Veterans Health Administration Research Articles

RETRACTION: Fibroblast Growth Factor-2 Promotes Catabolism via FGFR1-Ras-Raf-MEK1/2-ERK1/2 Axis That Coordinates With the PKCδ Pathway in Human Articular Chondrocytes.

D. Yan, D. Chen, and H.-J. Im, "Fibroblast Growth Factor-2 Promotes Catabolism via FGFR1-Ras-Raf-MEK1/2-ERK1/2 Axis That Coordinates With the PKCδ Pathway in Human Articular Chondrocytes," Journal of Cellular Biochemistry 113, no. 9 (2012): 2856-2865, https://doi.org/10.1002/jcb.24160. The above article, published online on 5 April 2012 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the journal Editor-in-Chief, Christian Behl; and Wiley Periodicals LLC. The retraction has occurred due to concerns related to the data presented in the article raised by the Office of Research Compliance at Rush University Medical Center following an investigation jointly conducted by Rush University and the Jesse Brown Veterans Affairs Medical Center (JBVAMC). Specifically, image elements of the experimental data in Figures 2, 4 A and 5 C were found to have been used by the same author(s) for publication elsewhere in a different scientific context. The corresponding author, Dr. Hee-Jeong Im Sampen, has been informed of the decision to retract but did not agree with it, as she is confident that any errors in the publication do not impact the reliability of the paper's findings. She also advised the editors that she stands ready to cooperate fully to make any necessary corrections. However, the article is retracted as the editors lost trust in the accuracy of the data and consider the conclusions invalid.

"We don't get that information right back to us unless it's a full-blown cancer": Challenges coordinating lung cancer screening across healthcare systems.

To examine how lung cancer screening (LCS) is coordinated across healthcare systems, specifically Veterans Affairs (VA) and non-VA settings. We conducted primary qualitative data collection in six VA medical centers with established LCS programs from November 2020 to November 2021. Semi-structured interviews were conducted with 48 primary care providers, LCS program coordinators and directors, and pulmonologists. Thematic analysis examined spontaneously raised narratives related to initiating and coordinating LCS for Veterans screened in non-VA settings. We mapped coordination challenges to each step of the LCS care continuum. While non-VA options increased access to LCS for Veterans, VA medical centers lacked clear processes for initiating LCS referrals and tracking Veterans across the LCS continuum when screening occurred in non-VA settings. The responsibility of coordinating LCS with community providers often fell to VA primary care providers rather than LCS programs. Gaps in communication and data transfer contributed to delayed evaluation of potentially cancerous nodules post-screening, raising concerns about compromised care quality when LCS was shared with non-VA settings. While policies expanding LCS for Veterans in non-VA settings increase access, lack of consistent processes to initiate referrals, obtain results, and promote timely downstream evaluation fragmented care and delayed evaluation of concerning nodules. These unintended consequences highlight a need to address cross-system coordination challenges. Strategies to better coordinate LCS between VA and non-VA settings are essential to achieve high quality LCS and prevent Veterans from falling through the cracks.

RETRACTION: Development of an Experimental Animal Model for Lower Back Pain by Percutaneous Injury-Induced Lumbar Facet Joint Osteoarthritis.

J.-S. Kim, K. Ahmadinia, X. Li, J. L. Hamilton, S. Andrews, C. A. Haralampus, G. Xiao, H.-M. Sohn, J.-W. You, Y.-S. Seo, G. S. Stein, A. J. Van Wijnen, S.-G. Kim, and H.-J. Im, "Development of an Experimental Animal Model for Lower Back Pain by Percutaneous Injury-Induced Lumbar Facet Joint Osteoarthritis," Journal of Cellular Physiology 230, no. 11 (2015): 2837-2847, https://doi.org/10.1002/jcp.25015. The above article, published online on 9 April 2015 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the journal Editor-in-Chief, Robert Heath; and Wiley Periodicals LLC. The retraction has occurred due to concerns related to the data presented in the article raised by the Office of Research Compliance at Rush University Medical Center following an investigation jointly conducted by Rush University and the Jesse Brown Veterans Affairs Medical Center (JBVAMC). Specifically, the journal has been made aware of discrepancies in the reported sample sizes for each of the three experimental groups in Figure 4A, with the indicated numbers exceeding the actual sample sizes. Additionally, image elements of the experimental data in Figure 7A and B were found to have been used by the same author(s) for publication elsewhere in a different scientific context. The corresponding author, Dr. Hee-Jeong Im Sampen, has been informed of the decision to retract but did not agree with it, as she is confident that any errors in the publication do not impact the reliability of the paper's findings. She also advised the editors that she stands ready to cooperate fully to make any necessary corrections. However, the article is retracted as the editors lost trust in the accuracy of the data and consider the conclusions invalid.

Masked Taper With Behavioral Intervention for Discontinuation of Benzodiazepine Receptor Agonists

Placebo effects are commonly observed in benzodiazepine receptor agonist hypnotic clinical trials. Clinical guidelines recommend discontinuing benzodiazepine receptor agonist hypnotics (particularly in older adults) and administering cognitive behavioral therapy for insomnia (CBTI) as first-line therapy for insomnia. It is unknown whether a novel intervention that masks the daily dose of benzodiazepine receptor agonist during tapering and augments CBTI with novel cognitive and behavioral exercises targeting placebo effect mechanisms improves benzodiazepine receptor agonist discontinuation. To compare a masked benzodiazepine receptor agonist taper plus augmented CBTI vs an unmasked taper plus standard CBTI. This randomized clinical trial conducted at an academic medical center and a Department of Veterans Affairs medical center included adults aged 55 years or older who had used lorazepam, alprazolam, clonazepam, temazepam, and/or zolpidem for current or prior insomnia, at doses of less than 8-mg diazepam-equivalent 2 or more nights per week for at least 3 months. Data were collected between December 2018 and November 2023. Data analyses were conducted between November 2023 and July 2024. Masked taper plus cognitive behavioral therapy-augmented program (MTcap); standard CBTI plus supervised (unmasked) gradual taper (SGT). The primary efficacy outcome was percentage achieving benzodiazepine receptor agonist discontinuation 6 months after treatment ended (6-month; intention-to-treat) measured with 7-day self-reported medication logs and for a subset, urine tests. Secondary outcomes were Insomnia Severity Index scores at 1 week posttreatment and 6 months posttreatment, percentage of participants that have discontinued benzodiazepine receptor agonist use at 1 week posttreatment, and benzodiazepine receptor agonist dose and the Dysfunctional Beliefs About Sleep-Medication subscale at 1 week and 6 months posttreatment. Of 338 participants who underwent in-depth screening, 188 participants (mean [SD] age, 69.8 [8.3] years, 123 male [65.4%] and 65 female [35.6%]) were randomly assigned to MTcap (n = 92) or SGT (n = 96). Compared with SGT, MTcap resulted in greater benzodiazepine receptor agonist discontinuation at 6 months (MTcap = 64 [73.4%], SGT = 52 [58.6%]; odds ratio [OR], 1.95; 95% CI 1.03-3.70; P = .04) and 1 week posttreatment (MTcap = 76 [88.4%], SGT = 62 [67.4%]; OR, 3.68; 95% CI, 1.67-8.12; P = .001) and reduced frequency of benzodiazepine receptor agonist use (nights/week) at 1 week posttreatment (-1.31; 95% CI, -2.05 to -0.57; P < .001). Insomnia Severity Index improved with no significant between-group difference at follow-up (baseline to 1 week posttreatment, 1.38; P = .16; baseline to 6 months, 0.16; P = .88). This randomized clinical trial found that a program combining masked tapering with novel cognitive and behavioral exercises targeting placebo mechanisms improved the percentage of long-term benzodiazepine receptor agonist discontinuation compared with standard CBTI plus an unmasked taper. ClinicalTrials.gov Identifier: NCT03687086.

RETRACTION: Environmental Disruption of Circadian Rhythm Predisposes Mice to Osteoarthritis-Like Changes in Knee Joint.

R. Kc, X. Li, R. M. Voigt, M. B. Ellman, K. C. Summa, M. H. Vitaterna, A. Keshavarizian, F. W. Turek, Q.-J. Meng, G. S. Stein, A. J. van Wijnen, D. Chen, C. B. Forsyth, and H.-J. Im, "Environmental Disruption of Circadian Rhythm Predisposes Mice to Osteoarthritis-Like Changes in Knee Joint," Journal of Cellular Physiology 230, no. 9 (2015): 2174-2183, https://doi.org/10.1002/jcp.24946. The above article, published online on 5 February 2015 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the journal Editor-in-Chief, Robert Heath; and Wiley Periodicals LLC. The retraction has occurred due to concerns related to the data presented in the article raised by the Office of Research Compliance at Rush University Medical Center following an investigation jointly conducted by Rush University and the Jesse Brown Veterans Affairs Medical Center (JBVAMC). Specifically, image elements of the experimental data in Figure 4 A were found to have been used by the same author(s) for publication elsewhere in a different scientific context. The corresponding author, Dr. Hee-Jeong Im Sampen, has been informed of the decision to retract but did not agree with it, as she is confident that any errors in the publication do not impact the reliability of the paper's findings. She also advised the editors that she stands ready to cooperate fully to make any necessary corrections. However, the article is retracted as the editors lost trust in the accuracy of the data and consider the conclusions invalid.

RETRACTION: Basic Fibroblast Growth Factor Accelerates Matrix Degradation via a Neuro-endocrine Pathway in Human Adult Articular Chondrocytes.

H.-J. Im, X. Li, P. Muddasani, G.-H. Kim, F. Davis, J. Rangan, C. B. Forsyth, M. Ellman, and E. J. Thonar, "Basic Fibroblast Growth Factor Accelerates Matrix Degradation via a Neuro-endocrine Pathway in Human Adult Articular Chondrocytes," Journal of Cellular Physiology 215, no. 2 (2008): 452-463, https://doi.org/10.1002/jcp.21317. The above article, published online on 24 October 2007 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the journal Editor-in-Chief, Robert Heath; and Wiley Periodicals LLC. The retraction has occurred due to concerns related to the data presented in the article raised by the Office of Research Compliance at Rush University Medical Center following an investigation jointly conducted by Rush University and the Jesse Brown Veterans Affairs Medical Center (JBVAMC). Specifically, image elements of the experimental data in Figure 6 A were found to have been used by the same author(s) for publication elsewhere in a different scientific context. The corresponding author, Dr. Hee-Jeong Im Sampen, has been informed of the decision to retract but did not agree with it, as she is confident that any errors in the publication do not impact the reliability of the paper's findings. She also advised the editors that she stands ready to cooperate fully to make any necessary corrections. However, the article is retracted as the editors lost trust in the accuracy of the data and consider the conclusions invalid.

6851 Rapidly Increasing Use of Anti-Obesity Medications among Veterans in the Veterans Health Administration (VA)

Abstract Disclosure: V. Vimalananda: None. S. Qian: None. R. Bolton: None. A. Hung: None. V. Smith: None. M. Maciejewski: None. Introduction: Obesity is a prevalent and costly chronic disease that compromises quality of life; increases risks of cardiometabolic disease, osteoarthritis, and several cancers; and accounts for 28% of U.S. health care costs. Anti-obesity medications (AOMs) may fill the treatment gap given the low uptake of bariatric surgery and limited effectiveness of behavioral interventions, and are guideline-recommended as part of a comprehensive obesity treatment plan. The landscape for obesity treatment has changed with introduction of the highly effective and in-demand glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and dual GLP-1 + GIP receptor agonists (GIP/GLP-1 RAs). Given limited knowledge of use patterns, we describe use of AOMs among patients receiving care in the Veterans Health Administration (VA), which is the largest integrated health system in the United States. Methods: In a retrospective cohort study of VA patients from 7/1/2021-6/30/2023, we examined data from the VHA Corporate Data Warehouse separately for patients on AOMs without and with diagnosed diabetes, since the newer AOMs can be used at lower doses for the diabetes indication. Results: There were 31,106 patients without diabetes and at least one AOM prescription in the two year study period, who were 60% male and 62% White. AOM prescriptions from Year 1 to Year 2 among this group increased 215%. Overall, prescriptions were: semaglutide 34%, liraglutide 18%, orlistat 18%, phentermine/topiramate 14%, bupropion/naltrexone 12%, phentermine 4% and tirzepatide 0.03%. Prescribers were physicians 60%, LIPs 25%, and pharmacists 13%. There were 188,017 patients with diagnosed diabetes and at least one AOM prescription, and they were 92% male and 67% white. AOM prescriptions from Year 1 to Year 2 among this group increased 14% and were primarily (87%) for semaglutide. Prescribers were physicians 63%, licensed independent practitioners (LIPs) 23%, and pharmacists 10%. Conclusions AOM use is increasing in VA across all AOM classes, particularly among patients without diabetes, indicating growing interest in medical treatment of obesity. As AOM use spreads, real-world evidence on weight loss and clinical outcomes is needed among patients like those in VA who tend to be older and less healthy than the highly selected patients included in randomized clinical trials. Data is especially needed to guide practice among patients with obesity and without diabetes, given the dramatic increase in use among that group over the past 2 years. Presentation: 6/1/2024

Interhospital transfer among US veterans admitted to community and veterans affairs hospitals for acute myocardial infarction and ischemic stroke before and during the COVID-19 pandemic.

Veterans Health Administration (VHA) enrollees may use community hospitals for inpatient care and sometimes require transfer to larger community or VHA hospitals. Little is known about interhospital transfer patterns among veterans using community and VHA hospitals or how coronavirus disease 2019 (COVID-19) case surges affected transfer. Retrospective cohort study among veterans age 65+ admitted to community and VHA hospitals for acute myocardial infarction (AMI) or acute ischemic stroke (AIS) during 2018-2021. We examined associations between COVID-19 case density in regional hospital referral networks and the likelihood of transfer. A total of 8373 (23.6%) veterans with AMI and 4630 (13.1%) with AIS were transferred in the prepandemic period. Transfer was especially common for rural veterans (36% with AMI, 20% with AIS). Most transfers (88%) were between community hospitals and 6% from community to VHA. Among AMI patients, transfer was less likely among patients age >90 (relative to age 65-69), those with non-White race/ethnicity, and females. Transfer was more common among patients initially seen in rural hospitals (AMI, odds ratio [OR] = 2.73, 95% confidence interval [CI], 2.90-3.74; AIS, OR = 2.43; 95% CI, 2.24-2.65). During 2020-2021, transfer among AMI patients was less likely during COVID-19 case density surges affecting the admitting hospital's referral network (OR = 0.86; 95% CI, 0.78-0.96 for highest compared with lowest quartile of COVID-19 cases). Interhospital transfer was common for veterans with AMI and AIS, especially among rural veterans. Few transfers were to VHA hospitals. COVID-19 case surges were associated with decreased transfer for veterans with AMI, potentially limiting access to needed care.

8139 Examining the Association of GLP1-RA or DPP4i with Bullous Skin Diseases in Veterans

Abstract Disclosure: S. Saad-Omer: None. M. Kinaan: None. N. Sami: None. I. Mansi: None. Introduction: Pemphigus vulgaris (PV) and bullous pemphigoid (BP) are Autoimmune Blistering Disorders (AIBDs). GLP-1 Receptor Agonists (GLP1-RA) and Dipeptidyl peptidase 4 inhibitors (DPP4i) have been noted in various case reports and case control studies to be linked with certain AIBDs; however, their overall role in these diseases is not completely understood, despite the exponential increase in use of these medications. This study aims to be the first study to investigate the association of DPP-4 inhibitors and GLP-1 agonists with incidence of AIBD, PV, and BP in a large cohort of American veterans. Methods: This retrospective cohort study of veterans enrolled in the Veterans Health Administration (VHA) used Corporate Data Warehouse (CDW). We extracted data of patients from fiscal years (FY) 2006 to end of FY 2021 who filled either GLP1-RA or DPP4i prescriptions. CDW is a comprehensive data source that encompasses vital status, demographic data, inpatient and outpatient diagnoses and procedure codes, vital signs, laboratory data, and pharmacy fill data. The study groups included: 1) GLP1-RA group: patients who initiated GLP1-RA; and 2) DPP4i group: patients who initiated DPP4i. Our primary outcome was the incidence of AIBDs. We compared baseline characteristics of patients who experienced the outcome and those who did not among GLP1-RA or DDP4i users. We, thereafter, examined factors associated with incidence of AIBD, PV, and BP among GLP1-RA users and DPP4i users. Results: The initial cohort of GLP1-RA or DPP4i users comprised a total of 415,895 patients, from which we excluded 397 (0.095%) patients with prior bullous skin diseases before starting GLP1-RA or DPP4i medications. Overall, a total of 154 patients developed PV/BP disease after initiation of either DPP4i or GLP1-RA. Of these 154 patients, 123 of these patients were on DPP4i and 31 of these patients were on GLP1-RA. The mean age (SD) of PV/BP patients was 72 (11) years compared to an average age of 66 (10) years in patients who did not develop PV/BP. Patients were also found to be predominately white (77.9%). Factors associated with increased risk of BP were use of DPP4i (Odds Ratio [OR] 1.90, 95% confidence interval [95% CI: 1.14-3.47, p=&amp;lt;0.01), and older age (OR: 1.07, 95%CI: 1.04-1.09, p&amp;lt;0.01). Use of GLP1-RA or DPP4i was not associated with PV incidence. (OR: 1.31, 95% CI: 0.65-2.62, p=&amp;lt;0.45). Conclusion: In conclusion, our study supports existing literature that DPP4i use is associated with an increased risk of developing BP. Our data does not find association with GLP-1 agonists nor DPP4 inhibitors in increasing the risk of PV. Presentation: 6/3/2024

Accounting for Red Cell Distribution Width Improves Risk Stratification by Commonly Used Mortality/Deterioration Risk Scores in Adult Patients Hospitalized Due to COVID-19.

Higher red blood cell distribution width (RDW) levels have gained attention in the prognostication of many chronic metabolic and malignant diseases, as well as coronavirus disease 2019 (COVID-19). We aimed to evaluate whether accounting for RDW might contribute to risk stratification when added to commonly used risk scoring systems in adult COVID-19 patients. We retrospectively analyzed a cohort of 3212 non-critical COVID-19 patients hospitalized in a tertiary-level institution from March 2020 to June 2021. Admission RDW values were considered normal if they were ≤14.5% in males or ≤16.1% in females. The Modified Early Warning Score (MEWS), International Severe Acute Respiratory and Emerging Infections Consortium Coronavirus Clinical Characterisation Consortium score (ISARIC 4C), and Veterans Health Administration COVID-19 (VACO) index were evaluated as prognostic scores. RDW exceeded the upper limit in 628 (19.6%) of the patients. When RDW was accounted for, risks of the predicted outcomes were considerably different within the same MEWS, 4C score, and VACO index levels. The same patterns applied equally to patients who started, and those who did not start, remdesivir before deterioration. RDW may be a useful tool for stratifying risk when considered on top of commonly used prognostic scores in non-critical COVID-19 patients.

Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate the written exposure therapy training program in the Veterans Health Administration.

The Veterans Health Administration (VHA) has rolled out evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD); however, reach has remained low, and there is a need for briefer interventions. The National Center for PTSD conducted a facilitated learning collaborative to train clinicians and support VHA PTSD teams in their adoption of an emerging best practice, written exposure therapy (WET). Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) evaluation framework, the present study utilized longitudinal data from 178 clinicians and 556 patients across seven training cohorts to evaluate key clinical and implementation outcomes and whether clinic (i.e., implementation climate) or clinician factors (i.e., treatment attitudes) were associated with effectiveness and implementation. Intent-to-treat analyses indicated WET was effective in reducing PTSD (d = 0.54) and depression symptoms (d = 0.39). Data indicated that 87.60% of clinicians reported using WET 6 months postconsultation. Clinic-wide reach was modest after training (14.53% of individuals with PTSD); however, WET-trained clinicians continued to offer WET to an average of 87.38% of their patients. Fidelity remained high after training, with essential session elements most often being offered "always" (M = 6.65 on a scale from 1 to 7). More positive postconsultation clinician treatment attitudes predicted higher posttraining rates of having patients engaged in WET. Clinician treatment attitudes and implementation climate did not predict any other implementation or effectiveness outcomes examined. Results suggest that WET implementation is advancing in VHA, with good clinical outcomes. Data provide evidence that a facilitated learning collaborative can be used to support and scale EBPs. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Suicide Rates by Age and Time Among American Indian and Alaskan Native Veterans.

Although recent work has highlighted high rates of suicide among American Indian and Alaska Native individuals who served in the US military, to date, a comprehensive evaluation of age-specific suicide rates, over time, has yet to be conducted. Population-based retrospective cohort study. Average annual suicide rates (2005-2020) were computed. The cohort included 207,955 Native Veterans who were alive as of January 1, 2005, and separated from military service on or before December 31, 2020. Suicide was identified via National Death Index codes. Between 2005 and 2020, average annual, age-specific suicide rates among Native Veterans ranged from 16.32/100,000 (55+ y) to 64.49/100,000 (18-34y). Compared with other age-related cohorts, the rate among those in the youngest age cohort (18-34y) was the highest between 2005 and 2018. The 2019-2020 average annual rate for 18- to 34-year-olds (41.86/100,000) dropped below that of the middle-aged cohort (35-45y; 44.66/100,000). Across all age cohorts, firearms were the most used method of suicide [57.2% (18-34 and 35-54y) to 66.17% (55+y)]; however, a notable percentage of Veterans died by suffocation, 16.54% (55y and older), 26.71% (35-54y), and 33.21% (18-34y). Findings highlight differences in suicide rates by age groups overtime for Native Veterans irrespective of Veterans Health Administration use and across service eras, as well as means of suicide, which also differed across groups. Increased efforts are needed to identify culturally and age-relevant intervention strategies, as well as factors associated with risk, to reduce deaths among Native Veterans.

Spending by the Veterans Health Administration for Medicare Advantage Dual Enrollees, 2011-2020

This study assesses veterans’ dual enrollment in the Veterans Health Administration (VHA) and Medicare Advantage and VHA spending from 2011 through 2020.

An Automated Electronic Health Record Score to Estimate Length of Stay and Readmission in Patients Undergoing Radical Cystectomy for Bladder Cancer.

Patients treated with radical cystectomy experience a high rate of postoperative complications and frequent hospital readmissions. We sought to explore the utility of the Care Assessment Need (CAN) score, derived from electronic health data, to estimate the risk of these adverse clinical outcomes, thereby aiding patient counseling and informed treatment decision-making. We retrospectively examined data from 982 patients with bladder cancer who underwent radical cystectomy between 2013 and 2018 within the national Veterans Health Administration system. We tested for associations between the preoperative CAN score and length of stay, discharge location, and readmission rates. We observed a correlation between higher CAN scores and longer hospital stays (adjusted relative risk = 1.03 [95% CI: 1.02-1.05]). An increased CAN score was also linked to greater odds of discharge to a skilled nursing facility or death (adjusted odds ratio = 1.16 [95% CI: 1.06-1.26]). Furthermore, the score was associated with hospital readmission at both 30 and 90 days postdischarge (adjusted HR = 1.03 [95% CI: 1.00-1.07] and 1.04 [95% CI: 1.00-1.07], respectively). The CAN score is associated with length of hospital stay, discharge to a skilled nursing facility, and readmission within 30 and 90 days after radical cystectomy. These findings highlight the potential of health care systems leveraging electronic health records for automatically calculating multidimensional tools, such as the CAN score, to identify patients at risk of adverse clinical outcomes after radical cystectomy.

Access and adherence to cancer care through the Veteran Affairs Close to Me cancer care service.

111 Background: Diagnosing and treating more than 56,000 Veterans annually, the Veterans Affairs (VA) National Oncology Program (NOP) is one of the nation’s largest integrated providers of oncology services. Within VA, oncology care and parenteral therapies are primarily offered at VA Medical Centers (VAMCs) in urban areas, often inaccessible to rural patients. Issues with travel distance, parking, time, and caregiver support can prevent patients from adhering to treatment appointments as evidenced by historical annual No-Show rates for VAMC infusion clinics that range from 1.1-6.7%. To mitigate potential barriers to access, NOP launched the Close to Me (CTM) cancer care service. The service deploys Registered Nurses (RNs) to local VA Community Based Outpatient Clinics (CBOCs) to administer cancer treatments. VA has opened 23 CTM clinics across 5 geographical regions since October 2021. Methods: The CTM service was implemented at VAMCs with NOP providing direct project management, safety assessment and resources such as a comprehensive implementation toolkit, standard operating procedures, care coordination tools, a tiered risk drug matrix and a standardized Healthcare Failure Mode and Effect Analysis risk evaluation. RNs followed a standardized workflow to assess patient eligibility and verify treatment clearances. Access to care was reported by numbers of unique patients and treatment visits. Patient appointment adherence was monitored by no-show rates documented in the electronic health record. Infusion reactions and medical emergencies were reported by RNs. Travel miles saved was calculated by subtracting the difference in miles round trip from the patient’s home to main VAMC and from home to CBOC, then multiplied by number of treatment visits to CBOC. Results: From October 2021 through April 2024, 23 new CTM clinics opened across 5 regions. 515 unique patients were enrolled for a total of 1,916 patient visits. Treatment appointment no-show rate was 1% across all CTM clinics. The most commonly administered medication classes include gonadotropin-releasing hormone agonist (30%), immune globulin (14.5%), immune checkpoint inhibitors (9.3%) and bisphosphonates (8.3%). Zero infusion reactions or medical emergencies were recorded across 1,430 treatments administered. A total of 204,000 travel miles were saved by patients enrolled in this program. Conclusions: The CTM cancer care service safely optimizes current VA CBOC infrastructure to increase access points to oncology treatment for patients across various geographical regions. CTM reduced travel burden for patients and increased ability to adhere to treatment appointments as evidenced by the service’s low no-show rate. These consistent results across CTM services at VAMCs nationwide have cemented CTM as a safe and effective treatment delivery model to expand access. CTM will be scaled to an additional 30 regions by end of 2025.

Women's Health Care Delivery and Coordination After Transitioning From One Electronic Health Record to Another: Perspectives From Staff in the Veterans Health Administration

ObjectivesThe Veterans Health Administration (VA) is transitioning its 1,300 health care facilities from one electronic health record (EHR) to another. The transition aims to improve care delivery and interoperability; however, specific effects on women veterans, who comprise only 7.5% of the patient population, may be obscured without focused evaluation. We aimed to characterize the perspectives of VA staff regarding the impact of transitioning EHRs on women's health care delivery. MethodsWe conducted semistructured interviews with VA staff members involved in delivering or coordinating care for women at three sites that had transitioned EHRs within the past year. Interviews were audio-recorded and transcribed. We used a rapid, templated qualitative analytic approach to identify salient themes in the data. ResultsWe interviewed 16 staff members across VA departments and roles. Although some participants felt the new EHR held promise, most identified challenges with the EHR rollout and implementation (e.g., insufficient training) and the EHR product (e.g., system inefficiencies and latency). Participants highlighted several ways the EHR transition disproportionately affected care delivery for women veterans, including via backlogs of community care referrals, insufficient opportunities for providers to gain proficiency with sex-specific workflows in the new EHR, and outdated listings for veterans who have changed their names. Participants reported that these issues affected their morale and contributed to decreases in productivity and delayed care. ConclusionsMany of our findings reflect challenges that affect VA staff broadly, whereas others may be compounded among women veterans and the VA staff who serve them. To achieve the goal of delivering timely, equitable, high-quality, comprehensive health care services to women veterans, continued efforts to monitor and address the impacts of the EHR transition on this population are needed.

Off-Label Bone Morphogenetic Protein 2 Use Results in Successful Posterolateral Lumbar Fusion in a Veteran Population.

Patients within the US Veterans Health Administration (VA) system have higher rates of comorbidities and chronic pain, increasing risks of complications/poor outcomes following spine surgery. Although the use of bone morphogenetic protein 2 (BMP-2) is established for anterior lumbar interbody fusion, its indications for off-label use in posterolateral fusion are unclear. The objective of this study was to evaluate safety and utility of BMP-2 in posterolateral fusion through a 15-year experience at the VA. Patients underwent posterolateral lumbosacral fusions with BMP-2 by a single VA surgeon from January 1, 2005, to January 1, 2020. The primary outcome was fusion assessed through postoperative radiographs. Secondary outcomes included adjacent segment disease (ASD) and postoperative pain clinic utilization. Sixty-eight patients underwent lumbosacral posterolateral fusion with BMP-2; 77.9% were discharged home and had no postoperative complications. All patients achieved bony fusion at a mean of 113.3 ± 59.9 days postoperatively. Five patients were diagnosed with cancer postoperatively, and eight patients required revision for ASD. No notable predictors of ASD exist. Preoperative opioid use predicted postoperative pain clinic utilization. Posterolateral lumbar fusion with BMP-2 in veterans yields high fusion rates and favorable complication profiles and should be considered in multimorbid hosts. Retrospective review of prospectively collected data.

The Educational Experience Improvement Collective for Inpatient Medicine Healthcare Professional Trainees at a University-Affiliated Veterans Affairs Medical Center

Background: Rotation evaluations reflect the resident-perceived value of clinical experiences in graduate medical education. In this study, we sought to improve the quality of education for internal medicine residents during their inpatient medicine rotation. Methods: Program stakeholders critically appraised a core medicine rotation at a university-affiliated U.S. Veterans Affairs Medical Center utilizing end-of-rotation evaluations by residents. Thematic analysis identified three areas for improvement: culture, communication, and workload. Solutions were developed to address each theme: (1) site-specific orientation was provided to new trainees, (2) real-time notification of admissions occurred via secure messaging platform, and (3) an assistive rounding tool was integrated into the electronic medical record. Outcome measures of education were obtained via end-of-rotation evaluations by residents. Results: This study included 198 pre-intervention and 58 post-intervention evaluations by trainees from October 2022 through December 2023. Using a 5-point Likert scale, the quality of education improved from good to very good (3.26 to 4.02, +15%, p &lt; 0.001) over the course of one year. All four subcategories also improved: diversity/quality of pathology (0.33; +7%), supervision (0.50; +10%), workload (0.42; +8%), and learning value (0.51; +10%). When the five categories are compared immediately pre-intervention (fourth quarter of 2022-2023 academic year) to full post-intervention (second quarter of 2023-2024 academic year) using a paired t-test, the change was statistically significant (p = 0.007). Conclusions: Significant educational enhancements were achieved over time for a core rotation in a residency program using solutions developed from interconnected themes found in learner evaluations.

Assessing 1-year sodium-glucose co-transporter-2 inhibitor tolerance in older adults.

Evidence concerning tolerability of sodium-glucose co-transporter-2 (SGLT2) inhibitors in older adults is limited due to under-representation in clinical trials. Our study aimed to determine the extent to which SGLT2 inhibitor intolerance increases with age and explore additional factors associated with intolerance. This retrospective observational study included patients in the Veterans Health Administration who initiated an SGLT2 inhibitor between 1 January 2013 and 31 December 2021. One-year discontinuation served as a proxy for intolerance. Relative risk (RR) for 1-year discontinuation was contrasted across age groups using log-binomial regression to adjust for confounding. Of 232 495 patients who initiated an SGLT2 inhibitor, 60 582 (26.1%) discontinued within one year. A difference was observed across age groups, <65, 65-74, 75-84 and ≥85years, where 25.8%, 25.3%, 28.5% and 34.9% of patients discontinued, respectively (P < .001). After adjustment for confounding factors, patients 75-84 and ≥85years were at 8% (RR = 1.08; 95% CI: 1.05, 1.10) and 21% increased risk (RR = 1.21; 95% CI: 1.15, 1.26) for discontinuation, respectively, relative to patients <65years. Additional risk factors were identified: female (RR = 1.41; 95% CI: 1.37, 1.45), estimated glomerular filtration rate stage 4 (RR = 1.49; 95% CI: 1.39, 1.60), underweight (RR = 1.15; 95% CI: 1.03, 1.29), urinary tract infection history (RR = 1.25; 95% CI: 1.21, 1.30) and yeast infection history (RR = 1.39; 95% CI: 1.27, 1.51). No clinically meaningful differences in SGLT2 inhibitor intolerance were observed in patients up to 84years. Our findings support having closer follow-up when initiating in patients 85years and older.

139EMF Assessing Efficacy and Value of Tele-Emergency Care Within the Veterans Health Administration

139EMF Assessing Efficacy and Value of Tele-Emergency Care Within the Veterans Health Administration