Veterans Health Administration Healthcare Research Articles

We Built it, But Did They Come: Veterans’ Use of VA Healthcare System-Provided Complementary and Integrative Health Approaches

BackgroundInterest in complementary and integrative health (CIH) approaches, such as meditation, yoga, and acupuncture, continues to grow. The evidence of effectiveness for some CIH approaches has increased in the last decade, especially for pain, with many being recommended in varying degrees in national guidelines. To offer nonpharmacological health management options and meet patient demand, the nation’s largest integrated healthcare system, the Veterans Health Administration (VA), greatly expanded their provision of CIH approaches recently.ObjectiveThis paper addressed the questions of how many VA patients might use CIH approaches and chiropractic care if they were available at modest to no fee, and would patients with some health conditions or characteristics be more likely than others to use these therapies.DesignUsing electronic medical records, we conducted a national, three-year, retrospective analysis of VA patients’ use of eleven VA-covered therapies: chiropractic care, acupuncture, Battlefield Acupuncture, biofeedback, clinical hypnosis, guided imagery, massage therapy, meditation, Tai Chi/Qigong, and yoga.ParticipantsWe created a national cohort of veterans using VA healthcare from October 2016–September 2019.Key ResultsVeterans’ use of these approaches increased 70% in three years. By 2019, use was 5.7% among all VA patients, but highest among patients with chronic musculoskeletal pain (13.9%), post-traumatic stress disorder (PTSD; 10.6%), depression (10.4%), anxiety (10.2%), or obesity (7.8%). The approach used varied by age and race/ethnicity, with women being uniformly more likely than men to use each approach. Patients having chronic musculoskeletal pain, obesity, anxiety, depression, or PTSD were more likely than others to use each of the approaches.ConclusionsVeterans’ use of some approaches rapidly grew recently and was robust, especially among patients most in need. This information might help shape federal/state health policy on the provision of evidence-based CIH approaches and guide other healthcare institutions considering providing them.

Risk of Prostate Cancer in US Veterans With Rheumatoid Arthritis.

Patients with rheumatoid arthritis (RA) have an increased risk of select cancers, including lymphoma and lung cancer. Whether RA influences prostate cancer risk is uncertain. We aimed to determine the risk of prostate cancer in patients with RA compared to patients without RA in the Veterans Health Administration (VA). We performed a matched (up to 1:5) cohort study of male patients with and without RA in the VA from 2000 to 2018. RA status, as well as covariates, were obtained from national VA databases. Prostate cancer was identified through linked VA cancer databases and the National Death Index. Multivariable Cox models compared prostate cancer risk between patients with RA and patients without RA, including models that accounted for retention in the VA system. We included 56,514 veterans with RA and 227,284 veterans without RA. During 2,337,104 patient-years of follow-up, 6,550 prostate cancers occurred. Prostate cancer incidence (per 1,000 patient-years) was 3.50 (95% confidence interval [95% CI] 3.32-3.69) in patients with RA and 2.66 (95% CI 2.58-2.73) in patients without RA. After accounting for confounders and censoring for attrition of VA health care, RA was modestly associated with a higher prostate cancer risk (adjusted HR [HRadj ] 1.12 [95% CI 1.04-1.20]). There was no association between RA and prostate cancer mortality (HRadj 0.92 [95% CI 0.73-1.16]). RA was associated with a modestly increased risk of prostate cancer, but not prostate cancer mortality, after accounting for relevant confounders and several potential sources of bias. However, even minimal unmeasured confounding could explain these findings.

Screening for Latent Infections Among Users of High-Risk Immunosuppressants: A Cross-Sectional Analysis From the Veterans Health Administration Healthcare System.

Guidelines recommend screening for latent hepatitis B virus (HBV), hepatitis C virus (HCV), and tuberculosis (TB) before initiating biologics or targeted synthetic disease-modifying antirheumatic drugs (b/ts DMARDs) to avoid reactivation of life-threatening infections. The extent to which such screening occurs in the national Veterans Health Administration (VA) healthcare system is unknown. Using data from the Veterans Affairs' (VA) Corporate Data Warehouse, we performed a cross-sectional analysis of veterans receiving b/ts DMARDs between October 1, 2017, and September 30, 2019. We calculated the proportion of patients with screening completed for latent HBV, HCV, and TB between October 1, 1999 and September 30, 2019. Patient characteristics associated with complete screening were evaluated using mixed-effects multivariate logistic regression models. We also examined facility-level factors associated with high versus lower performance. A total of 51,764 unique patients from 129 VA facilities received b/ts DMARDs from 2017 to 2019. Of these, 63% had complete screening. Among the 11,006 patients identified as new users, 64% had complete screening. Higher screening rates were observed among Hispanic/Latinx and Black/African American patients, users of B-cell therapies, and patients who had seen oncology subspecialists. Substantial variation was observed across facilities, with complete screening ranging from 13% to 98% of patients. Higher screening rates were associated with highly complex, urban, and higher-volume facilities. Approximately two-thirds of veterans taking b/ts DMARDs have received guideline-recommended screening for HBV, HCV, and TB, but substantial facility variation was observed. Performance measures, robust multidisciplinary workflows, and electronic health record-based tools to feed information back to providers may improve screening rates for low-performing facilities.

Association of Quality of Care With Where Veterans Choose to Get Knee Replacement Surgery

Recent legislation expanded veterans' access to Veterans Health Administration (VA)-purchased care. Quality should be considered when choosing where to get total knee arthroplasty (TKA), but currently available quality metrics provide little guidance. To determine whether an association exists between the proportion of TKAs performed (vs purchased) at each VA facility and the quality of care provided (as measured by short-term complication rates). This 3-year cohort study used VA and community care data (fiscal year 2017 to fiscal year 2019) from the VA's Corporate Data Warehouse. Complications were defined following the Centers for Medicare and Medicaid Services' methodology. The setting included 140 VA health care facilities performing or purchasing TKAs. Participants included veterans who had 43 371 primary TKA procedures that were either VA-performed or VA-purchased during the study period. Of the 43 371 primary TKA procedures, 18 964 (43.7%) were VA-purchased. The primary outcome was risk-standardized short-term complication rates of VA-performed or VA-purchased TKAs. The association between the proportion of TKAs performed at each VA facility and quality of VA-performed and VA-purchased care was examined using a regression model. Subgroups were also identified for facilities that had complication rates above or below the overall mean complication rate and for facilities that performed more or less than half of the facility's TKAs. Among the study sample's 41 775 veterans who underwent 43 371 TKAs, 38 725 (89.3%) were male, 6406 (14.8%) were Black, 33 211 (76.6%) were White, and 1367 (3.2%) had other race or ethnicity (including American Indian or Alaska Native, Asian, and Native Hawaiian or other Pacific Islander); mean (SD) age was 66.9 (8.5) years. VA-performed and VA-purchased TKAs had a mean (SD) raw overall short-term complication rate of 2.97% (0.08%). There was no association between the proportion of TKAs performed in VA facilities and risk-standardized complication rates for VA-performed TKAs, and no association for VA-purchased TKAs. In this cohort study, surgical quality did not have an association with where veterans had TKA, possibly because meaningful comparative data are lacking. Reporting local and community risk-standardized complication rates may inform veterans' decisions and improve care. Combining these data with the proportion of TKAs performed at each site could facilitate administrative decisions on where resources should be allocated to improve care.

Evaluating the MyPath web-based reproductive decision support tool in VA primary care: Protocol for a pragmatic cluster randomized trial

BackgroundCounseling to identify and support individuals' desires for family formation is a key component of preventive health care that is often absent in primary care visits. This study evaluates a novel, web-based, person-centered intervention to increase the frequency and quality of communication about reproductive goals and healthcare needs in Veterans Health Administration (VA) primary care. MethodsWe describe a hybrid type 1 effectiveness-implementation cluster randomized controlled trial in seven VA healthcare systems testing a web-based reproductive health decision support tool (MyPath). VA primary care providers are enrolled and randomized to intervention or usual care arms. Veterans scheduled to see intervention-arm providers receive a text message inviting them to use MyPath ahead of their appointment; Veterans scheduled to see control-arm providers receive usual care. Target enrollment is 36 providers and 456 Veterans. Outcomes are assessed by Veteran self-report after the visit and at 3- and 6-months follow-up. The primary outcome is occurrence of reproductive health discussions involving shared decision making; secondary outcomes include measures of communication, knowledge, decision conflict, contraceptive utilization, and receipt of services related to prepregnancy health. Data on implementation barriers, facilitators and cost are collected. ResultsThe trial is ongoing with no results to report. We have enrolled 36 primary care providers across 7 VA healthcare systems and recruitment of Veterans is ongoing. ConclusionsResults will inform efforts to increase the quality and person-centeredness of reproductive healthcare delivery in primary care and to operationalize and scale up use of digital decision support tools in clinical settings.Trial Registration:http://ClinicalTrials.gov Identifier: NCT04584294Trial Status: Recruiting.

Factors Associated With Declining Lung Cancer Screening After Discussion With a Physician in a Cohort of US Veterans

Lung cancer screening (LCS) is underused in the US, particularly in underserved populations, and little is known about factors associated with declining LCS. Guidelines call for shared decision-making when LCS is offered to ensure informed, patient-centered decisions. To assess how frequently veterans decline LCS and examine factors associated with declining LCS. This retrospective cohort study included LCS-eligible US veterans who were offered LCS between January 1, 2013, and February 1, 2021, by a physician at 1 of 30 Veterans Health Administration (VHA) facilities that routinely used electronic health record clinical reminders documenting LCS eligibility and veterans' decisions to accept or decline LCS. Data were obtained from the Veterans Affairs (VA) Corporate Data Warehouse or Medicare claims files from the VA Information Resource Center. The main outcome was documentation, in clinical reminders, that veterans declined LCS after a discussion with a physician. Logistic regression analyses with physicians and facilities as random effects were used to assess factors associated with declining LCS compared with agreeing to LCS. Of 43 257 LCS-eligible veterans who were offered LCS (mean [SD] age, 64.7 [5.8] years), 95.9% were male, 84.2% were White, and 37.1% lived in a rural zip code; 32.0% declined screening. Veterans were less likely to decline LCS if they were younger (age 55-59 years: odds ratio [OR], 0.69; 95% CI, 0.64-0.74; age 60-64 years: OR, 0.80; 95% CI, 0.75-0.85), were Black (OR, 0.80; 95% CI, 0.73-0.87), were Hispanic (OR, 0.62; 95% CI, 0.49-0.78), did not have to make co-payments (OR, 0.92; 95% CI, 0.85-0.99), or had more frequent VHA health care utilization (outpatient: OR, 0.70; 95% CI, 0.67-0.72; emergency department: OR, 0.86; 95% CI, 0.80-0.92). Veterans were more likely to decline LCS if they were older (age 70-74 years: OR, 1.27; 95% CI, 1.19-1.37; age 75-80 years: OR, 1.93; 95% CI, 1.73-2.17), lived farther from a VHA screening facility (OR, 1.06; 95% CI, 1.03-1.08), had spent more days in long-term care (OR, 1.13; 95% CI, 1.07-1.19), had a higher Elixhauser Comorbidity Index score (OR, 1.04; 95% CI, 1.03-1.05), or had specific cardiovascular or mental health conditions (congestive heart failure: OR, 1.25; 95% CI, 1.12-1.39; stroke: OR, 1.14; 95% CI, 1.01-1.28; schizophrenia: OR, 1.87; 95% CI, 1.60-2.19). The physician and facility offering LCS accounted for 19% and 36% of the variation in declining LCS, respectively. In this cohort study, older veterans with serious comorbidities were more likely to decline LCS and Black and Hispanic veterans were more likely to accept it. Variation in LCS decisions was accounted for more by the facility and physician offering LCS than by patient factors. These findings suggest that shared decision-making conversations in which patients play a central role in guiding care may enhance patient-centered care and address disparities in LCS.

Short-term effects of comprehensive caregiver supports on caregiver outcomes.

To estimate the association of the Veterans Health Administration (VHA) Program of Comprehensive Assistance for Family Caregivers (PCAFC) implemented in 2011 with caregiver health and health care use. VHA claims and electronic health records from May 2009 to May 2018. Using a retrospective, pre-post study design with inverse probability of treatment weights to address selection into treatment, we examine the association of PCAFC on caregivers who are veterans: (1) outpatient primary, specialty, and mental health care visits; (2) probability of uncontrolled hypertension and anxiety/depression; and (3) VHA health care costs. We compare outcomes for caregivers approved for PCAFC (treatment) to caregivers denied PCAFC (comparison). Not applicable. In the year pre-application, we observe similar probabilities of having any VHA primary care (~36%), VHA specialty care (~24%), and VHA or VHA-purchased mental health care (~22%) for treatment and comparison caregivers. In the year post-application, treated caregivers had a 5.89 percentage point larger probability of any outpatient VHA primary care (p=0.002) and 4.34 percentage points larger probability of any outpatient mental health care use (p=0.014). Post-application, probabilities of having uncontrolled hypertension or diagnosed anxiety/depression were higher for both treated and comparison groups. In the second year post-application, treated caregivers had a 1.88 percentage point larger probability of uncontrolled hypertension (p=0.019) and 4.68 percentage points larger probability of diagnosed anxiety/depression (predicted probabilities: treated=0.30; comparison=0.25; p=0.005). We find no evidence of differences in VHA total costs by PCAFC status. Our findings that PCAFC enrollment is associated with increased health care diagnosis and service use may reflect improved access for previously unmet needs in the population of veteran caregivers for veterans in PCAFC. The costs and value of these increases can be weighed against other effects of the program to inform national policies supporting caregivers.

Factors That Affect Legionella Positivity in Healthcare Building Water Systems from a Large, National Environmental Surveillance Initiative.

Legionella growth in healthcare building water systems can result in legionellosis, making water management programs (WMPs) important for patient safety. However, knowledge is limited on Legionella prevalence in healthcare buildings. A dataset of quarterly water testing in Veterans Health Administration (VHA) healthcare buildings was used to examine national environmental Legionella prevalence from 2015 to 2018. Bayesian hierarchical logistic regression modeling assessed factors influencing Legionella positivity. The master dataset included 201,146 water samples from 814 buildings at 168 VHA campuses. Overall Legionella positivity over the 4 years decreased from 7.2 to 5.1%, with the odds of a Legionella-positive sample being 0.94 (0.90-0.97) times the odds of a positive sample in the previous quarter for the 16 quarters of the 4 year period. Positivity varied considerably more at the medical center campus level compared to regional levels or to the building level where controls are typically applied. We found higher odds of Legionella detection in older buildings (OR 0.92 [0.86-0.98] for each more recent decade of construction), in taller buildings (OR 1.20 [1.13-1.27] for each additional floor), in hot water samples (O.R. 1.21 [1.16-1.27]), and in samples with lower residual biocide concentrations. This comprehensive healthcare building review showed reduced Legionella detection in the VHA healthcare system over time. Insights into factors associated with Legionella positivity provide information for healthcare systems implementing WMPs and for organizations setting standards and regulations.

Assessment of burnout and pandemic fatigue among pharmacy leadership in the Veterans Health Administration healthcare system.

PurposeFactors associated with burnout in Veterans Health Administration (VHA) pharmacy leadership positions were examined during the coronavirus disease 2019 (COVID-19) pandemic.MethodsA questionnaire was distributed to all pharmacy executives of the VHA healthcare system. It collected demographic and employment characteristics, career satisfaction and work-related variables, indicators of burnout using validated single-item measures adapted from the Maslach Burnout Inventory, and the impact of the COVID-19 pandemic on psychosocial and work-related variables. A χ 2 test with Bonferroni correction was used to evaluate the data. Burnout was defined as a score of 4 or greater on either of the 2 single-item validated statements adapted from the Maslach Burnout Inventory to assess emotional exhaustion and depersonalization.ResultsIn total, 407 (of 1,027; 39.6%) VHA pharmacy leaders representing Veterans Integrated Service Network pharmacy executives, chiefs of pharmacy, associate chiefs of pharmacy, and inpatient and outpatient supervisors completed the survey. The overall prevalence of burnout was 68.6% using the aggregate measure of emotional exhaustion or depersonalization. Pharmacy leaders who worked more than 60 hours a week reported significantly greater rates of burnout than those who worked 40 to 60 hours a week (86.7% vs 66.9%, χ2 = 7.34, degrees of freedom = 1, P < 0.05). Those experiencing increased workload related to COVID-19 also reported high burnout rates (72.1%, χ2 = 16.40, degrees of freedom = 1, P < 0.001). Burnout scores were similar across groups when respondents were stratified by leadership position, gender, age, or years in position.ConclusionAs of March 2021, two-thirds of pharmacy leaders were experiencing burnout. It is important for healthcare system leadership to identify patterns of burnout among their pharmacy leaders to ensure a productive and sustainable workforce.

Care rejection and aggression among veterans with dementia with and without posttraumatic stress disorder: A multi-group analysis

BackgroundIn residential long-term care, military service veterans with co-occurring posttraumatic stress disorder (PTSD) and dementia encounter a range of physical and social stimuli that may serve as triggers of trauma-related distress that manifests as care rejection or aggression. Yet, PTSD rarely has been examined in research to understand behaviors of care rejection and aggression in veterans with dementia. ObjectivesGuided by the need-driven dementia-compromised behavior model, we examined the moderation effect of PTSD on pathways from background factors and interpersonal triggers to rejection of care and aggression among veterans with dementia with and without co-occurring PTSD. DesignSecondary data analysis of the Staff Training in Assisted Living Residences-Veterans Health Administration (STAR-VA) intervention evaluation by the U.S. Veterans Health Administration healthcare system. Setting76 Veterans Health Administration-operated nursing homes. Participants315 veterans with dementia who participated in STAR-VA. MethodsWe converted text data on the occurrence of care rejection and aggression to binary variables, combined them with data on sociodemographic and PTSD status obtained using medical chart review, and measured anxiety, cognition, depression, and function using validated instruments. A multi-group structural equation modeling analysis was then conducted to test the moderating effect of PTSD on rejection of care and aggression. ResultsAlthough multi-group structural equation modeling did not support the hypothesis of overall moderation by PTSD, distinct patterns between the two groups were observed with respect to how background factors and interpersonal triggers related to care rejection and aggression. The magnitude of the direct effects of interpersonal triggers on rejection of care was greater in veterans with PTSD (β = 0.42, p = .014 compared to those without β = 0.29, p = .008). Depression had a statistically significant indirect effect on rejection of care via interpersonal triggers only in veterans with PTSD (β = 0.09, p = .009). Functional status had a statistically significant direct effect on aggression only in the PTSD group (β = 0.28, p = .044). ConclusionsOur study identified similar and distinct patterns of relationships among background factors, interpersonal triggers, and rejection of care and aggression between veterans with dementia with and without PTSD. The indirect effect of depression on care rejection via interpersonal triggers has implications for developing targeted interventions that focus on interpersonal triggers for veterans with dementia with PTSD who have greater depressive symptoms. This study underscores the importance of an enhanced focus on trauma-informed care for veterans with dementia and PTSD.

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration

BackgroundEmpirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings.MethodsPERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations.DiscussionThe PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.

"Advancing" Advance Care Planning to Veterans in the Veterans Health Administration.

The completion rate of Advance Directive (ADs) in the Veterans Health Administration (VHA) is unknown. There is substantial literature on the need for effective Advance Care Planning (ACP) that leads to an AD to ensure that health care preferences for patients are known. Advance Directive are essential to consider since ACP, which explains and plans Advance Directive, does not reach all individuals. Health inequities, such as those experienced in rural areas, continue to exist. While ACP may disproportionately affect rural-residing veterans and their providers, a VHA program was specifically designed to increase ACP engagement with rural veterans and to address several systemic barriers to ACP. This descriptive analysis seeks to identify patient, provider, and geographic characteristics associated with higher rates of ACP participation in VHA. An observational examination of the profile of veterans and the types of ACP (e.g., individual or in groups) using administrative data for all beneficiaries receiving VHA health care services in federal fiscal year (FY) 2020 was conducted as part of a national program evaluation. The measures include patient-level data on demographics (e.g., race, ethnicity, gender), unique patient identifiers (e.g., name, social security number), geographic characteristics of patient's location (e.g., rurality defined as Rural-Urban Commuting Areas [RUCA]), VHA priority group; provider-level data (e.g., type of document definition, clinic stop codes, visit date used to verify Advance Care Planning via Group Visits [ACP-GV] attendance; data not shown), and electronic health record note titles that indicated the presence of ACP in VHA (e.g., "Advance Directive [AD] Discussion" note title, "ACP-GV CHAR 4 code"). Pearson's chi-square statistics were used for between-group comparisons based on a two-sided test with a significance level of 0.05. The overall rate of AD discussions among unique VHA users in FY2020 was 5.2% (95% CI: 5.2%-5.2%) and for Advance Care Planning via Group Visits, which targets rural veterans using groups, it was 1.8% (95% CI: 1.8%-1.9%). Advance Directive discussions in VHA are more successful at reaching middle age (M = 64; SD = 16), African Americans, males, veterans living in urban areas, and veterans with a VA disability (Priority Group 1-4). Advance Care Planning delivered in groups is reaching slightly younger veterans under the age of 75 years (M = 62; SD = 15), African Americans, females, disabled veterans (e.g., Priority Group 1-4), and more veterans residing in rural communities compared to the national population of VHA users. Advance Directive discussion rates are low across VHA, yet intentional efforts with ACP via group visits are reaching veterans who are considered underserved owing to residing in rural areas. Advance Care Planning needs to be a well-informed clinical priority for VHA to engage with the entire veteran population and to support the completion of ADs.

1137-P: Continuous Glucose Monitoring (CGM) Use and Its Impact on Glycemic Control and Acute Complications among Older-Onset Type 1 Diabetes Patients within the Veterans Health Administration (VHA)

There is increasing recognition that older onset type 1 diabetes (T1D) is not uncommon. Although CGM use is rising dramatically among those with T1D, little is known regarding its use and benefits within this older T1D population. To address these questions, we identified new CGM users (new CGM sensor prescriptions for T1D developing after military enrollment) and non-users (T1D receiving care and glucose strips from the VHA) during the years 2015-2020 and used national VHA healthcare data and ICD-9/ICD-diagnostic codes from visit encounters to compare baseline characteristics, change in glucose control and new emergency (ER) or hospital admissions. Linear mixed models and Cox proportional models (with propensity score overlap weighting) , were used to compare pre/post changes in HbA1c, and time to acute admissions, respectively. Compared with 4732 nonCGM users, CGM users (n=5,143) had similar HbA1c levels but differed in many ways at initiation of CGM, including: being significantly younger (59 vs. 65 years) , higher proportion White (83 vs. 75%) , and more frequently using glucagon (36 vs. 12 %) , short-acting insulin (99 vs. 86%) and insulin pumps (54 vs.7%) . After propensity overlap weighting, all characteristics were nearly identical between groups. Initiation of CGM was associated with reduced HbA1c levels (- 0.2 and -0.26% at 6 and 12 months (p’s&amp;lt; 0.001) compared with nonCGM users. Similarly, CGM users also had greater declines in risk for total hospitalizations (HR = .88; CI 0.79-0.98) and hypoglycemic (HR = .69; CI 0.53-0.90) and hyperglycemic (HR = .77; CI 0.64-0.94) related ER visits/hospitalizations (all p’s &amp;lt; 0.02) . In this large national study of CGM initiation in older T1D patients, CGM use was linked with improved glucose control as well as reduced ER and/or hospital admissions for hypoglycemia, hyperglycemia or any cause. Disclosure J.Zhou: Research Support; Dexcom, Inc. M.Newell: Research Support; Dexcom, Inc. S.Rivas: None. X.Zhou: None. G.J.Norman: Employee; Dexcom, Inc. P.Reaven: Research Support; AstraZeneca, Dexcom, Inc. Funding DexCom, Inc

1138-P: Impact of Continuous Glucose Monitoring (CGM) on Glycemic Control and Acute Complications in Type 2 Diabetes (T2D) in the Veterans Health Administration (VHA)

Use of CGM in T2D is rising rapidly, yet little is known regarding its effects on glucose management in the VHA. We thus identified new CGM users (new CGM sensor prescriptions for T2D on insulin) and non-users (T2D receiving glucose strips) during the years 2015-2020 and used national VHA healthcare data from visit encounters to compare change over 12 months in glucose control and new emergency room (ER) or hospital admissions. Changes in HbA1c and acute admissions were compared by linear mixed models and generalized linear models, respectively. Compared with 36,082 non-users, CGM users (n=16,013) differed in many ways but were well-balanced with overlap weighting from propensity score modeling. CGM users had a greater reduction in HbA1c over 12 months (-0.25%; 95% CI -0.21-0.29, p&amp;lt;0.0001) and a decline in hypoglycemia related ER visits/hospitalizations (OR = 0.78; CI 0.62-0.97) . Among CGM users, those &amp;lt; 65 years old or with initial HbA1c &amp;gt; 8. 4% (median) had greater reductions in HbA1c, while those at higher hypoglycemia risk had reduced hypoglycemia and hyperglycemia related ER visits/hospitalizations and all-cause hospitalizations (Table) . In this large national study in T2D, CGM initiation was linked with better glucose control and reduced ER and/or hospital admissions for hypoglycemia and showed even greater benefits in subsets of CGM users. Disclosure P.Reaven: Research Support; AstraZeneca, Dexcom, Inc. M.Newell: Research Support; Dexcom, Inc. S.Rivas: None. X.Zhou: None. G.J.Norman: Employee; Dexcom, Inc. J.Zhou: Research Support; Dexcom, Inc. Funding DexCom, Inc

Mental health treatment and the role of tele-mental health at the veterans health administration during the COVID-19 pandemic.

To quantify overall trends in patients treated for mental health disorders and adverse events, including via tele-mental health (TMH) and psychopharmacology during pandemic-related health care transformation. Longitudinal observational study including veterans receiving mental health treatment at a Veterans Health Administration (VHA) facility from January 1, 2017 to June 16, 2020. Observed and expected patient care for on-going and new treatment of depression, posttraumatic stress, substance use disorder, severe mental illness diagnoses, overdose, and suicide attempts, and psychotropic prescriptions for antidepressant, antipsychotic, benzodiazepine, opioid, and mood stabilizing medications are depicted. Percent change between actual and expected counts in the early months of the COVID pandemic (March 18-May 5, 2020) are computed. Decreases in counts of patients receiving mental health treatment early in the pandemic ranged from 7% to 20% for on-going treatment, and 28% to 37% for new treatment. TMH rapidly expanded across VHA, becoming the primary means by which encounters were delivered. Counts of patients receiving on-going care for suicide attempts were stable, and for overdoses, decreased by 17%. Counts of patients initiating care for suicide attempts and overdoses decreased by 30% and 38%, respectively. Weekly prescriptions and medication on-hand for psychotropics ranged from a 2% decrease to a 4% increase. New patient prescribing decreased 21%-50%. VHA and other large healthcare systems will need to expand outreach and continue to develop TMH services to maintain care continuity and initiate care for existing and new patients during COVID-19 and future large-scale outbreaks, epidemics, and disasters. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A Two-Year Examination of Intimate Partner Violence and Associated Mental and Physical Health among Sexual Minority and Heterosexual Women Veterans

ABSTRACT Lesbian and bisexual women veterans may experience higher rates of intimate partner violence (IPV) experience compared to heterosexual women veterans, but more research is needed on IPV and healthcare needs among sexual minority women veterans, particularly those in the community who may not use Veterans Health Administration healthcare. This study assessed recent (prior 6–12 months) IPV, mental health symptoms (e.g., PTSD, anxiety, depression, insomnia), and physical health problems (e.g., physical pain, pain interference, general physical health) among 263 women veterans (11% lesbian, bisexual, or questioning [LBQ]) 18 months after baseline (Time 2), and 24 months after baseline (Time 3; N = 190). At both Time 2 and Time 3, compared to heterosexual women veterans, LBQ women veterans reported experiencing greater recent psychological and physical IPV and intimate partner stalking, and worse PTSD, anxiety, depression, insomnia symptoms, and general physical health problems. At Time 3 only, LBQ women veterans reported experiencing greater recent sexual IPV. As the population of women and sexual/gender minority veterans grows, the current findings can help increase clinician and policy maker knowledge of IPV experiences and concurrent health problems among LBQ women veterans. Future research should conduct intragroup comparisons between veterans across the gender and sexuality spectrum.

Hepatitis B Virus-related Care Quality in Patients With Hepatitis B/Human Immunodeficiency Virus Coinfection Versus Hepatitis B Monoinfection: A National Cohort Study.

Guideline-adherent hepatitis B virus (HBV) care is critical for patients with HBV, particularly patients with HBV-human immunodeficiency virus (HIV) given increased risks of liver-related complications. However, a comprehensive assessment of HBV-related care in patients with HBV-HIV is lacking. We retrospectively assessed adherence to HBV-related care guidelines in all patients with HBV-HIV and HBV monoinfection (HBV-M) in the national Veterans Health Administration healthcare system in 2019. We identified 1021 patients with HBV-HIV among 8323 veterans with chronic HBV. Adherence to HBV guidelines was similar or better in HBV-HIV versus HBV-M, including HBV treatment (97% vs 71%), biannual hepatocellular carcinoma (HCC) surveillance (55% vs 55%) for patients with cirrhosis, hepatitis A virus screening (69% vs 56%), hepatitis C virus screening (100% vs 99%), and on-therapy alanine aminotransferase monitoring (95% vs 96%). Compared with those seeing gastroenterology (GI) or infectious diseases (ID) providers, patients without specialty care were less likely to receive antiviral treatment (none, 39%; GI, 80%; ID, 84%) or HCC surveillance (none, 16%; GI, 66%; ID, 47%). These findings persisted in multivariable analysis. Compared with ID care alone, a higher proportion of patients with HBV-HIV seen dually by GI and ID received HCC surveillance (GI + ID 73% vs ID 31%) and on-therapy HBV-DNA monitoring (GI + ID, 82%; ID, 68%). Patients with HBV-HIV received similar or higher rates of guideline-adherent HBV-related care than patients with HBV-M. Patients with HBV-HIV under dual GI and ID care achieved higher quality care compared with ID care alone. Specialty care was independently associated with higher quality HBV care in patients with HBV-HIV and HBV-M.

Dose of Exercise Therapy Among Active Duty Soldiers With Chronic Pain Is Associated With Lower Risk of Long-Term Adverse Outcomes After Linking to the Veterans Health Administration.

Research in soldiers who had been deployed to Iraq or Afghanistan suggests that nonpharmacological treatments may be protective against adverse outcomes. However, the degree to which exercise therapy received in the U.S. Military Health System (MHS) among soldiers with chronic pain is associated with adverse outcomes after soldiers transition to the Veterans Health Administration (VHA) is unclear. The objective of this study was to determine if exercise therapy received in the MHS among soldiers with chronic pain is associated with long-term adverse outcomes after military separation and enrollment into the VHA and whether this association is moderated by prescription opioid use before starting exercise therapy. We conducted a longitudinal cohort study of electronic medical records of active duty Army soldiers with documented chronic pain after an index deployment to Iraq or Afghanistan (years 2008-2014) who subsequently enrolled in the VHA (N = 93,967). Coarsened exact matching matched 37,310 soldiers who received exercise therapy and 28,947 soldiers who did not receive exercise therapy in the MHS. Weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between groups with different exercise therapy exposure vs. no exercise therapy.Exercise therapy was identified by procedure codes on ambulatory records in the MHS and expressed as the number of exercise therapy visits in 1 year after the first diagnosis with a chronic pain condition. The number of visits was then stratified into seven dose groups.The primary outcomes were weighted proportional hazards for: (1) alcohol and drug disorders, (2) suicide ideation, (3) intentional self-injury, and (4) all-cause mortality. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from enrollment till September 30, 2020. Our main analysis indicated significantly lower hazard ratios (HRs) for all adverse outcomes except intentional self-injury, for soldiers with at least eight visits for exercise therapy, compared to soldiers who received no exercise therapy. In the proportional hazard model for any adverse outcome, the HR was 0.91 (95% CI 0.84-0.99) for soldiers with eight or nine exercise therapy visits and 0.91 (95% CI 0.86-0.96) for soldiers with more than nine visits. Significant exercise therapy × prior opioid prescription interactions were observed. In the group that was prescribed opioids before starting exercise therapy, significantly lower HRs were observed for soldiers with more than nine exercise therapy visits, compared to soldiers who received no exercise therapy, for alcohol and drug disorders (HR = 0.85, 95% CI 0.77-0.92), suicide ideation (HR = 0.77, 95% CI 0.66-0.91), and for self-injury (HR = 0.58, 95% CI 0.41-0.83). Exercise therapy should be considered in the multimodal treatment of chronic pain, especially when pain is being managed with opioids, as it may lower the risk of serious adverse outcomes associated with chronic pain and opioid use. Our findings may generalize only to those active duty soldiers with chronic pain who enroll into VHA after separating from the military.

Providers' Shift to Telerehabilitation at the U.S. Veterans Health Administration During COVID-19: Practical Applications.

Telerehabilitation provides Veteran patients with necessary rehabilitation treatment. It enhances care continuity and reduces travel time for Veterans who face long distances to receive care at a Veterans Health Administration (VHA) medical facility. The onset of the COVID-19 pandemic necessitated a sudden shift to telehealth–including telerehabilitation, where a paucity of data-driven guidelines exist that are specific to the practicalities entailed in telerehabilitation implementation. This paper explicates gains in practical knowledge for implementing telerehabilitation that were accelerated during the rapid shift of VHA healthcare from out-patient rehabilitation services to telerehabilitation during the COVID-19 pandemic. Group and individual interviews with 12 VHA rehabilitation providers were conducted to examine, in-depth, the providers' implementation of telerehabilitation. Thematic analysis yielded nine themes: (i) Willingness to Give Telerehabilitation a Chance: A Key Ingredient; (ii) Creativity and Adaptability: Critical Attributes for Telerehabilitation Providers; (iii) Adapting Assessments; (iv) Adapting Interventions; (v) Role and Workflow Adaptations; (vi) Appraising for Self the Feasibility of the Telerehabilitation Modality; (vii) Availability of Informal, In-Person Support Improves Feasibility of Telerehabilitation; (viii) Shifts in the Expectations by the Patients and by the Provider; and (ix) Benefit and Anticipated Future of Telerehabilitation. This paper contributes an in-depth understanding of clinical reasoning considerations, supportive strategies, and practical approaches for engaging Veterans in telerehabilitation.

Women Veterans' Attrition from the VA Health Care System.

Patient attrition from the Veterans Health Administration (VA) health care system could undercut its mission to ensure care for eligible veterans. Attrition of women veterans could exacerbate their minority status and impede systemic efforts to provide high-quality care. We obtained women veterans' perspectives on why they left or continued to use VA health care. A sampling frame of new women veteran VA patients was stratified by those who discontinued (attriters) and those who continued (non-attriters) using VA care. Semistructured interviews were conducted from 2017 to 2018. Transcribed interviews were coded for women's decision-making, contexts, and recommendations related to health care use. Fifty-one women veterans (25 attriters and 26 non-attriters) completed interviews. Reasons for attrition included challenging patient care experiences (e.g., provider turnover, claim processing challenges) and the availability of private health insurance. Personal experiences with VA care (e.g., gender-specific care) were impactful in women's decision to use VA. The affordability of VA care was influential for both groups to stay connected to services. More than one-third of women originally categorized as attriters described subsequently reentering or planning to reenter VA care. Suggestions to decrease attrition included increasing outreach, improving access, and continuing to tailor care delivery to women veterans' needs. Understanding the drivers of patients' decisions to use or not use the VA is critical for the development of strategies to improve retention of current patients and optimize health outcomes for veterans. Women veterans described complex reasons why they left or continued using VA, with cost/affordability playing an important role even in considerations of returning to VA after a long hiatus.