Veterans Affairs Center Research Articles

Use Patterns, Technical Challenges and Patient Selection Associated With Single Use Duodenoscopes & Duodenoscopes With Single Use Endcaps In The United States & Canada

Background & AimsThe extent of adoption, patient selection and use patterns of single use duodenoscopes and duodenoscopes with single use endcaps have not yet been characterized, nor have large scale assessments of endoscopist-reported function and challenges. MethodsAn anonymous 6-minute electronic survey assessing use and experience with single use duodensocopes and duodenoscopes with novel design features was distributed to US and Canadian endoscopy centers and responses were analyzed using descriptive statistics. ResultsThe survey was notable for a 70.2% response rate, with representation from academic (68.9%), community (18%) and veterans affairs (8.2%) centers. Most institutions use standard reprocessable duodenoscopes and duodenoscopes with single use endcaps (34.4%), or a mix of standard reprocessable duodenoscopes, duodenoscopes with single use endcaps and single use duodenoscopes (29.5%). No center used only single use duodenoscopes (0%). 10.3% planned to transition to the duodenoscope with a single use endcap, 10.3% to a mix of single use duodenoscopes and duodenoscopes with single use endcap, and 1.7% to single use duodenoscopes alone. Challenges were reported with each type of novel duodenoscope and selection patterns for use were characterized. ConclusionsThis first-of-its-kind large scale survey of use patterns and functionality of newly introduced duodenoscopes is notable for fairly widespread use of the duodenoscopes with single use endcaps and more limited use of the single use duodenoscope. Both novel duodenoscope designs are associated with mechanical limitations that respondents indicate represent challenges to successful completion of ERCPs.

Higher Rate of Spontaneous Bacterial Peritonitis Recurrence With Secondary Spontaneous Bacterial Peritonitis Prophylaxis Compared With No Prophylaxis in 2 National Cirrhosis Cohorts.

Spontaneous bacterial peritonitis (SBP) bacteriology has changed over time. Reappraisal of primary SBP prophylaxis showed an increased rate of resistance in patients on primary prophylaxis with resultant discontinuation of this prophylaxis throughout the Veterans Affairs (VA). We aimed to re-evaluate the risk-benefit ratio of secondary SBP prophylaxis (SecSBPPr). Using validated International Classification of Diseases-9/10 codes, we used the VA Corporate Data Warehouse and the Non-VA National TriNetX database to identify patients in 2 different large US systems who survived their first SBP diagnosis (with chart review from 2 VA centers) between 2009 and 2019. We evaluated the prevalence of SecSBPPr and compared outcomes between those who started on SecSBPPr vs not. We identified 4,673 veterans who survived their index SBP episode; 54.3% of whom were prescribed SecSBPPr. Multivariable analysis showed higher SBP recurrence risk in those on vs off SecSBPPr (hazards ratio 1.63 [1.40-1.91], P < 0.001). This was accompanied by higher fluoroquinolone resistance odds in SecSBPPr patients (odds ratio = 4.32 [1.36-15.83], P = 0.03). In TriNetX, we identified 6,708 patients who survived their index SBP episode; 48.6% were on SecSBPPr. Multivariable analysis similarly showed SecSBPPr increased SBP recurrence risk (hazards ratio 1.68 [1.33-1.80], P < 0.001). Both data sets showed higher SBP recurrence trends over time in SecSBPPr patients. Results remained consistent at 6-month and 2-year timepoints. In 2 national data sets of >11,000 patients with SBP, we found that SecSBPPr was prescribed in roughly half of patients. When initiated, SecSBPPr, compared with no prophylaxis after SBP, increased the risk of SBP recurrence in multivariable analysis by 63%-68%, and this trend worsened over time. SecSBPPr should be reconsidered in cirrhosis.

Exploring Colorectal Cancer Screening Reach Among United States Veterans: Analyzing Clinical, Sociodemographic, and Social Determinants of Health-Based Patient Factors Across Screening Methods: Analyzing Clinical, Sociodemographic, and Social Determinants of Health-based Patient Factors Across Screening Methods.

Mailed fecal immunochemical testing (mFIT), in-clinic FIT (cFIT), and colonoscopy are believed to reach distinct patient populations. This study aims to evaluate this belief. Sociodemographic, clinical, and social determinants of health (SDOH) characteristics of 201 patients completing mFIT, 203 patients completing cFIT, and 74 patients completing colonoscopy at a Northeastern United States Veterans Affairs center from August 2023 to January 2024 were compared using descriptive statistics, χ2, and ANOVA tests. Patients completing mFIT (P=0.003) and cFIT (P=0.001) were older than those completing colonoscopy. mFIT patients had more private health insurance as compared with cFIT (P<0.0001) patients. Patients completing colonoscopy had higher average disability ratings as compared with cFIT patients (P<0.0001). mFIT (P<0.0001) and colonoscopy (P<0.0001) patients had more time elapsed since their last primary care visit as compared with cFIT patients. mFIT patients had lower rates of mental health disorders as compared with colonoscopy (P<0.0001) and cFIT (P<0.0001) patients. cFIT patients had higher rates of past stool test use as compared with mFIT (P<0.0001) and colonoscopy (P<0.0001) patients. mFIT patients had lower rates of past colonoscopy completion as compared with cFIT (P<0.0001) and colonoscopy (P<0.0001) patients. There were no significant differences in SDOH domains among patients completing each of the screening methods. While each of the screening methods reaches a different patient population, mFIT does not reach a substantially more vulnerable population compared with cFIT and colonoscopy, highlighting the need for improvements in mFIT outreach.

Paroxysmal Atrial Fibrillation History is Associated with Earlier Recurrence After First Cardioversion Compared to Primary Persistent Atrial Fibrillation

BackgroundParoxysmal atrial fibrillation (pAF) may progress through cardiac remodeling to persistent atrial fibrillation (psAF). However, some may present in psAF without a preceding history of pAF. A preceding history of pAF may affect recurrence following direct current cardioversion (DCCV). ObjectiveTo determine if a preceding history of pAF is associated with a difference in recurrence rates after DCCV compared to patients without a preceding history of pAF. MethodsA prospective procedural database at a Veterans Affairs center identified 565 patients who underwent their first DCCV for psAF. Initial rhythm history was separated by prior pAF and those with none were considered primary psAF. ECG follow-up was standardized at 1- and 3- months post cardioversion. ResultsPatients who underwent their first DCCV for psAF were more likely to have presented with primary psAF (81.6%). Those with pAF had a similar left atrial size, but were more likely to have chronic kidney disease, sleep apnea, previous stroke, and utilizing antiarrhythmic drugs at the time of cardioversion. Patients with pAF had earlier recurrence and shorter median AF survival time, 1.6 months compared to 5 months (Kaplan-Meier plot p=0.0101). This difference persisted when controlling for AAD use. Recurrence type was mostly persistent AF, similar in both groups. ConclusionPatients with primary psAF may have a more sustained response to DCCV when compared to those with a preceding history of pAF. Thus, those patients with pAF may benefit from a more aggressive, early rhythm control strategy due to higher likelihood of recurrence with DCCV.

Implementation of an Accelerated Infusion Protocol (90-Minute Infusion) of Rituximab and Its Safety in Patients With Autoimmune Rheumatic Diseases at a Tertiary Veterans Affairs Center.

Background Rituximab, a chimeric monoclonal antibody targeting the CD20 protein on the surface of B cells, is used to treat several rheumatologic and oncologic diseases. The standard infusion duration of rituximab is four hours. Objective Evaluating the safety of administering the accelerated 90-minute protocol at our Veterans Affairs center to patients with rheumatologic diseases and monitoring for any infusion-related reactions. This study is unique as it examines infusion rates faster than those most described (120 minutes). Methods Patients treated with rituximab for autoimmune diseases between June 2020 and June 2022 at our center were included in the study. Our patients were over 18 years of age,met the inclusion criteria, and had received previous rituximab infusions without prior infusion-related reactions. They received the accelerated protocol of 90 minutes over their next cycles and were monitored for any reactions during their infusions. Results A total of 34 patients receiving 76 infusions were included in the analysis. Most of the patients were males (n = 27). The most prevalent indication for rituximab infusion was rheumatoid arthritis (n = 20).Out of 76 infusions, only two infusion-related reactions were recorded (2.6% incidence). The first patient had itching and a sore throat, indicating a grade 1A reaction. The second patient developed chest pain and dyspnea, which resolved with diphenhydramine and albuterol. For both, the infusion was completed after appropriate management. Conclusion The incidence of infusion-related reactions during the accelerated 90-minute rituximab infusion was remarkably low and well-tolerated by our rituximab-experienced patients. Only two infusions were complicated by a reaction, an incidence comparable to or even lower than other reported 120-minute infusion protocols.This protocol is time- and cost-efficient, allowing for more infusions per chair per day at our center.

Culture change and lessons learned from ten years in the VA centers of excellence in primary care education

BackgroundTeam-based care is critical to achieving health care value while maximizing patient outcomes. Few descriptions exist of graduate-level team training interventions and practice models. Experience from the multisite, decade-long Veterans Affairs (VA) Centers of Excellence in Primary Care Education provides lessons for developing internal medicine training experiences in interprofessional clinical learning environments.MethodsA review of multisite demonstration project transforming traditional silo-model training to interprofessional team-based primary care. Using iterative quality improvement approaches, sites evaluated curricula with learner, faculty and staff feedback. Learner- and patient-level outcomes and organizational culture change were examined using mixed methods, within and across sites. Participants included more than 1600 internal medicine, nurse practitioner, nursing, pharmacy, psychology, social work and physical therapy trainees. This took place in seven academic university-affiliated VA primary care clinics with patient centered medical home designResultsEach site developed innovative design and curricula using common competencies of shared decision making, sustained relationships, performance improvement and interprofessional collaboration. Educational strategies included integrated didactics, workplace collaboration and reflection. Sites shared implementation best practices and outcomes. Cross-site evaluations of the impacts of these educational strategies indicated improvements in trainee clinical knowledge, team-based approaches to care and interest in primary care careers. Improved patient outcomes were seen in the quality of chronic disease management, reduction in polypharmacy, and reduced emergency department and hospitalizations. Evaluations of the culture of training environments demonstrated incorporation and persistence of interprofessional learning and collaboration.ConclusionsAligning education and practice goals with cross-site collaboration created a robust interprofessional learning environment. Improved trainee/staff satisfaction and better patient care metrics supports use of this model to transform ambulatory care training.Trial registrationThis evaluation was categorized as an operation improvement activity by the Office of Academic Affairs based on Veterans Health Administration Handbook 1058.05, in which information generated is used for business operations and quality improvement (Title 38 Code of Federal Regulations Part 16 (38 CFR 16.102(l)). The overall project was subject to administrative oversight rather Human Subjects Institutional Review Board, as such informed consent was waived as part of the project implementation and evaluation.

Challenges of living with veterans with post-traumatic stress disorder from the perspective of spouses: a qualitative content analysis study

Background and objectiveThe needs and characteristics of veterans with post-traumatic stress disorder (PTSD) create significant challenges in family life, particularly for spouses. Identifying the nature of these challenges from the perspective of spouses leads to a more comprehensive and profound understanding of their existing problems and can be used for targeted interventions. Therefore, this research was conducted to explore the challenges of living with veterans suffering from PTSD from the perspective of their spouses.MethodsThis qualitative study used conventional content analysis to explore Challenges of spouses of veterans with post-traumatic stress disorder. Fifteen spouses of veterans with PTSD from the Veterans Affairs Center in Iran between June 2022 and January 2023, were purposively selected to participate in the study. Semi-structured in-depth interviews were conducted to collect data. The interviews were audio-recorded and transcribed verbatim. The data were analyzed using the method proposed by Graneheim and Lundman content analysis method with the support of MAXQDA 2020 software.ResultsThe mean age of the participants was 56.74 ± 6.43 years. Through data analysis, seven main categories and sixteen subcategories were identified. These categories included burnout (sleep disturbances, feelings of exhaustion), apathy towards self-care and caring for the veteran (neglecting self-care, lack of interest in continuing care), depression (feelings of hopelessness and being at the end of the line, decreased self-confidence ( Crushed and ignored (being mistreated, having multiple roles), relationship disturbances (Dissatisfaction with marital relationship,isolation and limited social interactions, disconnection from God), financial burden (heavy costs of care, lack of insurance support), and declining social status (negative attitude of the society, suffering from discrimination and inequality).ConclusionThe consequences of PTSD-related injuries in veterans directly and indirectly affect the overall living conditions of their spouses. These spouses experience emotional detachment and constant rejection, leading to a decrease in their resilience against existing stressors and exposing them to disruptive and challenging issues in individual, family, and social dimensions of life that affect their physical and mental well-being. Therefore, these spouses require empowerment and access to social support in dimensions of educational, caregiving, therapeutic, and supportive. It is recommended that health policymakers pay special attention to designing up-to-date interventions to enhance the health of these spouses in physical, mental, spiritual, and social dimensions.

Letter: Integration of Veterans Affairs Medical Centers Into Neurosurgical Residency Programs.

To the Editor: We read with great interest the recent article published by Yearly et al1 highlighting the integration of Veterans Affairs (VA) Medical Center rotation into neurosurgery residency programs across the United States. The authors summarize succinctly the current state of affairs. At the University of Miami training program, our postgraduate year 3 (PGY3) residents rotate at the Bruce W. Carter VA Medical Center for 4 months. The VA rotation at our program has become known for its breadth through the wide skillset of contracted attendings, its innovation through the robust VA infrastructure, and its flexibility to continue training opportunities at the primary teaching site through its manageable clinical obligations. All these elements add to the findings of Yearly et al,1 affirming the formative nature of a VA rotation within neurosurgery training programs when possible. BREADTH There are 3 contracted attendings at our VA center, who specialize in complex spine, functional, tumor, and general cranial. Through this range of interests, the VA resident is exposed to these areas on a one-to-one basis with the attending because they are the sole resident on service. Our VA service make-up mirrors much of what Yearly et al1 report, in that spine surgeries are the most common, but within that, the complexities range from single-level laminectomy to multilevel cervical laminoplasties and lumbar fusions. Outside spine, a variety of procedures are also performed—a recent week's example includes spinal cord stimulator placement for pain, radiofrequency ablation for spinal metastasis, and endoscopic transsphenoidal resection for pituitary tumor. By having attendings who specialize in different areas, the VA rotation can provide the rotating resident exposure to a large breadth of surgical techniques. INNOVATION The infrastructure at the VA allows our department to incorporate new concepts and materials for the better of our patients. So much so that the invested interest from our anesthesia colleagues, operating room staff, and hospital managers has allowed the VA rotation to become known for better exposure to particular techniques than some of the other teaching sites within our program. This includes navigated single-position corpectomies and fusions and percutaneous spinal cord stimulator placements (Supplemental Figure 1,https://links.lww.com/NEU/D758). Furthermore, on the horizon for approval includes robotic spine surgery and stereotactic deep brain stimulation. Our experience therefore demonstrates the potential for the VA rotation within training programs to not only expose residents to standard operative techniques but also new and emerging ones too. FLEXIBILITY A normal week at the VA for our resident includes 2 operative days and 2 clinic days. Outside these clinical obligations, the vicinity of the primary teaching hospital allows the VA resident to participate in other clinical activities at the primary site. This can include further operative time and pursuing research interests which are both encouraged pending the resident's preference. A unique aspect of our VA center is its close proximity to the primary teaching hospital of our program—across the road. This location allows the VA resident to participate in all primary site learning activities (both in the morning and in the evening), as well as talk in-house overnight call at the primary site. Although not all VA centers are located so close to the primary teaching sites, our experience demonstrates that within a flexible set of obligations, a VA rotation is not a compromise in operative and academic opportunities if appropriate arrangements and schedules can be made ahead of time. At the University of Miami training program, the VA rotation has become a key and much looked forward to rotation among the residents. This is because of both the reasons Yearly et al1 highlight, as well as the elements we detail above. The VA rotation can be a pivotal experience for neurosurgery residents in their training, and maximizing where possible its breadth, innovation, and flexibility is highly encouraged.

Equitable implementation of innovations to promote successful aging in place.

Equitable implementation of innovations to promote successful aging in place.

Variation in patient demographics across different modalities of tele-oncology.

394 Background: TeleOncology encompasses the delivery of care virtually though modalities such as electronic consultation (e-consult), telephone and video visits. The National TeleOncology (NTO) program was created by Veterans Affairs (VA) to address growing disparities in care across the VA network. Through NTO, subspecialty hematologists/oncologists can provide recommendations and care for patients located at VA centers across the county. We aimed to investigate differences in patient utilization of available forms of TeleOncology. Methods: NTO was started in 2020 and offers virtual care to over 20 VA sites. Patient visits were catalogued across different forms of TeleOncology including telephone, e-consult (chart review only), VA Video Connect (VVC, synchronous video visit with patient at home), and Clinical Video Telehealth (CVT, synchronous video visit with patient at local VA). Total and unique patient encounters were analyzed based on patient age, gender, race, care assessment need (CAN) score (predictor for identifying patients at high-risk for poor outcomes), and patient rurality. Modalities of telehealth were then compared. Results: 3008 unique patients and 5921 encounters were recorded (October 2019-May 2022). The majority of patients accessed care by CVT visit (n = 1915). Patient characteristics were statistically different between the modes of TeleOncology. Patients participating in CVT were older (Mean 70.5 (95% CI 69.97-70.97) vs 65.5 years old (95% CI 64.62-66.68) and had higher CAN scores (mean score 82 (95% CI 80.96-82.74) vs 69 (95% CI 66.76-70.74)), compared to patients assessed through e-consult. Conversely black and female patients were overrepresented in the e-consult group compared to the CVT group (Table). Patients receiving care by telephone were more often located in a rural or highly rural region compared to those seen through VVC (71.5% vs 52%). Conclusions: The NTO program offers unique insights into utilization patterns of different forms of virtual care. Patient characteristics were not similar across the e-consult, telephone, and video visit groups. Importantly racial and gender disparities were noted, with African American and female patients, being disproportionately cared for through chart review only compared to a video visit. These results represent a first step in understanding how patients’ interface with virtual care modalities. Future studies could investigate how patient and system factors might influence observed patterns.[Table: see text]

Antimicrobial stewardship in solid organ transplantation: Perspective from a Veterans Affairs Medical Center.

The importance of antimicrobial stewardship (AMS) activities specifically focused on solid organ transplant (SOT) recipients is increasingly recognized. In 2014, the Veterans Health Administration (VHA) created national guidance and committed resources to establish AMS programs at Veterans Affairs (VA) medical centers across the country. However, the AMS implementation is at the discretion of individual VA centers. We undertook an environmental scan of AMS activities in a tertiary care VA medical center. We describe AMS activities focused on SOT recipients. Strategies based on local epidemiology that leverage the electronic medical record together with engagement by transplant infectious diseases personnel are likely to be beneficial. AMS in SOT recipients is challenging yet impactful. Strategies described here may be useful for AMS activities focused on the SOT population.

Consensus Quality Measures and Dose Constraints for Breast Cancer From the Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology Expert Panel

Using evidence-based radiation therapy to direct care for patients with breast cancer is critical to standardize practice, improve safety, and optimize outcomes. To address this need, the Veterans Affairs (VA) National Radiation Oncology Program (NROP) established the VA Radiation Oncology Quality Surveillance Program to develop clinical quality measures (QMs). The VA NROP contracted with the American Society for Radiation Oncology to commission 5 Blue Ribbon Panels for breast, lung, prostate, rectal, and head and neck cancers. The Breast Cancer Blue Ribbon Panel experts worked collaboratively with the NROP to develop consensus QMs for use throughout the VA system, establishing a set of QMs for patients in several areas, including consultation and work-up; simulation, treatment planning, and treatment; and follow-up care. As part of this initiative, consensus dose-volume histogram (DVH) constraints were outlined. In total, 36 QMs were established. Herein, we review the process used to develop QMs and final consensus QMs pertaining to all aspects of radiation patient care, as well as DVH constraints. The QMs and expert consensus DVH constraints are intended for ongoing quality surveillance within the VA system and centers providing community care for Veterans. They are also available for use by greater non-VA community measures of quality care for patients with breast cancer receiving radiation.

Hospital Operative Volume and Esophagectomy Outcomes in the Veterans Affairs System.

Previous studies reported that increased hospital case volume improves outcomes after esophagectomy. Yet, the standard for high and low-volume hospitals varies in the literature. This study attempts to define the relationship between hospital operative volume and 30-day post-operative outcomes of esophagectomy in the Veterans Affairs (VA) system. This is a retrospective review of patients that underwent esophagectomy from 2008 to 2019 utilizing the Veterans Affairs Surgical Quality Improvement Program Database. Receiver operating characteristic (ROC) analysis quantified an inflection point of optimal association between 30-day morbidity and mortality by facility volume. This point was used to separate cohorts for comparison of outcomes using 1:1 propensity score matching (PSM) to account for confounding covariates. Two thousand two hundred and twelve esophagectomies were performed from 2008 to 2019 and ROC analysis identified an inflection point at 43 cases (4 cases/y) where bidirectional operative volume significantly affected outcomes. Subsequent PSM resulted in 1718 cases utilized for analysis (n=859 per cohort). Facility volume ≥4 cases/y was significantly associated with decreased odds of 30-day mortality (odds ratio(OR)=0.57; P=0.03), shorter length of stay (median 13 versus 14d; P=0.04) and longer operative times (6.5 versus 6.0h; P<0.001). VA hospitals that averaged ≥4 esophagectomies/y had significantly lower rates of mortality and length of stay. This volume threshold may serve as a benchmark to determine the optimal setting for esophageal resection. However, our findings also may reflect the benefits of cumulative operating room and multidisciplinary team experience at VA centers in conjunction with dedicated surgeons. Future studies should focus on long-term outcomes after esophagectomy in relation to hospital operative volume.

Cochlear Implants in Veterans: 10-Year Experience at a Single Referral Center.

Severe hearing loss is particularly prevalent among Veterans. In response, the Veterans Affairs (VA) provides hearing aids and cochlear implants as part of their comprehensive hearing loss treatment. The VA's national health care system and integrated electronic health records offer a unique opportunity to examine patterns and outcomes in the management of severe hearing loss. We retrospectively reviewed an urban VA center's database for all Veterans who underwent cochlear implantation between 2010 and 2019. We collected preoperative demographic and audiological data including cochlear implant outcomes. During the study period, 61 Veterans received a cochlear implant, totaling 70 ears implanted. Median age at implantation was 70.2 years. Over 90% of Veterans reported preoperative hearing aid use, and median preoperative four-frequency pure-tone average and aided word recognition score in the ear to be implanted were 100 dB HL and 7%, respectively. The median onset of severe hearing loss bilaterally was over 4 years prior to cochlear implant evaluation based on available audiometric data. Postoperative word recognition score was negatively correlated with self-reported duration of hearing loss. This study provides unique insights into how Veterans with severe hearing loss are managed at one VA center. Compared to data published on cochlear implant recipients in the civilian population, Veterans in this cohort were older and had higher rates of preoperative hearing aid use. Available VA data suggest most Veterans were appropriate candidates for cochlear implant referral years prior to undergoing an evaluation. Reasons for treatment delays in this population remain to be studied.

Racial and Ethnic Disparities in Prostate Cancer Outcomes in the Veterans Affairs Health Care System

Prostate cancer (PCa) disproportionately affects African American men, but research evaluating the extent of racial and ethnic disparities across the PCa continuum in equal-access settings remains limited at the national level. The US Department of Veterans Affairs (VA) Veterans Hospital Administration health care system offers a setting of relatively equal access to care in which to assess racial and ethnic disparities in self-identified African American (or Black) veterans and White veterans. To determine the extent of racial and ethnic disparities in the incidence of PCa, clinical stage, and outcomes between African American patients and White patients who received a diagnosis or were treated at a VA hospital. This retrospective cohort study included 7 889 984 veterans undergoing routine care in VA hospitals nationwide from 2005 through 2019 (incidence cohort). The age-adjusted incidence of localized and de novo metastatic PCa was estimated. Treatment response was evaluated, and PCa-specific outcomes were compared between African American veterans and White veterans. Residual disparity in PCa outcome, defined as the leftover racial and ethnic disparity in the outcomes despite equal response to treatment, was estimated. Self-identified African American (or Black) and White race and ethnicity. Time to distant metastasis following PCa diagnosis was the primary outcome. Descriptive analyses were used to compare baseline demographics and clinic characteristics. Multivariable logistic regression was used to evaluate race and ethnicity association with pretreatment clinical variables. Multivariable Cox regression was used to estimate the risk of metastasis. Data from 7 889 984 veterans from the incidence cohort were used to estimate incidence, whereas data from 92 269 veterans with localized PCa were used to assess treatment response. Among 92 269 veterans, African American men (n = 28 802 [31%]) were younger (median [IQR], 63 [58-68] vs 65 [62-71] years) and had higher prostate-specific antigen levels (>20 ng/mL) at the time of diagnosis compared with White men (n = 63 467; [69%]). Consistent with US population-level data, African American veterans displayed a nearly 2-fold greater incidence of localized and de novo metastatic PCa compared with White men across VA centers nationwide. Among veterans screened for PCa, African American men had a 29% increased risk of PCa detection on a diagnostic prostate biopsy compared with White (hazard ratio, 1.29; 95% CI, 1.27-1.31; P < .001). African American men who received definitive primary treatment of PCa experienced a lower risk of metastasis (hazard ratio, 0.89; 95% CI, 0.83-0.95; P < .001). However, African American men who received nondefinitive treatment classified as “other” were more likely to develop metastasis (adjusted hazard ratio, 1.29; 95% CI, 1.17-1.42; P < .001). Using the actual rate of metastasis from veterans who received definitive primary treatment, a persistent residual metastatic burden for African American men was observed across all National Comprehensive Cancer Network risk groups (low risk, 4 vs 2 per 100 000; intermediate risk, 13 vs 6 per 100 000; high risk, 19 vs 9 per 100 000). This cohort analysis found significant disparities in the incidence of localized and metastatic PCa between African American veterans and White veterans. This increased incidence is a major factor associated with the residual disparity in PCa metastasis observed in African American veterans compared with White veterans despite their nearly equal response to treatment.

The Effects of Equine Therapy on Military Veterans with PTSD

The purpose of this study was to investigate the effectiveness of an Equine-Assisted Therapy (EAT) group program on the reduction of Post-Traumatic Stress Disorder (PTSD) symptoms in military veterans. Prior research suggests that longitudinal equine therapy programs result in lowered PTSD scores, however, fail to acknowledge veterans in Suffolk County, Long Island. The researcher conducted a mixed method correlational case study with veterans from a local Veterans Affairs (VA) Center which acted as a control. Beck’s Anxiety Inventory and NIMH Loneliness surveys were disseminated and anecdotal comments were collected in order to achieve an all encompassing approach. Participants included veterans of ages 29-68 from the XYZ equine therapy foundation and from a local VA, with an overwhelming majority of participants being white females. Initial results showed decreased anxiety and loneliness scores, suggesting that equine therapy is associated with a decrease in PTSD symptoms. Therefore, the conclusion can be made that equine therapy is an effective alternative treatment for veterans suffering from PTSD. However, such conclusions are limited to veterans on Long Island, thus, future research should apply this method on a larger, more diverse, sample size to determine effects on a greater population before pushing this therapy out on a wider scale. &#x0D; &#x0D; Keywords: Equine-assisted therapy; military veterans; PTSD; anxiety; loneliness&#x0D;

142-LB: Comparing Two Telehealth Interventions for Patients with Clinic-Refractory Type 2 Diabetes: A Randomized Controlled Trial

Patients whose type 2 diabetes (T2D) remains persistently poorly-controlled despite receiving clinic-based care are at high risk for complications and costs. To address clinic-refractory T2D within the Veterans Health Administration, we conducted a randomized trial comparing two nurse-delivered telehealth strategies to augment clinic-based care: 1) telemonitoring and care coordination; and 2) a comprehensive intervention combining telemonitoring, self-management support, diet/activity support, medication management, and depression management. Delivery of both interventions utilized only existing clinical staff and infrastructure. Patients (n=200) with HbA1c continually ≥8.5% for ≥1 year despite receiving diabetes management from Primary Care and/or Endocrinology were randomized in a 1:1 ratio to the two 12-month intervention arms between 12/2018 and 1/2020. We analyzed our primary outcome, HbA1c collected at 0, 3, 6, 9 and 12 months, using linear mixed models. Secondary outcomes included BMI and hypoglycemia. Patients had a mean age of 58, and were mostly male (78%) and African American (72%); all patients were engaged with Primary Care prior to enrollment, and 68% with Endocrinology. Baseline characteristics were similar across arms. Estimated mean baseline HbA1c was 10.08%, which declined to an estimated 9.23% at 12 months in the telemonitoring arm and 8.67% in the comprehensive telehealth arm (estimated between-arm difference at 12 months -0.55%, 95%CI -1.06%,-0.05%, p=0.03). No difference in BMI between arms was seen. Hypoglycemia rates were low, and similar between arms. While both strategies improved HbA1c in this high-risk, clinic-refractory population, the comprehensive telehealth intervention led to a clinically and statistically significant added HbA1c benefit. Because its delivery relies solely on existing clinical resources, this comprehensive intervention may be a practical means to address clinic-refractory T2D. Disclosure M. J. Crowley: None. D. H. Jeter: None. E. Strawbridge: None. T. C. Wilmot: None. G. A. Tisdale: None. T. Marcano: None. D. L. Overby: None. M. A. Durkee: None. S. Bullard: None. M. Dar: None. A. Mundy: None. P. E. Tarkington: Stock/Shareholder; Self; Bristol-Myers Squibb Company, Eli Lilly and Company, Johnson &amp; Johnson. S. T. Szabo: None. S. Desai: None. E. A. Kobe: None. N. Majette elliott: None. D. Edelman: None. H. B. Bosworth: Board Member; Self; Preventric Diagnostics, LLC., Consultant; Self; Novartis Pharmaceuticals Corporation, VIDYA, Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Improved Patient Outcomes, Novo Nordisk, Otsuka America Pharmaceutical, Inc., Sanofi. M. L. Maciejewski: Employee; Spouse/Partner; Amgen Inc., Stock/Shareholder; Spouse/Partner; Amgen Inc. K. Steinhauser: None. A. S. Jeffreys: None. C. Coffman: None. V. Smith: None. S. Danus: None. Funding U.S. Department of Veterans Affairs (IIR 16-213); Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (CIN 13-410)

Video-Assisted Thoracoscopic Surgery Lung Resection in United States Veterans: Trends and Outcomes versus Thoracotomy.

Video-assisted thoracoscopic surgery (VATS) offers reduced morbidity compared with open thoracotomy (OT) for pulmonary surgery. The use of VATS over time has increased, but at a modest rate in civilian populations. This study examines temporal trends in VATS use and compares outcomes between VATS and OT in the Veterans Health Administration (VHA). Patients who underwent pulmonary surgery (wedge or segmental resection, lobectomy, or pneumonectomy) at Veterans Affairs centers from 2008 to 2018 were retrospectively identified using the Veterans Affairs Surgical Quality Improvement Project database. The cohort was divided into OT and VATS and propensity score matched, taking into account the type of pulmonary resection, preoperative diagnosis, and comorbidities. Thirty-day postoperative outcomes were compared. The prevalence of VATS use and respective complications over time was also analyzed. A total of 16,895 patients were identified, with 5,748 per group after propensity matching. VATS had significantly lower rates of morbidity and a 2-day reduction in hospital stay. Whereas 76% of lung resections were performed open in 2008, nearly 70% of procedures were performed using VATS in 2018. While VATS was associated with an 8% lower rate of major complications compared with thoracotomy in 2008, patients undergoing VATS lung resection in 2018 had a 58% lower rate of complications (p < 0.001). VATS utilization at VHA centers has become the predominant technique used for pulmonary surgeries over time. OT patients had more complications and longer hospital stays compared with VATS. Over the study period, VATS patients had increasingly lower complication rates compared with open surgery.

Estimated Costs and Long-term Outcomes of Patients With High-Risk Non–Muscle-Invasive Bladder Cancer Treated With Bacillus Calmette-Guérin in the Veterans Affairs Health System

Management of high-risk non-muscle-invasive bladder cancer (NMIBC) represents a clinical challenge due to high failure rates despite prior bacillus Calmette-Guérin (BCG) therapy. To describe real-world patient characteristics, long-term outcomes, and the economic burden in a population with high-risk NMIBC treated with BCG therapy. This retrospective cohort study identified 412 patients with high-risk NMIBC from 63 139 patients diagnosed with bladder cancer who received at least 1 dose of BCG within Department of Veterans Affairs (VA) centers across the US from January 1, 2000, to December 31, 2015. Adequate induction BCG therapy was defined as at least 5 installations, and adequate maintenance BCG therapy was defined as at least 7 installations. Data were analyzed from January 2, 2020, to January 20, 2021. Intravesical BCG therapy, including adequate induction BCG therapy, was defined as at least 5 intravesical instillations of BCG within 70 days from BCG therapy start date. Adequate maintenance BCG therapy was defined as at least 7 installations of BCG within 274 days of the start (the first instillation) of adequate induction BCG therapy (ie, adequate induction BCG plus some form of additional BCG). The Kaplan-Meier method was used to estimate outcomes, including event-free survival. All-cause expenditures were summarized as medians with corresponding interquartile ranges (IQRs) and adjusted to 2019 USD. Of the 412 patients who met inclusion criteria, 335 (81%) were male and 77 (19%) were female, with a median age of 67 (IQR, 61-74) years. Follow-up was 2694 person-years. A total of 392 patients (95%) received adequate induction BCG therapy, and 152 (37%) received adequate BCG therapy. For all patients with high-risk NMIBC, the 10-year progression-free survival rate and disease-specific death rate were 78% and 92%, respectively. Patients with carcinoma in situ (Cis) had worse disease-free survival than those without Cis (hazard ratio [HR], 1.85; 95% CI, 1.34-2.56). Total median costs at 1 year were $29 459 (IQR, $14 991-$52 060); at 2 years, $55 267 (IQR, $28 667-$99 846); and at 5 years, $117 361 (IQR, $59 680-$211 298). Patients with progressive disease had significantly higher median 5-year costs ($232 729 [IQR, $151 321-$341 195] vs $94 879 [IQR, $52 498-$172 631]; P < .001), with outpatient care, pharmacy, and surgery-related costs contributing. Despite adequate induction BCG therapy, only 37% of patients received adequate BCG therapy. Patients with Cis had increased risk of progression, and progression regardless of Cis was associated with significantly increased costs relative to patients without progression. Extrapolating cost figures, regardless of progression, resulted in nationwide costs at 1 year of $373 million for patients diagnosed with high-risk NMIBC in 2019.

PTSD, Risk of Suicide, and Unintended Death by Overdose in Mid- to Late-Life

<h3>Introduction</h3> Although posttraumatic stress disorder (PTSD) may increase risk of suicide in mid- to late-life, findings have been controversial, in large part, because studies have not accounted for comorbid disorders. Moreover, little is known about association between mid- to late-life PTSD and apparent accidental death by overdose, which could be due to suicidal intent. Thus, we conducted a comprehensive study to examine PTSD and risk of death by suicide, suicide attempt, and unintended death by overdose among veterans in mid- to late-life. <h3>Methods</h3> This nationwide cohort study included all veterans ≥50 years (N=1,038,980) seen in the Veterans Health Administration starting 2012-2013 (baseline) and followed through December 31, 2017. Veterans with a PTSD diagnosis were propensity-matched 1:1 with patients without PTSD. They were matched on age, gender, race/ethnicity, income, education, homelessness, service connection, Charlson comorbidity index, and neuropsychiatric disorders. Dates of suicide attempt and cause-specific mortality at follow up were defined using the National Suicide Prevention Applications Network and the Mortality Data Repository, respectively. PTSD was identified by two or more ICD-9 codes in electronic medical records at baseline. PTSD and risk of suicide-related outcomes were assessed using multivariable models. Fine-Gray proportional hazards regression was used to examine time to outcome event at follow up. Models were next adjusted in steps, with the final adjustment accounting for sociodemographics, Charlson comorbidity index, and neuropsychiatric diagnoses. Other outcomes examined using similar methods included death by drug overdose (i.e., antiepileptics/sedative-hypnotics, narcotics, and unspecified/other cause-specific drug categories) for suicide, unintentional, and undetermined death. <h3>Results</h3> Of 1,038,980 patients in our study, 519,490 had PTSD. The mean participant age was 63.56, 59,542 (5.73%) were women, and 765,572 (73.68%) were non-Hispanic White. Although firearms were by far the leading method of suicide death for those with and without PTSD, there was no significant between-group difference related to firearms. However, veterans with PTSD were significantly more likely to die by suicide by drug overdose compared with those without a PTSD diagnosis. As shown in Table 1, after adjusting for sociodemographics, Charlson comorbidities, and neuropsychiatric diagnoses, the hazard ratio for risk of suicide in veterans with PTSD was 1.57 (95% CI, 1.51, 1.63) for any suicide attempt; 1.09 (95% CI, 1.01, 1.19) for death by suicide; 1.43 (95% CI, 1.32, 1.56) for drug overdose death overall; 1.53 (95% CI, 1.21, 1.94) for suicide death by drug overdose. Further analyses explored type of drug involved in overdose and demonstrated that veterans with PTSD had hazard ratios of 1.44 (95% CI, 1.26, 1.65) for narcotics and 1.48 (1.31-1.68) for other /unspecified drugs (Figure 1). We also found that having PTSD increased unintentional death, suicide death, and undetermined intent for narcotics by 1.4 to 2.4 times, and for other/unspecified drugs by 1.4 to 1.8 times. <h3>Conclusions</h3> The findings suggest that veterans with PTSD aged ≥50 years in VA healthcare, have persistently elevated risk for suicide attempts and suicide death, particularly by drug overdose. This current work may inform clinical practice targeting late-life suicide prevention efforts by promoting improved prescribing and drug-monitoring. Future medication recommendations to treat PTSD may need to consider less risky drugs than narcotics, as well as emphasize inquiring about potential illicit drug use and access, for older adults. More research is needed to elucidate the relationship of PTSD to increased risk of mid- to late-life death by suicide and unintended drug overdose, exploring what other and unspecific drugs do and do not exacerbate this risk. <h3>Funding</h3> This work was supported by Award Number I01 CX001119 from the Clinical Science Research & Development Service of the U.S. Department of Veterans Affairs (VA) Office of Research and Development (PI: Dr. Byers). Support for the Mortality Data Repository (MDR; previously known as the Suicide Data Repository or SDR) and Suicide Prevention Applications Network (SPAN) is provided by the VA Center of Excellence for Suicide Prevention. Support for VA/CMS data is provided by the Department of Veterans Affairs, VA Health Services Research and Development Service, VA Information Resource Center (Project Numbers SDR 02-237 and 98-004).