Veterans Administration Health Care System Research Articles

Clinician and Patient Perspectives on the Use of Passive Mobile Monitoring and Self-Tracking for Patients With Serious Mental Illness: User-Centered Approach.

Early intervention in mental health crises can prevent negative outcomes. A promising new direction is remote mental health monitoring using smartphone technology to passively collect data from individuals to rapidly detect the worsening of serious mental illness (SMI). This technology may benefit patients with SMI, but little is known about health IT acceptability among this population or their mental health clinicians. We used the Health Information Technology Acceptability Model to analyze the acceptability and usability of passive mobile monitoring and self-tracking among patients with serious mental illness and their mental health clinicians. Data collection took place between December 2020 and June 2021 in 1 Veterans Administration health care system. Interviews with mental health clinicians (n=16) assessed the acceptability of mobile sensing, its usefulness as a tool to improve clinical assessment and care, and recommendations for program refinements. Focus groups with patients with SMI (n=3 groups) and individual usability tests (n=8) elucidated patient attitudes about engaging in health IT and perceptions of its usefulness as a tool for self-tracking and improving mental health assessments. Clinicians discussed the utility of web-based data dashboards to monitor patients with SMI health behaviors and receiving alerts about their worsening health. Potential benefits included improving clinical care, capturing behaviors patients do not self-report, watching trends, and receiving alerts. Clinicians' concerns included increased workloads tied to dashboard data review, lack of experience using health IT in clinical care, and how SMI patients' associated paranoia and financial instability would impact patient uptake. Despite concerns, all mental health clinicians stated that they would recommend it. Almost all patients with SMI were receptive to using smartphone dashboards for self-monitoring and having behavioral change alerts sent to their mental health clinicians. They found the mobile app easy to navigate and dashboards easy to find and understand. Patient concerns centered on privacy and "government tracking," and their phone's battery life and data plans. Despite concerns, most reported that they would use it. Many people with SMI would like to have mobile informatics tools that can support their illness and recovery. Similar to other populations (eg, older adults, people experiencing homelessness) this population presents challenges to adoption and implementation. Health care organizations will need to provide resources to address these and support successful illness management. Clinicians are supportive of technological approaches, with adapting informatics data into their workflow as the primary challenge. Despite clear challenges, technological developments are increasingly designed to be acceptable to patients. The research development-clinical deployment gap must be addressed by health care systems, similar to computerized cognitive training. It will ensure clinicians operate at the top of their skill set and are not overwhelmed by administrative tasks, data summarization, or reviewing data that do not indicate a need for intervention. RR2-10.2196/39010.

Procedure Mix and Regional Variation in Vascular Community Care Referrals in the Veterans Administration Health Care System

Procedure Mix and Regional Variation in Vascular Community Care Referrals in the Veterans Administration Health Care System

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.

Supervising and supporting trainees with disabilities in the Veterans Administration Healthcare System: An overlooked but critical need and opportunity.

Trainees with disabilities are chronically underrepresented in psychology and face many barriers throughout their training. Directors of Clinical Training and supervisors within the Veterans Administration Healthcare System (VAHCS), one of the largest employers of trainees with disabilities, have a unique opportunity to address this area of critical need. However, they must first understand the barriers facing psychology trainees with disabilities in VAHCS settings, including discrimination in trainee selection, barriers to obtaining reasonable accommodations, and attitudinal and cultural barriers. In this article, we illustrate how those barriers may present in VAHCS settings specifically and provide suggestions and frameworks for how the VAHCS can create accessible, disability-affirmative training environments in which trainees can truly thrive. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Frailty predicts referral for elder abuse evaluation in a nationwide healthcare system-Results from a case-control study.

Elder abuse (EA) is common and has devastating health impacts. Frailty may increase susceptibility to and consequences of EA for older adults, making healthcare system detection more likely, but this relationship has been difficult to study. We examined the association between a recently validated frailty index and referral to social work (SW) for EA evaluation in the Veterans Administration (VA) healthcare system. We conducted a case-control study of veterans aged ≥60 years evaluated by SW for suspected EA between 2010 and 2018 (n=14,723) and controls receiving VA primary care services in the same 60-day window (n=58,369). We used VA and Medicare claims data to measure frailty (VA Frailty Index) and comorbidity burden (the Elixhauser Comorbidity Index) in the 2 years prior to the index. We used adjusted logistic regression models to examine the association of frailty or comorbidity burden with referral to SW for EA evaluation. We used Akaike Information Criterion (AIC) values to evaluate model fit and likelihood ratio (LR) tests to assess the statistical significance of including frailty and comorbidity in the same model. The sample (n=73,092) had a mean age 72 years; 14% were Black, and 6% were Hispanic. More cases (67%) than controls (36%) were frail. LR tests comparing the nested models were highly significant (p < 0.001), and AIC values indicated superior model fit when including both frailty and comorbidity in the same model. In a model adjusting for comorbidity and all covariates, pre-frailty (aOR vs. robust 1.7; 95% CI 1.5-1.8) and frailty (aOR vs. robust 3.6; 95% CI 3.3-3.9) were independently associated with referral for EA evaluation. A claims-based measure of frailty predicted referral to SW for EA evaluation in a national healthcare system, independent of comorbidity burden. Electronic health record measures of frailty may facilitate EA risk assessment and detection for this important but under-recognized phenomenon.

Evaluation of a mindfulness and self-compassion-based psychotherapy incorporating horses for Veterans who have experienced trauma

ObjectivesThe primary aim of this pilot study was to assess the safety, feasibility, acceptability, as well as preliminary outcomes of a mindfulness and self-compassion-based psychotherapy incorporating horses (PIH) intervention, Whispers with Horses, for Veterans who had experienced trauma. Whispers with Horses was developed as a structured intervention that could be easily replicated for additional studies. If shown to be effective by future rigorous research, the aim is to disseminate a manualized version of the intervention to the field. DesignProspective open trial. SettingA large Veterans Administration healthcare system and local equine facilities. InterventionA six-session PIH intervention that focused on participants developing or enhancing mindfulness and self-compassion skills in the context of an emerging horse-human relationship. Main outcome measuresSafety, feasibility and acceptability were assessed, and psychological instruments were administered. Instruments utilized were the PTSD Checklist for DSM 5 (PCL-V), the Patient Health Questionnaire 9 (PHQ-9), the Positive and Negative Affect Scale (PANAS), the Acceptance and Action Questionnaire II (AAQ-II), and the Physical Activity Enjoyment Scale (PACES). ResultsSubjects were 33 Veterans who were 52% male with a mean age of 46 years-old. There were no adverse outcomes to participants indicating the intervention was safe. Participants completed an average of 3.8 sessions with 24% completing all sessions indicating the intervention is feasible to use, and acceptable to, the population studied. The mean PACES score for all sessions together was 110.4, indicating subjects generally enjoyed participation. Preliminary outcome assessments revealed pre- to post-session significant improvements in affect and psychological flexibility for some sessions (p ranging from.001 −0.015). Pre- to post-intervention outcomes indicated significant improvements in depression (p = .003) and psychological flexibility (p = .005). ConclusionsThe Whispers with Horses intervention shows promise as a PIH for Veterans who have experienced trauma. More rigorous studies of this intervention are warranted. Also, additional investigations aimed at better understanding mechanisms underlying changes in psychological flexibility are justified.

A pilot observational study of horsemanship skills training for veterans with posttraumatic stress disorder

ObjectivesPilot assessment of an equine-assisted services intervention for Veterans with posttraumatic stress disorder. DesignProspective cohort. SettingA large Veterans Administration healthcare system. InterventionTwo sessions of instruction in horsemanship skills and two sessions of trail rides. Main outcome measuresSafety and feasibility of recruitment, retention, providing the intervention, and measuring outcomes, as well as acceptability of the intervention to the population studied were the main outcome measures. ResultsThere were no injuries among the 18 participants, 6 staff, or 11 equines over the 3 months of the study. Eleven of 12 (92 %) planned intervention sessions were provided, with one being canceled due to weather. Out of approximately 1800 potential subjects, 21 were enrolled within three months and three dropped out before the first session. The mean number of sessions attended was 3 % and 52 % of participants completed all sessions. The mean PACES score for all sessions together was 109 (SD = 12), with a range of 50–126. Pre- to one-month post-intervention exploratory results indicated increased psychological flexibility (p = 0.008) and positive affect (p = 0.008) as measured by the Acceptance and Action Questionnaire II and the Positive and Negative Affect Scale, respectively as well as decreased PTSD (p = 0.001) and depressive symptoms (p = 0.017) as measured by the PTSD Checklist for DSM 5 and the Beck Depression Inventory, respectively. ConclusionsResults suggest the intervention can be conducted with minimal risk. Further, it was feasible to recruit participants as well as provide the intervention and measure exploratory outcomes. Session attendance and PACES scores indicate acceptability to the Veteran population. The exploratory results will provide sample size estimates for future randomized controlled studies of this intervention Future studies should plan for missed sessions due to weather and consider compensating subjects to enhance retention. Finally, this work provides preliminary evidence that this intervention, without a mental health treatment component, might benefit the mental health of Veterans with PTSD.

Use of the consolidated framework for implementation research in a mixed methods evaluation of the EQUIPPED medication safety program in four academic health system emergency departments.

Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) is an effective quality improvement program initially designed in the Veterans Administration (VA) health care system to reduce potentially inappropriate medication prescribing for adults aged 65 years and older. This study examined factors that influence implementation of EQUIPPED in EDs from four distinct, non-VA academic health systems using a convergent mixed methods design that operationalized the Consolidated Framework for Implementation Research (CFIR). Fidelity of delivery served as the primary implementation outcome. Four EDs implemented EQUIPPED sequentially from 2017 to 2021. Using program records, we scored each ED on a 12-point fidelity index calculated by adding the scores (1-3) for each of four components of the EQUIPPED program: provider receipt of didactic education, one-on-one academic detailing, monthly provider feedback reports, and use of order sets. We comparatively analyzed qualitative data from focus groups with each of the four implementation teams (n = 22) and data from CFIR-based surveys of ED providers (108/234, response rate of 46.2%) to identify CFIR constructs that distinguished EDs with higher vs. lower levels of implementation. Overall, three sites demonstrated higher levels of implementation (scoring 8-9 of 12) and one ED exhibited a lower level (scoring 5 of 12). Two constructs distinguished between levels of implementation as measured through both quantitative and qualitative approaches: patient needs and resources, and organizational culture. Implementation climate distinguished level of implementation in the qualitative analysis only. Networks and communication, and leadership engagement distinguished level of implementation in the quantitative analysis only. Using CFIR, we demonstrate how a range of factors influence a critical implementation outcome and build an evidence-based approach on how to prime an organizational setting, such as an academic health system ED, for successful implementation. This study provides insights into implementation of evidence-informed programs targeting medication safety in ED settings and serves as a potential model for how to integrate theory-based qualitative and quantitative methods in implementation studies.

Editorial introductions.

Current Opinion in Gastroenterology was launched in 1985. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of gastroenterology is divided into 12 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Jocelyn A. SilvesterJocelyn A. SilvesterDr Jocelyn A. Silvester, MD PhD, is Assistant Professor of Pediatrics at Harvard Medical School, USA, and Director of Research for the Celiac Disease Program at Children's Hospital (BCH) in Boston, Massachusetts, USA. She also maintains a general pediatrics practice in Northern Manitoba and Nunavut through the Ongomiizwin Health Services JA Hildes Northern Medical Unit. Dr Silvester completed her PhD in Biology at the University of Cambridge in England, UK, where she studied mitochondrial ATP synthase under the supervision of Professor Sir John E. Walker. She earned her medical degree from Dalhousie University in Canada and completed her residency in general pediatrics at the University of Manitoba, Canada. She came to the United States for pediatric gastroenterology fellowship training at Boston Children's Hospital. Dr Silvester is co-Chair of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) Celiac Disease Special Interest Group and serves on the American Gastroenterological Association Council for section for basic and clinical intestinal disorders. Her research interests include the diagnosis and management of celiac disease with a particular interest in what happens after the diagnosis of celiac disease is made. She is co-Investigator on the Manitoba Celiac Disease Cohort Study, involved in clinical trials for alternative therapies to a gluten-free diet and is leading a consortium of pediatric celiac centers across the United States to develop tools to improve follow-up care. Tilak U. ShahTilak U. ShahDr Shah is an Associate Professor of Medicine at Virginia Commonwealth University (VCU) Health Science Center, USA, as well as Director of Endoscopy and Interventional Endoscopy at the Central Virginia VA Healthcare system in Richmond, VA, USA. He serves as Associate GI Fellowship Program Director at VCU, and is a member of the Development and Therapeutics section of VCU Massey Cancer Center. Dr Shah graduated from the University of North Carolina (UNC) at Chapel Hill, USA, in 1997, and UNC School of Medicine in 2006. He completed internal medicine residency and fellowship training in gastroenterology at Duke University Medical Center, USA. Dr Shah also obtained a master's degree in clinical research from the Duke-NIH Clinical Research Training Program, and underwent formal training in Advanced Endoscopy at Emory University Medical Center, USA. He joined the medical faculty at Virginia Commonwealth University in 2014. Dr Shah has served on American College of Gastroenterology (ACG), American Society of Gastrointestinal Endoscopy (ASGE), and Veterans Administration (VA) Committees. He has served as a reviewer for several journals including American Journal of Gastroenterology, Clinical Gastroenterology and Hepatology, Digestive Diseases and Sciences, World Journal of Gastroenterology, and Cochrane Database of Systematic reviews, and is section editor for Current Opinion in Gastroenterology. Dr Shah's research interests involve endoscopic approaches to diagnose and treat esophageal and colorectal neoplasia, including advanced imaging, artificial intelligence, endoscopic resection, and cryotherapy. Dr Shah is the recipient of research awards from the ASGE and McGuire Research Institute, and is site investigator for VA Co-Operative and Merit studies. He is an author on over 30 original papers, and has authored two board preparation textbooks, “NMS Medicine Casebook,” and “Acing the Pancreaticobiliary Questions on the GI Boards.”

Inpatient Quality-of-Care Measures for Heart Failure: Treatment Gaps and Opportunities in the Contemporary Era.

Quality of care measures are vital tools to assess processes of care within and between health care systems. The 2020 American College of Cardiology/AHA performance measures for heart failure provide a new set of such measures. We evaluated the achievement of these and other performance measures within the Veterans Affairs hospital system in a contemporary cohort of patients hospitalized for heart failure. Hospital discharges from January 2010 to February 2021 with a primary diagnosis of heart failure (n=289 810) were evaluated. Adherence to each measure was determined using the measure's stated definition and by site. Among patients with reduced ejection fraction (53.0%), beta blocker use was high (89.0%), ACE (angiotensin-converting enzyme) inhibitor, angiotensin receptor blocker, or angiotensin receptor-neprilysin inhibitor (ARNI) use decreased over time (75.3% in 2010, 55.8% in 2020), and hydralazine/nitrate use in eligible Black patients (19.3%) was low. While 68.1% were eligible for ARNI, only 6.0% received them, reaching 17.2% by 2020. Mineralocorticoid receptor antagonists were used in 49.3% of those eligible; laboratory testing 7 days after their initiation was 73.0%, detecting hyperkalemia in 2.2%, although it occurred in 13.7% by 90 days. Achievement of ≥50% target dose was low (beta blocker 45.9%, ACE inhibitor/angiotensin receptor blocker 31.6%, ARNI 19.0%) and for ACE inhibitor/angiotensin receptor blocker/ARNI, decreased over time. Discharge appointments were 56.2% at 7 days and 78.8% at 14 days. Cardiac rehabilitation referral was low (10.5%) but increased. There were significant site-level differences, particularly for hydralazine, ARNI, devices, and cardiac rehabilitation. Important inpatient quality of care measures can be readily measured across the Veterans Administration health care system from electronic health records. Treatment gaps and site-level differences persisted into the contemporary era and will likely be exacerbated as newer treatments are added to this complex baseline. These measures and methods also offer the opportunity to target global, local, and individual processes of care for innovative quality improvement initiatives.

Novel case of Candida auris in the Veterans Health Administration and in the state of South Carolina

The emerging pathogen Candida auris poses major infection prevention challenges as the organism can remain on surfaces for unknown timeframes and can cause severe illness. These challenges are exacerbated in the healthcare environment with potential spread to a vulnerable population. This report describes the Columbia Veterans Administration Health Care System's encounter with this significant pathogen beginning in October 2020 during the COVID19 pandemic.

Iso-osmolar versus low-osmolar contrast media and outcomes after percutaneous coronary intervention: Insights from the VA CART Program.

To assess whether contrast media type is associated with outcomes in veterans undergoing percutaneous coronary intervention (PCI). There is uncertainty about the impact of iso-osmolar contrast medium (IOCM) versus low-osmolar contrast medium (LOCM) on acute kidney injury (AKI) and other major adverse renal or cardiovascular events (MARCE) after PCI. We assessed the association between contrast media type and MARCE in patients who underwent PCI within the Veterans Administration Healthcare System. We reviewed PCIs performed between 2009 and 2019 using data from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. The primary endpoint was MARCE, a composite of myocardial infarction, stroke, all-cause death, AKI, and dialysis onset at 30 days. The analysis cohort consisted of 50,389 patients of whom 25,555 received LOCM and 24,834 received IOCM. There was significant variation in contrast type across sites. After adjustment for comorbidities, no significant association between contrast media type and MARCE was observed in both site-unadjusted (odds ratio [OR] for IOCM: 0.99; 95% confidence interval [CI]:0.92-1.08; p = 0.97) and site-adjusted (OR: 1.06; 95% CI: 0.95-1.18; p = 0.30) analyses. Similar results were obtained when contrast volume was imputed or the data was subset to individuals with available contrast volume. In a large cohort of veterans undergoing PCI, we found considerable site variation in the type of contrast media used but no significant association between contrast media type and the incidence of MARCE, both before and after adjustment for the site.

Social Workers in Primary Care Increase Access to Palliative Care

Clinical trials show that palliative care improves patient experiences and reduces costs, and use of palliative care and hospice care have been increasing over the past three decades. In the Veterans Administration health care system (VA), Veterans may receive palliative care concurrently with other treatments. However, many barriers exist to the use of palliative care, such as patients’ misperceptions. Social workers in primary care teams may increase use of this valuable service by establishing trust between patient and care team, educating patients and caregivers, and coordinating services. Leveraging a national social-work-staffing program as a natural experiment, we evaluated the effect of hiring one or more social workers to the primary-care team on use of palliative or hospice care among Veterans with a recent hospital stay. Our data included 91,675 episodes of care between 2016 and 2018. 1.45 percent of episodes were followed by use of palliative care or hospice within 30 days. The addition of one or more social workers through the staffing program was associated with an increase of 0.53 percentage points (p<0.001) in the probability of any palliative or hospice care, i.e., a more than 30% increase relative to the mean. Policy makers and health system leaders who seek to improve patient experience and reduce costs through increased access to palliative and hospice care could consider social work staffing as a policy tool to achieve those aims.

857. Discussion and Initiation of HIV Pre-exposure Prophylaxis Were Rare Following Diagnoses of Sexually Transmitted Infections among Veterans

Abstract Background Healthcare encounters for the diagnosis and treatment of sexually transmitted infections (STIs) are common and represent a window of opportunity to discuss and initiate HIV pre-exposure prophylaxis (PrEP). Little is known about how frequently PrEP is discussed and initiated in association with encounters for STIs. Methods We conducted a retrospective cohort and nested case control study in the national Veterans Administration (VA) healthcare system to determine the frequency of PrEP discussion and initiation in association with clinical encounters for bacterial STIs (i.e. early syphilis, gonorrhea, and chlamydia). We used administrative data to identify patients with a first STI based on ICD 9 / 10 codes from January 2013–December 2018 , excluding patients with prior HIV diagnosis or PrEP use, or STI diagnosed in context of a visit to initiate PrEP (Figure 1). We used pharmacy data to determine the frequency of PrEP initiation within 90 days of the encounter for STI in this cohort. In the case control study, we matched 90 PrEP starters to 180 non-starters by day of STI diagnosis and reviewed chart notes from the STI diagnosis encounter to determine frequency of documentation of sexual history taking and PrEP discussions among subsequent PrEP initiators and non-initiators. Results We identified 23,312 patients with a first STI, of whom 90 (0.4%) started PrEP within 90 days. Adjusting for age, PrEP initiation was associated with urban residence (OR=5.0, 95Cl 1.8–13.4), White compared to Black race (OR=1.7, 95 Cl 1.1–2.8), and syphilis diagnosis (OR = 7.4, 95 Cl 4.7–11.6, table 1). Chart review revealed that discussion of PrEP was rare among people with STIs who did not subsequently start PrEP (1.1%, 95 CI 0.1–4.0, table 2). PrEP initiation was associated with documentation of any sexual history (80.0% of initiators vs. 51.0% of non-initiators, p &amp;lt; 0.01) and discussion of PrEP (52.2% vs. 1.1%, p &amp;lt; 0.01) during the initial STI diagnosis encounter. Figure 1. Study flow chart Table 1. Characteristics of patients with a first healthcare encounter with an STI diagnosis, by PrEP initiation within 90 days of encounter. N= 23,312 Table 2. Chart review findings from case control study. Ninety people who initiated PrEP (i.e., “cases”) were randomly matched to 180 who did not initiate PrEP (i.e., “controls”) by date of STI. Conclusion Discussion and initiation of PrEP were rare in association with healthcare encounters for STIs. Not all individuals with STIs will benefit from starting PrEP, but interventions are needed to improve low rates of sexual history-taking and discussion of PrEP during healthcare encounters for STIs. Disclosures Bruce Alexander, PharmD, Bruce Alexander Consulting (Independent Contractor)

Editorial introductions.

Current Opinion in Gastroenterology was launched in 1985. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of gastroenterology is divided into 12 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Jocelyn A. SilvesterJocelyn A. SilvesterDr Jocelyn A. Silvester, MD PhD, is Assistant Professor of Pediatrics at Harvard Medical School, USA, and Director of Research for the Celiac Disease Program at Children's Hospital (BCH) in Boston, Massachusetts, USA. She also maintains a general pediatrics practice in Northern Manitoba and Nunavut through the Ongomiizwin Health Services JA Hildes Northern Medical Unit. Dr Silvester completed her PhD in Biology at the University of Cambridge in England, UK, where she studied mitochondrial ATP synthase under the supervision of Professor Sir John E. Walker. She earned her medical degree from Dalhousie University in Canada and completed her residency in general pediatrics at the University of Manitoba, Canada. She came to the United States for pediatric gastroenterology fellowship training at Boston Children's Hospital. Dr Silvester is co-Chair of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) Celiac Disease Special Interest Group and serves on the American Gastroenterological Association Council for section for basic and clinical intestinal disorders. Her research interests include the diagnosis and management of celiac disease with a particular interest in what happens after the diagnosis of celiac disease is made. She is co-Investigator on the Manitoba Celiac Disease Cohort Study, involved in clinical trials for alternative therapies to a gluten-free diet and is leading a consortium of pediatric celiac centers across the United States to develop tools to improve follow-up care. Tilak U. ShahTilak U. ShahDr Shah is an Associate Professor of Medicine at Virginia Commonwealth University (VCU) Health Science Center, USA, as well as Director of Endoscopy and Interventional Endoscopy at the Central Virginia VA Healthcare system in Richmond, VA, USA. He serves as Associate GI Fellowship Program Director at VCU, and is a member of the Development and Therapeutics section of VCU Massey Cancer Center. Dr Shah graduated from the University of North Carolina (UNC) at Chapel Hill, USA, in 1997, and UNC School of Medicine in 2006. He completed internal medicine residency and fellowship training in gastroenterology at Duke University Medical Center, USA. Dr Shah also obtained a master's degree in clinical research from the Duke-NIH Clinical Research Training Program, and underwent formal training in Advanced Endoscopy at Emory University Medical Center, USA. He joined the medical faculty at Virginia Commonwealth University in 2014. Dr Shah has served on American College of Gastroenterology (ACG), American Society of Gastrointestinal Endoscopy (ASGE), and Veterans Administration (VA) Committees. He has served as a reviewer for several journals including American Journal of Gastroenterology, Clinical Gastroenterology and Hepatology, Digestive Diseases and Sciences, World Journal of Gastroenterology, and Cochrane Database of Systematic reviews, and is section editor for Current Opinion in Gastroenterology. Dr Shah's research interests involve endoscopic approaches to diagnose and treat esophageal and colorectal neoplasia, including advanced imaging, artificial intelligence, endoscopic resection, and cryotherapy. Dr Shah is the recipient of research awards from the ASGE and McGuire Research Institute, and is site investigator for VA Co-Operative and Merit studies. He is an author on over 30 original papers, and has authored two board preparation textbooks, “NMS Medicine Casebook,” and “Acing the Pancreaticobiliary Questions on the GI Boards.”

Late Breaking Abstracts

Late Breaking Abstracts

The Use of Same-Day Hearing Aid Fitting with Telehealth Follow-up Care: A Case Study of a Veteran Presenting with Tinnitus and Auditory Processing Disorder Symptoms.

Providing same-day hearing aid fitting appointments to patients being seen in an audiology clinic for an audiometric evaluation may help decrease clinic wait times and reduce the need for future in-person appointments. Prior to 2020, the Veterans Administration (VA) Healthcare System did not allow hearing aid manufacturers to provide functional demonstration (demo) hearing aids to VA audiology clinics. Due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2/COVID-19) pandemic, this rule was changed to minimize the number of required in-person VA audiology appointments. The audiology clinic at the Pittsburgh VA Healthcare System developed a hearing aid fitting protocol using demo hearing aids to provide same-day hearing aid fitting appointments. This case study pertains to a female Veteran who presented to the clinic with complaints of decreased hearing and bothersome tinnitus. The patient completed a comprehensive audiometric evaluation, auditory processing disorder screening, hearing aid evaluation, and hearing aid fitting in the clinic. All follow-up appointments were scheduled to be completed via telehealth. The initial findings in this case study indicate that same-day hearing aid fittings can be successful for some patients. Future telehealth follow-up appointments will determine this patient's level of success using hearing aid-related outcome measures.

Trauma-Sensitive Yoga for Post-Traumatic Stress Disorder in Women Veterans who Experienced Military Sexual Trauma: Interim Results from a Randomized Controlled Trial.

Objective: To conduct an interim analysis of data collected from an ongoing multisite randomized clinical trial (RCT) assessing the effectiveness of Trauma Center Trauma-Sensitive Yoga (TCTSY) for post-traumatic stress disorder (PTSD) among women veterans with PTSD related to military sexual trauma (MST). The purpose of the interim analysis was to assess outcomes from the primary site, which is geographically, demographically, culturally, and procedurally distinct from the second site. Design: RCT was conducted within a Veterans Administration Health Care System. Data collection included preintervention through 3 months postintervention. Participants: Enrollment for the main site was 152 women. The sample size for the intent-to-treat analysis was 104. The majority were African American (91.3%) with a mean age of 48.46 years. Intervention: The TCTSY intervention (n = 58) was conducted by TCTSY-certified yoga facilitators and consisted of 10 weekly 60-min group sessions. The control intervention, cognitive processing therapy (CPT; n = 46), consisted of 12 90-min weekly group sessions conducted per Veterans Administration protocol by clinicians in the PTSD Clinic. Outcome measures: The Clinician Administered PTSD Scale for DSM-5 (CAPS-5) was used to assess current PTSD diagnosis and symptom severity, including overall PTSD and four symptom clusters. The PTSD checklist for DSM-5 (PCL-5) was used to obtain self-report of PTSD symptom severity, including total score and four symptom clusters. Results: The findings reported here are interim results from one clinical site. For both the CAPS-5 and PCL-5, total scores and all four criterion scores decreased significantly (p < 0.01) over time in all five multilevel linear models within both TCTSY and CPT groups, without significant differences between groups. There were clinically meaningful improvements seen for both TCTSY and CPT with 51.1%-64.3% of TCTSY subjects and 43.5%-73.7% of CPT decreasing their CAPS-5 scores by 10 points or more. Effect sizes for total symptom severity were large for TCTSY (Cohen's d = 1.10-1.18) and CPT (Cohen's d = 0.90-1.40). Intervention completion was higher in TCTSY (60.3%) than in CPT (34.8%). Symptom improvement occurred earlier for TCTSY (midintervention) than for CPT (2 weeks postintervention). Safety: There were no unanticipated adverse events in this study. Conclusion: The results of this study demonstrate that TCTSY may be an effective treatment for PTSD that yields symptom improvement more quickly, has higher retention than CPT, and has a sustained effect. TCTSY may be an effective alternative to trauma-focused therapy for women veterans with PTSD related to MST. The study is registered in ClinicalTrials.gov (CTR no.: NCT02640690).

Abstract 15330: Association Between Elective Percutaneous Coronary Intervention Appropriateness and Publicly Reported Outcomes

Introduction: Public reporting of percutaneous coronary intervention (PCI) outcomes such as readmission and mortality may cause harm by adversely affecting patient selection for PCI. Little is known about the relationship between these outcomes and elective PCI appropriateness - a validated metric of PCI quality. Methods: We identified all patients in the national Veterans Administration healthcare system who underwent elective PCI for stable coronary disease between 2013 and 2015. We defined PCI appropriateness using 2012 criteria. The primary outcome was 90-day all-cause hospitalization or mortality. We used hierarchical Cox proportional hazards regression models adjusted for patient- and facility-level covariates to compare outcomes across PCI appropriateness categories, and a joint survival/logistic model to compare facility-level variation in inappropriate PCI and 90-day outcomes. Results: Among 2,561 patients (mean age 66 years, 99% men) undergoing PCI across 59 sites, 29.6% were classified as appropriate, 10.4% as inappropriate, and 60% as uncertain. The proportion of patients who were readmitted or died were 15.6%, 16.4%, and 15.3% among patients who received appropriate, inappropriate, and uncertain PCI respectively. There were no significant differences in 90-day outcomes between the groups (hazard ratio for appropriate compared to inappropriate PCI 0.82 [CI 0.57 to 1.17; p=0.28]). The site level covariance between inappropriate PCI and 90-day outcomes was -0.033 (95% CI -0.117 to 0.047), indicating no site-level correlation between appropriateness and 90-day outcomes (Figure). Conclusion: We found no association between elective PCI appropriateness and 90-day outcomes among a national cohort of Veterans. Including appropriateness in public reports may 1) characterize PCI quality more fully and 2) potentially mitigate the harms of reporting outcomes by empowering providers to perform appropriate PCI in higher-risk patients.

A nurse practitioner-led effort to reduce 30-day heart failure readmissions.

Heart failure (HF) affects over 6.5 million Americans and is the leading reason for hospital admissions in patients over the age of 65. Readmission rates within 30 days are 21.4% nationally, and 12% of those are likely preventable. Veterans are especially vulnerable to developing cardiac diseases requiring hospitalization and subsequent readmission. The Southern Arizona Veterans Administration Health Care System has over 5,600 patients diagnosed with HF and a 30-day readmission rate of 21.65%. The aim of this quality improvement project was to reduce 30-day all-cause readmissions by 1% over 8 weeks. To reduce HF readmissions, the plan-do-study-act rapid-cycle method of quality improvement was used. A dedicated multidisciplinary HF clinic was formed with a cardiology nurse practitioner, clinical pharmacists, and a dietician. A veteran-centered shared decision-making tool for setting self-care goals was implemented. The readmission rate of patients seen in the multidisciplinary clinic (n = 33) was reduced by 0.2%. The percentage of veterans seen within 14 days increased from 30% to 54.5%. The average number of days between discharge and cardiology follow-up improved from 45 to 19 days. Veterans were able to set at least one self-care goal 87% of the time. Patient satisfaction with the multidisciplinary clinic was high at 93%. Implementing a dedicated, multidisciplinary HF clinic reduced readmissions, improved timeliness of visits, and was well received. Use of a veteran-centered patient engagement tool resulted in more veterans setting self-care goals.