Veterans Affairs Settings Research Articles

"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.

Why Veterans Choose VA Versus non-VA Emergency Care: A Qualitative Study.

In ensuring the timely delivery of emergency care to Veterans, Veterans Affairs (VA) offers both emergency care services in its own facilities and, increasingly, purchases care for Veterans in non-VA (community) emergency department (ED) settings. Although in recent years emergency care coverage has become the single largest contributor to VA community care spending, no study to date has examined Veteran decision-making as it relates to ED setting choice. The purpose of this study is to identify and describe reasons why Veterans choose VA versus non-VA emergency care settings. Veterans Health Administration data were used to identify geographically diverse Veterans who recently used emergency care. We conducted semi-structured telephone interviews from December 2018 through March 2020 with 50 Veterans to understand the factors Veterans consider when deciding where to obtain ED care. Interviews were audio-recorded and transcribed verbatim. We conducted a directed content analysis of interview transcripts and developed a matrix to summarize and categorize each Veteran's decision-making process to compare participants and to identify common patterns. When choosing between VA and non-VA-EDs, Veterans described 3 distinct patterns of decision-making: (1) choosing the closest ED (often community) for acute conditions; (2) traveling farther for VA care due to preference and financial coverage; and (3) selecting VA when both types of ED care were equidistant. Perceptions of community resources, condition-specific needs, financial considerations, and personal preferences dominated the decision-making. For example, most Veterans (74%) rated their acuity as high, and self-perceived severity/urgency of their condition was the most cited factor influencing where Veterans decided to go for ED care. Our qualitative results help provide insight into how and why Veterans choose to seek emergency care. As the number of Veterans treated in non-VA EDs continues to rise, VA and non-VA ED providers as well as policy makers may benefit from understanding the challenges Veterans face when making this decision.

The business case for hospital mobility programs in the veterans health care system: Results from multi-hospital implementation of the STRIDE program.

To conduct a business case analysis for Department of Veterans Affairs (VA) program STRIDE (ASsisTed EaRly MobIlization for hospitalizeD older VEterans), which was designed to address immobility for hospitalized older adults. This was a secondary analysis of primary data from a VA 8-hospital implementation trial conducted by the Function and Independence Quality Enhancement Research Initiative (QUERI). In partnership with VA operational partners, we estimated resources needed for program delivery in and out of the VA as well as national implementation facilitation in the VA. A scenario analysis using wage data from the Bureau of Labor Statistics informs implementation decisions outside the VA. This budget impact analysis compared delivery and implementation costs for two implementation strategies (Replicating Effective Programs [REP]+CONNECT and REP-only). To simulate national budget scenarios for implementation, we estimated the number of eligible hospitalizations nationally and varied key parameters (e.g., enrollment rates) to evaluate the impact of uncertainty. Personnel time and implementation outcomes were collected from hospitals (2017-2019). Hospital average daily census and wage data were estimated as of 2022 to improve relevance to future implementation. Average implementation costs were $9450 for REP+CONNECT and $5622 for REP-only; average program delivery costs were less than $30 per participant in both VA and non-VA hospital settings. Number of walks had the most impact on delivery costs and ranged from 1 to 5 walks per participant. In sensitivity analyses, cost increased to $35 per participant if a physical therapist assistant conducts the walks. Among study hospitals, mean enrollment rates were higher among the REP+CONNECT hospitals (12%) than the REP-only hospitals (4%) and VA implementation costs ranged from $66 to $100 per enrolled. STRIDE is a low-cost intervention, and program participation has the biggest impact on the resources needed for delivering STRIDE. ClinicalsTrials.gov NCT03300336. Prospectively registered on 3 October 2017.

Neighborhood Deprivation, Race and Ethnicity, and Prostate Cancer Outcomes Across California Health Care Systems

Non-Hispanic Black (hereafter, Black) individuals experience worse prostate cancer outcomes due to socioeconomic and racial inequities of access to care. Few studies have empirically evaluated these disparities across different health care systems. To describe the racial and ethnic and neighborhood socioeconomic status (nSES) disparities among residents of the same communities who receive prostate cancer care in the US Department of Veterans Affairs (VA) health care system vs other settings. This cohort study obtained data from the VA Central Cancer Registry for veterans with prostate cancer who received care within the VA Greater Los Angeles Healthcare System (VA cohort) and from the California Cancer Registry (CCR) for nonveterans who received care outside the VA setting (CCR cohort). The cohorts consisted of all males with incident prostate cancer who were living within the same US Census tracts. These individuals received care between 2000 and 2018 and were followed up until death from any cause or censoring on December 31, 2018. Data analyses were conducted between September 2022 and December 2023. Health care setting, self-identified race and ethnicity (SIRE), and nSES. The primary outcome was all-cause mortality (ACM). Cox proportional hazards regression models were used to estimate hazard ratios for associations of SIRE and nSES with prostate cancer outcomes in the VA and CCR cohorts. Included in the analysis were 49 461 males with prostate cancer. Of these, 1881 males were in the VA cohort (mean [SD] age, 65.3 [7.7] years; 833 Black individuals [44.3%], 694 non-Hispanic White [hereafter, White] individuals [36.9%], and 354 individuals [18.8%] of other or unknown race). A total of 47 580 individuals were in the CCR cohort (mean [SD] age, 67.0 [9.6] years; 8183 Black individuals [17.2%], 26 206 White individuals [55.1%], and 13 191 individuals [27.8%] of other or unknown race). In the VA cohort, there were no racial disparities observed for metastasis, ACM, or prostate cancer-specific mortality (PCSM). However, in the CCR cohort, the racial disparities were observed for metastasis (adjusted odds ratio [AOR], 1.36; 95% CI, 1.22-1.52), ACM (adjusted hazard ratio [AHR], 1.13; 95% CI, 1.04-1.24), and PCSM (AHR, 1.15; 95% CI, 1.05-1.25). Heterogeneity was observed for the racial disparity in ACM in the VA vs CCR cohorts (AHR, 0.90 [95% CI, 0.76-1.06] vs 1.13 [95% CI, 1.04-1.24]; P = .01). No evidence of nSES disparities was observed for any prostate cancer outcomes in the VA cohort. However, in the CCR cohort, heterogeneity was observed for nSES disparities with ACM (AHR, 0.82; 95% CI, 0.80-0.84; P = .002) and PCSM (AHR, 0.86; 95% CI, 0.82-0.89; P = .007). Results of this study suggest that racial and nSES disparities were wider among patients seeking care outside of the VA health care system. Health systems-related interventions that address access barriers may mitigate racial and socioeconomic disparities in prostate cancer.

Evidence-based treatment for posttraumatic stress disorder decreases suicidal ideation by reducing perceived burdensomeness among veterans in an outpatient program.

Evidenced-based posttraumatic stress disorder (PTSD) treatments generally reduce suicidal ideation (SI), and the interpersonal theory of suicide (ITS) may theoretically account for this finding. The ITS posits that SI stems from feeling like a burden (i.e., perceived burdensomeness) and a lack of belonging (i.e., thwarted belongingness). Previous research suggests that change in PTSD severity has a significant indirect effect on change in SI through changes in perceived burdensomeness, but not thwarted belongingness, among patients receiving residential PTSD treatment in a Veterans Affairs (VA) medical center; however, no research has investigated these associations in an outpatient VA setting with fewer confounding factors that might affect ITS constructs. Therefore, the current sample included veterans (N = 126) who completed PTSD treatment and pre- and posttreatment assessments in a VA outpatient clinic. Results from parallel models of multiple indirect effects suggest that change in PTSD severity was indirectly associated with change in SI through changes in perceived burdensomeness, B = 0.35, p < .001; β = .36, p < .001, SE = .10, 95% CI [.15, .54], but not thwarted belongingness, B = 0.14, p = .146; β = .14, p = .161, SE = .10, 95% CI [-.05, .33]. Additional models were examined using PTSD cluster scores for exploratory purposes. The results indicate that PTSD treatment reduces the perceived and objective burden of PTSD to decrease SI. Study findings support the importance of access to evidence-based care to treat PTSD and alleviate burdensomeness for suicide prevention.

A Qualitative Study of Veterans' Perspectives on Tinnitus: An Invisible Wound.

Tinnitus is highly prevalent among U.S. military Veterans, yet referral to, and use of, tinnitus rehabilitation services to improve quality of life and functional status with tinnitus is low. Veterans with tinnitus often have other health issues that overlap or exacerbate the impact of tinnitus, potentially complicating referral and rehabilitative pathways. This qualitative study explores views on the daily impacts of tinnitus and experiences with tinnitus-related health care among Veterans. The goal of this research is to amplify the voices of Veterans regarding their experiences with tinnitus to illuminate the physiological and socioemotional sequelae associated with the condition and to increase clinician awareness of the complex, interdisciplinary rehabilitative needs among Veterans with bothersome tinnitus. This qualitative study was part of a larger study about tinnitus and traumatic brain injury (TBI). Veterans were sampled to represent national Department of Veterans Affairs (VA) users with and without comorbid TBI, and who were or were not interested in tinnitus rehabilitation services. Forty Veterans with tinnitus were interviewed (32 men, eight women). Data were analyzed using a modified grounded theory approach. Major themes across the Veteran interviews included (a) functional effects of tinnitus on daily life, (b) tinnitus and other health conditions, (c) reactions to the lack of a cure for tinnitus, (d) strategies to improve quality of life and function, and (e) use of VA services for tinnitus. Our findings highlight that bothersome tinnitus negatively impacted various aspects of daily functioning, including communication, sleep, concentration, and mood, suggesting a need for audiologists to work closely with mental health services to improve quality of life and functional status for those negatively impacted by the condition. Future work is needed to obtain the viewpoints of clinicians and other health care partners to better understand the barriers and facilitators to providing evidence-based tinnitus treatment in VA and non-VA settings.

Veterans Affairs Nurses' Perception of a Dignified Death.

A dignified death is described as a good death or dying with dignity. Nurses caring for veterans are aware of the honor veterans can receive at the time of death. The purpose of this study was to describe and compare perceptions of a dignified death in nurses who care for veterans in Veterans Affairs settings. This descriptive, exploratory design used an online survey including scales of dying with dignity and a good death. Subjects were nurses who worked at Veterans Affairs facilities. Dying with dignity scores were high and moderately high for a good death. Good death items of wishes, peace, spirituality, and pain free were considered essential by most nurses. There was no difference in scores based on age or end-of-life experiences. Veterans Affairs nurses had a good perception of a dignified death providing a foundation for veteran support before, during, and after death.

Comparison of guideline concordant antibiotic prophylaxis in Veterans Affairs and non-Veterans Affairs dental settings among those with cardiac conditions or prosthetic joints

BackgroundNo research has been conducted to assess whether antibiotic prophylaxis prescribing differs by dental setting. Therefore, the goal of this study was to compare the prescribing of antibiotic prophylaxis in Veterans Affairs (VA) and non-Veterans Affairs settings.MethodsThis was a retrospective study of veteran and non-veteran dental patients with cardiac conditions or prosthetic joints between 2015–2017. Multivariable log binomial regression analysis was conducted to compare concordant prescribing by setting with a sub-analysis for errors of dosing based on antibiotic duration (i.e., days prescribed).ResultsA total of 61,124 dental visits that received a prophylactic antibiotic were included. Most were male (61.0%), and 55 years of age or older (76.2%). Nearly a third (32.7%) received guideline concordant prophylaxis. VA dental settings had a lower prevalence of guideline concordant prescribing compared to non-VA settings in unadjusted results (unadjusted prevalence ratio [uPR] = 0.92, 95% CI: 0.90–0.95). After adjustment, prevalence of guideline concordant prescribing was higher in those with prosthetic joints in the VA setting (adjusted prevalence ratio [aPR] = 1.73, 95% CI: 1.59–1.88), with no difference identified in those without a prosthetic joint (aPR = 0.99, 95% CI: 0.96–1.01). Concordance of dosing was higher in VA compared to non-VA settings (aPR = 1.11, 95% CI: 1.07–1.15).ConclusionsVA has a higher prevalence of guideline concordant prescribing among those with prosthetic joints and when assessing dosing errors. Though the presence of an integrated electronic health record (EHR) may be contributing to these differences, other system or prescriber-related factors may be responsible. Future studies should focus on to what extent the integrated EHR may be responsible for increased guideline concordant prescribing in the VA setting.

Strategies used by inpatient VA social workers to facilitate their emotional well-being and job retention during the COVID-19 pandemic

The COVID-19 pandemic has created many unprecedented stressors among inpatient social workers. Stressors can impact provider turnover and quality of care to clients. Recent research suggests strategies that social work providers can engage in to facilitate peer support and address individual concerns during the pandemic. The purpose of this study is to explore the presence of nuanced strategies—emotional connectedness and emotional preparedness—that facilitated inpatient social workers’ well-being who retained employment during the pandemic. Researchers conducted thematic analyses of 12 social workers in two US Department of Veterans Affairs (VA) Medical Centers across the US. Sample consisted of (n = 10) females, and (n = 9) who worked in the VA setting for less than two years. Semi-structured qualitative interviews were conducted via Microsoft Teams software since in-person interviews were avoided out of precaution. A priori themes and open coding were applied. Results illustrate social workers endorsed multiple strategies of both emotional connectedness and emotional preparedness. Emerging themes included frustration tolerance and concerns with addressing events that precipitated the pandemic. Physical contact was avoided for fear of infection. Findings demonstrate that engaging in strategies of emotional connectedness and emotional preparedness facilitated social workers’ well-being and job retention. Future research should assess if these strategies are also utilized among outpatient social workers in other settings and roles when delivering crucial social services.

Evidence-based posttraumatic stress disorder treatment in a community sample: Military-affiliated versus civilian patient outcomes.

Posttraumatic stress disorder (PTSD) is a significant mental health issue among military service members and veterans. Although the U.S. Department of Veterans Affairs (VA) provides crucial resources for behavioral health care, many veterans seek mental health services through community clinics. Previous research illustrates that military and veteran patients benefit less from evidence-based treatments (EBTs) for PTSD than civilians. However, most PTSD treatment outcome research on military and veteran populations is conducted in VA or military settings. Little is known about outcomes among military-affiliated patients in community settings. The primary aim of this study was to directly compare civilian versus military-affiliated patient outcomes on PTSD and depression symptoms using the PTSD Checklist for DSM-5 (PCL-5) and the nine-item Patient Health Questionnaire (PHQ-9) in a community setting. Participants (N = 502) included military-affiliated (veteran, Guard/Reservist, active duty) and civilian patients who engaged in cognitive processing therapy (CPT) or prolonged exposure (PE) for PTSD in community clinics. Both groups demonstrated significant reductions on the PCL-5, military-affiliated: d = -0.91, civilian: d = -1.18; and PHQ-9, military-affiliated: d = -0.65, civilian: d = -0.88, following treatment. However, military-affiliated patients demonstrated smaller posttreatment reductions on the PCL-5, Mdiff = 5.75, p = .003, and PHQ-9, Mdiff = 1.71, p = .011, compared to civilians. Results demonstrate that military-affiliated patients benefit from EBTs for PTSD, albeit to a lesser degree than civilians, even in community settings. These findings also highlight the importance of future research on improving EBTs for military personnel with PTSD.

My Life, My Story: Integrating a Life Story Narrative Component Into Medical Student Curricula.

IntroductionMedical students experience burnout, depersonalization, and decreases in empathy throughout medical training. My Life, My Story (MLMS) is a narrative medicine project that aims to combat these adverse outcomes by teaching students to interview patients about their life story, with the goal of improving patient-centered care competencies, such as empathy.MethodsThe MLMS project was started in the Veterans Affairs (VA) system and has since spread to dozens of VA sites. We adapted and integrated this project into the Warren Alpert Medical School of Brown University curriculum. As part of the required curriculum, first- and third-year medical students participated in a life story interview with a community-based volunteer or a patient in the inpatient hospital setting, transcribed the story, and reviewed the written story with the patient. We assessed student perceptions of the project, changes in empathy, and changes in burnout symptoms.ResultsA total of 240 students participated in this project. Students spent an average of 70.7 minutes interviewing patients. A majority of the students believed MLMS was a good use of time (77%), fostered connection with patients (79%), and was effective in recognizing patients’ thoughts and feelings (69%).DiscussionTo our knowledge, this is one of the first life story interview interventions to be implemented into a required medical school curriculum and outside the VA setting. MLMS may assist students in improving clinical empathy skills and create a structure for medical trainees to better understand their patients.

Retrospective Review of Perioperative Multimodal Analgesia for Orthopedic Patients in a Veterans Affairs Setting.

To determine adherence of perioperative knee/hip arthroplasties and hip fracture repairs to the American Pain Society (APS) guideline recommendations for perioperative pain control. One secondary objective was to perform an internal quality audit on the use of enhanced recovery after surgery (ERAS) protocols; another secondary objective was to design an evidence-based, multi-modal perioperative quick-order menu (if warranted). A retrospective quality improvement (QI) review of uncomplicated knee/hip replacement and hip fracture repairs from January 2018 through March 2018. West Palm Beach Veterans Affairs Medical Center (WPB VAMC) including acute care, subacute rehabilitation, and outpatient setting. Analgesic use in the perioperative setting via electronic health record review. Forty-seven patients were retrospectively reviewed. Perioperative multi-modal analgesia was used in 85% of patients. Eighty-seven percent were discharged on multi-modal analgesia. There was a 67% response rate to the internal quality audit on ERAS protocol usage from the orthopedic team. A retrospective QI review completed approximately two years after APS guideline publication showed that compliance with these recommendations for multi-modal analgesia (consisting of the use of at least two medication classes) at the WPB VAMC in the postoperative setting for knee/hip arthroplasties and hip fracture repairs was 85%. This indicated potential for improvement in achieving a pharmacologic multimodal and ERAS intervention. The authors developed an evidence-based quick-order menu to further reinforce adherence to the APS perioperative guidelines.

Clinical yoga program utilization in a large health care system.

The U.S. Department of Veterans Affairs (VA) offers yoga for multiple conditions. Little information is available regarding how frequently yoga is utilized, by whom, or for which medical conditions. Here we describe referral patterns and patient adoption rates in a clinical yoga program, including telehealth yoga, at VA Palo Alto Health Care System (VAPAHCS). Referral and demographic data were extracted from the electronic medical records of 953 veterans (692 male, 261 female) referred to the outpatient clinical yoga program between 2010 and 2016. Attendance data were extracted from the same time plus 1 year. Referee demographics were compared to the overall VAPAHCS population. Twenty-two of the 187 referring providers accounted for half (50.4%) of referrals, predominantly from primary care and mental health clinics. Compared to the overall VAPAHCS patient population, referees were similar age and more likely to be female. Attendance was associated with age (older veterans were more likely to attend) but not gender. Those referred for mental health reasons were more likely to attend yoga compared to those referred for physical symptoms or for wellness (e.g., strength, health, mindfulness). Telehealth yoga follow through was lower but attendance rate similar to in-person yoga. These data provide an overview of referral and uptake in a large VA setting. Overall, referral was performed by a few providers in mental health and primary care clinics. The typical demographic of attendee was a White male from the Vietnam War era, reflective of the VA population. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Preventing Suicide Among Homeless Veterans: A Consensus Statement by the Veterans Affairs Suicide Prevention Among Veterans Experiencing Homelessness Workgroup.

Preventing Suicide Among Homeless Veterans: A Consensus Statement by the Veterans Affairs Suicide Prevention Among Veterans Experiencing Homelessness Workgroup.

Survey of prescriptive authority among psychiatric pharmacists in the United States.

IntroductionDespite the high prevalence of those with mental illnesses, there is a critical shortage of psychiatric providers in the United States. Psychiatric pharmacists are valuable members of the health care team who meet patient care needs, especially those practicing with prescriptive authority (PA).MethodsA cross-sectional electronic survey was administered to Board Certified Psychiatric Pharmacists (BCPPs) and non-BCPP members of the College of Psychiatric and Neurologic Pharmacists. The objective of this study was to compare demographic and practice characteristics between respondents with and without PA.ResultsOf the 334 respondents, 155 (46.4%) reported having PA. Those with PA, including those with Veterans Affairs (VA) affiliated PA, had fewer mean number of years of licensure than those without PA (P = .008 and P = .007, respectively). The majority with PA practiced in outpatient settings (53.5%). Respondents with PA (including those with VA-affiliated PA) were more likely to have their positions funded by practice sites (P < .001). The most common referral source for medication management for those with PA were physicians although pharmacists also provided referrals in both VA and non-VA settings. Pharmacists with PA were more likely to track practice outcomes versus those without PA (P < .001).DiscussionThe current study confirms the variability in PA among psychiatric pharmacists. Demographics of the respondents reflect changes in residency accreditation and increased numbers of psychiatric residencies within VA facilities. Psychiatric pharmacists with PA reported treating psychiatric and medical conditions, creating added value. Psychiatric pharmacists should be empowered to track outcomes and help meet the critical shortage of psychiatric providers.

Minimizing Opioids After Joint Operation: Protocol to Decrease Postoperative Opioid Use After Primary Total Knee Arthroplasty.

For decades, opioids have been the mainstay in pain management after total joint arthroplasty despite evidence that their use should be curtailed. To limit unnecessary prescribing of opioids, the US Department of Veterans Affairs (VA) Portland Health Care System Total Joints Service implemented the Minimizing Opioids After Joint Operation (MOJO) postoperative pain protocol in 2018 to reduce opioid use following total knee arthroplasty (TKA). This protocol included reductions of inpatient and outpatient opioid prescribing, preoperative optimization, use of perioperative nerve blocks, and surgery without a tourniquet. We performed a retrospective chart review that compared the first 20 consecutive patients undergoing TKA using the MOJO protocol with the last 20 patients using the prior routine. Outcomes included total inpatient opioid use, daily opioid use, emergency department (ED) visits or readmissions within 90 days, phone calls for pain or medication refills, length of stay (LOS), and pain during inpatient hospital stay. There were significant differences between the pre-MOJO and the MOJO groups with regard to daily inpatient morphine equivalent dose (MED) (82 mg vs 31 mg, P < .01) and total inpatient MEDs (306 mg vs 33 mg, P < .01). There was less self-reported pain on postoperative day 1 in the MOJO group (5.5 vs 4.1, P = .01), decreased LOS (4.4 days vs 1.1 days, P < .01), fewer total ED visits (6 vs 2, P < .07), and fewer discharges to skilled nursing facilities (12 vs 0, P < .01). The MOJO protocol reduced postoperative opioid use after TKA in the VA setting without compromising pain control or increasing ED visits. The framework and routines described are potentially applicable to other institutions and surgical specialties.

A Mixed Methods Study of the Association of Non-Veterans Affairs Care With Veterans' and Clinicians' Experiences of Care Coordination.

Poor coordination between the Department of Veterans Affairs (VA) and non-VA care may negatively impact health care quality. Recent legislation is intended to increase Veterans' access to care, in part through increased use of non-VA care. However, a possible consequence may be diminished patient experiences of coordination. The objective of this study was to determine VA patients' and clinicians' experiences of coordination across VA and non-VA settings. Observational mixed methods using patient surveys and clinician interviews. Sampled patients were diagnosed with type 2 diabetes mellitus and either cardiovascular or mental health comorbidities. Patient perspectives on coordination were elicited between April and September 2016 through a national survey supplemented with VA administrative records (N=5372). Coordination was measured with the 8-dimension Patient Perceptions of Integrated Care survey. Receipt of non-VA care was measured through patient self-report. Clinician perspectives were elicited through individual interviews (N=100) between May and October 2017. Veterans who received both VA and non-VA care reported significantly worse care coordination experiences than Veterans who only receive care in VA. Clinicians report limited information exchange capabilities, which, combined with bureaucratic and opaque procedures, adversely impact clinical decision-making. VA is working through a shift in how Veterans receive health care by increasing access to care from non-VA providers. Study findings suggest that VA should prioritize coordination of care in addition to access. This could include requiring monitoring of patient-experienced care coordination, surveys of referring and consulting clinicians, and pilot testing and evaluation of interventions to improve coordination.

Patient Perceptions of Video Visits Using Veterans Affairs Telehealth Tablets: Survey Study.

BackgroundVideo-based health care can help address access gaps for patients and is rapidly being offered by health care organizations. However, patients who lack access to technology may be left behind in these initiatives. In 2016, the US Department of Veterans Affairs (VA) began distributing video-enabled tablets to provide video visits to veterans with health care access barriers.ObjectiveThis study aimed to evaluate veterans’ experiences with VA-issued tablets and identify patient characteristics associated with preferences for video visits vs in-person care.MethodsA baseline survey was sent to the tablet recipients, and a follow-up survey was sent to the respondents 3 to 6 months later. Multivariate logistic regression was used to identify patient characteristics associated with preferences for care, and we examined qualitative themes around care preferences using standard content analysis methods for coding the data collected in the open-ended questions.ResultsPatient-reported access barriers centered around transportation and health-related challenges, outside commitments, and feeling uncomfortable or uneasy at the VA. Satisfaction with the tablet program was high, and in the follow-up survey, approximately two-thirds of tablet recipients preferred care via a tablet (194/604, 32.1%) or expressed that video-based and in-person care were “about the same” (216/604, 35.7%), whereas one-third (192/604, 31.7%) indicated a preference for in-person care. Patients were significantly more likely to report a preference for video visits (vs a preference for in-person visits or rating them “about the same”) if they felt uncomfortable in a VA setting, reported a collaborative communication style with their doctor, had a substance use disorder diagnosis, or lived in a place with better broadband coverage. Patients were less likely to report a preference for video visits if they had more chronic conditions. Qualitative analyses identified four themes related to preferences for video-based care: perceived improvements in access to care, perceived differential quality of care, feasibility of obtaining necessary care, and technology-related challenges.ConclusionsMany recipients of VA-issued tablets report that video care is equivalent to or preferred to in-person care. Results may inform efforts to identify good candidates for virtual care and interventions to support individuals who experience technical challenges.

The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS).

High-quality medication reconciliation reduces medication discrepancies, but smaller hospitals serving rural patients may have difficulty implementing this because of limited resources. We sought to adapt and implement an evidence-based toolkit of best practices for medication reconciliation in smaller hospitals, evaluate the effect on unintentional medication discrepancies, and assess facilitators and barriers to implementation. We conducted a 2-year mentored-implementation quality improvement feasibility study in 3 Veterans Affairs (VA) hospitals serving rural patients. The primary outcome was unintentional medication discrepancies per medication per patient, determined by comparing the "gold standard" preadmission medication history to the documented preadmission medication list and admission and discharge orders. In total, 797 patients were included; their average age was 68.7 years, 94.4% were male, and they were prescribed an average of 9.6 medications. Sites 2 and 3 implemented toolkit interventions, including clarifying roles among clinical personnel, educating providers on taking a best possible medication history, and hiring pharmacy professionals to obtain a best possible medication history and perform discharge medication reconciliation. Site 1 did not implement an intervention. Discrepancies improved in intervention patients compared with controls at Site 3 (adjusted incidence rate ratio [IRR], 0.55; 95% confidence interval [CI], 0.45-0.67) but increased in intervention patients compared with controls at Site 2 (adjusted IRR, 1.22; 95% CI, 1.08-1.36). An evidence-based toolkit for medication reconciliation adapted to the VA setting was adopted in 2 of 3 small, rural, resource-limited hospitals, resulting in both reduced and increased unintentional medication discrepancies. We highlight facilitators and barriers to implementing evidence-based medication reconciliation in smaller hospitals.

Cognitive Processing Therapy for Posttraumatic Stress Disorder Is Associated with Negligible Change in Subjective and Objective Sleep

ABSTRACT Background: Patients receiving Cognitive Processing Therapy (CPT), an evidence based therapy for posttraumatic stress disorder (PTSD), report improved sleep quality. However, the majority of studies have examined residual sleep disturbance via self-report surveys or separate items on PTSD measures. This study examined whether CPT delivered to veterans in a VA setting improved sleep indices using state-of-the-art objective and subjective insomnia measures. Participants: Participants were war veterans with a current PTSD diagnosis scheduled to begin outpatient individual or group CPT at two Veteran’s Affairs (VA) locations (n = 37). Methods: Sleep symptom severity was assessed using the recommended research consensus insomnia assessment, the consensus daily sleep diary and actigraphy. PTSD symptomatology pre- and post-treatment were assessed using the Clinician Administered PTSD Scale. Results: A small to moderate benefit was observed for the change in PTSD symptoms across treatment (ESRMC = .43). Effect sizes for changes on daily sleep diary and actigraphy variables after CPT were found to be negligible (Range ESRMC = − .16 to .17). Sleep indices remained at symptomatic clinical levels post-treatment. Discussion: These findings support previous research demonstrating a need for independent clinical attention to address insomnia either before, during, or after PTSD treatment.