Veterans Affairs Population Research Articles

Epidemiology and Racial Differences of EoE Patients in a U.S. Veterans Population.

Eosinophilic esophagitis (EoE) is increasing in prevalence but there is a lack of population-based studies. We sought to determine the prevalence, demographics, and associated atopic diseases in the Veterans Affairs (VA) population. A nationwide analysis of data from the VA patient population was done using a Veterans Health Administration database. EoE was identified using ICD9 (530.13) and ICD10 (K20.0) codes from October 2008 to June 2020. Demographic data, smoking status, BMI, treatment, and ICD codes for atopic diagnoses were collected. Two sample proportion z-tests, Chi-square tests, two-sample t tests, and one-way ANOVA were used to assess associations across demographic categories. We identified a total of 11,775 patients with an EoE diagnosis: 91% male, 83% White, 8.6% Black, and 5% were of Hispanic ethnicity. The prevalence of EoE increased over time. At diagnosis, the mean age was 48.5years overall, 51.6years for Black patients, 45.3years for Hispanic patients, and 48.2years for Whites. Dysphagia was the most common symptom overall, but a higher percentage of Blacks and females were found to report chest pain (p < 0.0001, h = 0.32). With the exception of urticaria and atopic dermatitis, both Blacks and Hispanics had a higher incidence of atopic conditions compared to other races and ethnicities (p < 0.0001). While EoE is seen primarily in White males, our study shows that a notable percentage of patients were Black or Hispanic, suggesting that EoE should be considered in non-white patients. The later age of diagnosis in this group could represent a lack of awareness about EoE among non-white patients. More research is needed to study these associations.

Impact of Tracheostomy Timing Within the National Veterans Affairs Population.

There is a lack of a definitive study in the literature comparing early versus late tracheostomy and exploring the impact of tracheostomy timing on patient outcomes. This study may help guide treatment paradigms and contribute to a consensus for optimal tracheostomy timing. A retrospective review was performed comparing early versus late timing of tracheostomy placement and their respective outcomes. The authors used data provided by VA Informatics and Computing Infrastructure (VINCI) to find patients who received a tracheostomy at any VA Medical Center in the United States. There were a total of 25,334 tracheostomies in the database which satisfied our criteria. These occurred between the years 1999 and 2022. Propensity score matching assessed 17,074 tracheostomies, 8537 in either group. The median age of patients in the matched groups was 66 years, and approximately 97.4% of patients were male. Early tracheostomy timing was defined as the placement of the tracheostomy within 10 days of intubation. Outcomes included post-tracheostomy intensive care unit (ICU) days, post-tracheostomy hospital days, successful ventilator weaning, and all-cause mortality. Early tracheostomy was associated with significantly fewer ICU days and hospital days, and the early group experienced higher rates of successful ventilator weaning. Survival analysis of data within 5 years of tracheostomy showed that early tracheostomy was associated with significantly lower hazard for all-cause mortality. Our results add to the body of evidence that an earlier transition to mechanical ventilation by tracheostomy confers benefits in patient morbidity and mortality as well as resource utilization. 3 Laryngoscope, 134:3555-3561, 2024.

Wrist Salvage and Fusion Outcomes in a Veterans Affairs Population

Abstract Introduction Wrist osteoarthritis (OA) is a common condition in the elderly population that can lead to significant impairment. Common causes of wrist OA are scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC). This study examines the outcomes of wrist salvage and fusion surgeries in the treatment of posttraumatic wrist arthritis caused by SLAC/SNAC in the Veteran population. Materials and Methods A retrospective review was performed of patients who presented to a single Veteran Affairs hospital with wrist arthritis over the period of 12 years. Information analyzed included patient demographics, SNAC/SLAC grade, and first operation (proximal row carpectomy, four-corner fusion, and total wrist fusion). Outcomes reviewed included postoperative malunion, impingement, hardware failure, postoperative range of motion (ROM), persistent pain, recurrent arthritis, and need for reoperation. Results In the proximal row carpectomy group, 11 (29%) patients had poor ROM postoperation, 14 (36.8%) had persistent pain, 3 (7.9%) had recurrent arthritis, and 2 (5.3%) needed reoperations. In the four corner fusion 4CF group, 3 (13.6%) patients had malunion, 3 (13.6%) had impingement, 5 (22.7%) had a hardware failure, 2 (8.7%) had poor ROM postop, 9 (40.9%) had persistent pain, 6 (27.3%) had recurrent arthritis, and 6 (27.3%) needed reoperations. In the total wrist fusion TWF group, 2 (18.2%) patients had malunion, 2 (18.2%) had impingement, and 2 (18.2%) had hardware failure. No patients had poor ROM postoperation, 5 (45.5%) had persistent pain, 2 (18.2%) had recurrent arthritis, and 3 (27.3%) needed reoperations. Conclusions In the treatment of wrist arthritis, partial wrist fusions are optimal for maintaining ROM while improving pain control. Level of Evidence III

Compliance with recommended pneumococcal vaccination schedule in patients treated for rheumatoid arthritis: A retrospective cohort study in the Veterans Affairs population

IntroductionInvasive pneumococcal disease (IPD) is a leading cause of death. Rheumatoid arthritis (RA) patients are at risk of IPD due to immunosuppressant medications. Up until 2022, two pneumococcal vaccines, the 13-valent Pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23), were recommended. Despite the recommendation change to give a single 20-valent PCV vaccine (PCV20), some still require multiple vaccinations. There is a need to identify barriers to vaccine uptake. MethodsWe conducted a retrospective cohort study to assess the on-time vaccination rates for PCV13 and PPSV23 in treated RA patients between 2010 and 2018 using national Veterans Affairs data. Patients > 18 years of age diagnosed with RA and newly initiated on RA treatment were included. Pneumococcal vaccine compliance was assessed by measuring on-time receipt of PCV13 and PPSV23 vaccinations. We identified factors using multivariate logistic regression and described the occurrence of these factors using descriptive statistics. ResultsA total of 39,243 patients were included in the study. Most patients were white (75.8 %), male (85.4 %), on methotrexate therapy (41.4 %). The average age was 62.3 years. The proportion of patients considered vaccine compliant is 43.9 %. The primary independent risk factors for vaccine non-compliance were black/African American race (Odds Ratio [OR] 1.26, 95 % Confidence Interval [CI] 1.19–1.34) or missing/unknown race (OR 1.45, 95 % CI 1.31–1.61), missing/unknown ethnicity (OR 1.21, 1.02–1.43), never married (OR 1.10, 95 % CI 1.02–1.19) or widowed (OR 1.23, 95 % CI 1.12–1.34), diagnosed with congestive heart failure (OR 1.10, 95 % CI 1.00–1.22), or dementia (OR 1.48, 95 % CI 1.16–1.91). The proportion of patients who were non-compliant in patients who were vaccine naïve was 32.1 % and the non-compliance rate for non-naïve patients was 65.3 %. ConclusionsProviders should identify barriers to pneumococcal vaccination in RA patients to improve compliance. Efforts to increase vaccination should be tailored to specific high-risk groups.

Practice Patterns and Patient Experience of Care Among US Veterans with Prostate Cancer: A 10-Year Scoping Review

Purpose: This study evaluated and synthesized the literature on prostate cancer practice patterns and patient experience of care within the US Veterans Affairs (VA) population. Materials and Methods: A scoping review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews standards. Search terms were prostate cancer, Veterans, treatment patterns, healthcare, resource, patient experience, quality of care, healthcare quality. The search was limited to human studies published in English in the past 10 years (2013-2022). Studies were included if they evaluated treatment patterns, health care resource use, and/or patient experience of care among US Veterans with prostate cancer. Results: Among 150 included studies, most were retrospective VA database evaluations (n = 119, 79.3%) or retrospective cohort studies (n = 8, 5.3%), with the remaining being prospective observational cohort studies (n = 16, 10.7%), randomized controlled trials (n = 5, 3.3%), a meta-analysis (n = 1, 0.7%), and a provider survey (n = 1, 0.7%). Sample sizes ranged from 11 to 214,649 patients. The most common topics were pharmacological therapies (n = 28), racial/ethnic disparities (n = 27), and definitive radiation therapy or radical prostatectomy (n = 24). Some studies indicated Veterans may not have access to the same quality of prostate cancer care compared with the general population. Opportunities for improvement in shared decision making remain. Conclusion: Some findings from this scoping review indicate that Veterans may not have access to the same quality of prostate cancer care compared with the US general population. Research is needed to confirm whether observed practice pattern differences are warranted given the potential negative care impact.

418. Possible Risk Factors and Clinical Features of Post-COVID-19 Syndrome in a Veteran Affairs population

Abstract Background Post-COVID-19 syndrome (PCS) refers to debilitating physical and neuropsychiatric symptoms for at least ≥ 4 weeks following the recovery from COVID-19 infection. The goal of this study is to identify shared epidemiological and clinical features among patients with PCS to identify possible risk factors that can guide studies in the prevention of PCS. Methods Chart reviews of patients referred to the post-COVID clinic of Northport VA Medical Center, NY between January 2021 to March 2023 were performed. 57 patients with mild COVID-19 infection without requiring hospitalization that met CDC definition of PCS were included. Cases were reviewed and demographics, comorbidities, treatment/vaccine status, common symptoms reported and baseline inflammatory markers were recorded and analyzed. Results The mean age was 56 years, and most patients were between the ages of 46-60 years old (28.1%, table 1). More male patients reported symptoms of PCS compared to females (56.1% vs. 43.9%, table 1). Common comorbidities included pre-existing psychiatric diagnoses (47.4%), obesity (40.4%), hypertension (40.4%), hyperlipidemia (43.9%), and chronic lung disease (36.9%), with an average Charlson comorbidity index of 1.9. Most patients (59.6%) reported only being infected with COVID-19 once (table 1). Most patients (75.4%) did not receive outpatient therapy against COVID-19 and most had only two vaccines against COVID-19 (38.6%, table 2). Predominant symptoms included fatigue (56.1%), brain fog (56.1%), dyspnea on exertion/decreased exercise tolerance (42.1%), and cough (24.6%) (table 3). Of those with values measured, baseline ESR, CRP, ferritin values were normal and a small percentage had elevated D-dimer &amp;gt;150 ng/mL D-DU (table 4). Conclusion Majority had comorbidities such as hypertension, hyperlipidemia, pre-existing mental health conditions and obesity. Most had only 2 doses of a COVID-19 vaccine and did not receive any outpatient treatment for COVID-19. This suggests that these features may serve as potential risk factors for PCS and further study is needed to elucidate the relationship between these attributes and PCS. Disclosures All Authors: No reported disclosures

B - 93 Appropriateness of Test of Premorbid Functioning for Predicting Premorbid Functioning in Spanish/English Speaking Military Veterans Affairs Population.

To examine the degree of discrepancy between Test of Premorbid Functioning (TOPF) predicted and actual WAIS-IV FSIQ between monolingual English-speaking veterans (MV) and bilingual English/Spanish-speaking veterans (BV). Data from neuropsychological evaluation of 97 clinically referred veterans (Mage = 53.02, SD = 14.24, range = 23-80; Medu = 13.87, SD = 2.86, range = 6-20; 81 MV, 16 BV) were included. The percentage of male participants was 80.4. Inclusion criteria were completion of the TOPF and the full standard Wechsler Adult Intelligence Scale - Fourth Edition (WAIS-IV). Exclusion criteria were PVT failure, neurocognitive disorder, learning disability, substance use disorders, and psychotic disorders. Mean TOPF-predicted FSIQ (combined demographic + TOPF) and mean WAIS-IV FSIQ were computed for each group, as well as mean discrepancy between observed and predicted FSIQ (DISo-p). MV and BV differed in mean WAIS-IV FSIQ (t = 3.20, p = .0002) and mean TOPF-predicted FSIQ (t = 2.09, p = .039). Mean DISo-p was -1.88 for MV and -5.75 for BV. Mean DISo-p did not differ significantly between monolingual and bilingual groups (t = 1.71, p = .090). In a veteran sample, the TOPF combined prediction model functioned similarly for MV and BV without cognitive impairment. This provides preliminary support for the use of this measure to predict premorbid intellectual functioning among English/Spanish bilingual veterans. Additional research is needed to examine impact of English proficiency, age of acquisition, and education level on FSIQ prediction among bilingual veterans and in the population at large.

Evaluation of the Effects of Surgical Smoke During Mohs Micrographic Surgery in the Veterans Affairs Population.

Evaluation of the Effects of Surgical Smoke During Mohs Micrographic Surgery in the Veterans Affairs Population.

Association of select psychiatric disorders with incident brain aneurysm and subarachnoid hemorrhage among veterans.

Brain aneurysms represent a significant cause of hemorrhagic stroke. Prior research has demonstrated links between stress and stroke, including brain aneurysms. We aimed to determine relationships between select psychiatric disorders and aneurysms and aneurysmal SAH. We performed retrospective, case-control study of a National Veterans Affairs population with two experimental groups (aneurysm-only and aneurysmal SAH) and 10-fold controls per group matched by age, date, and clinical data source. The studied the presence of 4 psychiatric disorders: Posttraumatic stress disorder (PTSD), major depressive disorder (MDD), generalized anxiety disorder (GAD), and other mood disorders. Our main outcomes Unadjusted and multivariable adjusted ORs of PTSD, MDD, GAD, and mood disorders within aneurysm-only and aSAH groups. In 6,320,789 US Veterans who were enrolled for at least 5 years in Medicare and/or the Veterans Health Administration, we identified 35,094 cases of aneurysm without SAH and 5,749 cases of aneurysm with SAH between 1/2005 and 12/2019. In analyses adjusted for sex, hypertension, and tobacco use, patients with aneurysm were more likely than matched controls to have a history of PTSD (OR 1.48), MDD (OR 1.33), GAD (OR 1.26), and other mood disorders (OR 1.34) (all p-values < 0.0001). Similarly, patients with aSAH were more likely than controls to have a history of PTSD (OR 1.35), MDD (OR 1.38), GAD (OR 1.18), and other mood disorders (OR 1.30) (all p-values < 0.0001). The study, the largest of its kind, further suggests links between psychiatric disorders and stroke. This is important as patients with aneurysms are not routinely screened for such psychiatric risk factors. Additional research on this topic could lead to novel strategies to improve stroke prevention.

Nursing leadership and influence in practice domains at a Veterans Affairs Health Care System

BackgroundStudies in Veteran populations have examined disparities in health service use, care quality, outcomes and increased demands for behavioral health. PurposeThe purpose is to describe the development of nursing leadership roles that influenced practice improvements and demonstrated outcomes related to health disparities in a Veterans Affairs (VA) population over a 12-year period. MethodsThe Sundean and colleagues' concept analysis of nurse leadership influence was applied to frame the initiative process and impacts. DiscussionAntecedents and processes that facilitated leadership development included mentorship, disparities expertise, partnerships, consultation, scholarship, dissemination, advocacy, education, and strong coauthor collaboration. Improvements and outcomes included access to services, improved health indicators, tools, workforce, funding, innovations, and nurse investigator studies, consistent with VA priorities and policy related to disparities and equity. Limitations and barriers were addressed. ConclusionThis initiative models’ strategies to increase nurse leadership in health equity and care transformation in health systems and community practices.

Epidemiology of Sarcoidosis in U.S. Veterans from 2003 to 2019.

Rationale: United States veterans represent an important population to study sarcoidosis. Their unique history of environmental exposures, wide geographic distribution, and long-term enrollment in a single integrated healthcare system provides an unparalleled opportunity to understand the incidence, prevalence, and risk factors for sarcoidosis. Objectives: To determine the epidemiology, patient characteristics, geographic distribution, and associated risk factors of sarcoidosis among U.S. veterans. Methods: We used data from the Veterans Health Administration (VHA) electronic health record system between 2003 and 2019 to evaluate the annual incidence, prevalence, and geographic distribution of sarcoidosis (defined using the International Classification of Diseases codes). We used multivariate logistic regression to examine patient characteristics associated with sarcoidosis incidence. Results: Among more than 13 million veterans who received care through or paid for by the VHA, 23,747 (0.20%) incident diagnoses of sarcoidosis were identified. Compared with selected VHA control subjects using propensity score matching, veterans with sarcoidosis were more likely to be female (13.5% vs. 9.0%), of Black race (52.2% vs. 17.0%), and ever-tobacco users (74.2% vs. 64.5%). There was an increase in the annual incidence of sarcoidosis between 2004 and 2019 (from 38 to 52 cases/100,000 person-years) and the annual prevalence between 2003 and 2019 (from 79 to 141 cases/100,000 persons). In a multivariate logistic regression model, Black race (odds ratio [OR], 4.49; 95% confidence interval [CI], 4.33-4.65), female sex (OR, 1.64; 95% CI, 1.56-1.73), living in the Northeast compared with the western region (OR, 1.57; 95% CI, 1.48-1.67), history of tobacco use (OR, 1.36; 95% CI, 1.31-1.41), and serving in the Army, Air Force, or multiple branches compared with the Navy (OR, 1.08; 95% CI, 1.03-1.13; OR, 1.10; 95% CI, 1.04-1.17; OR, 1.27; 95% CI, 1.16-1.39, respectively) were significantly associated with incident sarcoidosis (P < 0.0001). Conclusions: The incidence and prevalence of sarcoidosis are higher among veterans than in the general population. Alongside traditionally recognized risk factors such as Black race and female sex, we found that a history of tobacco use within the Veterans Affairs population and serving in the Army, Air Force, or multiple service branches were associated with increased sarcoidosis risk.

Cognitive Impairment is Common in a Veterans Affairs Population with Peripheral Arterial Disease

Despite the shared pathogenesis of peripheral arterial disease (PAD) and vascular dementia, there is little data on cognitive impairment in PAD patients. We hypothesized that cognitive impairment will be common and previously unrecognized. Cognitive impairment screening was prospectively performed for Veterans presenting to a single Veterans Affairs outpatient vascular surgery clinic from 2020-2021 for PAD consultation or disease surveillance. Overall, 125 Veterans were screened. Cognitive impairment was defined as a score of <26 on the Montreal Cognitive Assessment (MoCA) survey. A multivariable logistic regression assessed for independent risk factors for cognitive impairment. Overall, 77 (61%) had cognitive impairment, 92% was previously unrecognized. Cognitive impairment was associated with increased age (74.4 vs. 71.8 years, p=0.03), Black vs. White race (94% vs. 54%, p<0.01), hypertension (66% vs. 31%, p=0.01), prior stroke/TIA (79% vs. 58%, p=0.03), diabetes treated with insulin (79% vs. 58%, p=0.05), and post-traumatic stress disorder (PTSD) (80% vs. 57%, p=0.04). On multivariable analysis, risk factors for newly diagnosed cognitive impairment included age ≥ 70 years, diabetes treated with insulin, PTSD, and Black race. Many Veterans with PAD have evidence of cognitive impairment and is overwhelmingly underdiagnosed. This study suggests cognitive impairment is an unrecognized issue in a VA population with PAD, requiring more study to determine cognitive impairment's impact on surgical outcomes, and how it can be mitigated and incorporated into clinical care.

Oral Therapy for Aerococcus urinae Bacteremia and Thoracic Spondylodiscitis of Presumed Urinary Origin.

Aerococcus urinae (A urinae), considered a rare pathogen, has been identified with increasing frequency in urine cultures. Only 8 cases of spondylodiscitis due to A urinae have been reported. Optimal treatment for invasive A urinae infection is undefined. However, the reported cases were treated successfully with diverse antibiotic regimen combinations, all including a β-lactam and beginning with at least 2 weeks of IV antibiotics. A 74-year-old man presented to the emergency department after 2 weeks of midthoracic back pain, lower extremity weakness, gait imbalance, fatigue, anorexia, rigors, and subjective fevers. The patient was presumed to have discitis secondary to a urinary tract infection with possible pyelonephritis and was given empiric vancomycin and ceftriaxone. Spinal magnetic resonance imaging with contrast supported spondylodiscitis. Preliminary results from the admission blood and urine cultures showed gram-positive cocci in clusters. A urinae urinary tract infection in the absence of obvious predisposing factors should prompt evaluation for urinary outflow obstruction. We suspect a review of a US Department of Veterans Affairs population might uncover a higher incidence of A urinae infection than previously suspected.

Association of entry into hospice or palliative care consultation during acute care hospitalization with subsequent antibiotic utilization

ObjectiveWe aimed to estimate antibiotic use during the last 6 months of life for hospitalized patients under hospice or palliative care and identify potential targets (i.e. time points) for antibiotic stewardship during the end-of-life period. MethodsWe conducted a retrospective cohort study of nationwide Veterans Affairs (VA) patients who died between January 1, 2014 and December 31, 2019 and who had been hospitalized within 6 months prior to death. Data from the VA's integrated electronic medical record were collected, including demographics, comorbid conditions, and duration of inpatient antibiotics administered, along with outpatient antibiotics dispensed. A propensity score–matched cohort analysis was conducted to compare antibiotic use between hospitalized patients placed into palliative care or hospice matched to hospitalized patients not receiving palliative care or hospice. ResultsThere were 9808 and 40 796 propensity score–matched patient pairs in the hospice and palliative care groups, respectively. Within 14 days of placement or consultation, 41% (4040/9808) of hospice patients and 48% (19 735/40 796) of palliative care patients received at least one antibiotic, while 25% (2420/9808) matched nonhospice and 27% (10 991/40 796) matched nonpalliative care patients received antibiotics. Entry into hospice was independently associated with a 12% absolute increase in antibiotic prescribing, and entry into palliative care was associated with a 17% absolute increase during the 14 days post-entry vs. pre-entry period. DiscussionWe observed that patients receiving end-of-life care had high levels of antibiotic exposure across this VA population, particularly during admissions when they received hospice or palliative care consultation.

Mortality and Conversion to Transfemoral Amputation After Transtibial Amputation in the Veterans Affairs Health System.

Transtibial below-knee amputation (BKA) is associated with considerable morbidity, particularly in the vasculopathic population. The purpose of this study was to determine the cumulative probability of undergoing transfemoral above-knee amputation (AKA) conversion within 5 years of BKA and associated risk factors while accounting for the competing risk of death. This is a retrospective, national database study with structured query of the Veterans Affairs (VA) database for patients who underwent BKA from 1999 to 2020, identified by Current Procedural Terminology codes. Above-knee amputation conversion was identified using Current Procedural Terminology codes in combination with natural language processing to match procedure laterality. After internally validating our patient identification method, risk factors were collected. Competing risk analysis estimated the cumulative incidence rate of AKA conversion and associated risk factors with death as a competing risk. Our query yielded 19,875 patients (19,640 men, 98.8%) who underwent BKA with a median age of 66 years (interquartile range, 60 to 73). The median follow-up was 951 days (interquartile range, 275 to 2,026). The crude cumulative probabilities of AKA conversion and death at 5 years were 15.4% (95% confidence interval [CI], 14.9% to 16.0%) and 47.7% (95% CI, 46.9% to 48.4%), respectively. In the Fine and Gray subdistribution hazard model, peripheral vascular disease had the highest AKA conversion risk (hazard ratio [HR] 2.66; 95% CI, 2.22 to 3.20; P < 0.001). Other factors independently associated with AKA conversion included urgent operation (HR 1.32; 95% CI, 1.23 to 1.42), cerebrovascular disease (HR 1.19; 95% CI, 1.11 to 1.28), chronic obstructive pulmonary disease (HR 1.15; 95% CI, 1.07 to 1.24), and previous myocardial infarction (HR 1.10; 95% CI, 1.02 to 1.19) (All P < 0.02). Within this predominantly male, VA population, BKA carries a high risk of conversion to AKA within 5 years, without reaching a steady risk of AKA conversion within 5 years. Peripheral vascular disease, chronic obstructive pulmonary disease, cerebrovascular disease, previous myocardial infarction, and urgent BKA increase the risk of AKA conversion. Level III.

Radium-223 Utilization Patterns and Outcomes in Clinical Practice.

Radium-223 was approved for metastatic castration-resistant prostate cancer based on the ALSYMPCA trial. We characterize radium-223 treatment patterns and overall survival (OS) in a large equal access health system. We identified all men within the Veterans Affairs (VA) Healthcare System who received radium-223 between January 2013 and September 2017. Patients were followed until death or last followup. We abstracted all treatments received prior to radium; no treatments after radium were abstracted. Our primary aim was understanding practice patterns, and secondary outcome was the association between treatment pattern and OS measured using Cox models. We identified 318 bone metastatic castration-resistant prostate cancer patients who received radium-223 within the VA Healthcare System. Of these patients 277 (87%) died during followup. The 5 predominant treatment patterns that encompassed 88% of patients (279/318) were 1) androgen receptor-targeted agent (ARTA)-radium, 2) docetaxel-ARTA-radium, 3) ARTA-docetaxel-radium, 4) docetaxel-ARTA-cabazitaxel-radium and 5) radium alone. Median OS was 11 months (95% CI 9.7-12.5). Men who received ARTA-docetaxel-radium had the worst survival. All other treatments had similar outcomes. Only 42% of patients completed the full 6 injections; 25% received only 1 or 2 injections. We identified the most common radium-223 treatment patterns and their association with OS within the VA population. The better survival in ALSYMPCA (14.9 months) vs our study (11 months) along with 58% of patients not receiving the full radium-223 course suggests radium is being used later in the disease course in the real world in a more heterogeneous population.

Antibiotic use in end-of-life care patients: A nationwide Veterans’ Health Administration cohort study

Background: Antibiotic use during end-of-life (EOL) care is an increasingly important target for antimicrobial stewardship given the high prevalence of antibiotic use in this setting with limited evidence on safety and effectiveness to guide antibiotic decision making. We estimated antibiotic use during the last 6 months of life for patients under hospice or palliative care, and we identified potential targets (ie time points) during the EOL period when antimicrobial stewardship interventions could be targeted for maximal benefit. Methods: We conducted a retrospective cohort study of nationwide Veterans’ Affairs (VA) patients, 18 years and older who died between January 1, 2014, and December 31, 2019, and who had been hospitalized within 6 months prior to death. Data from the VA’s integrated electronic medical record (EMR) were collected including demographics, comorbid conditions, and duration of inpatient antibiotics administered, along with outpatient antibiotics dispensed. A propensity-score matched-cohort analysis was conducted to compare antibiotic use between patients placed into palliative care or hospice matched to patients not receiving palliative care or hospice care. Repeated measures ANOVA and repeated measures linear regression methods were used to analyze difference in difference (D-I-D) of days of therapy (DOT) between the 2 cohorts. Results: There were 251,822 patients in the cohort, including 23,746 in hospice care, 89,768 in palliative care, and 138,308 without palliative or hospice care. The median days from last discharge to death was 9 days. The most common comorbidities were chronic obstructive pulmonary diseases (50%), malignancy (46%), and diabetes mellitus (43%). Overall, 18,296 (77%) of 23,746 hospice patients, and 71,812 (80%) of 89,768 palliative care patients received at least 1 antibiotic, whereas 95,167 (69%) of 138,308 who were not placed in hospice or did not receive palliative care received antibiotics. In the primary matched cohort analysis that compared patients placed into hospice or palliative care to propensity-score matched controls, entry into palliative care was associated with a 11% absolute increase in antibiotic prescribing, and entry into hospice was associated with a 4% absolute increase during the 7–14 days after entry versus the 7–14 days before entry (Fig. 1). The stratified cohorts had very similar balanced covariates as the overall cohort. Conclusions: In our large cohort study, we observed that patients receiving EOL care had high levels of antibiotic exposure across VA population, particularly on entry to hospice or during admissions when they received palliative care consultation. Future studies are needed to identify the optimal EOL strategies for collaboration between antimicrobial stewardship and palliative care.Funding: NoneDisclosures: None

C-56 | The Heart Knows: How Heart Failure Exacerbations Predict Mortality in Veterans Undergoing Transcatheter Aortic Valve Replacement

Heart failure exacerbations (HFE) are associated with adverse clinical outcomes in all-comers undergoing transcatheter aortic valve replacement (TAVR). However, to our knowledge, this has not been studied in the Veterans Affairs (VA) population, a patient population that has not been well studied or represented. The purpose of this study is to determine if HFE following TAVR predicts outcomes in VA patients.

Context-Based Identification of Muscle Invasion Status in Patients With Bladder Cancer Using Natural Language Processing.

Mortality from bladder cancer (BC) increases exponentially once it invades the muscle, with inherent challenges delineating at the population level. We sought to develop and validate a natural language processing (NLP) model for automatically identifying patients with muscle-invasive bladder cancer (MIBC). All patients with a Current Procedural Terminology code for transurethral resection of bladder tumor (TURBT; n = 76,060) were selected from the Department of Veterans Affairs (VA) database. A sample of 600 patients (with 2,337 full-text notes) who had TURBT and confirmed pathology results were selected for NLP model development and validation. The NLP performance was assessed by calculating the sensitivity, specificity, positive predictive value, negative predictive value, F1 score, and overall accuracy at the individual note and patient levels. In the validation cohort, the NLP model had average overall accuracies of 94% and 96% at the note and patient levels. Specifically, the F1 score and overall accuracy for predicting muscle invasion at the patient level were 0.87% and 96%, respectively. The model classified nonmuscle-invasive bladder cancer (NMIBC) with overall accuracies of 90% and 93% at the note and patient levels. When applying the model to 71,200 patients VA-wide, the model classified 13,642 (19%) as having MIBC and 47,595 (66%) as NMIBC and was able to identify invasion status for 96% of patients with TURBT at the population level. Inherent limitations include a relatively small training set, given the size of the VA population. This NLP model, with high accuracy, may be a practical tool for efficiently identifying BC invasion status and aid in population-based BC research.

Impact of Implicit Abdominal Aortic Aneurysm Screening in the Veterans Affairs Health Care System Over 10 Years.

BackgroundAbdominal aortic aneurysm (AAA) screening programs have been active in the United States since 2005, but are not the only way AAAs are detected. AAA management and outcomes have not been investigated broadly in the context of “implicit AAA screening,” whereby radiologic examinations not intended for focused screening can identify AAAs.Methods and ResultsWe examined the association between imaging‐based AAA screening, both explicit and implicit, and various outcomes for ≈1.6 million veterans in the Veterans Affairs health care system from 2005 to 2015. Screened‐positive, screened‐negative, and unscreened veterans were identified in the overall cohort and within a subgroup of veterans aged 65 years in 2005. The yearly composite screening rate increased over 10 years, from 11.7% to 18.3%, whereas the screened‐positive rate decreased from 7.3% to 4.9%. Only 12.9% of screening examinations were explicit AAA screening ultrasounds. The subgroup’s composite screening rate was 74% within its 10‐year eligibility window, with implicit screening accounting for 91.8% of examinations. In the 2005 subgroup, all‐cause mortality and Charlson comorbidity scores were higher for veterans who underwent screening compared with those unscreened (31.2% versus 23.1% and 0.47 versus 0.25, respectively; P<0.001). AAA rupture rates were similar between those unscreened and screened‐negative individuals.ConclusionsAccounting for both explicit and implicit screening, AAA screening in the Veterans Affairs population has moderate reach. Efforts to expand explicit AAA screening are not likely to impact either all‐cause mortality or AAA rupture on the population scale as significantly as a careful accounting for and use of implicit screening data.