Veterans Administration Facility Research Articles

Disparate Risk Factors Among Pregnant Veterans Using Veterans Administration Health Benefits for Community-Based Obstetrical Care.

Veterans using the Veterans Administration Health Care System (VAHCS) for obstetrical care experience disparate pregnancy-related risks and health outcomes when compared to their pregnant counterparts. This study examined the prevalence of risk factors associated with pregnancy-related comorbidities among U.S. Veterans receiving obstetrical care using VAHCS benefits in Birmingham, Alabama. A retrospective chart review was conducted of pregnant Veterans receiving care at a large Veterans Administration facility from 2018 to 2021. Using one-sample t-tests, the data from the study charts were compared to the Alabama overall prevalence of tobacco and alcohol use, pregnancy-related hypertension/preeclampsia, and gestational diabetes and, when the Alabama data were unavailable, the U.S. national average prevalence of overweight, obesity, pre-pregnancy hypertension, posttraumatic stress disorder, depression, and anxiety among patients receiving obstetrical care. The institutional review board at the Birmingham VAHCS approved the study, with an exemption for human subjects research. The study sample (N = 210) experienced higher levels of obesity (42.3% vs. 24.3%, P < .001), tobacco (21.9% vs. 10.8%, P < .001) and alcohol (19.5% vs. 5.4%, P < .001) use, pre-pregnancy hypertension (10.5% vs. 2.1%, P < .001), posttraumatic stress disorder (33.8% vs. 3.3%, P < .001), anxiety (66.7% vs. 15.2%, P < .001), and depression (66.7% vs. 15.0, P < .001). Fewer patients in the study sample were classified as overweight (16.7% vs. 25.5%, P < .001), developed pregnancy-related hypertension/preeclampsia (7.6% vs. 14.4%, P < .001), or were diagnosed with gestational diabetes (7.1% vs. 10.2%, P < .001). The results did not vary by race or age. The findings highlight the need for further examination of social factors that may be driving disparities among pregnant Veterans, who may benefit from supplemental services to address modifiable comorbidities. Additionally, the implementation of a centralized database to track pregnancy-related outcomes for Veterans would allow these comorbidities to be more closely monitored and addressed. Heightened awareness of a patient's Veteran status and associated increased risks can alert providers to screen for depression and anxiety more frequently and to familiarize themselves with additional services the VAHCS may offer to patients. These steps could improve referrals to counseling and/or targeted exercise interventions.

Senator Elbert Thomas and the Hope for Industrial Equity

Senator Elbert Thomas and the Hope for Industrial Equity

“Love Is Love”: Unitary Caring Science Principles in Veteran’s Illness Narratives of Living With Heart Failure in Stories of the Heart Research Study

Heart failure impacts millions globally, yet relatively little information is available from a holistic, narrative perspective. This research brief used a unitary caring science perspective to explore illness narratives of military veterans with heart failure receiving care from a U.S. Veterans Administration facility. Five veterans were interviewed. Results were analyzed using established narrative methods. Components of unitary caring science that emerged included interconnection, caring, the importance of story, and meaning creation. These findings inform and expand unitary caring science research, expanding this approach to interdisciplinary applications and advancing understanding of the experience of U.S. veterans with heart failure.

Sustainment stories: a qualitative analysis of barriers to sustainment of the National Rural Transitions of Care Nurse Program

BackgroundUnderstanding how to successfully sustain evidence-based care coordination interventions across diverse settings is critical to ensure that patients continue to receive high quality care even after grant funding ends. The Transitions Nurse Program (TNP) is a national intervention in the Veterans Administration (VA) that coordinates care for high risk veterans transitioning from acute care VA medical centers (VAMCs) to home. As part of TNP, a VA facility receives funding for a full-time nurse to implement TNP, however, this funding ends after implementation. In this qualitative study we describe which elements of TNP sites planned to sustain as funding concluded, as well as perceived barriers to sustainment.MethodsTNP was implemented between 2016 and 2020 at eleven VA medical centers. Three years of funding was provided to each site to support hiring of staff, implementation and evaluation of the program. At the conclusion of funding, each site determined if they would sustain components or the entirety of the program. Prior to the end of funding at each site, we conducted midline and exit interviews with Transitions nurses and site champions to assess plans for sustainment and perceived barriers to sustainment. Interviews were analyzed using iterative, team-based inductive deductive content analysis to identify themes related to planned sustainment and perceived barriers to sustainment.ResultsNone of the 11 sites planned to sustain TNP in its original format, though many of the medical centers anticipated offering components of the program, such as follow up calls after discharge to rural areas, documented warm hand off to PACT team, and designating a team member as responsible for patient rural discharge follow up. We identified three themes related to perceived sustainability. These included: 1) Program outcomes that address leadership priorities are necessary for sustainment.; 2) Local perceptions of the need for TNP or redundancy of TNP impacted perceived sustainability; and 3) Lack of leadership buy-in, changing leadership priorities, and leadership turnover are perceived barriers to sustainment.ConclusionsUnderstanding perceived sustainability is critical to continuing high quality care coordination interventions after funding ends. Our findings suggest that sustainment of care coordination interventions requires an in-depth understanding of the facility needs and local leadership priorities, and that building adaptable programs that continually engage key stakeholders is essential.

Do Veterans Need Access to Care Outside Veterans Administration Facilities?

The US Veterans Administration (VA), with 1,255 facilities and 9 million patients, is described as the largest integrated health care network in the United States.1 It has an ambitious mission that includes not just health care but the overall well-being of veterans. The VA employs nearly 6,000 advanced practice nurses,2 including a large contingent of nurse practitioners (NPs) who set standards for clinical practice and policy advances both inside and outside the VA. As of September 2020, NPs in all VA facilities practice without restriction to the full scope of their education and training regardless of any barriers to practice that may still be in effect in the state in which the VA facility is located.

Evaluation of the VA Medical Foster Home Program: Factors Important for Expansion and Sustainability During COVID19

In 2020, the Center of Innovation for Veteran Centered and Value Driven Care (COIN) continued its monitoring and evaluation of the Veterans Administration (VA) Medical Foster Home (MFH) programs expansion into rural areas. Veterans in MFHs are provided 24/7 care by VA trained and supervised community caregivers and primary care by VA Home Based Primary Care (HBPC) teams. One year after the three-year (2017-2019) expansion funds stopped, COIN continued monitoring remaining programs. Objectives were to understand factors critical for program expansion and sustainability and the impact of COVID-19. Phone interviews were conducted with sixteen coordinators from seventeen programs. A thematic analysis approach was used to address the evaluation objectives using transcript data. Findings showed factors important to program sustainability were: 1) Program fit (finding caregivers in the community); and 2) Local VA facility support (staffing, adaptation, and local leadership support). COVID prompted losing some caregivers and prevented others from joining. Program staffing was not impacted as many program activities ceased. Recreational therapists (RTs) were significant to maintaining Veterans well-being and reducing social isolation through virtual activities. COVID required coordinators transition their supervision of MFHs to new virtual environments and HBPC to increase telehealth to new levels. Local leadership became important to monitoring local conditions and providing support to programs. The evaluation: 1) Found factors important to program sustainability were also critical to keeping programs operational during the pandemic; and 2) Stimulated future research on the suitability of MFH programs to meet challenges to resurgences of COVID or other national emergencies.

The Brody School of Medicine at East Carolina University.

The Brody School of Medicine at East Carolina University.

VA Program Allows Vets to Access MH Care in Community

VA Program Allows Vets to Access MH Care in Community

1250 Gastric Intestinal Metaplasia Is a Common Finding Among Veterans Undergoing Endoscopy in South Texas

INTRODUCTION: Gastric intestinal metaplasia (GIM) is a premalignant change of the mucosa of the stomach. Risk factors for intestinal metaplasia previously identified include chronic infection with Helicobacter pylori (HP), dietary factors, smoking, alcohol consumption, and chronic bile reflux. We aim to study the prevalence of GIM and its risk factors in a Texan Veteran population. METHODS: A retrospective chart review was performed among adults undergoing outpatient esophagogastroduodenoscopy (EGD) in 2013 and 2017 at a large Veterans Administration facility in Texas. Patient records were reviewed for demographic information, medication use, smoking and alcohol use, indication for EGD, presence of HP or GIM on gastric biopsies. Studies performed specifically to survey for known GIM were excluded. For patients with presence of GIM, data for type and location on biopsy were recorded. Student's t test was used for quantitative comparisons while the chi-square test or Fisher's exact test was used for qualitative comparisons using R. RESULTS: A total of 860 EGDs were reviewed, of which 340 (39.5%) underwent gastric biopsy. Of those undergoing gastric biopsy, 298 (87.7%) were male with a mean age of 58.0 years (±12.5) and 155 (45.6) were Non-Hispanic Caucasian, 92 (27.1) were Hispanic, and 39 (11.5%) were African-American. A total of 38 (11.2%) patients were found to have GIM. Among patients with GIM, 6 (15.8%) were found to have incomplete GIM. There was no significant difference in mean age among patients with GIM, 61.1 (±13.1) versus those without GIM, 57.6 (±12.4), P = 0.11. The rate of GIM among the non-Hispanic Caucasian population was significantly lower than patients of other ethnicities (7.7% vs. 16.9%, P = 0.02). We did not identify a statistically significant difference between GIM rates among those with HP and those without HP (18.4% vs. 10.3%, P = 0.17). PPI use was associated with lower rates of GIM (8.4% vs. 16.0%, P = 0.03). CONCLUSION: GIM was identified in 1 out of 9 patients in this Veterans cohort in Texas. As previously reported, GIM rates were higher in the Hispanic, African American and Asian patients. Patients taking PPIs were less like to have GIM. HP infection was not associated with GIM in this cohort. Longitudinal data is needed to better understand the risks of gastric cancer and how to risk stratify patients for ongoing surveillance in this diverse population.

Mode of Hysterectomy in the Veterans Administration: Associations With Race/Ethnicity and Clinical Factors [2H

INTRODUCTION: Evidence from the general population suggests that factors such as race/ethnicity and socioeconomic status, in addition to clinical factors, may influence hysterectomy route. We investigated factors associated with mode of hysterectomy in the Veterans Administration (VA). METHODS: We conducted a retrospective cohort study using VA data from 2008-2014 to identify women undergoing hysterectomy for benign indications. The outcome was hysterectomy mode [laparoscopic (total laparoscopic, laparoscopic-assisted vaginal, and robotic), vaginal, or abdominal], classified by ICD-9 codes. We used modified Poisson regression to estimate associations of demographic and clinic factors with hysterectomy mode including age, race/ethnicity, income, body mass index (BMI), indication (fibroids, endometriosis, prolapse), medical and mental health conditions, and where the procedure was performed (VA versus non-VA facility). RESULTS: Among 7844 identified hysterectomies, 58% were abdominal, 25% laparoscopic, and 17% vaginal. In adjusted models, compared to Whites, Blacks had 36% lower risk of having a laparoscopic versus abdominal hysterectomy (RR:0.64, 95%CI 0.16-0.51) and 44% lower risk of having vaginal versus abdominal hysterectomy (RR:0.56, 95%CI 0.28-0.56). Hispanics were equally likely to have laparoscopic versus abdominal hysterectomy compared to Whites, but had lower risk of vaginal versus abdominal hysterectomy (RR:0.62, 95%CI 0.10-0.58). Women with fibroids and BMI &gt;30 were less likely to undergo laparoscopic or vaginal versus abdominal hysterectomy, whereas women with endometriosis were more likely to undergo laparoscopic versus abdominal hysterectomy. CONCLUSION: In addition to indication for surgery and BMI, race/ethnicity is independently associated with benign hysterectomy mode in VA. Further study is needed to explore the underlying causes of this apparent disparity.

Abstract WP320: Uncertainty: A Key Influence in the Decision to Admit Patients With Transient Ischemic Attack

Introduction: Hospitalization of TIA patients has been shown to improve the timeliness and quality of TIA care yet admission rates for patients presenting with TIA vary considerably across centers. Methods: We sought to identify patient and system level factors linked to the decision to admit a patient with TIA. Trained interviewers conducted face-to-face semi-structured interviews with staff involved in TIA care at diverse Veterans Administration (VA) sites. All transcripts were de-identified and imported into a single NVivo10 project file for data coding and analysis. Results: 70 audiotaped interviews of multidisciplinary clinical staff took place at 14 Veterans Administration Medical Centers (VAMCs). We identified emergent themes and patterns in providers’ decision making. Uncertainty was a key theme in factors that staff reported as an influence in providers’ decisions to admit including: lack of guidance at sites without a facility TIA-specific policy, diagnostic uncertainty related to the TIA event (versus stroke or stroke mimic), general lack of confidence in the ability to complete a timely workup, and specific concerns about patients living a long distance from a VAMC or lacking a support system. Overall, the ABCD 2 score was reported by participants not as a rationale for decisions to admit, but rather for decisions not to admit. Other reported factors related to the decision not to admit included: longer period of time since symptom onset, lack of symptoms, confidence in the ability to get a timely workup as an outpatient, recent evaluation for a prior TIA or stroke event, close proximity of the patient’s residence to a VA facility, strong patient support at home, currently maximized medical management, and availability of observation beds. Conclusions: Issues related to uncertainty were reported as key factors in clinical decisions concerning admittance of patients presenting with TIA. Quality improvement interventions for TIA care may need to take into consideration how factors like uncertainty relate to the TIA admission decision-making process.

Acceptability of Medication and Nonmedication Treatment for Insomnia Among Female Veterans: Effects of Age, Insomnia Severity, and Psychiatric Symptoms

PurposeFemale veterans are at high risk for sleep problems, and there is a need to provide effective treatment for this population who experience insomnia. This study’s primary goal was to compare the acceptability of medication versus nonmedication treatments for insomnia among female veterans. In addition, we examined the role of patient age, severity of sleep disturbance, and psychiatric symptoms on acceptability of each treatment approach and on the differences in acceptability between these approaches. MethodsA large nationwide postal survey was sent to a random sample of 4000 female veterans who had received health care at a Veterans Administration (VA) facility in the previous 6 months (May 29, 2012–November 28, 2012). A total of 1559 completed surveys were returned. Survey items used for the current analyses included: demographic characteristics, sleep quality, psychiatric symptoms, military service experience, and acceptability of medication and nonmedication treatments for insomnia. For analysis, only ratings of “very acceptable” were used to indicate an interest in the treatment approach (vs ratings of “not at all acceptable,” “a little acceptable,” “somewhat acceptable,” and “no opinion/don׳t know”). FindingsIn the final sample of 1538 women with complete data, 57.7% rated nonmedication treatment as very acceptable while only 33.5% rated medication treatment as very acceptable. This difference was statistically significant for the group as a whole and when examining subgroups of patients based on age, sleep quality, psychiatric symptoms, and military experience. The percentage of respondents rating medication treatment as very acceptable was higher for women who were younger, had more severe sleep disturbances, had more psychiatric symptoms, who were not combat exposed, and who had experienced military sexual trauma. By contrast, the percentage of respondents rating nonmedication treatment as very acceptable differed only by age (younger women were more likely to find nonmedication treatment acceptable) and difficulty falling asleep. ImplicationsFemale veterans are more likely to find nonmedication insomnia treatment acceptable compared with medication treatment. Thus, it is important to match these patients with effective behavioral interventions such as cognitive behavioral therapy for insomnia. Efforts to educate providers about these preferences and about the efficacy of cognitive behavioral therapy for insomnia may serve to connect female veterans who have insomnia to the treatment they prefer. These findings also suggest that older female veterans may be less likely to find either approach as acceptable as their younger counterparts.

Risk and Predictors of Variceal Bleeding in Cirrhosis Patients Receiving Primary Prophylaxis With Non-Selective Beta-Blockers.

Prior studies have demonstrated the efficacy of non-selective beta-blockers (NSBB) in preventing first variceal bleeding in patients with cirrhosis. However, little is known about the overall effectiveness of NSBB in routine clinical care. We conducted a retrospective cohort study of cirrhotic patients without prior bleeding who initiated a NSBB (propranolol, nadolol) at any Veterans Administration facility between 2008 and 2013. The primary outcome was variceal bleeding within 12 months. We conducted Cox-proportional hazards analyses to identify demographic, clinical, and NSBB-related (type of NSBB, mean dose, dose change, and heart rate response) factors associated with variceal bleeding. Of 5,775 patients, 678 (11.7%) developed variceal bleeding. Mean daily dose of NSBB was <40 mg in 58.8%, 18.1% had either upward or downward titration in NSBB dose, and 9.8% had hemodynamic response. Patients who were younger, with ascites, greater medical comorbidity, and higher MELD (Model for end-stage liver disease) scores had a higher risk of variceal bleeding. Patients on a higher daily dose (>60 vs. <40 mg, adjusted hazard ratio (HR) 0.64; 95% confidence interval (CI): 0.51-0.81), who had either upward or downward dose titration (adjusted HR 0.69; 95% CI: 0.52-0.90 and 0.64; 95% CI 0.45-0.90, respectively), and those who achieved hemodynamic response (adjusted HR 0.75; 95% CI=0.57-1.0) had lower risk. Approximately 12% of patients bled while being on NSBB for primary prophylaxis. A higher NSBB dose and dose titration were protective; yet most patients did not have the NSBB dose titrated to the recommended levels. Our data highlight the need for careful monitoring of cirrhotic patients on NSBB.

Social Support and Adherence for Military Veterans With Hepatitis C

The aim of this study was to describe military veterans' experiences of support and how those experiences influence their decisions to be adherent, during hepatitis C virus (HCV) treatment. A qualitative phenomenological design was used. Inclusion criteria were veterans 18 years or older, receiving standard treatment for HCV, able to read, write, and communicate in English. A US Veterans Administration facility in Texas. Convenience sampling was used to obtain a final sample of 21 veterans. Data collection consisted of 1-time, in-depth interviews with analysis occurring simultaneously. Follow-up phone calls with participants verified that the themes were accurate reflections of their lived experience. Because of the fear of stigma, veterans make choices about to whom they tell their diagnosis. This limits the circle of friends and coworkers who could provide support. For some veterans, family members provide emotional and practical support, but family can also be a burden. In order to cope with family and treatment demands, some veterans hibernate, whereas others socialize with friends and coworkers. Some veterans found providers to be supportive, but others did not. Veterans experience both supportive and unsupportive reactions from family, friends, and healthcare providers while receiving HCV treatment. Those reactions either support or frustrate efforts to be adherent to treatment. In order to support treatment adherence, healthcare providers need to assess sources of support, or burden, experienced by military veterans during HCV treatment. When veterans do not have a supportive network, they need to be encouraged to attend a support group or seek counseling. Support services need to be funded by the Veterans Administration. Providers need to practice empathy and caring in order to support adherence during treatment. Further research is needed on how military veterans manage their health after hepatitis C treatment, contrasting successful versus unsuccessful treatment outcomes.

Statins Are Underutilized in Patients with Nonalcoholic Fatty Liver Disease and Dyslipidemia.

Cardiovascular disease provides the greatest mortality risk in patients with nonalcoholic fatty liver disease (NAFLD). Clinical practice guidelines recommend statins to treat dyslipidemia in patients with NAFLD; however, the extent to which such patients receive statins has not been studied. We conducted a structured medical record review to assess for appropriate statin use in patients in a Veterans Administration facility with dyslipidemia and NAFLD as well as a parallel cohort without NAFLD. Appropriate statin use was defined as receipt of statins without a clinically significant, unjustified dose change during the study period. Of 255 patients with NAFLD and dyslipidemia, 152 (59.6%) patients received appropriate statin care. Primary care providers (PCPs) recognized the presence of NAFLD in 106 patients (41.6%). Among the 63 of 106 (59.4%) patients who were on a statin at the time of detection, 24 (38.1%) received a clinically significant dose reduction or discontinuation. Patients whose PCPs recognized the presence of NAFLD (adjusted OR=0.34, 95% CI=0.18-0.64) were less likely to receive appropriate statin care than patients with undetected NAFLD. Also, patients with detected NAFLD were less likely than dyslipidemic patients without NAFLD to receive appropriate statin care (OR=0.45, 95% CI=0.25-0.79). Statins are underused in patients with NAFLD and dyslipidemia. The most important determinant for inappropriate statin use was PCP recognition of NAFLD. While these results need to be confirmed in non-VA healthcare systems, they highlight the need for efforts to enhance PCP knowledge of existing guidelines regarding statin use in NAFLD.

The Veterans Choice Act and Dual Health System Use.

T he Veterans Access, Choice and Accountability Act (Choice Act), formally enacted on August 7, 2014, arose largely in response to outrage about delays in veteran access to health care and falsification of wait time records by Veterans Administration (VA) employees. The law includes a number of provisions to improve care for veterans, including increasing health care staffing and residency training positions, streamlining employee disciplinary procedures, improving treatment of military sexual trauma, and establishing a Presidential Commission on Care to evaluate access to VA health care. The most well-known, and perhaps controversial, provision is the Choice Program, which established a mechanism for eligible veterans to receive care outside the VA for 3 years. Veterans unable to schedule an appointment within 30 days of their preferred date or who live more than 40 miles from a VA facility are now eligible to receive care from non-VA providers. However, many of these veterans will also continue to use VA facilities and services, and this ‘dual use’ of health care systems may lead to care fragmentation and its ensuing adverse consequences. This commentary describes the problems of dual use and care fragmentation, the complexity of the Choice Program, and some ideas for ensuring its safe and effective implementation. The challenges surrounding the implementation of the Choice Program have been monumental. In the 90 days between passage of the law and the start of the program on November 5, 2014, the VA developed a system for identifying and reaching out to eligible veterans, tracking Choice Program visits, and paying for services through the program. As of April 2015, the VA had coordinated more than 45,000 Choice Program medical appointments and dispensed more than 3,200 Choice prescriptions. However, this implementation has received tremendous public criticism because of the relatively low uptake of services compared to the perceived need for immediate care. In response, in May of 2015, the U.S. Senate unanimously voted to amend the Choice Act, expanding access to veterans living within 40 miles of a VA facility if it does not offer them the needed medical care. The measure, however, has not passed the U.S. House of Representatives. The Choice Program is not the first time that an expansion of non-VA care for veterans has increased the complexity or fragmentation of care. In 2006, the rollout of Medicare Part D prescription drug coverage gave millions of VA patients the opportunity to obtain prescription drugs through the private health care system. Despite almost 10 years having elapsed since Part D’s implementation, however, and the concerns related to dual use, there are limited data on its impact on care fragmentation among veterans. In 2014, the Affordable Care Act (ACA) again expanded access for veterans to non-VA care through both the private insurance marketplace and Medicaid. Similar concerns have been raised about increased care fragmentation with dual use as a consequence of the ACA, although the full impact will not be known for some time. Even before these insurance expansions, veterans with Medicare coverage were known to receive care through both Medicare and VA. Prior work has documented convincing evidence that dual use of Medicare and VA services comes with inherent risks of care fragmentation and duplication of services, including, for example, higher rates of hospitalization for ambulatory care-sensitive conditions, higher cost and worse outcomes in cancer, and higher rates of rehospitalization. 4 Despite the best efforts, care received outside the VA cannot be seamlessly integrated into the sophisticated electronic medical record (EMR) and decision support systems that unify the VA. Physicians outside the VA do not have access to the VA’s EMR and ordering systems, leading to risks of duplication of services, errors, and inefficient care. These risks of care fragmentation with dual use extend to the Choice Program, especially given its complexity. As an example, consider how prescription drugs are dispensed through Choice. Under the Program, non-VA providers must prescribe within the same formulary rules that guide VA providers. Choice providers do not have access to the electronic ordering with decision support that helps VA providers prescribe within formulary guidelines. In 2003, when VA temporarily implemented the Transitional Pharmacy Benefit for patients waiting more than 30 days for their initial primary care appointment, roughly 40% of prescriptions received from non-VA providers were non-formulary, substantially increasing the workload and costs for VA pharmacy. Each Choice prescription must be faxed, mailed, or delivered in person to a VA facility to be processed; verbal and telephone prescriptions Published online August 20, 2015

Nonalcoholic fatty liver disease is underrecognized in the primary care setting.

The prevalence and disease burden of nonalcoholic fatty liver disease (NAFLD) are increasing. Nonetheless, little is known about the processes related to identification, diagnosis, and referral of patients with NAFLD in routine clinical care. Using automated data, we isolated a random sample of patients in a Veterans Administration facility who had ≥2 alanine transaminase (ALT) values >40 IU/ml >6 months apart in the absence of any positive results for hepatitis C RNA, hepatitis B surface antigen, or screens for excess alcohol use. We conducted a structured medical record review to confirm NAFLD and abstracted data from the primary care providers' notes for (i) recognition of abnormal ALT levels, (ii) mention of NAFLD as a possible diagnosis, (iii) recommendations for diet or exercise, and (d) referral to a specialist for further NAFLD evaluation. Using a multilevel logistic regression model, we identified patient demographic, clinical, comorbidity, and health-care utilization factors associated with recognition and receipt of early NAFLD care. Of 251 patients identified with NAFLD by our methods, 99 (39.4%) had documentation in medical record notes of abnormal ALT, 54 (21.5%) had NAFLD mentioned as a possible diagnosis, 37 (14.7%) were counseled regarding diet and exercise, and 26 (10.4%) were referred to a specialist. Only the magnitude of ALT elevation (adjusted odds ratio (OR) for ALT >80 IU/ml vs. <80 IU/ml=4.4, 95% confidence interval (CI)=2.65-7.30) and proportion of elevation (adjusted OR for >50% vs. <50% of ALT values >40 IU/ml=1.8, 95% CI=1.03-3.14) were associated with receiving specified NAFLD care. Only 3% of patients at a high risk of fibrosis (NAFLD fibrosis score >0.675) were referred to specialists. Most patients in care who may have NAFLD are not being recognized and evaluated for this condition. Our data suggest that providers may be using an incorrect heuristic in delivering NAFLD care by concentrating on those with high ALT levels.

Associations of mental illness and substance use disorders with prescription contraception use among women veterans

ObjectiveTo investigate whether mental illness and substance use disorder (SUD) are associated with having a prescription contraceptive method among women veterans. Study designWe conducted a retrospective analysis of National Veterans Administration (VA) administrative and clinical data for women veterans aged 18–45 years who made at least one primary care visit in 2008. We assessed associations between mental illness (depression, posttraumatic stress disorder, anxiety, bipolar disorder, schizophrenia and adjustment disorder) and SUD (drug/alcohol use disorder) with having a prescription contraceptive method from VA (pill, patch, ring, injection, implant and intrauterine device) using multivariable logistic regression with random effects for VA facility, adjusting for confounders. ResultsAmong 94,115 reproductive aged women, 36.5% had mental illness only, 0.6% had SUD only, 5.3% had both mental illness and SUD and 57.7% had neither diagnosis. In these groups, 22.1%, 14.6%, 18.2% and 17.7% (p<0.001), respectively, had documentation in 2008 of prescription contraception. After adjusting for potential confounders, women with mental illness only were as likely as women with neither diagnosis to have a prescription method and were more likely to use a highly effective prescription method (implant or intrauterine device) if using contraception [adjusted odds ratio (aOR) 1.17, 95% confidence interval (CI) = 1.08–1.27]. Women with SUD (with or without mental illness) were significantly less likely to have a prescription method than women with neither diagnosis (aOR 0.73, 95% CI = 0.57–0.95 and aOR 0.79, 95% CI = 0.73–0.86, respectively). ConclusionWomen veterans with SUD are less likely to have prescription contraception compared to other women, which may increase their risk of unintended pregnancy.

She Sought Volunteer Clinicians, and Hundreds Answered the Call

Psychiatrists are needed to donate their time and skills to help soldiers piece their lives back together upon returning to the United States from Iraq and Afghanistan.

A Pilot Test of Videoconferencing to Improve Access to a Stroke Risk-Reduction Programme for Veterans

We conducted a pilot study to determine the feasibility of using videoconferencing for a programme of self-management to prevent stroke (V-STOP). A total of 37 Veterans with a history of stroke, or with multiple risk factors for stroke, were enrolled in the study from two rural sites. The V-STOP intervention consisted of 6 weekly sessions of self-management classes and clinic visits delivered via videoconferencing, with one or two individual telephone counselling sessions. Participants’ mean satisfaction scores were 4.7 out of 5, indicating very high approval of the programme. Attendance was 87%, almost twice as high as at an equivalent in-person programme. Access was improved as participants saved, on average, 160 km by travelling to a community centre instead of the main Veterans Administration facility. Stroke risk knowledge and self-management behaviours such as communication with healthcare providers significantly improved from baseline. Overall, videoconferencing is feasible for delivering self-management classes and clinic visits and the V-STOP programme shows promise as a method for delivery of self-management education and preventive care services to reduce stroke risk.