Veterans Health Administration Care Research Articles

Use of In-Laboratory Sleep Studies in the Veterans Health Administration and Community Care.

Use of In-Laboratory Sleep Studies in the Veterans Health Administration and Community Care.

Suicide and Traumatic Brain Injury Among Individuals Seeking Veterans Health Administration Services Between Fiscal Years 2006 and 2015.

Examine associations between traumatic brain injury (TBI) and (1) suicide and (2) suicide method among individuals receiving Veterans Health Administration (VHA) care. VHA, Fiscal Years 2006-2015. Veterans with a TBI diagnosis during/prior to the study window (n = 215 610), compared with a 20% random sample of those without TBI (n = 1 187 639). Retrospective, cohort study. Cox proportional hazards models were fit accounting for time-dependent measures, chronic conditions, and demographics for those with TBI compared with those without. Additional models evaluated the impact of TBI severity on the association between TBI and suicide, and method. Death by and method of suicide. The hazard of suicide was 2.19 times higher for those with TBI than for those without TBI (95% CI = 2.02-2.37), and was still significant after accounting for covariates (hazard ratio [HR] = 1.71; 95% confidence interval [CI] = 1.56-1.87). Considering severity, mild TBI compared with no TBI was significantly associated with an elevated hazard of suicide, after adjusting for covariates (HR = 1.62; 95% CI = 1.47-1.78). There was also a significant difference in death by suicide between moderate/severe TBI when compared with no TBI, after adjusting for covariates (HR = 2.45; 95% CI = 2.02-2.97). Moderate/severe TBI was significantly associated with an increase in the odds of suicide by firearm among decedents (odds ratio = 2.39; 95% CI = 1.48-3.87). Traumatic brain injury is associated with an elevated risk for suicide. Particular concern is warranted for those with moderate/severe TBI. Lethal means safety should be explored as an intervention.

Lifetime Smoking Patterns and Preferences for Smoking Cessation Among Women Veterans Receiving Veterans Health Administration Care.

The objective of this study was to identify common themes among women veterans who smoke or recently quit and had used smoking cessation treatment within the Veterans Health Administration (VHA). The study built upon previous research by utilizing in-depth interviews to encourage disclosure of potentially stigmatized topics. Twenty women veterans enrolled in VHA care engaged in a quality improvement project focused on improving smoking cessation services. Qualitative analysis of de-identified interviews used a combination of content analysis and thematic analysis within the sociopharmacological model of tobacco addiction. Findings revealed that participants' smoking was influenced by woman veteran identity and by several gender-related contextual factors, including military sexual trauma and gender discrimination. Findings also highlighted other contextual factors, such as personal autonomy, emotional smoking triggers, and chronic mental health concerns. Findings are interpreted within the context of cultural power imbalances, and recommendations are provided for VHA smoking cessation for women veterans.

Changing Rates of Mental Health Disorders Among Veterans Treated in the VHA During Troop Drawdown, 2007-2013.

Nationally representative data on mental health disorder prevalence are critical to set informed mental health priorities and policies. Data indicating mental health diagnoses within our nation's veteran population treated at the Veterans Health Administration (VHA) are available, but have yet to be examined for changing trends to inform both VHA and community care. We use VHA national program evaluation data from a time of increasing military enrollment (2007) to troop draw down (2013) to examine changes over time in the number of diagnoses in veterans receiving VHA services. The number of veterans in all diagnostic categories increased during our study period with the smallest increase in psychotic disorders (8%) and the largest in posttraumatic stress disorder (71%). Trends in behavioral health diagnoses among veterans have important implications for policy and clinician competencies within VHA and community providers as veteran mental health care needs change.

Military Sexual Trauma and Intimate Partner Violence: Subtypes, Associations, and Gender Differences

Military sexual trauma (MST) is associated with future intimate partner violence (IPV) experiences among women Veterans. Yet, no studies have examined this relationship among men nor determined whether MST, as a sexual trauma, is more related to sexual IPV than other forms of IPV. Thus, this study examined the associations between MST, and separately military sexual harassment (MSH) and assault (MSA), with both lifetime IPV and past-year IPV (physical, sexual, and emotional) among men and women Veterans. Participants included 1094 Veterans (567 women, 524 men, 3 unknown) from a survey of post-9/11 Veterans enrolled in Veterans Administration healthcare. The survey assessed MST using the VA 2-item screen, past year IPV using the Extended-Hurt Insult Threaten Scream screener, and lifetime IPV using the Traumatic Life Events Questionnaire. Chi-square tests revealed that women Veterans reported higher rates of MST, lifetime IPV, and recent sexual IPV. Men reported higher rates of recent overall IPV and recent psychological IPV. Men and women had equal rates of recent physical IPV. For men, MST was associated with lifetime IPV and recent psychological IPV. Among women, MST was associated with lifetime IPV and all forms of recent IPV, particularly sexual IPV. Moreover, IPV had a stronger relationship to MSA than to MSH. Results indicate that MST is related to IPV for men and women Veterans yet this relationship is stronger for women. Importantly, MSA appears more related to IPV than does MSH, underscoring a need to examine these variables separately in future studies.

Abstract 5044: Prostate adenocarcinoma incidence and risk factors in Veterans with well controlled HIV infection

Abstract (a) Although prostate cancer is projected to be one of the most frequently diagnosed cancers in HIV-infected men overall, little is known about its risk in the sub-group with well-controlled HIV-infection. (b) We performed a retrospective cohort study to determine age-adjusted incidence of prostate adenocarcinoma in HIV-positive male veterans utilizing Veterans Administration (VA) healthcare between 10/01/1999 and 12/31/2016. HIV infection and prostate adenocarcinoma diagnosis as well as related clinical, sociodemographic, and lifestyle risk factors were obtained using extant VA administrative healthcare databases, the VA cancer registry, and augmented prostate cancer diagnosis with direct electronic medical record (EMR) review. We defined well controlled HIV as >60% of time with an undetectable HIV viral load and limited our analyses to those with a minimum of 90 days between HIV and prostate diagnosis, death, their last recorded health care encounter, or study end. We employed time-varying Cox proportional hazard regression models and used backward elimination to identify risk factors associated with incident prostate adenocarcinoma; effects are reported as Hazard ratios (HR) and 95% confidence intervals (CI). (c) During an average 10.26 years of follow-up, we identified 587 incident prostate adenocarcinomas among our cohort of 19,079 HIV positive men with well-controlled infection (age-adjusted incidence rate [IR] = 83.31 per 100,000-person years, 95% CI: 76.83-90.33); with a significant increasing trend over time. We identified several factors associated with significant increased risk of incident prostate adenocarcinoma, after adjusting for HIV medication use, in our well-controlled HIV-positive cohort including substance abuse (HR=1.68, 95% CI: 1.27-2.24, p=0.0003), age at HIV diagnosis (HR=1.73, 95% CI: 1.25-2.39, p=0.0010), and black race (HR=2.07, 95% CI: 1.58-2.72, p<.0001). History of alcohol abuse (HR=0.54, 95% CI: 0.39-0.75, p=0.0002), longer time with well-controlled infection (HR=0.63, 95% CI: 0.59-0.67, p<.0001), and receiving integrase inhibitors (HR=0.64, 95% CI: 0.45-0.92, p=0.041) were associated with reduced risk. Several risk factors included in the multivariable model, such as PSA testing, testosterone levels, and maximum BMI, were not found to be significantly associated with or protective for prostate cancer. (d) Further research is needed to confirm our findings and to better identify sub-groups of well-controlled HIV-positive men at greatest increased prostate cancer risk. Citation Format: Kathryn E. Royse, Jose M. Garcia, Donna L. White, Jennifer R. Kramer, Yongquan Dong, Suchismita Raychaudhury, Peter A. Richardson, Christine Hartman, Elizabeth Y. Chiao. Prostate adenocarcinoma incidence and risk factors in Veterans with well controlled HIV infection [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 5044.

Perioperative opioid use and pain-related outcomes in the Veterans Health Administration

Understanding variation in perioperative opioid exposure and its effect on patients’ outcomes is critical for pain management. This study characterized perioperative exposure to morphine and its association with postoperative pain and 30-day readmissions. We utilized nationwide Veterans Healthcare Administration (VHA) data on four high-volume surgical procedures, 2007–2014. We identified 235,239 Veterans undergoing orthopedic, general, or vascular surgery; 5.4% high trajectories (116.1 OME/Day), 53.2% medium trajectories (39.7 OME/Day), and 41.4% low trajectories (19.1 OME/Day). Modeled estimates suggest that patients in the high OME group had higher risk of a pain-related readmission (OR: 1.59; CI: 1.39, 1.83) compared to the low OME trajectory. Yet when stratified by pain trajectory, patients with high pain and high OME had lower risk of a pain-related readmission compared to patients in the high pain low OME group (OR: 0.76, CI: 0.62, 0.94). In conclusion, patients receiving high perioperative OME are more likely to return to care for pain-related problems. This study highlights opportunities to reduce the amount of prescriptions opioids in the communities.

Obesity and Health Care Experiences among Women and Men Veterans.

Obesity is highly stigmatized, especially for women, and therefore may negatively affect health care experiences. Past findings on the relationship between obesity and health care experiences are mixed, perhaps because few studies examine relationships by gender and obesity class. Our objective was to evaluate whether women and men with more severe obesity report worse health care experiences related to Veterans Health Administration (VA) care. Health care experiences (self-management support, mental health assessments, office staff courtesy, communication with providers) and overall provider ratings were assessed with the 2014 VA Survey of Health Care Experiences of Patients. Using multiple regression analyses (n=13,462 women, n=268,180 men), we assessed associations among obesity classes, health care experiences, and overall provider ratings, adjusting for sociodemographic, health, and primary care use characteristics. The greatest differences in health care experiences between patients with and without obesity were in self-management support experiences, which were more favorable among women and men of all obesity classes. There were gender differences in associations between obesity and mental health assessments: for men, but not women, those in any obesity class gave higher ratings than those without obesity. For most other health care experiences and provider ratings, men with obesity reported slightly less favorable experiences than those without. There was no consistent pattern for women. It is promising that VA patients with obesity report more self-management support, given the behavior change required for weight management. Lower health care experience and provider ratings among men with obesity suggest a need to further investigate possible obesity-related stigma in VA primary care.

Gender Differences in Veterans' Perceptions of Harassment on Veterans Health Administration Grounds.

Stranger harassment at Veterans Health Administration (VA) facilities is prevalent, affecting one in four women veteran VA primary care users. Harassment interferes with health care quality and may result in veterans forgoing or delaying needed care. To better understand this phenomenon, gender-stratified discussion groups were held with men and women veterans. This article examines gender differences in veterans' perceptions and experiences of harassment on VA grounds. We conducted a total of 15 discussion groups at four VA medical centers, eight with men (n=57) and seven with women (n=38). Transcripts were coded using the constant comparative method and analyzed for overarching themes. Awareness of harassment was not uniformly high among participants. Although women voiced clear understandings and experiences of specific behaviors constituting harassment (e.g., cat-calls, sexual comments), many men expressed confusion about how to differentiate between harassment, "harmless flirting," and general friendliness; they were unsure which behaviors "cross a line." Furthermore, men placed the onus on women for setting boundaries, whereas women indicated it was not their responsibility to "train" men about acceptable behavior. Men and women agreed that VA staff hold primary responsibility for preventing and managing harassment. Substantive gender differences in understandings of harassment exist among veteran VA users. To minimize harassment, veterans recommend education of men veteran VA users, and staff-oriented trainings. Privacy, safety, dignity, and security are the cornerstones of women veterans' health care, per VA policy. Harassment undermines these standards, impeding women's access to VA care and compromising both their health outcomes and health care experiences. Understanding harassment through a gendered lens is a critical step in designing comprehensive initiatives that respond to diverse viewpoints and experiences.

Acute Hepatitis A Infection and Vaccination in the Veterans Health Administration

Acute Hepatitis A Infection and Vaccination in the Veterans Health Administration

Changing Trends in Opioid Overdose Deaths and Prescription Opioid Receipt Among Veterans

To inform overdose prevention, this study assessed both recent trends in opioid overdose mortality across opioid categories and receipt of prescription opioid analgesics among Veterans who died from overdose in the Veterans Health Administration. Using Veterans Health Administration records linked to National Death Index data, annual cohorts (2010-2016) of Veterans who received Veterans Health Administration care were obtained and were examined by opioid overdose categories (natural/semisynthetic opioids, heroin, methadone, and other synthetic opioids) on (1) overdose rates and changes in rates adjusted for age, sex, and race/ethnicity; and (2) Veterans Health Administration prescription opioid receipt. Analyses were conducted in 2018. The overall rate of opioid overdose among Veterans increased from 14.47 per 100,000 person-years in 2010 to 21.08 per 100,000 person-years in 2016 (adjusted rate ratio=1.65, 95% CI=1.51, 1.81). There was a decline in methadone overdose (adjusted rate ratio=0.66, 95% CI=0.51, 0.84) and no significant change in natural/semisynthetic opioid overdose (adjusted rate ratio=1.08, 95% CI=0.94, 1.24). However, the synthetic opioid overdose rate (adjusted rate ratio=5.46, 95% CI=4.41, 6.75) and heroin overdose rate (adjusted rate ratio=4.91, 95% CI=3.92, 6.15) increased substantially. Among all opioid overdose decedents, prescription opioid receipt within 3 months before death declined from 54% in 2010 to 26% in 2016. Opioid overdose rates among Veterans Health Administration Veterans increased because of increases in heroin and synthetic opioid overdose rates. Prescriptions of opioids declined among patients who died from all categories of opioid overdose; by 2016, only a minority received an opioid analgesic from Veterans Health Administration within 3 months of overdose. Future prevention efforts should extend beyond patients actively receiving opioid prescriptions.

Why Women Veterans Do Not Use VA-Provided Health and Social Services: Implications for Health Care Design and Delivery

Background: The Veterans Administration (VA) is transforming its historically male-dominated health care system to better serve women veterans, few of whom, nevertheless, use VA health care. We describe the factors affecting women veterans’ use of VA-provided health care. Methods: We conducted in-person interviews with 22 women veterans in Los Angeles, California, from 2013 to 2015 who received some non-VA health care. Using grounded theory, we inductively identified the major themes and selected illustrative quotations. Results: Why women veterans do not use VA health care is shaped by factors related to the safety, quality, and value of health care, including poor linkage to VA services during and after military service, limited knowledge and inaccurate beliefs regarding eligibility for VA services, bureaucratic barriers impeding receipt of VA care, VA environments triggering memories of negative military experiences, negative interpersonal experiences with VA staff, and perceiving VA settings as unsafe, ill-equipped to address addiction, and insensitive to women-specific needs and preferences. Women are attracted to VA health care for its whole health care capacity, peer social support, and proactive clinicians. Conclusion: Findings can inform improvements to VA health care design and delivery, thereby bolstering those aspects of VA care that women veterans value while reducing health care utilization barriers.

Rates and Correlates of Depression Symptoms in a Sample of Pregnant Veterans Receiving Veterans Health Administration Care.

Depression is the most commonly diagnosed medical condition among women veterans ages 18 to 44; however, depression symptoms occurring during pregnancy have not been well-studied in this population. Pregnant veterans were recruited from 15 Veterans Health Administration sites across the United States; our sample included 501 participants. Sociodemographic characteristics, military service, health status, and pregnancy related factors, as well as the Edinburgh Postnatal Depression Scale (EPDS), were collected as part of a telephone survey. Additional data were obtained from electronic health record data. We used multivariable logistic regression models to examine factors associated with an EPDS score suggestive of clinically significant depressive symptoms (≥10). Prenatal EPDS scores of 10 or greater were calculated for 28% of our sample. Our final model indicated that factors associated with decreased odds of an EPDS score of 10 or greater included spousal or partner support during pregnancy (adjusted odds ratio [aOR], 0.35; 95% confidence interval [CI], 0.16-0.77) and employment (aOR, 0.40; 95% CI, 0.24-0.67). A past diagnosis of anxiety (aOR, 2.54; 95% CI, 1.43-4.50), past antidepressant use (aOR, 3.27; 95% CI, 1.71-6.24), and active duty service (aOR, 1.91; 95% CI, 1.08-3.37) were associated with increased odds of having an EPDS score of 10 or greater. This is the first quantitative estimate of depression symptoms in pregnant veterans across multiple Veterans Affairs facilities. The prevalence of depression symptomology was greater than the high end of prevalence estimates in the general pregnant population. Given that the risk of depression increases during the postpartum period, women who can be identified with depressive symptomatology during pregnancy can be offered critical resources and support before giving birth.

Comparing drug interaction frequencies of various hepatitis C treatment regimens among monoinfected patients

Introduction and ObjectivesFour regimens are recommended for treating hepatitis C (HCV) genotype 1 infection. Study aims were to (1) compare frequencies of contraindicated drug interactions (XDDIs) when each HCV regimen is added to medication profiles of HCV-monoinfected patients, (2) quantify the proportion of patients with XDDIs to all four regimens and (3) determine covariates independently associated with having a XDDI to all four regimens. Materials and methodsA cross-sectional study was performed within Upstate New York Veterans Healthcare Administration. Inclusion criteria: (1) age ≥18 years, (2) HCV monoinfection and (3) available medication list. Data extracted were: demographics, comorbidities, and medication list. Primary outcome was XDDIs involving patient's home medications and each HCV regimen. University of Liverpool drug interaction website was used to define XDDIs. Two-way comparisons of regimens were performed using McNemar's test where p<0.0083 was considered statistically significant. Multivariate regression analyses were performed to determine predictors. ResultsOf the 4047 subjects, mean±standard deviation age was 59.8±7.6. Median (interquartile range) number of medications used was 7 [4–11]. Frequencies of XDDIs after the addition of each regimen ranged from 2.8% to 17.8% and were mostly statistically different from one another. There were 95 (2.3%) patients with XDDIs to all four regimens. Predictors of having XDDIs to all four regimens were ≥6 medications and HCV infection ≥10 years. ConclusionThe frequencies of XDDIs varied between HCV regimens. Number of medications and duration of HCV infection were predictors of having XDDIs to all four regimens.

Coordinating Care Across VA Providers and Settings: Policy and Research Recommendations from VA's State of the Art Conference.

Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran.

Metformin modifies disparity in hepatocellular carcinoma incidence in men with type 2 diabetes but without chronic liver diseases.

BackgroundWe assessed racial/ethnic disparity in hepatocellular carcinoma (HCC) incidence among men with type 2 diabetes (T2D) but without chronic liver diseases (CLD), and whether metformin use modified the disparity.MethodsStudy cohort: the nationwide Veterans Administration Health Care System electronic medical records among 40‐89 years old men with T2D; without CLD, cancer, cardiovascular or renal diseases previously; insulin and thiazolidinedione naive. Logistic regression analyses compared HCC incidence between race/ethnicity groups under no metformin use adjusted for covariates and inverse propensity score weights (IPSW) for race/ethnicity. The generalizability technique integrated with IPSW was incorporated to compare covariates adjusted odds ratios (aOR) of HCC associated with metformin use among race/ethnicity groups.ResultsStudy cohort: N = 84 433; 79.47% non‐Hispanic white (NHW), 15.5% non‐Hispanic African American (NHAA), 5.03% Hispanics; 36.76% metformin users; follow‐up 6.10 ± 2.87 years; age 67.8 ± 9.8 years, HbA1c 6.57 ± 0.98%; 0.14% HCC cases. Under no metformin use, HCC incidence was lower for NHAA vs NHW (aOR = 0.60 [0.40‐0.92]), similar between NHW and Hispanics. Metformin was associated with reduced HCC risk: aOR = 0.57 (0.40‐0.81) for NHW; aOR = 0.35 (0.25‐0.47) for NHAA; aOR = 0.31 (0.22‐0.43) for Hispanics. Metformin dose >1000 mg/d was neutral for NHW; less effective for NHAA (P = 0.02); more effective for Hispanics (P = 0.002).ConclusionsIn men with T2D but without CLD nor metformin use, HCC incidence was lower for NHAA compared to NHW or Hispanics; similar between NHW and Hispanics. Metformin use reduced HCC risk and modified the race/ethnicity disparity.ImpactMetformin's heterogeneous HCC prevention effect elucidates potential interventions to modify HCC disparity in patients with T2D.

(318) Case Study of a Psychologically Complex VA Spinal Cord Stimulator Recipient: A Multi-Component Intervention and Significant Change on Repeated Psychological Measures

Patients in the Veterans Healthcare Administration system are known to have more physical and psychological morbidities than civilian age and gender matched controls. Relatedly, psychological disorders are known in the Spinal Cord Stimulator (SCS) literature to be a factor negatively affecting efficacy of the SCS device in recipients. This patient had an extensive history of multiple psychological morbidities but had successfully completed a CBT-based pain management and coping skills group and maintained a productive relationship with their psychiatrist for 10 years. Thus, the patient demonstrated themselves capable of positive change over time, which may be a prognostic indicator of SCS success if that psychological stability can be maintained. As part of an ongoing Veterans Affairs Quality Improvement (VAQI) Project, psychological measures of Depression, as measured by the Patient Health Questionnaire (PHQ-9); Catastrophizing, as measured by the Pain Catastrophizing Scale (PCS); and PTSD symptoms as measured by the Posttraumatic Stress Disorder Checklist (PCL 5) were administered to patients considered candidates for Spinal Cord Stimulator placement at initial evaluation. Those measures were repeated with recipients after device implantation at 1 and 6 month follow ups. Measure scores were converted to z-scores to be able to compare results across measures. Time between measure administration was the Independent Variable and represented the effect of the Spinal Cord Stimulator implant. Results indicated significant differences in the desired direction between baseline and six months for the PHQ-9 and the PCS; baseline and both one month and six months on the PCL5. Data collection is currently underway with additional patients advancing to the SCS trial and permanent implant stage. The PROMIS Function, Pain Interference, and World Health Organization Quality of Life (WHOQOL) measures have been added to further identify factors responsive to psychological intervention prior to SCS implantation and prognostic potential for SCS efficacy.

Abstract P336: Predictors of High Intensity Statin Initiation for Primary Prevention in Veterans With Familial Hypercholesterolemia Phenotype

Introduction: Familial hypercholesterolemia (FH) phenotype, defined in part by LDL-Cholesterol (LDL-C) ≥190mg/dL, is a strong risk factor for cardiovascular disease (CVD). The 2013 ACC/AHA cholesterol guidelines recommend high intensity statins for primary prevention irrespective of global risk assessment. We sought to determine predictors of high intensity statin initiation in patients with FH phenotype in the Veteran’s Health Administration (VHA). Methods: Inclusion criteria consisted of VHA care (2002-2014), age ≥21 years, absence of prevalent CVD, baseline maximum LDL-C ≥190 mg/dL, no prior statin use, and statin initiation within 90 days of outpatient LDL-C measurement. Baseline characteristics were obtained from the electronic health record. We defined baseline LDL-C using quartile cutoffs. High intensity statin definitions were based on the 2013 cholesterol guidelines plus high dose simvastatin when it was available. Multivariable logistic regression models were constructed to determine the odds of high intensity statin initiation versus low or moderate intensity. Results: A total of 88,878 Veterans (age=53.7±11.6, men=91%; white race=74%, LDL-C mean=209.5±23.9, Q1=195, median=202, Q3=215) met inclusion criteria. High intensity statin was initiated in 29,533 (33%) of patients. Comorbidities included smoking history (80%), hypertension (39%), diabetes (10%), and chronic kidney disease (3%). Significant predictors were age &gt;40 years, male sex, diabetes, hypertension, black race, smoking, higher baseline LDL-C quartile, and recent calendar year. Veterans with cancer and white race had lower odds of statin initiation. Conclusion: Nearly 1/3 of the Veteran population with the FH phenotype was started on high intensity statins. They were more likely to be older, black, smokers, hypertensive, diabetic, and have a higher baseline LDL-C. The odds of high intensity statin initiation increased in recent years, which may partly reflect practice changes concordant with recent cholesterol guidelines.

CARING FOR OLDER PATIENTS WITH COMPLEX PROBLEMS: CHALLENGES, STRATEGIES, AND THE VETERANS HEALTH ADMINISTRATION EXPERIENCE: Session 411

An aging population with complex and interacting medical, functional, psychosocial, and behavioral concerns poses a challenge for our healthcare systems and healthcare policy. A small percentage of patients accounts for most health care spending in the United States, including in the Veterans Health Administration (VHA). In VHA, particular concern has focused on aging Veterans with medical, neurocognitive, and/or mental disorder comorbidities whose behaviors may be disruptive to care. These behaviors may put patients at risk for harm to self or others and lead to inefficient, ineffective, or inappropriate use of resources. This session aims to engage participants in considering varying definitions of patients with complex needs, and how VHA has worked to understand these needs, identify promising practices, and prepare a workforce capable of meeting these needs. In the first presentation, the presenter will discuss varying conceptualizations of “complex patients” and related challenges for targeted program development and dissemination. An overview of the development, activities, and plans for the VHA Care for Patients with Complex Problems Program will be presented. The audience will be engaged in discussing the challenges for providing geriatric behavioral care across inpatient mental health, nursing home, and rehabilitation care settings, and VHA efforts to develop guidance for teams wishing to enhance capacity to provide geriatric behavioral care in these settings will be shared. A unique program, the Behavioral Recovery Outreach (BRO) Team, that facilitates transitions of care for Veterans with complex behavioral needs from inpatient nursing care to community-based care settings will be described. A closing discussion with the audience will center around the next steps in policy and program development and evaluation needed to meet the needs of aging population with complex care needs.

Barriers to a Timely Discharge From Short-Term Care in VA Community Living Centers

ABSTRACTThis study aimed to identify the barriers to a timely discharge from short-term care in Veterans Health Administration (VHA) Community Living Centers (CLCs). Ninety-nine interviews were conducted with CLC staff in leadership and direct-care positions in eight varied CLCs. Major themes identified through qualitative analysis as barriers to a timely discharge were a lack of patients’ financial resources, low social support, and reluctance of some veterans and staff to view a timely veteran discharge as their goal. Staff also perceived that barriers were much more difficult to overcome in regions where community-based long-term services and supports were limited or nonexistent. Because VHA has lagged behind Medicaid more generally in terms of investment in these types of services, additional strategies are warranted to achieve the important policy goal of deinstitutionalizing VHA care and returning veterans to their homes in the community.