Veterans Affairs Facilities Research Articles

A cross-sectional survey of Department of Veterans Affairs laboratory practices for identification of carbapenem-resistant Acinetobacter baumannii and Pseudomonas aeruginosa

Abstract Control of carbapenem-resistant Acinetobacter baumannii and Pseudomonas aeruginosa spread in healthcare settings begins with timely and accurate laboratory testing practices. Survey results show most Veterans Affairs facilities are performing recommended tests to identify these organisms. Most facilities report sufficient resources to perform testing, though medium-complexity facilities report some perceived barriers.

Antibiotic utilization trends in Veterans Affairs patients with Stenotrophomonas maltophilia bloodstream infections.

Stenotrophomonas maltophilia is a multidrug-resistant gram-negative bacillus that can cause serious infections but has limited treatment options. This study aims to establish trends in the treatment of S. maltophilia bloodstream infections (BSI) across the United States in Department of Veterans Affairs (VA) facilities. Data was evaluated over a 10-year timeframe (2012 to 2021) in this retrospective cohort study. Veterans with ≥ 1 blood culture with S. maltophilia within a VA medical encounter were included. Microbiology, pharmacy, and patient information were collected through national VA data sources and chart review. Descriptive statistics and Poisson regression were used to summarize patient demographics, facility characteristics, microbiologic data, and treatment trends. A total of 374 blood cultures positive for S. maltophilia were identified across 75 VA facilities. Of 282 unique patients with BSI, the majority were male (93.6%), white (67.4%), with a mean age of 64 ± 13.1 years. Of those patients, 78% received treatment, 12.8% had a polymicrobial blood culture, and 5.3% had a documented sulfa allergy. Susceptibility results were most reported for trimethoprim-sulfamethoxazole (TMP-SMX), levofloxacin, and ceftazidime, with 4.5%, 4.3%, and 44.4% resistant isolates, respectively. Antibiotics most prescribed included TMP-SMX (41.5%) and levofloxacin (39.4%), followed by ciprofloxacin (13.8%) and ceftazidime (12.4%). Combination therapy was prescribed in 33% of patients. No significant trends were found with antibiotic utilization over time. TMP-SMX and levofloxacin were the most prescribed antibiotics for S. maltophilia BSI treatment. No significant changes were seen with antibiotic prescribing trends in Veterans from 2012 to 2021.

Antimicrobial use before and during COVID-19: data from 108 Veterans Affairs medical centers

Abstract Objective: Inpatient antibiotic use increased during the early phases of the COVID-19 pandemic. We sought to determine whether these changes persisted in persons with and without COVID-19 infection. Design: Retrospective cohort analysis. Setting: 108 Veterans Affairs (VA) facilities. Patients: Persons receiving acute inpatient care from January 2016 to October 2022. Methods: Data on antibacterial use, patient days present, and COVID-19 care were extracted from the VA Corporate Data Warehouse. Days of therapy (DOT) per 1000 days present (DP) were calculated and stratified by Centers for Disease Control and Prevention-defined antibiotic classes. Results: Antibiotic use increased from 534 DOT/1000 DP in 11/2019–2/2020 to 588 DOT/1000 DP in 3/2020–4/2020. Subsequently, antibiotic use decreased such that total DOT/1000 DP was 2% less in 2020 as a whole than in 2019. Driven by treatment for community acquired pneumonia, antibiotic use was 30% higher in persons with COVID-19 than in uninfected persons in 3/2020–4/2020, but only 4% higher for the remainder of 2020. In 2022 system-wide antibiotic use was 9% less in persons with COVID-19; however, antibiotic use remained higher in persons with COVID-19 in 25% of facilities. Discussion: Although antibiotic use increased during the early phases of the COVID-19 pandemic, overall use subsequently decreased to below previous baseline levels and, in 2022, was less in persons with COVID-19 than in persons without COVID-19. However, further work needs to be done to address variances across facilities and to determine whether current levels of antibiotic use in persons with COVID-19 are justified.

IMPLEMENTING AGE-FRIENDLY HEALTH SYSTEMS: SCALING 4MS CARE ACROSS VA

Abstract The U.S. Department of Veterans Affairs (VA) provides health care to 9 million enrolled Veterans across a variety of settings. Nearly 50% of enrolled Veterans are age 65 and older, compared to 16% of the U.S. population. The VA has set out to become the largest integrated Age-Friendly Health System (AFHS), using the 4Ms as a framework to improve care for older adults: what Matters, Medication, Mentation and Mobility. When implemented together, the 4Ms allow interprofessional teams and health systems to provide care consistent with what Matters to each older adult. Since joining AFHS movement in 2020, over 190 care settings at 100 VA facilities have earned recognition from the Institute for Healthcare Improvement (IHI). VA has identified key drivers to scale-up and spread 4Ms care at the national, local, and team level. Drivers include active and visible national leadership, building a coalition of local champions, and regular commmunication with teams. VA has accelerated adoption of the 4Ms by following IHI’s Action Community (AC) model. At close of registration, 145 teams from 69 VA facilities enrolled in the VA AC. The VA AC offered a series of monthly webinars and coaching calls to empower teams to create a 4Ms plan building on exisiting best practices. In addition to using evidence-based tools identified by IHI, teams may also leverage VA clinical innovations to support their 4Ms plan. Implementation of AFHS provides a framework for interdisciplinary teams to continuously improve Veteran-centered care and ultimately, fulfill VA’s mission to honor America’s aging Veterans.

VETERAN DIRECTED CARE: A MIXED METHODS STUDY TO INFORM SELF DIRECTED CARE PROGRAM EXPANSION FOR VETERANS AFFAIRS (VA)

Abstract The Department of Veterans Affairs (VA) is shifting from institutional to Home and Community Based Services, such as the Veteran-Directed Care (VDC) program, a self-directed program in which Veterans choose services and employ their providers to avoid or delay long-term institutionalization. The VA plans to expand VDC to all VA facilities by FY2026, but factors affecting VDC expansion are poorly understood. We focused on facilitators and barriers in the seven Veterans Integrated Service Network (VISN) 8 VDC programs between May 2022 and January 2023 to inform program expansion. We used a mixed-methods approach, with surveys followed by semi-structured interviews with VA VDC staff, their partners at Aging and Disability Network Agencies (ADNAs) and VISN 8 leadership, such as lead program coordinators, using the Consolidated Framework for Implementation Research to guide the project rapid analysis techniques. We found substantial variability in the structure, size, and operations of the VDC programs reflecting challenges noted by respondents. VA staff were consistently enthusiastic about VDC’s quality benefits for Veterans, however, they recommended additional staff, a dedicated VDC coordinator, and a national guidebook or standard operating procedures to streamline processes. Respondents also noted the need for more program education targeting referring providers. Unique local challenges, like the lack of available caregivers or no local ADNA, and limited local leadership support were other factors noted that could limit expansion. Importantly, Veterans were often overwhelmed by the employer responsibilities they needed to fulfill. Addressing these concerns remains a challenge to VISN 8 and national leadership.

A Predictive Decision Analysis Tool for Risk Informed, Capital Investment Planning within the Department of Veterans Affairs

The Department of Veterans Affairs (VA) advances healthcare research and contributes to the Federal Response in the state of a national healthcare emergency while providing healthcare to veterans. The VA needs to maintain and improve accessible and safe healthcare infrastructure using risk-informed decision models. The VA relies on the Strategic Capital Investment Planning (SCIP) process to allocate resources but lacks predictive modeling. The Strategic Analysis and Risk Tool (START) creates a user-friendly interface to display environmental and veteran migration risk data, leveraging Power BI and Python. Our research presents a georeferenced risk assessment model that provides insights to regional and facility decision makers about these risks. This risk score helps SCIP decision makers allocate limited resources among VA facilities.

Increasing Local Productivity Through a Regional Antimicrobial Stewardship Collaborative.

Antimicrobial stewardship programs (ASPs) are vital to improving patient safety and ensuring quality of care but are often underresourced, limiting their effectiveness and reach. While barriers to ASP success have been well documented, approaches to address these barriers with limited resources are needed. Stewardship networks and collaboratives have emerged as possible solutions. In January 2020, 5 US Department of Veterans Affairs facilities created a regional ASP collaborative. In this article, we describe the impact of this collaborative on the productivity of the facilities' ASPs. ASP annual reports for each of the 5 facilities provided retrospective data. Reports from fiscal year (FY) 2019 and reports from FY 2020-2022 were reviewed. Staffing, inpatient and outpatient stewardship reporting, individual and collaborative initiatives, and publications data were collected to measure productivity. Yearly results were trended for each facility and for the region. Additionally, the COVID-19 antibiotic use dashboard and upper respiratory infection dashboard were used to review the impact of initiatives on antibiotic prescribing during the collaborative. Regular reporting of outpatient metrics increased; 27% of measures showed improvement in 2019 and increased to 60% in 2022. For all 5 facilities, ASP initiatives increased from 33 in 2019 to 41 in 2022 (24% increase) with a corresponding increase in collaborative initiatives from 0 to 6. Likewise, publications increased from 2 in 2019 to 17 in 2022 (750% increase). Rates of reporting and improvement in inpatient metrics did not change significantly. The ASP collaborative aided in efficiency and productivity within the region by sharing improvement practices, distributing workload for initiatives, and increasing publications.

2250. Fluoroquinolone Stewardship at a Veterans Affairs Facility: A Six Year Review

Abstract Background Increased utilization of antibiotics leads to decreased antimicrobial susceptibility, a well-established phenomenon. Antimicrobial stewardship programs (ASP) promote appropriate prescribing of antibiotics by decreasing inappropriate use, aiming to improve patient outcomes and reducing antimicrobial resistance. Fluroquinolones (FQ) are among the most prescribed antibiotics. We describe out institutional FQ use since inception of our ASP and followed the trend for susceptibility of Enterobacteriaceae and Pseudomonas Methods Northport Veterans Affairs Medical Center (VAMC) provides care for over 30000 Veterans in Long Island, New York, with emergency room, acute care hospital, nursing homes and outpatient clinics A Retrospective review investigated FQ use by total refills per year and by days of therapy per 1000 patient days at Northport VAMC from 2012 to 2022, along with review of local annual antibiograms focusing on ciprofloxacin susceptibility to E. coli, K. pneumoniae, P. mirabilis and P. aeruginosa. An ASP in our facility was initiated in 2016. FQs are restricted antibiotics and require approval by the infectious diseases team (attendings, fellows, pharmacist) Results Figure 1 provides the outpatient total fills per year for Ciprofloxacin, Levofloxacin, Moxifloxacin. Inpatient FQ use during the ASP years was low: Figure 2 shows the FQ inpatient use (days of therapy/1000days) from 2019 to 2022. Comparing years 2012-2016 vs 2017-2022 there was a decrease in fills of ciprofloxacin (median 604 vs. 308 fills, P: 0.009), levofloxacin (276 vs. 116, P: 0.032), and moxifloxacin (116 vs. 14, P: 0.015). By same period comparison (see figure 3), Ciprofloxacin susceptibility for E. coli ranged median 66.5% to 61.5%, P: 0.126, K. pneumoniae 67% vs. 75.5% P: 0.086, P. mirabilis 45% vs. 47.5% P: 0.451, and P. aeruginosa 63% vs. 68.5% P: 0.308 Figure 2 inpatient FQ use 2019 to 2022 Figure 3 Ciprofloxacin susceptibility trend over time Conclusion There was a statistically significant decrease in the use of FQ in the outpatient setting after ASP was initiated in our facility. Although there was a trend in improvement in ciprofloxacin susceptibilities for Klebsiella, Proteus, and Pseudomonas, it was not statistically significant. Nevertheless, our results show that reducing FQ consumption can prevent worsening susceptibility trends for enteric gram negatives and Pseudomonas. Disclosures All Authors: No reported disclosures

Abstract 12799: Geographic Variation in Cardiac Amyloidosis in U.S. Veterans From 2012 to 2021

Background: Prior studies suggest variability in cardiac amyloidosis (CA) detection across the U.S. with underdiagnosis in some regions. Research Question: It is unknown whether geographic variation exists in the occurrence of CA amongst U.S. Veterans in a contemporary cohort. Method: This is a retrospective observational cohort study. CA was defined as ≥ 1 heart failure (ICD9/10) and ≥ 1 amyloidosis diagnosis. For geographic mapping the location was the state of the diagnosing Veterans Affairs (VA) facility. The population at risk was patients in each state with ≥1 VA encounter during the year. The outcomes were incidence and prevalence rates of CA at the state and U.S. Census regional level (per 100,000 patients). The data source was the VA Corporate Data Warehouse (MDClone ADAMS platform). Results: The incidence and prevalence rates of CA by region are shown in the Table, and by state in the Figure. There was an increase in incidence and prevalence in all regions in 2012 and 2021. In both years, incidence and prevalence were highest in the Northeast and lowest in the South. Conclusion: Despite increasing recognition of CA in the VA Health System, there is regional variation in incidence and prevalence in 2012 and 2021. VA facilities in the Midwest, West and especially the South may have differences in CA detection relative to those in the Northeast region. Further research into health system, provider, and patient factors leading to this variation is needed to ensure health equity and quality of care for patients with CA.

Personalized Multilevel Intervention for Improving Appropriate Use of Colorectal Cancer Screening in Older Adults

Despite guideline recommendations, clinicians do not systematically use prior screening or health history to guide colorectal cancer (CRC) screening decisions in older adults. To evaluate the effect of a personalized multilevel intervention on screening orders in older adults due for average-risk CRC screening. Interventional 2-group parallel unmasked cluster randomized clinical trial conducted from November 2015 to February 2019 at 2 US Department of Veterans Affairs (VA) facilities: 1 academic VA medical center and 1 of its connected outpatient clinics. Randomization at the primary care physician/clinician (PCP) level, stratified by study site and clinical full-time equivalency. Participants were 431 average-risk, screen-due US veterans aged 70 to 75 years attending a primary care visit. Data analysis was performed from August 2018 to August 2023. The intervention group received a multilevel intervention including a decision-aid booklet with detailed information on screening benefits and harms, personalized for each participant based on age, sex, prior screening, and comorbidity. The control group received a multilevel intervention including a screening informational booklet. All participants received PCP education and system-level modifications to support personalized screening. The primary outcome was whether screening was ordered within 2 weeks of clinic visit. Secondary outcomes were concordance between screening orders and screening benefit and screening utilization within 6 months. A total of 436 patients were consented, and 431 were analyzed across 67 PCPs. Patients had a mean (SD) age of 71.5 (1.7) years; 424 were male (98.4%); 374 were White (86.8%); 89 were college graduates (21.5%); and 351 (81.4%) had undergone prior screening. A total of 258 (59.9%) were randomized to intervention, and 173 (40.1%) to control. Screening orders were placed for 162 of 258 intervention patients (62.8%) vs 114 of 173 control patients (65.9%) (adjusted difference, -4.0 percentage points [pp]; 95% CI, -15.4 to 7.4 pp). In a prespecified interaction analysis, the proportion receiving orders was lower in the intervention group than in the control group for those in the lowest benefit quartile (59.4% vs 71.1%). In contrast, the proportion receiving orders was higher in the intervention group than in the control group for those in the highest benefit quartile (67.6% vs 52.2%) (interaction P = .049). Fewer intervention patients (106 of 256 [41.4%]) utilized screening overall at 6 months than controls (96 of 173 [55.9%]) (adjusted difference, -13.4 pp; 95% CI, -25.3 to -1.6 pp). In this cluster randomized clinical trial, patients who were presented with personalized information about screening benefits and harms in the context of a multilevel intervention were more likely to receive screening orders concordant with benefit and were less likely to utilize screening. ClinicalTrials.gov Identifier: NCT02027545.

Using the RE-AIM framework to assess national teledermatology expansion.

Teledermatology has been utilized in the United States Department of Veterans Affairs (VA) for decades but continues to have incomplete penetration. VA has funded an initiative to enhance access to dermatology services since 2017 to support asynchronous teledermatology for Veterans living in rural areas. As part of an ongoing evaluation of this program, we assessed the teledermatology activity between the fiscal years 2020 and 2022. We focused on the second cohort of the initiative, comprising six VA facilities and their 54 referral clinics. We studied teledermatology programs at cohort facilities using the reach, effectiveness, adoption, implementation, and maintenance framework. We used a mixed-methods design including annual online reports completed by participating facilities and VA administrative data. When possible, we compared the data from the 3 years of teledermatology funding with the baseline year prior to the start of funding. Reach: Compared with the baseline year, there was a 100% increase in encounters and a 62% increase in patients seen at the funded facilities. Over 500 clinicians and support staff members were trained. Effectiveness: In FY 2022, primary or specialty care clinics affiliated with the funded facilities had more dermatology programs than primary or specialty care clinics across the VA (83% vs. 71% of sites). Adoption: By the end of the funding period, teledermatology constituted 16% of dermatology encounters at the funded facilities compared with 12% nationally. This reflected an increase from 9.2% at the funded facilities and 10.3% nationally prior to the funding period. Implementation: The continued funding for staff and equipment facilitated the expansion to rural areas. Maintenance: By the end of the funding period, all facilities indicated that they had fully implemented their program for patients of targeted primary care providers. The Program Sustainability Index scores generally increased during the funding period. Targeted funding to support asynchronous teledermatology implementation for rural Veterans increased its reach, adoption, and implementation, ultimately improving access. Providing program guidance with staffing and training resources can increase the impact of these programs. Ongoing efforts to maintain and increase communication between primary care and dermatology will be needed to sustain success.

Depression symptom outcomes and re-engagement among VA patients who discontinue care while symptomatic

ObjectiveEvaluate outcomes of Veterans who discontinued treatment with at least moderate ongoing depressive symptoms. MethodVeterans with elevated depression symptoms from 29 Department of Veterans Affairs facilities completed baseline surveys and follow-up assessments for one year. Analyses examined rates and predictors of treatment discontinuation, treatment re-engagement, and subsequent symptoms among patients who remained out of care. ResultsA total of 242 (17.8%; n = 1359) participants discontinued treatment while symptomatic, with Black participants, participants with less severe depression, and participants receiving only psychotherapy (versus combined psychotherapy and antidepressant medications) discontinuing at higher rates. Among all participants who discontinued treatment (n = 445), 45.8% re-engaged within the following six months with participants receiving combined treatment re-engaging at higher rates. Of participants who discontinued while symptomatic within the first 6 months of the study and did not return to care (n = 112), 68.8% remained symptomatic at 12 months. Lower baseline treatment expectancy and greater depression symptom severity were associated with remaining symptomatic while untreated. ConclusionsBlack race, lower symptom severity, and treatment modality may help identify patients at higher risk for discontinuing care while symptomatic, whereas patients with lower treatment expectations may be at greater risk for remaining out of care despite continuing symptoms.

Validation of Electronic Health Record-Based Algorithms to Identify Specialist Palliative Care Within the Department of Veterans Affairs.

The measurement of specialist palliative care (SPC) across Department of Veterans Affairs (VA) facilities relies on algorithms applied to administrative databases. However, the validity of these algorithms has not been systematically assessed. In a cohort of people with heart failure identified by ICD 9/10 codes, we validated the performance of algorithms to identify SPC consultation in administrative data and differentiate outpatient from inpatient encounters. We derived separate samples of people by receipt of SPC using combinations of stop codes signifying specific clinics, current procedural terminology (CPT), a variable representing encounter location, and ICD-9/ICD-10 codes for SPC. We calculated sensitivity, specificity, and positive and negative predictive values (PPV, NPV) for each algorithm using chart review as the reference standard. Among 200 people who did and did not receive SPC (mean age=73.9 years (standard deviation [SD]=11.5), 98% male, 73% White), the validity of the stop code plus CPT algorithm to identify any SPC consultation was: Sensitivity=0.89 (95% Confidence Interval [CI] 0.82-0.94), Specificity=1.0 [0.96-1.0], PPV=1.0 [0.96-1.0], NPV=0.93 [0.86-0.97]. The addition of ICD codes increased sensitivity but decreased specificity. Among 200 people who received SPC (mean age=74.2 years [SD=11.8], 99% male, 71% White), algorithm performance in differentiating outpatient from inpatient encounters was: Sensitivity=0.95 (0.88-0.99), Specificity=0.81 (0.72-0.87), PPV=0.38 (0.29-0.49), and NPV=0.99 (0.95-1.0). Adding encounter location improved the sensitivity and specificity of this algorithm. VA algorithms are highly sensitive and specific in identifying SPC and in differentiating outpatient from inpatient encounters. These algorithms can be used with confidence to measure SPC in quality improvement and research across the VA.

Space-time clustering of COVID-19 cases in the United States veteran population

To assess the distribution and clustering of coronavirus disease 2019 (COVID-19) testing and incidence over space and time, U.S. Department of Veteran's Affairs (VA) data were used to describe where and when veterans experienced highest proportions of test positivity. Data for 6,342,455 veterans who utilized VA services between January 1, 2018, and September 30, 2021, were assessed for COVID-19 testing and test positivity. Testing and positivity proportions by county were mapped and focused-cluster tests identified significant clustering around VA facilities. Spatial cluster analysis also identified where and when veterans experienced highest proportions of test positivity. Within the veterans study population and our time window, 21.3% received at least one COVID-19 test, and 20.4% of those tested had at least one positive test. There was statistically significant clustering of testing around VA facilities, revealing regional variation in testing practices. Veterans experienced highest test positivity proportions between November 2020 and January 2021 in a cluster of states in the Midwest, compared to those who received testing outside of the identified cluster (RR: 3.45). Findings reflect broad regional trends in COVID-19 positivity which can inform VA policy and resource allocation. Additional analysis is needed to understand patterns during Delta and Omicron variant periods.

History and current status of contingency management programs in the Department of Veterans Affairs

ObjectiveThis article describes the Department of Veterans Affairs (VA) national implementation of contingency management within VA substance use disorder (SUD) treatment programs. Methods: The rationale for implementing CM, role of VA leadership, and training and supervision procedures are detailed. The role of the Veterans Canteen Service (VCS) in sustaining the CM implementation through the donation of incentives is outlined. Updated outcomes from the primary program, CM to incentivize stimulant abstinence, are provided. Data presented were gathered from June 2011 to January 2023, from VA facilities across the country. ResultsMore than 6000 Veterans from 119 VA facilities have received CM in a 12-week program in which two urine samples are obtained per week, with 92% of the samples negative for the targeted substance. Two other CM pilot projects are described. The first incentivizes adherence to injectable medications for opioid and alcohol use disorders, with over 580 veterans from 27 VA sites participating to date. The second incentivized smoking cessation in 312 patients from four sites. A new initiative in which CM is implemented in smaller community-based VA facilities through use of onsite prize cabinets is presented and the possibility of providing CM remotely in VA is discussed. ConclusionsIt has proved feasible to implement abstinence CM and several other CM pilot programs at many VA facilities. Factors that contributed to the success of the VA CM rollout, challenges that were encountered along the way, and lessons learned that may facilitate wider use of CM outside VA are discussed.

Veterans Affairs Nurses' Perception of a Dignified Death.

A dignified death is described as a good death or dying with dignity. Nurses caring for veterans are aware of the honor veterans can receive at the time of death. The purpose of this study was to describe and compare perceptions of a dignified death in nurses who care for veterans in Veterans Affairs settings. This descriptive, exploratory design used an online survey including scales of dying with dignity and a good death. Subjects were nurses who worked at Veterans Affairs facilities. Dying with dignity scores were high and moderately high for a good death. Good death items of wishes, peace, spirituality, and pain free were considered essential by most nurses. There was no difference in scores based on age or end-of-life experiences. Veterans Affairs nurses had a good perception of a dignified death providing a foundation for veteran support before, during, and after death.

Differences in perceptions and acceptance of COVID-19 vaccination between vaccine hesitant and non-hesitant persons.

Acceptance of the COVID-19 vaccination becomes more critical as new variants continue to evolve and the United States (US) attempts to move from pandemic response to management and control. COVID-19 stands out in the unique way it has polarized patients and generated sustained vaccine hesitancy over time. We sought to understand differences in perceptions and acceptance of COVID-19 vaccination between vaccine hesitant and non-hesitant patients, with the goal of informing communication and implementation strategies to increase uptake of COVID-19 vaccines in Veteran and non-Veteran communities. This qualitative study used interview data from focus groups conducted by the Department of Veterans Affairs (VA) and the University of Utah; all focus groups were conducted using the same script March-July 2021. Groups included forty-six United States Veterans receiving care at 28 VA facilities across the country and 166 non-Veterans across Utah for a total of 36 one-hour focus groups. We identified perceptions and attitudes toward COVID-19 vaccination through qualitative analysis of focus group participant remarks, grouping connections with identified themes within domains developed based on the questions asked in the focus group guide. Responses suggest participant attitudes toward the COVID-19 vaccine were shaped primarily by vaccine attitude changes over time, impacted by perceived vaccine benefits, risks, differing sources of vaccine information and political ideology. Veterans appeared more polarized, being either largely non-hesitant, or hesitant, whereas non-Veterans had a wider range of hesitancy, with more participants identifying minor doubts and concerns about receiving the vaccine, or simply being altogether unsure about receiving it. Development of COVID-19 vaccine communication strategies in Veteran and non-Veteran communities should anticipate incongruous sources of information and explicitly target community differences in perceptions of risks and benefits associated with the vaccine to generate candid discussions and repair individuals' trust. We believe this could accelerate vaccine acceptance over time.

Let’s Talk About Firearms: Perspectives of Older Veterans and VA Clinicians on Universal and Dementia-Specific Firearm Safety Discussions

ABSTRACT Objectives Veterans experience high rates of fatal and non-fatal firearm injuries. This risk may be compounded among Veterans who are rural-residing, aging, and/or experiencing cognitive decline or dementia. Firearm safety discussions are not broadly implemented across Department of Veterans Affairs (VA) healthcare settings due, in part, to concerns of causing Veterans to disengage from care. This study examines perceptions about firearm safety discussions to inform healthcare-based harm-reduction efforts. Methods We conducted interviews with 34 Veterans (median age 70) and 22 clinicians from four VA facilities that treat high rates of rural patients with firearm-related injuries. Results Most Veterans accepted the idea of universal firearm safety discussions at the VA. Some reported they might not be forthright in such discussions, but raising the topic would not stop them from engaging with VA care. Veterans and clinicians unanimously endorsed firearm safety discussions for older patients experiencing cognitive decline or dementia. Conclusions VA patients and clinicians are amenable to firearm safety discussions during healthcare visits and especially endorse the need for such discussions among high-risk populations. Clinical Implications Universal firearm safety discussions could be incorporated into standard VA practice, particularly for Veterans experiencing cognitive decline or dementia, without risking Veteran disengagement from care.

Spreading pride in all who served: A health education program to improve access and mental health outcomes for sexual and gender minority veterans.

Access to effective, replicable services is critical to reduce known mental health disparities for sexual and gender minority or LGBTQ+ veterans (lesbian, gay, bisexual, transgender, queer, questioning, and related identities). This paper examines the impact of a manualized 10-week health education group, called PRIDE in All Who Served on veteran patient experience, protective factors (e.g., identity acceptance), and mental health outcomes (e.g., suicide risk) at 10 Department of Veterans Affairs (VA) facilities. Implementation facilitation strategies (e.g., consultation, staff training) supported adoption at new sites and initial facilitators and barriers are described. Forty-four veterans (M = 47.21 years old) completed outcome surveys before and after the group. Significant improvement in acceptance concerns, identity uncertainty, community involvement, and likelihood of future suicide attempts were observed; other changes in mental health symptoms were not replicated in this sample (e.g., depression, anxiety). Open-ended veteran feedback reflected improved social support and engagement and increased self-understanding as the most frequent themes. At the facility level, Healthcare Equality Index scores (a Human Rights Campaign measure of affirmative care climate) improved from 30% to 90% achieving top-performer/leader status from pre- to postimplementation. Manualized approaches, like PRIDE in All Who Served, that are based on established minority stress models and can be spread for use with diverse LGBTQ+ veterans (e.g., age, race, gender identity, sexual orientation, rurality, housing) are needed. The PRIDE in All Who Served program is an increasingly available resource to VA clinicians advocating for greater health equity within a national healthcare setting. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Integrating infection control and environmental management work systems to prevent Clostridioides difficile infection

Effective infection prevention and control within health care settings requires collaboration and coordination between infection control and environmental management teams. However, the work systems of these teams can be difficult to integrate despite their shared goals. We provide results from a qualitative study of Clostridioides difficile infection prevention in Veterans Affairs facilities regarding challenges in coordination between these teams and opportunities to improve coordination and maximize infection prevention activities.