Veterans Affairs Health Care Facilities Research Articles

Schizophrenia, Off-Label Antipsychotics, and Dementia Risk in People with HIV.

Comorbidities such as schizophrenia and medication such as antipsychotics may influence the risk of dementia among people living with HIV (PLWH). The objective of this paper is to assess the associations among HIV patients with schizophrenia, off-label antipsychotics, and dementia risk. US Department of Veterans Affairs healthcare facilities from 2000 to September 2023. Retrospective cohort study of PLWH treated by the U.S. Department of Veterans Affairs with prior history of schizophrenia, off-label antipsychotic use and neither schizophrenia nor antipsychotic use. Propensity score matched non-HIV controls were included for the respective HIV groups. The hazard of dementia is estimated using Cox proportional hazards models. PLWH and schizophrenia, were found to have a 2.49 higher hazard of dementia compared to HIV patients with no history of schizophrenia or antipsychotic medication use (HR=2.49, 95%CI=(1.85-3.35)). PLWH and off-label antipsychotic use were found to have a 1.77-fold higher hazard of dementia compared to HIV patients with no history of schizophrenia or antipsychotic medication use (HR=1.77, 95% CI=(1.37-2.28)). Propensity score matched analysis reveals that, among schizophrenia patientis, those with HIV had a 1.65-fold higher hazard of dementia (HR=1.65, 95%CI=(1.12-2.44)). Among patients with no schizophrenia or antipsychotic medication, those with HIV had a 1.47 fold higher hazard of dementia (HR=1.47, 95%CI=(1.33-1.63)). This study demonstrates that among PLWH, history of schizophrenia or off-label antipsychotic medication use are associated with substantial increases in dementia incidence. Furthermore, propensity-matched control analysis reveals that HIV infection itself is independently and significantly associated with elevated dementia risk.

Long-term Patiromer Use and Outcomes Among US Veterans With Hyperkalemia and CKD: A Propensity-Matched Cohort Study

Patiromer is a potassium binder approved for the long-term management of hyperkalemia. Although patiromer use among patients with advanced chronic kidney disease (CKD) has been shown to reduce the discontinuation of renin-angiotensin-aldosterone system inhibition therapy, it remains unclear whether patiromer can improve clinical outcomes. The aim of this study was to examine the association of long-term patiromer use with clinical outcomes among hyperkalemic patients with CKD. This was a longitudinal observational study. We evaluated a national cohort of 854,217 US Veterans who had at least 1 serum potassium measurement of≥5.1 mEq/L and were treated at US Department of Veterans Affairs health care facilities between January 2016 and September 2019. The exposure was long-term patiromer use. The outcomes were as follows: (1) composite endpoint of kidney failure with replacement therapy (KFRT) or all-cause death and (2) all-cause death including the post-KFRT period. Cox proportional Fine-Graysubdistributionhazard models were used in a propensity-matched cohort. Among 2,004 patients who ever used patiromer during the study period (0.2% of the cohort), 666 met the criteria for long-term patiromer use. We matched 308 long-term patiromer users to 308 nonusers based on propensity scores. The median estimated glomerular filtration rate was 23.5mL/min/1.73m2, and the median potassium level was 5.2 mEq/L. Approximately 45% were on renin-angiotensin system inhibitor(s) at baseline. During follow-up, 93 patients developed KFRT, and 134 patients died. Long-term patiromer users, when compared to nonusers, experienced a 26% lower risk of the composite outcome (HR, 0.74; 95% CI, 0.53-1.01; P=0.06) and a 41% lower risk of all-cause mortality (HR, 0.59; 95% CI, 0.41-0.84; P=0.003). The study cohort included mostly male veterans with relatively short follow-up periods. Long-term patiromer use was associated with a lower risk of all-cause mortality among patients with CKD and hyperkalemia. Long-term potassium binder use for hyperkalemia may improve clinical outcomes in CKD. Hyperkalemia is a common complication of chronic kidney disease (CKD) and can result in the discontinuation of renin-angiotensin-aldosterone system inhibition therapy, a cornerstone of CKD management. Patiromer is a new potassium binder approved for the long-term management of hyperkalemia, but it remains unclear whether patiromer can improve clinical outcomes. We examined a cohort of US Veterans with hyperkalemia between January 2016 and September 2019 and found that patiromer use was uncommon for treating hyperkalemia during this study period. We then matched 308 long-term patiromer users and 308 nonusers based on propensity scores. Long-term patiromer users, when compared to nonusers, experienced a 26% lower risk of the composite outcome and a 41% lower risk of all-cause mortality. These findings indicate that long-term potassium binder use for hyperkalemia may improve clinical outcomes in CKD.

Projected Outcomes of Optimized Statin and Ezetimibe Therapy in US Military Veterans with Coronary Artery Disease

Many patients with coronary artery disease (CAD) do not achieve the guideline-directed goals for low-density lipoprotein cholesterol (LDL-C) levels. To estimate reductions in the rates of adverse events associated with CAD in a large US military veteran population that may be achieved through use of optimized statin therapy alone or with ezetimibe compared with the prevailing lipid-lowering therapy (LLT). In this observational cohort study, US military veterans with CAD were identified by coronary angiography between June 2015 and September 2020 across 82 US Department of Veterans Affairs health care facilities. The exposures were observed LLT, LLT with an optimized statin regimen, and LLT with optimized statin and ezetimibe. Observed rates of death, myocardial infarction, stroke, and coronary revascularization, and potential reductions in those outcomes with optimized LLT based on expected further reductions in LDL-C levels and application of formulas from The Cholesterol Treatment Trialists' Collaboration. The analysis cohort comprised 111 954 veterans (mean [SD] age, 68.4 [8.8] years; 109 390 men [97.7%]; 91 589 White patients [81.8%]; 17 592 Black patients [15.7%]). The median (IQR) observation period for this study was 3.4 (2.1-4.0) years. At the time of index angiography, 66 877 patients (59.7%) were treated with statin therapy, and 623 patients (0.6%) were treated with ezetimibe. At 6 months, the number of patients with statin prescriptions increased to 74 400 (68.7%), but the number of patients with high-intensity statin prescriptions was only 57 297 (52.9%). At 6 months, ezetimibe use remained low (n = 1168 [1.1%]), and LDL-C levels were 70 mg/dL or more in 56 405 patients (52.1%). At 4 years, observed incidences of death, myocardial infarction, stroke, and coronary revascularization were 21.6% (95% CI, 21.3%-21.8%), 5.0% (95% CI, 4.9%-5.2%), 2.2% (95% CI, 2.1%-2.3%), and 15.4% (95% CI, 15.2%-15.7%), respectively. With optimized statin treatment, projected absolute reductions in these incidences were 1.3% (95% CI, 0.9%-1.7%), 0.8% (95% CI, 0.7%-1.0%), 0.2% (95% CI, 0.1%-0.3%), and 2.3% (95% CI, 2.0%-2.7%), respectively. With optimized statin and ezetimibe treatment, projected absolute reductions were 1.8% (95% CI, 1.2%-2.4%), 1.1% (95% CI, 0.9%-1.3%), 0.3% (95% CI, 0.2%-0.4%), and 3.1% (95% CI, 2.6%-3.6%), respectively. In this cohort study of veterans with CAD, suboptimal LLT was prevalent in the clinical setting. Optimization of statin therapy was projected to produce clinically relevant reductions in the risks of death and cardiovascular events. Despite a lesser lipid-lowering efficacy of ezetimibe, its widespread use on a population level in conjunction with optimized statin therapy may be associated with further meaningful reductions in cardiovascular risk.

Impact of Alcohol Use, Traumatic Stress, and Cigarette Smoking on Cognitive Functioning in Veterans With Co-occurring Alcohol Use Disorder and Posttraumatic Stress Disorder.

Alcohol use disorder (AUD) and PTSD have high rates of co-occurrence in U.S. Military Veterans resulting in incrementally worse functional outcomes relative to having either one of these disorders alone. Cognitive dysfunction can impede one's ability to benefit from standard behavioral AUD and PTSD treatments. Cigarette smoking is also highly prevalent among U.S. Military Veterans, and cognitive dysfunction is associated with chronic cigarette use among individuals with AUD and PTSD independently. However, much less is known about to what extent cigarette smoking further impairs cognitive functioning in individuals with both co-occurring AUD and PTSD. U.S. Veterans with co-occurring AUD and PTSD (n = 162) completed a comprehensive cognitive assessment covering various domains: working memory, processing speed, mental switching, cognitive inhibition, auditory-verbal learning, auditory-verbal memory, and verbal fluency. To examine the impact of alcohol use, traumatic stress, and cigarette smoking on cognitive function, we conducted a three-way interaction examining the moderated effects of smoking status on the association between alcohol use and PTSD symptoms on a composite domain of global cognition. Smoking status in Veterans with co-occurring AUD and PTSD moderated the relationship between alcohol use and global cognition (P = .042), such that higher levels of alcohol use in the past week were related to worse global cognitive function among Veterans cigarette smokers (P = .015) but not among nonsmokers (P = .833). On follow-up analyses of individual cognitive domains, greater alcohol use in the past week was associated with lower cognitive inhibition in smokers but not nonsmokers, with traumatic stress symptoms moderating this effect (P = .039). Additionally, smoking status moderated the relationship between alcohol use and auditory-verbal learning, such that there was a differential relationship between alcohol use and auditory-verbal learning between smokers and nonsmokers. Overall, results provide evidence for the compounding impact of alcohol use, traumatic stress, and cigarette smoking on cognitive functioning. Impaired cognitive performance on a global level as well as on individual domains of cognitive inhibition and auditory-verbal learning were evident. Cognitive dysfunction may impede a Veteran's ability to benefit from therapeutic treatment, and these cognitive domains may represent potential targets for cognitive training efforts. Further, study results support smoking cessation initiatives and smoke-free policies enacted at Veterans Affairs healthcare facilities and medical centers.

Systemic Adverse Events Among Patients With Diabetes Treated With Intravitreal Anti–Vascular Endothelial Growth Factor Injections

Anti-vascular endothelial growth factor (VEGF) agents are currently the mainstay of treatment for diabetic retinopathy (DR). Although effective, data on their systemic safety remains inconclusive, particularly in high-risk patient groups. To explore the systemic safety of intravitreal anti-VEGF agents among patients with diabetes. This was a retrospective, longitudinal population-based analysis of the Corporate Data Warehouse, a large-scale database of patients within the US Veteran Health Affairs. All patients 18 years and older with type 2 diabetes who were seen at any Veterans Affairs health care facility in the US between January 1, 2011, and December 31, 2012, were identified. Data were then extracted on incident systemic adverse events among this patient cohort from January 1, 2013, to December 31, 2017. All individuals with diabetes who did and did not receive anti-VEGF injections were included. Patients with a history of prior systemic adverse events and those who received an intravitreal injection between January 1, 2011, and December 31, 2012, were excluded. Data were analyzed from October 2019 to March 2023. Anti-VEGF injection. Proportion of patients with any incident systemic adverse event, acute myocardial infarction, cardiovascular disease, or kidney disease at 1-, 3-, and 5-year follow-up. A total of 1 731 782 patients (mean [SD] age, 63.8 [12.3] years; 1 656 589 [95.7%] male) with type 2 diabetes were included. DR was present in 476 013 (27.5%), and 14 022 (0.8%) received anti-VEGF injections. Of the total number of patients with type 2 diabetes, 321 940 (18.6%) developed systemic adverse events between 2013 and 2017. The 5-year cumulative incidence of any systemic adverse event was 37.0% (5187/14 022) in the injection group vs 18.4% (316 753/1 717 760) in the noninjection group (P < .001). Anti-VEGF injections were independently associated with a higher likelihood of developing any systemic adverse event (odds ratio, 1.8; 95% CI, 1.7-1.9) when controlling for age, race, sex, ethnicity, tobacco use, severity of DR, Deyo-Charlson Comorbidity Index score, mean hemoglobin A1c, total number of injections, and statin use. In this study, intravitreal anti-VEGF injections were independently associated with a higher likelihood of systemic adverse events among patients with diabetes.

Frontline perspectives of C. difficile infection prevention practice implementation within veterans affairs health care facilities: A qualitative study

In 2012, the Veteran's Affairs (VA) Multidrug-Resistant Organism (MDRO) Program Office launched a national Clostridioides difficile Infection (CDI) Prevention Initiative to address CDI as the most common cause of healthcare associated infections, mandating use of a VA CDI Bundle of prevention practices in inpatient facilities. We draw upon frontline worker perspectives to explore work system barriers and facilitators to the sustained implementation of the VA CDI Bundle using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. We interviewed 29 key stakeholders at 4 participating sites between October 2019-July 2021. Participants included infection prevention and control (IPC) leaders, nurses, physicians, and environmental management staff. Interviews were analyzed to identify themes and perceptions of facilitators and barriers to CDI prevention. IPC leadership was most likely to know of the specific VA CDI Bundle components. Other participants demonstrated general knowledge of CDI prevention practices, with role-based variation in the depth of awareness of specific practices. Facilitators included leadership support, mandated CDI training and prevention practices, and readily available training from multiple sources. Barriers included limits to communication about facility or unit-level CDI rates, ambiguous communications about CDI prevention practice updates and VA mandates, and role-hierarchies that may limit team members' clinical contributions. Recommendations include improving centrally-mandated clarity about and standardization of CDI prevention policies, including testing. Regular IPC training updates for all clinical stakeholders are also recommended. A work system analysis using SEIPS identified barriers and facilitators to CDI prevention practices that could be addressed both nationally at the system level and locally at the facility level, specifically in the areas of communication and coordination.

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.

Emergency Departments Treating Veterans for Suicide: Ensuring Quality Care for Veterans Outside of Department of Veterans Affairs Health Care Facilities

IntroductionVeterans die by suicide at higher rates than nonveterans. Given that the emergency department is often the first point of entry to healthcare following a suicide attempt, it would be beneficial for community providers to have knowledge of the characteristics, medical issues, and effective treatments most often associated with those having served in the military to ensure guideline concordant and quality suicide care. This study aimed to identify assessment and referral practices of emergency departments at rural community hospitals related to care for suicidal veterans and explore the feasibility and acceptability of identifying veterans in need of postdischarge aftercare. MethodsThis qualitative exploratory study involved content analysis of semistructured interviews. Ten emergency clinicians from 5 rural Arkansas counties with high suicide rates were interviewed about their experiences working with suicidal patients within the emergency department and perceptions of assessment, management, and referral practices. ResultsAlthough most of the emergency departments had a process for assessing for suicide risk, emergency clinicians did not always feel confident in their knowledge of assessing and caring for suicidal patients. Military history was not included in assessment, treatment, or aftercare planning, nor were brief interventions such as safety planning or lethal means safety education provided. DiscussionBest practices for suicide assessment and management of veterans exist; however, challenges specific to the emergency department regarding staff training and engaging the community to effectively link at-risk veterans to needed care hinder implementation. Veteran-inclusive assessment and intervention practices could enhance the quality of care provided in community emergency departments.

Association of Uric Acid–Lowering Therapy With Incident Chronic Kidney Disease

Uric acid is a waste metabolite produced from the breakdown of purines, and elevated serum uric acid levels are associated with higher risk of hypertension, cardiovascular disease, and mortality and progression of chronic kidney disease (CKD). Treatment of hyperuricemia in patients with preexisting CKD has not been shown to improve kidney outcomes, but the associations of uric acid-lowering therapies with the development of new-onset kidney disease in patients with estimated glomerular filtration rate (eGFR) within reference range and no albuminuria is unclear. To examine the association of initiating uric acid-lowering therapy with the incidence of CKD. This cohort study included patients with eGFR of 60 mL/min/1.73 m2 or greater and no albuminuria treated at US Department of Veterans Affairs health care facilities from 2004 to 2019. Clinical trial emulation methods, including propensity score weighting, were used to minimize confounding. Data were analyzed from 2020 to 2022. Newly started uric acid-lowering therapy. The main outcomes were incidences of eGFR less than 60 mL/min/1.73 m2, new-onset albuminuria, and end-stage kidney disease. A total of 269 651 patients were assessed (mean [SD] age, 57.4 [12.5] years; 252 171 [94%] men). Among these, 29 501 patients (10.9%) started uric acid-lowering therapy, and 240 150 patients (89.1%) did not. Baseline characteristics, including serum uric acid level, were similar among treated and untreated patients after propensity score weighting. In the overall cohort, uric acid-lowering therapy was associated with higher risk of both incident eGFR less than 60 mL/min/1.73 m2 (weighted subhazard ratio [SHR], 1.15 [95% CI, 1.10-1.20; P < .001) and incident albuminuria (SHR, 1.05 [95% CI, 1.01-1.09; P < .001) but was not associated with the risk of end-stage kidney disease (SHR, 0.96 [95% CI, 0.62-1.50]; P = .87). In subgroup analyses, the association of uric acid-lowering therapy with worse kidney outcomes was limited to patients with baseline serum uric acid levels of 8 mg/dL or less. These findings suggest that in patients with kidney function within reference range, uric acid-lowering therapy was not associated with beneficial kidney outcomes and may be associated with potential harm in patients with less severely elevated serum uric acid levels.

Staff and Patient Perspectives on Bystander Intervention Training to Address Patient-Initiated Sexual Harassment in Veterans Affairs Healthcare Settings.

One in four women veteran patients experience public harassment by men veterans at Veterans Affairs (VA) health care facilities. Bystander intervention training-teaching bystanders to identify harassment, assess appropriate responses, and safely intervene before, during, or after an event-is a popular strategy for addressing harassment in military and education settings. We explored staff and veteran patient perspectives on bystander intervention training to address harassment of women veterans in VA health care settings. We conducted 24 staff interviews and 15 veteran patient discussion groups (eight men's groups and seven women's groups) at four VA Medical Centers. We analyzed transcripts using the constant comparative method. Participants expressed divergent views about bystander intervention training to address harassment of women veteran patients at VA. Most participants supported training staff in bystander intervention, but support for training patients was mixed. Participants identified potential benefits of bystander intervention, including staff and patient empowerment and improvements to organizational culture. They also identified potential concerns, including provocation of conflict between patients, lack of buy-in among the VA community, and difficulty in identifying intervention-appropriate situations. Finally, participants offered recommendations for tailoring training content and format to the VA context. Bystander intervention training has the potential to raise collective responsibility for addressing harassment of women in VA and other health care contexts. However, our results illustrate divergent stakeholder views that underscore the importance of engaging and educating stakeholders, securing buy-in, and tailoring bystander intervention programs to local contexts before implementation.

Health Insurance Coverage Among Veterans Receiving Care From VA Health Care Facilities

Reasons for acquiring insurance outside Department of Veterans Affairs (VA) health care coverage among VA enrollees are incompletely understood. To assess Veterans’ decision-making and acquisition of non-VA health care insurance in the Affordable Care Act era, we used mailed questionnaires and semistructured interviews in a stratified random sample of VA enrollees &lt;65 years in the Midwest. Of the 3,666 survey participants, 32.1% reported non-VA insurance. Frequently reported reasons included wanting coverage for emergency situations or family members. Those without non-VA insurance cited unaffordability as the main obstacle. Analysis of the semistructured interview data revealed similar findings. In multivariable logistic regression analyses, characteristics associated with non-VA insurance included higher income (&gt;$50,000 vs. &lt;$10,000, odds ratio [OR] = 5.95, 95% confidence interval [CI]: 3.45–10.3, p &lt; .001). As financial barriers exist for acquisition of non-VA insurance and hence community care, it is critically important that VA enrollees’ health care needs are met through VA or community providers financed through VA.

Effect of Immersive Virtual Reality on Pain and Anxiety at a Veterans Affairs Health Care Facility

Objectives: The primary objective of this evaluation is to determine the impact of virtual reality (VR) distraction on acute and chronic pain in Veterans within the Veterans Affairs Health Care System (VA). A secondary objective is to determine the impact of VR on the experience of stress and anxiety in Veterans utilizing VR for the indication of pain. A third objective is to develop an understanding of the Veteran experience of using VR in a healthcare setting.Methods: This prospective, pretest-posttest mixed methods assessment was performed at a VA medical center from August 30, 2019 to November 23, 2020. VR experiences lasted between 10 and 30 min utilizing an immersive head-mounted display with multiple, autonomously chosen virtual environments. Qualitative data was collected concurrently to provide context to quantitative measures which included pain scores and stress/anxiety levels. Data from 79 participants was included in this analysis. Data included pre- and post-VR session Defense and Veterans Pain Rating Scale and stress/anxiety levels.Results: Results for the cohort demonstrated a statistically significant decrease in pain intensity (p &amp;lt;0 .001) with an average 12% decrease in pain levels and an 92% reduction in anxiety for those in concurrent pain.Conclusion: VR as a non-pharmacological adjunct or alternative modality, appears to be a viable option for improving pain management and reducing anxiety in Veteran populations across various age ranges, and levels of acuity and chronicity. VR was found to be an effective distraction from pain, a pleasurable experience for the majority, and opened the door to other non-pharmacological modalities in a Veteran population.

Association of Medication-Assisted Treatment and Age With Treatment Completion Among Veterans Seeking Non-VA Treatment for Opioid use Disorder at Non-Veterans Health Administration Facilities.

Medication-assisted treatment has been shown to be effective in treating opioid use disorder among both older adults and veterans of U.S. Armed Forces. However, limited evidence exists on MAT's differential effect on treatment completion across age groups. This study aims to ascertain the role of MAT and age in treatment completion among veterans seeking treatment in non-Department of Veterans Affairs healthcare facilities for opioid use disorder. We used the Treatment Episode Data Set-Discharges (TEDS-D; 2006-2017) to examine trends in treatment and MAT usage over time and TEDS-2017 to determine the role of age and MAT in treatment completion. We examined a subset of those who self-identified as veterans and who sought treatment for an opioid use disorder. Veterans presented in treatment more often as heroin users than prescription opioid users, and older veterans were more likely to get MAT than younger veterans. We found that before propensity score matching, MAT initially appeared to be associated with a lower likelihood of treatment completion in inpatient ($\beta $ = -1.47, 95% CI -1.56 to -1.39) and outpatient ($\beta $ = -1.40, 95% CI -2.21 to -0.58) settings, and age (50+ years) appeared to mediate the effect of MAT on treatment completion ($\beta $ = -0.54, 95% CI -0.87 to -0.21). After matching, older veterans were more likely to complete substance use disorder treatment ($\beta $ = 0.21, 95% CI 0.01-0.42), while age no longer mediated the effect of MAT, and MAT had a significant positive impact on treatment completion in detox settings ($\beta $ = 1.36, 95% CI 1.15-1.50) and inpatient settings ($\beta $ = 1.54, 95% CI 1.37 -1.71). The results show that age plays an important role in outpatient treatment completion, while MAT plays an important role in inpatient treatment completion. Implications for veterans are discussed.

Association of Social and Behavioral Risk Factors With Mortality Among US Veterans With COVID-19

The US Department of Veterans Affairs (VA) offers programs that reduce barriers to care for veterans and those with housing instability, poverty, and substance use disorder. In this setting, however, the role that social and behavioral risk factors play in COVID-19 outcomes is unclear. To examine whether social and behavioral risk factors were associated with mortality among US veterans with COVID-19 and whether this association might be modified by race/ethnicity. This cohort study obtained data from the VA Corporate Data Warehouse to form a cohort of veterans who received a positive COVID-19 test result between March 2 and September 30, 2020, in a VA health care facility. All veterans who met the inclusion criteria were eligible to participate in the study, and participants were followed up for 30 days after the first SARS-CoV-2 or COVID-19 diagnosis. The final follow-up date was October 31, 2020. Social risk factors included housing problems and financial hardship. Behavioral risk factors included current tobacco use, alcohol use, and substance use. The primary outcome was all-cause mortality in the 30-day period after the SARS-CoV-2 or COVID-19 diagnosis date. Multivariable logistic regression was used to estimate odds ratios, clustering for health care facilities and adjusting for age, sex, race, ethnicity, marital status, clinical factors, and month of COVID-19 diagnosis. Among 27 640 veterans with COVID-19 who were included in the analysis, 24 496 were men (88.6%) and the mean (SD) age was 57.2 (16.6) years. A total of 3090 veterans (11.2%) had housing problems, 4450 (16.1%) had financial hardship, 5358 (19.4%) used alcohol, and 3569 (12.9%) reported substance use. Hospitalization occurred in 7663 veterans (27.7%), and 1230 veterans (4.5%) died. Housing problems (adjusted odds ratio [AOR], 0.96; 95% CI, 0.77-1.19; P = .70), financial hardship (AOR, 1.13; 95% CI, 0.97-1.31; P = .11), alcohol use (AOR, 0.82; 95% CI, 0.68-1.01; P = .06), current tobacco use (AOR, 0.85; 95% CI, 0.68-1.06; P = .14), and substance use (AOR, 0.90; 95% CI, 0.71-1.15; P = .41) were not associated with higher mortality. Interaction analyses by race/ethnicity did not find associations between mortality and social and behavioral risk factors. Results of this study showed that, in an integrated health system such as the VA, social and behavioral risk factors were not associated with mortality from COVID-19. Further research is needed to substantiate the potential of an integrated health system to be a model of support services for households with COVID-19 and populations who are at risk for the disease.

Big Data in the Veterans Health Administration: A Nursing Informatics Perspective.

This article reviews the missions of the U.S. Department of Veterans Affairs (VA) and the evolution of its electronic health record (EHR), the Veterans Health Information Systems and Technology Architecture (VistA). This system, along with its clinical graphical user interface the Computerized Patient Record System, form a key link in VA health care. A Veteran who receives healthcare through the VA can have their EHR accessed by clinicians at any VA healthcare facility across the United States and its territories. Data aggregated daily at a corporate data warehouse supports VA quality improvement and research. Serving over 9 million Veterans, the VA is one of the largest integrated healthcare systems in the United States. It has been a leader in the development and use of healthcare informatics, EHR, and big data analytics for over 30 years. Nurses engaged in major roles in the evolution of these developments. With over 500 nurses as members, the Office of Nursing Informatics' Field Alliance demonstrates the VA's continuing commitment to fostering nursing informatics. The commitment includes investment by the VA to develop nursing informaticists from among its own staff. Exemplars of the impact of nursing informatics are shared. Future directions include an EHR that begins during military service and follows the Veteran into VA health care.

Expert Stakeholder Prioritization of Process Quality Measures to Achieve Patient- and Family-Centered Palliative and End-of-Life Cancer Care.

Importance: Quality measures of palliative and end-of-life care relevant to patients with advanced cancer have been developed, but few are in routine use. It is unclear which of these measures are most important for providing patient- and family-centered care and have high potential for improving quality of care. Objective: To prioritize process quality measures for assessing delivery of patient- and family-centered palliative and end-of-life cancer care in US Veterans Affairs (VA) health care facilities. Design, Setting, Participants: A panel of 10 palliative and cancer care expert stakeholders (7 physicians, 2 nurses, 1 social worker) rated process quality measure concepts before and after a 1-day meeting. Measures: Panelists rated 64 measure concepts on a nine-point scale on: (1) importance to providing patient- and family-centered care, and (2) potential for quality improvement (QI). Panelists also nominated five highest priority measure concepts ("top 5") on each attribute. Results: Panelists rated most measure concepts (54 premeeting, 56 post-meeting) as highly important to patient- and family-centered care (median rating ≥7). Considerably fewer (17 premeeting, 22 post-meeting) were rated as having high potential for QI. Measure concepts having postpanel median ratings ≥7 and nominated by one or more panelists as "top 5" on either attribute comprised a shortlist of 20 measure concepts. Conclusions: A panel of expert stakeholders helped prioritize 64 measure concepts into a shortlist of 20. Half of the shortlisted measures were related to communication about patient preferences and decision making, and half were related to symptom assessment and treatment.

Effect of the Affordable Care Act on healthcare utilization for Veterans with spinal cord injuries and disorders

Context/Objective: Provisions of the Affordable Care Act (ACA) potentially increase insurance options for Veterans with disabilities. We examined Veterans with spinal cord injuries and disorders (SCI/D) to assess whether the ACA was associated with changes in healthcare utilization from Department of Veterans Affairs (VA) healthcare facilities. Design: Using national VA data, we investigated impacts on VA healthcare utilization pre- (2012/13) and post-ACA (2014/15) implementation with negative binomial regression models. Setting: VA healthcare facilities. Participants: 8,591 VA users with SCI/D. Veterans with acute myelitis, Guillain-Barré syndrome, multiple sclerosis, or amyotrophic lateral sclerosis were excluded as were patients who died during the study period. Interventions: We assessed VA healthcare utilization before and after ACA implementation. Outcome Measures: Total numbers of VA visits for SCI/D care, diagnostic care, primary care, specialty care, and mental health care, and VA admissions. Results: The number of VA admissions was 7% higher in the post than pre-ACA implementation period (P < 0.01). The number of VA visits post-implementation increased for SCI/D care (8%; P < 0.01) and specialty care (12%; P < 0.001). Conversely, the number of mental health visits was 17% lower in the post-ACA period (P < 0.001). Veterans with SCI/D who live <5 miles from their nearest VA facility received VA care more frequently than those ≥40 miles from VA (P < 0.001). Conclusion: Counter to expectations, results suggest that Veterans with SCI/D sought more frequent VA care after ACA implementation, indicating Veterans with SCI/D continue to utilize the lifelong, comprehensive care provided at VA.

VA National Precision Oncology Program.

The US Department of Veterans Affairs (VA) is the largest integrated health care system in the US. The VA sees about 50,000 new cancer diagnoses each year and provides care for more than 400,000 veterans with cancer. The heterogeneity of molecular testing practice patterns and methods of testing at VA health care facilities and the increasing number and complexity of molecular tests led to the development of national program for precision oncology. The National Precision Oncology Program (NPOP) provides tumor sequencing and consultative services for the treatment of veterans with cancer. NPOP is used by nearly all VA oncology practices and has now sequenced > 13,000 samples. The initial focus was on advanced-stage nonsquamous non-small cell lung cancer, which has one of the highest number of mutated genes that result in sensitivity to antineoplastic drugs. Recently, testing was expanded to include metastatic prostate cancer and hematologic malignancies with prior approval. The program also offers cell-free DNA (liquid biopsy) and PD-L1 immunohistochemistry analyses. The VA NPOP is one of the largest clinical DNA sequencing programs in the US with integrated consultation services and health informatics resources to facilitate patient care, clinical trials, and health outcomes research. The clinical services of NPOP provide cutting-edge oncology services to veterans throughout VA without exacerbating disparities and will be a national resource for research.

Establishment of a COVID-19 Recovery Unit in a Veterans Affairs Post-Acute Facility.

Coronavirus disease 2019 (COVID‐19) is now an epidemic of global proportion, with major adverse impacts on older adults, persons with chronic diseases, and especially residents of long‐term care facilities. This health catastrophe has challenged healthcare facilitiesʼ capacity to deliver care to not only COVID‐19 patients but all patients who need hospital care. We report on a novel approach of utilizing long‐term care beds at a Department of Veterans Affairs healthcare facility for managing recovering COVID‐19 patients. J Am Geriatr Soc 68:2163–2166, 2020.

The Use of Communication Technology to Affect Patient Outcomes in the Intensive Care Unit

The aim of the study was to increase interprofessional functional nutrition and mindful eating education interventions that improve patient-driven/value-based Whole Health care among patients with spinal cord injury and neurologic disorders. Pilot quality improvement project, pre-post design was used in the study. Functional nutrition and mindful eating Whole Health interventions were implemented through a preestablished education program over 6 weeks in a Veterans Affairs healthcare facility. An increased level of participants' self-awareness related to internal (60.6%) and external (54.5%) food environments was apparent. The evaluation of the Personal Health Inventory was indicative of value-based improvement on the "Food and Drink" component (35.7%), whereas 21.4% of participants reported a value-based improvement in "Power of the Mind." Interprofessional nutrition and mindful eating interventions, and personal health assessment tools support Whole Health care for management of chronic disease. Nutrition and mindfulness group education can be implemented into clinical care. The project modeled successful interprofessional collaboration.