Veterans Health Administration Facilities Research Articles

The economic impact of cannabis use disorder and dementia diagnosis in veterans diagnosed with traumatic brain injury.

Studies have demonstrated that individuals diagnosed with traumatic brain injury (TBI) frequently use medical and recreational cannabis to treat persistent symptoms of TBI, such as chronic pain and sleep disturbances, which can lead to cannabis use disorder (CUD). We aimed to determine the Veterans Health Administration (VHA) healthcare utilization and costs associated with CUD and dementia diagnosis in veterans with TBI. This observational study used administrative datasets from the population of post-9/11 veterans from the Long-term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium and the VA Data Warehouse. We compared the differential VHA costs among the following cohorts of veterans: (1) No dementia diagnosis and No CUD group, (2) Dementia diagnosis only (Dementia only), (3) CUD only, and (4) comorbid dementia diagnosis and CUD (Dementia and CUD). Generalized estimating equations and negative binomial regression models were used to estimate total annual costs (inflation-adjusted) and the incidence rate of healthcare utilization, respectively, by dementia diagnosis and CUD status. Data from 387,770 veterans with TBI (88.4% men; median [interquartile range (IQR)] age at the time of TBI: 30 [14] years; 63.5% white) were followed from 2000 to 2020. Overall, we observed a trend of gradually increasing healthcare costs 5 years after TBI onset. Interestingly, in this cohort of veterans within 5 years of TBI, we observed substantial healthcare costs in the Dementia only group (peak = $46,808) that were not observed in the CUD and dementia group. Relative to those without either condition, the annual total VHA costs were $3,368 higher in the CUD only group, while no significant differences were observed in the Dementia only and Dementia and CUD groups. The findings suggest that those in the Dementia only group might be getting their healthcare needs met more quickly and within 5 years of TBI diagnosis, whereas veterans in the Dementia and CUD group are not receiving early care, resulting in higher long-term healthcare costs. Further investigations should examine what impact the timing of dementia and CUD diagnoses have on specific categories of inpatient and outpatient care in VA and community care facilities.

Beyond Hospital-Level Aggregated Data: A Methodology to Adapt Clinical Data From the Electronic Health Record for Nursing Unit-Level Research.

Studies of nurse staffing frequently use data aggregated at the hospital level that do not provide the appropriate context to inform unit-level decisions, such as nurse staffing. Describe a method to link patient data collected during the provision of routine care and recorded in the electronic health record (EHR) to the nursing units where care occurred in a national dataset. We identified all Veterans Health Administration acute care hospitalizations in the calendar year 2019 nationwide. We linked patient-level EHR and bar code medication administration data to nursing units using a crosswalk. We divided hospitalizations into segments based on the patient's time-stamped location (ward stays). We calculated the number of ward stays and medication administrations linked to a nursing unit and the unit-level and facility-level mean patient risk scores. We extracted data on 1117 nursing units, 3782 EHR patient locations associated with 1,137,391 ward stays, and 67,772 bar code medication administration locations associated with 147,686,996 medication administrations across 125 Veterans Health Administration facilities. We linked 89.46% of ward stays and 93.10% of medication administrations to a nursing unit. The average (standard deviation) unit-level patient severity across all facilities is 4.71 (1.52), versus 4.53 (0.88) at the facility level. Identification of units is indispensable for using EHR data to understand unit-level phenomena in nursing research and can provide the context-specific information needed by managers making frontline decisions about staffing.

EFFICACY OF MALNUTRITION SCREENING AMONG OLDER VETERANS AT AN URBAN VA HOSPITAL

Abstract Nearly half of the Veteran population is >65 years. Older Veterans are at increased risk of malnutrition associated with increased mortality, morbidity, length of stay, and readmissions. Malnutrition-focused quality measures are needed to combat this public health issue. The purpose of this study was to identify gaps in malnutrition screening at an urban VA facility. Chart auditing was conducted for all medical admissions during 72 hour periods across 14 months. Auditing determined if nutrition screening was completed, with an admission weight, and if nutrition was consulted for nutritionally compromised Veterans. Screening was conducted using the Malnutrition Screening Tool (MST). Additionally, estimated prevalence of nutritionally compromised Veterans was assessed using auditing data from 30 days. Audit data showed that on average only 57.4% (n=458) of Veterans admitted for inpatient care were screened correctly. Of those screened incorrectly, the three most common errors were 1) not collecting a weight on admission (N=82 (42.1%)); 2) inaccurate weight change interpretations (N=41 (21%)); 3) failure to refer nutritionally at-risk Veterans to nutrition services (N=38 19.5%)). Prevalence auditing demonstrated over 1/3 of Veterans were nutritionally compromised at the start of their hospitalization (36.43%, (N=295)). With an increasingly aging population in the United States there is a focus on shifting to value based payment systems. The new CMS Global Composite Malnutrition Score will include evaluation of hospitals malnutrition screening processes. There is a significant opportunity to close these gap areas and to adopt clinically relevant best practices to provide nutrition care earlier to at risk Veterans.

ROOTS TO GROW AND WINGS TO FLY: EDUCATING MEDICINE AND PHARMACY TRAINEES ON VIONE MEDICATION DEPRESCRIBING METHODOLOGY

Abstract An aging world population translates to more chronic illnesses, more medications with potential and relevant cumulative burdens such as non-compliance, adverse outcomes, prescription cascades, confusion, compromised patient safety and quality of life standards. VIONE stands for the 5 filters that categorize medications as Vital, Important, Optional, Not indicated, Every medication has an indication. This is an electronic health record methodology currently implemented in 122 VA facilities across the nation. Physicians and pharmacists review medications, prioritize medications that merit deprescribing interventions, deprescribe through shared decision making and monitor outcomes. In the VA system, within 7 years, we successfully deprescribed over 1.4 million inappropriate medications impacting over 600,000 veterans, used by over 14000 medical providers, with an annualized cost savings of ~ 132 million US dollars. We incorporate VIONE deprescribing education while training our pharmacy residents, medical students, residents and fellows rotating at our VA Medical Center through case based, bed side, didactic and team based multi media learning strategies . The engagement, feedback, demonstrated formal and informal responses remain very promising. Capturing the attention of trainees in their formative years deepens their roots as they spread their wings into practicing safe medication prescribing practices that are current, cutting edge, evidence based and empowering as we train the trainers. We envision medication deprescribing to be part of future academic core curriculum. Our Interdisciplinary team will present compelling data, experiences and outcomes stemming from education of trainees regarding safe medication optimization and deprescribing practices utilizing VIONE methodology that won national and international acclaim.

Harm reduction stories: leveraging graphic medicine to engage veterans in substance use services within the VA

BackgroundHarm reduction strategies can decrease morbidity and mortality associated with substance use. Various barriers limit conversation around substance use between clinicians and patients. Graphic medicine techniques can inform and encourage patient-centered conversations about substance use. We describe the co-development of a harm reduction-focused graphic medicine comic that depicts the infectious risks associated with injection drug use and patient-centered approaches to providing education about potential risk mitigation strategies.MethodsWe formed a co-design group of veterans with lived experience with substance use, physicians, health services researchers, and community-based harm reduction leaders. Over the course of ten sessions, the co-design team developed a storyline and key messages, reviewed draft content and worked with a graphic designer to develop a comic incorporating the veterans’ input. During each session, co-design leads presented drafts of the comic and invited feedback from the group. The comic was edited and adapted via this iterative process.ResultsThe comic depicts a fictionalized clinical vignette in which a patient develops an injection-related abscess and presents to their primary care provider. The dialogue highlights key healthcare principles, including patient autonomy and agency, and highlights strategies for safer use, rather than emphasizing abstinence. Feedback from co-design group participants highlights lessons learned during the development process.DiscussionGraphic medicine is ideally suited for a patient-centered curriculum about harm reduction. This project is one of several interventions that will be integrated into VA facilities nationally to support incorporation of harm reduction principles into the care of persons who inject drugs.

Antimicrobial stewardship strategy implementation and impact in acute care spinal cord injury and disorder units

Context Antimicrobial Stewardship Programs (ASPs) are crucial to optimizing antibiotic use. ASPs are implemented in the Veterans Health Administration (VAs), but they do not target the needs of populations at high risk for resistant infections, such as spinal cord injury and disorder (SCI/D). Objective The goal of this study was to assess key ASP leader and SCI/D clinicians’ perceived level of implementation and impact of 33 Antimicrobial Stewardship (AS) strategies. Method SCI/D clinicians and ASP leaders across 24 VA facilities with SCI/D units were surveyed. Participants rated their perceived level of impact (“high”, “mild”, “low”) and perceived level of implementation (“not”, “partially”, “fully”) for 33 AS strategies in SCI/D units in VAs. Strategies were grouped into core elements which they support. We conducted a Fisher’s exact test to assess differences between respondent perceptions based on role (SCI/D clinicians versus ASP leaders). Results AS strategy implementation varied across VA facilities. Of the AS strategies, pre-authorization was perceived to be highly impactful (78%) and fully implemented (82%). SCI/D clinicians and ASP leaders rated AS strategies differently such that SCI/D clinicians were less aware of implementation of AS strategies related to reporting requirements; further, SCI/D clinicians rated strategies which guide treatment duration and which limit C. difficile antibiotic exposure as more impactful than ASP leaders. Ratings for facility-wide and SCI/D unit ratings did not significantly differ for impact or implementation. Conclusion Implementation practices varied across VA facilities. Future work should implement highly impactful AS strategies according to facility and unit needs.

Strategies to enhance remote monitoring adherence among patients with cardiovascular implantable electronic devices

Remote monitoring (RM) of patients with cardiovascular implantable electronic devices (CIEDs) (pacemakers and implantable cardioverter-defibrillators) has a Class 1, Level of Evidence A Heart Rhythm Society recommendation. Yet RM adherence varies widely across settings, and factors associated with variation are not understood. The purpose of this study was to identify strategies for supporting RM across Veterans Health Administration (VHA) facilities. In a national evaluation, we surveyed and interviewed 27 nurses, medical instrument technicians, and advanced practice providers across 26 VHA facilities (following approximately 15,000 CIED patients). Participants were selected based on overall patient adherence by facility, which ranged from 46%-96%. Questions covered RM adherence strategies, manufacturer resources, organizational characteristics, and workflows for optimizing adherence. All clinicians reported that RM adherence was extremely important (53.8%), very important (34.6%), or important (11.5%) for improving patient outcomes. High performing facilities prioritized consistent patient education about RM and evaluated nonadherence using dashboards and manufacturer web sites. High performing facilities instituted clear standard operating procedures that defined staff responsibilities and facilitated efficient contact with nonadherent patients and then family members by phone and then mail. Clinicians based at high performing facilities spent twice as many hours per week (9.1) on average managing RM adherence compared to other facilities (4.5). Effective communication (internally and with non-VHA care partners) and use of CIED manufacturer resources were essential. Facilities that were not high performing rarely used these strategies. Clinicians can support high RM adherence by emphasizing patient education, regularly assessing and addressing nonadherence using staff protocols, and engaging CIED manufacturers.

The effectiveness of a telephone smoking cessation program in mental health clinic patients by level of mental well-being and functioning: a secondary data analysis of a randomized clinical trial

BackgroundFew studies have examined the effectiveness of telephone smoking cessation interventions by severity of behavioral health symptoms. Using data from a telephone counseling study, we examined whether abstinence rates varied by level of behavioral health symptoms.MethodsThe parent study recruited adults who smoke cigarettes (N = 577) referred by mental health providers at six Veterans Health Administration facilities. Participants were randomized to specialized telephone counseling (intervention) or state Quitline referral (control). Participants completed assessments at baseline and 6 months, including the BASIS-24, a self-report measure of behavioral health symptoms and functioning. We used the BASIS-24 median to dichotomize participants as having high or low scores. The primary outcome was 30-day self-reported abstinence at 6 months. We compared groups on outcomes by logistic regression and performed an interaction effect analysis between treatment assignment and groups.ResultsAt baseline, those with high behavioral health symptoms scores reported heavier nicotine dependence and more sedative and/or antidepressant use, compared to participants with low behavioral health symptoms. At 6 months, participants with low behavioral health symptoms scores in the intervention reported higher rates of 30-day abstinence compared to those in the control arm (26% vs 13%, OR = 2.3, 95% CI = 1.8, 2.9). People with high behavioral health symptoms scores reported no difference in 30-day abstinence between the treatment assignments at 6 months (12% vs. 13%, OR = 1.1, 95% CI = 0.6, 2.0).ConclusionsOnly participants with low behavioral health symptoms scores reported higher abstinence rates in the intervention compared to the state Quitline. Future research can examine alternative approaches for people with worse mental well-being and functioning.Trial registrationThe parent study is registered at www.clinicaltrials.gov NCT00724308.

Abstract 12545: Inpatient Physical Therapy Use Among US Veterans Hospitalized for Heart Failure

Background: Physical debilitation is a common adverse effect of heart failure (HF) hospitalization and is associated with adverse outcomes. Hypothesis: Inpatient physical therapy (PT) mitigates the adverse effects of HF hospitalization, and improves outcomes in patients hospitalized with HF. Methods: Patients with an index hospitalization for HF at a VA facility between January 1, 2013 to December 31, 2017 were identified. Change in PT use over time was evaluated using the Cochran-Armitage trend test. After propensity matching, the impacts of inpatient PT exposure on 90-day all-cause mortality, and a composite of all-cause mortality and readmission were assessed. Results: Of 44,299 patients admitted with HF, 11,685 (26.3%) received inpatient PT. Compared with those who did not receive PT, those who did were older (70.7 vs 75.8; P<0.001), more frequently White (70.0% vs 74.0%; P<0.001), and had a longer length of stay (3.9 vs 7.4; P<0.001). The proportion of patients who utilized PT increased from 24.9% to 55.4% during the study period (P<0.001). After propensity matching, inpatient PT use was associated with worse all-cause mortality (HR: 1.24 [1.14 - 1.36]; P<0.0001) ( Figure ), and a composite outcome of death or all-cause hospitalization (HR: 1.07 [1.02 - 1.12]; P=0.0038) at 90 days. Conclusions: Inpatient PT use significantly increased from 2013 to 2017. After propensity matching, utilization of PT services was associated with adverse outcomes.

Abstract 16234: Higher 30-Day Mortality Following Diagnostic Coronary Angiographies Performed at Community versus VA Hospitals Despite Similar Pre-Procedure Mortality Risk

Introduction: Polices to improve access increased referrals to VA community care (VACC), including diagnostic coronary angiography (DCA). Yet, studies showing higher mortality rates following percutaneous coronary intervention at VACC vs VA facilities (VAF), raise concern about VACC quality. Hypothesis: 30-day mortality following DCA would be greater at VACC vs VAF. Methods: We identified outpatient DCAs at VAF and VACC from October 2014-June 2019 (N=75,950) and were matched to balance DCAs on eight characteristics including baseline mortality risk. DCAs with same-day PCI, missing covariates or without a good match were excluded (n=33,060). Primary exposure was DCA at VACC (vs. VAF). We examined weighted characteristics of DCAs and 30-day mortality by VACC status; used weighted logistic regression, adjusting for Veterans’ age, race, rurality, insurance, distance to VAF, Elixhauser mortality risk score and presence of ischemic heart disease, to compare 30-day mortality following DCA at VACC vs VAF. We used instrumental variables analysis to explore any confounders. Results: Among 42,890 DCAs, 27% were at VACC. Weighted characteristics of DCAs were similar by VACC status; were predominantly among male, white race, older aged patients. VACC vs VAF patients had similar mean pre-DCA mortality risk scores (4.7 [SD 9.2]) vs 4.8 [SD 9.2]), respectively (SMD=-0.01). Overall, 30-day mortality was 0.9%; 2.5% at VACC and 0.4% at VAF (SMD=0.18). Overall, predicted probabilities of 30-day mortality were greater in VACC vs VAF (Figure 1).In weighted regression analysis, odds of 30-day mortality were greater in VACC vs VAF (aOR 7.07, 95% CI=4.88, 10.24, p lt0.001). Instrument variable analysis suggested selection on unobserved factors contributed to VACC assignment and mortality. Conclusions: Risk of 30-day mortality was greater following DCAs performed at VACC vs VAF, despite comparable baseline mortality risk. Further research is needed to explain this difference.

Abstract 13466: Trends in Prevalence of Psychiatric Cardiovascular Risk Factors for Women Veterans

Introduction: Psychiatric disorders such as anxiety, depression, and posttraumatic stress disorder (PTSD) have been increasingly recognized as cardiovascular disease (CVD) risk factors in the past two decades. US women Veterans (WV) are a growing and high-risk population for CVD. The goal of this study was to investigate the prevalence of these psychiatric CVD risk factors among US WV over a two-decade period. Methods: The national Veterans Affairs electronic health records were utilized to assess prevalence of the above disorders among US WV who visited a VA facility from 1/1/2000 to 12/31/2019. All diagnoses were based on International Classification of Disease (ICD) 9 th and 10 th version diagnostic codes. Results: Over the study period, the population of WV grew from 80,707 to 739,309, and the average age of the WV remained stable, 48 (2000) and 49 (2019) years old. Table 1 reveals the prevalence of these psychiatric CVD risk factors over the study period. Prevalence of each psychiatric disorder increased over the study period, with accelerated growth over the last decade of the study period. Conclusion: The prevalence and growth of these psychiatric l CVD risk factors among US WV is alarming. Focused research is warranted on potential interventions to reduce, and treat these nontraditional CVD risk factors to improve both psychiatric and cardiovascular health for WV.

The role of therapy delivery and clinic organizational factors in explaining therapist effects for trauma-focused psychotherapies in the Veterans Health Administration.

This study estimated the size of therapist effects (TEs) for dropout and clinical effectiveness of two trauma-focused psychotherapies (TFPs) and evaluated whether therapy delivery and clinic organizational factors explained observed TEs. Participants were 180 therapists (54.4% psychologists, 42.2% social workers) from 137 Veterans Health Administration facilities and 1,735 patients (24.7% women; 27.2% people of color) who completed at least two TFP sessions. Outcomes were dropout (< 8 TFP sessions) and for a subsample (n = 1,273), clinically meaningful improvement and recovery based on posttraumatic stress disorder checklist for DSM-5 (PCL-5) scores. Therapist-level predictors were ascertained through survey, manual chart review, and administrative data. Multilevel models estimated TEs. Over half (51.2%) of patients dropped out and those who dropped out were less likely to meet criteria for clinically meaningful improvement or recovery (ps < .001). Adjusting for case-mix and TFP type, therapists accounted for 5.812% (p < .001) of the unexplained variance in dropout. The average dropout rate for the 45 therapists in the top performing quartile was 27.0%, while the average dropout rate for the 45 therapists in the bottom performing quartile was 78.8%. Variation between therapists was reduced to 2.031% (p = .140) when therapists' mean of days between sessions, adherence, implementation climate, and caseload were added to multilevel models. TEs were nonsignificant for clinically meaningful improvement and recovery. Interventions targeting therapy delivery and clinic organization have the potential to reduce variation between therapists in TFP dropout, so that more patients stay engaged long enough to experience clinical benefit. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Reducing medical errors for older veterans through communication, mediation and quality assurance

This study aims to evaluate the effectiveness of integrated strategies—communication protocols, mediation techniques, and quality assurance (QA) measures—in reducing medical errors among older veterans within the Veterans Health Administration (VHA). The research seeks to identify key factors contributing to errors and assess the impact of targeted interventions on enhancing patient safety. A mixed-methods research design was employed, combining qualitative interviews with healthcare providers, veterans, and caregivers, alongside quantitative analysis of medical records, incident reports, and patient safety surveys. The study utilized stratified sampling to ensure diversity across different VHA facilities and applied statistical techniques, including chi-square tests, logistic regression, and bootstrapping, to evaluate the effectiveness of interventions. The findings indicate a significant reduction in medical errors through the implementation of standardized communication protocols, particularly during patient handoffs. Mediation effectively resolved conflicts arising from errors, fostering a culture of transparency and continuous improvement. Facilities with robust QA programs demonstrated higher success rates in identifying and mitigating potential risks. The integration of these strategies led to a 45% reduction in overall error rates, with communication errors showing the most substantial decline. The study highlights the critical role of communication, mediation, and QA in enhancing patient safety within veterans' healthcare. While the results demonstrate the effectiveness of these strategies, challenges such as resource variability and the need for ongoing training persist. The research underscores the importance of adopting a multi-faceted approach to error reduction and suggests further exploration of advanced technologies and longitudinal studies to assess the sustainability of these interventions.

Maximizing Veterans Health Affairs Community Hospice Collaborations: Review of Perceived Resource Needs to Support Veterans at End of Life.

Within the United States, approximately 330 000 military veterans die annually, but only 5% of deaths occur in Veterans Health Administration (VHA) facilities. To help provide end-of-life care for veterans, the VHA built community partnerships with community hospice and palliative care (HPC) organizations. Veterans experience unique psychosocial factors making it vital to ensure HPC organizations have access to veteran-specific knowledge and resources to reduce suffering. To better understand the strengths and limitations of these partnerships, community HPC staff (N = 483) responded to quantitative and qualitative survey questions developed using an access to care theory for veterans. Survey responses demonstrated variable perceptions of access to VHA care and resources. Respondents reported excellent experiences (44%) and relationships with their local facility (50%) and had a reliable contact who provided needed assistance (92%). Thematic analysis identified a need for VHA care and barriers to access, which were associated with technical characteristics, and geographical and cultural issues. These findings can help inform future research and policy regarding access to VHA resources for end-of-life care for veterans in the community and guide resource development for community HPC providers.

Using a human-factors engineering approach to evaluate environmental cleaning in Veterans' Affairs acute and long-term care facilities: A qualitative analysis.

Environmental cleaning is important in the interruption of pathogen transmission. Although prevention initiatives have targeted environmental cleaning, practice variations exist and compliance is low. Evaluation of human factors influencing variations in cleaning practices can be valuable in developing interventions to standardized practices. We conducted a work-system analysis using a human-factors engineering (HFE) framework to identify barriers and facilitators to environmental cleaning practices in acute and long-term care settings within the Veterans' Affairs health system. We conducted a qualitative study with key stakeholders at 3 VA facilities. We analyzed transcripts for thematic content and mapped themes to the HFE framework. Staffing consistency was felt to improve cleaning practices and teamwork. We found that many environmental management service (EMS) staff were veterans who were motivated to serve fellow veterans, especially to prevent infections. However, hiring veterans comes with regulatory hurdles that affect staffing. Sites reported some form of monitoring their cleaning process, but there was variation in method and frequency. The EMS workload was affected by whether rooms were occupied by patients or were semiprivate rooms; both were reportedly more difficult to clean. Room design and surface finishes were identified as important to cleaning efficiency. HFE work analysis identified barriers and facilitators to environmental cleaning. These findings highlight intervention entry points that may facilitate standardized work practices. There is a need to develop task-specific procedures such as cleaning occupied beds and semiprivate rooms. Future research should evaluate interventions that address these determinants of environmental cleaning.

Location and Types of Treatment for Prostate Cancer After the Veterans Choice Program Implementation

The Veterans Choice Program (VCP) was implemented in 2014 to help veterans gain broader access to specialized care outside of the Veterans Health Administration (VHA) facilities by providing them with purchased community care (CC). To describe the prevalence and patterns in VCP-funded purchased CC after the implementation of the VCP among veterans with prostate cancer. This cohort study used VHA administrative data on veterans with prostate cancer diagnosed between January 1, 2015, and December 31, 2018. These veterans were regular VHA primary care users. Analyses were performed from March to July 2023. Driving distance (in miles) from residence to nearest VHA tertiary care facility. The location (VHA or purchased CC) in which treatment decisions were made was ascertained by considering 3 factors: (1) location of the diagnostic biopsy, (2) location of most of the postdiagnostic prostate-specific antigen laboratory testing, and (3) location of most of the postdiagnostic urological care encounters. The main outcome was receipt of definitive treatment and proportion of purchased CC by treatment type (radical prostatectomy [RP], radiotherapy [RT], or active surveillance) and by distance to nearest VHA tertiary care facility. Quality was evaluated based on receipt of definitive treatment for Gleason grade group 1 prostate cancer (low risk/limited treatment benefit by guidelines). The cohort included 45 029 veterans (mean [SD] age, 67.1 [6.9] years) with newly diagnosed prostate cancer; of these patients, 28 866 (64.1%) underwent definitive treatment. Overall, 56.8% of patients received definitive treatment from the purchased CC setting, representing 37.5% of all RP care and 66.7% of all RT care received during the study period. Most patients who received active surveillance management (92.5%) remained within the VHA. Receipt of definitive treatment increased over the study period (from 5830 patients in 2015 to 9304 in 2018), with increased purchased CC for patients living farthest from VHA tertiary care facilities. The likelihood of receiving definitive treatment of Gleason grade group 1 prostate cancer was higher in the purchased CC setting (adjusted relative risk ratio, 1.79; 95% CI, 1.65-1.93). This cohort study found that the percentage of veterans receiving definitive treatment in VCP-funded purchased CC settings increased significantly over the study period. Increased access, however, may come at the cost of low care quality (overtreatment) for low-risk prostate cancer.

Full practice authority and burnout among primary care nurse practitioners

BackgroundFull practice authority (FPA) improves clinical autonomy for nurse practitioners (NPs). Autonomy may reduce burnout. PurposeEstimate the effect of changing from reduced or restricted practice authority to FPA on NP burnout. MethodsIn this quasi-experimental study, we compared NP burnout before (2016) and after (2018) a Veterans Health Administration (VHA) regulation authorized NP FPA. Burnout proportions were estimated for VHA facilities by aggregating responses to the VHA's All Employee Survey from 1,352 primary care NPs. DiscussionSeventy-seven percent of facilities changed to FPA postregulation. Burnout was six points lower among NPs in facilities that changed to FPA compared to facilities that had FPA prior to the regulation; however, this association was not statistically significant. ConclusionNPs are increasingly working under independent practice. While changing to FPA did not reduce NP burnout, this association may vary by health care setting or when burnout is measured for individuals or teams.

What Goes into Patient Selection for Lung Cancer Screening? Factors Associated with Clinician Judgments of Suitability for Screening.

Rationale: Achieving the net benefit of lung cancer screening (LCS) depends on optimizing patient selection. Objective: To identify factors associated with clinician assessments that a patient was unlikely to benefit from LCS ("LCS-inappropriate") because of comorbidities or limited life expectancy. Methods: Retrospective analysis of patients assessed for LCS at 30 Veterans Health Administration facilities from January 1, 2015 to February 1, 2021. We conducted hierarchical mixed-effects logistic regression analyses to determine factors associated with clinicians' designations of LCS inappropriateness (primary outcome), accounting for 3-year predicted probability (i.e., competing risk) of non-lung cancer death. Measurements and Main Results: Among 38,487 LCS-eligible patients, 1,671 (4.3%) were deemed LCS-inappropriate by clinicians, whereas 4,383 (11.4%) had an estimated 3-year competing risk of non-lung cancer death greater than 20%. Patients with higher competing risks of non-lung cancer death were more likely to be deemed LCS-inappropriate (odds ratio [OR], 2.66; 95% confidence interval [CI], 2.32-3.05). Older patients (ages 75-80; OR, 1.45; 95% CI, 1.18-1.78) and those with interstitial lung disease (OR, 1.98; 95% CI, 1.51-2.59) were more likely to be deemed LCS-inappropriate than would be explained by competing risk of non-lung cancer death, whereas patients currently smoking (OR, 0.65; 95% CI, 0.58-0.73) were less likely to be deemed LCS-inappropriate, suggesting that clinicians over- or underweighted these factors. The probability of being deemed LCS-inappropriate varied from 0.4% to 74%, depending on the clinician making the assessment (median OR, 3.07; 95% CI, 2.89-3.25). Conclusion: Concerningly, the likelihood that a patient is deemed LCS-inappropriate is more strongly associated with the clinician making the assessment than with patient characteristics. Patient selection may be optimized by providing decision support to help clinicians assess net LCS benefit.

Addressing Veteran Health-Related Social Needs: How Joint Commission Standards Accelerated Integration and Expansion of Tools and Services in the Veterans Health Administration

The Joint Commission recently named reduction of health care disparities and improvement of health care equity as quality and safety priorities (Leadership [LD] Standard LD.04.03.08 and National Patient Safety Goal [NPSG] Standard NPSG.16.01.01). As the largest integrated health system, the Veterans Health Administration (VHA) sought to leverage these new accreditation standards to further integrate and expand existing tools and initiatives to reduce health care disparities and address health-related social needs (HRSNs). A combination of existing data tools (for example, Primary Care Equity Dashboard), resource tools (for example, Assessing Circumstances and Offering Resources for Needs tool), and a care delivery approach (for example, Whole Health) are discussed as quality improvement opportunities to further integrate and expand how VHA addresses health care disparities and HRSNs. The authors detail the development timeline, building, limitations, and future plans for these tools and initiatives. Responding to new health care equity Joint Commission standards led to new implementation strategies and deeper partnerships across VHA that facilitated expanded dissemination, technical assistance activities, and additional resources for VHA facilities to meet new standards and improve health care equity for veterans. Health care systems may learn from VHA's experiences, which include building actionable data platforms, employing user-centered design for initiative development and iteration, designing wide-reaching dissemination strategies for tools, and recognizing the importance of providing technical assistance for stakeholders. VHA continues to expand implementation of a diverse set of tools and resources to reduce health care disparities and identify and address unmet individual veteran HRSNs more widely and effectively.

SAT681 Obesity Is A Disease. Maximize Positive Patient Outcome With Medical Treatment

Abstract Disclosure: S. Casula: None. P. Rios Florez: None. L. Oropesa Gonzalez: None. J. Molina: None. V. Nagpal: None. T. Sawyer: None. V.S. Lagari-Libhaber: None. Objective: Obesity has been recognized as a disease by the American Medical Association since 2013. Despite this, medical treatment is currently offered only to 2% of the patients in the USA. In comparison, 86% of the patients diagnosed with Type 2 Diabetes receive pharmacotherapy. Recent studies suggest that one out of every three Veterans (32.7%) have a BMI &amp;gt;30. As obesity is well known to be associated with multiple comorbidities, programs implementing early recognition and treatment are critical. While dietary counseling, behavioral therapy, and lifestyle changes are important components of obesity management, they are often not enough. Nevertheless, only a minority of these patients are offered weight loss medications. This analysis shows the impact of combining medications with lifestyle modifications at one of the largest VA facilities. Methods: From 2020-2022, a multidisciplinary team comprised of endocrinologists and clinical pharmacists at the Miami VA Healthcare System, implemented a weekly weight management clinic offering medications to all those patients who met clinical criteria and had previously tried and failed lifestyle modifications. A follow up in 3 months was provided to monitor effectiveness and/or side effects. Results: A total of 161 patients were evaluated from November 2020 to October 2022; 67% men and 33% women. The average age was 54 years old, ranging between 31 and 86. 39.1% patients were Black, 60.2% White, 0.6% Asian. 28% of the patients were Hispanic. Comorbidities included T2DM (30%), sleep apnea (37%), osteoarthritis (36%), hypogonadism (5%), dyslipidemia (55%), NASH (22%), and 9% of the women had PCOS. Of the 161 patients, 138 were started on one of the FDA-approved weight loss medications available (Orlistat, Phentermine/Topiramate, Naltrexone/Bupropion, Liraglutide or Semaglutide). 35 patients had side effects from the initial medication and 23 patients had a poor clinical response (less than 5% weight loss). These patients were offered alternative treatment. The number of prescriptions for Phentermine/Topiramate increased from 17 (Nov 2019 to Oct 2020) to 52 (Nov 2020-Oct 2021), and to 67 (Nov 2021-Oct 2022). The prescriptions for Semaglutide (for weight loss as main indication) increased from 18 (Nov 2020-Oct 2021) to 91 (Nov 2021-Oct 2022). Of the 102 patients who were on the same medication for at least 3 months (11.4 months average), on average the BMI decreased by 10.1% (-4.2 kg/m2), and their weight decreased by 9.4% ( -26.2 pounds). 46 patients were on the same treatment for at least 12 months (15.4 months average) and on average their BMI decreased by 10.9% (-4.7 kg/m2), and their weight decreased by 11% (-31.4 pounds). Conclusions: The successful implementation of this clinic highlights the importance of approaching obesity as a disease and incorporating pharmacotherapeutic agents to support weight loss in addition to lifestyle changes. Presentation: Saturday, June 17, 2023