veterans with diabetes, we observed 31,330 prostate cancer events including 6,779 advanced prostate cancers. For NHW men, poor glycemic control (A1c &amp;gt;8%) and moderate control (A1c 7-8%) were associated with a 19% (HR=0.81; 95%CI=0.78-0.84) and 8% lower risk (HR=0.92; 95%CI=0.89-95) of total prostate cancer incidence (p-trend&amp;lt;0.001). Among NHB men, inverse associations were attenuated for poor (HR=0.90; 95% CI=0.86-0.95) and moderate (HR=1.01; 95% CI=0.96-1.06) glycemic control and total prostate cancer risk (p-trend &amp;lt;0.001). For advanced prostate cancer, associations were inverse for poor (HR=0.90; 95% CI=0.83-0.97) and moderate glycemic control (HR=0.90; 95% CI=0.84-0.97) and advanced prostate cancer risk in NHW men, while non-statistically significant associations were observed in NHB men with poor HR=1.06; 95%CI=0.96-1.18) and moderate glycemic control (HR=1.04; 95%CI=0.94-1.16). Conclusion In the largest equal access healthcare system in the US, inverse associations for glycemic control and risk of total and advanced prostate cancer varied by race/ethnicity with stronger inverse associations observed in NHW men compared to NHB men. Whether the racial differences in diabetes treatment and care contribute to the observed disparities in total and advanced prostate cancer risk could inform precision public health efforts aimed at reducing inequities in both diabetes and prostate cancer outcomes. Citation Format: Michael T. Marrone, Kinfe G. Bishu, Neal Axon, Hermes Florez, Robert L. Grubb, Mulugeta Gebregziabher. Glycemic control and risk of total and advanced prostate cancer in Veterans with diabetes: analysis of disparities by race/ethnicity [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A062.

Quality and access outcomes in 2 Veterans Health Administration facilities with fidelity to the comprehensive medication management framework

Quality and access outcomes in 2 Veterans Health Administration facilities with fidelity to the comprehensive medication management framework

Influences of the criminal justice system on use of medications for opioid use disorder: a qualitative study

BackgroundLegal-involved veterans with opioid use disorder (OUD) have lower receipt of medications for opioid use disorder (MOUD) than other veterans served at the Veterans Health Administration (VHA). This qualitative study examined the influence of the criminal justice system on access to MOUD for legal-involved veterans in the U.S.MethodsVHA facilities (n = 14) that varied in their provision of MOUD to legal-involved veterans were selected for qualitative interviews. Interviewees included legal-involved veterans (n = 18), VHA Veterans Justice Programs Specialists (n = 15), substance use disorder treatment providers (n = 5), and criminal justice staff (n = 12). Team members applied codes to meaningful units of analysis (quotations) in the transcribed interviews. Using a matrix approach, team members created a spreadsheet matrix with codes, facility rate of MOUD, and relevant quotations summarized for each participant. Themes and connections between individual participants and cross-interview concepts were explored. Participants were not asked to provide feedback on the findings.ResultsThemes identified were as follows: (1) Veterans Treatment Court policies both enhanced and limited MOUD treatment access and utilization among participants; (2) cross-system collaboration strengths and challenges existed; and (3) criminal justice system treatment preferences and policies both enhanced and limited MOUD in jails and prisons.ConclusionsThe influence of the criminal justice system on MOUD has led to variable access to MOUD for legal-involved veterans. Our findings can help inform recommendations to enhance access to MOUD for veterans within the criminal justice system, including the development of a national database of MOUD education materials for Veterans Treatment Courts, strengthening community-court relationships, allowing individuals to use their own healthcare coverage within jails and prisons and extend Medicaid coverage into criminal justice settings, and applying national quality measures for MOUD to criminal justice settings and develop a national system for tracking these quality measures.

HIV Preexposure Prophylaxis Use Among U.S. Veterans using Veterans Health Administration Services, 2014─2022

Objectives. It is important to monitor national HIV preexposure prophylaxis (PrEP) use in the United States. However, PrEP use data in the Veterans Health Administration (VHA) system are not included in the current monitoring surveillance. To address this gap, we examined the trends in PrEP use among U.S. Veterans receiving health services in the VHA system. Methods. We analyzed 2014-2022 VHA data to identify the annual number and prevalence of persons aged ≥18 years prescribed PrEP, stratified by sex, age, race and ethnicity, and region. We also assessed trends by calculating the estimated annual percent change (EAPC) and 95% confidence intervals (CIs) using Poisson models. Results. The number of Veterans prescribed PrEP increased from 361 in 2014 to 6,050 in 2022 with an EAPC of 29.6% (95% CI, 22.6–37.1). Of 6,050 Veterans with PrEP prescriptions in 2022, 95.2% were men, 4.8% were women, 50.4% were White, 24.5% Black or African American (Black) and 14.0% Hispanic or Latino. The prevalence of Black and Hispanic or Latino individuals prescribed PrEP increased significantly from 2014-2022. Conclusion. VHA data fill a gap in monitoring PrEP use in the United States. We observed an increasing trend in the number of Veterans prescribed PrEP similar to trends among persons with commercial or public health insurance.

Increasing Access to Naloxone in Veterans Receiving Opioids Through Community Care

The United States is battling an opioid overdose epidemic, and Veterans are at almost double the risk compared to the general population. Veterans Health Administration (VHA) recognizes the critical role naloxone plays as a risk mitigation strategy in opioid prescribing; however, there was not a standardized process within the Kansas City VA Medical Center’s (KCVAMC) community care program. This quality improvement project included Veterans that received opioids through community care from 2022 to 2023. The Stratification Tool for Opioid Risk Mitigation and chart review were used along with descriptive statistics. Results found 11% (22 of 206) of Veterans were dispensed naloxone within one year prior to receiving their opioid prescription. This data indicated the importance of expanding access to naloxone in Veterans receiving opioids from community care providers. As a result of this data, the KCVAMC implemented an outpatient pharmacy protocol to dispense naloxone to appropriate Veterans that receive an opioid through the community care program. The protocol was initiated on March 29, 2023. From the end of March through 2023, naloxone dispensing for these Veterans increased from 11% to 67%.

Incidence and risk of post-COVID-19 thromboembolic disease and the impact of aspirin prescription; nationwide observational cohort at the US Department of Veteran Affairs.

COVID-19 triggers prothrombotic and proinflammatory changes, with thrombotic disease prevalent in up to 30% SARS-CoV-2 infected patients. Early work suggests that aspirin could prevent COVID-19 related thromboembolic disorders in some studies but not others. This study leverages data from the largest integrated healthcare system in the United States to better understand this association. Our objective was to evaluate the incidence and risk of COVID-19 associated acute thromboembolic disorders and the potential impact of aspirin. This retrospective, observational study utilized national electronic health record data from the Veterans Health Administration. 334,374 Veterans who tested positive for COVID-19 from March 2, 2020, to June 13, 2022, were included, 81,830 of whom had preexisting aspirin prescription prior to their COVID-19 diagnosis. Patients with and without aspirin prescriptions were matched and the odds of post-COVID acute thromboembolic disorders were assessed. 10.1% of Veterans had a documented thromboembolic disorder within 12 months following their COVID-19 diagnosis. Those with specific comorbidities were at greatest risk. Preexisting aspirin prescription was associated with a significant decrease risk of post-COVID-19 thromboembolic disorders, including pulmonary embolism (OR [95% CI]: 0.69 [0.65, 0.74]) and deep vein thrombosis (OR [95% CI]: 0.76 [0.69, 0.83], but an increased risk of acute arterial diseases, including ischemic stroke (OR [95% CI]: 1.54 [1.46, 1.60]) and acute ischemic heart disease (1.33 [1.26, 1.39]). Findings demonstrated that preexisting aspirin prescription prior to COVID-19 diagnosis was associated with significantly decreased risk of venous thromboembolism and pulmonary embolism but increased risk of acute arterial disease. The risk of arterial disease may be associated with increased COVID-19 prothrombotic effects superimposed on preexisting chronic cardiovascular disease for which aspirin was already prescribed. Prospective clinical trials may help to further assess the efficacy of aspirin use prior to COVID-19 diagnosis for the prevention of post-COVID-19 thromboembolic disorders.

GLP-1 Receptor Agonists and Risk for Cirrhosis and Related Complications in Patients With Metabolic Dysfunction-Associated Steatotic Liver Disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) is an increasing cause of cirrhosis. Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) are effective in improving liver inflammation in patients with MASLD. To determine whether use of GLP-1 RAs is associated with lower risk of developing cirrhosis and its complications, including decompensation and hepatocellular cancer (HCC), among patients with MASLD. This retrospective cohort study with an active comparator, new-user design used data from the national Veterans Health Administration Corporate Data Warehouse and Central Cancer Registry. Patients with MASLD and diabetes who were seen at 130 Veterans Health Administration hospitals and associated ambulatory clinics and who initiated either a GLP-1 RA or dipeptidyl peptidase 4 inhibitor (DPP-4i) between January 1, 2006, and June 30, 2022, were included. Patients were followed up from baseline until one of the study outcomes or the end of the study period (December 31, 2022), whichever came first. Each GLP-1 RA new user was propensity score matched in 1:1 ratio to a patient who initiated a DPP-4i during the same month. Separate analyses were conducted among patients without and with cirrhosis at baseline. For patients without cirrhosis, the primary outcome was progression to cirrhosis defined by validated diagnoses codes or a noninvasive marker of liver fibrosis, and secondary outcomes were cirrhosis complications defined both as a composite and individual complications, including decompensation, HCC, or liver transplant, and all-cause mortality. For patients with cirrhosis, the primary outcome was a composite outcome of cirrhosis complications, and secondary outcomes were decompensation, HCC, and all-cause mortality. Of 16 058 patients who initiated GLP-1 RAs, 14 606 did not have cirrhosis (mean [SD] age, 60.56 [10.31] years; 13 015 [89.1%] male), and 1452 had cirrhosis (mean [SD] age, 66.99 [7.09] years; 1360 [93.7%] male) at baseline. These patients were matched to an equal number of patients who initiated a DPP-4i. In patients without cirrhosis, GLP-1 RA use, compared with DPP-4i use, was associated with a lower risk of cirrhosis (9.98 vs 11.10 events per 1000 person-years; hazard ratio [HR], 0.86; 95% CI, 0.75-0.98). Similar results were seen for the secondary outcomes. GLP-1 RA use, compared with DPP-4i use, was associated with a lower risk of the composite outcome of cirrhosis complications (1.89 vs 2.55 events per 1000 person-years; HR, 0.78; 95% CI, 0.59-1.04) and mortality (21.77 vs 24.43 events per 1000 person-years; HR, 0.89; 95% CI, 0.81-0.98). There were no associations between GLP-1 RA use and outcomes in patients with cirrhosis. In this cohort study, GLP-1 RA use was associated with a lower risk of progression to cirrhosis and mortality among patients with MASLD and diabetes. The protective association was not seen in patients with existing cirrhosis, underscoring the importance of treatment earlier in the disease course.

Implementation of collaborative care for depression in VA HIV clinics: Translating Initiatives for Depression into Effective Solutions (HITIDES): protocol for a cluster-randomized type 3 hybrid effectiveness-implementation trial

BackgroundDepression is the most diagnosed mental health condition among people living with HIV. Collaborative care is an effective intervention for depression, typically delivered in primary care settings. The HIV Translating Initiatives for Depression into Effective Solutions (HITIDES) clinical intervention involves a depression care team housed off-site that supports depression care delivery by HIV care providers. In a randomized controlled trial, HITIDES significantly improved depression symptoms for veterans living with HIV and delivered cost savings. However, no HIV clinics in the Veterans Health Administration (VHA) have implemented HITIDES; as such, it is unclear what implementation strategies are necessary to launch and sustain this intervention.MethodsThis hybrid type-3 effectiveness-implementation trial examines the implementation and effectiveness of HITIDES in 8 VHA HIV clinics randomly assigned to one of two implementation arms. Each arm uses a different implementation strategy package. Arm 1 includes an intervention operations guide; an on-site clinical champion who, with the help of a peer community of practice, will work with local clinicians and leadership to implement HITIDES at their site; and patient engagement in implementation tools. Arm 2 includes all strategies from Arm 1 with assistance from an external facilitator. The primary implementation outcomes is reach; secondary outcomes include adoption, implementation dose, depressive symptoms, and suicidal ideation. We will conduct a budget impact analysis of the implementation strategy packages. We hypothesize that Arm 2 will be associated with greater reach and adoption and that Arm 1 will be less costly.DiscussionPreliminary work identified implementation strategies acceptable to veterans living with HIV and HIV care providers; however, the effectiveness and cost of these strategies are unknown. While the depression care team can deliver services consistently with high quality, the ability of the depression care team to engage with HIV care providers at sites is unknown. Findings from this study will be used to inform selection of implementation strategies for a broad rollout to enhance depression and suicide care for people living with HIV.Trial registrationClinicalTrials.gov ID: NCT05901272, Registered 10 May 2023, https://clinicaltrials.gov/study/NCT05901272

Exploring Veterans' Experiences Accessing Chronic Pain Treatment in the VA Community Care Network.

Chronic pain is common among Veterans, and rural Veterans commonly struggle obtaining chronic pain care due to large travel distances to the nearest Veterans Affairs (VA) medical center. In 2019, the VA established the Community Care Network (CCN) to provide Veterans access to care in community-based settings, including chronic pain management. To explore the experiences of rural Veterans receiving chronic pain treatment in the VA CCN, including their perceptions about perceived barriers, facilitators, and benefits to accessing comprehensive chronic pain management. Qualitative study using semi-structured interviews. Ten rural Veterans receiving chronic pain management in the VA CCN took part in a qualitative interview focused on their experiences accessing and utilizing the VA CCN. A descriptive qualitative approach was used. Major themes were identified through thematic content analysis. Veterans described challenges navigating the approval process, finding approved CCN providers for pain management, and they perceived that communication between the VA and community providers was not seamless. Once enrolled in the CCN, however, Veterans valued the freedom to choose providers specializing in pain management within their local communities, timely access to appointments, and opportunities to explore a wider range of pain treatment options and alternative therapies, in addition to traditional medical interventions, all in their local community. As the CCN seeks to improve collaboration between VA and community providers, recognition of Veterans' experiences could serve to drive the development of network improvements. Findings reported here suggest that Veterans preferred obtaining care in the CCN once they could navigate administrative complexity to access it. Thus, efforts to streamline VA administrative requirements for initiating CCN care would better support Veterans in meeting their needs in this context.