Veterans Affairs Experience Research Articles

Stringent public health measures during COVID-19 across ischemic stroke care systems: the potential impact of patient perceptions on health care-seeking behaviors.

Decreases in acute stroke presentations have been reported during the coronavirus disease 2019 (COVID-19) pandemic surges. A recent study by Bojti et al. (GeroScience. 2021;43:2231–2248) sought to understand the relationship of public health mandates in Hungary as they were implemented with acute ischemic stroke admissions and interventions during two separate COVID-19 waves. We sought to perform a similar analysis of changes in ischemic stroke care at two distinct medical institutions in the USA. Two separate institutions and systems of ischemic stroke care were evaluated through a regional comprehensive stroke center telestroke service and a Veterans Affairs (VA) inpatient stroke and neurorehabilitation service. Telestroke consultations in a single system in Chicago, IL, were significantly decreased during the first COVID-19 wave during severely restricted public health mandates (z-score < − 2), and were less depressed during a subsequent wave with less severe restrictions (z-score approaching − 1), which resembles findings in Hungary as reported by Bojti et al. In contrast, inpatient admissions during the first and second COVID-19 waves to a VA stroke and neurorehabilitation service in Oklahoma City remained unchanged. The Chicago and Hungary patterns of stroke presentations suggest that public perceptions, as informed by regional health mandates, might influence healthcare-seeking behavior. However, the VA experience suggests that specific patient populations may react differently to given public health mandates. These observations highlight that changes in stroke presentation during the COVID-19 pandemic may vary regionally and by patient population as well as by the severity of public health mandates implemented. Further study of COVID-19-related public health policies on acute stroke populations is needed to capture the long-term impact of such policies. Learning from the real-time impact of pandemic surges and public health policy on presentation of acute medical conditions, such as ischemic stroke, may prove valuable for designing effective policies in the future.

Association of Chiropractic Colleges Research Agenda Conference 2021 Abstracts of Proceedings.

Association of Chiropractic Colleges Research Agenda Conference 2021 Abstracts of Proceedings.

Experiences and Knowledge of US Department of Veterans Affairs Clinical Services, Research, and Education: Results From a National Survey of Veterans.

This study examined (1) sociodemographic, health, and psychosocial characteristics associated with using the Department of Veterans Affairs (VA) health care system as a primary health care provider; (2) veterans' experience and knowledge of VA clinical services, research, and education; and (3) veteran characteristics associated with VA experience and knowledge. A nationally representative survey was conducted in 2018; eligibility criteria for participation were adults aged 18 years or older, currently living in the United States, and having served on active duty in the US military. The survey was conducted online using large national survey panels. A sample of 1002 veterans across 49 states participated. The survey assessed experience and knowledge of majority of VA clinical services, research, and education. One-quarter of the total sample reported that the VA was their primary health care provider. Among veterans who had ever used VA health care, the majority (68%) reported overall high satisfaction with VA health care but also agreed with "privatizing parts of the VA" (70%). The majority (51%-73%) of veterans reported knowledge of major VA clinical services, with the exception of comprehensive management for chronic pain (24%) and treatment of opioid use disorders (31%). One-quarter to one-half also reported knowledge of several VA research and education centers. Less than 10% of veterans reported having ever used a VA mobile app. The US veterans generally reported positive experiences and good knowledge of VA services and resources. Greater awareness of available VA services for chronic pain and opioid use disorders, as well as VA mobile apps, may help promote more comprehensive care in this population.

Infertility evaluation and access to assisted reproductive technologies among male military veterans: analysis of the South Florida Veterans Affairs experience.

BackgroundRecent legislation extended coverage for assisted reproductive technologies (ART) to male veterans within the United States Veterans Affairs (VA) healthcare system. We sought to characterize the appropriateness of male infertility diagnosis and access to assisted reproductive technologies (ART) among men within the local VA healthcare system after passage of the new legislation.MethodsWe retrospectively identified male patients within the South Florida VA Network who underwent semen analysis (SA) or were diagnosed with infertility between January 1999 and June 2017. Men were classified by infertility diagnosis and sperm concentration/mL (normal, oligospermia <15, severe oligospermia <5 million, azoospermia). We compared the number of oligospermic men before versus after the legislation. Men who did not receive ART were characterized according to eligibility criteria of military service connection to the infertility diagnosis.ResultsSix hundred twenty-seven men underwent SA or were diagnosed with infertility. Among 474 men with SA, 206 (43.5%) were diagnosed with infertility and 268 (56.5%) were not. Additionally, 153 men received an infertility diagnosis without SA. More men had oligospermia and severe oligospermia after the legislation (1 vs. 6, 1 vs. 10). Of 10 men with severe oligospermia post-legislation, 7 did not proceed to ART consultation due to lack of military service connection to the infertility diagnosis.ConclusionsA substantial proportion of veterans with abnormal sperm concentrations were not diagnosed with infertility, while others carrying an infertility diagnosis did not undergo SA. Most patients clinically eligible for ART did not proceed with further evaluation due to lack of military service connection to their infertility diagnosis.

Targeting Access to Kidney Care Via Telehealth: The VA Experience.

The Veterans Affairs (VA) is the largest integrated health care system in the United States and is responsible for the care of a population with a disproportionately high rate of CKD. As such, ensuring access to kidney health services is a VA imperative. One facet of the VA's strategy to reduce CKD is to leverage the use of teletechnology to expand the VA's outreach to Veterans with kidney disease. A wide array of teletechnology services have been deployed to both pull in Veterans and push out kidney health services to Veterans in their preferred health care venue. Teletechnology, thus, expands Veteran choice, facilitates their access to care, and furthers the goal of delivering patient-centered kidney specialty care. The VA has demonstrated the feasibility of virtual delivery of kidney specialty care services and education via synchronous and asynchronous approaches. The challenges ahead include determining the relative health care value of kidney telehealth services, identifying Veterans most likely to benefit from specific technologies and optimizing the adoption of effective kidney telehealth services by both providers and patients alike to ensure optimal and timely kidney health care delivery.

Assessment of the healthcare needs and barriers to VA use experienced by women veterans: findings from the national survey of women Veterans.

Prior regional studies of women Veterans identified barriers to Veterans Affairs (VA) healthcare use. However, these studies do not reflect the demographic profile of women Veterans nationally, recent advances in VA women's healthcare, and the national context of expanded healthcare alternatives. To characterize health, VA perceptions, barriers, healthcare delivery preferences, and reasons for VA or non-VA healthcare use in a national women Veteran sample. Cross-sectional, population-based 2008-2009 National Survey of Women Veterans (n=3611). VA users had worse physical and mental health than non-VA-only users and healthcare nonusers. Older women Veterans had worse physical health, whereas younger groups had worse mental health. Healthcare use was highest for dual users, followed by VA-only users, but did not differ by age group. Healthcare nonusers were most likely to lack a regular source for healthcare. Perceptions of VA care quality and sex-appropriateness were highest for VA-only, followed by dual, then non-VA-only users. VA perceptions were guided by personal experience for 90% of VA users, versus media or other secondhand sources for 70% of other groups. Non-VA-only users and healthcare nonusers had more knowledge gaps about VA and misperceptions about VA eligibility and services; non-VA-only users more likely encountered VA enrollment barriers. Many nonusers had healthcare needs that were not met. Positive VA perceptions by women with first-hand VA experience, contrasted with VA knowledge gaps by those without such exposure, suggests the need for more education about available VA healthcare services. VA planning should account for mental health needs and healthcare use by younger women Veterans.

Surgery for constipation in patients with prior spinal cord injury: The Department of Veterans Affairs experience

ObjectivePatients with spinal cord injury (SCI) typically have difficulty with constipation. Some undergo surgery for bowel management. We predicted that SCI patients would have higher mortality and/or morbidity rates following such surgery than neurally intact patients receiving the same procedures. We sought to evaluate this using a large population-based data set.MethodsPatients receiving care at Department of Veterans Affairs Medical Centers (DVAMCs) with computer codes for SCI and constipation who later underwent colectomy, colostomy, or ileostomy during fiscal years 1993–2002 were identified. Charts were requested from the VAMCs where the surgery had been performed and a retrospective chart review of these charts was done. We collected data on patient demographics, six specific pre-operative co-morbidities, surgical complications, and post-operative mortality. Comparisons were made to current literature evaluating a population receiving total abdominal colectomy and ileorectal anastomosis for constipation but not selected for SCI.ResultsOf 299 patients identified by computer search, 43 (14%) had codes for SCI and 10 of 43 (24%) met our inclusion criteria. All were symptomatic and had received appropriate medical management. Co-morbid conditions were present in 9 of 10 patients (90%). There were no deaths within 30 days. The complication rate was zero. The mean post-operative length of stay was 17 days.ConclusionsPatients with SCI comprise about 14% of the population who receive surgery for severe constipation in the Department of Veterans Affairs system. The mortality and morbidity rates in these patients are similar to those reported in other constipated patients who have surgery for intractable constipation. Our data suggest that stoma formation ± bowel resection in patients with SCI is a safe and effective treatment for chronic constipation.

Long-term electrical survival analysis of Riata and Riata ST silicone leads: National Veterans Affairs experience

A medical device advisory issued by St Jude Medical in November 2011 estimated 0.63% all-cause abrasion rate on their Riata and Riata ST silicone high-voltage lead families (Riata/ST), leading to Food and Drug Administration class I recall. We performed an independent comparative, long-term electrical survival analysis of Riata/ST and 3 other high-voltage lead families in a large national cohort of patients. To evaluate long-term electrical survival of Riata/ST leads relative to other commonly evaluated high-voltage leads. Failure rates of Riata/ST, Sprint Quattro Secure (Quattro), Sprint Fidelis (Fidelis), and Endotak Reliance G/SG (Endotak) leads from the Veterans Administration's National Cardiac Device Surveillance Center database, consisting of 24,145 patients with remote transmissions since 2003, were analyzed. Survival Probabilities were determined with Kaplan-Meier survival analysis and compared using the log-rank test. Of 1,403 Riata/ST, 6,091 Quattro, 5,073 Fidelis, and 2,401 Endotak leads identified, 5-year survival probability of Riata/ST leads (97.5%) was significantly lower than that of Quattro (99.3%) and Endotak (99.4%) leads (P <.0001) but higher than that of Fidelis leads (89.6%) (P <.0001). Riata ST leads showed a 5-year survival of 95.5% (95% confidence interval 92.4-97.4) compared to 98.4% (95% confidence interval 97.1-99.1) in Riata leads (P = .003). There is decreased survival probability of Riata/ST leads compared to other contemporary high-voltage leads, with decreased survival of Riata ST silicone compared to Riata lead series. Careful long-term follow-up should be maintained in patients with Riata/ST leads in order to prevent inappropriate shocks or failed device interventions. Our results were determined in advance of Food and Drug Administration class I recall, which suggested that large-scale remote monitoring may be an effective tool for continued implantable cardioverter-defibrillator system surveillance.

Surgery For Constipation In Patients With Prior Spinal Cord Injury: The Department Of Veterans Affairs Experience

Surgery For Constipation In Patients With Prior Spinal Cord Injury: The Department Of Veterans Affairs Experience

Management of Vascular Graft Infections with Soft Tissue Flap Coverage: Improving Limb Salvage Rates–A Veterans Affairs Experience

Graft infections are one of the most challenging issues in surgery with an incidence of 0.7 to 7 per cent, with femoral site infections being the most common (13% incidence). The gold standard treatment has been graft removal, wide débridement, and extra-anatomical bypass. Routine excision of infected peripheral arterial grafts and vascular reconstruction with extraanatomic conduits are associated with mortality rates ranging from 10 to 30 per cent and amputation rates of up to 70 per cent. As a result of the high morbidity and mortality associated with this approach, selective graft preservation techniques have been developed. Newer treatment plans discuss preservation of the graft with débridement and coverage of the infected region. Better wound care, nutrition optimization, and robust flap coverage have led to significantly improved graft salvage, lower amputation rates, and improved outcomes. The objective of this study was to evaluate the Veterans Affairs (VA) experience with flap coverage for femoral vascular graft infections. A retrospective review was conducted of all VA data from 1997 to 2008 with inclusion criteria of patients with deep groin wound infections requiring flap coverage after femoral bypass surgery. Eleven such patients were identified with a mean age of 73 years and with multiple comorbidities (hypertension, malnutrition, diabetes mellitus, chronic obstructive pulmonary disease, coronary artery disease, chronic renal insufficiency). Patients presented with wound drainage, exposed graft, hematoma, perigraft fluid collection, and pseudoaneurysm. Treatment protocol included: 1) aggressive débridement of the wound bed; 2) early soft tissue (flap) coverage; 3) wound vacuum assisted closure device or frequent dressing changes; and 4) skin graft once the bed was prepared. Eighty-two per cent of wounds had positive cultures with equal numbers of patients with Staphylococcus epidermidis, Pseudomonas, Escherichia coli (22%), and higher methicillin-resistant Staphylococcus aureus (33%), whereas in the literature Staphylococcus is the most common (greater than 50%). Average hospital length of stay was 94 days with average follow up at 10 months. Fifty-five per cent graft salvage (one Dacron [50%], two polytetrafluoroethylene [33%], two saphenous vein graft [100%], one cryovein [100%]) was achieved with 91 per cent limb salvage. Complications included graft blowout (two) requiring partial flap loss (one), retroperitoneal hematoma (one), limb loss (one), sepsis (one), and death (one). Infected vascular grafts remain a challenging problem requiring multidisciplinary care. Careful débridement and aggressive wound care followed by selective flap coverage appears to decrease morbidity and increase graft and limb salvage.

QS35. Colectomy for Colon Cancer in Patients With a Prior Ventriculoperitoneal Shunt the Department of Veterans Affairs Experience

Objective: Many patients have VP shunts implanted for congenital conditions. Subsequent abdominal operations in these patients are reportedly hazardous. We aimed to determine the clinical course of adults with ventriculoperitoneal (VP) shunts for acquired conditions who later required colectomy for colon cancer. Introduction: Approximately 18,000 cerebrospinal fluid shunts, the majority of which are VP, are implanted each year in the USA. These patients may subsequently require colectomy for colon cancer.

The VA Health System: A National Alternative?

In 2007, as in 1993, acknowledging the need for reforming U.S. medical care resembles breathing: No one can escape it. But now, as one or two or three decades before, the obvious question is not whether problems exist, but whether there is a politically acceptable, administratively workable, and economically affordable policy at hand. Phillip Longman’s book, with the foreword by his journalistic sidekick Timothy Noah, claims to have an answer, if not the answer. It is the Department of Veterans Affairs (VA) arrangements, through the Veterans Health Administration (VHA), for the financing, organizing, and delivering of medical care to its clientele. Longman first outlined this bold, unexpected argument in a 2005 Washington Monthly article with the same title as his book: “Best Care Anywhere.” “Ten years ago,” he then claimed, “veterans hospitals were dangerous, dirty, and scandal ridden. ...Now they’re producing the highest quality care in the country. Their turnaround points the way towards solv ing America’s healthcare cr isis .” Longman’s book indisputably documents the amazing improvement in the reality and imagery of the VA medical system. The book elaborates two separable themes. First, it is a fascinating case study of organizational change, the transformation noted above in the operation of the VA’s nationwide medical care system. As such, it shows what is organizationally possible when leaders have both workable reform ideas and the levers of power to put them into practice. In that sense, Longman’s work is a tribute to both the leaders and staff of the VA reform—Ken Kizer most prominently—and the VA’s various constituents in Congress and interest groups for permitting this transformation to take place. Second, he claims, the VA presents a model for U.S. medical care reform. But that is quite another, controversial matter. The central claims of the reform story are easy to state. With the help of electronic medical records across the VA system nationwide, it has been possible to greatly improve the quality of care. Whether the VA is better at that task than, say, Kaiser Permanente, will no doubt generate dispute in the medical journals. But that it does a better job than the disjoined care most Americans receive is not only plausible, but highly likely. Not only is the quality comparatively high, but the cost of the care given is modest by comparison with the rest of U.S. medicine. This is especially true for prescription drugs, where the VA uses its market muscle to purchase the products of Big Pharma at prices Medicare’s congressional masters would be delirious to pay. And, in addition, eligible veterans face medical ailments without a glimmer of financial fear, with a range of benefits (and trivial cost sharing) that makes the rest of U.S. health insurance seem terribly restrictive. Yet the obvious question is whether this remarkable reform story has all that much to offer our national debate over what to do about the cost, quality, and organizational complexity of medical care. Here one should acknowledge the moral zeal and the emotional intensity of the message Longman (and Noah) send. B o o k R e v i e w s

Curative-intent resection for bronchogenic carcinoma in patients with prior spinal cord injury: The Department of Veterans Affairs experience

17127 Background: There are approximately 250,000 people with spinal cord injury (SCI) in the US, and they have a high prevalence of smoking. A literature search yielded no published information concerning the clinical course of SCI patients who subsequently develop bronchogenic carcinoma and undergo pulmonary resection for this condition. We hypothesized that poorer outcomes of surgery would be observed in this population, as compared to neurally-intact patients. Methods: We conducted a study of all veterans at Department of Veterans Affairs (DVA) Medical Centers during fiscal years 1993–2002 who were diagnosed with SCI, subsequently developed non-small cell lung cancer and were then surgically treated with curative intent. Inclusion criteria included American Spinal Injury Association type A injury (complete loss of neural function distal to the injury site) and traumatic etiology. Data were compiled from national DVA datasets and supplemented by operative reports, pathology reports, progress notes, and discharge summaries. Results: Of 12,634 patients who underwent surgery for bronchogenic carcinoma, 55 also had codes for prior SCI; 7 were evaluable. The mean age was 64. Five (71%) had one or more co-morbid conditions in addition to their spinal cord injuries. All 7 underwent pulmonary lobectomy. Post-operative complications occurred in 4 patients (57%). Two patients died post-operatively on days 29 and 499, yielding a 30-day mortality rate of 14% and an in-hospital mortality rate of 29%. Conclusions: We believe this isthe only report in the English language literature on this topic. SCI patients with resectable bronchogenic carcinoma have a high incidence of co-morbid conditions. Those who undergo curative-intent surgery have high morbidity and mortality rates. This evidence suggests that SCI should be considered a risk factor for adverse outcomes of surgery for primary lung cancer, strengthening the case for alternative treatments. No significant financial relationships to disclose.

Psychiatric Education at a Veterans Affairs Medical Center

The authors describe how a small and relatively low-functioning psychiatric teaching program at a Department of Veterans Affairs (VA) medical center was transformed over a 6-year period into an active and well-functioning program for both medical students and residents. Steps were taken to address trainees' negative perceptions about VA patients and faculty, recruit and support an education-oriented staff, and improve the "user-friendliness" of the system. Efforts were made to integrate education into the missions of a variety of clinical and research programs while emphasizing the convergence of trends in the field of psychiatry with the VA experience. Data are presented indicating improvements in student and resident evaluations. Training was significantly expanded on inpatient units, chemical dependence units, a research unit, and an outpatient clinic. The authors offer suggestions that may be helpful to those developing psychiatric education at other academically affiliated VA medical centers.