Veterans Affairs Health System Research Articles

Moving psychedelic-assisted therapies from promising research into routine clinical practice: Lessons from the field of implementation science.

Psychedelics (e.g., 3,4-Methylenedioxymethamphetamine [MDMA], lysergic acid diethylamide [LSD], psilocybin) are molecules that have the potential to produce rapid therapeutic effects when paired with psychotherapy. Randomized clinical trials of psychedelic-assisted psychotherapy (PAT) have shown promising results for post-traumatic stress disorder (PTSD), depression, and substance use disorders. The U.S. Food and Drug Administration has acknowledged the promise of PAT, signaling potential approval of psilocybin-assisted therapy for depression by 2026. Given this timeline, implementation scientists must engage with PAT researchers, policymakers, and practitioners to think critically about bringing these promising new treatments into routine practice settings while maintaining quality and safety. This commentary aims to initiate a dialogue between implementation scientists and PAT researchers and practitioners on addressing these questions with a lens toward equity. Specifically, we discuss how the field of implementation science can support PAT stakeholders to accelerate the translational process from research into practice, focusing specifically on safety-net settings (i.e., Federally Qualified Health Centers and Veterans Affairs health systems) that serve historically marginalized populations. We use the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework to illustrate five critical areas where implementation science can help move PAT from research into real-world practice. For each RE-AIM dimension, we highlight ways the field of implementation science can contribute tools (e.g., implementation strategies), methodologies (e.g., pragmatic hybrid implementation-effectiveness trials), and approaches (community-based participatory research) for establishing the safety, effectiveness, and accessibility of PAT for historically underserved communities.

Artificial Intelligence in Identifying Patients With Undiagnosed Nonalcoholic Steatohepatitis.

Background: Although increasing in prevalence, nonalcoholic steatohepatitis (NASH) is often undiagnosed in clinical practice. Objective: This study identified patients in the Veterans Affairs (VA) health system who likely had undiagnosed NASH using a machine learning algorithm. Methods: From a VA data set of 25 million adult enrollees, the study population was divided into NASH-positive, non-NASH, and at-risk cohorts. We performed a claims data analysis using a machine learning algorithm. To build our model, the study population was randomly divided into an 80% training subset and a 20% testing subset and tested and trained using a cross-validation technique. In addition to the baseline model, a gradient-boosted classification tree, naïve Bayes, and random forest model were created and compared using receiver operator characteristics, area under the curve, and accuracy. The best performing model was retrained on the full 80% training subset and applied to the 20% testing subset to calculate the performance metrics. Results: In total, 4 223 443 patients met the study inclusion criteria, of whom 4903 were positive for NASH and 35 528 were non-NASH patients. The remainder was in the at-risk patient cohort, of which 514 997 patients (12%) were identified as likely to have NASH. Age, obesity, and abnormal liver function tests were the top determinants in assigning NASH probability. Conclusions: Utilization of machine learning to predict NASH allows for wider recognition, timely intervention, and targeted treatments to improve or mitigate disease progression and could be used as an initial screening tool.

Artificial Intelligence in Identifying Patients With Undiagnosed Nonalcoholic Steatohepatitis

Background: Although increasing in prevalence, nonalcoholic steatohepatitis (NASH) is often undiagnosed in clinical practice. Objective: This study identified patients in the Veterans Affairs (VA) health system who likely had undiagnosed NASH using a machine learning algorithm. Methods: From a VA data set of 25 million adult enrollees, the study population was divided into NASH-positive, non-NASH, and at-risk cohorts. We performed a claims data analysis using a machine learning algorithm. To build our model, the study population was randomly divided into an 80% training subset and a 20% testing subset and tested and trained using a cross-validation technique. In addition to the baseline model, a gradient-boosted classification tree, naïve Bayes, and random forest model were created and compared using receiver operator characteristics, area under the curve, and accuracy. The best performing model was retrained on the full 80% training subset and applied to the 20% testing subset to calculate the performance metrics. Results: In total, 4 223 443 patients met the study inclusion criteria, of whom 4903 were positive for NASH and 35 528 were non-NASH patients. The remainder was in the at-risk patient cohort, of which 514 997 patients (12%) were identified as likely to have NASH. Age, obesity, and abnormal liver function tests were the top determinants in assigning NASH probability. Conclusions: Utilization of machine learning to predict NASH allows for wider recognition, timely intervention, and targeted treatments to improve or mitigate disease progression and could be used as an initial screening tool.

A Comparative Analysis of International Drug Price Negotiation Frameworks: An Interview Study of Key Stakeholders.

In 2022, Congress passed the Inflation Reduction Act, which allowed Medicare, for the first time, to begin negotiating the prices for certain high-cost brand-name prescription drugs. Many other industrialized countries negotiate drug prices, and we sought to compare and contrast key features of the negotiation process across several health systems. We focused, in particular, on the criteria for selecting drugs for price negotiation, procedures for negotiation, factors that influence negotiated prices, and how prices are implemented. We included four G7 countries in our analysis (Canada, France, Germany, and the United Kingdom [England]), two Benelux countries (Belgium and the Netherlands), and one Scandinavian country (Norway) with long-established frameworks for drug price negotiation. We also analyzed the Veterans Affairs Health System in the United States. For each system, we gathered relevant legislation, government publications, and guidelines to understand negotiation frameworks, and we reached out to key drug price negotiators in each system to conduct semistructured interviews. All interviews were recorded, transcribed, and coded, and data were analyzed based on an internal assessment tool that we developed. All eight systems negotiate the prices of brand-name prescription drugs soon after approval and rely on formal clinical assessments that compare newly approved drugs with existing therapies. Systems in our study differed on characteristics such as whether the body performing clinical assessments is separate from the negotiating authority, how added health benefit is assessed, whether explicit willingness-to-pay thresholds are employed, and how specific approaches for priority disease areas are taken. High-income countries around the world adopt different approaches to conducting price negotiations on brand-name drugs but coalesce around a set of practices that will largely be absent from the current Medicare negotiation framework. US policymakers might consider adding some of these characteristics in the future to improve negotiation outcomes.

53261 Real-world effectiveness of immune checkpoint inhibitors and BRAF/MEK inhibitors among cutaneous melanoma patients in the Veterans Affairs Health System

53261 Real-world effectiveness of immune checkpoint inhibitors and BRAF/MEK inhibitors among cutaneous melanoma patients in the Veterans Affairs Health System

Outcomes of a 1-Year Pilot Study Implementing Universal Hepatitis Delta Virus Testing Among Veterans With Chronic Hepatitis B.

Current US guidelines recommend risk-based testing for hepatitis delta virus (HDV) in persons with chronic hepatitis B (CHB). While there is debate as to whether a risk-based or universal testing approach is most effective, limited data exist on universal HDV testing programs in the United States. We performed a 1-year pilot study evaluating the outcomes of a universal HDV testing approach among US veterans with CHB. All consecutive adults with CHB receiving care at hepatology clinics at a single-centre Veterans Affairs Health System from 1 October 2022 to 30 September 2023 were prospectively tested for anti-HDV antibody (anti-HDV). Patients who were anti-HDV Ab-positive were subsequently tested for HDV RNA. Comparison of HDV testing between groups utilised chi-square testing. A total of 91 consecutive CHB patients (90.0% male, mean age 60.9 ± 14.1 years, 73.9% Asian, 26.1% non-Asia, 16.5% cirrhosis and 17.1% with active or past history of drug use) had anti-HDV ordered. Overall, 76.9% (n = 70) completed anti-HDV testing; 4.3% (n = 3) were positive. HDV RNA testing was ordered in all three patients; two patients completed HDV RNA testing and one had detectable HDV RNA. No significant differences in completion of anti-HDV testing was observed by age, sex, race/ethnicity, cirrhosis status or drug use history. Among a single-centre prospective cohort study piloting a universal HDV testing approach, one patient with viremic HDV was identified. Implementing true reflex testing of all CHB patients with anti-HDV, followed by automated HDV RNA testing for anti-HDV-positive patients would improve the HDV testing cascade and timely diagnosis of HDV.

Improving Colorectal Cancer Screening via Mailed Fecal Immunochemical Testing in a Veterans Affairs Health System.

Colorectal cancer screening rates at the Veterans Affairs Connecticut Healthcare System (VACHS) decreased during the COVID-19 pandemic. Fecal immunochemical testing is recognized as a tier 1 preferred screening method by the US Multi-Society Task Force on Colorectal Cancer. The VACHS implemented a program that mailed fecal immunochemical testing kits to patients to improve colorectal cancer screening rates. This article describes the components of the VACHS patient aligned care team-based mailed fecal immunochemical testing program. Fecal immunochemical testing utilization, completion, and colorectal cancer screening rates at VACHS substantially increased after the implementation of this project. Through a proactive, population-based colorectal cancer screening program centered on mailed fecal immunochemical testing kits outside of a traditional patient visit, VACHS substantially increased the utilization of fecal immunochemical testing kits as well as colorectal cancer screening rates.

Rural veteran perception of healthcare access in South Carolina and Florida: a qualitative study

BackgroundAccess to mental and physical healthcare in rural areas is challenging for Veterans and their families but essential for good health. Even though recent research has revealed some of the challenges rural Veterans face accessing healthcare, a complete understanding of the gap in access is still unclear.MethodsThis qualitative study aimed to explore participants’ perceptions of healthcare access. Structured interviews were conducted with 124 Veterans and spouses of Veterans from rural qualifying counties in South Carolina and Florida.ResultsThe study’s results revealed five main dimensions of access: geographic proximity, transportation, communication, cultural competence, and resources. Distance to service needed can negatively impact access for Veterans and their families in general, especially for those whose health is declining or who cannot drive because of their age. Lack of transportation, problems with transportation services, and lack of public transportation can lead to delays in care. Additionally, the lack of communication with the Veterans Affairs (VA) Health System and with the healthcare team, as well as inefficient communication among the healthcare team, lack of coordination of care between the VA health system and community providers, and the lack of cultural competence of healthcare providers and contracted personnel made access to services even more challenging.ConclusionsImproving communication can help to develop a sense of trust between Veterans and the VA, and between Veterans and spouses with the healthcare team. It can also lead to increased patient satisfaction. Ensuring healthcare providers and contracted personnel are culturally competent to talk and treat Veterans can improve patient trust and adherence to treatment. Lastly, resource-related challenges included financial problems, lack of prompt access to appointments, lack of providers, limited access to local clinics and hospitals, limited local programs available, and reimbursement issues.

Real-world evidence of 18F-fluciclovine Positron emission tomography/computed tomography performance for recurrent prostate cancer in the Veterans Affairs Health System.

There are no population-level studies assessing 18F-fluciclovine (fluciclovine) utilization of Positron emission tomography/computed tomography (PET/CT) for biochemically recurrent prostate cancer (PC). We assessed fluciclovine PET/CT in the Veterans Affairs Health Care System. Of 1153 men with claims suggesting receipt of fluciclovine PET/CT, we randomly reviewed charts of 300 who indeed underwent fluciclovine PET/CT. The primary outcome was fluciclovine PET/CT result (positive or negative). Comparison among groups stratified by androgen deprivation therapy (ADT) (yes vs. no) and prostate-specific antigen (PSA) (≤1 vs. >1 ng/mL) at imaging were performed. Logistic regression tested associations between PSA, ADT receipt, and race with fluciclovine PET/CT positive imaging. Fluciclovine PET/CT positivity rate was 33% for patients with PSA 0-0.5 ng/mL, 21% for >0.5-1.0, 54% for >1.0-2.0, and 66% for >2.0 (p < 0.01). A 59% positivity rate ocurred in patients treated with concurrent ADT versus 37% in those not on ADT (p < 0.01). White were more likely to have a positive scan versus Black patients (55% vs. 38%; p = 0.02). Patients whose primary treatment was radical prostatectomy had a lower positivity rate (33%) versus those treated with radiotherapy (55%) (p < 0.001). On multivariable logistic regression, PSA > 1 ng/mL (all men odds ratio [OR]: 4.06, 95% confidence interval [CI]: 2.07-7.96; men on ADT only OR: 4.42, 95% CI: 1.73-11.26) and use of ADT (OR: 3.94, 95% CI: 1.32-11.75), and White (all men OR: 2.22, 95% CI: 1.20-4.17) predicted positive fluciclovine PET/CT. This real-world study assessing 18F-fluciclovine PET/CT performance in an equal access health care system confirms higher detection rates than traditional imaging methods, but positivity is highly influenced by PSA at time of imaging. Additionally, patients currently receiving ADT have at least four times higher likelihood of a positive scan, showing that scan positivity isn't negatively affected by ADT status in this study. Finally, White men were more likely to have a positive scan, the reasons for which should be explored in future studies.

An evidence-based screening tool for heart failure with preserved ejection fraction: the HFpEF-ABA score.

Heart failure with preserved ejection fraction (HFpEF) is under-recognized in clinical practice. Although a previously developed risk score, termed H2FPEF, can be used to estimate HFpEF probability, this score requires imaging data, which is often unavailable. Here we sought to develop an HFpEF screening model that is based exclusively on clinical variables and that can guide the need for echocardiography and further testing. In a derivation cohort (n = 414, 249 women), a clinical model using age, body mass index and history of atrial fibrillation (termed the HFpEF-ABA score) showed good discrimination (area under the curve (AUC) = 0.839 (95% confidence interval (CI) = 0.800-0.877), P < 0.0001). The performance of the model was validated in an international, multicenter cohort (n = 736, 443 women; AUC = 0.813 (95% CI = 0.779-0.847), P < 0.0001) and further validated in two additional cohorts: a cohort including patients with unexplained dyspnea (n = 228, 136 women; AUC = 0.840 (95% CI = 0.782-0.900), P < 0.0001) and a cohort for which HF hospitalization was used instead of hemodynamics to establish an HFpEF diagnosis (n = 456, 272 women; AUC = 0.929 (95% CI = 0.909-0.948), P < 0.0001). Model-based probabilities were also associated with increased risk of HF hospitalization or death among patients from the Mayo Clinic (n = 790) and a US national cohort across the Veteran Affairs health system (n = 3076, 110 women). Using the HFpEF-ABA score, rapid and efficient screening for risk of undiagnosed HFpEF can be performed in patients with dyspnea using only age, body mass index and history of atrial fibrillation.

Determinants of appropriate antibiotic and NSAID prescribing in unscheduled outpatient settings in the veterans health administration

BackgroundDespite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration.MethodsWe conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process.ResultsWe conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal.ConclusionsThe diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.

Factors Associated with Acute Telemental Health Consultations in Older Veterans.

The United States Veterans Health Administration is a leader in the use of telemental health (TMH) to enhance access to mental healthcare amidst a nationwide shortage of mental health professionals. The Tennessee Valley Veterans Affairs (VA) Health System piloted TMH in its emergency department (ED) and urgent care clinic (UCC) in 2019, with full 24/7 availability beginning March 1, 2020. Following implementation, preliminary data demonstrated that veterans ≥65years old were less likely to receive TMH than younger patients. We sought to examine factors associated with older veterans receiving TMH consultations in acute, unscheduled, outpatient settings to identify limitations in the current process. This was a retrospective cohort study conducted within the Tennessee Valley VA Health System. We included veterans ≥55years who received a mental health consultation in the ED or UCC from April 1, 2020-September 30, 2022. Telemental health was administered by a mental health clinician (attending physician, resident physician, nurse practitioner, or physician assistant) via iPad, whereas in-person evaluations were performed in the ED. We examined the influence of patient demographics, visit timing, chief complaint, and psychiatric history on TMH, using multivariable logistic regression. Of the 254 patients included in this analysis, 177 (69.7%) received TMH. Veterans with high-risk chief complaints (suicidal ideation, homicidal ideation, or agitation) were less likely to receive TMH consultation (adjusted odds ratio [AOR]: 0.47, 95% confidence interval [CI] 0.24-0.95). Compared to attending physicians, nurse practitioners and physician assistants were associated with increased TMH use (AOR 4.81, 95% CI 2.04-11.36), whereas consultation by resident physicians was associated with decreased TMH use (AOR 0.04, 95% CI 0.00-0.59). The UCC used TMH for all but one encounter. Patient characteristics including their visit timing, gender, additional medical complaints, comorbidity burden, and number of psychoactive medications did not influence use of TMH. High-risk chief complaints, location, and type of mental health clinician may be key determinants of telemental health use in older adults. This may help expand mental healthcare access to areas with a shortage of mental health professionals and prevent potentially avoidable transfers in low-acuity situations. Further studies and interventions may optimize TMH for older patients to ensure safe, equitable mental health care.

Addressing racial disparities in prostate cancer pathology prediction models: external validation and comparison of four models of pathological outcome prediction before radical prostatectomy in the multiethnic SEARCH cohort.

Certain widely used pathological outcome prediction models that were developed in tertiary centers tend to overpredict outcomes in the community setting; thus, the Michigan Urological-Surgery Improvement Collaborative (MUSIC) model was developed in general urology practice to address this issue. Additionally, the development of these models involved a relatively small proportion of Black men, potentially compromising the accuracy of predictions in this patient group. We tested the validity of the MUSIC and three widely used nomograms to compare their overall and race-stratified predictive performance. We extracted data from 4139 (1138 Black) men from the Shared Equal Access Regional Cancer Hospital (SEARCH) database of the Veterans Affairs health system. The predictive performance of the MUSIC model was compared to the Memorial-Sloan Kettering (MSK), Briganti-2012, and Partin-2017 models for predicting lymph-node invasion (LNI), extra-prostatic extension (EPE), and seminal vesicle invasion (SVI). The median PSA of Black men was higher than White men (7.8 vs. 6.8 ng/ml), although they were younger by a median of three years and presented at a lower-stage disease. MUSIC model showed comparable discriminatory capacity (AUC:77.0%) compared to MSK (79.2%), Partin-2017 (74.6%), and Briganti-2012 (76.3%), with better calibration for LNI. AUCs for EPE and SVI were 72.7% and 76.9%, respectively, all comparable to the MSK and Partin models. LNI AUCs for Black and White men were 69.6% and 79.6%, respectively, while EPE and SVI AUCs were comparable between races. EPE and LNI had worse calibration in Black men. Decision curve analysis showed MUSIC superiority over the MSK model in predicting LNI, especially among Black men. Although the discriminatory performance of all models was comparable for each outcome, the MUSIC model exhibited superior net benefit to the MSK model in predicting LNI outcomes among Black men in the SEARCH population.

A Pharmacist-Led Process to Monitor Discrepant Urine Drug Screen Results.

A urine drug screen (UDS) is a common risk-mitigation strategy tool for prescribing controlled substances, particularly opioids. Due to their complexity, UDS results can be misinterpreted and thereby have profound impacts on the patient-clinician relationship. From 2021 to 2022, a clinical dashboard to review potentially discrepant UDS results-based on a comparison of the results to the patient's medication list-was made available by the Veterans Health Administration. This quality improvement project implemented a process for weekly clinical pharmacist reviews of the UDS dashboard. Significant discrepant UDS results were reviewed in depth. From June 2022 through September 2022, 700 UDSs were performed and 60 patients had significant discrepancies that warranted in-depth review. Pharmacist interventions during the review included 39 collaborations with medication prescribers to discuss follow up (65%), 25 queries to a prescription drug monitoring program (42%), and 9 confirmatory UDS on the original sample (15%). In-depth reviews were required for about 4 patients weekly, with a mean length of 14 minutes. A pharmacist-led process to monitor discrepant UDS results led to opportunities for collaboration with prescribers and positively impacted confirmatory testing at a rural veterans affairs health system.

Men with adrenal-permissive HSD3B1 genotype and prostate cancer mortality: Results from the Veterans Affairs Health System Million Veteran Program.

Men with adrenal-permissive <i>HSD3B1</i> genotype and prostate cancer mortality: Results from the Veterans Affairs Health System Million Veteran Program.

Patient Focus: Sodium-Glucose Cotransporter-2 Inhibitor Rates for Patients with Heart Failure in the Veterans Affairs Health System: We Need to Move the Needle! An Explanation of Uptake of Sodium-Glucose Cotransporter-2 Inhibitors in Patients Hospitalized due to Heart Failure: Insights from the Veterans Affairs Healthcare System

Patient Focus: Sodium-Glucose Cotransporter-2 Inhibitor Rates for Patients with Heart Failure in the Veterans Affairs Health System: We Need to Move the Needle! An Explanation of Uptake of Sodium-Glucose Cotransporter-2 Inhibitors in Patients Hospitalized due to Heart Failure: Insights from the Veterans Affairs Healthcare System

PATIENT PRIORITIES CARE FOR VETERANS

Abstract People receiving care in the Veterans Affairs (VA) health system are older, have greater socioeconomic disadvantage, and more chronic conditions than those receiving healthcare outside of VA. PPC is well-suited for older adults with multiple chronic conditions and aligns with the VA’s Whole Health movement. A small VA PPC pilot study demonstrated that those receiving PPC compared to usual care had fewer medications added and more home and community services aligned with priorities. VA primary care is a cornerstone and hub for veteran care utilizing a team-based approach. A two-site randomized controlled trial exploring the implementation of PPC in VA primary care is currently recruiting veterans. The early phase of the project involved semi-structured formative assessment interviews with key stakeholders to obtain feedback and perspectives on PPC implementation in VA primary care. Interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis. Concerns elicited were time constraints, follow up and documentation of changes in priorities over time, managing patient expectation, communication between primary care and specialty care, as well as how PPC would impact quality metrics. In response to these findings, the patient priorities note template was shortened and streamlined, and the study communications workflow was adapted to align with clinician preferences. Succinct templated language for care alignment was crafted and shared with study providers. Education for clinicians highlighted ways in which priorities could be used to optimize communication. Study procedures were added to identify quality metric exclusions. The study will explore how PPC impacts veteran care and experience.

Housing Status, Cancer Care, and Associated Outcomes Among US Veterans

Cancer is a leading cause of death among older people experiencing homelessness. However, the association of housing status with cancer outcomes is not well described. To characterize the diagnosis, treatment, surgical outcomes, and mortality by housing status of patients who receive care from the US Department of Veterans Affairs (VA) health system for colorectal, breast, or lung cancer. This retrospective cohort study identified all US veterans diagnosed with lung, colorectal, or breast cancer who received VA care between October 1, 2011, and September 30, 2020. Data analysis was performed from February 13 to May 9, 2023. Veterans were classified as experiencing homelessness if they had any indicators of homelessness in outpatient visits, clinic reminders, diagnosis codes, or the Homeless Operations Management Evaluation System in the 12 months preceding diagnosis, with no subsequent evidence of stable housing. The major outcomes, by cancer type, were as follows: (1) treatment course (eg, stage at diagnosis, time to treatment initiation), (2) surgical outcomes (eg, length of stay, major complications), (3) overall survival by cancer type, and (4) hazard ratios for overall survival in a model adjusted for age at diagnosis, sex, stage at diagnosis, race, ethnicity, marital status, facility location, and comorbidities. This study included 109 485 veterans, with a mean (SD) age of 68.5 (9.7) years. Men comprised 92% of the cohort. In terms of race and ethnicity, 18% of veterans were Black, 4% were Hispanic, and 79% were White. A total of 68% of participants had lung cancer, 26% had colorectal cancer, and 6% had breast cancer. There were 5356 veterans (5%) experiencing homelessness, and these individuals more commonly presented with stage IV colorectal cancer than veterans with housing (22% vs 19%; P = .02). Patients experiencing homelessness had longer postoperative lengths of stay for all cancer types, but no differences in other treatment or surgical outcomes were observed. These patients also demonstrated higher rates of all-cause mortality 3 months after diagnosis for lung and colorectal cancers, with adjusted hazard ratios of 1.1 (95% CI, 1.1-1.2) and 1.3 (95% CI, 1.2-1.4) (both P < .001), respectively. In this large retrospective study of US veterans with cancer, homelessness was associated with later stages at diagnosis for colorectal cancer. Differences in lung and colorectal cancer survival between patients with housing and those experiencing homelessness were present but smaller than observed in other settings. These findings suggest that there may be important systems in the VA that could inform policy to improve oncologic outcomes for patients experiencing homelessness.

Abstract A063: Critical factors influencing clinical trial enrollment and autologous stem cell transplantation in African-American patients with multiple myeloma: A retrospective, interview-based analysis

Abstract Purpose: The backbone of multiple myeloma (MM) therapy include chemotherapy, targeted therapies, autologous stem cell transplantation (ASCT), amongst others. Patient enrollment in clinical trials and uptake of complex interventions such as ASCT is crucial for these advancements and to improve patient outcomes. Furthermore, MM is more than twice as common in Black/African-American (B/AA) persons, yet many B/AA people decline to enroll in clinical trials or undergo transplant. However, at the Cleveland Clinic, many B/AA patients do elect to undergo ASCT and enroll in clinical trials. We interview these patients to understand the conditions under which B/AA patients elect trial/transplant. Experimental Procedures: To study differences in access to care, which have the potential to lead to differences in survival and disease progression, we conduct semi-structured interviews with patients to better understand the breadth of their complex decision making about electing trial/transplant. We gather rich descriptive patient perceptions about their experiences on and with other novel therapies including understanding how these interventions were described by their healthcare teams and the factors that were most influential in rendering their decisions. The study includes two arms: patients who elected trial/transplant and a second cohort of B/AA patients comprised of patients matched for disease state and socioeconomic attributes who did not elect to undergo these interventions. In concert with these qualitative evaluations, we collect and analyze quantitative and categorical data regarding disease response, survival, post-protocol therapies where applicable, and patient reported outcomes including healthcare associated quality of life. We also analyze follow up surveys and a range of patient reported outcomes data collected throughout the patient’s treatment. Data Summary: We examine the impact of critical social and disease-related factors, including income, health insurance status, access to caregiving, understanding of the disease process, initial point of access to the healthcare system, health literacy, and perception of the intervention on the decision to enroll or decline enrollment in clinical trials or undergo ASCT. Conclusion: Our findings examine the mechanisms behind patient enrollment in clinical trials/transplant. B/AA patients comprise only 4% of enrollees in large MM trials worldwide. Many studies have also demonstrated that B/AA patients are less likely to undergo ASCT and are more likely to do so later in their disease course. Furthermore, a study conducted in the Veterans Affairs health system showed that with equal access to care for MM, B/AA patients actually have superior overall survival as compared to their white counterparts. We focus on patient’s complex decision making process, to provide better care and expand diverse research on MM. Study implications include improving equity in MM care for B/AA patients. Citation Format: Louis Williams, Heathe M. Hurwitz, Tiffany Onger, Diana Basali. Critical factors influencing clinical trial enrollment and autologous stem cell transplantation in African-American patients with multiple myeloma: A retrospective, interview-based analysis [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A063.

911. Burden of Herpes Zoster among Employed Adults in the Department of Veterans Affairs Health System

Abstract Background Herpes zoster (HZ) is characterized by a painful dermatomal rash and is associated with increased healthcare costs. Research quantifying work productivity loss and activity impairment associated with HZ is limited and outdated. This study aimed to describe severity of HZ related pain, health related quality of life, activity impairment, and work productivity among employed adults diagnosed with HZ in the Department of Veterans Affairs (VA) Health System. Methods This cross-sectional study utilized a self-reported survey among adults in the VA health system. Eligibility was assessed biweekly from electronic health record data, and adults with an incident International Classification of Diseases, 10th Revision (ICD-10) HZ diagnosis were invited to complete an online survey. Respondents were indexed on their HZ diagnosis and included if aged 18-70 years, reported working for pay at index, and had 6 months of baseline continuous enrollment. Respondents were excluded if they had a baseline HZ vaccine, did not complete the survey within 30 days after index, or reported not having HZ or experiencing a rash &amp;gt; 14 days prior to index. Questions used to assess outcomes were based on validated survey instruments (Table 1). Work productivity was described among respondents employed at survey completion. Data were collected from 05/04/2021 to 07/07/2022. Descriptive statistics were used to summarize survey responses. Results Among 231 respondents completing the survey, mean (standard deviation [SD]) age was 49 (10) years and 79% were male. Overall, 70% reported experiencing pain in the last 7 days. Mean (SD) [minimum, maximum] “average-pain” severity and EQ-5D-3L scores were 4.0 (2.8) [0, 10] and 0.69 (0.22) [-0.04, 1.00], respectively. Mean (SD) activity impairment was 42% (33%). Mean (SD) absenteeism, presenteeism, and overall work impairment were 17% (27%), 35% (30%), and 43% (35%) out of 202, 192, and 202 respondents, respectively. Conclusion Burden associated with HZ is substantial, with a significant proportion experiencing pain, activity impairment, and work productivity loss. These results provide updated context on the impact of HZ in this population of employed adults in the VA health system. Funding: GlaxoSmithKline Biologicals SA (GSK study identifiers: 208907/HO-16-16967). Disclosures Shaloo Gupta, MS; ORCID: 0000-0002-2535-2892, Cerner Enviza: Salary|GSK: Funding to employer to conduct and support this study Nai-Chung N. Chang, PhD; ORCID: 0000-0002-4541-8967, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Kantar Health: Grant/Research Support|Myriad Genetic Laboratories, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support Nikita Stempniewicz, MSc, GSK: Salary|GSK: Ownership Interest Chenchu Bhavani K. Tirupati, MS, MBA, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Kantar Health: Grant/Research Support|Myriad Genetic Laboratories, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support Gregorio Coronado, MBA, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Kantar Health: Grant/Research Support|Myriad Genetic Laboratories, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support Julie A. Lynch, PhD, RN, MBA; ORCID: 0000-0003-0108-2127, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support Cosmina Hogea, PhD; ORCID: 0000-0002-0686-2395, Gilead Sciences: Ownership Interest|GSK: Salary at the time of the submitted work|GSK: Ownership Interest Emily Mulvihill, MBA; ORCID: 0000-0002-1430-8837, Cerner Enviza: Salary|GSK: Funding to employer to conduct and support this study Scott L. DuVall, PhD, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support