Veterans Benefits Research Articles

Promoting Health and Wellbeing Through Non-Clinical Arts Programming: Multi-Stakeholder Perspectives From the Veterans Health Administration.

While the value of art therapy is well-established and arts are increasingly leveraged to promote health and wellbeing more broadly, little is known about the impacts of non-clinical arts programs. In this preliminary investigation, we sought to fill this gap by exploring diverse stakeholders' perspectives on the impacts of non-clinical arts programming on Veterans receiving care at the Veterans Health Administration (VA). Semi-structured qualitative interviews with Veterans, VA staff, and community partners. Interviewees were recruited from 7 VA medical centers that have recently implemented non-clinical arts programming to promote Veterans' health and wellbeing, some of them in partnership with community organizations. 33 individuals were interviewed, including 9 Veterans, 14 VA staff, and 10 community partners involved in non-clinical arts program implementation. Interview transcripts were analyzed using iterative rounds of qualitative content analysis. The following impacts on Veterans were described: (1) mental health improvements, (2) renewed sense of purpose; (3) increased social connectedness, (4) improved self-esteem, and (5) self-driven engagement in art activities. Non-clinical arts programming was perceived by diverse stakeholders to offer important benefits for Veterans' health and well-being. Offering non-clinical arts programming inside and outside healthcare facilities' walls is a promising direction for the field of public health undergoing a shift towards holistic approaches to improving individual and population health outcomes.

Germline testing for veterans with advanced prostate cancer: concerns about service-connected benefits.

To better understand veterans' decisions about germline testing, we conducted a single-site, qualitative study of 32 veterans with advanced prostate cancer. Seven days after oncologist-patient discussions about germline testing, we conducted semistructured interviews with patients to explore their decision-making process using an interview guide. Four of 14 veterans with service-connected disability benefits for prostate cancer declined germline testing for fear of losing benefits because their livelihood depended on these benefits. All 18 veterans without service-connected benefits agreed to testing. Veterans declining germline testing based on this concern can lead to suboptimal cancer care because targeted treatments that could improve their outcomes may go unrecognized. Our findings contributed to new language in the Veterans Benefits Administration Compensation and Pension Manual clarifying that genetic testing showing hereditary predisposition is insufficient to deny service-connected benefits for conditions presumed to be caused by military exposures. Clinicians should communicate this protection when counseling veterans about genetic testing.

Clinical benefits of self-guided mindfulness coach mobile app use for veterans with posttraumatic stress disorder: A pilot randomized control trial.

Mindfulness training can relieve posttraumatic stress disorder (PTSD) symptoms in military veterans and others but is inconsistently accessible. Self-guided mobile apps could improve access but their acceptability, feasibility, and benefits for veterans with PTSD have not been established. We conducted a pilot randomized trial of Mindfulness Coach (MC), a free, publicly available, trauma-informed mobile app tailored to veterans. U.S. veterans with PTSD (n = 173) were randomized to self-guided use of MC or waitlist control (WLC) with 8-week follow-up. Clinical outcomes were PTSD symptoms (PTSD Symptom Checklist-5), depression symptoms (Patient Health Questionnaire, nine item), and psychosocial functioning (Brief Inventory of Psychosocial Functioning). Primary analyses were intent-to-treat using linear mixed models with maximum likelihood estimation. App uptake, objective usage, and usability ratings measured acceptance and feasibility. Participants varied in age, gender, and ethnoracial identity; most reported recent mental health care utilization. Although study attrition was high (68.4% overall) due to participant dropout (treatment: 43.0%; control: 43.7%) and technical study issues (23% overall), diagnostic tests showed no evidence of bias due to missingness. Study completers (MC: n = 19; WLC: n = 37) showed medium effects on PTSD symptoms (b = -9.31, d = -0.69) and depression (b = -3.10, d = -0.52). Higher-intensity users showed greater benefits. App engagement trended lower for women and minoritized subpopulations. No changes were observed in psychosocial functioning. Usability and helpfulness ratings were favorable. Transdiagnostic clinical benefits indicate promise for MC as a public health resource for veterans with PTSD. Further study is warranted to confirm these benefits and ensure consistent engagement across subpopulations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Prevalence of ALS in all 50 states in the United States, data from the National ALS Registry, 2011–2018

Objective: To summarize the prevalence of ALS in all 50 states and Washington, DC in the United States from 2011 to 2018 using data collected and analyzed by the National ALS Registry. In October 2010, the federal Agency for Toxic Substances and Disease Registry (ATSDR) launched the congressionally mandated Registry to determine the incidence and prevalence of ALS within the USA, characterize the demographics of persons with ALS, and identify the potential risk factors for the disease. This is the first analysis of state-level ALS prevalence estimates. Methods: ALS is not a notifiable disease in the USA, so the Registry uses a two-pronged approach to identify cases. The first approach uses existing national administrative databases (Medicare, Veterans Health Administration, and Veterans Benefits Administration). The second method uses a secure web portal to gather voluntary participant data and identify cases not included in the national administrative databases. Results: State-level age-adjusted average prevalence from 2011–2018 ranged from 2.6 per 100,000 persons (Hawaii) to 7.8 per 100,000 persons (Vermont), with an average of 4.4 per 100,000 persons in the US. New England and Midwest regions had higher prevalence rates than the national average. Conclusions: These findings summarize the prevalence of ALS for all 50 states from 2011 to 2018. This is a continuing effort to identify ALS cases on a national population basis. The establishment of the National ALS Registry has allowed for epidemiological trends of this disease and the assessment of potential risk factors that could cause ALS.

Congressional Expansion of Enhancing Breast Cancer Screening and Care at the Veterans Health Administration.

Despite high screening rates, breast cancer disparities persist among women veterans because of occupational risks and barriers to access. Three essential bills recently passed in Congress seek to expand access to breast cancer screenings and cancer care within the Veterans Health Administration. The Making Advances in Mammography and Medical Options for Veterans Act expands screening via partnerships with the National Cancer Institute, integrating telescreening and upgrading imaging technology. The Dr. Kate Hendricks Thomas Supporting Expanded Review for Veterans In Combat Environments Act broadens eligibility for those exposed to toxins and personalized risk assessments. The bipartisan Sergeant First Class Health Robinson Honoring our Promise to Address Comprehensive Toxics Act extends benefits for toxin-exposed veterans with presumptive conditions, including breast cancer. Further programs such as National TeleOncology, the Breast & Gynecologic Oncology System of Excellence, and research collaborations between the Veterans Health Administration, National Cancer Institute, and Surveillance, Epidemiology and End Results Program seek to improve access, enhance understanding and care for women veterans with cancer, and mark significant progress in comprehensive care.

USA EXPERIENCE REGARDING THE REINTEGRATION OF WAR VETERANS INTO CIVILIAN LIFE

The article summarizes the experience of the United States regarding the reintegration of veterans into civilian life, namely: the peculiarities of regulatory and legal regulation and the main directions of veteran policy. It was established that the American legislation uses two terms –«veteran» and «active military serviceman», while in Ukraine – «combatant», «military serviceman», «war veteran», «war participant». The American practice of military reintegration into civilian life involves mandatory participation in the Transition Assistance Program (TAP). The main directions of military reintegration into civilian life in the USA, which are under the competence of the Department of Defense, the Department of Veterans Affairs and the Department of Labor, are: social adaptation; psychological support; professional retraining; support with housing. Social adaptation includes social communication, social support and formation of new social skills. Psychological support includes specialized support and treatment. Professional retraining of veterans is the acquisition of new professional qualifications through the acquisition of additional education or skills. Support with housing includes providing a loan for the purchase of housing, maintenance and adaptation of houses to new requirements in case of disability.It has been established that the USA is a country where «military social work» was formed, which is understood as a specialized practice of social work that provides support to military personnel, war veterans and their family members. Military social workers provide a range of services (counseling, crisis intervention, supervision), conduct training and coaching, and organize presentations of special client health support events to colleagues at all levels. Regarding the provision of social benefits, the USA has an exclusive approach to veterans policy – welfare programs for veterans operate separately from programs for the general population. The current system of benefits for veterans in the United States is complex.

Legal Services for Veterans (LSV): Protocol for evaluating the grant-based LSV initiative supporting community organizations' delivery of legal services to veterans.

1.8 million Veterans are estimated to need legal services, such as for housing eviction prevention, discharge upgrades, and state and federal Veterans benefits. While having one's legal needs met is known to improve one's health and its social determinants, many Veterans' legal needs remain unmet. Public Law 116-315 enacted in 2021 authorizes VA to fund legal services for Veterans (LSV) by awarding grants to legal service providers including nonprofit organizations and law schools' legal assistance programs. This congressionally mandated LSV initiative will award grants to about 75 competitively selected entities providing legal services. This paper describes the protocol for evaluating the initiative. The evaluation will fulfill congressional reporting requirements, and inform continued implementation and sustainment of LSV over time. Our protocol calls for a prospective, mixed-methods observational study with a repeated measures design, aligning to the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) and Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) frameworks. In 2023, competitively selected legal services-providing organizations will be awarded grants to implement LSV. The primary outcome will be the number of Veterans served by LSV in the 12 months after the awarding of the grant. The evaluation has three Aims. Aim 1 will focus on measuring primary and secondary LSV implementation outcomes aligned to RE-AIM. Aim 2 will apply the mixed quantitative-qualitative Matrixed Multiple Case Study method to identify patterns in implementation barriers, enablers, and other i-PARIHS-aligned factors that relate to observed outcomes. Aim 3 involves a mixed-methods economic evaluation to understand the costs and benefits of LSV implementation. The LSV initiative is a new program that VA is implementing to help Veterans who need legal assistance. To optimize ongoing and future implementation of this program, it is important to rigorously evaluate LSV's outcomes, barriers and enablers, and costs and benefits. We have outlined the protocol for such an evaluation, which will lead to recommending strategies and resource allocation for VA's LSV implementation.

Supporting animals and veterans through enrichment: An exploratory study on a brief canine socializing intervention

Abstract Veterans pursuing post-secondary education may experience reintegration challenges and academic-related stress. To support student well-being, colleges and universities have begun to offer animal-assisted interventions (AAI); however, the influence of AAI programs on student veteran populations remains underexplored. Furthermore, the welfare impact of AAI programs on incorporating animals has begun to be assessed. As shelter dogs can benefit from human interaction, a mixed-methods design was used to assess if dogs and student veterans could benefit from participating in a brief 30-min unstructured interaction. We aimed to identify whether: the interaction influenced veteran reported mood state, the dog and the interaction activities completed influenced veteran experience, and the interaction influenced shelter dog behavior. Thirty veterans ( M age = 34, SD = 9.2; 24 males, 4 females) enrolled in a southern United States mid-size public university participated along with screened shelter dogs ( N = 30, M age = 2, SD = 0.9; 17 males, 13 females). Veterans were instructed to engage in the activities of their choosing (i.e., petting, playing, talking, providing treats, brushing) with a shelter dog. To assess changes in veteran mood, a pictorial self-report scale (assessing arousal (activated, deactivated), and valence (pleasant, unpleasant)) was completed pre- and post-interaction. Dog behavior was measured in shelter before the interaction and during the beginning, middle, and end of the interaction. Results reveal veterans reported pleasant post-interaction mood states, an overall positive experience and activity enjoyment. Qualitative results indicated that veterans perceived the dog behavior to be the most memorable aspect of participation, positively influencing their overall interaction experience. Dogs entered the interaction with more behavioral displays of fear (e.g., reduced posture), general activity (e.g., jumping), and soliciting contact behaviors (e.g., soliciting play), with all behavioral activity reducing halfway into the interaction, potentially suggesting increased relaxation over the course of the interaction. Observed decreases in dog fear behavior and veteran reported activity enjoyment suggests benefits for shelter dogs and student veterans.

Two Decades of Department of Veterans Affairs Traumatic Brain Injury Care and Benefits for Veterans of Post-9/11 Conflicts.

To describe the background, methodology, and results of the congressionally mandated Department of Veterans Affairs (VA) Traumatic Brain Injury (TBI) Veterans Health Registry. Veterans Health Administration (VHA) and Veterans Benefit Administration (VBA). A total of 441 639 Veterans of post-9/11 conflicts who exhibited symptoms associated with TBI and sought care or benefits from the VA between September 2001 and September 2021. Design: Retrospective analysis of VHA and VBA administrative records. (1) VA/Department of Defense Identity Repository to identify Veterans with a deployment to the Southwest Asia theater of operations; (2) the VA TBI Screening and Evaluation Program data; (3) Inpatient and Outpatient Encounter data; and (4) an extract of the VBA Corporate Database to identify Veterans filing benefit claims based on TBI. An unduplicated total of 441 639 post-9/11 Veterans were identified in the Registry via three different pathways to entry: 369 909 Veterans through a positive TBI Screen, 253 177 Veterans receiving healthcare including a TBI diagnosis, and 108 541 Veterans filing TBI disability claims. Among Veterans reporting current TBI symptoms who completed a clinical evaluation, a diagnosis of TBI was confirmed by a TBI specialist in 68.7% of the cases. The TBI severity of confirmed cases was classified as mild in 86.6% of the cases, moderate in 8.3%, and severe in 4.1%. The TBI Registry Veterans were hospitalized 66 503 times and seen 1 521 898 times as outpatients in VHA facilities with diagnoses including TBI. Among Veterans filing TBI disability claims, 67.3% were adjudicated as service-connected. The VA TBI Health Registry has identified over 440 000 Veterans of post-9/11 conflicts who presented to the VA for care or benefits with TBI symptomatology. This large number and the volume of TBI health care and benefits provided over the two decades since 9/11 demonstrate the need for the VA's strong ongoing focus on screening, evaluation, and rehabilitation of TBI.

Challenges in patient-centered germline testing delivery for veterans with advanced prostate cancer (APC).

71 Background: In a quest to tailor care to tumor biology, oncologists now offer germline testing to all patients with APC. We explored the degree to which germline testing decisions reflect patient preferences about potential benefits and harms discussed by oncologists. Methods: We conducted a prospective qualitative study of consecutive patients with APC who were offered germline testing at an oncology visit at the San Francisco VA. We audio-recorded visits and conducted semi-structured interviews using a theory-informed guide with patients after their visit to understand their decision-making process for germline testing. We analyzed the interviews using the Critical Incident Technique to identify positive or negative deviations from well-informed, preference-based decisions. We also reviewed consent documentation in the electronic health record. Results: Of 61 patients approached, 30 completed interviews after their germline testing discussion. Mean age was 75y; 19 (63%) were White, 9 (30%) Black, and 2 (6%) Other race; and 13 (43%) were service-connected for APC. Twenty-six (87%) patients consented to germline testing; the primary reasons were altruistic (to help family and contribute to knowledge). Four patients (13%) declined testing, all primarily due to the fear of potential loss or reduction of service-connected benefits. All four patients reported they would reconsider testing if assured that these benefits would be protected regardless of test results. Of the four patients, two had initially consented to testing with their oncologist but later changed their minds and did not notify anyone. The two patients received germline testing when they underwent PSA testing, but they were not aware that they had germline testing performed. Both had negative test results, and they therefore did not experience threats to their service-connected benefits. Conclusions: Some Veterans with service-connected benefits for APC decline germline testing due to the fear of potential loss or reduction of these benefits, thereby foregoing potential treatment benefits. An advisory board is working with the Veterans Benefits Administration to protect service-connected benefits for these Veterans. In addition, a few Veterans may agree to germline testing with their oncologist, but then change their minds due to concerns surrounding service-connected benefits. From a quality improvement perspective, the experiences of the patients in this study who changed their minds counts as a near-miss. Although uptake of germline testing was high in this cohort, current workflows may need to be addressed to account for a change of heart, and further research is needed to understand root causes and identify possible remedies of the near-misses. Overall, our findings illustrate the importance of informed consent for germline testing to ensure that results are desired and valued by both oncologist and patient.

Benefits Trafficking: human trafficking of older adults and adults with disabilities.

An emerging type of trafficking is targeting overlooked at-risk adults. Benefits Trafficking is the systematic recruitment, harboring, neglect, and financial exploitation of elder and disabled adults who receive government benefits such as Social Security, Veteran's Benefits, Medicaid, and Medicare. Traffickers often pose as kind-hearted individuals offering to provide care for at-risk adults in an in-home setting. Once recruited, at-risk adults are stripped of their government benefits, held against their will, moved from location to location, and denied basic needs such as food, clothing, and adequate shelter. While Benefits Trafficking is a basic civil rights violation issue, it is also a growing public health issue. Victims of Benefits Trafficking are often the forgotten at-risk adults who have fallen through the cracks of various mental health systems, are unhoused, and no longer have a social support system in place. This area of human trafficking is unresearched and its prevalence is largely unknown outside of the few entities working in this space. This paper focuses mainly on raising awareness of Benefits Trafficking and suggestions for future funding and research initiatives.

Military sexual trauma-related posttraumatic stress disorder service-connection: Characteristics of claimants and award denial across gender, race, and compared to combat trauma.

The current study characterizes a cohort of veteran claims filed with the Veterans Benefits Administration for posttraumatic stress disorder secondary to experiencing military sexual trauma, compares posttraumatic stress disorder service-connection award denial for military sexual trauma-related claims versus combat-related claims, and examines military sexual trauma -related award denial across gender and race. We conducted analyses on a retrospective national cohort of veteran claims submitted and rated between October 2017-May 2022, including 102,409 combat-related claims and 31,803 military sexual trauma-related claims. Descriptive statistics were calculated, logistic regressions assessed denial of service-connection across stressor type and demographics, and odds ratios were calculated as effect sizes. Military sexual trauma-related claims were submitted primarily by White women Army veterans, and had higher odds of being denied than combat claims (27.6% vs 18.2%). When controlling for age, race, and gender, men veterans had a 1.78 times higher odds of having military sexual trauma-related claims denied compared to women veterans (36.6% vs. 25.4%), and Black veterans had a 1.39 times higher odds of having military sexual trauma-related claims denied compared to White veterans (32.4% vs. 25.3%). Three-fourths of military sexual trauma-related claims were awarded in this cohort. However, there were disparities in awarding of claims for men and Black veterans, which suggest the possibility of systemic barriers for veterans from underserved backgrounds and/or veterans who may underreport military sexual trauma.

Canada’s varying approach to compensating disabled Reserve Force members and Veterans since 1866

LAY SUMMARY This article examines the different levels of liability Canada has assumed for disabled serving military members and Veterans from 1866 to 2020. Throughout Canada’s history, the first consideration for financial compensation has been the enrolment component of the casualty, that is, Regular, Reserve, or Special Force. Since 1883, disabled serving Regular Force members have received full pay and benefits while recovering from service-related injuries. Whether through the Militia Act, the Pension Act, long-term disability insurance, or the current Veterans Well-being Act (VWA), disabled Regular Force Veterans received financial compensation based on lost earnings. Before 1914, Canada’s military was a predominantly part-time militia, and if a member was disabled or killed due to a service-related injury or illness, lost civilian earnings and family circumstances were considered in financial compensation. From the First World War until the 1970s, serving reservists were eligible for military pay and benefits while recovering from service-related injuries. Currently, subject to an investigation clearing them of fault or malfeasance, they may apply for an allowance equivalent to military pay with no benefits. Between 1919 and 1999, the government accepted less and less liability for disabled Reserve Force Veterans until recent changes to Veterans benefits legislation incrementally improved this.

Fiduciary assignment as a potential intervention for substance use disorder: a retrospective chart review

ABSTRACT Background: Assignment of fiduciaries to veterans with disability payments is an intervention thought to improve quality of life; however, in veterans who use substances, a proportion of these payments may be misspent on drugs and/or alcohol. While fiduciary assignment may reduce funds available to purchase substances, clinical efficacy of this intervention in the management of substance use disorders has not been rigorously demonstrated. Objectives: The purpose of this study is to evaluate changes in clinical status before and after fiduciary assignment. Methods: This was a retrospective chart review of 50 (44 male, 6 female) veterans who were assigned a fiduciary and determined to have a substance use disorder (SUD). SUD-related data including outpatient and inpatient treatment, toxicology testing, and measures of psychosocial functioning for the three years before and after fiduciary assignment were extracted and compared. Results: Veterans were found to have higher rates of any form of employment after fiduciary assignment (Wilcoxon, Signed Ranked S-statistic = 0.22, pr = 0.02). Two changes in measures of substance use were found after fiduciary assignment. There was a reduction in positive screens for heroin (tstatistic = −2.7, p = .01), but an increase in positive screens for fentanyl (t statistic = 2.53, p = .02). There were some potentially clinically but not statistically significant trends in increased adherence with mental health appointments, number of medical hospitalizations, and rates of employment post-fiduciary assignment. Conclusions: Understanding the clinical impact of fiduciary assignment for veteran’s benefits is desirable but still pending at this time.

The Mask of the Warrior: unraveling deep-seated health vulnerabilities in veteran identities.

As service members transition from deployment to civilian life, they are also expected to reintegrate into society. An important part of this process is to "soften up" veteran or warrior identities and open up the self for both existing and new identities, mindsets, and ways of life. Past research has shown that the warrior mindset, in particular, can have negative health implications in the long run. The mindset can be costly, not only for the individual and their loved ones, but also for the healthcare services and other agencies. This article draws from a recent interview study with 24 deployed Swedish veterans suffering from deteriorating mental health without receiving a clinical diagnosis. Purposeful sampling was conducted with the support of the medical staff at the Veterans' Clinic at Uppsala University Hospital. Participants had been screened for posttraumatic stress disorder (PTSD) but had not received a clinical diagnosis. This constitutes a large and understudied patient group in the clinic. The medical staff selected patients based on the following criteria: deteriorating mental health, increased suffering related to PTSD symptoms, and issues related to moral issues, existential concerns, and identity. The sample included veterans from both the Swedish Armed Forces and other deploying agencies. Of the 24 interviewees, 19 were from the Swedish Armed Forces (16 men and three women), and five (four women and one man) were deployed by other agencies. The number of overseas deployments varied widely, with some interviewees having completed 1-2 deployments, while others had completed 3-8. Additionally, some interviewees had interrupted planned or ongoing deployments for various reasons. At the time of the interviews, none were serving full-time in the armed forces; all were veterans. The interviews took place during an intense wave of COVID-19 infections in Sweden in early 2022, so the majority were conducted via videoconference. The participants' veteran identities were abductively analyzed through the mask of secrecy, the stoic mask, and the mask of denial, which are elements of the "Mask of the Warrior." This mask functions to safeguard mission focus, to endure, to execute tasks in extremely stressful situations, and to solve operational tasks during deployments and combat operations. The analysis of the interviews suggests that certain elements in these powerful veteran identities can serve as breeding grounds for suffering later in life. The veterans in the study tended to be stoic about their deteriorating mental health, kept the suffering to themselves, and denied the harmful aspects of their deployments. Thus, the Mask of the Warrior played a counterproductive role for the individual, their friends and family, and life in the aftermath of deployments. Another implication of secrecy and denial occurred on the societal or macro and system levels due to the absence of sufficient insight, knowledge, and understanding of veterans among personnel within the healthcare system and other agencies. This made it difficult for the healthcare system, and other relevant agencies, to offer adequate care and to understand the participants' health issues during sick leave. The perceived absence of societal and organizational rewards and benefits for veterans who risk their mental health and lives during deployment can be seen as a failing implicit work contract. This lack of recognition may lead to the corrosion of character.

VETERAN DIRECTED CARE: A MIXED METHODS STUDY TO INFORM SELF DIRECTED CARE PROGRAM EXPANSION FOR VETERANS AFFAIRS (VA)

Abstract The Department of Veterans Affairs (VA) is shifting from institutional to Home and Community Based Services, such as the Veteran-Directed Care (VDC) program, a self-directed program in which Veterans choose services and employ their providers to avoid or delay long-term institutionalization. The VA plans to expand VDC to all VA facilities by FY2026, but factors affecting VDC expansion are poorly understood. We focused on facilitators and barriers in the seven Veterans Integrated Service Network (VISN) 8 VDC programs between May 2022 and January 2023 to inform program expansion. We used a mixed-methods approach, with surveys followed by semi-structured interviews with VA VDC staff, their partners at Aging and Disability Network Agencies (ADNAs) and VISN 8 leadership, such as lead program coordinators, using the Consolidated Framework for Implementation Research to guide the project rapid analysis techniques. We found substantial variability in the structure, size, and operations of the VDC programs reflecting challenges noted by respondents. VA staff were consistently enthusiastic about VDC’s quality benefits for Veterans, however, they recommended additional staff, a dedicated VDC coordinator, and a national guidebook or standard operating procedures to streamline processes. Respondents also noted the need for more program education targeting referring providers. Unique local challenges, like the lack of available caregivers or no local ADNA, and limited local leadership support were other factors noted that could limit expansion. Importantly, Veterans were often overwhelmed by the employer responsibilities they needed to fulfill. Addressing these concerns remains a challenge to VISN 8 and national leadership.

Racial/Ethnic Disparity for Hematologic Malignancies in Different Healthcare Systems in the U.S

Introduction: Various studies have shown that Black and certain minority patients with hematologic malignancies have worse survival outcomes than White patients in the United States. In the current study, we compared the survival outcomes of Non-Hispanic Black (NHB), Hispanic, and NH Asian/Pacific Islander (API) to Non-Hispanic White (NHW) across different types of hematologic malignancies in multiple different healthcare settings. Methods: We identified adult patients with newly diagnosed lymphoma, myeloma, or leukemia from 2011-2020 in Surveillance, Epidemiology, and End Results Program (SEER), as well as respective cancer registries linked to electronic data warehouses at Veterans Affairs (VA) national healthcare system and Harris Health System (HHS). VA is a unique single-payer system with patients covered by veteran benefits. HHS is a large safety-net county hospital system in the Houston metropolitan area with >80% of uninsured and charity care. These hospital systems were chosen to represent opposite ends of the spectrum of healthcare access; however, we explicitly chose not to compare survival outcomes across institutions due to inherent differences. For each patient cohort, we built unadjusted and adjusted multivariable Cox regression models to assess the impact of race/ethnicity on overall survival. The adjusted factors included age, sex, marital status, rurality, median household income, diagnosis year, cancer histologic subtype, and cancer stage (for lymphoma). Type and time to treatment were not included as these were associated with access to care. In a sensitivity analysis, we also included NCI comorbidity index and ECOG performance status (PS) in VA and HHS (not available in SEER). Results: Patient characteristics from the 3 cohorts are shown in Table 1. SEER patients (n=339,351) were more representative of the US census (71% NHW, 14% Hispanic, 8% NHB, 7% API). In contrast, VA patients (n=27,388) were mostly male (97%) with lower median income ($45,000) and with more NHB (16%); HHS patients (n=2,141) were notably younger (median 53) with lower median income ($47,409) and more Hispanic (57%) and NHB (25%). On unadjusted analysis, significant variables associated with mortality in all cohorts included older age, male sex, lower income, aggressive histology, advanced stage, higher PS, and more comorbidities. Race/ethnicity had variable association with mortality depending on the healthcare setting. On multivariable analysis adjusted for other confounders (Figure 1), race/ethnicity continued to exhibit variable association with overall mortality depending on cancer type and healthcare setting. Across all cancers, minority groups had similar or worse adjusted survivals than NHW in SEER, while they had similar or better adjusted survivals than NHW in VA. With exception of NHB vs. NHW in lymphoma, minority groups had no significant differences than NHW in HHS. Since both VA and HHS were enriched with NHB patients, we next focused on the comparison between NHB vs. NHW. For lymphoma, the adjusted hazard ratio (HR) for mortality was 1.41 (95% CI 1.36-1.45), 1.47 (95% CI 1.04-2.07), and 0.96 (95% CI 0.88-1.04) in SEER, HHS, and VA, respectively. For leukemia, the adjusted HR was 1.07 (95% CI 1.04-1.11), 1.07 (95% CI 0.65-1.75), and 0.95 (95% CI 0.87-1.03) in SEER, HHS, and VA, respectively. For myeloma, the adjusted HR was 0.99 (95% CI 0.95-1.03), 1.00 (95% CI 0.52-1.93), and 0.88 (95% CI 0.80-0.96) in SEER, HHS, and VA, respectively. The other minority groups followed a similar trend. In the sensitivity analysis where ECOG PS and NCI comorbidity index were included for HHS and VA, the overall observations by race/ethnicity were not significantly different. In additional subgroup analyses limited to older patients or males, the overall finding was also not different. Conclusions: In summary, racial/ethnic disparity persists at-large in the US (SEER) for most hematologic malignancies, even after accounting for cancer-, patient-, and socioeconomic factors. However, minority status has neutral or protective effect vs. NHW in healthcare system without barrier to access (VA), while its impact appears similar to the national trend in healthcare system with significant barriers to access due to the lack of insurance (HHS). Healthcare access may contribute to the ongoing racial/ethnic disparity for survival outcomes observed in hematologic malignancies in the US.

Prevalence of amyotrophic lateral sclerosis in the United States, 2018

Objective To estimate prevalent ALS cases in the United States for calendar year 2018. Methods The National ALS Registry (Registry) compiled data from national administrative databases (from the Centers for Medicare and Medicaid Services, the Veterans Health Administration, and the Veterans Benefits Administration) and enrollment data voluntarily submitted through a web portal (www.cdc.gov/als). We used log-linear capture-recapture (CRC) model-based methodology to estimate the number of cases not ascertained by the Registry. Results The Registry identified 21,655 cases of ALS in 2018, with an age-adjusted prevalence of 6.6 per 100,000 U.S. population. When CRC methods were used, an estimated 29,824 cases were identified, for an adjusted prevalence of 9.1 per 100,000 U.S. population. The demographics of cases of ALS did not change from previous year’s reports. ALS continues to impact Whites, males, and persons over 50 years of age more so than other comparison groups. The results from the present report suggest case ascertainment for the Registry has improved, with the estimate of missing prevalent cases decreasing from 44% in 2017 to 27% in in 2018. Discussion Consistent with previous estimates that used CRC, ALS prevalence in the United States is about 29,824 cases per year.

VA social workers identify factors predictive of enrollment and variability in Veterans’ access to aid and attendance benefits

ABSTRACT The Aid and Attendance (A&A) benefit is a cash entitlement for Veterans who served in the U.S. military to obtain personal care services. Our objective was to identify factors contributing to variation in A&A enrollment across VA Medical Centers (VAMCs). We used VA data to calculate the enrollment rate among older Veterans receiving a VA pension or compensation in 2015, then purposefully sampled social work leaders at 15 VAMCs with the highest (n = 7) and lowest (n = 8) enrollment rates for interviews. All respondents viewed A&A as an important benefit. Participants at high-enrollment sites indicated strong working relationships with Veterans Benefits Administration (VBA) and Veterans Service Organizations (VSOs) with onsite presence and education about A&A facilitate access. Participants at low-enrollment sites indicated they desired education around A&A eligibility criteria and collaboration with VBA/VSOs. VA and non-VA social workers would benefit from education about VBA’s benefits, and this requires collaboration with VBA representatives.

Views on and experiences with medicinal cannabis among Canadian veterans who live with pain: A qualitative study

ABSTRACT Background During fiscal year 2021–2022, Veterans Affairs Canada (VAC) reimbursed 18,388 veterans for medicinal cannabis at a cost of $153 million. Yet, it is not known whether the reimbursement program is producing a net benefit for veterans. Aims This study investigated the views and experiences Canadian that veterans who live with pain have about medicinal cannabis use, including its use for the management of chronic pain, poor sleep, and emotional distress. Methods Twelve Canadian veterans who live with pain—eight men, four women; split across four focus groups—were recruited to participate in a semistructured discussion around their experiences with medicinal cannabis use. Results Using inductive thematic analysis, seven broad categories were identified: (1) cannabis use behaviors, (2) reasons for cannabis use, (3) outcomes from cannabis use, (4) facilitators of cannabis use, (5) barriers to cannabis use, (6) stigma around cannabis use, and (7) questions and concerns about cannabis use. Conclusions Most veterans initiated cannabis use to manage the symptoms of preexisting medical and/or mental health conditions. Despite some negative side effects, most veterans reported improvements in their overall quality of life, sleep, relationships, mood, and pain. Concern remains around the discrepancy between veterans’ qualitative reports of beneficial outcomes from medicinal cannabis use and equivocal findings around the benefit-to-harm ratio in the wider literature. Currently, the VAC reimbursement program remains challenged by unclear indication for which veterans, with what condition(s), at what dose, and in what form medical cannabis is most beneficial.