Veterans Health Administration Care Research Articles

Perspectives on supporting Veterans’ social needs during hospital to home health transitions: findings from the Transitions Nurse Program

BackgroundVeterans who need post-acute home health care (HHC) are at risk for adverse outcomes and unmet social needs. Veterans’ social needs could be identified and met by community-based HHC clinicians due to their unique perspective from the home environment, acuity of Veterans they serve, and access to Veterans receiving community care. To understand these needs, we explored clinician, Veteran, and care partner perspectives to understand Veterans’ social needs during the transition from hospital to home with skilled HHC.MethodsQualitative data were collected through individual interviews with Veterans Health Administration (VHA) inpatient & community HHC clinicians, Veterans, and care partners who have significant roles facilitating Veterans’ hospital to home with HHC transition. To inform implementation of a care coordination quality improvement intervention, participants were asked about VHA and HHC care coordination and Veterans’ social needs during these transitions. Interviews were recorded, transcribed, and analyzed inductively using thematic analysis and results were organized deductively according to relevant transitional care domains (Discharge Planning, Transition to Home, and HHC Delivery).ResultsWe conducted 35 interviews at 4 VHA Medical Centers located in Western, Midwestern, and Southern U.S. regions during March 2021 through July 2022. We organized results by the three care transition domains and related themes by VHA, HHC, or Veteran/care partner perspective. Our themes included (1) how social needs affected access to HHC, (2) the need for social needs screening during hospitalization, (3) delays in HHC for Veterans discharged from community hospitals, and (4) a need for closed-loop communication between VHA and HHC to report social needs.ConclusionsHHC is an underexplored space for Veterans social needs detection. While this research is preliminary, we recommend two steps forward from this work: (1) develop closed-loop communication and education pathways with HHC and (2) develop a partnership to integrate a social risk screener into HHC pathways.

Development and Validation of a Measure to Assess Patient Experiences With Video Care Encounters

As video-based care expands in many clinical settings, assessing patient experiences with this care modality will help optimize health care quality, safety, and communication. To develop and assess the psychometric properties of the video visit user experience (VVUE) measure, a patient-reported measure of experiences with video-based technology. In this survey study, veterans completed a web-based, mail, or telephone survey about their use of Veterans Healthcare Administration (VHA) virtual care between September 2021 and January 2022. The survey was completed by patients who reported having a VHA video visit on their own device or a VHA-issued device and linked to VHA utilization data for the 6 months following the survey. Data analysis was performed from March 2022 to February 2023. The survey included 19 items about experiences with video visits that were rated using a 4-point Likert-type scale (strongly disagree to strongly agree). First, an exploratory factor analysis was conducted to determine the factor structure and parsimonious set of items, using the McDonald Omega test to assess internal consistency reliability. Then, a confirmatory factor analysis was conducted to test structural validity, and bivariate correlations between VVUE and VHA health care engagement were calculated to test concurrent validity. Finally, predictive validity was assessed using logistic regression to determine whether VVUE was associated with future VHA video visit use. Among 1887 respondents included in the analyses, 83.2% (95% CI, 81.5%-84.8%) were male, 41.0% (95% CI, 38.8%-43.1%) were aged 65 years or older, and the majority had multiple chronic medical and mental health conditions. The exploratory factor analysis identified a 10-item single-factor VVUE measure (including questions about satisfaction, user-centeredness, technical quality, usefulness, and appropriateness), explaining 96% of the total variance, with acceptable internal consistency reliability (ω = 0.95). The confirmatory factor analysis results confirmed a single-factor solution (standardized root mean squared residual = 0.04). VVUE was positively associated with VHA health care engagement (ρ = 0.47; P < .001). Predictive validity models demonstrated that higher VVUE measure scores were associated with future use of video visits, where each 1-point increase on VVUE was associated with greater likelihood of having a video visit in subsequent 6 months (adjusted odds ratio, 1.04; 95% CI, 1.02-1.06). The findings of this study of veterans using video visits suggest that a brief measure is valid to capture veterans' experiences receiving VHA virtual care.

Informational letters or postcards to initiate remote monitoring among veterans with pacemakers and implantable cardioverter-defibrillators: A randomized, controlled trial.

Remote monitoring (RM) of pacemakers and implantable cardioverter-defibrillators (ICDs) is a Class 1, Level of Evidence A recommendation because of its multitude of clinical benefits. However, RM adherence rates are suboptimal, precluding patients from achieving these benefits. There is a need for direct-to-patient efforts to improve adherence. In this national randomized, controlled trial conducted in the Veterans Health Administration (VHA), 2120 patients with a pacemaker or ICD who had not sent an RM transmission for ≥1 year (and usually ≥3 years) while under VHA care for their device were randomly assigned to be mailed a postcard (n=1076) or a detailed letter (n=1044). The postcard described what RM does and its key benefits (reduced mortality and fewer in-person visits). The letter provided a similar message but included more details about RM benefits and the process. The primary outcome was an RM transmission sent within 90 days of mailing, and a secondary outcome was an RM transmission sent within 365 days. The primary outcome was achieved in 121 (11.3%) in the postcard and 96 patients (9.2%) in the letter group (p=.12). The secondary outcome was achieved in 266 (24.7%) and 239 (22.9%), respectively (p=.32). This randomized trial showed no significant difference in the proportion of chronically non-adherent patients who sent an RM transmission after receiving a low-cost postcard or a detailed, higher-cost letter encouraging their participation in RM. However, as only a minority of patients responded to either, further work is needed to engage patients in the life-saving benefits of RM.

Alcohol-Related Care Among Veterans With Unhealthy Alcohol Use: The Role of Long-term Opioid Therapy Receipt.

Long-term opioid therapy (LTOT) is potentially dangerous among patients with unhealthy alcohol use because of possible adverse interactions. We examined receipt of alcohol-related care among patients with unhealthy alcohol use receiving LTOT and without opioid receipt. We use data collected from 2009 to 2017 in the Women Veterans Cohort Study, a national cohort of Veterans engaged in Veterans Health Administration care. We included patients who screened positive for unhealthy alcohol use (score ≥5) using the Alcohol Use Disorder Identification Consumption questionnaire. Our primary exposure was LTOT (receipt of prescribed opioids for ≥90 days) versus no opioid receipt at the time of the first positive Alcohol Use Disorder Identification Consumption. Our primary outcome was receipt of brief intervention within 14 days of positive alcohol screen. Unadjusted and 4 adjusted modified Poisson regression models assessed prevalence and relative rates (RRs) of outcomes. Among eligible veterans, 6222 of 113,628 (5.5%) received LTOT at screening. Among patients receiving LTOT, 67.5% (95% confidence interval [CI], 66.3%-68.6%) had a documented brief intervention within 14 days of positive screen, compared with 70.1% (95% CI, 69.8%-70.4%) among patients without opioid receipt (RR, 0.96; 95% CI, 0.95-0.98; P < 0.001). Within adjusted models, the rate of brief intervention among patients receiving LTOT remained lower than patients without opioid receipt. Among patients with unhealthy alcohol use, patients receiving LTOT had significantly lower rates of brief intervention receipt compared with those without opioid receipt, and they should be a focus for interventions to improve alcohol-related care and safer opioid prescribing.

Abstract P510: Trends in Statin Therapy for Primary Prevention Among Older Veterans, 2003-2020

Introduction: The burden and risk of atherosclerotic cardiovascular disease (ASCVD) in US Veterans is higher than the general population, yet rates of use of medications for primary prevention, specifically statins, are not well described. Since the early 2000s, trial data have proven the efficacy of statins for primary prevention, further encouraged by updated guidelines (notably 2001, 2013, 2018). Therefore, we sought to examine the proportion of older veterans free of ASCVD and trends of statin use for primary prevention within this cohort from 2003 to 2020. Methods: Study participants comprised all US Veterans ≥65 years, free of ASCVD, and with at least one visit in the Veteran’s Health Administration (VHA) in the year prior. Statin users had at least two or more prescriptions of any statin in each one-year period studied. VA prescription data were linked to Medicare/Medicaid to ensure complete capture of statin use. Descriptive statistics and crude proportions were calculated by year of study entry. Results: From 2003-2020, there were 5.1 million Veterans aged 65 and older who received regular care in VHA. The overall proportion of veterans free of ASCVD in that period was 60% (N=3,159,705). Statin prescriptions for primary prevention have increased from 39% in 2003 to 52% in 2020, remaining steady after 2007. For example, in 2011, 51% were prescribed statins, mean age 73±7, 87% white, 98% male, 82% hypertension, 37% diabetes, 94% hyperlipidemia; while in 2017, 53% were prescribed statins (age 72± 7, 80% white, 97% male, 73% hypertension, 31% diabetes, 74% hyperlipidemia), received statin therapy for primary prevention (Figure). Conclusion: A substantial proportion of Veterans ≥65 years were at risk for ASCVD. While statin prescriptions for primary prevention have increased from 2003-2020, over the past 15 years, they have remained at around 50%. These findings indicate a focus on primary prevention among older Veterans is needed.

Abstract P169: Cardiovascular Disease Incidence Among Male Veterans by Sexual Orientation and Race

Introduction: Studies of cardiovascular disease (CVD) in sexual minority (SM) men (i.e., gay, bisexual) vs. heterosexual men are limited by small sample sizes and lack of objective CVD ascertainment. Small samples also hinder study at the intersection of race and sexual orientation on CVD events. We used the Veterans Healthcare Administration Lesbian, Gay, Bisexual, Transgender Electronic Health Record cohort to fill these knowledge gaps. Methods: We studied 919,404 male cisgender veterans who were free of prevalent CVD and classified as SM or non-SM by a natural language processing tool. We defined incident CVD as first instance of AMI, ischemic stroke, cardiac revascularization, or CVD death between baseline and date of death or 8/31/22. We stratified sample statistics by SM status and race. We used Cox proportional hazards regression to assess the intersection of sexual orientation and race with incident CVD; we adjusted for Hispanic ethnicity and age. Based on the minority stress model, non-SM White men were the referent. Results: Within races, traditional CVD risk factors were similarly distributed by SM status but SM men had greater prevalence of stress-associated characteristics like substance use, depression, and anxiety. Heterosexual, gay, and bisexual Asian men had lower CVD risk than non-SM White men, while Black/African American and Multiracial men had persistently increased CVD risk ( Table ). White and American Native gay men had increased CVD risk vs. non-SM White men. With the exception of Asians, all unclassified SM men had increased CVD incidence vs. non-SM White men. Risk was highest in among Black or Multiracial SM men. Conclusion: This is one of the first studies to examine the intersection of sexual orientation and race on CVD risk in male veterans. CVD risk appears increased or decreased in certain racial groups regardless of sexual orientation but this is not always true and invites further study into the mechanisms by which stress results in inequitable CVD events across groups.

Rural Native Veterans' Perceptions of Care in the Context of Navigator Program Development.

American Indian and Alaska Natives serve in the military at one of the highest rates of all racial and ethnic groups. For Veterans, the already significant healthcare disparities Natives experience are aggravated by barriers to accessing care, care navigation, and coordination of health care within the Veterans Health Administration (VHA) between the VHA and tribal health systems. To mitigate these barriers, the VHA is developing a patient navigation program designed specifically for rural Native Veterans. We describe formative work aimed at understanding and addressing barriers to VHA care from the perspective of rural Native Veterans and those who facilitate their care. Thirty-four individuals participated in semi-structured interviews (22 Veterans, 6 family members, and 6 Veteran advocates) drawn from 9 tribal communities across the US. Participants described many barriers to using the VHA, including perceptions of care scarcity, long travel distances to the VHA, high travel costs, and bureaucratic barriers including poor customer service, scheduling issues, and long waits for appointments. Many Veterans preferred IHS/tribal health care over the VHA due to its proximity, simplicity, ease of use, and quality. Rural Native Veterans must see a clear benefit to using the VHA given the many obstacles to its use. Veteran recommendations for addressing barriers to VHA care within a navigation program include assistance enrolling in, scheduling, and navigating VHA systems; paperwork assistance; cost reimbursement; and care coordination with the IHS/tribal health care.

Behavioral weight management use in the Veterans Health Administration: Sociodemographic and health correlates

IntroductionOver 40 % of United States Veterans Health Administration (VHA) primary care patients have obesity. Few patients use VHA's flagship weight management program, MOVE! and there is little information on other behavioral weight management program use. MethodsThe national United States cohort included over 1.5 million primary care patients with obesity, age 18–79, based on VHA administrative data. Gender stratified multivariable logistic regression identified correlates of weight management use in the year after a patient's first primary care appointment (alpha of 0.05). Weight management use was defined as MOVE! or nutrition clinic visits. ResultsThe cohort included 121,235 women and 1,521,547 men with 13 % and 7 % using weight management, respectively. Point estimates for specific correlates of use were similar between women and men, and across programs. Black patients were more likely to use weight management than White patients. Several physical and mental health diagnoses were also associated with increased use, such as sleep apnea and eating disorders. Age and distance from VHA were negatively associated with weight management use. ConclusionsWhen assessing multiple types of weight management visits, weight management care in VHA appears to be used more often by some populations at higher risk for obesity. Other groups may need additional outreach, such as those living far from VHA. Future work should focus on outreach and prevention efforts to increase overall use rates. This work could also examine the benefits of tailoring care for populations in greatest need.

Recruitment tools for transgender and gender diverse veterans in health care research.

Transgender and gender diverse (TGD) veterans in the Veterans Health Administration experience health and health care disparities, and research with this population is needed to improve gender-affirming care in Veterans Health Administration. However, TGD veterans may experience hesitancy to participate in research. We must address barriers to participation through feasible and acceptable methods. Opt-out letters are an effective tool used to recruit veterans in mental health research. The present study examined the feasibility and acceptability of opt-out letters modified for TGD veterans. Opt-out letters were sent to 54 potential TGD participants at three sites. The letters stated the research team would begin contacting veterans by phone in 2 weeks if they did not opt out of being contacted. Feasibility was measured through response rate. Acceptability was assessed through qualitative template analysis of interview data. Of the 54 potential participants, two opted out, three letters were undeliverable, and eight veterans called to opt in. Veterans reported that they found the letters to be clear and useful. The responses to the opt-out letters resulted in completing recruitment for two of the three sites. The research team then called the veterans who received the letter at the third site (three veterans) and recruited one additional veteran, for a total of nine TGD veterans. Opt-out letters may be a helpful tool to recruit TGD veterans to participate in research. Although these letters were designed to opt out, 89% of participants called the research team to opt in. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Predictors of non-fatal suicide attempts among Veterans Health Administration (VHA) patients who experienced military sexual trauma.

Military sexual trauma (MST) has been identified as a risk factor for suicidal behavior. To inform suicide prevention efforts within the Veterans Health Administration (VHA), this study evaluates predictors of non-fatal suicide attempts (NFSAs) among VHA patients who experienced MST. For VHA patients in fiscal year (FY) 2019 who previously screened positive for a history of MST, documented NFSAs were assessed. Using multivariable logistic regression, demographic, clinical, and VHA care utilization predictors of NFSAs were assessed. Of the 212,215 VHA patients who screened positive for MST prior to FY 2019 and for whom complete race, service connection, and rurality information was available, 1742 (0.8%) had a documented NFSA in FY 2019. In multivariable logistic regression analyses, total physical and mental health morbidities were not associated with NFSA risk. Predictors of a documented NFSA included specific mental health diagnoses [adjusted odds ratio (aOR) range: 1.28-1.94], receipt of psychotropic medication prescriptions (aOR range: 1.23-2.69) and having a prior year emergency department visit (aOR = 1.32) or inpatient psychiatric admission (aOR = 2.15). Among VHA patients who experienced MST, specific mental health conditions may increase risk of NFSAs, even after adjustment for overall mental health morbidity. Additionally, indicators of severity of mental health difficulties such as receipt of psychotropic medication prescriptions and inpatient psychiatric admissions are also associated with increased risk above and beyond risk associated with diagnoses. Findings highlight targets for suicide prevention initiatives among this vulnerable group within VHA and may help identify patients who would benefit from additional support.

Health Equity in the Veterans Health Administration From Veterans’ Perspectives by Race and Sex

Advancing equitable patient-centered care in the Veterans Health Administration (VHA) requires understanding the differential experiences of unique patient groups. To inform a comprehensive strategy for improving VHA health equity through the comparative qualitative analysis of care experiences at the VHA among veterans of Black and White race and male and female sex. This qualitative study used a technique termed freelisting, an anthropologic technique eliciting responses in list form, at an urban academic VHA medical center from August 2, 2021, to February 9, 2022. Participants included veterans with chronic hypertension. The length of individual lists, item order in those lists, and item frequency across lists were used to calculate a salience score for each item, allowing comparison of salient words and topics within and across different groups. Participants were asked about current perceptions of VHA care, challenges in the past year, virtual care, suggestions for change, and experiences of racism. Data were analyzed from February 10 through September 30, 2022. The Smith salience index, which measures the frequency and rank of each word or phrase, was calculated for each group. Responses from 49 veterans (12 Black men, 12 Black women, 12 White men, and 13 White women) were compared by race (24 Black and 25 White) and sex (24 men and 25 women). The mean (SD) age was 64.5 (9.2) years. Some positive items were salient across race and sex, including "good medical care" and telehealth as a "comfortable/great option," as were some negative items, including "long waits/delays in getting care," "transportation/traffic challenges," and "anxiety/stress/fear." Reporting "no impact" of racism on experiences of VHA health care was salient across race and sex; however, reports of race-related unprofessional treatment and active avoidance of race-related conflict differed by race (present among Black and not White participants). Experiences of interpersonal interactions also diverged. "Impersonal/cursory" telehealth experiences and the need for "more personal/attentive" care were salient among women and Black participants, but not men or White participants, who associated VHA care with courtesy and respect. In this qualitative freelist study of veteran experiences, divergent experiences of interpersonal care by race and sex provided insights for improving equitable, patient-centered VHA care. Future research and interventions could focus on identifying differences across broader categories both within and beyond race and sex and bolstering efforts to improve respect and personalized care to diverse veteran populations.

Identifying clinical phenotypes of frontotemporal dementia in post-9/11 era veterans using natural language processing.

Frontotemporal dementia (FTD) encompasses a clinically and pathologically diverse group of neurodegenerative disorders, yet little work has quantified the unique phenotypic clinical presentations of FTD among post-9/11 era veterans. To identify phenotypes of FTD using natural language processing (NLP) aided medical chart reviews of post-9/11 era U.S. military Veterans diagnosed with FTD in Veterans Health Administration care. A medical record chart review of clinician/provider notes was conducted using a Natural Language Processing (NLP) tool, which extracted features related to cognitive dysfunction. NLP features were further organized into seven Research Domain Criteria Initiative (RDoC) domains, which were clustered to identify distinct phenotypes. Veterans with FTD were more likely to have notes that reflected the RDoC domains, with cognitive and positive valence domains showing the greatest difference across groups. Clustering of domains identified three symptom phenotypes agnostic to time of an individual having FTD, categorized as Low (16.4%), Moderate (69.2%), and High (14.5%) distress. Comparison across distress groups showed significant differences in physical and psychological characteristics, particularly prior history of head injury, insomnia, cardiac issues, anxiety, and alcohol misuse. The clustering result within the FTD group demonstrated a phenotype variant that exhibited a combination of language and behavioral symptoms. This phenotype presented with manifestations indicative of both language-related impairments and behavioral changes, showcasing the coexistence of features from both domains within the same individual. This study suggests FTD also presents across a continuum of severity and symptom distress, both within and across variants. The intensity of distress evident in clinical notes tends to cluster with more co-occurring conditions. This examination of phenotypic heterogeneity in clinical notes indicates that sensitivity to FTD diagnosis may be correlated to overall symptom distress, and future work incorporating NLP and phenotyping may help promote strategies for early detection of FTD.

Combining Charlson comorbidity and VACS indices improves prognostic accuracy for all-cause mortality for patients with and without HIV in the Veterans Health Administration.

As people age with HIV (PWH), many comorbid diseases are more common than among age matched comparators without HIV (PWoH). While the Veterans Aging Cohort (VACS) Index 2.0 accurately predicts mortality in PWH using age and clinical biomarkers, the only included comorbidity is hepatitis C. We asked whether adding comorbid disease groupings from the Charlson Comorbidity Index (CCI) improves the accuracy of VACS Index. To maximize our ability to model mortality among older age groups, we began with PWoH in Veterans Health Administration (VA) from 2007-2017, divided into development and validation samples. Baseline predictors included age, and components of CCI and VACS Index (excluding CD4 count and HIV RNA). Patients were followed until December 31, 2021. We used Cox models to develop the VACS-CCI score and estimated mortality using a parametric (gamma) survival model. We compared accuracy using C-statistics and calibration curves in validation overall and within subgroups (gender, age </≥65 years, race/ethnicity, and CCI score). We then applied VACS-CCI in PWH and compared its accuracy to age, VACS Index 2.0, CCI and VACS-CCI with CD4 and HIV RNA added. The analytic sample consisted of 6,588,688 PWoH and 30,539 PWH. Among PWoH/PWH, median age was 65/55 years; 6%/3% were women; 15%/48% were Black and 5%/7% Hispanic. VACS-CCI provided the best discrimination (C-statistic = 0.81) with excellent calibration (predicted and observed mortality largely overlapped) overall and within subgroups. When VACS-CCI was applied to PWH it demonstrated similar discrimination as VACS Index 2.0 (C-statistic = 0.77 for both) but superior calibration among those with CD4 < 200. Discrimination was improved when CD4 and HIV RNA were added VACS-CCI (C-statistic = 0.79). Liver and kidney disease, congestive heart failure, malignancy, and dementia were negatively associated with CD4 (p-trends all <0.0001). Among PWH and PWoH in VA care, age alone weakly discriminates risk of mortality. VACS Index 2.0, CCI, and VACS-CCI all provide better discrimination, but VACS-CCI is more consistently calibrated. The association of comorbid diseases with lower CD4 underscores the likely role of HIV in non-AIDS conditions. Future work will include adding CD4 and HIV RNA to VACS-CCI and validating it in independent data.

Success of the US Veterans Health Administration's Hepatitis C Virus Care Continuum in the Direct-acting Antiviral Era.

Estimated hepatitis C prevalence within the Veterans Health Administration is higher than the general population and is a risk factor for advanced liver disease and subsequent complications. We describe the hepatitis C care continuum within the Veterans Health Administration January 1, 2014-December 31, 2022. We included individuals in Veterans Health Administration care 2021-2022 who were eligible for direct-acting antiviral treatment January 1, 2014-December 31, 2022. We evaluated the proportion of Veterans who progressed through each step of the hepatitis C care continuum, and identified factors associated with initiating direct-acting antivirals, achieving sustained virologic response, and repeat hepatitis C viremia. We identified 133,732 Veterans with hepatitis C viremia. Hepatitis C treatment was initiated in 107,134 (80.1%), with sustained virologic response achieved in 98,136 (91.6%). In those who achieved sustained virologic response, 1,097 (1.1%) had repeat viremia and 579 (52.8%) were retreated for hepatitis C. Veterans of younger ages were less likely to initiate treatment and achieve sustained virologic response, and more likely to have repeat viremia. Stimulant use and unstable housing were negatively associated with each step of the hepatitis C care continuum. The Veterans Health Administration has treated 80% of Veterans with hepatitis C in care 2021-2022 and achieved sustained virologic response in more than 90% of those treated. Repeat viremia is rare and is associated with younger age, unstable housing, opioid use, and stimulant use. Ongoing efforts are needed to reach younger Veterans, and Veterans with unstable housing or substance use disorders.

Factors Associated with Veteran Self-Reported Use of Digital Health Devices

BackgroundDigital health devices (DHDs), technologies designed to gather, monitor, and sometimes share data about health-related behaviors or symptoms, can support the prevention or management of chronic conditions. DHDs range in complexity and utility, from tracking lifestyle behaviors (e.g., pedometer) to more sophisticated biometric data collection for disease self-management (e.g., glucometers). Despite these positive health benefits, supporting adoption and sustained use of DHDs remains a challenge.ObjectiveThis analysis examined the prevalence of, and factors associated with, DHD use within the Veterans Health Administration (VHA).DesignNational survey.ParticipantsVeterans who receive VHA care and are active secure messaging users.Main MeasuresDemographics, access to technology, perceptions of using health technologies, and use of lifestyle monitoring and self-management DHDs.ResultsAmong respondents, 87% were current or past users of at least one DHD, and 58% were provided a DHD by VHA. Respondents 65 + years were less likely to use a lifestyle monitoring device (AOR 0.57, 95% CI [0.39, 0.81], P = .002), but more likely to use a self-management device (AOR 1.69, 95% [1.10, 2.59], P = .016). Smartphone owners were more likely to use a lifestyle monitoring device (AOR 2.60, 95% CI [1.42, 4.75], P = .002) and a self-management device (AOR 1.83, 95% CI [1.04, 3.23], P = .037).ConclusionsThe current analysis describes the types of DHDs that are being adopted by Veterans and factors associated with their adoption. Results suggest that various factors influence adoption, including age, access to technology, and health status, and that these relationships may differ based on the functionalities of the device. VHA provision of devices was frequent among device users. Providing Veterans with DHDs and the training needed to use them may be important factors in facilitating device adoption. Taken together, this knowledge can inform future implementation efforts, and next steps to support patient-team decision making about DHD use.

Administration’s Share of Personnel in Veterans Health Administration and Private Sector Care

Health care administrative overhead is greater in the US than some other nations but has not been assessed in the Veterans Health Administration (VHA). To compare administrative staffing patterns in the VHA and private (non-VHA) sectors. This cross-sectional study was conducted using US employment data from 2019, prior to pandemic-related disruptions in health care staffing, and was carried out between January 14 and August 10, 2023. A nationally representative sample of federal and nonfederal personnel in hospitals and ambulatory care settings from the American Community Survey (ACS), all employees reported in VHA personnel records, and personnel in health insurance carriers and brokers tabulated by the Bureau of Labor Statistics (BLS) were analyzed. VHA vs private sector health care employment, including 397 occupations grouped into 18 categories. The proportion of staff working in administrative occupations. Among 3 239 553 persons surveyed in the ACS, 122 315 individuals (weighted population, 12 501 185 individuals) were civilians working in hospitals or ambulatory care; of the weighted population, 12 156 988 individuals (mean age, 42.6 years [95% CI, 42.5-42.7 years]; 76.2% [95% CI, 75.9%-76.5%] females) were private sector personnel and 344 197 individuals (mean age, 46.2 years [95% CI, 45.7-46.7 years]; 63.8% [95% CI, 61.8%-65.8%] females) were federal employees. In clinical settings, administrative occupations accounted for 23.4% (95% CI, 23.1%-23.8%) of private sector vs 19.8% (95% CI, 18.1%-21.4%) of VHA personnel. After including 1 000 800 employees at private sector health insurers and brokers and 13 956 VHA Central Office personnel with administrative occupations, administration accounted for 3 851 374 of 13 157 788 private sector employees (29.3%) vs 77 500 of 343 721 VHA employees (22.5%). Physicians represented approximately 7% of personnel in the VHA (7.2% [95% CI, 6.1%-8.2%]) and private sector (6.5% [95% CI, 6.3%-6.7%]), while the VHA deployed more registered nurses (23.7% [95% CI, 21.6%-25.8%] vs 21.2% [95% CI, 20.9%-21.5%]) and social service personnel (6.3% [95% CI, 5.4%-7.1%] vs 4.9% [95% CI, 4.7%-5.0%]) than the private sector. In this study, administrative occupations accounted for a smaller share of personnel in the VHA compared with private sector care, a difference possibly attributable to the VHA's simpler financing system. These findings suggest that if staffing patterns in the private sector mirrored those of the VHA, nearly 900 000 fewer administrative staff might be needed.

Nurse and Social Worker Palliative Telecare Team and Quality of Life in Patients With COPD, Heart Failure, or Interstitial Lung Disease

Many patients with chronic obstructive pulmonary disease (COPD), heart failure (HF), and interstitial lung disease (ILD) endure poor quality of life despite conventional therapy. Palliative care approaches may benefit this population prior to end of life. Determine the effect of a nurse and social worker palliative telecare team on quality of life in outpatients with COPD, HF, or ILD compared with usual care. Single-blind, 2-group, multisite randomized clinical trial with accrual between October 27, 2016, and April 2, 2020, in 2 Veterans Administration health care systems (Colorado and Washington), and including community-based outpatient clinics. Outpatients with COPD, HF, or ILD at high risk of hospitalization or death who reported poor quality of life participated. The intervention involved 6 phone calls with a nurse to help with symptom management and 6 phone calls with a social worker to provide psychosocial care. The nurse and social worker met weekly with a study primary care and palliative care physician and as needed, a pulmonologist, and cardiologist. Usual care included an educational handout developed for the study that outlined self-care for COPD, ILD, or HF. Patients in both groups received care at the discretion of their clinicians, which could include care from nurses and social workers, and specialists in cardiology, pulmonology, palliative care, and mental health. The primary outcome was difference in change in quality of life from baseline to 6 months between the intervention and usual care groups (FACT-G score range, 0-100, with higher scores indicating better quality of life, clinically meaningful change ≥4 points). Secondary quality-of-life outcomes at 6 months included disease-specific health status (Clinical COPD Questionnaire; Kansas City Cardiomyopathy Questionnaire-12), depression (Patient Health Questionnaire-8) and anxiety (Generalized Anxiety Disorder-7) symptoms. Among 306 randomized patients (mean [SD] age, 68.9 [7.7] years; 276 male [90.2%], 30 female [9.8%]; 245 White [80.1%]), 177 (57.8%) had COPD, 67 (21.9%) HF, 49 (16%) both COPD and HF, and 13 (4.2%) ILD. Baseline FACT-G scores were similar (intervention, 52.9; usual care, 52.7). FACT-G completion was 76% (intervention, 117 of 154; usual care, 116 of 152) at 6 months for both groups. Mean (SD) length of intervention was 115.1 (33.4) days and included a mean of 10.4 (3.3) intervention calls per patient. In the intervention group, 112 of 154 (73%) patients received the intervention as randomized. At 6 months, mean FACT-G score improved 6.0 points in the intervention group and 1.4 points in the usual care group (difference, 4.6 points [95% CI, 1.8-7.4]; P = .001; standardized mean difference, 0.41). The intervention also improved COPD health status (standardized mean difference, 0.44; P = .04), HF health status (standardized mean difference, 0.41; P = .01), depression (standardized mean difference, -0.50; P < .001), and anxiety (standardized mean difference, -0.51; P < .001) at 6 months. For adults with COPD, HF, or ILD who were at high risk of death and had poor quality of life, a nurse and social worker palliative telecare team produced clinically meaningful improvements in quality of life at 6 months compared with usual care. ClinicalTrials.gov Identifier: NCT02713347.

Experiences of Veterans, Caregivers, and VA Home-Based Care Providers before, during, and Post-Hurricane Ian.

On 28 September 2022, Hurricane Ian pummeled parts of south Florida. Disaster and climate change research has shown that disasters exacerbate inequalities, especially amongst older and physically vulnerable people. Florida has a large population of Veterans managing multiple chronic health conditions and receiving long-term care in-home from Veterans Health Administration (VA) programs, including Home Based Primary Care and Medical Foster Home. To describe how VA staff provided high quality care during and after the hurricane, and how Veterans and caregivers accessed needed healthcare and supports post-hurricane, we conducted a site visit to Lee County, Florida area in May 2023, conducting N = 25 interviews with VA staff, Veterans, and caregivers. Findings from qualitative thematic analysis showed that while some Veterans and caregivers experienced significant challenges during and after the hurricane, including displacement and difficulty accessing oxygen, they felt highly supported by VA care teams. Staff efforts post-hurricane focused on improving care coordination in anticipation of future disasters, especially around communicating with Veterans and their caregivers, and a VA workgroup formed to implement changes. As climate change causes more severe hazard events, lessons learned from this project can better support healthcare staff, older adults, and their caregivers before and after major disasters.

PREMATURE MORTALITY IN LGBT VERSUS NON-LGBT VETERANS: THE ROLE OF HEALTH RISK FACTORS AND SOCIAL DETERMINANTS OF HEALTH

Abstract Lesbian, Gay, Bisexual, and Transgender (LGBT) adults experience substantially higher rates of mental health conditions and other health risk factors than non-LGBT adults, but there is limited reseach on how these conditions increase risk for premature mortality. The current study examined this issue among middle-aged and older Veterans ages 40-99 who used Veterans Administration healthcare services from 01OCT2009 to 30SEP2019 (N = 845,122). Earlier age of death by suicide, overdose, or all-causes was hypothesized for LGBT (n = 675,639 ) vs. non-LGBT (n = 675,639) Veterans, and health factors and social determinants of health were predicted as key risk factors of earlier age of mortality. As hypothesized, LGBT Veterans had significantly higher rates of death by suicide, overdose, and all-causes among younger age groups than non-LGBT Veterans. Adjusted risk ratios indicate a significant contribution of mental health conditions (e.g., anxiety/depression), medical comorbidity, pain, smoking history, and military sexual trauma accounting for differential mortality rates by age in LGBT and non-LGBT participants. Social determinants of health, such racial/ethnic minority status and housing instability, were also significant contributors. Findings suggest the need for Whole Health interventions for LGBT Veterans to manage multiple health risk factors contributing to increased mortality risk. Suicide prevention is critical for the many middle-aged and older adults who die from suicide each year, and for LGBT Veterans especially, beginning targeted suicide prevention efforts earlier in middle age may prevent suicide deaths in later life. Lastly, findings implicate subgroups of Veterans who may particularly benefit from outreach and services.

Disparities in Preoperative Goals of Care Documentation in Veterans

Preoperative goals of care discussion and documentation are important for patients undergoing surgery, a major health care stressor that incurs risk. To assess the association of race, ethnicity, and other factors, including history of mental health disability, with disparities in preoperative goals of care documentation among veterans. This retrospective cross-sectional study assessed data from the Veterans Healthcare Administration (VHA) of 229 737 veterans who underwent surgical procedures between January 1, 2017, and October 18, 2022. Patient-level (ie, race, ethnicity, medical comorbidities, history of mental health comorbidity) and system-level (ie, facility complexity level) factors. Preoperative life-sustaining treatment (LST) note documentation or no LST note documentation within 30 days prior to or on day of surgery. The standardized mean differences were calculated to assess the magnitude of differences between groups. Odds ratios (ORs) and 95% CIs were estimated with logistic regression. In this study, 13 408 patients (5.8%) completed preoperative LST from 229 737 VHA patients (209 123 [91.0%] male; 20 614 [9.0%] female; mean [SD] age, 65.5 [11.9] years) who received surgery. Compared with patients who did complete preoperative LST, patients tended to complete preoperative documentation less often if they were female (19 914 [9.2%] vs 700 [5.2%]), Black individuals (42 571 [19.7%] vs 2416 [18.0%]), Hispanic individuals (11 793 [5.5%] vs 631 [4.7%]), or from rural areas (75 637 [35.0%] vs 4273 [31.9%]); had a history of mental health disability (65 974 [30.5%] vs 4053 [30.2%]); or were seen at lowest-complexity (ie, level 3) facilities (7849 [3.6%] vs 78 [0.6%]). Over time, despite the COVID-19 pandemic, patients undergoing surgical procedures completed preoperative LST increasingly more often. Covariate-adjusted estimates of preoperative LST completion demonstrated that patients of racial or ethnic minority background (Black patients: OR, 0.79; 95% CI, 0.77-0.80; P <.001; patients selecting other race: OR, 0.78; 95% CI, 0.74-0.81; P <.001; Hispanic patients: OR, 0.78; 95% CI, 0.76-0.81; P <.001) and patients from rural regions (OR, 0.91; 95% CI, 0.90-0.93; P <.001) had lower likelihoods of completing LST compared with patients who were White or non-Hispanic and patients from urban areas. Patients with any mental health disability history also had lower likelihood of completing preoperative LST than those without a history (OR, 0.93; 95% CI, 0.92-0.94; P = .001). In this cross-sectional study, disparities in documentation rates within a VHA cohort persisted based on race, ethnicity, rurality of patient residence, history of mental health disability, and access to high-volume, high-complexity facilities.