Veterans Health Administration Providers Research Articles

Decisional Needs of Veterans With Mild Traumatic Brain Injury Initiating Treatment for Insomnia Disorder and Obstructive Sleep Apnea.

We sought to elicit key informant (KI) perspectives regarding decisional needs of Veterans with mild traumatic brain injury (mTBI) who are initiating insomnia disorder and obstructive sleep apnea (OSA) treatment within the Veterans Health Administration (VHA) Polytrauma/TBI System of Care (PSC). Specifically, we sought to understand: (1) information regarding treatment options that Veterans with mTBI require in order to make an informed decision; and (2) values used to guide decision-making (ie, personally meaningful aspects of the decision used to compare treatment options). Nationwide VHA PSC sites. Clinicians included VHA providers and policymakers involved in the management of mTBI and/or sleep disorders in the VHA PSC (n =29). Veterans included those with a clinician-confirmed mTBI who received care for insomnia disorder and/or OSA within the past year (n =20). Semi-structured interviews with the 49 KIs were recorded and transcribed verbatim. Themes were identified using a descriptive and interpretive approach to qualitative analysis. Not applicable. Informational needs identified by both KI groups included information regarding outcomes and downsides of treatment, accessible delivery, treatment candidates, description of diagnosis, and level of commitment. Values used to guide decision-making for both insomnia disorder and OSA treatment included benefits, downsides, and availability of treatments. Values used to decide on insomnia treatments alone included time commitment, intrinsic management of sleep, beliefs regarding mental health treatment, and time course of benefit. Values used to decide on OSA treatment alone included intrusiveness of the treatment, appearance, and impact on bed partners. The current study revealed the decisional needs of Veterans with mTBI who are initiating sleep disorder treatment. Findings can inform the development of decision aids and other efforts aimed at promoting patient-centered management of comorbid mTBI and sleep disorders, thereby improving care quality and clinical outcomes.

Patient-reported pain and physical health for acupuncture and chiropractic care delivered by Veterans Affairs versus community providers.

Acupuncture and chiropractic care are evidence-based pain management alternatives to opioids. The Veterans Health Administration (VA) provides this care in some VA facilities, but also refers patients to community providers. We aimed to determine if patient-reported outcomes differ for acupuncture and chiropractic care from VA versus community providers. We conducted an observational study using survey outcome data and electronic medical record utilization data for acupuncture and chiropractic care provided in 18 VA facilities or in community facilities reimbursed by VA. Study participants were users of VA primary care, mental health, pain clinic, complementary and integrative therapies, coaching or education services in 2018-2019. Patients received 1) 4+ acupuncture visits (N = 201) or 4+ chiropractic care visits (N = 178) from a VA or community provider from 60 days prior to baseline to six-months survey and 2) no acupuncture or chiropractic visits from 1 year to 60 days prior to baseline. Outcomes measured included patient-reported pain (PEG) and physical health (PROMIS) at baseline and six-month surveys. Multivariate analyses examined outcomes at six months, adjusting for baseline outcomes and demographics. In unadjusted analyses, pain and physical health improved for patients receiving community-based acupuncture, while VA-based acupuncture patients experienced no change. Unadjusted analyses also showed improvements in physical health, but not pain, for patients receiving VA-based chiropractic care, with no changes for community-based chiropractic care patients. Using multivariate models, VA-based acupuncture was no different from community-based acupuncture for pain (-0.258, p = 0.172) or physical health (0.539, p = 0.399). Similarly, there were no differences between VA- and community-based chiropractic care in pain (-0.273, p = 0.154) or physical health (0.793, p = 0.191). Acupuncture and chiropractic care were associated with modest improvements at six months, with no meaningful differences between VA and community providers. The choice to receive care from VA or community providers could be based on factors other than quality, like cost or convenience.

Veteran Experiences With an mHealth App to Support Measurement-Based Mental Health Care: Results From a Mixed Methods Evaluation.

Mental health conditions are highly prevalent among US veterans. The Veterans Health Administration (VHA) is committed to enhancing mental health care through the integration of measurement-based care (MBC) practices, guided by its Collect-Share-Act model. Incorporating the use of remote mobile apps may further support the implementation of MBC for mental health care. This study aims to evaluate veteran experiences with Mental Health Checkup (MHC), a VHA mobile app to support remote MBC for mental health. Our mixed methods sequential explanatory evaluation encompassed mailed surveys with veterans who used MHC and follow-up semistructured interviews with a subset of survey respondents. We analyzed survey data using descriptive statistics. We then compared responses between veterans who indicated having used MHC for ≥3 versus <3 months using χ2 tests. We analyzed interview data using thematic analysis. We received 533 surveys (533/2631, for a 20% response rate) and completed 20 interviews. Findings from these data supported one another and highlighted 4 key themes. (1) The MHC app had positive impacts on care processes for veterans: a majority of MHC users overall, and a greater proportion who had used MHC for ≥3 months (versus <3 months), agreed or strongly agreed that using MHC helped them be more engaged in their health and health care (169/262, 65%), make decisions about their treatment (157/262, 60%), and set goals related to their health and health care (156/262, 60%). Similarly, interviewees described that visualizing progress through graphs of their assessment data over time motivated them to continue therapy and increased self-awareness. (2) A majority of respondents overall, and a greater proportion who had used MHC for ≥3 months (versus <3 months), agreed/strongly agreed that using MHC enhanced their communication (112/164, 68% versus 51/98, 52%; P=.009) and rapport (95/164, 58% versus 42/98, 43%; P=.02) with their VHA providers. Likewise, interviewees described how MHC helped focus therapy time and facilitated trust. (3) However, veterans also endorsed some challenges using MHC. Among respondents overall, these included difficulty understanding graphs of their assessment data (102/245, 42%), not receiving enough training on the app (73/259, 28%), and not being able to change responses to assessment questions (72/256, 28%). (4) Interviewees offered suggestions for improving the app (eg, facilitating ease of log-in, offering additional reminder features) and for increasing adoption (eg, marketing the app and its potential advantages for veterans receiving mental health care). Although experiences with the MHC app varied, veterans were positive overall about its use. Veterans described associations between the use of MHC and engagement in their own care, self-management, and interactions with their VHA mental health providers. Findings support the potential of MHC as a technology capable of supporting the VHA's Collect-Share-Act model of MBC.

A framework for inferring and analyzing pharmacotherapy treatment patterns

BackgroundTo discover pharmacotherapy prescription patterns and their statistical associations with outcomes through a clinical pathway inference framework applied to real-world data.MethodsWe apply machine learning steps in our framework using a 2006 to 2020 cohort of veterans with major depressive disorder (MDD). Outpatient antidepressant pharmacy fills, dispensed inpatient antidepressant medications, emergency department visits, self-harm, and all-cause mortality data were extracted from the Department of Veterans Affairs Corporate Data Warehouse.ResultsOur MDD cohort consisted of 252,179 individuals. During the study period there were 98,417 emergency department visits, 1,016 cases of self-harm, and 1,507 deaths from all causes. The top ten prescription patterns accounted for 69.3% of the data for individuals starting antidepressants at the fluoxetine equivalent of 20-39 mg. Additionally, we found associations between outcomes and dosage change.ConclusionsFor 252,179 Veterans who served in Iraq and Afghanistan with subsequent MDD noted in their electronic medical records, we documented and described the major pharmacotherapy prescription patterns implemented by Veterans Health Administration providers. Ten patterns accounted for almost 70% of the data. Associations between antidepressant usage and outcomes in observational data may be confounded. The low numbers of adverse events, especially those associated with all-cause mortality, make our calculations imprecise. Furthermore, our outcomes are also indications for both disease and treatment. Despite these limitations, we demonstrate the usefulness of our framework in providing operational insight into clinical practice, and our results underscore the need for increased monitoring during critical points of treatment.

Improving the Maternity Care Safety Net: Establishing Maternal Mortality Surveillance for Non-Obstetric Providers and Institutions.

The siloed nature of maternity care has been noted as a system-level factor negatively impacting maternal outcomes. Veterans Health Administration (VA) provides multi-specialty healthcare before, during, and after pregnancy but purchases obstetric care from community providers. VA providers may be unaware of perinatal complications, while community-based maternity care providers may be unaware of upstream factors affecting the pregnancy. To optimize maternal outcomes, the VA has initiated a system-level surveillance and review process designed to improve non-obstetric care for veterans experiencing a pregnancy. This quality improvement project aimed to describe the VA-based maternal mortality review process and to report maternal mortality (pregnancy-related death up to 42 days postpartum) and pregnancy-associated mortality (death from any cause up to 1 year postpartum) among veterans who use VA maternity care benefits. Pregnancies and pregnancy-associated deaths between fiscal year (FY) 2011-2020 were identified from national VA databases. All deaths underwent individual chart review and abstraction that focused on multi-specialty care received at the VA in the year prior to pregnancy until the time of death. Thirty-two pregnancy-associated deaths were confirmed among 39,720 pregnancies (PAMR = 80.6 per 100,000 live births). Fifty percent of deaths occurred among individuals who had experienced adverse social determinants of health. Mental health conditions affected 81%. Half (n = 16, 50%) of all deaths occurred in the late postpartum period (43-365 days postpartum) after maternity care had ended. More than half of these late postpartum deaths (n = 9, 56.2%) were related to suicide, homicide, or overdose. Integration of care delivered during the perinatal period (pregnancy through postpartum) from primary, mental health, emergency, and specialty care providers may be enhanced through a system-based approach to pregnancy-associated death surveillance and review. This quality improvement project has implications for all healthcare settings where coordination between obstetric and non-obstetric providers is needed.

Patient Experiences and Provider Perspectives on Accessing Gender-Affirming Surgical Services in the Veterans Health Administration.

Transgender and gender diverse (TGD) veterans have a greater prevalence of suicide morbidity and mortality than cisgender veterans. Gender-affirming surgery (GAS) has been shown to improve mental health for TGD veterans. In 2021, the Veterans Health Administration (VHA) announced the initiation of a rulemaking process to cover GAS for TGD patients. This study explores patients' and providers' perspectives about access to GAS and other gender-affirming medical interventions not offered in the VHA including barriers, facilitators, and clinical and policy recommendations. TGD patients (n = 30) and VHA providers (n = 22). Semi-structured telephone interviews conducted from August 2019 through January 2020. Two TGD analysts used conventional and directed content analysis to code transcribed data. VHA policy exclusions were the most cited barrier to GAS. Additional barriers included finding information about GAS, traveling long distances to non-VHA surgeons, out-of-pocket expenses, post-surgery home care, and psychological challenges related to the procedure. Factors facilitating access included surgical care information from peers and VHA providers coordinating care with non-VHA GAS providers. Pre- and post-operative care through the VHA also facilitated receiving surgery; however, patients and providers indicated that knowledge of these services is not widespread. Respondents recommended disseminating information about GAS-related care and resources to patients and providers to help patients navigate care. Additional recommendations included expanding access to TGD mental health specialists and establishing referrals to non-VHA GAS providers through transgender care coordinators. Finally, transfeminine patients expressed the importance of facial GAS and hair removal. A policy change to include GAS in the VHA medical benefits package will allow the largest integrated healthcare system in the United States to provide evidence-based GAS services to TGD patients. For robust and consistent policy implementation, the VHA must better disseminate information about VHA-provided GAS-related care to TGD patients and providers while building capacity for GAS delivery.

Understanding Veterans' intimate partner violence use and patterns of healthcare utilization.

To understand the association between Veterans' healthcare utilization and intimate partner violence (IPV) use (i.e., perpetration) in order to (1) identify conditions comorbid with IPV use and (2) inform clinical settings to target for IPV use screening, intervention, and provider training. We examined survey data from a national sample of 834 Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) Veterans. We assessed associations between past-year IPV use and medical treatment, health issues, and use of Veterans Health Administration (VA) and non-VA services using chi-square tests and logistic regression. Data were derived from the Department of Defense OEF/OIF/OND Roster. Surveys were sent to all women Veterans and a random sample of men from participating study sites. Half (49%) of the Veterans who reported utilizing VA healthcare in the past year indicated using IPV. Q values using a 5% false discovery rate indicated that Veterans who used IPV were more likely than Veterans who did not use IPV to have received treatment for post-traumatic stress disorder (PTSD; 39% vs. 27%), chronic sleep problems (36% vs. 26%), anxiety or depression (44% vs. 36%), severe chronic pain (31% vs. 22%), and stomach or digestive disorders (24% vs. 16%). Veterans who used IPV were also more likely than Veterans who did not use IPV to have received medical treatment in the past year (86% vs. 80%), seen psychiatrists outside VA (39% vs. 20%), and have outpatient healthcare outside VA (49% vs. 41%). IPV use was not related to whether Veterans received care from VA or non-VA providers. Veterans' IPV use was related to greater utilization of services for mental health, chronic pain, and digestive issues. Future research should examine whether these are risk factors or consequences of IPV use.

The integration of harm reduction services in the Veterans Health Administration (VHA): a qualitative analysis of barriers and facilitators

Background Substance use is common among U.S. military veterans and veterans are at high risk for negative consequences associated with substance use, such as injection-related infections and overdose. Although harm reduction services (HRS) are highly evidence-based, implementation in traditional healthcare settings has been limited. This formative, qualitative study sought to identify barriers and facilitators to the integration of HRS and identify appropriate implementation strategies to support the optimized integration of a comprehensive bundle of HRS in the Veterans Health Administration (VHA). Methods Semi-structured interviews explored how harm reduction is currently understood by VHA providers and elicited input on perceived facilitators and barriers to implementation. Data were analyzed using a directed content analysis and the Practical, Robust Implementation and Sustainability Model (PRISM) implementation framework was used to organize findings. Results were then mapped to relevant implementation strategies using the Consolidated Framework for Implementation Research - Expert Recommendations for Implementing Change (CFIR – ERIC) tool. Results 15 interviews with VHA providers were conducted across 5 sites. Respondents reported that current HRS are fragmented and dependent on the knowledge, time, and comfort level of individual providers. Stigma around substance use at the patient, provider, and institutional levels was noted to be a key barrier to HRS adoption. Based on identified barriers and facilitators, strategies that may be effective for increasing adoption of HRS include engagement of champions, communication and educational strategies, and adaptation of existing infrastructure. Conclusions Many of the barriers identified in this formative study may be addressed using evidence-based implementation strategies. Additional research is needed to identify implementation strategies that are effective for addressing stigma, which is perceived to be a persistent challenge to the provision of integrated harm reduction services.

Refining Expert Recommendations for Implementing Change (ERIC) strategy surveys using cognitive interviews with frontline providers

BackgroundThe Expert Recommendations for Implementing Change (ERIC) compilation includes 73 defined implementation strategies clustered into nine content areas. This taxonomy has been used to track implementation strategies over time using surveys. This study aimed to improve the ERIC survey using cognitive interviews with non-implementation scientist clinicians.MethodsStarting in 2015, we developed and fielded annual ERIC surveys to evaluate liver care in the Veterans Health Administration (VA). We invited providers who had completed at least three surveys to participate in cognitive interviews (October 2020 to October 2021). Before the interviews, participants reviewed the complete 73-item ERIC survey and marked which strategies were unclear due to wording, conceptual confusion, or overlap with other strategies. They then engaged in semi-structured cognitive interviews to describe the experience of completing the survey and elaborate on which strategies required further clarification.ResultsTwelve VA providers completed surveys followed by cognitive interviews. The “Engage Consumer” and “Support Clinicians” clusters were rated most highly in terms of conceptual and wording clarity. In contrast, the “Financial” cluster had the most wording and conceptual confusion. The “Adapt and Tailor to Context” cluster strategies were considered to have the most redundancy. Providers outlined ways in which the strategies could be clearer in terms of wording (32%), conceptual clarity (51%), and clarifying the distinction between strategies (51%).ConclusionsCognitive interviews with ERIC survey participants allowed us to identify and address issues with strategy wording, combine conceptually indistinct strategies, and disaggregate multi-barreled strategies. Improvements made to the ERIC survey based on these findings will ultimately assist VA and other institutions in designing, evaluating, and replicating quality improvement efforts.

Analysis of Reported Suicide Safety Events Among Veterans Who Received Treatment Through Department of Veterans Affairs-Contracted Community Care.

Veteran patients have access to a broad range of health care services in the Veterans' Health Administration (VHA). There are concerns, however, that all Veteran patients may not have access to timely care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act was passed in 2018 to ensure that eligible Veterans can receive timely, high-quality care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act makes use of Department of Veterans Affairs (VA)-contracted care to achieve its goal. There are concerns, however, that these transitions of care may, in fact, place Veterans at a higher risk of poor health outcomes. This is a particular concern with regard to suicide prevention. No study has investigated suicide-related safety events in Veteran patients who receive care in VA-contracted community care settings. A retrospective analysis of root-cause analysis (RCA) reports and patient safety reports of suicide-related safety events that involved VA-contracted community care was conducted. Events that were reported to the VHA National Center for Patient Safety between January 1, 2018, and June 30, 2022, were included. A coding book was developed to abstract relevant variables from each report, for example, report type and facility and patient characteristics. Root causes reported in RCAs were also coded, and the factors that contributed to the events were described in the patient safety reports. Two reviewers independently coded 10 cases, and we then calculated a kappa. Because the kappa was greater than 80% (i.e. 89.2%), one reviewer coded the remaining cases. Among 139 potentially eligible reports, 88 reports were identified that met the study inclusion criteria. Of these 88 reports, 62.5% were patient safety reports and 37.5% were RCA reports. There were 129 root causes of suicide-related safety events involving VA-contracted community care. Most root causes were because of health care-related processes. Reports cited concerns around challenges with communication and deficiencies in mental health treatment. A few reports also described concerns that community care providers were not available to engage in patient safety activities. Patient safety reports voiced similar concerns but also pointed to specific issues with the safety of the environment, for example, access to methods of strangulation in community care treatment settings in an emergency room or a rehabilitation unit. It is important to strengthen the systems of care across VHA- and VA-contracted community care settings to reduce the risk of suicide in Veteran patients. This includes developing standardized methods to improve the safety of the clinical environment as well as implementing robust methods to facilitate communication between VHA and community care providers. In addition, Veteran patients may benefit from quality and safety activities that capitalize on the collective knowledge of VHA- and VA-contracted community care organizations.

VA Outreach Is an Essential Area for Improving Veterans' Health Care Accessibility.

The Veterans Health Administration (VHA) is tasked with providing access to health care to veterans of military service. However, many eligible veterans have either not yet enrolled or underutilized VHA services. Further study of barriers to access before veterans enroll in VHA care is necessary to understand how to address this issue. The ChooseVA (née MyVA Access) initiative aims to achieve this mission to improve veterans' health care access. Although veteran outreach was not specifically addressed by the initiative, it is a critical component of improving veterans' access to health care. Findings from this multisite evaluation of ChooseVA implementation describe sites' efforts to improve VHA outreach and veterans' experiences with access. This quality improvement evaluation employed a multi-method qualitative methodology, including 127 semi-structured interviews and 81 focus groups with VHA providers and staff ("VHA staff") completed during 21 VHA medical center facility site visits between July and November 2017 and 48 telephone interviews with veterans completed between May and October 2018. Interviews and focus groups were transcribed and analyzed using deductive and inductive analysis to capture challenges and strategies to improve VHA health care access (VHA staff data), experiences with access to care (veteran data), barriers and facilitators to care (staff and veteran data), contextual factors, and emerging categories and themes. We developed focused themes describing perceived challenges, descriptions of VHA staff efforts to improve veteran outreach, and veterans' experiences with accessing VHA health care. VHA staff and veteran respondents reported a lack of veteran awareness of eligibility for VHA services. Veterans reported limited understanding of the range of services offered. This awareness gap served as a barrier to veterans' ability to successfully access VHA health care services. Veterans described this awareness gap as contributing to delayed VHA enrollment and delayed or underutilized health care benefits and services. Staff focused on community outreach and engaging veterans for VHA enrollment as part of their efforts to implement the ChooseVA access initiative. Staff and veteran respondents agreed that outreach efforts were helpful for engaging veterans and facilitating access. Although efforts across VHA programs informed veterans about VHA services, our results suggest that both VHA staff and veterans agreed that missed opportunities exist. Gaps include veterans' lack of awareness or understanding of VHA benefits for which they qualify for. This can result in delayed access to care which may negatively impact veterans, including those separating from the military and vulnerable populations such as veterans who experience pregnancy or homelessness.

Veteran Behavioral Health Care in the VHA and Elsewhere.

Veteran Behavioral Health Care in the VHA and Elsewhere.

Trends in Follow-up Testing Among Patients Positive for Chlamydia and Gonorrhea in the Veterans Health Administration, 2013 to 2019.

The Centers for Disease Control and Prevention (CDC) recommends testing patients with chlamydia (CT)/gonorrhea (GC) for other sexually transmitted infections (STIs) and repeating CT/GC testing 3 to 12 months later. We assessed repeat CT/GC testing and testing for HIV/syphilis in accordance with CDC guidelines in the US Veterans Health Administration. Molecular laboratory testing for CT/GC during January 1, 2013-December 31, 2020 was retrieved from Veterans Health Administration data sources. Patients were evaluated for syphilis, HIV, and repeat CT/GC testing within 1 year after a positive CT/GC test result. Differences of CT/GC-positive patients associated with receiving recommended testing were assessed using χ2 /Fisher exact tests. A total of 41,630 of 1,005,761 CT (4.1%) and 17,649 of 1,013,198 GC (1.7%) results were positive. Median ages of positive CT/GC patients were 29 and 36 years, respectively. Repeat testing rates for CT/GC within 90 to 119 days were 3.9% and 2.9%, and rates within 90 to 365 days were 32.8% and 34.7%, with 8.6% and 15% being positive again, respectively. Guideline-compatible repeat testing in known HIV-positive patients nearly doubled (75.7% for CT and 67.8% for GC). The CDC-recommended HIV testing was performed for 72.4% and 65.5% CT and GC first positives, respectively, whereas syphilis testing was completed for 66.5% and 60.5% CT and GC, respectively. Compared with 25- to 34-year-old patients with CT or GC, those younger than 25 years had higher odds of guideline-discordant repeat testing but had lower odds of not receiving HIV/syphilis testing. Nearly two-thirds of patients did not receive recommended repeat testing, and nearly one-third were not tested for HIV/syphilis. Veterans Health Administration providers may benefit from additional education on CDC-recommended sexually transmitted infection guidelines and testing recommendations.

2093. Utilizing Implementation Science to Identify Barriers and Facilitators to Implementing Harm Reduction Services in the Veterans Health Administration (VHA)

Abstract Background Rising rates of substance use, particularly synthetic opioids, have led to increases in fatal overdoses and injection-associated infections. Harm reduction, including infection prevention via provision of supplies and education, is an approach to minimize risk of severe outcomes. Although harm reduction services (HRS) are highly evidence-based, implementation in most healthcare settings is limited. The aim of this study was to identify facilitators and barriers to the implementation of HRS to inform strategies for increasing access and adoption of a comprehensive bundle of harm reduction resources within the VHA. Methods Qualitative interviews were conducted using a semi-structured interview guide and explored how harm reduction is currently understood and implemented by VHA providers and was designed to identify perceived gaps and barriers. Data were analyzed using a directed content analysis. After barriers and facilitators were identified, they were mapped to relevant implementation strategies using the Consolidated Framework for Implementation Research - Expert Recommendations for Implementing Change (CFIR – ERIC) tool. Results 15 interviews with VHA providers (physicians, social workers, pharmacists, and directors of addiction and mental health services) were conducted across 5 sites. Multiple barriers and few facilitators to the provision of HRS were identified (Table 1). Currently, HRS were thought to be fragmented and dependent on the knowledge, time, and comfort level of individual providers. Participants also highlighted stigma around substance use, limited support, and burdensome regulatory requirements. Existing infrastructure, social programming, and local champions were highlighted as facilitators. Given these factors, implementation strategies that may be bundled to promote adoption of HRS include engagement of champions, communications and educational strategies, existing policies, and creation of dashboards and tracking and feedback systems (Table 1). Conclusion HRS are effective, evidence-based, and patient-centered tools. Mapping of barriers to evidence-based implementation strategies may help improve integration of HRS into VHA healthcare, however, challenges addressing stigma remain a substantial barrier. Disclosures Westyn Branch-Elliman, MD, MMSc, DLA Piper,LLC/Medtronic: Advisor/Consultant|Gilead Pharmaceuticals: Grant/Research Support.

2220. Trends in Follow-up Testing among Patients Positive for Chlamydia and Gonorrhea in the Veterans Health Administration (VHA), 2013-2019

Abstract Background Chlamydia (CT) and gonorrhea (GC) infections are an ongoing public health issue. CDC recommends testing patients with CT/GC for other sexually transmitted illnesses (STIs) and repeating CT/GC testing 3-12 months later. We described repeat testing and testing for other STIs among GC/CT cases in VHA. Methods Molecular laboratory testing for CT/GC during 1/1/2013-12/31/2020 was retrieved from VHA data sources. Patients were evaluated for syphilis, HIV, and repeat CT/GC testing within one year after a positive GC or CT test. Differences in characteristics of CT/GC positive patients associated with receiving recommended testing were assessed using the chi-squared test. Results 41,630 of 1,005,762 (4.1%) CT results (36,138 unique patients) and 17,649 of 1,013,198 (1.7%) GC results (14,598 unique patients) were positive; mean age of positive CT/GC patients were 31.5 and 40yo respectively with the largest percentage of cases in the 25-34yo group. Repeat testing within 91-365 days after a positive result were 32.6% and 34.5% for CT and GC, respectively (Table 1-2). Of CT/GC positives receiving repeat testing, 9% of CT and 15% of GC were again positive. HIV testing was performed for 72.4% and 65.5% CT and GC first positives, respectively, while syphilis testing was completed for 66.5% and 60.5% CT and GC, respectively (Table 3-4). In CT and GC patients tested for other STIs, HIV was positive in 2.1% and 5.9%, and syphilis was positive in 4.1% and 11.3%, respectively. Compared to 25-34yo patients with CT or GC, those &amp;lt; 25 had higher odds of inappropriate repeat testing (i.e., retested &amp;lt; 91 days, or not retested within 365 days after positive) but had lower odds of not being tested for HIV and syphilis. CT/GC positive females had lower odds of not being tested for HIV and syphilis. Conclusion In VHA, nearly 2/3rds CT/GC patients had inappropriate repeat testing, nearly 1/3rd were not tested for HIV/syphilis and up to 15% remained positive for CT/GC, suggesting testing practices and treatment could be improved to better align with current CDC recommendations. STIs not identified and treated appropriately can have serious individual and public health consequences. VHA providers may benefit from additional education on CDC recommended STI guidelines. Disclosures All Authors: No reported disclosures.

How Did Veterans' Reliance on Veterans Health Administration Outpatient Care Change After Expansion of the Veterans Community Care Program?

The Veterans Community Care Program (VCCP) aims to address access constraints in the Veterans Health Administration (VA) by reimbursing care from non-VA community providers. Little existing research explores how veterans' choice of VA versus VCCP providers has evolved as a significant VCCP expansion in 2014 as part of the Veterans Access, Choice, and Accountability Act. We examined changes in reliance on VA for primary care (PC), mental health (MH), and specialty care (SC) among VCCP-eligible veterans. We linked VA administrative data with VCCP claims to retrospectively examine utilization during calendar years 2016-2018. 1.78 million veterans enrolled in VA before 2013 and VCCP-eligible in 2016 due to limited VA capacity or travel hardship. We measured reliance as the proportion of total annual outpatient (VA+VCCP) visits occurring in VA for PC, MH, and SC. Of the 26.1 million total outpatient visits identified, 45.6% were for MH, 29.9% for PC, and 24.4% for SC. Over the 3 years, 83.2% of veterans used any VA services, 23.8% used any VCCP services, and 20.0% were dual VA-VCCP users. Modest but statistically significant declines in reliance were observed from 2016-2018 for PC (94.5%-92.2%), and MH (97.8%-96.9%), and a more significant decline was observed for SC (88.5%-79.8%). Veterans who have the option of selecting between VA or VCCP providers continued using VA for most of their outpatient care in the initial years after the 2014 VCCP expansion.

Dually-enrolled patients choose providers with lower wait times: Budgetary implications for the VHA.

To estimate the effect of wait times on patients' choice of provider and simulate changes in choice of provider due to compliance with VA MISSION Act wait time targets. We use nationwide administrative data (2014-2017) on Veterans who are enrolled in Medicare and the Veterans Health Administration (VHA), the Survey of VHA Enrollees, Area Health Resource Files, and other data provided by the Centers for Medicare & Medicaid Services. We use an instrumental variables approach to identify the effect of VHA wait times on the proportion of total (Medicare and VHA) services that are paid for by the VHA ("reliance"). We exploit shocks to VHA provider supply to isolate supply-driven changes in wait times and estimate the effect on VHA reliance. We control for market and time fixed effects and local demand factors. We use monthly aggregated data on 140 markets (groups of counties). VHA reliance is computed among patients aged 65 years or older who are dually enrolled in VHA and Medicare. VHA wait times and reliance are calculated for multiple specialties: cardiology, gastroenterology, orthopedics, urology, dermatology, and ophthalmology/optometry. A 10% increase in the mean wait time (+2.8 days) reduces VHA reliance by 2.3 percentage points (95% CI: 2.3, 2.7), or 7.9% of the sample mean. This implies that meeting the MISSION Act wait time targets may have multi-billion-dollar budgetary impacts. Effects vary across specialties. For example, a 10% increase in the mean wait time for cardiology services (+2.0 days) reduces reliance by 1.8 percentage points (95% CI: 1.6, 2.1), or 6.3% of the sample mean for cardiology services. Meeting statutory wait time targets may have substantial unforeseen impacts on federal health care spending as patients sort to providers who have lower wait times.

Medications with Potential for Fetal Risk Prescribed to Veterans.

Background: Women service members of the past 20 years experienced high rates of traumatizing events resulting in pharmacological treatment. Post-military lives may include having children. Typically, Veterans Health Administration (VHA) patients' pregnancies are managed outside the VHA. This study examined medication exposures during pregnancy. Materials and Methods: The Center for Maternal and Infant Outcomes Research in Translation (COMFORT) study collected primary survey data and linked secondary health care data from the VHA from 2015 to 2021. Medication fills and covariates were extracted for three 9-month periods: preconception, pregnancy, and postpartum. Multiple regression assessed factors associated with use during pregnancy of selective serotonin reuptake inhibitor (SSRI)/serotonin norepinephrine reuptake inhibitor (SNRI) or of non-recommended, potentially risky drugs, and of discontinuation of those medications from prepregnancy to pregnancy. Results: The cohort comprised 501 women-29% Black, 65% White, and 6% other races, of whom 63% had 50%-100% service-connected disability. During pregnancy, 36% had a pain-related disorder, 19% major depression, and 18% post-traumatic stress disorder. The median number of drug classes prescribed during pregnancy was 5. The use of SSRI/SNRI antidepressants dropped from 36% preconception to 26% during pregnancy including new starts; 15% discontinued SSRI/SNRI. Comorbidity predicted medication use. Depression predicted discontinuing SSRI/SNRI during pregnancy; no predictors of discontinuing potentially risky drugs were identified. Conclusions: Based on prescriptions filled within the VHA only-ignoring potential community-based fills-women veterans were prescribed numerous medications during pregnancy and discontinued antidepressants alarmingly. Veterans of childbearing potential should receive counseling about medication use before pregnancy occurs. Their non-VHA obstetricians and VHA providers should share information to optimize outcomes, reviewing medications as soon as pregnancy is detected as well as after pregnancy concludes.

Core implementation strategies for improving cirrhosis care in the Veterans Health Administration.

The Veterans Health Administration (VHA) provides care for more than 80,000 veterans with cirrhosis. This longitudinal, multimethod evaluation of a cirrhosis care quality improvement program aimed to (1) identify implementation strategies associated with evidence-based, guideline-concordant cirrhosis care over time, and (2) use qualitative interviews to operationalize strategies for a manualized intervention. VHA providers were surveyed annually about the use of 73 implementation strategies to improve cirrhosis care in fiscal years 2018 (FY18) and 2019 (FY19). Implementation strategies linked to guideline-concordant cirrhosis care were identified using bivariate statistics and comparative configurational methods. Semistructured interviews were conducted with 12 facilities in the highest quartile of cirrhosis care to specify the successful implementation strategies and their mechanisms of change. A total of 106 VHA facilities (82%) responded at least once over the 2-year period (FY18, n = 63; FY19, n = 100). Facilities reported using a median of 12 (interquartile range [IQR] 20) implementation strategies in FY18 and 10 (IQR 19) in FY19. Of the 73 strategies, 35 (48%) were positively correlated with provision of evidence-based cirrhosis care. Configurational analysis identified multiple strategy pathways directly linked to more guideline-concordant cirrhosis care. Across both methods, a subset of eight strategies was determined to be core to cirrhosis care improvement and specified using qualitative interviews. In a national cirrhosis care improvement initiative, a multimethod approach identified a core subset of successful implementation strategy combinations. This process of empirically identifying and specifying implementation strategies may be applicable to other implementation challenges in hepatology.

Provider perceptions of challenges to identifying women Veterans with hazardous substance use

BackgroundApproximately one-third of women Veterans Health Administration (VHA) users have substance use disorders (SUD). Early identification of hazardous substance use in this population is critical for the prevention and treatment of SUD. We aimed to understand challenges to identifying women Veterans with hazardous substance use to improve future referral, evaluation, and treatment efforts.MethodsDesign: We conducted a secondary analysis of semi-structured interviews conducted with VHA interdisciplinary women’s SUD providers at VA Greater Los Angeles Healthcare System. Participants: Using purposive and snowball sampling we interviewed 17 VHA providers from psychology, social work, women’s health, primary care, and psychiatry. Approach: Our analytic approach was content analysis of provider perceptions of identifying hazardous substance use in women Veterans.ResultsProviders noted limitations across an array of existing identification methodologies employed to identify women with hazardous substance use and believed these limitations were abated through trusting provider-patient communication. Providers emphasized the need to have a process in place to respond to hazardous use when identified. Provider level factors, including provider bias, and patient level factors such as how they self-identify, may impact identification of women Veterans with hazardous substance use. Tailoring language to be sensitive to patient identity may help with identification in women Veterans with hazardous substance use or SUD who are not getting care in VHA but are eligible as well as those who are not eligible for care in VHA.ConclusionsTo overcome limitations of existing screening tools and processes of identifying and referring women Veterans with hazardous substance use to appropriate care, future efforts should focus on minimizing provider bias, building trust in patient-provider relationships, and accommodating patient identities.