Veterans Affairs Health System Research Articles

Evaluation of the Strength at Home Group Intervention for Intimate Partner Violence in the Veterans Affairs Health System

Intimate partner violence (IPV) is a serious and prevalent public health issue that is interconnected with experiences of trauma, mental and physical health difficulties, and health disparities. Strength at Home (SAH) is a group intervention for persons using IPV in their relationships. Although previous studies have provided evidence of SAH's effectiveness in reducing IPV, its patient outcomes as implemented within organized health care have not been examined. To evaluate patient outcomes from implementation of SAH in the Department of Veterans Affairs (VA) health system. This quality improvement study evaluated patient outcomes from a national implementation and training program conducted between December 11, 2015, and September 24, 2021. Data were collected as part of treatment and submitted by clinicians at 73 VA health care facilities. Patients were 1754 veterans seeking care aimed at addressing and/or preventing their use of aggression in intimate relationships. They completed 1 pretreatment assessment and 1 follow-up assessment in the immediate weeks after group completion. Strength at Home is a 12-week trauma-informed and cognitive behavioral group intervention to address and prevent the use of IPV in relationships. Changes in IPV were measured with the Centers for Disease Control and Prevention 2010 National Intimate Partner and Sexual Violence Survey. Changes in posttraumatic stress disorder (PTSD) symptoms were measured with the PTSD Checklist for DSM-5, and alcohol misuse was measured with the Alcohol Use Disorders Identification Test. The study included 1754 participants (mean [SD] age, 44.3 [13.0] years; 1421 men [81%]), of whom 1088 (62%) were involved with the criminal legal system for IPV charges. Analyses indicate that SAH was associated with reductions in use of physical IPV (odds ratio, 3.28; percentage difference from before to after treatment, -0.17 [95% CI, -0.21 to -0.13]) and psychological IPV (odds ratio, 2.73; percentage difference from before to after treatment, -0.23 [95% CI, -0.27 to -0.19]), coercive control behaviors (odds ratio, 3.19; percentage difference from before to after treatment, -0.18 [95% CI, -0.22 to -0.14), PTSD symptoms (mean change, -4.00; 95% CI, 0.90-7.09; Hedges g = 0.10), and alcohol misuse (mean change, 2.70; 95% CI, 1.54-3.86; Hedges g = 0.24). In this quality improvement study of the patient outcomes after implementation of SAH, results suggested that the program was associated with reductions in IPV behaviors, PTSD symptoms, and alcohol misuse. Results also suggest that IPV intervention in routine health care at VA health care facilities was successful; extension to other organized health care systems could be warranted.

Long-Term Health Care Costs for Service Members Injured in Iraq and Afghanistan.

Over the last two decades, the conflicts in Iraq and Afghanistan have cost the United States significantly in terms of lives lost, disabling injuries, and budgetary expenditures. This manuscript calculates the differences in costs between veterans with combat injuries vs veterans without combat injuries. This work could be used to project future costs in subsequent studies. In this retrospective cohort study, we randomly selected 7,984 combat-injured veterans between February 1, 2002, and June 14, 2016, from Veterans Affairs Health System administrative data. We matched injured veterans 1:1 to noninjured veterans on year of birth (± 1 year), sex, and first service branch. We observed patients for a maximum of 10 years. This research protocol was reviewed and approved by the David Grant USAF Medical Center institutional review board (IRB), the University of Utah IRB, and the Research Review Committee of the VA Salt Lake City Health Care System in accordance with all applicable Federal regulations. Patients were primarily male (98.1% in both groups) and White (76.4% for injured patients, 72.3% for noninjured patients), with a mean (SD) age of 26.8 (6.6) years for the injured group and 27.7 (7.0) years for noninjured subjects. Average total costs for combat-injured service members were higher for each year studied. The difference was highest in the first year ($16,050 compared to $4,135 for noninjured). These differences remained significant after adjustment. Although this difference was greatest in the first year (marginal effect $12,386, 95% confidence interval $9,736-$15,036; P < 0.001), total costs continued to be elevated in years 2-10, with marginal effects ranging from $1,766 to $2,597 (P < 0.001 for all years). More severe injuries tended to increase costs in all categories. Combat injured patients have significantly higher long-term health care costs compared to their noninjured counterparts. If this random sample is extrapolated to the 53,251 total of combat wounded service members, it implies a total excess cost of $1.6 billion to date after adjustment for covariates and a median follow-up time of 10 years. These costs are likely to increase as injured veterans age and develop additional chronic conditions.

Adaptation of a social risk screening and referral initiative across clinical populations, settings, and contexts in the Department of Veterans Affairs Health System.

Identifying and addressing social risks and social needs in healthcare settings is an important step towards achieving health equity. Assessing Circumstances and Offering Resources for Needs (ACORN) is a Department of Veterans Affairs (VA) social risk screening and referral model that aims to systematically identify and address social needs. Since initial piloting in 2018, our team has collaborated with clinical and operations partners to implement ACORN across multiple VA clinical settings while adapting and tailoring the initiative to meet the needs of different populations, specialties, and individuals administering screening. Given ACORN's complexity as a growing initiative with multiple partners and frequent real-time modifications within a large national healthcare system, we recognized a need to systematically document the rationale and process of adaptations over time. We looked to three implementation frameworks-RE-AIM, the Adaptome, and FRAME-to describe the rationale for adaptations, the nature of and context within which adaptations were made, and the details of each adaptation. In this manuscript, we uniquely interweave these three frameworks to document adaptations to ACORN across diverse VA clinical settings, with a focus on how adaptations support the promotion of heath equity in the Veteran population.

Association of a Positive Drug Screening for Cannabis With Mortality and Hospital Visits Among Veterans Affairs Enrollees Prescribed Opioids

Cannabis has been proposed as a therapeutic with potential opioid-sparing properties in chronic pain, and its use could theoretically be associated with decreased amounts of opioids used and decreased risk of mortality among individuals prescribed opioids. To examine the risks associated with cannabis use among adults prescribed opioid analgesic medications. This cohort study was conducted among individuals aged 18 years and older who had urine drug screening in 2014 to 2019 and received any prescription opioid in the prior 90 days or long-term opioid therapy (LTOT), defined as more than 84 days of the prior 90 days, through the Veterans Affairs health system. Data were analyzed from November 2020 through March 2022. Biologically verified cannabis use from a urine drug screen. The main outcomes were 90-day and 180-day all-cause mortality. A composite outcome of all-cause emergency department (ED) visits, all-cause hospitalization, or all-cause mortality was a secondary outcome. Weights based on the propensity score were used to reduce confounding, and hazard ratios [HRs] were estimated using Cox proportional hazards regression models. Analyses were conducted among the overall sample of patients who received any prescription opioid in the prior 90 days and were repeated among those who received LTOT. Analyses were repeated among adults aged 65 years and older. Among 297 620 adults treated with opioids, 30 514 individuals used cannabis (mean [SE] age, 57.8 [10.5] years; 28 784 [94.3%] men) and 267 106 adults did not (mean [SE] age, 62.3 [12.3] years; P < .001; 247 684 [92.7%] men; P < .001). Among all patients, cannabis use was not associated with increased all-cause mortality at 90 days (HR, 1.07; 95% CI, 0.92-1.22) or 180 days (HR, 1.00; 95% CI, 0.90-1.10) but was associated with an increased hazard of the composite outcome at 90 days (HR, 1.05; 95% CI, 1.01-1.07) and 180 days (HR, 1.04; 95% CI, 1.01-1.06). Among 181 096 adults receiving LTOT, cannabis use was not associated with increased risk of all-cause mortality at 90 or 180 days but was associated with an increased hazard of the composite outcome at 90 days (HR, 1.05; 95% CI, 1.02-1.09) and 180 days (HR, 1.05; 95% CI, 1.02-1.09). Among 77 791 adults aged 65 years and older receiving LTOT, cannabis use was associated with increased 90-day mortality (HR, 1.55; 95% CI, 1.17-2.04). This study found that cannabis use among adults receiving opioid analgesic medications was not associated with any change in mortality risk but was associated with a small increased risk of adverse outcomes and that short-term risks were higher among older adults receiving LTOT.

1234. Analysis of an Automated Letter HCV Screening Program within a Veterans Affairs Health System: Implications for Universal HCV Screening

Abstract Background Although universal Hepatitis C Virus (HCV) Screening in the US was recommended in 2020, the optimal implementation method is unknown. We characterized the efficacy of an automated letter HCV screening program at the Veteran’s Affairs (VA) Greater Los Angeles Healthcare System (VAGLAHS) and evaluated associations with linkage to care. Methods From January 2017 to May 2020, 14,804 Veterans born between 1945-1965 who did not have an HCV antibody (Ab) test result within the last 10 years and who were within the VAGLAHS catchment area were identified. Veterans were mailed a letter recommending HCV screening via a centralized process. Veterans then used the letter to present to a VA laboratory for HCV Ab testing, which included reflex HCV viral load. Those who were HCV viremic were referred to Hepatology/Infectious Diseases clinics for initiation of HCV treatment. Baseline characteristics of those with subsequent HCV viremia were collected. To determine associations with the first HCV visit (linkage to care), we performed independent chi-squared tests. Flowchart of Automated Letter HCV Screening for Veterans Results A total of 12,875 Veterans were identified, 4,011 (31%) Veterans presented for HCV Ab testing, 167/4011 were HCV Ab + (4.2%), and 69/167 (41.3%) had HCV viremia. Of those viremic, 94 % were male, 26% were African-American, 62% had stable housing, 24% lived &amp;gt;90 miles from the nearest VA clinic, and 17% had cirrhosis. Fifty-five Veterans (80%) were evaluated in a viral hepatitis clinic and 84 % (46/55) initiated HCV treatment (Figure 1). Patients’ housing status (p = 0.02), cirrhosis (p&amp;lt; 0.0001), and distance to clinic (p=0.063) were associated with non-linkage to an initial HCV appointment. Conclusion One third of Veterans approached via mail participated in HCV Ab testing. Overall HCV Ab positivity rates were 4% and nearly half had HCV viremia. The majority of Veterans were linked to care but housing status, cirrhosis, and distance to clinic were associated with non-linkage to care. Automated letter screening is a promising approach to HCV screening, including universal screening. Future research should include investigations of telehealth and e-consults for linkage to care, especially for those who have marginalized housing status and live far from clinic. Disclosures Debika Bhattacharya, MD, MSc, Gilead: Grant/Research Support|Regeneron: Grant/Research Support.

Chlorthalidone vs. Hydrochlorothiazide for Hypertension–Cardiovascular Events

BackgroundWhether chlorthalidone is superior to hydrochlorothiazide for preventing major adverse cardiovascular events in patients with hypertension is unclear.MethodsIn a pragmatic trial, we randomly assigned adults 65 years of age or older who were patients in the Department of Veterans Affairs health system and had been receiving hydrochlorothiazide at a daily dose of 25 or 50 mg to continue therapy with hydrochlorothiazide or to switch to chlorthalidone at a daily dose of 12.5 or 25 mg. The primary outcome was a composite of nonfatal myocardial infarction, stroke, heart failure resulting in hospitalization, urgent coronary revascularization for unstable angina, and non–cancer-related death. Safety was also assessed.ResultsA total of 13,523 patients underwent randomization. The mean age was 72 years. At baseline, hydrochlorothiazide at a dose of 25 mg per day had been prescribed in 12,781 patients (94.5%). The mean baseline systolic blood pressure in each group was 139 mm Hg. At a median follow-up of 2.4 years, there was little difference in the occurrence of primary-outcome events between the chlorthalidone group (702 patients [10.4%]) and the hydrochlorothiazide group (675 patients [10.0%]) (hazard ratio, 1.04; 95% confidence interval, 0.94 to 1.16; P=0.45). There were no between-group differences in the occurrence of any of the components of the primary outcome. The incidence of hypokalemia was higher in the chlorthalidone group than in the hydrochlorothiazide group (6.0% vs. 4.4%, P<0.001).ConclusionsIn this large pragmatic trial of thiazide diuretics at doses commonly used in clinical practice, patients who received chlorthalidone did not have a lower occurrence of major cardiovascular outcome events or non–cancer-related deaths than patients who received hydrochlorothiazide. (Funded by the Veterans Affairs Cooperative Studies Program; ClinicalTrials.gov number, NCT02185417.)

Nationwide Implementation of a Population Management Dashboard for Monitoring Direct Oral Anticoagulants: Insights From the Veterans Affairs Health System.

Direct oral anticoagulants are first-line therapy for common thrombotic conditions, including atrial fibrillation and venous thromboembolism. Despite their strong efficacy and safety profile, evidence-based prescribing can be challenging given differences in dosing based on indication, renal function, and drug-drug interactions. The Veterans Health Affairs developed and implemented a population management dashboard to support pharmacist review of anticoagulant prescribing. The dashboard includes information about direct oral anticoagulants and dose prescribed, renal function, age, and weight, potential interacting medications, and the need for direct oral anticoagulant medication refills. It is a stand-alone system. Using login data from the dashboard, nationwide implementation was evaluated using elements from the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Between August 2016 and June 2020, 150/164 sites within the Veterans Health Affairs system used the dashboard, averaging 1875 patients per site. The dashboard was made available to sites on a staggered basis. Moderate or high adoption, defined as at least one login on at least 2 separate days per month, began slowly with 3/5 sites in the pilot phase but rapidly grew to 142/150 (94.7%) sites by June 2020. The average number of unique users per site increased from 2.4 to 7.5 over the study period. Moderate to high adoption of the dashboard's use was maintained for > 6 months in 126/150 (84.0%) sites by the end of the study period. There was rapid and sustained implementation and adoption of a population health dashboard for evidence-based anticoagulant prescribing across the national United States Veterans Health Administration health system. The impact of this tool on clinical outcomes and strategies to replicate this care model in other health systems will be important for broad dissemination and uptake.

Clinical Pharmacy Specialist Collaborative Management and Prescription of Diabetes Medications with Cardiovascular Benefit.

Background: Involvement of Clinical Pharmacy Specialists (CPS) in the care of patients with diabetes mellitus (DM) has been demonstrated to be beneficial. Whether this positive impact applies to increased use of cardiovascular risk-reducing medications is less well established. Objective: To determine the association of CPS co-management on the prescription of diabetes medications with proven cardiovascular benefits for patients with DM and established cardiovascular disease in the primary care setting. Methods: This retrospective cohort study evaluated patients in a Veterans Affairs health-system in primary care settings from February 1, 2019, through January 31, 2020. Patients were included if they had type 2 DM treated with at least one medication and had CVD. Patients were grouped into two cohorts for comparison, those with CPS co-management and those without. The primary outcome was the proportion of patients in each group with new prescriptions for empagliflozin or liraglutide initiated during the study timeframe. Results: In total, 8058 patients were found eligible for inclusion in the study. Clinical co-management by a CPS was provided to 2099 patients. Study medications were prescribed, approved, and initiated in 596 patients during the study period, including 391 (18.6%) in the CPS group and 205 (3.4%) in the non-CPS group (P < .001). Conclusion: This study showed CPS involvement is associated with increased prescribing of diabetes medications with proven cardiovascular benefits.

Association Between Primary Care Use Prior to Cancer Diagnosis and Subsequent Cancer Mortality in the Veterans Affairs Health System

Primary care physicians (PCPs) are significant contributors of early cancer detection, yet few studies have investigated whether consistent primary care translates to improved downstream outcomes. To evaluate the association of prediagnostic primary care use with metastatic disease at diagnosis and cancer-specific mortality (CSM). This cohort study used databases with primary care and referral linkage from multiple Veterans' Affairs centers from 2004 to 2017 and had a 68-month median follow-up. Analysis was completed between July 2021 and September 2022. Participants included veterans older than 39 years who had been diagnosed with 1 of 12 cancers. Inclusion criteria included known clinical staging, survival follow-up, cause of death, and receiving care at the Veterans Affairs health system (VA). Prediagnostic PCP use, measured in the 5 years prior to diagnosis. PCP visits were binned into none (0 visits), some (1-4 visits), and annual (5 visits). Metastatic disease at diagnosis, cancer-specific mortality (CSM) for entire cohort and stratified by tumor subtype. Among 245 425 patients representing 12 tumor subtypes, mean age was 65.8 (9.3) years, and the cohort skewed male (97.6%), and White (76.1%), with higher levels of comorbidity (58.6% with Charlson Comorbidity Index scores ≥2). Compared with no prior visit, some PCP use was associated with 26% decreased odds of metastatic disease at diagnosis (odds ratio [OR], 0.74; 95% CI, 0.71-0.76; P < .001) and 12% reduced risk of CSM (subdistribution hazard ratio [SHR], 0.88; 95% CI, 0.86-0.89; P < .001). Annual PCP use was associated with 39% decreased odds of metastatic disease (OR, 0.61; 95% CI, 0.59-0.63; P < .001) and 21% reduced risk of CSM (SHR, 0.79; 95% CI, 0.77-0.81; P < .001). Among tumor subtypes, prostate cancer had the largest effect size for prior PCP use on metastatic disease at diagnosis (OR for annual use, 0.32; 95% CI, 0.30-0.35; P < .001) and CSM (SHRfor annual use, 0.51; 95% CI, 0.48-0.55; P < .001). In this cohort study, increased primary care use before cancer diagnosis was associated with significant decreases in metastatic disease at diagnosis and cancer-related death, with potentially the greatest difference from annual use. PCPs play a vital role in cancer prevention, and additional resources should be allocated to assist these physicians.

Personality disorder and suicide risk among patients in the veterans affairs health system.

Among veterans in Veterans Health Administration (VHA) care, patients with mental health and substance use conditions experience elevated suicide rates. However, despite previously demonstrated high rates of suicidal behavior, little is known regarding suicide rates among veteran VHA users with personality disorders (PDs) as a whole, or by PD clusters (A: Eccentric; B: Dramatic; C: Fearful; and PD-not otherwise specified). PD prevalence and suicide rates were assessed through 2017; overall and by clusters for 5,517,024 veterans alive as of 12/31/2013 and with more than 2 VHA encounters in 2012-2013. In all, 46,050 (.83%) had a PD diagnosis in 2012-2013. Suicide risk was examined using proportional hazards regressions adjusted for age, sex, veteran status, clustering within a geographic region, and other mental health diagnoses. Patients with PDs had greater suicide risk than those without (156.5 vs. 46.7 per 100,000 person-years). Individuals in Cluster B, which includes borderline and antisocial PDs, were at the highest risk (178.5 per 100,000 person-years), followed by PD-not otherwise specified and Cluster C (152.6 and 121.4 per 100,000 person-years, respectively). Rates of PDs in the VHA system were lower than those usually found in community samples. Veterans with a PD diagnosis had an increased risk of suicide, which was especially elevated for those with Cluster B diagnoses. Study findings document the importance of enhancing diagnosis and treatment for veterans with PDs and targeted suicide prevention services. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Trends in Stenotrophomonas maltophilia antibiotic resistance rates in the United States Veterans Affairs Health System.

Introduction. Stenotrophomonas maltophilia is an important multidrug-resistant Gram-negative pathogen. While largely a hospital-acquired pathogen, there have been increasing reports of the pathogen in the community.Gap Statement. Trends in S. maltophilia prevalence and resistance rates that include outpatient isolates are unknown.Aim. We described recent trends in prevalence and resistance of S. maltophilia in the national Veterans Affairs (VA) Healthcare system.Methodology. The study identified positive S. maltophilia clinical cultures among VA adult patients from 2010 to 2018 across all VA hospitals, long-term care facilities/units, and outpatient settings. Annual S. maltophilia resistance rates were evaluated. Multidrug resistant (MDR) was defined as resistance to sulfamethoxazole/trimethoprim (SMX/TMP) and minocycline or levofloxacin. Time trends were assessed with regression analyses to estimate annual average percent changes (AAPC) with 95 % confidence intervals using Joinpoint software.Results. Over the 9 year study period, 18 285 S. maltophilia cultures were identified (57 % hospital, 3 % long-term care, 40 % outpatient). The most common source of S. maltophilia cultures were respiratory cultures (34.6 %) followed by urine cultures (30.4 %). In VA hospitals and long-term care facilities, the number of S. maltophilia cultures decreased significantly (by 5.4% and 8.4 % per year respectively). Overall, 3.1 % of isolates were MDR which remained stable over the study period. Resistance to other antibiotics assessed mostly remained stable, except SMX/TMP resistance decreased significantly by 8.5 % (2010, 15 %; 2018, 6 %) per year in VA hospitals.Conclusion. While previous work has recognized S. maltophilia as primarily a nosocomial pathogen, the present study found that 40 % of cultures collected were among outpatients. Between 2010 and 2018, the number of positive S. maltophilia cultures decreased significantly in the national VA Healthcare System. Resistance to SMX/TMP decreased over the study period in VA hospitals and now more closely reflects previously reported resistance rates worldwide (0-10 %). MDR S. maltophilia remained stable and low in the national VA Healthcare System.

Monitoring policy in the context of preventive treatment of cardiovascular disease.

Preventing chronic diseases is an essential aspect of medical care. To prevent chronic diseases, physicians focus on monitoring their risk factors and prescribing the necessary medication. The optimal monitoring policy depends on the patient's risk factors and demographics. Monitoring too frequently may be unnecessary and costly; on the other hand, monitoring the patient infrequently means the patient may forgo needed treatment and experience adverse events related to the disease. We propose a finite horizon and finite-state Markov decision process to define monitoring policies. To build our Markov decision process, we estimate stochastic models based on longitudinal observational data from electronic health records for a large cohort of patients seen in the national U.S. Veterans Affairs health system. We use our model to study policies for whether or when to assess the need for cholesterol-lowering medications. We further use our model to investigate the role of gender and race on optimal monitoring policies.

Prognostic Value of the Intermediate Risk Feature in Men with Favorable Intermediate Risk Prostate Cancer: Implications for Active Surveillance

<h3>Purpose/Objective(s)</h3> Active surveillance (AS) is an appropriate treatment option for carefully selected men with favorable intermediate risk prostate cancer. Additional strategies are needed to help identify patients that are most suitable for AS. As the presence of Gleason Score (GS) 4 disease on biopsy is thought to be a stronger risk factor than a prostate-specific antigen (PSA) of 10-20, some guidelines express caution regarding the use of AS for these men. We sought to investigate whether outcomes differed for men with favorable intermediate risk prostate cancer on AS based on whether they were classified as intermediate risk due to PSA or GS. <h3>Materials/Methods</h3> We identified a cohort of patients diagnosed with localized intermediate risk prostate cancer between January 2001 and December 2015 in the United States Veterans Affairs Health System who pursued AS. AS was defined as not having received a prostatectomy, radiation, or androgen deprivation therapy in the first year from diagnosis and the receipt of at least 1 prostate biopsy after diagnosis. From this cohort, we selected patients who had a single favorable intermediate risk feature, either GS 3+3 = 6 and PSA 10-20 or a GS of 3+4 with PSA <10. Demographic data were collected including race, age, Charlson Comorbidity Index (CCI), and smoking status. Education level (% with bachelor's degree) and median income were estimated based on patient ZIP code using US census data. The primary endpoint of the study was the competing risk-adjusted cumulative incidence of receiving definitive treatment (prostatectomy or radiation). Secondary endpoints included rates of metastatic prostate cancer, prostate cancer-specific mortality (PSCM), and all-cause mortality (ACM). <h3>Results</h3> The cohort included 663 men with a median follow up of 7.5 years. A majority of patients (n=404, 60.9%) were intermediate risk due to GS only, the remainder (n=259, 30.1%) were PSA only. The GS only group was slightly younger (median age 65.1 years vs 66.3, p=0.017) but there were no other significant differences between groups in race, CCI score, smoking status, education or income. The cumulative incidence of definitive treatment at 5 years was similar in the GS only and PSA only groups (67.6% vs 63.6%, p=0.32). There were also no differences between groups in 5-year rates of metastatic disease (4.0% vs 4.4%, p=0.77), PSCM (0.5% vs 2.4%, p=0.27), or ACM (5.3% vs 5.6%, p=0.14). <h3>Conclusion</h3> Men with favorable intermediate risk prostate cancer due to GS who pursued active surveillance had similar outcomes to those who were intermediate risk due to PSA. Clinical intermediate risk features alone do not appear sufficient to risk-stratify patients for AS. Incorporation of additional data such as tumor genomic classifiers may be essential to predict outcomes after AS for intermediate risk patients.

S111 Outcomes of Endoscopic Retrograde Cholangiopancreatography in Patients With Situs Inversus Viscerum

Introduction: Situs inversus (SIV) is a rare congenital condition defined by the left to right transposition of all viscera as a mirror image. This uncommon anatomic variant has been reported to cause technical challenges while performing endoscopic retrograde cholangiopancreatography (ERCP). Data of patients with situs inversus undergoing ERCP is limited to case reports and the clinical and technical success rate of ERCP in these patients is unknown. The goal of our study is to evaluate the clinical and technical success rates and procedural characteristics of patients with situs inversus undergoing ERCP. Methods: A retrospective review of data from consecutive patients with SIV undergoing ERCP. Data was collected by querying the nationwide Veterans Affairs Health System database for patients with a diagnosis of situs inversus (ICD Q89.3) who underwent ERCP between January 1, 2010, to March 31, 2022. Patient demographic and procedure characteristics were collected (Table). Results: A total of 654 patients with situs inversus were identified. Eight of these patients had undergone ERCP. The median age was age of 68. The most common indication for ERCP was choledocholithiasis (5 patients, 62.5%). The technical success rate (defined as ability to achieve successful biliary cannulation) was 63%. Subsequent ERCP with interventional radiology assisted rendezvous increased the technical success rate to 88%. Clinical success (defined as successful management of choledocholithiasis, cholangitis, stricture, or obtaining specimens for the diagnosis of malignancy) was achieved in 63% of cases. When considering subsequent rendezvous ERCP if conventional ERCP failed, clinical success was achieved in 88% of cases. Conclusion: In our limited series, the clinical and technical success rate of ERCP for patients with SIV is higher than previously reported. In patients with SIV where conventional ERCP biliary cannulation fails, IR assisted rendezvous ERCP can be considered. Table 1. - Patient demographic and procedure characteristics Gender Race Age Indication Technical Success Clinical Success Reason for failure Rendezvous ERCP attempted Rendezvous ERCP technically successful Rendezvous ERCP clinically successful Male White 72 Choledocholithiasis Yes Yes Male African American 74 Pancreatic adenocarcinoma Yes Yes Male White 88 Choledocholithiasis with cholangitis No No Unable to cannulate the ampulla Yes Yes Yes Male White 62 Periampullary Adenocarcinoma Yes Yes Male White 59 Choledocholithiasis No No Unable to cannulate the ampulla No Male White 88 Choledocholithiasis Yes Yes Female Native American 63 Benign biliary stricture Yes Yes Male Hispanic 63 Choledocholithiasis with cholangitis No No Unable to visualize the ampulla Yes Yes Yes

Training the next generation of learning health system scientists.

IntroductionThe learning health system (LHS) aligns science, informatics, incentives, stakeholders, and culture for continuous improvement and innovation. The Agency for Healthcare Research and Quality and the Patient‐Centered Outcomes Research Institute designed a K12 initiative to grow the number of LHS scientists. We describe approaches developed by 11 funded centers of excellence (COEs) to promote partnerships between scholars and health system leaders and to provide mentored research training.MethodsSince 2018, the COEs have enlisted faculty, secured institutional resources, partnered with health systems, developed and implemented curricula, recruited scholars, and provided mentored training. Program directors for each COE provided descriptive data on program context, scholar characteristics, stakeholder engagement, scholar experiences with health system partnerships, roles following program completion, and key training challenges.ResultsTo date, the 11 COEs have partnered with health systems to train 110 scholars. Nine (82%) programs partner with a Veterans Affairs health system and 9 (82%) partner with safety net providers. Clinically trained scholars (n = 87; 79%) include 70 physicians and 17 scholars in other clinical disciplines. Non‐clinicians (n = 29; 26%) represent diverse fields, dominated by population health sciences. Stakeholder engagement helps scholars understand health system and patient/family needs and priorities, enabling opportunities to conduct embedded research, improve outcomes, and grow skills in translating research methods and findings into practice. Challenges include supporting scholars through roadblocks that threaten to derail projects during their limited program time, ranging from delays in access to data to COVID‐19‐related impediments and shifts in organizational priorities.ConclusionsFour years into this novel training program, there is evidence of scholars' accomplishments, both in traditional academic terms and in terms of moving along career trajectories that hold the potential to lead and accelerate transformational health system change. Future LHS training efforts should focus on sustainability, including organizational support for scholar activities.

ASO Author Reflections: Identification of High-Performing Veterans Affairs Health System Regions to Improve Patient Outcomes of Veterans with Hepatocellular Carcinoma.

ASO Author Reflections: Identification of High-Performing Veterans Affairs Health System Regions to Improve Patient Outcomes of Veterans with Hepatocellular Carcinoma.

Variation of Hepatocellular Carcinoma Treatment Patterns and Survival Across Geographic Regions in a Veteran Population.

Veteran populations have five times the incidence of hepatocellular carcinoma (HCC) compared with the general population. The incidence of HCC has increased in the Veteran's Affairs Health System (VAHS), primarily due to the increased prevalence of cirrhosis. This study aimed to characterize differences in treatment patterns and overall survival rates across the five VAHS geographic regions. Using the VA Corporate Data Warehouse, the authors built a comprehensive national dataset of Veteran patients with HCC diagnosed between 2001 and 2015 to compare patients across VAHS regions. A multivariable Cox proportional hazards model was used to identify factors associated with 5-year all-cause mortality. Kaplan-Meier curves were used to visualize the patient survival function, and the log-rank test was applied to test statistical significance. This retrospective study analyzed 13,434 patients. The West region had the highest rate of overall treatment receipt (63.6%), and the Southwest had the lowest rate (52.9%). After adjustment for demographic, clinicopathologic, treatment, and hospital factors, treatment in a non-West region continued to be significantly associated with a 10% to 13% increased risk of 5-year mortality (Midwest: hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.03-1.17; Northeast: HR, 1.10; 95% CI, 1.03-1.17; Southeast: HR, 1.13; 95% CI, 1.06-1.21; Southwest: HR, 1.11; 95% CI, 1.03-1.19) (p < 0.01). Treatment patterns and overall survival rates of HCC patients differ significantly across VAHS geographic regions. Targeted interventions to increase the rate of treatment in the non-West regions are needed to improve survival of HCC Veterans and provide uniformly high-quality care across VAHS facilities.

Are higher pre-diagnosis follicle stimulating hormone levels associated with long-term prostate cancer risk?

Follicle stimulating hormone (FSH) is a pituitary hormone that helps regulate testosterone homeostasis. Although it is generally accepted that FSH levels increase with LHRH-agonist therapy for prostate cancer (PC), the specific impact of FSH levels on risk of PC diagnosis is largely unknown. The objective of this study was to perform a population-level analysis to assess the association between FSH levels and PC diagnosis. All men (n = 386,018) who had a pre-PC diagnosis FSH level and complete data were identified within the Veterans Affairs Health System between 1999 and 2018. The association between FSH level and time from FSH test to PC diagnosis was tested using stratified Cox proportional hazards models. Multivariable models were adjusted for age, year, race, body mass index, and Charlson comorbidity index. Due to nonproportional hazards over time, time to PC was modeled separately: ≤4 years after an FSH test and >4 years following an FSH test. Median age at first FSH level was 64 years (interquartile range [IQR]: 54-72), median year of FSH was 2010 (IQR: 2005-2014), and 70% of the cohort was white. Median follow-up was 76 months (IQR: 38-126) during which 17,519 men (4.5%) were diagnosed with PC. On multivariable analysis, in the first 4 years after FSH test, there was no association between FSH and time to PC diagnosis. Starting from 4 years after FSH test, on multivariable analysis, a higher FSH level was associated with lower risk of PC with continuous modeling, but found no association with log continuous and categorical modeling. In this population-level study among male veterans receiving an FSH test for an unknown clinical indication, associations between FSH levels and PC risk were inconsistent and likely driven by selection bias and confounding variables. Future studies should consider different study designs.

Patient-Centered Pain Care Using Artificial Intelligence and Mobile Health Tools

Cognitive behavioral therapy for chronic pain (CBT-CP) is a safe and effective alternative to opioid analgesics. Because CBT-CP requires multiple sessions and therapists are scarce, many patients have limited access or fail to complete treatment. To determine if a CBT-CP program that personalizes patient treatment using reinforcement learning, a field of artificial intelligence (AI), and interactive voice response (IVR) calls is noninferior to standard telephone CBT-CP and saves therapist time. This was a randomized noninferiority, comparative effectiveness trial including 278 patients with chronic back pain from the Department of Veterans Affairs health system (recruitment and data collection from July 11, 2017-April 9, 2020). More patients were randomized to the AI-CBT-CP group than to the control (1.4:1) to maximize the system's ability to learn from patient interactions. All patients received 10 weeks of CBT-CP. For the AI-CBT-CP group, patient feedback via daily IVR calls was used by the AI engine to make weekly recommendations for either a 45-minute or 15-minute therapist-delivered telephone session or an individualized IVR-delivered therapist message. Patients in the comparison group were offered 10 therapist-delivered telephone CBT-CP sessions (45 minutes/session). The primary outcome was the Roland Morris Disability Questionnaire (RMDQ; range 0-24), measured at 3 months (primary end point) and 6 months. Secondary outcomes included pain intensity and pain interference. Consensus guidelines were used to identify clinically meaningful improvements for responder analyses (eg, a 30% improvement in RMDQ scores and pain intensity). Data analyses were performed from April 2021 to May 2022. The study population included 278 patients (mean [SD] age, 63.9 [12.2] years; 248 [89.2%] men; 225 [81.8%] White individuals). The 3-month mean RMDQ score difference between AI-CBT-CP and standard CBT-CP was -0.72 points (95% CI, -2.06 to 0.62) and the 6-month difference was -1.24 (95% CI, -2.48 to 0); noninferiority criterion were met at both the 3- and 6-month end points (P < .001 for both). A greater proportion of patients receiving AI-CBT-CP had clinically meaningful improvements at 6 months as indicated by RMDQ (37% vs 19%; P = .01) and pain intensity scores (29% vs 17%; P = .03). There were no significant differences in secondary outcomes. Pain therapy using AI-CBT-CP required less than half of the therapist time as standard CBT-CP. The findings of this randomized comparative effectiveness trial indicated that AI-CBT-CP was noninferior to therapist-delivered telephone CBT-CP and required substantially less therapist time. Interventions like AI-CBT-CP could allow many more patients to be served effectively by CBT-CP programs using the same number of therapists. ClinicalTrials.gov Identifier: NCT02464449.

Protocol for a multi-center randomized controlled trial to evaluate the benefits of exercise incentives and corticosteroid injections in osteoarthritis of the knee (MOVE-OK)

BackgroundKnee osteoarthritis (KOA) is a high-priority problem among the aging population. While exercise has been shown to be beneficial in management of the disease, scalable and low-cost interventions to improve exercise in this population are lacking. Recent controversy over the value of corticosteroid injections for palliation has also arisen. Therefore, we designed a randomized, double-blind, placebo-controlled clinical trial with a 2-period crossover design to study (1) behavioral incentives to promote exercise and (2) corticosteroid injections to reduce pain and improve function in patients with KOA when compared to lidocaine only.MethodsThe study design is a pragmatic factorial and crossover randomized clinical trial. Patients with KOA who are deemed eligible by their provider to receive knee injections and are able to walk without assistive devices will be recruited from clinical practices at four sites within the Veterans Affairs (VA) Health System in the USA. In total, 220 participants will be randomized to receive social incentives with gamification (i.e., incorporation of game elements) to promote exercise and compared to controls that receive a Fitbit but no incentive. Each patient will also be assigned to receive a blinded corticosteroid injection and a lidocaine-only injection in random order. The primary outcomes are the change in average daily step counts from baseline and the change in Knee Osteoarthritis Outcome Score (KOOS) from baseline. The study team will continuously collect step count, heart rate, and sleep data using activity monitors and patient-reported outcomes using the Way to Health (WTH) platform at two four-week intervals over eight months of follow-up. Mixed effects regression incorporating all available data points will be used for analysis.DiscussionThe “Marching on for Veterans with Osteoarthritis of the Knee” (MOVE-OK) trial will take a pragmatic approach to evaluate (1) whether incentives based on behaviorally enhanced gamification can improve physical activity in this patient population and (2) whether corticosteroids injections reduce pain and disability in patients with KOA. Results of this trial will help to direct clinical practice and inform management guidelines.Trial registrationClinicalTrials.gov NCT05035810. Registered on 5 September 2021.