Veterans Affairs Health Services Research Research Articles

"Development and validation of a brief warfare exposure measure among U.S. Iraq and Afghanistan war veterans: The Deployment Risk and Resilience Inventory-2 Warfare Exposure-Short Form (DRRI-2 WE-SF)": Correction.

It is important to assess warfare experiences beyond direct combat exposure, as these exposures can negatively impact military veterans' health. Although two validated scales from the Deployment Risk and Resilience Inventory-2 [DRRI-2] together capture a broad range of stressful warfare experiences, the length of this combined measure (30 items) is prohibitively long for some settings. Therefore, the goal of this project was to develop and validate a short form Warfare Exposure measure (DRRI-2-WE-SF). U.S. veterans deployed for the wars in Iraq and Afghanistan completed questionnaires across 2 studies (study 1, N = 1046; study 2, N = 7141) to develop and validate the DRRI-2 WE-SF. Study 1 involved developing the DRRI-2 WE-SF, a 9-item self-report instrument with strong internal consistency (α = .86) and large correlations with the full Warfare Exposure measure (r = .97). In study 2, the DRRI-2 WE-SF again demonstrated high levels of reliability and validity and evidenced high levels of classification accuracy (89.7% correct classification) and significant time savings (all ts > 39; all ps < .05) in comparison to the full measure. The DRRI-2 WE-SF is a psychometrically sound measure of direct exposures to warfare and its consequences. This measure of proximal warfare exposure retains the strong properties of the full measure while significantly reducing completion time. These properties make the DRRI-2 WE-SF a useful tool for efficiently evaluating proximal warfare exposure among individuals who have served in both combat and noncombat roles. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Development and validation of a brief warfare exposure measure among U.S. Iraq and Afghanistan war veterans: The Deployment Risk and Resilience Inventory-2 Warfare Exposure-Short Form (DRRI-2 WE-SF).

U.S. veterans deployed for the wars in Iraq and Afghanistan completed questionnaires across 2 studies (study 1, N = 1046; study 2, N = 7141) to develop and validate the DRRI-2 WE-SF. Study 1 involved developing the DRRI-2 WE-SF, a 9-item self-report instrument with strong internal consistency (α = .86) and large correlations with the full Warfare Exposure measure (r = .97). In study 2, the DRRI-2 WE-SF again demonstrated high levels of reliability and validity and evidenced high levels of classification accuracy (89.7% correct classification) and significant time savings (all ts > 39; all ps < .05) in comparison to the full measure. The DRRI-2 WE-SF is a psychometrically sound measure of direct exposures to warfare and its consequences. This measure of proximal warfare exposure retains the strong properties of the full measure while significantly reducing completion time. These properties make the DRRI-2 WE-SF a useful tool for efficiently evaluating proximal warfare exposure among individuals who have served in both combat and noncombat roles. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Using Research to Transform Electronic Health Record Modernization: Advancing a VA Partnered Research Agenda to Increase Research Impacts.

The U.S. Department of Veterans Affairs (VA) is undergoing an enterprise-wide transition from a homegrown electronic health record (EHR) system to a commercial off-the-shelf product. Because of the far-reaching effects of the EHR transformation through all aspects of the healthcare system, VA Health Services Research and Development identified a need to develop a research agenda that aligned with health system priorities so that work may inform evidence-based improvements in implementation processes and outcomes. The purpose of this paper is to report on the development of a research agenda designed to optimize the EHR transition processes and implementation outcomes in a large, national integrated delivery system. We used a sequential mixed-methods approach (portfolio assessment, literature review) combined with multi-level stakeholder engagement approach that included research, informatics, and healthcare operations experts in EHR transitions in and outside the VA. Data from each stage were integrated iteratively to identify and prioritize key research areas within and across all stakeholder groups. VA informatics researchers, regional VA health system leaders, national VA program office leaders, and external informatics experts with EHR transition experience. Through three rounds of stakeholder engagement, priority research topics were identified that focused on operations, user experience, patient safety, clinical outcomes, value realization, and informatics innovations. The resulting EHR-focused research agenda was designed to guide development and conduct of rigorous research evidence aimed at providing actionable results to address the needs of operations partners, clinicians, clinical staff, patients, and other stakeholders. Continued investment in research and evaluation from both research and operations divisions of VA will be critical to executing the research agenda, ensuring its salience and value to the health system and its end users, and ultimately realizing the promise of this EHR transition.

The Future of Veteran Community Engagement: Perspectives on Engaging Veterans and Other Stakeholders in Research Agenda Setting

Veteran communities including veterans, their families, and their caregivers are vital collaborators in the field of veterans studies. Veteran community engaged research (CEnR) generates findings that are impactful and applicable to target populations. Veteran CEnR is a valuable emerging methodological approach. In the two decades since 9/11, clinical and health services researchers have increasingly prioritized participatory veteran research designs. The purpose of this article is to illustrate the important application of veteran CEnR to the development of a US Department of Veterans Affairs (VA) Health Services Research and Development (HSR&amp;D) research agenda that tackles a nuanced subject—veteran community reintegration. The Enhancing Veteran Community Reintegration Research (ENCORE) project includes a multi-stakeholder partnership (MSP) that engages veterans, families and caregivers, VA program directors, leaders in veteran community reintegration research, and representatives from community based veteran service organizations. Veteran CEnR was used as an approach to co-author this article with MSP research partners. Contributions from MSP volunteer authors are woven throughout the article to illustrate the organization and functioning of the MSP and impact of this type of stakeholder engagement throughout the project.

0562 Associations of Insomnia Symptoms and Unhealthy Alcohol Use with Post-Operative Healthcare Utilization in Veterans Undergoing Decompressive Laminectomy for Lumbar Spinal Stenosis

Abstract Introduction Lumbar spinal stenosis (LSS) affects 11-39% of adults and contributes to significant pain and disability. Decompressive laminectomy (DL) is a common surgical intervention for LSS but many with medical and psychosocial comorbidities may not improve. Insomnia and unhealthy alcohol use, for example, are common among people living with chronic pain and may affect key laminectomy outcomes, such as healthcare utilization rates. We examined associations of self-reported rates of post-DL healthcare utilization in Veterans with insomnia symptoms and alcohol use. Methods We analyzed data from a multi-site prospective cohort study of Veterans with LSS undergoing DL. Participants (N=200) self-reported prior 12-month alcohol use behavior (Short Michigan Alcohol Screening Test; SMAST) and prior two-week insomnia symptoms (Insomnia Severity Index; ISI) prior to surgery; 12-months of post DL healthcare office visits, ER visits, hospitalizations, and mental health visits were reported over the telephone monthly. Negative binomial regression models via incident rate ratios (IRR) compared healthcare utilization rates between individuals reporting alcohol-related problems only (SMAST &amp;gt;2), insomnia symptoms only (ISI ≥ 8), and both to those reporting neither. Results Approximately 52% of participants reported insomnia symptoms, 75% unhealthy alcohol use, and 39% both. Rates of office, ER, and hospital visits were descriptively highest in those reporting insomnia only; mental health visits were highest in those with both insomnia and unhealthy alcohol use. Those with insomnia only had more ER (IRR=2.39, p=.04) and mental health visits (IRR=4.32, p=.03) than those with neither insomnia nor unhealthy alcohol use; individuals with both insomnia and unhealthy alcohol use also had more mental health visits (IRR=4.22, p=.01). Adjusting for covariates rendered IRRs attenuated and statistically nonsignificant, but magnitudes remained high. Conclusion Most Veterans with LSS reported insomnia symptoms and/or unhealthy alcohol use. Those with insomnia symptoms reported the highest rates of healthcare utilization, including higher rates of ER and mental health visits. Insomnia symptoms may contribute to post-operative healthcare utilization, lending support for assessment and intervention of sleep-related problems pre-laminectomy. Support (If Any) This material is based on work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, grant # RX000798. Dr. Tighe is supported by Career Development/Capacity Building Award Number IK2 RX003393 from the United States (U.S.) Department of Veterans Affairs Rehabilitation R&amp;D (Rehab RD) Service. Dr. Bachrach is supported by a U.S. Department of Veterans Affairs Health Services Research and Development Service (HSR&amp;D) Career Development Award (CDA 20-057).

Racial and Ethnic Disparities in Chronic Pain-related Mental Health Care in a Cohort of U.S. Military Veterans

Chronic pain is a significant problem that impacts the physical and psychological health of many U.S. Veterans. Fortunately, evidenced-based psychological treatments are available through the VA for chronic pain management. However, prior research has broadly shown racial/ethnic minority disparities regarding chronic pain management. The aim of the current study was to examine differences in utilization of VA chronic pain-related mental health care for African American, Asian American, and Hispanic Veterans compared to Whites. Veterans with chronic pain receiving care at the VA in 2018 were included (N = 2,135,216). Mental health care included clinic and telephone visits. Multivariate log binominal regression models were conducted, controlling for age and sex. Interactions with rurality were also explored. A point estimate between groups was considered clinically significant if p < .05 and a difference >10% was observed. Included Veterans had a mean age of 60.5 years (SD = 15.1) and identified as mostly White non-Hispanic (68%), male (89%), and urban residing (81%). Asian Americans were significantly less likely than Whites to receive chronic pain-related mental health care (aRR = 0.86, 95% CI: 0.81, 0.91). Both African Americans (aRR = 1.07, 95% CI: 1.05, 1.08) and Hispanics (aRR = 1.08, 95% CI: 1.05, 1.10) were more likely to receive mental health care than Whites, but this did not reach the level of clinical significance. A clinically significant interaction between rurality and race were observed, such that rural African Americans and Hispanic utilized mental health care more than Whites. These findings suggest that Asian American Veterans with chronic pain may be missing out on effective treatment services to manage their chronic pain. Possible reasons related to these disparities will be discussed. Funding was provided by the U.S. Department of Veterans Affairs (VA) Office of Rural Health (project number 16023). Visit www.ruralhealth.va.gov to learn more. The work reported here was also supported by the US Department of Veterans Affairs Health Services Research and Development (HSR&D) Service through the Center for Access and Delivery Research and Evaluation (CADRE) Center (CIN 13-412). The views expressed in this poster are those of the authors and do not necessarily reflect the position or policy of the US Department of Veterans Affairs or the United States Government.

Stakeholder Research Priorities to Promote Implementation of Shared Decision-Making for Lung Cancer Screening: An American Thoracic Society and Veterans Affairs Health Services Research and Development Statement.

Rationale: Shared decision-making (SDM) for lung cancer screening (LCS) is recommended in guidelines and required by Medicare, yet it is seldom achieved in practice. The best approach for implementing SDM for LCS remains unknown, and the 2021 U.S. Preventive Services Task Force calls for implementation research to increase uptake of SDM for LCS. Objectives: To develop a stakeholder-prioritized research agenda and recommended outcomes to advance implementation of SDM for LCS. Methods: The American Thoracic Society and VA Health Services Research and Development Service convened a multistakeholder committee with expertise in SDM, LCS, patient-centered care, and implementation science. During a virtual State of the Art conference, we reviewed evidence and identified research questions to address barriers to implementing SDM for LCS, as well as outcome constructs, which were refined by writing group members. Our committee (n = 34) then ranked research questions and SDM effectiveness outcomes by perceived importance in an online survey. Results: We present our committee's consensus on three topics important to implementing SDM for LCS: 1) foundational principles for the best practice of SDM for LCS; 2) stakeholder rankings of 22 implementation research questions; and 3) recommended outcomes, including Proctor's implementation outcomes and stakeholder rankings of SDM effectiveness outcomes for hybrid implementation-effectiveness studies. Our committee ranked questions that apply innovative implementation approaches to relieve primary care providers of the sole responsibility of SDM for LCS as highest priority. We rated effectiveness constructs that capture the patient experience of SDM as most important. Conclusions: This statement offers a stakeholder-prioritized research agenda and outcomes to advance implementation of SDM for LCS.

Polypharmacy-associated risk of hospitalisation among people ageing with and without HIV: an observational study

SummaryBackgroundPolypharmacy, defined as use of five or more medications concurrently, is associated with adverse health outcomes and people ageing with HIV might be at greater risk than similar uninfected individuals. We aimed to determine whether known pairwise drug interactions (KPDIs) were associated with risk of admission to hospital (hereafter referred to as hospitalisation) and medication count among people ageing with and without HIV after accounting for physiological frailty.MethodsIn this observational study, we collected individual-level data for participants of the Veterans Aging Cohort Study (VACS) with HIV on antiretroviral therapy (ART) and with supressed HIV-1 RNA and people without HIV who were receiving at least one prescription medication, based on active medications in the 2009 fiscal year (ie, Oct 1, 2008, to Sept 30, 2009). We identified KPDIs among these patients by linking prescription fill and refill data with data from DrugBank (version 5.0.11). We collected data on all-cause mortality and hospitalisations between Oct 1, 2009, and March 31, 2019. We compared KPDI counts using random selection and actual patterns of use across medication counts from two to 12. We created a weighted KPDI Index on the basis of the average association of each KPDI with mortality among people ageing without HIV and used nested Cox models stratified by HIV status to estimate the association between medication count and hospitalisation, with incremental adjustments for demographics, physiological frailty, and KPDI Index.FindingsWe collected data for 9186 people ageing with HIV and 37 930 individuals without HIV. 45 913 (97·4%) of 47 116 patients were men and the sample was predominantly aged 50–64 years (30 413 [64·6%]). Compared with a random sample of medications, real-world pattern of medication counts and combinations were associated with five-to-six times more KPDIs (eg, for a combination of six medications, KPDI count was 1·09 in the random sample, 5·49 in the HIV-negative population, and 7·13 in the HIV-positive population). For each additional observed medication, people ageing with HIV had approximately 2·94 additional KPDIs and comparators had approximately 2·67 additional KPDIs. Adjustment for demographics, physiological frailty, and KPDI Index reduced the association between medication count and risk of hospitalisation for people ageing with HIV (hazard ratio 1·08 [95% CI 1·07–1·09] reduced to 1·06 [1·05–1·07]) and those without HIV (1·08 [1·07–1·08] reduced to 1·04 [1·03–1·05]).InterpretationFor each additional medication, people ageing with HIV have more drug–drug interactions than those without HIV. Adjusting for known non-ART drug–drug interactions, each additional non-ART medication confers excess risk of hospitalisation for people ageing with HIV. Randomised trials will be needed to determine whether reducing these interactions improves outcomes.FundingNational Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, Department of Veterans Affairs Health Services Research & Development, and Office of Research and Development.

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).

Screening for Depression in People with Kidney Failure.

A large proportion of patients with CKD before and after initiation of maintenance dialysis suffer from major depressive disorder, such that about 20% of those with non-dialysis CKD and 25% of those with kidney failure are affected ([1][1]). More daunting is the actuality, validated in multiple

Secondary Prevention for Atherosclerotic Cardiovascular Disease: Comparing Recent US and European Guidelines on Dyslipidemia.

Secondary Prevention for Atherosclerotic Cardiovascular Disease: Comparing Recent US and European Guidelines on Dyslipidemia.

Accelerating implementation of research in Learning Health Systems: Lessons learned from VA Health Services Research and NCATS Clinical Science Translation Award programs.

Translation of research to practice is challenging. In addition to the scientific challenges, there are additional hurdles in navigating the rapidly changing US health care system. There is a need for innovative health interventions that can be adopted in "real-world" settings. Barriers to translation involve misaligned timing of research funding and health system decision-making, lack of research questions aligned with health system and community priorities, and limited incentives in academia for health system and community-based research. We describe new programs from the US Department of Veterans Affairs Health Services Research and Development (HSR&D) and the National Center for Advancing Translational Sciences (NCATS) Clinical and Translational Science Award (CTSA) Programs that are building capacity for Learning Health System research. These programs help to incentivize adopting and adapting Learning Health System principles to ensure that, primarily in implementation science within academic/veterans affairs health systems, there is alignment of the research with the health system and community needs. Both HSR&D and NCATS CTSA Program encourage researchers to develop problem-focused research innovations in partnership with health systems and communities to ultimately facilitate design treatments that are feasible in "real-world" practice.

Enrollment and Retention of Men and Women in Health Services Research and Development Trials.

Sex- and gender-specific science is essential to inform patient-centered, evidence-based care. Developing such evidence requires adequate inclusion of both women and men in trials. We sought to describe study participation of women and men in Department of Veterans Affairs Health Services Research and Development trials. We identified recent health services research trials from one Health Services Research and Development Center of Innovation and compared the participation of women and men from trial recruitment to study completion. We also calculated the participation to prevalence ratio (PPR) by sex for each trial. We included eight trials that started recruitment between 2011 and 2014. Only one study purposefully attempted to boost the recruitment of women. Overall, the PPR for women ranged from 0.2 to 4.5, with seven studies having a PPR of greater than 1, indicating that women participated in these trials at proportions greater than their prevalence in the disease population within the Department of Veterans Affairs. The PPR for men ranged from 0.8 to 1.1. Retention was best with those studies that used administrative data for final outcomes assessment. No studies provided results stratified by sex or conducted analyses to explore treatment effect by sex. At a single site, women participated in Health Services Research and Development trials at similar or greater rates to men without cross-study efforts to enrich the recruitment or retention of women. Adding strategic recruitment approaches could further boost the proportion of women in Department of Veterans Affairs trials and enable adequately powered sex-based analyses.

Accelerating the Growth of Evidence-Based Care for Women and Men Veterans.

Accelerating the Growth of Evidence-Based Care for Women and Men Veterans.

Determining Best Practices for Management of Bacteriuria in Spinal Cord Injury: Protocol for a Mixed-Methods Study.

BackgroundBacteriuria, either asymptomatic (ASB) or symptomatic, urinary tract infection (UTI), is common in persons with spinal cord injury (SCI). Current Veterans Health Administration (VHA) guidelines recommend a screening urinalysis and urine culture for every veteran with SCI during annual evaluation, even when asymptomatic, which is contrary to other national guidelines. Our preliminary data suggest that a positive urine culture (even without signs or symptoms of infection) drives antibiotic use.ObjectiveThrough a series of innovative studies utilizing mixed methods, administrative databases, and focus groups, we will gain further knowledge about the attitudes driving current urine testing practices during the annual exam, as well as quantitative data on the clinical outcomes of these practices.MethodsAim 1 will identify patient, provider, and facility factors driving bacteriuria testing and subsequent antibiotic use after the SCI annual evaluation through qualitative interviews and quantitative surveys. Aim 2 will use national VHA databases to identify the predictors of urine testing and subsequent antibiotic use during the annual examination and compare the clinical outcomes of those who received antibiotics with those who did not. Aim 3 will use the information gathered from the previous 2 aims to develop the Test Smart, Treat Smart intervention, a combination of patient and provider education and resources that will help stakeholders have informed conversations about urine testing and antibiotic use; feasibility will be tested at a single site.ResultsThis protocol received institutional review board and VHA Research and Development approval in July 2017, and Veterans Affairs Health Services Research and Development funding started on November 2017. As of submission of this manuscript, 10/15 (67%) of the target goal of provider interviews were complete, and 77/100 (77%) of the goal of surveys. With regard to patients, 5/15 (33%) of the target goal of interviews were complete, and 20/100 (20%) of the target goal of surveys had been completed. Preliminary analyses are ongoing; the study team plans to present these results in April 2019. Database analyses for aim 2 will begin in January 2019.ConclusionsThe negative consequences of antibiotic overuse and antibiotic resistance are well-documented and have national and even global implications. This study will develop an intervention aimed to educate stakeholders on evidence-based management of ASB and UTI and guide antibiotic stewardship in this high-risk population. The next step will be to refine the intervention and test its feasibility and effectiveness at multiple sites as well as reform policy for management of this common but burdensome condition.International Registered Report Identifier (IRRID)DERR1-10.2196/12272

(182) - Pain care utilization following episodes of specialty substance use disorder treatment

Substance use disorders (SUDs) are common in patients with chronic non-cancer pain and associated with poor pain treatment engagement and clinical outcomes. Unfortunately, patients with active SUDs are often difficult to engage in care. Specialty SUD treatment programs may be optimally positioned to concomitantly treat active SUDs and help patients engage in needed pharmacologic and non-pharmacologic pain care. We utilized retrospective VA administrative data to identify a cohort of all U.S. Department of Veterans Affairs (VA) patients with chronic non-cancer pain and a SUD between 2010 and 2013. A total of 126,390 patients met study inclusion criteria. 18,964 of these patients subsequently received a full episode of SUD treatment, while an additional 63,939 received some specialty SUD treatment without completing a full treatment episode. Generalized estimating equations controlled for key demographic and clinical variables and compared 12-month pain care utilization between patients with specialty SUD treatment engagement to those with no specialty SUD treatment. Relative to patients who received no specialty SUD treatment, those who received incomplete episodes of SUD treatment were more likely to be prescribed Non-opioid Pharmacotherapy (OR = 1.05 [95% CI = 1.02–1.08]), and engage in Occupational Therapy (OR = 1.47 [1.40–1.53]), while less likely to be prescribed Opioid Pharmacotherapy (OR = .92[.88–.96]) or Primary Care encounters (OR = .98[.97–.99]). Patients who completed full episodes of SUD treatment, compared to patients who received no SUD treatment, were more likely to be prescribed Non-opioid Pharmacotherapy (OR = 1.72[1.66–1.79]) and receive Rehabilitation Medicine (OR = 1 .75[1.63–1.89]), Occupational Therapy (OR = 5.60[528-5.94]), Specialty Pain Clinic (OR = 1.20[1.11–1.30]), and Primary Care treatment (OR = 1.57[1.53–1.60]), while less likely to be prescribed Opioid Pharmacotherapy (OR = .82[.79–.85]). For patients with comorbid chronic non-cancer pain and active SUDs, episodes of specialty SUD treatment may present an optimal time for delivering needed pain care to this hard-to-reach population. Supported by grant IK2HX001516 from VA Health Services Research & Development.

Formative Usability Evaluation of a Novel Tool for Medication Reconciliation

To decrease medication errors, a common cause of injury to patients, we developed a novel electronic tool to facilitate asynchronous communication between healthcare professionals (HCPs) and patients for medication reconciliation. However, it was unknown whether the tool adequately supported HCPs’ usability needs. Our objective was to conduct an iterative usability evaluation of the tool with physicians, nurses, and pharmacists, in preparation for a randomized controlled trial. We hypothesized that we would identify design weaknesses that could be addressed via interface modifications prior to the trial. We completed a mixed-method, formative usability evaluation with 20 HCPs in the Veterans Affairs (VA) Health Services Research and Development, Human-Computer Interaction and Simulation Laboratory located within a major medical center. The tool in this study is formally known as the Secure Messaging for Medication Reconciliation Tool (SMMRT). The evaluation consisted of four sequential steps: 1) phase I usability testing to assess the baseline tool along with small, iterative design changes throughout testing; 2) heuristic evaluation; 3) implement major design changes that incorporate findings from previous steps; and 4) phase II usability testing to assess the implemented design changes and further refine the tool. This presentation focuses on steps 1 and 4 related to usability testing. During testing, HCPs worked through a real case consisting of a patient discharged from the hospital within the past 30 days who had at least 5 outpatient medications. We collected data on efficiency, usability errors, and participants’ satisfaction, along with participants’ ability to detect and address three distinct types of medication errors via the tool. For the latter, we inserted three safety probes into the simulation: 1) a missing medication (i.e., omission); 2) an extraneous medication (i.e., commission); and 3) an inaccurate dose (i.e., dose discrepancy). Data were analyzed descriptively, rather than via statistical comparisons, due to the formative and iterative nature of this research. There was no indication of efficiency gains during iterative prototyping and testing. Highlights of usability errors included confusion about medication entry fields; incorrect assumptions regarding medication list accuracy; inadequate medication information sorting and organization; and premature closure. Additionally, HCPs described usability errors that might occur in clinical practice. For example, medication images on the tool may not match what is dispensed to patients. HCPs also expressed concern that medication updates made via the tool may not be consistently updated in the electronic health record. In terms of satisfaction, HCPs’ ratings tended to increase as design modifications were implemented. After phase II usability testing, their overall satisfaction was favorable. Finally, for each of the three safety probes, 50% or fewer of HCPs identified the associated medication error. This research illustrates the importance of usability evaluations as a precursor to randomized trials of health information technology. Our multi-step approach to usability testing, with heuristic evaluation at the midpoint, may inform the design of other usability evaluations. While efficiency gains were not realized, user satisfaction improved. The inclusion of safety probes was especially valuable, since probes allowed us to assess error detection rates. There may be opportunities for human factors professionals to expand the sophistication and types of probes used in future healthcare research. Future studies are needed to develop more advanced design approaches that facilitate healthcare professionals’ detection of medication errors.

Institutional Incentives for Mentoring at the U.S. Department of Veterans Affairs and Universities: Associations With Mentors' Perceptions and Time Spent Mentoring.

Limited empirical attention to date has focused on best practices in advanced research mentoring in the health services research domain. The authors investigated whether institutional incentives for mentoring (e.g., consideration of mentoring in promotion criteria) were associated with mentors' perceptions of mentoring benefits and costs and with time spent mentoring. The authors conducted an online survey in 2014 of a national sample of mentors of U.S. Department of Veterans Affairs (VA) Health Services Research and Development Service (HSR&D) mentored career development award recipients who received an award during 2000-2012. Regression analyses were used to examine institutional incentives as predictors of perceptions of benefits and costs of mentoring and time spent mentoring. Of the 145 mentors invited, 119 (82%) responded and 110 (76%) provided complete data for the study items. Overall, mentors who reported more institutional incentives also reported greater perceived benefits of mentoring (P = .03); however, more incentives were not significantly associated with perceived costs of mentoring. Mentors who reported more institutional incentives also reported spending a greater percentage of time mentoring (P = .02). University incentives were associated with perceived benefits of mentoring (P = .02), whereas VA incentives were associated with time spent mentoring (P = .003). Institutional policies that promote and support mentorship of junior investigators, specifically by recognizing and rewarding the efforts of mentors, are integral to fostering mentorship programs that contribute to the development of early-career health services researchers into independent investigators.

Rapid Evidence Review of Bariatric Surgery in Super Obesity (BMI ≥ 50 kg/m2).

Despite accumulating evidence of the important health benefits of bariatric surgery in morbidly obese patients in general, bariatric surgery outcomes are less clear in higher-risk, high-priority populations of patients with BMI ≥ 50 kg/m2. To help the Department of Veterans Affairs (VA) Health Services Research & Development Service (HSR&D) develop a research agenda, we conducted a rapid evidence review to better understand bariatric surgery outcomes in adults with BMI ≥ 50 kg/m2. We searched MEDLINE®, the Cochrane Database of Systematic Reviews, the Cochrane Central Registry of Controlled Trials, and ClinicalTrials.gov through June 2016. We included trials and observational studies. We used pre-specified criteria to select studies, abstract data, and rate internal validity and strength of the evidence (PROSPERO registration number CRD42015025348). All decisions were completed by one reviewer and checked by another. Among 1892 citations, we included 23 studies in this rapid review. Compared with usual care, one large retrospective VA study provided limited evidence that bariatric surgery can lead to increased mortality in the first year, but decreased mortality long-term among super obese veterans. Studies that compared different bariatric surgical approaches suggested some differences in weight loss and complications. Laparoscopic gastric bypass generally resulted in greater short-term proportion of excess weight loss than did other procedures. Duodenal switch led to greater long-term weight loss than did gastric bypass, but with more complications. The published literature that separates the super obese is insufficient for determining the precise balance of benefits and harms of bariatric surgery in this high-risk subgroup. Future studies should evaluate a more complete set of key outcomes with longer follow-up in larger samples of more broadly representative adults.

Patient-Centered Pain Care Using Artificial Intelligence and Mobile Health Tools: Protocol for a Randomized Study Funded by the US Department of Veterans Affairs Health Services Research and Development Program.

BackgroundCognitive behavioral therapy (CBT) is one of the most effective treatments for chronic low back pain. However, only half of Department of Veterans Affairs (VA) patients have access to trained CBT therapists, and program expansion is costly. CBT typically consists of 10 weekly hour-long sessions. However, some patients improve after the first few sessions while others need more extensive contact.ObjectiveWe are applying principles from “reinforcement learning” (a field of artificial intelligence or AI) to develop an evidence-based, personalized CBT pain management service that automatically adapts to each patient’s unique and changing needs (AI-CBT). AI-CBT uses feedback from patients about their progress in pain-related functioning measured daily via pedometer step counts to automatically personalize the intensity and type of patient support. The specific aims of the study are to (1) demonstrate that AI-CBT has pain-related outcomes equivalent to standard telephone CBT, (2) document that AI-CBT achieves these outcomes with more efficient use of clinician resources, and (3) demonstrate the intervention’s impact on proximal outcomes associated with treatment response, including program engagement, pain management skill acquisition, and patients’ likelihood of dropout.MethodsIn total, 320 patients with chronic low back pain will be recruited from 2 VA healthcare systems and randomized to a standard 10 sessions of telephone CBT versus AI-CBT. All patients will begin with weekly hour-long telephone counseling, but for patients in the AI-CBT group, those who demonstrate a significant treatment response will be stepped down through less resource-intensive alternatives including: (1) 15-minute contacts with a therapist, and (2) CBT clinician feedback provided via interactive voice response calls (IVR). The AI engine will learn what works best in terms of patients’ personally tailored treatment plans based on daily feedback via IVR about their pedometer-measured step counts, CBT skill practice, and physical functioning. Outcomes will be measured at 3 and 6 months post recruitment and will include pain-related interference, treatment satisfaction, and treatment dropout. Our primary hypothesis is that AI-CBT will result in pain-related functional outcomes that are at least as good as the standard approach, and that by scaling back the intensity of contact that is not associated with additional gains in pain control, the AI-CBT approach will be significantly less costly in terms of therapy time.ResultsThe trial is currently in the start-up phase. Patient enrollment will begin in the fall of 2016 and results of the trial will be available in the winter of 2019.ConclusionsThis study will evaluate an intervention that increases patients’ access to effective CBT pain management services while allowing health systems to maximize program expansion given constrained resources.