Veterans Health Administration Care Research Articles

Perspectives of VA healthcare from rural women veterans not enrolled in or using VA healthcare.

Women Veterans have unique healthcare needs and often experience comorbid health conditions. Despite this, many women Veterans are not enrolled in the Veterans Health Administration (VHA) and do not use VHA services. Underutilization of VHA services may be particularly prevalent among rural women Veterans, who may experience unique barriers to using VHA care. Nonetheless, knowledge of rural women Veterans and their experiences remains limited. We sought to understand rural women Veterans' perceptions and needs related to VHA healthcare, including barriers to enrolling in and using VHA services, and perspectives on how to communicate with rural women Veterans about VHA services. Rural women Veterans were recruited through community engagement with established partners and a mass mailing to rural women Veterans not enrolled in or using VHA healthcare. Ten virtual focus groups were conducted with a total of twenty-nine rural women Veterans (27 not enrolled in VHA care and 2 who had not used VHA care in the past 5 years) in 2021. A thematic inductive analytic approach was used to analyze focus group transcripts. Primary themes regarding rural women Veterans' perceptions of barriers to enrollment and use of VHA healthcare included: (1) poor communication about eligibility and the process of enrollment; (2) belief that VHA does not offer sufficient women's healthcare services; and (3) inconvenience of accessing VHA facilities. Although VHA has substantially expanded healthcare services for women Veterans, awareness of such services and the nuances of eligibility and enrollment remains an impediment to enrolling in and using VHA healthcare among rural women Veterans. Recommended strategies include targeted communication with rural women Veterans not enrolled in VHA care to increase their awareness of the enrollment process, eligibility, and expansion of women's healthcare services. Creative strategies to address access and transportation barriers in rural locations are also needed.

Feasibility of an intensive outpatient treatment program for posttraumatic stress disorder within the veterans health care administration.

Trauma-focused treatments for posttraumatic stress disorder (PTSD), such as Prolonged Exposure (PE) therapy and Cognitive Processing Therapy (CPT), are effective and supported by various Clinical Practice Guidelines; however, drop-out rates for the treatments are as high as 40% within clinical programs. One promising solution is delivering the evidence-based psychotherapies (EBPs) three or more times per week within an intensive outpatient program (IOP) for PTSD. The present study examined the feasibility and effectiveness of a relatively low-resourced PTSD IOP within a larger PTSD program at the Veterans Healthcare Administration. The intensive program offers two tracks (2 week or 4 week) grounded in the massed delivery of PE and CPT. Over a 12-month period, 351 veterans completed an assessment for PTSD and 172 started within one of the local PTSD programs (e.g., weekly, IOP, or residential). Results of the study demonstrated that the IOP is an acceptable (i.e., 87.3% completion rate) and effective (e.g., PTSD Checklist for Diagnostic and Statistical Manual [DSM-5] [PCL-5] decrease effect size d = 1.80) treatment option. There was also adequate demand for the program (e.g., 37.2% of patients engaged in care with the PTSD programs started the IOP), and the program was implemented with fidelity to the design. Taken together, the results of this study demonstrate that this low-resource IOP model is a promising approach to improve completion rates within the continuum of care for the treatment of PTSD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A Pilot Replication Study ofImplementing an Equine-Assisted Services Program Within a VA Residential Substance Use Disorder Treatment Program.

Veterans have high rates of substance use disorders and other mental health conditions including post-traumatic stress disorder. Effective treatments for these conditions exist; however, high attrition rates and residual symptoms after completing treatment are common. Complementary treatment approaches could enhance treatment engagement and/or response among this population. We previously reported a study of one such intervention, an equine-assisted learning, and psychotherapy incorporating horses intervention provided to veterans admitted to a Veterans Health Care Administration residential substance abuse treatment program. The first aim of this study was to replicate the previous study assessing the safety, feasibility, and preliminary outcomes of this intervention. The second aim was to examine the effect of participants attending multiple intervention sessions. Participants were 94 veterans who participated in one to six sessions of a 3-4-hour program consisting of both equine-assisted learning and psychotherapy incorporating horses. Pre- and post-session administration of the Positive and Negative Affect Scale, State-Trait Anxiety Inventory, and Craving Experience Questionnaire was utilized to assess changes in affect, anxiety, and craving. Wilcoxon signed-rank or paired two-tailed t-tests were utilized for pre- to post-session comparisons of the outcome measures for sessions 1-4. Generalized linear mixed-effects (GLME) models were constructed to determine the impact of dosage. GLME models were constructed to determine the impact of dosage. As with our previous study, the intervention was safe and feasible to utilize for this population. There were statistically significant pre- to post-session improvements, with medium-to-large effect sizes, for sessions 1-3 for negative affect and sessions 1 and 2 for positive affect, anxiety, and craving. The GLME models revealed no statistical significance for any of the predictors. Taken together, this study and our previous investigation of this equine-assisted services intervention suggest that it is safe and feasible to utilize for veterans admitted to a residential substance abuse treatment program and we have now found short-term benefits in two separate studies. Thus, a randomized controlled trial of this intervention is warranted to demonstrate cause and effect and determine whether longer-term benefits are associated with the intervention. The finding that there was no additional benefit from attendance at more than two intervention sessions suggests that dose-response relationship studies of equine-assisted services interventions for veterans are needed.

Hospitalizations Among Veterans Treated for Metastatic Prostate Cancer With Abiraterone or Enzalutamide

BackgroundAbiraterone and enzalutamide are second generation androgen receptor pathway inhibitors (ARPIs) used to treat advanced or metastatic prostate cancer. Without head-to-head comparative studies identifying 1 agent as preferred initial therapy, physician preferences guide initial ARPI choice. This study compares hospitalizations among patients treated initially with abiraterone versus enzalutamide. Patients and MethodsUnited States veterans treated with abiraterone or enzalutamide between May 13, 2011 and December 31, 2019; then compared hospitalization rate during first treatment with ARPI in the Veterans Healthcare Administration. Baseline incidence rate of hospitalization was determined from data 1 year prior to ARPI. Incidence Rate Difference (IRD) was calculated using χ2 test and difference in IRD using Poisson Regression. Results19,775 veterans were identified; 13,527 (68.4%) were initially treated with abiraterone and 6248 (31.6%) initially with enzalutamide. The enzalutamide cohort was older (75.8 vs. 74.5 years, P < .001) and had higher baseline comorbidities at ARPI initiation (4.4 vs. 4.0, P < .001). Patients were treated with enzalutamide longer than abiraterone (median 9.0 vs. 8.0 months, P < .001). Total hospitalizations increased from 465 per 1000 person-years in the year prior to treatment with abiraterone to 567 during treatment. Total hospitalizations increased from 417 per 1000 person-years in the year prior to treatment with enzalutamide to 430 during treatment. Total rate of hospitalization increased 22% for abiraterone compared to a 3% increase for enzalutamide in the 12 months after ARPI initiation (P < .0001). Abiraterone was associated with greater increase in rates of acute heart failure, atrial fibrillation, acute kidney injury, urinary tract infections, sepsis, and pneumonia. ConclusionBy comparing the rate of hospitalization before vs. during treatment, real world analyses identified a 22% versus 3% increase in hospitalizations with abiraterone compared to enzalutamide respectively, despite being used in a younger population with less comorbid disease. Abiraterone was also associated with higher risk of infections, a novel finding.

Unhealthy alcohol use and brief intervention rates among high and low complexity veterans seeking primary care services in the Veterans Health Administration

IntroductionBrief intervention (BI) is recommended for all primary care (PC) patients who screen positive for unhealthy alcohol use; however, patients with multiple chronic health conditions who are at high-risk of hospitalization (i.e., “high complexity” patients) may face disparities in receiving BIs in PC. The current study investigated whether high complexity and low complexity patients in the Veterans Health Administration (VHA) differed regarding screening positive for unhealthy alcohol use, alcohol-use severity, and receipt of BI for those with unhealthy alcohol use. MethodsPatients were veterans receiving PC services at the VHA in a mid-Atlantic region of the United States. The study extracted VHA administrative and clinical data for a total of 282,242 patients who had ≥1 PC visits between 1/1/2014 and 12/31/2014, during which they were screened for unhealthy alcohol use by the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C). The study defined high complexity patients as those within and above the 90th percentile of risk for hospitalization per the VHA's Care Assessment Need Score. Logistic regression models assessed if being a high complexity patient was associated with screening positive for unhealthy alcohol use (AUDIT-C ≥ 5), severity of unhealthy alcohol use in those who screened positive (AUDIT-C score range 5–12), and receipt of BI in those who screened positive. ResultsOur sample was 94.5% male, 83% White, 13% Black, 4% other race, and 1.7% Hispanic. A total of 10,813 (3.8%) patients screened positive for unhealthy alcohol use from which we identified 569 (5.3%) high complexity and 10,128 (93.6%) low complexity patients (n = 116 removed due to missing complexity data). Relative to low complexity patients, high complexity patients were less likely to screen positive for unhealthy alcohol use (3.3% vs. 4.1%, AOR = 0.59, p < .001); however, in patients who screened positive, high complexity patients had higher AUDIT-C scores (Mean AUDIT-C = 7.75 vs. 6.87, AOR = 1.46, p < .001) and were less likely to receive a BI (78.0% vs. 92.6%, AOR = 0.42, p < .001). ConclusionsDisparities in BI exist for highly complex patients despite having more severe unhealthy alcohol use. Future research should examine the specific patient- and/or clinic-level factors impeding BI delivery for complex patients.

Effect of a National VHA Medical Scribe Pilot on Provider Productivity, Wait Times, and Patient Satisfaction in Cardiology and Orthopedics

BackgroundSection 507 of the VA MISSION Act of 2018 mandated a 2-year pilot study of medical scribes in the Veterans Health Administration (VHA), with 12 VA Medical Centers randomly selected to receive scribes in their emergency departments or high wait time specialty clinics (cardiology and orthopedics). The pilot began on June 30, 2020, and ended on July 1, 2022.ObjectiveOur objective was to evaluate the impact of medical scribes on provider productivity, wait times, and patient satisfaction in cardiology and orthopedics, as mandated by the MISSION Act.DesignCluster randomized trial, with intent-to-treat analysis using difference-in-differences regression.PatientsVeterans using 18 included VA Medical Centers (12 intervention and 6 comparison sites).InterventionRandomization into MISSION 507 medical scribe pilot.Main MeasuresProvider productivity, wait times, and patient satisfaction per clinic-pay period.Key ResultsRandomization into the scribe pilot was associated with increases of 25.2 relative value units (RVUs) per full-time equivalent (FTE) (p < 0.001) and 8.5 visits per FTE (p = 0.002) in cardiology and increases of 17.3 RVUs per FTE (p = 0.001) and 12.5 visits per FTE (p = 0.001) in orthopedics. We found that the scribe pilot was associated with a decrease of 8.5 days in request to appointment day wait times (p < 0.001) in orthopedics, driven by a 5.7-day decrease in appointment made to appointment day wait times (p < 0.001), and observed no change in wait times in cardiology. We also observed no declines in patient satisfaction with randomization into the scribe pilot.ConclusionsGiven the potential improvements in productivity and wait times with no change in patient satisfaction, our results suggest that scribes may be a useful tool to improve access to VHA care. However, participation in the pilot by sites and providers was voluntary, which could have implications for scalability and what effects could be expected if scribes were introduced to the care process without buy-in. Cost was not considered in this analysis but is an important factor for future implementation.Trial RegistrationClinicalTrials.gov Identifier: NCT04154462.

An open trial of VA CONNECT: Caring for Our Nation's Needs Electronically during the COVID-19 Transition.

The COVID-19 pandemic impacted emotional well-being due to safety concerns, grief, employment impacts, and social interaction limitations. Face-to-face mental health treatment restrictions were especially impactful to veterans who often gain social enrichment from Veterans Health Administration (VHA) care. We present results from a novel group-based telehealth intervention, VA Caring for Our Nation's Needs Electronically during the COVID-19 Transition (VA CONNECT), which integrates skills training and social support to develop a COVID-19 Safety & Resilience Plan. Veterans (n​=​29) experiencing COVID-related stress participated in an open trial of this 10-session, manualized group VHA telehealth intervention. We examined whether COVID-19-related stress, adjustment disorder symptoms, and loneliness decreased, and coping strategy use increased after participation in VA CONNECT. Between baseline and two-month follow-up, participants reported a significant reduction in perceived stress and adjustment disorder symptoms, and an increase in planning coping skills use. Significant changes were not observed in loneliness or other specific coping strategies. Findings may support the utility of VA CONNECT as an intervention for pandemic-related stress and improving certain coping skills. Future research should explore group-based telehealth interventions like VA CONNECT with other populations within and outside of the VA, which have value during major disruptions to face-to-face mental healthcare access.

Mortality Among US Veterans Admitted to Community vs Veterans Health Administration Hospitals for COVID-19

Veterans Health Administration (VHA) enrollees receive care for COVID-19 in both VHA and non-VHA (ie, community) hospitals, but little is known about the frequency or outcomes of care for veterans with COVID-19 in VHA vs community hospitals. To compare outcomes among veterans admitted for COVID-19 in VHA vs community hospitals. This retrospective cohort study used VHA and Medicare data from March 1, 2020, to December 31, 2021, on hospitalizations for COVID-19 in 121 VHA and 4369 community hospitals in the US among a national cohort of veterans (aged ≥65 years) enrolled in both the VHA and Medicare with VHA care in the year prior to hospitalization for COVID-19 based on the primary diagnosis code. Admission to VHA vs community hospitals. The main outcomes were 30-day mortality and 30-day readmission. Inverse probability of treatment weighting was used to balance observable patient characteristics (eg, demographic characteristics, comorbidity, mechanical ventilation on admission, area-level social vulnerability, distance to VHA vs community hospitals, and date of admission) between VHA and community hospitals. The cohort included 64 856 veterans (mean [SD] age, 77.6 [8.0] years; 63 562 men [98.0%]) dually enrolled in the VHA and Medicare who were hospitalized for COVID-19. Most (47 821 [73.7%]) were admitted to community hospitals (36 362 [56.1%] admitted to community hospitals via Medicare, 11 459 [17.7%] admitted to community hospitals reimbursed via VHA's Care in the Community program, and 17 035 [26.3%] admitted to VHA hospitals). Admission to community hospitals was associated with higher unadjusted and risk-adjusted 30-day mortality compared with admission to VHA hospitals (crude mortality, 12 951 of 47 821 [27.1%] vs 3021 of 17 035 [17.7%]; P < .001; risk-adjusted odds ratio, 1.37 [95% CI, 1.21-1.55]; P < .001). Readmission within 30 days was less common after admission to community compared with VHA hospitals (4898 of 38 576 [12.7%] vs 2006 of 14 357 [14.0%]; risk-adjusted hazard ratio, 0.89 [95% CI, 0.86-0.92]; P < .001). This study found that most hospitalizations for COVID-19 among VHA enrollees aged 65 years or older were in community hospitals and that veterans experienced higher mortality in community hospitals than in VHA hospitals. The VHA must understand the sources of the mortality difference to plan care for VHA enrollees during future COVID-19 surges and the next pandemic.

Evidence-Based Intervention Adaptations Within the Veterans Health Administration: a Scoping Review.

Veterans receiving care within the Veterans Health Administration (VA) are a unique population with distinctive cultural traits and healthcare needs compared to the civilian population. Modifications to evidence-based interventions (EBIs) developed outside of the VA may be useful to adapt care to the VA healthcare system context or to specific cultural norms among veterans. We sought to understand how EBIs have been modified for veterans and whether adaptations were feasible and acceptable to veteran populations. We conducted a scoping review of EBI adaptations occurring within the VA at any time prior to June 2021. Eligible articles were those where study populations included veterans in VA care, EBIs were clearly defined, and there was a comprehensive description of the EBI adaptation from its original context. Data was summarized by the components of the Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME). We retrieved 922 abstracts based on our search terms. Following review of titles and abstracts, 49 articles remained for full-text review; eleven of these articles (22%) met all inclusion criteria. EBIs were adapted for mental health (n = 4), access to care and/or care delivery (n = 3), diabetes prevention (n = 2), substance use (n = 2), weight management (n = 1), care specific to cancer survivors (n = 1), and/or to reduce criminal recidivism among veterans (n = 1). All articles used qualitative feedback (e.g., interviews or focus groups) with participants to inform adaptations. The majority of studies (55%) were modified in the pre-implementation, planning, or pilot phases, and all were planned proactive adaptations to EBIs. The reviewed articles used a variety of methods and frameworks to guide EBI adaptations for veterans receiving VA care. There is an opportunity to continue to expand the use of EBI adaptations to meet the specific needs of veteran populations.

Improving suicide prevention for women veterans: Recommendations from VHA suicide prevention coordinators

ObjectiveWomen are a minority veteran subpopulation experiencing particular risk for suicide and facing distinct challenges in accessing Veterans Health Administration (VHA) care. As part of efforts to enhance suicide prevention, the VHA established Suicide Prevention Coordinators (SPC) as clinicians who work exclusively to connect high-risk veterans to the scope of VHA's services. To understand the experiences of women veterans with suicide risk who access care, this study presents findings from qualitative interviews with SPCs regarding the care needs, preferences, and concerns of women veterans who utilize VHA for enhanced suicide-related care. MethodsWe conducted qualitative interviews with 20 SPCs from 13 VAMCs around the United States. We specifically asked SPCs to share perspectives on women veterans' barriers to accessing care and their recommendations to improve suicide prevention for this subpopulation. We conducted a thematic content analysis to extract key themes. ResultsSPCs revealed that women veterans opt to avoid VHA due to prior negative experiences, often related to provider sensitivity to women's issues. Safety was another key concern, specifically related to feeling unwelcome or intimidated in the male dominated veteran community. Key provider recommendations include increasing the availability of gender-sensitive providers and making changes to the physical spaces of the VHA to better facilitate women veterans' access to care. ConclusionsSPCs underscored the importance of comfort and relatability between women patients and providers, especially in relation to enhanced care for suicide risk. This study presents important evidence in support of enhancing suicide prevention by better engaging women veterans in care that is more inclusive and more sensitive to their experiences and identity, in and outside VHA.

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.

Assessing Racial Disparities in Access, Use, and Outcomes for Pregnant and Postpartum Veterans and Their Infants in Veterans Health Administration.

Objective: Limited population-based data examines racial disparities among pregnant and postpartum Veterans. Our objective was to determine whether Black/white racial disparities in health care access, use, and Veteran and infant outcomes are present among pregnant and postpartum Veterans and their infants using Veterans Health Administration (VA) care. Methods: The VA National Veteran Pregnancy and Maternity Care Survey included all Veterans with a VA paid live birth between June 2018 and December 2019. Participants could complete the survey online or by telephone. The independent variable was self-reported race. Outcomes included timely initiation of prenatal care, perceived access to timely prenatal care, attendance at a postpartum check-up, receipt of needed mental health care, cesarean section, postpartum rehospitalization, low birthweight, preterm birth, admission to a neonatal intensive care unit, and breastfeeding. Nonresponse weighted general linear models with a log-link were used to examine associations of race with outcomes. Cox regression was used to examine the association of race with duration of breastfeeding. Models adjusted for age, ethnicity, urban versus rural residence, and parity. Results: The analytic sample consisted of 1,220 Veterans (Black n = 916; white n = 304) representing 3,439 weighted responses (Black n = 1,027; white n = 2,412). No racial disparities were detected for health care access or use. Black Veterans were more likely than white Veterans to have a postpartum rehospitalization (RR 1.67, 95% CI: 1.04-2.68) and a low-birthweight infant (RR 1.67, 95% CI: 1.20-2.33). Conclusion: While no racial disparities were detected for health care access and use, we identified disparities in postpartum rehospitalization and low birthweight, underscoring that access is not sufficient for ensuring health equity.

Research Priorities to Support Women Veterans' Reproductive Health and Health Care Within a Learning Health Care System.

Research Priorities to Support Women Veterans' Reproductive Health and Health Care Within a Learning Health Care System.

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).

The epidemiology of mild cognitive impairment, Alzheimer's disease and related dementia in U.S. veterans.

US veterans have a unique dementia risk profile that may be evolving over time. Age-standardized incidence and prevalence of Alzheimer's disease (AD), AD and related dementias (ADRD), and mild cognitive impairment (MCI) was estimated from electronic health records (EHR) data for all veterans aged 50 years and older receiving Veterans Health Administration (VHA) care from 2000 to 2019. The annual prevalence and incidence of AD declined, as did ADRD incidence. ADRD prevalence increased from 1.07% in 2000 to 1.50% in 2019, primarily due to an increase in the prevalence of dementia not otherwise specified. The prevalence and incidence of MCI increased sharply, especially after 2010. The prevalence and incidence of AD, ADRD, and MCI were highest in the oldest veterans, in female veterans, and in African American and Hispanic veterans. We observed 20-year trends of declining prevalence and incidence of AD, increasing prevalence of ADRD, and sharply increasing prevalence and incidence of MCI.

Clinical Validity of the PROMIS Healthcare Engagement 8-Item Short Form.

Healthcare engagement is a key measurement target for value-based healthcare, but a reliable and valid patient-reported measure has not yet been widely adopted. To assess the validity of a newly developed patient-reported measure of healthcare engagement, the 8-item PROMIS Healthcare Engagement (PHE-8a). Prospective cohort study of the association between healthcare engagement and quality of care over 1 year. We fit mixed effects models of quality indicators as a function of engagement scores, adjusting for age, race/ethnicity, rural residence, and risk scores. National stratified random sample of 9552 Veterans receiving Veterans Health Administration care for chronic conditions (hypertension, diabetes) or mental health conditions (depression, post-traumatic stress disorder). Patient experience: Consumer Assessment of Health Plans and Systems communication and self-management support composites; no-show rates for primary care and mental health appointments; use of patient portal My HealtheVet; and Healthcare Effectiveness Data and Information Set electronic quality measures: HbA1c poor control, controlling high blood pressure, and hyperlipidemia therapy adherence. Higher engagement scores were associated with better healthcare quality across all outcomes, with each 5-point increase (1/2 standard deviation) in engagement scores associated with statistically significant and clinically meaningful gains in quality. Across the continuum of low to high engagement scores, we observed a concomitant reduction in primary care no-show rates of 37% and 24% for mental health clinics; an increased likelihood of My HealtheVet use of 15.4%; and a decreased likelihood of poor diabetes control of 44%. The PHE-8a is a brief, reliable, and valid patient-reported measure of healthcare engagement. These results confirm previously untested hypotheses that patient engagement can promote healthcare quality.

Unmet Need for Outpatient Occupational Therapy Services Among Veterans With Mild Traumatic Brain Injury in the Veterans Health Administration: The Role of Facility Characteristics

ObjectiveTo investigate whether participation restrictions, an indicator of need for occupational therapy (OT), was associated with outpatient OT utilization in the Veterans Health Administration (VHA) among Veterans with mild traumatic brain injury (mTBI), and whether this relation differs by facility characteristics. DesignIn a secondary analysis of national VHA data, we used modified Poisson regression to model OT utilization (yes/no) as a function of participation restrictions (Mayo-Portland Adaptability Inventory Participation Index [M2PI]), facility characteristics, and covariates. Facility characteristics included complexity, geographic region, and self-reported access to specialty care. Covariates included prior OT utilization, sociodemographic factors, injury characteristics, and spatial access (eg, drive time). Interactions estimated whether the relation between participation restrictions and OT utilization differed across facility characteristics. SettingOutpatient setting in the VHA. Participants8684 Veterans with a clinician-confirmed mTBI who received outpatient VHA care between 2012 and 2020 (N=8684). InterventionsNone. Main Outcome Measure(s)OT utilization was measured within a year of M2PI administration using VHA administrative data. ResultsMany Veterans who did not receive OT reported participation limitations, indicating unmet need for OT (eg, 67% with leisure restrictions). Participation restrictions were associated with increased likelihood of receiving OT (risk ratio [RR]=1.01; 95% confidence interval [CI]=1.006-1.019), suggesting a tendency for Veterans’ OT-related needs to be satisfied. However, interactions indicated that this was not the case among Veterans receiving care in lower complexity facilities, and those in the South. Veterans with longer drive times were less likely to receive OT (RR=0.82; 95% CI=0.744-0.904). ConclusionsParticipation restrictions were associated with OT utilization, yet many Veterans with mTBI who may have benefited did not receive such care. Specific barriers to accessing OT (eg, OT practitioner supply) should be investigated. Novel care models can ensure access to OT services among Veterans seeking care at less-resourced and/or geographically distant VHA facilities.

41 Prevalence of Diabetes Among Veterans by Sexual Orientation

OBJECTIVES/GOALS: There is evidence that lesbian, gay, and bisexual (LGB) adults have poorer cardiovascular health than their heterosexual peers, but studies of the association between sexual orientation (SO) and diabetes mellitus (DM) have been few with mixed findings. To further investigate this association, large cohorts with objective data capture are needed. METHODS/STUDY POPULATION: We used data from the Veterans Healthcare Administration Lesbian, Gay, Bisexual, Transgender EHR cohort which includes veterans with at least 2 encounters October 1, 2009-September 30, 2019. The first clinic visit in this window was the index date with the baseline date one year later; the intervening year served as a baseline period for observation of prevalent disease and comorbidities. We did not include transgender veterans in this analysis in order to focus on SO rather than on the intersection of SO with gender identity. The SO of 1,108,990 veterans was identified using a natural language processing tool; 185,788 veterans were classified as LGB. We first examined sample characteristics by sex and SO and then used logistic regression to assess the association between SO and prevalent DM. RESULTS/ANTICIPATED RESULTS: DM was present among 193,330 veterans (32,986 LGB). Mean age was similar across SO in women (41) and men (53). Distribution of race was similar across groups, but LGB veterans were more likely to be Hispanic (11%, both sexes) than non-LGB men (6%) and women (8%). Current smoking was more prevalent among LGB (44% men, 39% women) than non-LGB veterans (40% men, 30% women). Adjusting for age, sex, race, Hispanic ethnicity, BMI, smoking status, health insurance, marital status, and enrollment priority, LGB veterans had 1.12 [1.10, 1.13] times the odds of DM vs. non-LGB veterans. Bisexual (0.87 [0.74, 1.01]) or lesbian (1.03 [0.97, 1.10]) women did not have significantly different DM odds than non-LGB women. Bisexual men had lower DM odds (0.86 [0.80, 0.93]) while gay men had higher odds (1.04 [1.01, 1.06]) than non-LGB men. DISCUSSION/SIGNIFICANCE: This is one of the first studies to report DM in a veteran cohort stratified by SO. Our findings highlight the importance of examining SO groups separately and jointly, as to further elucidate the association between SO, cardiovascular risk factors, and general cardiovascular health. Future work will examine the intersection of SO and gender identity.

Analysis of Reported Suicide Safety Events Among Veterans Who Received Treatment Through Department of Veterans Affairs-Contracted Community Care.

Veteran patients have access to a broad range of health care services in the Veterans' Health Administration (VHA). There are concerns, however, that all Veteran patients may not have access to timely care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act was passed in 2018 to ensure that eligible Veterans can receive timely, high-quality care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act makes use of Department of Veterans Affairs (VA)-contracted care to achieve its goal. There are concerns, however, that these transitions of care may, in fact, place Veterans at a higher risk of poor health outcomes. This is a particular concern with regard to suicide prevention. No study has investigated suicide-related safety events in Veteran patients who receive care in VA-contracted community care settings. A retrospective analysis of root-cause analysis (RCA) reports and patient safety reports of suicide-related safety events that involved VA-contracted community care was conducted. Events that were reported to the VHA National Center for Patient Safety between January 1, 2018, and June 30, 2022, were included. A coding book was developed to abstract relevant variables from each report, for example, report type and facility and patient characteristics. Root causes reported in RCAs were also coded, and the factors that contributed to the events were described in the patient safety reports. Two reviewers independently coded 10 cases, and we then calculated a kappa. Because the kappa was greater than 80% (i.e. 89.2%), one reviewer coded the remaining cases. Among 139 potentially eligible reports, 88 reports were identified that met the study inclusion criteria. Of these 88 reports, 62.5% were patient safety reports and 37.5% were RCA reports. There were 129 root causes of suicide-related safety events involving VA-contracted community care. Most root causes were because of health care-related processes. Reports cited concerns around challenges with communication and deficiencies in mental health treatment. A few reports also described concerns that community care providers were not available to engage in patient safety activities. Patient safety reports voiced similar concerns but also pointed to specific issues with the safety of the environment, for example, access to methods of strangulation in community care treatment settings in an emergency room or a rehabilitation unit. It is important to strengthen the systems of care across VHA- and VA-contracted community care settings to reduce the risk of suicide in Veteran patients. This includes developing standardized methods to improve the safety of the clinical environment as well as implementing robust methods to facilitate communication between VHA and community care providers. In addition, Veteran patients may benefit from quality and safety activities that capitalize on the collective knowledge of VHA- and VA-contracted community care organizations.