Veterans Affairs Research Articles (Page 1)

Postoperative red blood cell transfusion guidelines recommend transfusion for hemoglobin levels less than 7 g/dL. However, the safety of this strategy in patients at high risk of cardiac events undergoing major operations remains unclear. To evaluate the risk of death or major ischemic events within 90 days after a liberal transfusion strategy compared with a restrictive transfusion strategy in patients at high risk of cardiac events who had undergone major vascular or general surgery operations and developed postoperative anemia. This parallel, single-blind, randomized clinical superiority trial included 1428 veterans (≥18 y) at high cardiac risk undergoing major vascular or general surgery operations. Participants were enrolled from February 2018 to March 2023 across 16 Veterans Affairs Medical Centers in the US. Seven hundred fourteen participants with postoperative hemoglobin less than 10 g/dL were randomized to a liberal strategy (transfusion trigger at hemoglobin level <10 g/dL) and 714 to a restrictive strategy (transfusion trigger at hemoglobin <7 g/dL). The primary end point was a composite of all-cause death, myocardial infarction, coronary revascularization, acute kidney failure, or ischemic stroke within 90 days after randomization. Secondary end points included a composite of cardiac complications other than myocardial infarction (arrhythmias, heart failure, and nonfatal cardiac arrest). Of the 1424 analyzed veterans (mean age, 69.9 [SD, 7.9] years; 1393 male [97.8%]; 268 Black [18.8%]; 48 Hispanic [4.1%]; 1071 White [75.2%]), 1297 (91.1%) underwent vascular surgical procedures. The mean hemoglobin difference between transfusion strategies was 2.0 g/dL on day 5 after randomization. The primary outcome rate in the liberal group was 9.1% (61 of 670) compared with 10.1% (71 of 700) in the restrictive group (relative risk, 0.90; 95% CI, 0.65-1.24). The secondary end point of cardiac complications without myocardial infarction, which was 1 of 5 secondary end points, occurred in 5.9% (38 of 647) of patients in the liberal group and 9.9% (67 of 678) of patients in the restrictive group (relative risk, 0.59; 99% CI, 0.36-0.98). After major vascular or general surgery operations among patients at high risk of a cardiac event, a liberal transfusion strategy did not reduce 90-day death or major ischemic outcome rates compared with a restrictive strategy. ClinicalTrials.gov Identifier: NCT03229941.

Meaningful engagement of patients in the research process is a growing component of learning health systems; however, few studies have examined efforts to facilitate or foster patient-engaged research among large healthcare organizations. To describe patient engagement activities and infrastructure among the seven national research networks funded by US Veterans Affairs (VA) Health Systems Research (HSR). We conducted an environmental scan comprised of (1) structured searches of peer-reviewed publications and other publicly available documents and (2) qualitative, semi-structured group interviews with VA HSR research network representatives. Staff and leaders with knowledge of their research network's engagement-related activities. We used principles of thematic analysis and content analysis to code and categorize networks' engagement activities and key considerations identified through the environmental scan. We identified 129 discrete engagement-related activities across the seven VA HSR research networks in three domains of (1) facilitating patient-engaged research, (2) network engagement infrastructure, and (3) building and maintaining relationships with partners. The number and types of reported activities varied across the networks. All five networks with a current or planned patient engagement group budgeted for staff effort and patient compensation, and offered patient engagement services that spanned research and care implementation projects. We identified five themes essential to engagement infrastructure (supportive network environment; team environment and relationship building; patient engagement group characteristics; flexibility and adaptability; and efficiency). This work documents patient engagement activities and infrastructure among seven VA-funded national research networks within VA's integrated learning health system. Network representatives' experiences highlight important considerations for developing and sustaining patient engagement infrastructure. Future research is needed to examine quality, outcomes, and costs of patient engagement services within different contexts, and how this infrastructure could best be deployed to meaningfully incorporate patient perspectives across learning health system improvement cycles.

Long COVID is common and includes nervous system-related symptoms (e.g., autonomic dysfunction, cognitive impairment, fatigue, and pain). We sought to develop just-in-time evidence-informed guidance for nervous system-related Long COVID, a condition for which mature evidence is limited. The U.S. Veterans Affairs (VA) Veterans Health Administration (VHA) Long COVID Field Advisory Board commissioned an expert panel that worked with a GRADE methodologist to develop an evidence-to-decision framework for emergent conditions by applying core elements of the Standards for Developing Trustworthy Clinical Practice Guidelines and those of GRADE. We also convened a multidisciplinary writing group that identified a list of clinically relevant questions and commissioned an independent review and synthesis of existing evidence. The writing group conducted structured discussions and used this evidence base to make recommendations for evaluation and treatment ("Evidence-informed Recommendations"). For history-taking, physical exam, and commonly used, noninvasive diagnostic tests, statements were based on consensus determinations of useful and safe care ("Good Practice Statements"). We used a Whole Health Systems approach to support the development of guidance that was patient-centered, culturally appropriate, and available regardless of literacy or disability. Feedback was solicited from Veterans and other stakeholders. Where the published literature was insufficient, we used evidence from treatment of similar conditions. We drafted 30 Evidence-informed Recommendations and 41 Good Practice Statements for nervous system-related Long COVID in Veterans and disseminated them VA-wide, targeting specialty care providers. More research on the effectiveness of diagnostic and therapeutic interventions is needed. In particular, evidence "borrowed" from other conditions and populations should be replaced or supplemented by evidence in Long COVID. Clinical guidance should be updated as this evidence becomes available. QUESTION: How can clinicians provide evidence-informed care for nervous system-related Long COVID (e.g., autonomic dysfunction, cognitive impairment, fatigue, and pain)? We commissioned an independent rapid evidence review whichfound that evidence supporting the care of nervous system-related Long COVID symptoms was limited. Using available evidence and other considerations (e.g., costs, equity, and applicability to Veterans experiencing Long COVID), we drafted 30 Evidence-informed Recommendations and 41 Good Practice Statements for nervous system-related Long COVID. Although mature evidence was limited, this guidance can provide a framework for clinicians caring for patients with nervous system-related Long COVID. More research on the effectiveness of diagnostic and therapeutic interventions in Long COVID is needed.

Federal agencies including the National Institutes of Health (NIH), the Department of Defense (DoD) Congressionally Directed Medical Research Program (CDMRP) Spinal Cord Injury Research Program (SCIRP), and the Department of Veterans Affairs (VA) provide the majority of funding for spinal cord injury (SCI) research in the United States. However, systematic evaluation of how funding is distributed across research areas, therapeutic approaches, and translational stages has been limited. To understand the distribution of funds, we curated and classified 1,589 federally funded SCI research awards from the NIH (2008-2023), the CDMRP SCIRP (2009-2023), and the VA (2017-2025). Each award was annotated based on the biological system or problem studied, the therapeutic intervention or approach utilized, and its placement along the translational continuum. Our analysis revealed that the NIH predominantly supports basic and early-stage translational research, especially in areas of SCI pathology, regeneration, and motor functional recovery. In contrast, the CDMRP funding is more concentrated on applied and clinical research, particularly in the areas of pain, bladder function, and neuromodulatory device development. The VA predominantly invests in rehabilitation-focused studies and interventions aimed at improving musculoskeletal and functional health outcomes. While the complementary missions of these agencies collectively support a diverse SCI research ecosystem, we identified critical gaps in funding for high-priority areas such as bowel/gastrointestinal health, cardiovascular function, and mental health. Furthermore, the recent discontinuation of the CDMRP SCIRP and proposed NIH budget reductions are projected to lead to an approximate 50% decline in federal SCI research funding by 2026-posing a substantial risk to the field's progress and threatening the stability of this ecosystem. These findings underscore the urgent need for coordinated, data-driven funding strategies that align more closely with the needs and priorities of the SCI community. To that end, we propose the development of a publicly accessible "living dashboard" to enhance transparency, foster interdisciplinary collaboration, and guide strategic investment in SCI research moving forward.

Hypertension treatment advances have resulted in improvements in blood pressure control and self-management. Yet, disparities persist for Black veterans. To examine the impact of a narrative-informed texting intervention with educational content and bidirectional text messaging on blood pressure and hypertension self-management. This nonblinded, 2-arm randomized clinical trial recruited participants from March 2021 to July 2022 at 2 Veterans Affairs (VA) medical centers (1 in Chicago, Illinois, and 1 in Philadelphia, Pennsylvania); follow-up was completed in May 2023. Participants were Black veterans with at least 1 medication for hypertension, with oversampling of female veterans. Participants were randomly assigned to the intervention arm or control arm. Data analysis was based on the intention-to-treat principle. Those assigned to the intervention group received the Continuing the Conversation intervention, which involved watching 5 videos (5-7 minutes each) of Black veterans sharing stories of their challenges and successes with managing hypertension. Participants selected a favorite storyteller and were enrolled in a 6-month texting protocol wherein they received 3 types of text messages: narrative (quotations from storytellers), educational, and bidirectional. The comparison or control arm received 6 months of bidirectional text messages (BTMs) only. Change in systolic and diastolic blood pressure from baseline to 6-month follow-up was the primary outcome. Secondary outcomes included change in self-reported hypertension management activities (medication adherence, diet, physical activity). All outcomes were prespecified. Difference-in-differences (DID) regression models assessed whether the intervention arm had a 6-month improvement larger than that in the control arm. Engagement (6-month response rates to BTMs) and motivation of participants were also evaluated. Of the 600 Black veterans enrolled (469 males [78.7%]; mean [SD] age, 64.0 [9.1] years), 516 veterans (86.0%; 262 in intervention arm, 254 in control arm) completed the 6-month follow-up. There was no significant difference between arms in mean change of systolic (DID, -0.8 mm Hg; 95% CI, -3.9 to 2.3 mm Hg; P = .62) or diastolic (DID, 0.4 mm Hg; 95% CI, -1.6 to 2.4 mm Hg; P = .70) blood pressure or in secondary outcomes. Mean systolic (-2.1 mm Hg; 95% CI, -3.7 to -0.6 mm Hg; P = .006) and diastolic (-1.8 mm Hg; 95% CI, -2.8 to -0.8 mm Hg; P = .001) blood pressure measurements decreased significantly for the entire cohort. In the intervention arm, 221 of 239 participants (92.5%) agreed with the statement: "I could identify with the Veteran in the video." Across both arms, the response rate to BTMs was 57.5% (11 427 of 19 875 possible opportunities to respond), and 60.7% (10 564 of 17 407 possible opportunities to respond) among those completing follow-up. Of 516 veterans, 410 (79.5%) described text messages as helpful motivators for improving health. In this randomized clinical trial of video stories followed by narrative, educational, and BTMs to support hypertension self-management, this intervention did not improve blood pressure compared with receiving BTMs alone. Text messages supported engagement and enhanced motivation for Black veterans. ClinicalTrials.gov Identifier: NCT03970590.

To provide a comprehensive bibliometric analysis of global research on nystagmus from 1980 to 2024, highlighting key contributors, evolving themes, collaborative patterns, and future directions. A total of 2,570 English-language articles and reviews with "nystagmus" in the title were retrieved from the Web of Science Core Collection. Data were analyzed using VOSviewer, CiteSpace, and Microsoft Excel. Trends in publication output, citation impact, keyword evolution, and co-authorship were examined. Mann-Kendall trend tests and linear regression were used to assess changes over time. Nystagmus research has increased steadily since 1980, with a significant surge after 2010 and peak output in 2021 (τ = 0.3509, P < .001). The United States led in publications (32.18%) and centrality (0.52), followed by Japan and England. Among 1,999 contributing institutions, the U.S. Department of Veterans Affairs and Case Western Reserve University were most productive. Authors such as Louis F. Dell'Osso, Irene Gottlob, and Ji-Soo Kim were prominent. Keyword clustering identified 10 thematic domains, with recent hotspots including infantile nystagmus, FRMD7 mutations, and optical coherence tomography. Citation burst analysis revealed both historic and emerging influential authors and topics. This is the first study to systematically map the intellectual structure of nystagmus research over four decades. Findings underscore increasing academic attention, but also reveal fragmented collaboration and underrepresentation of low- and middle-income countries. Future efforts should promote global partnerships and integration of artificial intelligence, imaging, and genetics to advance diagnosis and management of nystagmus.

Introduction: The VA New York Harbor Healthcare System (NYHHS) is one of 50 VA sites participating in a national quality improvement initiative called the VA Lipid Optimization Reimagined Quality Improvement Project (VALOR-QI). VALOR-QI is a collaborative project between the U.S. Department of Veterans Affairs (VA) and the American Heart Association (AHA) with the goal of positively impacting Veterans’ cardiovascular (CV) health. As part of the program, VA sites work with an AHA QI Consultant to develop and deploy a local QI plan to help overcome site specific barriers preventing Veterans from achieving optimal cholesterol levels (LDL-C). Aims: To develop, implement, and evaluate a personalized approach for Veterans with ASCVD to achieve LDL-C control (&lt;70 mg/dL). Methods: Health Coaches (HCs) used feedback from primary care, cardiology, geriatrics, endocrinology, and neurology providers; the literature; and local system knowledge to refine and develop enrollment plans and tiered intervention strategies (Fig 1). HCs used motivational interviewing (MI) to coach on medication routines, lifestyle habits, and LDL-C literacy. Using medication possession ratio (MPR) to assess adherence, HCs tailored coaching with MI and made pharmacy referrals (if MPR&lt;0.8) or suggested medication intensification (if MPR≥0.8). We compared baseline and follow-up data to evaluate LDL-C lowering (Wilcoxon Signed-Rank and Kruskal-Wallis tests) and LDL-C control (Binomial tests and Fisher’s Exact tests). Results: We enrolled 152 Veterans. Median age was 74 years, 144 (94.7%) were male, 64 (42.1%) had DM, 141 (92.8%) had HTN, and 48 (31.6%) had BMI&gt;30. At baseline, 88 (57.9%) had 70 mg/dL≤LDL-C&lt;100 mg/dL, 63 (41.4%) had LDL-C≥100 mg/dL, and 1 (0.7%) had no data in the last year. Median baseline LDL-C was 92.0 mg/dL; follow-up 76.0 mg/dL. Mean change in LDL-C from baseline was -22.7 mg/dL (Wilcoxon Signed Rank test p&lt;0.001). The proportion with LDL-C&lt;70 mg/dL was 42.6%, higher than the benchmark goal of 30% (Binomial test p=0.001). All specialties, except geriatrics, had significant LDL-C lowering (Fig 2) and exceeded the 30% goal (Fig 3). LDL-C control rates did not statistically differ by specialty (Fisher’s Exact test p=0.091). Conclusions: HC interventions optimized lipids in Veterans with ASCVD. Medication adherence was the greatest challenge to lipid lowering on a patient-level. Lack of provider consensus on LDL-C target, especially in geriatrics, was the main system-level barrier.

Telehealth can improve glycemic control for patients with type 2 diabetes (T2D), but programs must be designed in a manner that facilitates real-world uptake and effectiveness within learning health systems (LHS). To highlight how the Veterans Affairs (VA) LHS supports real-world practice change by examining Advanced Comprehensive Diabetes Care (ACDC), a telehealth program for persistently poor T2D control, in the context of the Learning Health System Consolidated Framework (LHS-CF) taxonomy. Evaluation of program implementation within an LHS. N = 1154 real-world ACDC participants INTERVENTIONS: ACDC is a 6-month program that leverages widely available VA telehealth infrastructure to deliver telemonitoring, self-management support, and medication management. In applying the LHS-CF, we accessed clinical hemoglobin A1c (HbA1c) data, examined ACDC encounter completion, and interviewed participants and staff. ACDC's development benefited from LHS-CF Enabling Conditions, including a workforce prepared to engage in structured learning and quality improvement; well-developed clinical data systems; strong VA investments in innovation; and a collaborative culture. Consequently, ACDC has contributed to multiple LHS-CF-aligned Bodies of Work, including building new evidence to improve T2D outcomes; translation of effective, telehealth-based T2D care into practice; authentic engagement of partners; ongoing analyses of data to support effective care; and development of new approaches to foster innovation and improvement. In practice, ACDC has reduced HbA1c from 9.7% at baseline to 8.0% at 6months (-1.7%, 95% CI -1.7, -1.6, p < 0.0001), with retention of this benefit at 4years; the program has been delivered with good fidelity and has been valued by participants and staff. The conditions created by VA's LHS facilitate the development, testing, and implementation of programs like ACDC, which promote further LHS success. As a result of its intentional development within VA's LHS, ACDC is well-positioned to improve outcomes for Veterans with poorly controlled T2D nationwide.

Introduction: Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in male service members and veterans. This study assessed the 10-year ASCVD risk in male military service members and veterans using the model construct of the VA women CVD risk score and the 2013 ACC/AHA ASCVD risk calculator using direct military health system and Veterans Affairs (VA) Electronic Health Records (EHR) data extracted from national VA corporate data warehouse (CDW) database. Research hypothesis: Military exposure at earlier life may lead to poorer health and ultimately decreased longevity. We hypothesize that military services in earlier life may alter aging trajectory and ASCVD risk—elevated risk of ASCVD events at a younger age than 40. Methods: We retrospectively followed 3.6 million Non-Hispanic (N-H) White (n=2,823,446) and Black (n=734,940) male military service members aged 20-79 from 2012 to 2024 (development cohort). Risk factors and ASCVD events (non-fatal myocardial infarction, non-fatal stroke, cardiac arrests, and cardiac deaths) were identified using diagnostic and procedural codes from Electronic Health Records (EHR) data. Following the same constructs of the VA women CVD risk score and the 2013 ACC/AHA ASCVD risk calculators, coefficients for risk factors were estimated for men by applying time-varying Cox models to the study male development cohort data. Results: N-H Black male service members, on average 3 years younger than their white counterparts, had significantly higher systolic blood pressure, total cholesterol, HDL-C, and were more likely to be treated with anti-hypertensive medications (Tables 1 and 2). We found a log-linear association of aging with increased risk of 10-year ASCVD event in military service male members starting at ages as young as 20 years old (Figure 1.A.) across both N-H White and Black groups in contrast with the ACC/AHA ASCVD risk score (Figure 1.B.). The VA CVD risk model performed well in predicting ASCVD events at 10 years for men (C statistics N-H White 0.72 and N-H Black 0.71), while the ACC/AHA ASCVD risk calculator showed a moderate performance (C statistics N-H White 0.69; N-H Black 0.69). Conclusions: Our results point to a log-linear association of aging with increased ASCVD risk in military males starting at age 20. We call to action the need to create a better cardiovascular risk calculator that adequately assesses young male (&lt;40 years old) military service members’ ASCVD risk.

Introduction: Uncontrolled lipid levels significantly contribute to recurrent cardiovascular events and atherosclerotic cardiovascular disease (ASCVD) progression, resulting in increased morbidity and mortality. In the Veterans Affairs (VA) system, more than 65% of Veterans with ASCVD are poorly managed due to: clinical inertia, patient preferences, and outdated therapies. To improve lipid management and medication adherence, healthcare providers and pharmacists need to collaborate. The VA Caribbean Healthcare System (VACHS) is one of 50 VA sites participating in a national quality improvement initiative called the VA Lipid Optimization Reimagined Quality Improvement Program (VALOR-QI). This is a collaborative project between the U.S. Department of Veterans Affairs and the American Heart Association (AHA) and aims to impact Veterans’ cardiovascular health positively. VA sites work with an AHA QI consultant to develop and implement local quality improvement plans that address specific barriers preventing Veterans from achieving optimal cholesterol levels. Methodology: At VACHS, a comprehensive care model was adopted, focusing on guideline-directed therapy using high-intensity statins and combination treatment for Veterans aged ≥18 years with ASCVD and LDL-C ≥70 mg/dL or non-HDL-C ≥100 mg/dL. Veterans identified as non-adherent to cholesterol-lowering medications were referred to a cardiology pharmacist for targeted education, refill assistance, adherence support, and follow-up laboratory testing 12 weeks after therapeutic optimization. A healthcare coach reinforced this approach by coordinating medication refills, clinical reminders, appointments, and continuous patient engagement. Results: This analysis includes 322 Veterans stratified by pharmacist involvement. Veterans followed by the PharmD (n=185) had a mean baseline LDL-C of 114 mg/dL, compared to 101 mg/dL in those not followed (n=137). The PharmD group had 85% of Veterans that reached the target versus 68% in the not followed group (P&lt;0.0001). Veterans followed by the PharmD are 71% compliant versus 54% (P&lt;0.0001). Conclusions: These findings underscore the critical importance of multidisciplinary clinical engagement, particularly the pharmacist’s role in achieving and maintaining lipid goals, improving long-term adherence, reducing the overall burden of ASCVD and supporting the role of pharmacist integration in chronic disease management programs to optimize ASCVD outcomes.

This commentary presents the five principles of a sustained efficiency model proven to be effective for partnering with operational and clinical partners in rigorous and rapid evaluations, utilizing a case study to demonstrate the efficacy of the model in use in a congressionally mandated Veterans Health Administration staffing evaluation initiative. The Veterans Affairs (VA) system faces increasing demands for timely, evidence-based decision making to enhance efficiency while maintaining high-quality care. To address these needs, the StrAtegic PoLicy EvIdence-Based Evaluation Center (SALIENT) developed a Sustained Efficiency Model grounded in implementation science and applied it in a congressionally mandated Specialty Care workforce evaluation. Our model integrates five interdependent principles: (1) proactive collaborative interdisciplinary partnerships that unite operational leaders, researchers, and stakeholders to enable rapid course corrections, (2) multi-level theoretical modeling that combines Lean Six Sigma, Human-Centered Design, and QUERI implementation frameworks to identify determinants of change, (3) systematic processes and strategies, as well as tailored applications and templates, (4) triangulating mixed-methods data and integrating diverse perspectives to enhance the rigor of analysis and offer real-time knowledge translation, and (5) progressive rapid iterative reporting to deliver timely findings to policy makers and congressional partners. The model's utility was demonstrated in the VA's SALIENT Staffing Project, which informed VA workforce guidelines required by the Honoring our PACT Act of 2022. Via close coordination with the Partnered Evidence-Based Policy Resource Center, the team collected and analyzed qualitative and quantitative data on an accelerated timeline, producing high-quality and relevant recommendations.

Introduction: Cardiometabolic risk factors remain the leading cause of cardiovascular disease (CVD) and death in the US. US women veterans (WV) are a growing, high-risk population with higher rates of chronic conditions and increasing engagement with veteran affair (VA) healthcare yet remain understudied. Objectives: This study aimed to investigate the potential ethnic/racial and age group differences in the life-long prevalence of traditional cardiometabolic risk factors among US WV from 2000-2019. Methods: The national VA electronic health records (her) were used to assess the prevalence of diabetes, hypertension, hyperlipidemia, smoking, and neuroendocrine disorders among US WV who visited a VA facility from 1/1/2000 to 12/31/2019. Diagnoses were based on international classification of disease (ICD)-9 and -10 codes. Participants were stratified by races/ethnicities (non-Hispanic White, Black, Asian, American Indian/Pacific Islander, and Hispanic/Latino) and age group (18-39, 40-59, 60+). Age-standardized lifelong prevalence of CVD risk factors was assessed overall, by races/ethnicities, and by age groups. Age-standardized lifelong prevalence represents the sum of raw age-specific risk factor rates multiplying the standard age-specific proportion in the 2000 U.S. census reference population Results: The WV cohort expanded from 80,707 in 2000 to 739,309 in 2019. Significant racial/ethnic disparities emerged. Blacks demonstrated the highest prevalence of diabetes (from 13.5% to 19.2%) and hypertension (38.2% to 43.9%). Notably, American Islanders showed the most rapid escalation in diabetes (1.9-fold increase). Whites maintained the highest prevalence of smoking, hyperlipidemia, and neuroendocrine disorders. Asians experienced a 9.6-fold surge in smoking (3.8% to 36.5%), while Black saw a 3.1-fold rise in hyperlipidemia (11.5% to 35.8%) and a 3.1-fold rise in neuroendocrine disorders. The remaining subgroups exhibited absolute prevalence increases of approximately 40% for smoking and 20% for hyperlipidemia. Marked age-related patterns also emerged. The 60+ age group had the highest prevalence of risk factors from 2000-2019, except smoking. This group also exhibited the greatest fold increases in every category except hypertension. Conclusion: The cardiometabolic risk burden among U.S. women veterans has reached critical levels, with pronounced racial/ethnic and age group disparities, necessitating immediate targeted public health interventions.

Introduction: Quality improvement interventions may seek to identify positive and negative outlier clinicians to promote practice change. We sought to assess variability in performance metric achievement by clinician and patient characteristics in the Veterans Affairs (VA) Health System. Methods: We assessed performance measure achievement for cardiology clinicians with at least 50 annual outpatient encounters from 2017-2023 in the VA. We evaluated a composite performance metric of ten measures of guideline-directed medical therapies for coronary artery disease (CAD), heart failure with reduced ejection fraction (HFrEF), and atrial fibrillation or flutter with elevated stroke risk (AF). This opportunity composite was calculated as the proportion of times each applicable measure was achieved divided by the number of eligible encounters for each clinician. Data on clinician demographics, patient demographics, and patient diagnoses codes were collected. Clinician performance was considered a “low-outlier” or “high-outlier” if it was more than 2 standard deviations below or above the mean achievement, respectively, using a funnel plot that accounts for case volume. Results: Of 715,608 unique encounters, there were 312,331 CAD, 224,599 HFrEF, and 178,678 AF encounters. Of 1,043 clinicians, 53.1% were physicians, 9.3% were physician assistants (PA), and 37.6% were nurse practitioners (NP); 51.0% were female. Clinicians were 71.5% White, 19.4% Asian, 5.8% Black, 0.7% Native, and 2.6% unknown race. Clinicians achieved a mean composite measure achievement of 0.65 with outlier status varying by patient volume (Figure) . Low-outlier clinicians cared for patients with a greater number of cardiac diagnoses compared with non-outliers (Table) . In contrast, high-outliers cared for a higher proportion of patients with HF and patients who were Black, Hispanic, and from urban areas. NPs were overrepresented in both the low- and high-outlier groups, while PAs were modestly overrepresented in the low-outlier group. Regarding clinician demographics, Asian clinicians were more likely to be high-outliers, and white clinicians were more likely to be low-outliers, with women overrepresented in both groups. Conclusion: Positive and negative outlier performance by clinicians may be partially explained by case mix. Understanding differences in performance by clinician training and demographics may lead to interventions to support all clinicians in high quality care delivery.

Background: Lipid management is critical for reducing cardiovascular events among those with atherosclerotic cardiovascular disease (ASCVD). Barriers to lipid management are multifactorial, including process-level and patient-level factors, which may require a multipronged approach to address. Aims: To evaluate lipid lowering therapy (LLT) use and LDL-C levels at baseline and 12 months among Veterans who worked with a health coach (HC) vs. those who did not in the Veterans Affairs Lipid Optimization Reimagined Quality Improvement (VALOR-QI) Program. Methods: VALOR-QI is a national quality improvement collaboration between the US Department of Veterans Affairs (VA) and the American Heart Association (AHA) with the goal of improving lipid management among Veterans with ASCVD across 50 VA sites. While some sites focused on process-level approaches, others additionally had a HC work directly with Veterans, providing education on the importance of LLT and lifestyle modifications and coordinating referrals to local programs (e.g., Whole Health). Data were analyzed from Veterans with ASCVD and a baseline LDL-C ≥ 70 mg/dL who received care from a VALOR-QI provider during the program, had 12 months pass since their first visit, and had at least two lipid labs during that time. We investigated changes in LLT use and LDL-C in Veterans who worked with a HC vs. those who did not. Results: Among Veterans included in the analysis, 2,093 worked with a HC [mean (SD) age 70 (9.8) years, 93% men, 64% white race], and 37,834 did not [mean (SD) age 70 (10) years, 93% men, 70% white race]. Both groups experienced improvements in LLT use and LDL-C levels, though Veterans who worked with a HC saw greater improvements in statin + additional LLT use (15% vs. 7%), LLT adherence (24% vs. 14%), percent meeting LDL-C goal &lt;70mg/dL (40% vs. 31%), and mean LDL-C (-25.5 vs. -14.7 mg/dL). Conclusion: Among US Veterans in VALOR-QI, both those who worked with a HC and those who did not saw improvements in LLT use and LDL-C at 12-month follow-up, although improvements in some metrics were greater in Veterans working with a HC.

Background: Due to teratogenic risks of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB), the current guideline recommends prescribing ACEI and ARB for women of childbearing age concurrently with contraceptives to prevent unexpected pregnancy. However, adherence to this guideline in patient care settings is unknown. Research Hypothesis: This study examines patterns of concomitant contraceptive use with antihypertensive treatment and pregnancy outcomes among women of reproductive ages using Veterans Affairs electronic health records data. Methods: The study includes 131,598 women veterans and active military service members aged 20-50 on antihypertensive medication who received care from the Veterans Health Care System or the Military Health System between January 1, 2007 to December 31, 2022. Average age of women was 39 years, and majority (45.5%) were Non-Hispanic White (Table 1). Types of contraceptive medication include combined oral contraceptive pills (yaz, ortho tri-cyclen), progestin-only pills (emicronor), vaginal rings (NuvaRing), transdermal patch (Ortho Evra), and injection (Depo-Provera). Results: The most prescribed antihypertensive medication were beta blockers (43.78%), followed by diuretics (39.91%), alpha blockers (32.80%) and ACEI/ARBs (30.79%, n=40,518). Twelve percent (n=4,862) of those on an ACEI/ARB (n=40,518) were concurrently on contraceptives, while 17% and 19% of those on beta blockers and alpha blockers were concomitantly on contraceptives, respectively. Furthermore, 1.5% (n=588) women on ACEI/ARB, 3.5% on beta blockers, and 3.7% on alpha blockers were pregnant (Figure 1). An increasing number of women were prescribed an ACEI/ARB over 12 years (p=0.0089), but the percent of women concurrently on ACEI/ARBs and contraceptives has significantly decreased (p=0.0022; Figure 2). Conclusion: Despite the current guideline, very low concomitant use of contraceptives (12%) with ACEI/ARB was observed in the study. While ACEI/ARB is the least prescribed medication to treat hypertension for reproductive age women, its use has been steadily increasing over the past decade, while rates of concurrent contraceptive use has decreased placing women at an increased risk of teratogenic exposure during pregnancy. Future studies are warranted to investigate the cause and barriers of suboptimal concomitant contraceptive utilization with ACEI/ARBs and pregnancy outcomes, including low birth weight and preterm delivery.

Introduction: Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive, often fatal disease. Recognition and diagnosis of ATTR-CM have increased due to greater awareness, improved diagnostics, and introduction of disease-modifying treatments (DMT). Hypothesis: Geographic disparities in ATTR-CM prevalence exist due to healthcare system and societal factors that impact the Veterans Affairs (VA) population. Methods: This study included a retrospective analysis of electronic health records of veterans with ATTR-CM (01/2012-12/2021) across all VA facilities in the United States (US). The primary outcome of this analysis was ATTR-CM prevalence, defined as cases per 100,000 person-years (PY). Prevalence was analyzed by state after the approval of DMT (2019). The distribution of US amyloidosis centers, classified by the International Society of Amyloidosis, Amyloidosis Foundation, and/or Amyloid Research Consortium, was also assessed. Results: A total of 2433 patients with ATTR-CM were included. The majority (85.7%) were aged ≥65 years, with 20.8% aged ≥85 years. Most (86.8%) patients were male; 51.5% were White and 41.3% were Black/African American. ATTR-CM prevalence in veterans was 6.1 per 100,000 PY in 2012 and increased to 16.8 in 2021 ( Figure 1 ). After 2019, the prevalence in veterans was high in Oregon (50.9), Utah (39.5), and South Dakota (35.4), and in many states in the Northeast (Massachusetts, 43.2; Rhode Island, 43.0; Vermont, 33.6; Connecticut, 29.3) ( Figure 2 ). Prevalence appeared to correlate with the distribution of amyloidosis centers in many regions, though prevalence was high in New Mexico and South Dakota despite the lack of dedicated amyloidosis centers. Conclusion: The documented prevalence of ATTR-CM increased over time in US veterans, though geographic disparities exist at the state level that appear to correlate with access to amyloidosis centers. For regions with lower-than-expected prevalence, strategies are needed to address regional disparities in disease awareness, diagnosis, and access to care.

Introduction: Acute myocardial infarction (MI) triggers acute inflammation. A subset of patients experience subsequent chronic systemic inflammation (SI) post-MI. Question: Among patients with a prior MI, is SI associated with a higher risk of major adverse cardiovascular (CV) events? Methods: We identified Veterans with a nonfatal MI from 2008-2022 and a subsequent outpatient high-sensitivity C-reactive protein (hsCRP) measurement 60-730 days post-MI. Veterans with select comorbidities known to increase SI and mortality (e.g., active cancer or end-stage renal or severe hepatic diseases) were excluded. The primary outcome was a composite of death, MI, and ischemic stroke post-hsCRP measurement. Secondary outcomes included components of the primary outcome, CV death, and heart failure (HF) hospitalization. Cox regression was used to compare outcomes between patients with SI (hsCRP &gt; 2 mg/L and &lt; 10 mg/L) vs. without SI (hsCRP &lt;2 mg/L), adjusting for demographics, comorbidities, CV treatment (statins, antiplatelets, GLP1RA, and SGLT2i), and the duration between MI and hsCRP. Results: We identified 11,230 Veterans with a nonfatal MI with a subsequent hsCRP: 3,362 had hsCRP &lt;2 mg/L, 4,594 had hsCRP &gt; 2 mg/L and &lt; 10 mg/L, and 3,274 had hsCRP &gt;10 mg/L. Among Veterans with hsCRP &lt;10 mg/L, the mean age was 68 years (SD: 9.7), 96.8% were men, 73.2% had NSTEMI, and 55.6% underwent coronary revascularization. Veterans with SI were more likely to have diabetes (41.1% vs. 33.0%, p&lt;0.001) compared to those without SI. The composite outcome incidence was 7.2 events/100 patient-years in those with SI vs. 5.0/100 patient-years in those without SI (p&lt;0.001). After adjustment, SI was associated with a higher risk of the primary outcome (HR: 1.31; 95% CI: 1.22–1.42). SI was also associated with an increased risk of each of the following: all-cause death, CV death, recurrent MI, and HF hospitalization (Figure 1). The results were similar after excluding patients with autoimmune disease and across subgroups by age, diabetes, heart failure, and NSTEMI vs. STEMI. Conclusion: SI following a nonfatal MI is a marker of increased risk of death, recurrent MI, and HF hospitalizations after adjustment for patient demographics, comorbidities, and CV treatment.

Background: Positron emission tomography (PET) combined with computed tomography (CT) is a valuable strategy for myocardial perfusion imaging (MPI) in ischemic heart disease evaluation. CT attenuation correction (CTAC) enhances the diagnostic performance of PET and provides further characterization of the coronary vasculature. CTAC performed as part of MPI, however, frequently reveals incidental extracardiac findings whose clinical significance remains underexplored. Research Question: This study aimed to assess the prevalence of incidental extracardiac lesions on 82 Rb-chloride PET/CT MPI and investigate whether subsequent 18 F-FDG (fluorodeoxyglucose) uptake patterns identify clinically actionable lesions, particularly those suggesting occult malignancy. Methods: This retrospective study included 468 patients from the West Los Angeles Veterans Affairs Medical Center who underwent 18 F-FDG PET/CT within six months of 82 Rb-chloride PET/CT MPI between January 2017 and July 2022. From this cohort, 162 patients who underwent 82 Rb-chloride PET/CT MPI first and had no prior malignancy history were identified as the target cohort. Positive predictive values and chi-squared analyses evaluated the association between extracardiac lesions identified on CTAC and subsequent 18 F-FDG uptake. Results: A total of 209 extracardiac findings were noted on CTAC in the target cohort, with 108 demonstrating positive 18 F-FDG uptake. Pulmonary nodules were the most commonly identified extracardiac finding on CTAC and comprised 30% of all incidental lesions. Pulmonary nodule size was significantly associated with 18 F-FDG uptake, particularly in smokers (chi-squared value = 26.4, P &lt; 0.001). In non-smokers, while isolated pulmonary nodules had no association with 18 F-FDG uptake, those accompanied by lymphadenopathy exhibited a trend towards significant association with 18 F-FDG uptake (chi-squared value = 10.9, P = 0.052). Conclusions: Extracardiac findings observed on CTAC during 82 Rb-chloride PET MPI in patients without a history of cancer are associated with subsequent 18 F-FDG uptake on PET/CT. This association is influenced by pulmonary nodule size, with a stronger relationship observed in patients with a history of smoking. These findings underscore the importance of integrating extracardiac lesion evaluation with patient demographics into routine cardiovascular imaging workflows to identify patients at highest risk for indolent malignancy.

Background: Over 800,000 individuals are hospitalized for a myocardial infarction (MI) annually in the United States. Temporal trends in post-discharge outcomes are uncertain. Question: Among Veterans who survive an MI hospitalization, how have post-discharge outcomes changed? Methods: Veterans who survived an MI hospitalization within or outside the VHA between 2008-2022 were identified based on a principal diagnosis of MI from an acute care hospitalization. We identified comorbidities, vital signs, and laboratory values pre-hospitalization. The primary outcome was a 4-point composite MACE (death, MI, ischemic stroke, and heart failure (HF) hospitalization) over 1 year post-discharge. Temporal trends were analyzed by comparing outcomes across 3 time periods (2008-2012, 2013-2017, and 2018-2022) with the Cuzick rank test. We also evaluated 1-year death alone and performed a landmark analysis evaluating 1-year death following HF hospitalization within the first 12 months post-MI. The annual change in outcomes was examined while adjusting for demographics, comorbidities, pre-admission vital signs and laboratory values, and STEMI vs. NSTEMI classification. Results: There were 444,659 Veterans with a non-fatal MI hospitalization between 2008 and 2022. The median age was 73 (interquartile range: 66-80) and 1.8% were women. Over time, the proportion with STEMI decreased (2008-2012: 26.1%, 2013-2017: 23.1%, and 2018-2022: 23.1%; p&lt;0.01). The proportion with inpatient revascularization decreased from 49.6% to 48.1% to 36.9% (p&lt;0.01). The 1-year risk of the composite MACE outcome decreased from 26.1% to 23.2% to 22.2% (p&lt;0.01) across time periods. After adjustment, there was a 3.9% annual relative decrease in the odds of 1-year MACE (OR: 0.965; 95% CI: 0.963-0.967). The risk of 1-year death post-MI hospitalization decreased from 20.7% to 18.1% to 16.3% (p&lt;0.01) (Figure). After adjustment, there was a 4.2% annual relative decrease in the odds of 1-year mortality (OR 0.958 per year; 95% CI: 0.956-0.960). There were 23,048 (5.2%) Veterans with HF hospitalization within 12 months of MI discharge. Among this cohort, 44.9% died within 1-year post-HF hospitalization. Conclusion: Among Veterans, the risk of death post-MI hospitalization has improved over time. However, over 1 in 5 Veterans post-MI continue to have major adverse cardiovascular outcomes within 1 year. Veterans with a HF hospitalization post-MI are at substantially elevated risk of death.

Introduction/Background: The Department of Veterans Affairs’ (VA’s) Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act expanded opportunities for Veterans to obtain care outside the VA. However, the MISSION Act's impact on healthcare quality and outcomes is uncertain. Goals: To measure the MISSION Act’s association with travel times and outcomes of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and aortic valve replacement (AVR). Hypothesis: MISSION Act implementation in mid-2019 likely reduced travel times to care, but also may have negatively impacted cardiovascular procedural outcomes. Methods/Approach: This was a retrospective difference-in-differences (DiD) cohort study of Veterans receiving PCI, CABG, or AVR between October, 2016 and September, 2022. We compared Veterans made eligible for non-VA care under the MISSION Act by living &gt;60 minutes from the nearest VA Medical Center (VAMC), versus MISSION-Act-ineligible Veterans living ≤60 minutes from a VAMC. Main outcome measures were average travel time to the procedure site and major adverse cardiovascular events (MACE) within 30 days of the procedure. Results/Data: The cohort comprised Veterans receiving PCI (n=43,000), CABG (n=23,301), or AVR (n=14,682). After MISSION Act implementation, mean PCI travel times increased by 1.3 minutes for “near” patients and decreased by 29.2 minutes for “far” patients (DiD=-30.5 minutes, P&lt;.001). Mean CABG travel times increased by 9.4 minutes for “near” patients and decreased by 18.1 minutes for “far” patients (DiD=-27.4 minutes, P&lt;.001). Mean AVR travel times increased by 10.0 minutes for “near” patients and decreased by 23.0 minutes for “far” patients (DiD=-33.1 minutes, P&lt;.001). After MISSION Act implementation, mean PCI MACE rates decreased by .5 percentage points for “near” patients and increased by 2.3 percentage points for “far” patients (DiD=2.8 percentage points, P=&lt;.001). Mean CABG MACE rates decreased by 6.5 percentage points for “near” patients and increased by 1.6 percentage points for “far” patients (DiD=8.1 percentage points, P&lt;.001). AVR MACE rates were not statistically different (p=.45). Conclusion(s): MISSION Act implementation was associated with substantial decreases in travel times among Veterans who became geographically eligible for non-VA care. For these patients undergoing PCI or CABG, MISSION Act Implementation was also associated with worsened 30-day MACE rates.