Veterans Health Administration Population Research Articles

14-Year Epidemiologic study of Pseudomonas aeruginosa bloodstream infection incidence and resistance in the Veterans Health Administration system, 2009-2022.

Multidrug resistant Pseudomonas aeruginosa (PA) represents a serious threat to hospitalized patients. Characterizing the incidence of PA infection and degree of resistance can inform empiric treatment and preventative measures. We sought to describe trends in incidence and resistance characteristics of PA bloodstream infections (BSI) observed within the Veterans Health Administration (VHA) system and identify factors contributing to higher observed mortality within this population. We characterized demographic and clinical features of unique patients among the VHA population presenting with their first episode of PA-BSI between 2009 and 2022 and summarized trends related to mortality and resistance phenotype based on year and geographical location. We additionally used logistic regression analysis to identify predictors of 30-day mortality among this cohort. We identified 8039 PA-BSIs during the study period, 32.7% of which were hospital onset. Annual PA-BSI cases decreased by 35.8%, and resistance among all antimicrobial classes decreased during the study period, while the proportion of patients receiving early active treatment based on susceptibility testing results increased. Average 30-day mortality rate was 23.3%. Higher Charlson Comorbidity Index, higher mAPACHE score, VHA facility complexity 1b and hospital-onset cases were associated with higher mortality, and early active treatment was associated with lower mortality. PA-BSI resistance decreased across the VHA system during the study period. Further investigation of antimicrobial stewardship measures possibly contributing to the observed decreased resistance in this cohort and identification of measures to improve on the high mortality associated with PA-BSI in the VHA population is warranted.

Mortality among US veterans with a physician-documented diagnosis of pyruvate kinase deficiency

ABSTRACT Real-world studies of pyruvate kinase (PK) deficiency and estimates of mortality are lacking. This retrospective observational study aimed to identify patients with PK deficiency and compare their overall survival (OS) to that of a matched cohort without PK deficiency. Patients with ≥1 diagnosis code related to PK deficiency were selected from the US Veterans Health Administration (VHA) database (01/1995–07/2019); patients with a physician-documented diagnosis were included (PK deficiency cohort; index: date of first diagnosis code related to PK deficiency). Patients in the PK deficiency cohort were matched 1:5 to patients from the general VHA population (non-PK deficiency cohort; index: random visit date during match’s index year). OS from index was compared between the two cohorts. Eighteen patients in the PK deficiency cohort were matched to 90 individuals in the non-PK deficiency cohort (both cohorts: mean age 57 years, 94% males; median follow-up 6.0 and 8.0 years, respectively). At follow-up, patients in the non-PK deficiency cohort had significantly longer OS than the PK deficiency cohort (median OS: 17.1 vs. 10.9 years; hazard ratio: 2.3; p = 0.0306). During their first-year post-index, 75% and 40% of the PK deficiency cohort had laboratory-confirmed anemia and iron overload, respectively. Among patients who died, cause of death was highly heterogeneous. These results highlight the increased risk of mortality and substantial clinical burden among patients with PK deficiency. While the intrinsic characteristics of the VHA database may limit the generalizability of the results, this is the first real-world study to characterize mortality in patients with PK deficiency.

Emergency department visits at Veterans Health Administration hospitals related to alcohol intoxication: A ten-year retrospective

We sought to quantify and describe the volume of emergency department visits related to alcohol intoxication at the Veterans Health Administration (VHA), the largest healthcare system in the United States. This is a retrospective cohort study of patients with VHA emergency department visits for alcohol intoxication from 2010 to 2019 as identified via ICD-9/10 code and/or serum ethanol concentration >50 mg/dL. Encounters were identified and demographic and clinical data were acquired by automated query of the VHA Corporate Data Warehouse. Descriptive statistics and univariate analysis were performed. We identified 95,123 patients with a total of 251,310 emergency department visits. The annual number of visits increased over the study period, reaching 32,333 in 2019. Men aged 40–60 were the most common demographic group in the cohort (48% of all patients), and men made up a higher proportion of patients in the database (94%) than the VHA population overall (90%). A disproportionate number of visits (32%) came from the top 4.4% of most frequent visitors. Most of the emergency department visits in the database (68%) were associated with medical or psychiatric admission, or interfacility transfer for admission elsewhere. Patients in the cohort accounted for 1.3% of all VHA emergency department visits during the study period, a proportion that is somewhat smaller than what has been reported at non-VHA facilities, despite the high prevalence of addiction disorders in the VHA patient population. We submit that this lower-than-expected proportion of alcohol-related emergency department visits may be due to the access to primary and mental care which is afforded by VHA patient benefits.

Impact of Social Determinants of Health and Novel Therapies on the Outcomes of Relapsed and Refractory Diffuse Large B Cell Lymphoma

Introduction: Outcomes for patients with relapsed and refractory diffuse large B cell lymphoma (R/R DLBCL) have improved dramatically with the recent approvals of chimeric antigen receptor (CAR) T cell therapies and novel immunotherapies. Unfortunately, studies show persistent disparities in DLBCL that impact survival, including patient race, income, and rural residence. The U.S. Veterans Health Administration (VA) is a single-payer healthcare system that provides coverage for cancer therapies and travel support, which could address barriers to treatment. This national VA study examines the influence of social determinants of health (SDoH) and treatment patterns on the outcomes of veterans with R/R DLBCL in the era of novel therapies. Methods: Patients who received frontline anthracycline at any time and any systemic therapy for R/R DLBCL between 2019-2022 were identified through the VA Corporate Data Warehouse and retrospective chart review. The Social Deprivation Index (SDI) was estimated at the zip code level using the 2019 American Community Survey (Butler et al, 2013). Median household income was estimated from federal census tract data. Logistic regression was used to evaluate binary outcomes, and Cox regression for survival analyses. Results: 225 patients across 70 VA medical centers met eligibility (Table 1). The median age was 69, and most (96%) were male, reflecting the VA population. The median follow-up was 32.7 months (range, 2.3-217.5). Patients received a median of 3 lines of therapy (range, 2-8). Novel immunotherapies were administered to 98 patients (44%): 10 (4%) received loncastuximab, 23 (10%) tafasitamab, and 83 (37%) polatuzumab. 52 (23%) and 26 (12%) patients received CAR T and autologous stem cell transplant (auto-SCT), respectively. The estimated 2-year overall survival (OS) was 65.8% (95% CI, 59.1-71.7). In univariate analyses, age < 70 (HR 0.58, 95% CI 0.41-0.82), use of CAR T (HR 0.64, 95% CI 0.40-0.99), and auto-SCT (HR 0.39, 95% CI 0.19-0.73) were associated with improved OS. Interestingly, the use of novel immunotherapies was associated with worse OS (HR 1.43, 95% CI 1.01-2.01), but among those who received it, using it in earlier lines had better survival (HR 0.71, 95% CI 0.54-0.94). Notably, Hispanic white had worse survival than non-Hispanic white patients (HR 1.97, 95% CI 1.13-3.23), while African Americans had similar survival to non-Hispanic white patients. Higher stage showed worse survival, but this did not reach significance (HR 1.12, 95% CI 0.93-1.40). Other SDoH (sex, income, rural residence, SDI), disease traits (transformed, LDH, cell of origin, double-hit), and medical comorbidities did not impact survival. In multivariate analysis, the impacts of CAR T, auto-SCT, and Hispanic ethnicity persisted (Figure 1). Among patients receiving at least 3 lines of therapy ( n = 143), the only significant covariate in multivariate regression for OS was CAR T (HR 0.57, 95% CI 0.32-0.96). Referrals for SCT and CAR T were sent for 65 (29%) and 81 (36%) patients, respectively. The most advantaged SDI quartile had higher odds of getting an SCT referral than the least advantaged quartile (OR 5.00, p = 0.0015). Similarly, household income ≥ $75,000 had higher odds of SCT referral vs. lower incomes (OR 2.88, p = 0.004). Race did not affect SCT referral rates, and SDoH in general did not impact CAR T referrals. SDoH was not associated with whether patients actually received novel immunotherapies, CAR T, or SCT (only affecting referral rates in the latter). The most common reasons for not pursuing auto-SCT after referral were comorbidities ( n = 23, 33%), pursuance of other cell therapies ( n = 17, 25%), and patient decision ( n = 12, 17%). The most common reasons for deferring CAR T were comorbidities ( n = 15, 28%), death ( n = 15, 28%), and patient decision ( n = 6, 11%). At last follow-up, of the 47 patients in remission for > 1 year, 27 (57%) had CAR T or SCT as their last therapy. Conclusion: Cellular approaches were the most impactful factors in improving OS. Hispanic ethnicity remained an independent poor prognostic factor, but other SDoH did not impact survival in this cohort. Broad drug coverage by a single-payer system, front-line anthracycline, and equal receipt of cell therapies may have mitigated some of the impact of SDoH on DLBCL survival. Nonetheless, cell therapies had a high referral but low administration rate, highlighting the challenge of getting patients to definitive treatment.

Durvalumab Treatment Patterns for Patients with Unresectable Stage III Non-Small Cell Lung Cancer in the Veterans Health Administration (VHA): A Nationwide, Real-World Study.

Durvalumab is approved for the treatment of adults with unresectable stage III non-small cell lung cancer (NSCLC) post-chemoradiotherapy (CRT). This real-world study describes patient characteristics and durvalumab treatment patterns (number of doses and therapy duration; treatment initiation delays, interruptions, discontinuations, and associated reasons) among VHA-treated patients. This was a retrospective cohort study of adults with unresectable stage III NSCLC receiving durvalumab at the VHA between 1 January 2017 and 30 June 2020. Patient characteristics and treatment patterns were presented descriptively. A total of 935 patients were included (median age: 69 years; 95% males; 21% Blacks; 46% current smokers; 16% ECOG performance scores ≥ 2; 50% squamous histology). Durvalumab initiation was delayed in 39% of patients (n = 367). Among the 200 patients with recorded reasons, delays were mainly due to physician preference (20%) and CRT toxicity (11%). Overall, patients received a median (interquartile range) of 16 (7-24) doses of durvalumab over 9.0 (2.9-11.8) months. Treatment interruptions were experienced by 19% of patients (n = 180), with toxicity (7.8%) and social reasons (2.6%) being the most cited reasons. Early discontinuation occurred in 59% of patients (n = 551), largely due to disease progression (24.2%) and toxicity (18.2%). These real-world analyses corroborate PACIFIC study results in terms of the main reasons for treatment discontinuation in a VHA population with worse prognostic factors, including older age, predominantly male sex, and poorer performance score. One of the main reasons for durvalumab initiation delays, treatment interruptions, or discontinuations was due to toxicities. Patients could benefit from improved strategies to prevent, identify, and manage CRT and durvalumab toxicities timely and effectively.

An electronic health record cohort of Veterans with amyotrophic lateral sclerosis

Objective To assemble and characterize an electronic health record (EHR) dataset for a large cohort of US military Veterans diagnosed with ALS (Amyotrophic Lateral Sclerosis). Methods An EHR dataset for 19,662 Veterans diagnosed with ALS between January 1, 2000 to December 31, 2020 was compiled from the Veterans Health Administration (VHA) EHR database by a query for ICD9 diagnosis (335.20) or ICD10 diagnosis (G12.21) for Amyotrophic Lateral Sclerosis. Results The cohort is predominantly male (98.94%) and white (72.37%) with a median age at disease onset of 68 years and median survival from the date of diagnosis of 590 days. With the designation of ALS as a compensable illness in 2009, there was a subsequent increase in the number of Veterans diagnosed per year in the VHA, but no change in median survival. The cohort included a greater-than-expected proportion of individuals whose branch of service at the time of separation was the Army. Conclusions The composition of the cohort reflects the VHA population who are at greatest risk for ALS. The greater than expected proportion of individuals whose branch of service at the time of separation was the Army suggests the possibility of a branch-specific risk factor for ALS.

Health Equity in Patients Receiving Durvalumab for Unresectable Stage III Non-Small Cell Lung Cancer in the US Veterans Health Administration.

Real-world evidence is limited regarding the relationship between race and use of durvalumab, an immunotherapy approved for use in adults with unresectable stage III non-small cell lung cancer (NSCLC) post-chemoradiotherapy (CRT). This study aimed to evaluate if durvalumab treatment patterns differed by race in patients with unresectable stage III NSCLC in a Veterans Health Administration (VHA) population. This was a retrospective analysis of White and Black adults with unresectable stage III NSCLC treated with durvalumab presenting to any VHA facility in the US from January 1, 2017, to June 30, 2020. Data captured included baseline characteristics and durvalumab treatment patterns, including treatment initiation delay (TID), interruption (TI), and discontinuation (TD); defined as CRT completion to durvalumab initiation greater than 42 days, greater than 28 days between durvalumab infusions, and more than 28 days from the last durvalumab dose with no new durvalumab restarts, respectively. The number of doses, duration of therapy, and adverse events were also collected. A total of 924 patients were included in this study (White = 726; Black = 198). Race was not a significant factor in a multivariate logistic regression model for TID (OR, 1.39; 95% CI, 0.81-2.37), TI (OR, 1.58; 95% CI, 0.90-2.76), or TD (OR, 0.84; 95% CI, 0.50-1.38). There were also no significant differences in median (interquartile range [IQR]) number of doses (White: 15 [7-24], Black: 18 [7-25]; P = .25) or median (IQR) duration of therapy (White: 8.7 months [2.9-11.8], Black: 9.8 months [3.6-12.0]; P = .08), although Black patients were less likely to experience an immune-related adverse event (28% vs. 36%, P = .03) and less likely to experience pneumonitis (7% vs. 14%, P < .01). Race was not found to be linked with TID, TI, or TD in this real-world study of patients with unresectable stage III NSCLC treated with durvalumab at the VHA.

0568 Trends in OSA Disease Severity Over Nearly Two Decades: Update on the VA San Diego Experience

Abstract Introduction The Veterans Health Administration (VA) is one of the largest integrated healthcare systems in the United States. Key risk factors for obstructive sleep apnea (OSA) include aging, weight, and male gender, all of which are highly prevalent in the VA population and help to explain the higher rates of OSA in the VA. The Pulmonary Sleep Program at the VA San Diego Healthcare System (VASDHS) started a patient database over twenty years ago for its home sleep apnea testing (HSAT) program. An analysis of ten years of diagnostic HSAT data was reported on over 12,500 patients in 2014. This analysis focuses on an update on the last four years and a comparison to 2014. Methods A retrospective review of the local clinical database of HSAT diagnostic testing was conducted. The database contained 8,928 sleep studies from 2018 to 2022. Invalid studies were removed. Only initial diagnostic studies were included. Results Of the 8,928 diagnostic studies, 2,564 tested negative for OSA (28.7%). Of the 6,364 positive cases, 43.3% were mild, 28.8% were moderate, and 27.9% were severe. The percentages of each OSA severity level were stable across these years (mild: 42%-45%; moderate: 27%-32%; and severe: 26%-29%). The mean AHI did not significantly change from 2018 (24.1+/-20.6) to 2022 (25.1+/-21.2) (overall mean 24.4+/-20.3; range: 5-140). Conclusion Based on this extensive retrospective review of diagnostic testing at a single, high-volume HSAT program, it appears that OSA severity levels have stabilized over these past five years, with the highest percentage of mild OSA cases (~43%) followed by moderate (~29%) and severe (~28%). Our facility saw a significant decrease in severe cases (60% to 30%) and increase in mild OSA (7% to 35%) from 2004 to 2013. Today, over 4 out of every 10 new OSA diagnoses are mild, which has significant treatment implications given that adherence to the two primary medical device options is suboptimal. Identifying patient-centered treatment options for these patients is a priority. Support (if any) VA RR&amp;D D2651-R and the Sleep Medicine Section of the VA San Diego Healthcare System supported this project.

118. Rapid Uptake of 2014 ACIP Pneumococcal Vaccination Recommendations among Adults Aged 65 or Higher at the Veterans Health Administration

Abstract Background Vaccination of the 13-valent pneumococcal conjugate vaccine (PCV13) for adults 65 years and older was recommended by the Advisory Committee on Immunization Practices (ACIP) in 2014 until it was withdrawn in 2019. While estimated overall vaccination coverage rates with both vaccines at ∼30% were previously reported using data from surveys or Medicare claims, it is unclear how rapidly the uptake of this ACIP recommendation occurred. We aimed to describe the uptake of the ACIP among the Veterans Health Administration (VHA) population. Methods We conducted a retrospective cohort study of patients who were at 65 years or older in October 2014 who were registered in primary care of VHA. The study period was from October 2014 to November 2019. We obtained data on the first PCV13 and 23-valent pneumococcal polysaccharide vaccine (PPSV23) vaccination and dropout from primary care follow-up due to death and termination of primary care relationship from the VHA Corporate Data Warehouse. We calculated the monthly proportion of PCV13 and PPSV23 vaccination among primary care follow-up patients in VHA. Results We enrolled 2,166,173 patients at the beginning of the study period (median age: 73 (interquartile range: 68–81)), and at the end of the study period, 30% (645,975) were dropout due to death. The numbers of patients who had at least one PCV13 and PPSV23 vaccination at the beginning of the study period were 17,718 (0.8%) and 934,836 (43.2%), respectively. Of the PCV13 used during the study period, 78.4% were administered in the first two years (Figure 1). At the end of the study period, 50.3% of the follow-up patients had been vaccinated with PCV13 and 53.3% with PPSV23 (Figure 2). 55.3% of patients received at least one dose of any vaccine, and 48.2% received both. Figure 1.Administered dose of first PCV13 and PPSV23 among the study populationFigure 2.The proportion of vaccination coverage among the study population Conclusion At the VHA, there was a very rapid uptake of 2014 ACIP pneumococcal vaccination recommendations in the first two years, followed by a steady increase. At the end of the study period, the VHA achieved comparable or higher vaccination coverage in this population with both PCV13 and PPSV23 than the previously reported Medicare population. Further studies are needed to elucidate factors contributing to this rapid uptake and improve the implementation of future vaccine recommendations. Disclosures Michihiko Goto, MD MSCI, Merck &amp; Co.: Grant/Research Support.

736. Impact of COVID-19 on Mortality Associated with Pseudomonas aeruginosa Bloodstream Infection in the Veterans Health Administration System

Abstract Background Pseudomonas aeruginosa bloodstream infection (PA-BSI) is associated with high mortality. The extent to which the COVID-19 pandemic has introduced challenges to diagnosis and treatment of this infection is unknown. In this study, we examined the direct and indirect effects of COVID-19 on PA-BSI associated mortality in the Veterans Health Administration (VHA) population. Methods We identified patients within the VHA database with PA-BSI identified between January 1, 2009 and December 31, 2019 (pre-COVID) and January 1, 2020 to December 31, 2021 (COVID). Extracted data included age, race, ethnicity, Charlson Comorbidity Index (CCI), susceptibility testing, treatment, and COVID-19 infection. Antimicrobial resistance was characterized as pan-susceptible, any unclassified resistance, multi-drug resistant (MDR), difficult to treat resistant (DTR), and extremely or pan-drug resistant (XDR/PDR). Active therapy was defined as an effective antibiotic initiated within 48 hours of blood culture collection. We used logistic regression to assess the impact of each factor on 30-day mortality. Results We identified 7,578 patients with PA-BSI and known 30-day mortality status, which was 24% overall (Table 1). Age and CCI were higher during COVID, while effective treatment and resistance improved (Table 2). In the multivariate analysis, concomitant COVID infection tripled the odds of mortality (odds ratio [OR] 3.00, 95% confidence interval [CI] 1.40–6.37) (Figure 1). However, the COVID period itself was not associated with higher mortality. Effective treatment was associated with 19% lower odds of mortality (OR 0.81, 95% CI 0.66–1.01), while DTR and XDR/PDR nearly doubled mortality (OR 1.75, 95% CI 1.23–2.47 and OR 2.06, 95% CI 1.25–3.34, respectively). Conclusion We observed higher odds of mortality in patients with PA-BSI and COVID-19 coinfection, supporting the hypothesis that COVID-19 directly impacts PA-BSI outcomes. Annual PA-BSI incidence and associated 30-day mortality, however, were similar during the COVID period. Favorable resistance trends, effective treatment, and a low rate of PA-BSI and COVID-19 coinfection may explain these findings, despite increased age and comorbidities in this vulnerable population. Disclosures Federico Perez, MD, MS, Accelerate: Grant/Research Support|Merck: Grant/Research Support|Pfizer: Grant/Research Support Robert A. Bonomo, MD, Merck: Grant/Research Support|Pfizer: Honoraria|VenatoRx: Grant/Research Support|Wockhardt: Grant/Research Support.

Modernization of a Large Spinal Cord Injuries and Disorders Registry: The Veterans Administration Experience.

Since the 1990s, Veterans Health Administration (VHA) has maintained a registry of Veterans with Spinal Cord Injuries and Disorders (SCI/Ds) to guide clinical care, policy, and research. Historically, methods for collecting and recording data for the VHA SCI/D Registry (VSR) have required significant time, cost, and staffing to maintain, were susceptible to missing data, and caused delays in aggregation and reporting. Each subsequent data collection method was aimed at improving these issues over the last several decades. This paper describes the development and validation of a case-finding and data-capture algorithm that uses primary clinical data, including diagnoses and utilization across 9 million VHA electronic medical records, to create a comprehensive registry of living and deceased Veterans seen for SCI/D services since 2012. A multi-step process was used to develop and validate a computer algorithm to create a comprehensive registry of Veterans with SCI/D whose records are maintained in the enterprise wide VHA Corporate Data Warehouse. Chart reviews and validity checks were used to validate the accuracy of cases that were identified using the new algorithm. An initial cohort of 28,202 living and deceased Veterans with SCI/D who were enrolled in VHA care from 10/1/2012 through 9/30/2017 was validated. Tables, reports, and charts using VSR data were developed to provide operational tools to study, predict, and improve targeted management and care for Veterans with SCI/Ds. The modernized VSR includes data on diagnoses, qualifying fiscal year, recent utilization, demographics, injury, and impairment for 38,022 Veterans as of 11/2/2022. This establishes the VSR as one of the largest ongoing longitudinal SCI/D datasets in North America and provides operational reports for VHA population health management and evidence-based rehabilitation. The VSR also comprises one of the only registries for individuals with non-traumatic SCI/Ds and holds potential to advance research and treatment for multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), and other motor neuron disorders with spinal cord involvement. Selected trends in VSR data indicate possible differences in the future lifelong care needs of Veterans with SCI/Ds. Future collaborative research using the VSR offers opportunities to contribute to knowledge and improve health care for people living with SCI/Ds.

Unemployment, Homelessness, and Other Societal Outcomes Among US Veterans With Schizophrenia Relapse: A Retrospective Cohort Study.

Objective: To evaluate societal outcomes including unemployment and homelessness among US veterans with schizophrenia with a history of relapse. Methods: A retrospective cohort study was conducted using US Veterans Health Administration (VHA) data from January 1, 2013, to September 30, 2019. Veterans with ≥ 2 diagnoses of schizophrenia, schizotypal disorder, and/or schizoaffective disorders (ICD-9-CM 295.xx, ICD-10-CM F20.x, F21, or F25.x) during the study period on different days were identified. The index date was the earliest observed diagnosis. Two cohorts were created and propensity score matched: (1) the relapse cohort of veterans with ≥ 1 prior relapse, defined as hospitalization or emergency department visit associated with a schizophrenia diagnosis during the 12-month preindex period, and (2) the nonrelapse cohort of veterans with no evidence of relapse during the preindex period. The frequencies of unemployment, divorce, homelessness, incarceration, and premature death were compared between matched cohorts using standardized mean difference (SMD ≥ 0.1 indicating imbalance). Results: Each cohort included 16,862 veterans (92.0% male, 57.0% White, median age of 58–59 years). In the relapse cohort, 67.4% and 42.0% of veterans had a history of substance use disorder and non-schizophrenia mental health disorder, respectively, compared to 43.5% and 23.8% in the matched nonrelapse cohort (both SMD > 0.1). The relapse cohort had a higher frequency of unemployment (75.4% vs 71.4%), divorce (35.6% vs 33.7%), homelessness (38.9% vs 23.7%), incarceration (0.6% vs 0.4%), and premature death (23.3% vs 16.9%) compared to the nonrelapse cohort (all SMD > 0.1). Conclusions: Schizophrenia relapse is associated with increased adverse societal outcomes in the VHA population.

Spectrum of Advanced Colorectal Neoplasia and Anticipated Yield of Average-Risk Screening in Veterans Under Age 50

The incidence of early onset colorectal cancer, or colorectal cancer (CRC) diagnosed before age 50, is increasing.1 In response, multiple societal guidelines in the United States now recommend initiating CRC screening at age 45 in average-risk individuals (ie, those without high-risk clinical characteristics, such as bleeding, or iron deficiency anemia), inflammatory bowel disease, or family history of colorectal neoplasia.2 The Veterans Health Administration (VHA) is the largest integrated health system in the United States and is contending with how best to expand CRC screening access to this younger population in the setting of limited colonoscopy resources. Understanding the rate and anatomic location of colorectal neoplasia in Veterans younger than age 50 can inform the expected yield of different screening modalities. Prior work has shown that individuals undergoing colonoscopy for low-risk diagnostic indications have equivalent risk of colorectal neoplasia as those undergoing average-risk screening.3 This study and a recent meta-analysis4 reported that 3.6% (95% confidence interval, 1.9%-6.7%) to 3.7% (95% confidence interval, 3.0%-4.7%) of average-risk individuals age 45-49 have advanced colorectal neoplasia (ACN), defined as an advanced polyp or carcinoma; however, data specific to the VHA population are lacking.

Accuracy of the Veterans Health Administration COVID-19 (VACO) Index for predicting short-term mortality among 1307 US academic medical centre inpatients and 427 224 US Medicare patients

BackgroundThe Veterans Health Administration COVID-19 (VACO) Index predicts 30-day all-cause mortality in patients with COVID-19 using age, sex and pre-existing comorbidity diagnoses. The VACO Index was initially developed and validated...

PD13-12 EFFECTS OF RACE AND ETHNICITY ON THE INCIDENCE OF DEPRESSION AFTER PROSTATE CANCER TREATMENT

You have accessJournal of UrologyProstate Cancer: Epidemiology & Natural History I (PD13)1 Sep 2021PD13-12 EFFECTS OF RACE AND ETHNICITY ON THE INCIDENCE OF DEPRESSION AFTER PROSTATE CANCER TREATMENT Dylan Peterson, Arjun Parthipan, Tina Hernandez-Boussard, Catherine Curtin, and James Brooks Dylan PetersonDylan Peterson More articles by this author , Arjun ParthipanArjun Parthipan More articles by this author , Tina Hernandez-BoussardTina Hernandez-Boussard More articles by this author , Catherine CurtinCatherine Curtin More articles by this author , and James BrooksJames Brooks More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001989.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Depression following prostate cancer treatment occurs in up to 1 in 5 men. Prior research has primarily focused on the impact of treatment modality on depression incidence; however, the contribution of other important patient factors, including race and ethnicity, remains unclear. Improved understanding of who is at risk of poor quality of life after treatment is needed. The aim of this study is to investigate the role of these demographic features on depression following prostate cancer treatment. METHODS: This is a retrospective cohort study of prostate cancer patients treated from 2001-2016 at the Veterans Health Administration (VHA) and 2007-2018 at Stanford Health Care (SHC). Evidence of depression from clinical text and diagnoses, demographic and treatment data were obtained from the electronic health records at each institution. Patients depressed prior to the start of treatment were excluded from analysis. Relative risk (RR) of new onset depression was calculated using univariable models. RESULTS: The final cohorts included 443,803 VHA and 9,350 SHC patients. Overall, VHA patients had higher rates of depression following treatment (87748 cases, 20% incidence) than SHC patients (477 cases, 5% incidence) (p <0.0001). Within the VHA population, compared to White patients, Black patients were at increased risk for depression (RR 1.04; 95% CI [1.02-1.06]; p <0.0001) while Asian patients had decreased risk for depression (RR 0.78; 95% CI [0.71-0.87]; p <0.0001). Hispanic or Latino ethnicity was also associated with increased risk for depression (RR 1.22; 95% CI [1.18-1.25]; p <0.0001). Additionally, relative to active surveillance, all treatment modalities were associated with increased risk for depression (RR for any treatment 1.26; 95% CI [1.31-1.41]; p <0.0001 for all comparisons). CONCLUSIONS: Patient race and ethnicity were significantly associated with the development of depression following prostate cancer treatment. These results can help clinicians better understand which survivors may be at increased risk of depression after treatment. Future work will include determining the role of potentially confounding factors including socioeconomic and insurance status on depression incidence in this population. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e214-e214 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dylan Peterson More articles by this author Arjun Parthipan More articles by this author Tina Hernandez-Boussard More articles by this author Catherine Curtin More articles by this author James Brooks More articles by this author Expand All Advertisement Loading ...

Suicide After Stroke in the United States Veteran Health Administration Population

ObjectiveTo evaluate risk for suicide among veterans with a history of stroke, seeking care within the Veterans Health Administration (VHA), we analyzed existing clinical data. DesignThis retrospective cohort study was approved and performed in accordance with the local Institutional Review Board. Veterans were identified via the VHA's Corporate Data Warehouse. Initial eligibility criteria included confirmed veteran status and at least 90 days of VHA utilization between fiscal years 2001-2015. Cox proportional hazards models were used to assess the association between history of stroke and suicide. Among those veterans who died by suicide, the association between history of stroke and method of suicide was also investigated. SettingVHA. ParticipantsVeterans with at least 90 days of VHA utilization between fiscal years 2001-2015 (N=1,647,671). Data from these 1,647,671 veterans were analyzed (1,405,762 without stroke and 241,909 with stroke). InterventionsNot applicable. Main Outcome MeasuresSuicide and method of suicide. ResultsThe fully adjusted model, which controlled for age, sex, mental health diagnoses, mild traumatic brain injury, and modified Charlson/Deyo Index (stroke-related diagnoses excluded), demonstrated a hazard ratio of 1.13 (95% confidence interval, 1.02-1.25; P=.02). The majority of suicides in both cohorts was by firearm, and a significantly larger proportion of suicides occurred by firearm in the group with stroke than the cohort without (81.2% vs 76.6%). ConclusionsFindings suggest that veterans with a history of stroke are at increased risk for suicide, specifically by firearm, compared with veterans without a history of stroke. Increased efforts are needed to address the mental health needs and lethal means safety of veterans with a history of stroke, with the goal of improving function and decreasing negative psychiatric outcomes, such as suicide.

Reasons Older Veterans Use the Veterans Health Administration and Non-VHA Care in an Urban Environment.

Older veterans in urban settings rely less on the Veterans Health Administration (VHA) health care, suggesting deficits of access and services for aging veterans. We aimed to identify reasons for VHA and non-VHA use across the health status of older, urban-dwelling veterans. We examined open-ended responses from 177 veterans who were enrolled in primary care at the Bronx VA Medical Center, used non-VHA care in prior 2 years, and completed baseline interviews in a care coordination trial from March 2016 to August 2017. Using content analysis, we coded and categorized key terms and concepts into an established access framework. This framework included 5 categories: acceptability (relationship, second opinion), accessibility (distance, travel); affordability; availability (supply, specialty care); and accommodation (organization, wait-time). Self-reported health status was stratified by excellent/very good, good, and fair/poor. We were able to categorize the responses of 166 veterans, who were older (≥75 years, 61%), minority race and ethnicity (77%), and low income (<$25,000/y, 51%). Veterans mentioned acceptability (42%) and accessibility (37%) the most, followed by affordability (33%), availability (25%), and accommodation (11%). With worse self-reported health status, accessibility intensified (excellent/very good, 24%; fair/poor, 46%; P = .031) particularly among minority veterans, while acceptability remained prominent (excellent/very good, 49%; fair/poor, 37%; P = .25). Other categories were mentioned less with no significant difference across health status. Even in an urban environment, proximity was a leading issue with worse health. Addressing urban accessibility and coordination for older, sicker veterans may enhance care for a growing vulnerable VHA population.

Outcomes in chronic lymphocytic leukemia patients on novel agents in the US Veterans Health Administration System

The US veteran population has a high proportion of chronic lymphocytic leukemia (CLL) risk factors. Using the Veterans Health Administration (VHA) population, we conducted a retrospective chart review of 1205 CLL patients who initiated treatment with a novel oral agent. For 1L ibrutinib, 33% (n = 107) discontinued therapy during the study, of which 64% discontinued due to adverse events (AEs). For relapsed/refractory (R/R) ibrutinib, 35% (n = 262) discontinued therapy, of which 63% discontinued due to AEs. For R/R venetoclax, 31% (n = 27) discontinued therapy, of which 41% were due to AEs. For idelalisib, 84% (n = 41) discontinued therapy, of which 54% were due to AEs. This real-world study suggests that AEs play an important role in dose reductions and discontinuations; however, physician inexperience in using these drugs when they were first introduced could be part of what is leading to these negative outcomes.

Mortality Among Veterans with a Diagnosis of Pyruvate Kinase (PK) Deficiency: A Real-World Study Using US Veterans Health Administration Data

Background: Pyruvate kinase (PK) deficiency is a rare, inherited disorder caused by autosomal recessive mutations in the PKLR gene, whereby a glycolytic defect causes reduced adenosine triphosphate levels and leads to hemolytic anemia. Patients with PK deficiency can experience serious complications associated with the disease and its treatment, including osteoporosis, pulmonary hypertension, sepsis, iron overload, and liver cirrhosis. The current standard of care for PK deficiency is supportive, including blood transfusions, splenectomy, iron chelation therapy and/or interventions for other disease-related morbidity. There is no approved therapy for this condition. Identifying PK deficiency in real-world data is challenging due to a lack of diagnosis codes and treatments that are specific to PK deficiency. As a result, population-based studies of PK deficiency using claims or electronic health record databases are limited. In addition, data on mortality in this patient population are lacking and limited to a few individual case reports. This study aimed to identify patients with a PK deficiency diagnosis as documented by physicians and to compare their mortality to an age- and gender-matched cohort of individuals without PK deficiency. Methods: Patients with ≥ 1 diagnosis code related to PK deficiency (i.e., anemia due to disorders of glycolytic enzymes [International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) D55.2], other hemolytic anemias due to enzyme deficiency [ICD-9-CM 282.3], or unspecified hereditary hemolytic anemia [ICD-9-CM 282.9, ICD-10-CM D58.9]) between January 1995 and July 2019 were selected from the US Veterans Health Administration (VHA) database. To be considered for inclusion, physicians' notes were required to contain the words "pyruvate", "kinase", and "deficiency." A manual review of these physicians' notes was performed to identify patients with a physician-documented diagnosis of PK deficiency (PK deficiency cohort). The index date for the PK deficiency cohort was defined as the date of the first medical record with a diagnosis code related to PK deficiency. Each patient in the PK deficiency cohort was matched 1:5 by age at index, sex, and index year (± 1 year) to patients from the general VHA population with no diagnosis codes related to PK deficiency (non-PK deficiency cohort). The index date for the non-PK deficiency cohort was defined as a random visit date during their match's index year. Survival time from the index date was compared between the PK deficiency cohort and their non-PK deficiency cohort matches using a univariate Cox proportional hazards model with robust standard error estimation. Results: A total of 18 patients met inclusion criteria for the PK deficiency cohort and were matched to 90 individuals in the non-PK deficiency cohort. Baseline characteristics for both cohorts are shown in the Table. For both cohorts, the mean age at index was 57 years and 94% of patients were male; 83-85% were white and the mean Charlson Comorbidity Index score was 0.4-0.5 (no significant differences between cohorts). Imbalances remained between the two cohorts with regard to region and body mass index. The median follow-up was 6.0 years for the PK deficiency cohort and 8.0 years for the non-PK deficiency cohort. Over the follow-up period, there were 9 (50%) observed deaths in the PK deficiency cohort and 28 (31%) observed deaths in the non-PK deficiency cohort. The median time until death was 10.9 years for the PK deficiency cohort and 17.1 years for the non-PK deficiency cohort; the Kaplan-Meier curves for both cohorts are shown in the Figure. Patients in the non-PK deficiency cohort had a significantly longer time to death than the PK deficiency cohort (hazard ratio: 2.3; p = 0.0306); 10 years after index, 42% of patients in the PK deficiency cohort had died compared with 28% of those in the non-PK deficiency cohort. Conclusions: The results of this study suggest that patients with PK deficiency may be at an increased risk of mortality. Further research to understand cause of death in this population is warranted, as is the replication of this study using larger sample sizes and other real-world data sources that better represent females and the pediatric and adolescent PK deficiency age groups. Disclosures Zagadailov: Agios Pharmaceuticals: Current Employment, Current equity holder in publicly-traded company. Boscoe:Agios Pharmaceuticals: Current Employment, Current equity holder in private company. Garcia-Horton:Agios Pharmaceuticals: Consultancy; Analysis Group, Inc.: Current Employment. Shi:Agios Pharmaceuticals: Consultancy; Analysis Group, Inc.: Current Employment. Liu:Analysis Group, Inc.: Consultancy. Shi:Analysis Group, Inc.: Consultancy. Macaulay:Agios Pharmaceuticals: Consultancy; Analysis Group, Inc.: Current Employment.

Testing Practices and Incidence of Chlamydial and Gonococcal Infection in the Veterans Health Administration, 2009-2019.

Chlamydia trachomatis and Neisseria gonorrhoeae cases reached a record high in the United States in 2018. Although active-duty military service members have high rates of chlamydia and gonorrhea infection, trends in chlamydia and gonorrhea in the Veterans Health Administration (VHA) system have not been previously described, including among patients living with human immunodeficiency virus (HIV) and young women. We identified all veterans in VHA care from 2009 through 2019. Tests and cases of chlamydia and gonorrhea were defined based on laboratory results in the electronic health record. Chlamydia and gonorrhea incidence rates were calculated each year by demographic group and HIV status. In 2019, testing for chlamydia and gonorrhea occurred in 2.3% of patients, 22.6% of women aged 18-24 years, and 34.1% of persons living with HIV. The 2019 incidence of chlamydia and gonorrhea was 100.8 and 56.3 cases per 100 000 VHA users, an increase of 267% and 294%, respectively, since 2009. Veterans aged ≤34 years accounted for 9.5% of the VHA population but 66.9% of chlamydia and 42.9% of gonorrhea cases. Chlamydia and gonorrhea incidence rates in persons living with HIV were 1432 and 1687 per 100 000, respectively. The incidence of chlamydia and gonorrhea rose dramatically from 2009 to 2019. Among tested persons, those living with HIV had a 15.2-fold higher unadjusted incidence of chlamydia and 34.9-fold higher unadjusted incidence of gonorrhea compared with those not living with HIV. VHA-wide adherence to chlamydia and gonorrhea testing in high-risk groups merits improvement.