Veterans Administration Research Articles

REHOSPITALIZATION RISK AMONG VETERANS RECEIVING POST-ACUTE HOME HEALTH SERVICES: DIFFERENCES BY PAYOR SOURCE

Abstract Medicare-eligible Veterans who require post-acute skilled home health (HH) after a hospitalization can have HH paid for by the Veterans’ Administration (VA) or Medicare. Our prior work showed Veterans enrolled in Medicare Advantage (MA) are more likely to have the VA pay for HH than MA. In this analysis, we look at differences in 90-day rehospitalization among MA-enrolled Veterans receiving VA-paid post-acute HH versus MA-paid post-acute HH. All Veterans enrolled in MA and receiving HH after an index hospitalization at a VA medical center between October 1, 2016 and September 30, 2019 were included. Data were extracted from the VA electronic medical record. We used inverse probability weighting to address baseline differences in age, patient complexity, and past utilization. We used cox proportional hazards models to estimate the effect of VA- versus MA-paid HH on the risk of 90-day rehospitalization. There were 14,501 eligible hospitalizations requiring HH; 8,753 (60.4%) received VA-paid HH, and 5,748 (39.6%) received MA-paid HH. On average, Veterans receiving VA-paid HH waited 3.7 days (SD: 3.2) to start HH, compared to 4.8 days (SD: 3.8) for Veterans receiving MA-paid HH. After preliminary weighting, Veterans who received VA-paid HH had a lower risk of 90-day rehospitalization, compared to Veterans who received MA-paid HH (adjusted hazard ratio=0.88; 95% CI: 0.83,0.93). Veterans whose HH was paid for by MA received services one day later, on average, and had higher risk of 90-day rehospitalization compared to Veterans receiving VA-paid HH. Potential implications on quality of post-acute care for MA-enrolled Veterans discussed.

Frontal Pole Neuromodulation for Impulsivity and Suicidality in Veterans With Mild Traumatic Brain Injury and Common Co-Occurring Mental Health Conditions: Protocol for a Pilot Randomized Controlled Trial.

Suicide remains a leading cause of death among veterans in the United States, and mild traumatic brain injury (mTBI) increases the risk of suicidal ideation (SI) and suicide attempts (SAs). mTBI worsens impulsivity and contributes to poor social and occupational functioning, which further increases the risk of SI and SAs. Repetitive transcranial magnetic stimulation is a neuromodulatory treatment approach that induces neuroplasticity, potentially repairing neurodamage. Intermittent theta burst stimulation (iTBS) is a second-generation form of transcranial magnetic stimulation that is safe, shorter in duration, displays a minimal side effect profile and is a promising treatment approach for impulsivity in mTBI. Our novel proposed treatment protocol uses frontal pole iTBS to target the ventromedial prefrontal cortex, which may reduce impulsivity by strengthening functional connectivity between the limbic system and frontal cortex, allowing for improved top-down control of impulsive reactions, including SI and SAs. The objectives of this study are to (1) develop an iTBS intervention for veterans with mTBI, impulsivity, and SI; (2) assess the feasibility and tolerability of the intervention; and (3) gather preliminary clinical outcome data on SI, impulsivity, and functions that will guide future studies. This is a pilot, double-blinded, randomized controlled trial. In developing this protocol, we referenced the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) guidelines. We will enroll 56 participants (28 active iTBS and 28 sham iTBS). The iTBS intervention will be performed daily, 5 days a week, for 2 weeks. We will collect 10 validated, psychometric, quantitative outcome measures before, during, and after the intervention. Measures included will assess functioning, impulsivity, suicidality, posttraumatic stress disorder, and depressive symptoms. We will collect qualitative data through semistructured interviews to elicit feedback on the participants' experiences and symptoms. We will perform quantitative and qualitative analyses to (1) assess the feasibility, tolerability, and acceptability of the treatment; (2) gather advanced neuroimaging data to assess neural changes elicited by treatment; and (3) assess improvements in outcome measures of impulsivity and suicidality in veterans with mTBI. This study protocol was approved by the Edward Hines, Jr. VA Hospital Institutional Review Board (Hines IRB number 14-003). This novel treatment is a 5-year research project (April 1, 2023, to March 31, 2028) funded by the Veterans Administration Rehabilitation Research and Development service (CDA2 award IK2 RX002938). Study results will be disseminated at or before the project's end date in March 2028. We will provide preliminary evidence of the safety, feasibility, and acceptability of a novel frontal pole iTBS treatment for mTBI, impulsivity, SI and SAs, and functional deficits. ClinicalTrials.gov NCT05647044; https://clinicaltrials.gov/study/NCT05647044. PRR1-10.2196/58206.

Radioimmunoassay and revolution in medical investigation: Nobel Prize winner in Physiology or Medicine (1977) Rosalyn Yalow – scientist with a fighting spirit

An intelligent but poor New York City girl, whom her parents saw in the future only as a teacher at best, Rosalyn Yalow after finishing school in 1937 went to all-female Hunter College and was the first woman with a degree in physics at a time when being a woman, much less a Jewish women, was a severe barrier to success. Although she was called somewhat aggressive and high-brow she became the first woman student in the physics department at the University of Illinois, the only woman among 400 members of the College of Engineering faculty and after receiving Ph. D the only women engineer at the Bronx Telecommunications Laboratory. By 1950, she established a radioisotope laboratorу in the Bronx Veterans Administration Hospital, one of the first in the United States. In collaboration with an M.D. Sol Berson, a research partnership with whom lasted for 22 years, Yalow investigated the metabolism of 131I-labeled insulin in diabetic patients and not only demonstrated for the first time the production of antibodies against such a small protein but also developed the breakthrough radioimmunoassay (RIA) to measure insulin concentration in patient’s blood with no radioactivity entered a body. This revolutionary technique began to be widely used around the world for measuring a variety of biological substances. In 1977 R. Yalow was awarded the Nobel Prize for Physiology or Medicine “for developing radioimmunoassays of peptide hormones.” The review describes the scientific career and life path of this extraordinary woman. Keywords: ELIZA, insulin, Nobel Prise, radioimmunoassay, Rosalyn Yalow

Creating infrastructure for supporting nurse engagement in evidence-based practice at a Veterans Administration Hospital.

Evidence-based practice (EBP) is foundational to safe and quality health care; however, barriers to nursing engagement in EBP have been well documented. To circumvent these barriers, nursing leadership must proactively implement system-level, multifaceted strategies within their organization to enhance EBP engagement. One Veterans Administration (VA) hospital has operationalized these strategies. To provide a description of the multifaceted strategies employed to promote a EBP culture and enhance nurses' engagement with EBP at a VA Hospital. Although it takes time, nursing leadership can overcome barriers and ensure nurse engagement in EBP at their organizations through implementation of multifaceted, system-wide strategies.

Doing More with Less: Predicting Primary Care Provider Effectiveness

Abstract We use data from the Veterans Administration to examine the efficacy of primary care providers (PCPs). Leveraging quasi-random assignment of veterans to PCPs, we measure effectiveness using ambulatory care sensitive conditions (ACSC) and hospitalizations/emergency department (ED) visits for mental health or circulatory conditions. PCPs’ variation along these dimensions predicts future outcomes. For example, a 1 standard deviation improvement in mental health effectiveness reduces patient risk of death by 3.8% and lowers costs by 4.4% over the next three years. More effective PCPs do more with less: their patients have fewer primary care visits, specialist referrals, lab panels, or imaging tests.

Validation of Parkinson's Disease Ascertainment in the Veterans Administration Electronic Medical Record.

Electronic medical record (EMR)-based studies hold great potential for epidemiologic investigations of Parkinson's disease (PD) causal factors and phenomenology, but diagnostic misclassification may obscure or bias inferences. The aims were to determine the validity of PD diagnostic codes in the Veterans Administration (VA) national electronic medical databases and develop recommendations for maximizing ascertainment accuracy. We investigated a cohort of 146,776 veterans who utilized VA healthcare between 1999 and 2021. We reviewed the medical records of individuals with a PD International Classification of Diseases (ICD) code in outpatient, inpatient, or community care encounters to assign a gold-standard diagnosis. We determined diagnostic accuracy based on provider type, coding frequency, medications, and potentially exclusionary ICD codes overall and by race. A total of 377 of 810 (46.5%) with a PD ICD code had PD. Veterans whose PD was coded by a PD-specialist neurologist were most likely to have PD (83.6%), but sensitivity was low (15.0%). Diagnostic accuracy decreased for PD coded by any neurologist (66.9%), but sensitivity improved (69.4%). Requiring two or more PD codes in combination with two or more levodopa prescriptions improved accuracy, particularly among nonneurologists. Neuroleptic-induced parkinsonism was the most frequent diagnosis in those without PD (15.6%). Accuracy was lower in Black (29.0%) than White (50.5%) veterans regardless of provider type (miscoding odds ratio 2.5, 95% confidence interval 1.7-3.6). These results highlight the limitations of EMR-based PD ascertainment. Researchers can maximize accuracy by considering provider specialty, coding frequency, pharmacy data, and exclusionary diagnoses, but some degree of record review is required to ensure high accuracy. Higher miscoding among Black veterans warrants further study. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

Geographic Variation in Receipt of Electroconvulsive Therapy Among US Department of Veterans Affairs Patients.

The aim of the study is to characterize geographic variation in electroconvulsive therapy (ECT) receipt across the United States (US) Veterans Administration (VA) healthcare system and explore potential explanatory variables. ECT is a highly effective and rapidly acting treatment for multiple mental disorders. However, there may be geographic disparities in access to ECT across the US. We conducted a retrospective, cross-sectional study of all VA patients from 2003 to 2019 to describe rates of ECT within previously defined mental health referral regions (MHRRs). We investigated differences between the population that received ECT and other patients with a mental health condition severe enough to warrant inpatient hospitalization. We analyzed crude as well as age, sex, race, and ethnicity-adjusted ECT rates and explored potential explanatory variables. We compared MHRRs in the highest and lowest tertiles of ECT receipt. The rate of ECT receipt among VA patients was 1.7 individuals per 10,000 (SD = 1.6) annually. Among 115 MHRRs, the rate ranged from a minimum of 0 (effectively no utilization in some areas) to a maximum of 8.9. Regression analysis revealed few significant explanatory variables. There is significant geographic variation in ECT receipt among VA patients that is not well explained by population characteristics and may be indicative of suboptimal treatment for several mental health conditions.

Cohort Profile: Baseline Characteristics of Veterans from Improving Veteran Access to Integrated Management of Back Pain (AIM-Back) - an Embedded Pragmatic, Cluster Randomized Trial in the United States.

AIM-Back is an embedded pragmatic clinical trial (ePCT) with cluster randomization designed to increase access and compare the effectiveness of two different non-pharmacological care pathways for low back pain (LBP) delivered within the Veteran Administration Health Care System (VAHCS). This manuscript describes baseline characteristics of AIM-Back participants as well as the representativeness of those referred to the AIM-Back program by sex, age, race, and ethnicity, relative to Veterans with low back pain at participating clinics. To be eligible for AIM-Back, Veterans were referred to the randomized pathway at their clinic by trained primary care providers (Referral cohort). Veterans from the Referral cohort that participated in the study included: 1) an Electronic Health Record (EHR) sample of Veterans enrolled in the program (i.e., attended initial AIM-Back visit with no consent required) and a Survey sample of Veterans that were consented for further study. Descriptive statistics for age, race, ethnicity, sex, high-impact chronic pain (HICP), a comorbidity measure, post-traumatic stress diagnosis (PTSD) and opioid exposure were reported for the Referral cohort and by sample; mean baseline PROMIS pain interference, physical function and sleep disturbance scores were reported by sample. Additional measures of pain, mental health and social risk were reported on the Survey sample. Participation to prevalence ratios (PPRs) were calculated for sex, age, race, and ethnicity by clinic to describe representativeness of the Referral cohort. Across 17 randomized primary care clinics, the Referral cohort included 2767 unique Veterans with n=1817 in the EHR sample, n=996 in the Survey sample and n=799 of the EHR sample (44%) were also in the Survey sample. High rates of HICP were observed in the EHR and Survey samples (>59%). Mean scores (SD) based on self-reported PROMIS Pain Interference (63.2 (6.8), 63.1 (6.6)) and PROMIS Physical Function (37.1 (5.3), 38.1 (5.8)) indicated moderate impairment in the EHR sample and Survey sample respectively. Approximately 10% of the EHR sample had documented opioid use in the year leading up to the AIM-Back referral. At most clinics, older Veterans (>=65 years) were underrepresented in the Referral cohort compared to those with LBP visits at clinics (PPRs < 0.8). The AIM-Back trial will conduct analysis to examine the comparative effectiveness of the two care pathways and identify individual characteristics that may improve responses to each pathway. The trial is expected to complete 12-month follow-up data collection by December 2024, with subsequent analyses and publications providing insights into optimizing non-pharmacological care for Veterans with LBP. NCT04411420 ( clinicaltrials.gov ). Strengths: Embedded features (e.g., EHR documentation and clinical staff serving as interventionist) of the AIM-Back trial have potential to facilitate implementation of these care pathways more broadly in Veteran's Health Administration clinics and in health systems outside the Veteran's Health AdministrationParticipating clinics were in 10 states providing regional geographic representation across the study.Trial was delivered within an integrated health system optimal for consistent documentation templates and data extraction across the trial sites.Limitations: Due to clinical personnel's role in participant recruitment, sample biases may exist in those referred to the program and/or those who agreed to participate in additional surveysThese findings may not be generalizable to older aged Veterans due to our lower enrollment of those 65+.

As-Needed Blood Pressure Medication and Adverse Outcomes in VA Hospitals

Asymptomatic blood pressure (BP) elevations in the hospital are commonly treated with as-needed BP medications, including recurring as-needed and 1-time administration. Veterans represent a population at risk of ischemic events from rapid lowering of BP, but the impact of as-needed BP medication use in this population is unknown. To assess the risks of acute kidney injury (AKI) and other outcomes from as-needed BP medication administration in a hospitalized veteran cohort. This retrospective cohort study using target trial emulation and propensity score matching included adult veterans, who were hospitalized 3 or more days in Veterans Administration hospitals between October 1, 2015, and September 30, 2020. Participants must have been hospitalized on a non-intensive care unit medical or surgical floor, must not have undergone surgery, and must have received at least 1 scheduled BP medication in the first 24 hours of admission. Participants also must have had at least 1 systolic BP more than 140 mm Hg during hospitalization. Data in this study were analyzed from April 2023 to August 2024. The primary outcome was time to first AKI occurrence during hospitalization. Secondary outcomes included greater than 25% reduction in systolic BP within 3 hours of as-needed BP medication administration and the composite outcome of myocardial infarction, stroke, or death during hospitalization. Of the 133 760 veterans eligible for analysis (mean [SD] age, 71.2 [11.6] years), 96% were male. The mean (SD) baseline estimated glomerular filtration rate was 75.7 (22.7) mL/min/1.73m2. A total of 28 526 patients (21%) received as-needed BP medication. As-needed BP medication use was associated with an increased AKI risk (adjusted hazard ratio, 1.23 [95% CI, 1.18-1.29]) compared to nonusers. Subgroup analyses showed higher AKI risk with intravenous as-needed BP medication use (compared to oral or combined oral and intravenous routes). Secondary analyses indicated as-needed BP medication users had a 1.5-fold greater risk of rapid BP reduction (95% CI, 1.39-1.62) and 1.69-fold higher rate of the composite outcome (95% CI, 1.49-1.92) compared to nonusers. The results of this retrospective cohort study showed that as-needed BP medication use among veterans is associated with increased AKI risk. The risks and benefits of this type of BP medication use would best be determined through a prospective trial, and these data suggest that there is the necessary equipoise to conduct such a trial.

EEG Infrastructure Within the Veterans Administration: A Survey.

EEG is a vital tool in the diagnosis and management of neurologic conditions prevalent among veterans such as seizures, epilepsy, and brain injuries. This cross-sectional study aimed to assess the state of EEG infrastructure within the Veterans Administration (VA), focusing on availability, utilization, and the potential avenues to addressing gaps in infrastructure. This survey was distributed to 123 VA hospitals using the Research Electronic Data Capture (REDCap) platform, gathering data on EEG equipment, staffing, and service provision from June to December 2023. Of the 123 VA hospitals surveyed, 70 responded (56.9% response rate). Most respondents (88.6%) reported having EEG services, although only 38.7% offering continuous EEG (cEEG). Respondents reported having less EEG technologists, machines, and faculty readers than what they thought would be ideal. Significant correlations were found between the availability of resources (e.g., number of EEG machines) and service capabilities, including remote access and cEEG. The use of alternative EEG technologies such as rapid or quantitative EEG varied greatly. Interest in participating in the VA Tele-EEG program was reported by 59.4% of respondents. There is large variability in EEG infrastructure across the VA. Tele-EEG has the potential to maintain continuity of operations through challenges affecting staffing and to improve EEG service access, especially in resource-limited settings. Expanding access to quantitative, rapid, and tele-EEG services may enhance patient management and may be a potential avenue to explore as the VA continues to invest in and grow its capacity for treating neurologic conditions.

Design and methodology of a randomized clinical trial of quetiapine to reduce central nervous system polypharmacy in veterans with postconcussive syndrome symptoms

Lack of evidence to guide medication treatments for mild traumatic brain injury (mTBI) in veterans too often results in polypharmacy practices attempting to provide symptomatic relief from multiple postconcussive syndrome symptoms. Therefore, the field needs to find an effective medication that reduces the burden of postconcussive symptoms without complicating the treatment burden of veterans. This clinical trial seeks to determine whether switching veterans to quetiapine monotherapy (intervention) is superior to continuing to receive treatment as usual (TAU, control) polypharmacy for veterans with symptoms of postconcussive syndrome and posttraumatic stress disorder who are receiving rehabilitation treatment for mTBI. This study will test the conceptual mediation model hypothesis that quetiapine monotherapy may enhance recovery from mTBI by (1) increasing engagement in rehabilitation services, and/or (2) reducing the adverse effects of TAU polypharmacy. This study will enroll 146 patients from two Veterans Administration Medical Centers into a 12- week phase III, randomized, pragmatic clinical trial comparing outcomes from treatment with quetiapine monotherapy and TAU. Quetiapine will be cross tapered up to a maximum dose of 200 mg (as tolerated) as other medications are discontinued. The primary outcome measures are postconcussive syndrome symptoms (Neurobehavioral Symptom Inventory), functional disability (World Health Organization Disability Assessment), and quality of life (World Health Organization Quality of Life Assessment). Overall, this study aims to determine whether quetiapine monotherapy is superior to TAU polypharmacy and improves the quality of life for veterans with comorbid postconcussive syndrome and posttraumatic stress disorder symptoms who are receiving rehabilitation treatment for mTBI.

Development of Novel Peripheral Blood Count-Based Prognostic Index for Multiple Myeloma

In multiple myeloma (MM), clonal plasma cells evade immune surveillance and proliferate within an inflammatory bone marrow microenvironment. During pathogenesis, monocyte-derived tumor-associated macrophages help myeloma cells to avoid apoptosis; effector T cell lymphocytes undergo senescence to enable preferential upregulation of their immunosuppressive regulatory T cell counterparts; and myeloma cells interact with hematopoietic stem cells to inhibit downstream megakaryocyte differentiation into platelets.1 Our prior research has suggested a prognostic role for the absolute monocyte count (AMC), absolute lymphocyte count (ALC), and platelet count as biomarkers. We have shown that abnormal AMC and decreased ALC and platelet count are associated with decreased overall survival (OS) among patients with MM at diagnosis and follow-up. Based on the easy accessibility of these peripheral blood markers and need for dynamic prognostication among patients with MM undergoing novel therapies, we created a categorical peripheral blood-based prognostic index for MM incorporating AMC, ALC and platelet count. We retrospectively evaluated this index in 10790 patients diagnosed with MM between 2000 and 2019 at Veterans Administration hospitals using cell counts obtained closest to diagnosis and up to 2.5 years thereafter. Patients were stratified into 3 levels based on a logarithmic risk score, where those with the lowest counts across all cell lines (AMC, ALC, and platelet count) were in level III and those with counts approaching normalcy were in level I. At diagnosis, 8% of patients were in level III and had the highest risk of death (hazard ratio [HR] 2.04; 95% confidence interval [CI] 1.85-2.24; P &amp;lt; .01) compared to those in levels I (HR 1.15; 95% CI, 1.08-1.23; P &amp;lt; .01) and II (HR 1.37; 95% CI, 1.28-1.46; P &amp;lt; .01). Moreover, the risk of inferior OS associated with level III status persisted during treatment and follow-up and existed independently of other known risk stratification tools (including Charlson comorbidity index, lactate dehydrogenase, International Staging System classification). With further validation, our findings support the use of our novel prognostic index, which potentially reflects the underlying tumor microenvironment, as an available tool for risk stratification during the MM disease course.

Lymphopenia predicts poor outcomes in newly diagnosed multiple myeloma

AbstractBone marrow microenvironment plays an important role in promoting growth and survival of multiple myeloma (MM) cells. The tumor-promoting immune microenvironment is augmented while antitumor immune responses are inhibited. Although clinical and genomic markers of high-risk MM have been described, the immune status is just being recognized as a potential mediator of disease behavior. This is even more important with the development of a number of immune-based therapies. Based on these considerations, we evaluated peripheral blood absolute lymphocyte count (ALC) as an easily accessible marker representing immune microenvironment at diagnosis and after treatment of MM. We retrospectively evaluated 11 427 patients diagnosed with MM between 2000 and 2019 at Veterans Administration hospitals using ALC obtained closest to diagnosis and up to 2.5 years thereafter. Patients were stratified into 3 ALC categories: severely low, low, and normal (<1 × 103/mm3, 1 × 103/mm3 to 1.5 × 103/mm3, and >1.5 × 103/mm3, respectively). Lymphopenia (including severely low and low ALC) was present in 53% of patients at MM diagnosis and was associated with inferior overall survival (OS). The median OS for patients with severely low, low, and normal ALC at diagnosis was 2.7, 3.3, and 4.2 years (P < .001), respectively. Moreover, persistent or new development of lymphopenia during treatment and follow-up was also associated with inferior OS. Our findings support the use of ALC as a biomarker for risk stratification in MM.

Cannabis Use and Cannabis Use Disorder Among U.S. Adults with Psychiatric Disorders: 2001-2002 and 2012-2013

Background Rates of cannabis use disorder (CUD) have increased disproportionately among Veterans Administration (VA) patients with psychiatric disorders compared to patients with no disorder. However, VA patient samples are not representative of all U.S. adults, so results on disproportionate increases in CUD prevalence could have been biased. To address this concern, we investigated whether disproportionate increases in the prevalence of cannabis outcomes among those with psychiatric disorders would replicate in nationally representative samples of U.S. adults. Methods Data came from two national surveys conducted in 2001-2002 (n = 43,093) and 2012-2013 (n = 36,309). Outcomes were any past-year non-medical cannabis use, frequent non-medical use (≥3 times weekly), and DSM-IV CUD. Psychiatric disorders included mood, anxiety and antisocial personality disorders. Logistic regression was used to generate predicted prevalences of the outcomes, prevalence differences calculated and additive interactions compared differences between those with and without psychiatric disorders. Results Cannabis outcomes increased more among those with psychiatric disorders. The difference in prevalence differences included any past-year non-medical cannabis use, 2.45% (95%CI = 1.29-3.62); frequent non-medical cannabis use, 1.58% (95%CI = 0.83-2.33); CUD, 1.40% (95%CI = 0.58-2.21). For most specific disorders, prevalences increased more among those with the disorder. Conclusions In the U.S. general population, rates of cannabis use and CUD increased more among adults with psychiatric disorders than other adults, similar to findings from VA patient samples. Results suggest that although VA patients are not representative of all U.S. adults, findings from this important patient group can be informative. Greater clinical and policy attention to CUD is warranted for adults with psychiatric disorders.

Real-world analysis of two ischaemic stroke and TIA systolic blood pressure goals on 12-month mortality and recurrent vascular events

IntroductionWhether obtaining the more intensive goal systolic blood pressure (SBP) of <130 mm Hg, rather than a less intensive SBP goal of <140 mm Hg poststroke/transient ischaemic attack (TIA) is...

Improving Patient Understanding of Emergency Department Discharge Instructions.

Previous studies have shown that patients in the emergency department (ED) are frequently given incomplete discharge instructions that are written at least four grade levels above the recommended sixth-grade reading level, leading to poor understanding. Our aims in this study were to implement standardized discharge instructions containing six key components written at a more appropriate reading level for common emergency department (ED) diagnoses to improve patient understanding. We conducted this study in a 20-bed ED at an urban Veteran's Administration hospital. Data was collected via in-person patient and clinician interviews. Patient interviews were conducted after patients received their discharge instructions. We compared patient responses to clinician responses and marked them as incorrect, partially correct, or correct with a score of 0, 0.5, or 1, respectively. The maximum possible score for each interview was six. Six key components of discharge instructions were asked about: diagnosis; new medications; at-home care; duration of illness; reasons to return; and follow-up. There were 25 patients in the pre-intervention group and 20 in the intervention group with the standardized set of instructions. We performed a Mann-Whitney U test on the total interview scores in the control and intervention groups and conducted a sub-analysis on the individual scores for each of the six key components. The patients in the intervention demonstrated a statistically significant increase in patient-clinician correlation when compared to the patients in the pre-intervention group overall (P < 0.05), and two of the six key components of the discharge instructions individually showed statistically significant increase in patient-clinician correlation when standardized discharge instructions were used. Patients who received the standardized discharge instructions had improved understanding of their discharge instructions. Future opportunities extending off this pilot study include expanding the number of diagnoses for which standardized instructions are used and investigating patient-centered outcomes related to these instructions.

Assessment of primary patency for femoropopliteal graft entrapment within the sartorius muscle

PurposeBlind tunneling of subfascial femoropopliteal bypass grafts may result in inadvertent graft passage through the sartorius. The purpose of this study was to determine whether intramuscular passage of femoropopliteal bypass grafts affects primary patency.MethodsPatients undergoing femoropopliteal bypass at a Veterans Administration hospital and associated university medical center over a recent 13-year period who also had postoperative cross-sectional imaging adequate to determine graft location were examined. Five-year primary patency of grafts circumferentially enveloped by the muscle was compared with that of both extramuscular subfascial grafts and subcutaneous grafts.Results370 femoropopliteal grafts were identified, among which 258 (70%) were subfascial. Vein grafts comprised 51% of the subfascial grafts, and 53% were inserted above the knee. Available postoperative imaging in 110 subfascial grafts demonstrated 74 (67%) to lie completely within the muscle at some point. Among imaged subfascial grafts, primary patency at five years for intramuscular grafts was not significantly worse than extramuscular grafts (P = 0.31). This remained true whether grafts were vein (P = 0.39) or prosthetic (P = 0.31) and whether grafts inserted to the above-knee (P = 0.43) or below-knee (P = 0.21) popliteal artery. Multivariable Cox regression revealed a significant relationship between use of vein grafts (P = 0.013), active smoking (P = 0.01), and hypertension (P = 0.041) and primary patency, but not intramuscular graft location (P = 0.31).ConclusionThis study failed to demonstrate significantly inferior primary patency among subfascial femoropopliteal grafts tunneled intramuscularly. Larger studies may be required to adequately detect any differences in patency by muscular entrapment, especially among subgroups.

B - 15 Symptom Presentation on the Neurobehavioral Symptom Inventory and Post Traumatic Stress Disorder Checklist for DSM-5 in a Cohort of Explosive Ordnance Disposal Veterans

Abstract Objective This preliminary research examined symptom differences on the Neurobehavioral Symptom Inventory (NSI) and Post Traumatic Stress Disorder Checklist DSM-5 (PCL-5) for Explosive Ordnance Disposal (EOD) and Non-EOD Veterans receiving care at the Washington DC-War Related Illness and Injury Study Center (DC-WRIISC) Veterans Administration Medical Center. EOD Veterans have extensive repetitive blast-exposure histories, exposure to environmental toxins, and operated under high-stress/allostatic load throughout their careers. Therefore, we aim to understand how these unique occupational exposures influence long-term health outcomes for EOD Veterans. Method Eligible participants (N = 39, Mage = 51 years (SD = 9.5 years); EOD, n = 21) completed comprehensive interdisciplinary evaluations, self-report questionnaires, were combat deployed, and experienced traumatic brain injury. Total and component scores for the NSI (affective, cognitive, somatic, vestibular, and validity-10) and PCL-5 (criterion B-E symptom clusters), and total score for the Holmes-Rahe Life Stress Inventory, (HRLSI) were included. Results Regression analysis revealed overall NSI severity was positively correlated to PCL-5 total scores for both groups (EOD: F(1,19) = 25.30, p &amp;lt; 0.001); (Non-EOD: F(1,16) = 25.48, p &amp;lt; 0.001). However, significant differences in symptom presentation were noted between groups. NSI Cognitive scores were positively correlated with PCL-5 component scores for Criterion B for EOD (F(3,17) = 8.40, p &amp;lt; 0.001) and Criterion E for Non-EOD (F(3,14) = 24.32, p &amp;lt; 0.001). Post-hoc analysis suggested stress/resiliency may further contribute to group differences (HRLSI; Non-EOD, F(2,12) = 33.96, p &amp;lt; 0.001). Conclusion DC-WRIISC Veterans often present with cognitive concerns and complex medical presentations. Our findings suggest the presence of unique symptom presentations that may improve diagnostic formulation, treatment planning, and engagement. These findings highlight the need for continued research examining the influence occupational exposures have on Veteran health.

Elevating Geriatric Mental Healthcare within an Evolving Healthcare Landscape

This presentation illuminates the imperative role of geriatric psychiatry amidst an ever- changing healthcare paradigm and the rising prevalence of older adults with mental health challenges and neurocognitive disorders that drive an escalation in health care spending. Utilizing a holistic approach to assessment and treatment, the field of geriatric psychiatry has the transformative potential to streamline care costs and elevate the quality of mental health services for older adults and individuals with dementia.Exploring diverse healthcare frameworks such as the value-based care model in the US and global payment systems such as those in the Veterans Administration and other socialized medical environments, the lecture advocates for the implementation of integrated geriatric mental health care models. Through an evidence-based analysis of models such as Collaborative Care, Care Ecosystem and Alzheimer’s Dementia Care (ADC), the presentation highlights the central role of geriatric mental health care in driving improvements in care quality while reducing overall healthcare expenditures.Drawing from personal insights and professional experiences, the speaker offers a nuanced perspective on the journey towards comprehensive geriatric mental health integration within healthcare system environments. By championing innovation and advocating for integrated care practices, the presentation aims to inspire attendees to embrace a proactive stance in designing and implementing progressive and interdisciplinary geriatric mental health solutions on a global scale.

Lee Gurel (1926-2023).

Lee Gurel, who had a distinguished career as a research psychologist with the Veterans Administration, passed away at home in Alexandria, Virginia, on July 24, 2023, at the age of 96. Gurel was born on October 1, 1926, in Poland, and came to the United States with his family in 1930. He was a prolific researcher with over 120 publications. Some of his lasting contributions to the field came from his tireless philanthropic efforts to support educators and students. The depth of his engagement in the communities of which he was a part led him to receive multiple honors. Gurel's strong analytic and quantitative skills, combined with his quiet leadership style, contributed to improving our research understanding in psychology. His compassion for others and his insatiable belief in the transformative power of education helped model for the field the importance of the linkages between research, teaching, and civic life. (PsycInfo Database Record (c) 2024 APA, all rights reserved).