Veterans Health Administration Settings Research Articles

Contingency management for substance use disorders in the U.S. Veterans Health Administration: 2018–2022

Introduction: Contingency management (CM) is one of the most effective interventions for substance use disorders (SUDs), including stimulant use disorder. In the United States, the Veterans Health Administration (VHA) led the largest-scale rollout of CM in the US to date, but little is known about characteristics of patients treated and CM clinical practices.Methods: In this retrospective cohort study, we used VHA electronic health records data to descriptively examine CM treatment course (e.g., number of visits, time between visits, duration of treatment episode) and characteristics of patients receiving CM for SUDs from 2018 to 2022.Results: From January 2018 to September 2022, 2844 patients received CM at 90 VA Health Systems (including 98 VA Medical Center, 7 community-based outpatient clinics, and 15 other sites). The median number of CM visits was 8 (mean = 10.17, SD = 8.12) visits over the course of 1.5 months (median = 45 days, mean = 57.46 days, SD = 62.65). The target substance was stimulants in 86.42 % of visits. Average age of patients was 52.29 years (SD = 12.10), with 55.06 % of patients experiencing homelessness or housing instability, and 97.50 % of patients diagnosed with more than one SUD. Compared to the year prior to the COVID-19 pandemic (03/2019–02/2020; mean = 957.33, SD = 157.71 visits/month), CM visits declined by 83.20 % in the year following the pandemic (03/2020–02/2021; mean = 160.83, SD = 164.14), and have yet to return to pre-pandemic levels.Conclusions: The CM rollout has been markedly successful in the VHA, with adoption across multiple VHA sites within a complex patient population, indicating the potential for effective, more widespread CM implementation. At the same time, there was a considerable reduction in CM care during the COVID-19 pandemic and CM has not yet returned to pre-pandemic levels. Moreover, only a small minority of VA patients with stimulant use disorder have received CM. Given increasing rates of overdose, including stimulant-involved overdose, it is important to increase CM provision in VHA and non-VHA settings.

Building Tailored Resource Guides to Address Social Risks and Advance Health Equity in the Veterans Health Administration.

Health care organizations, including the Veterans Health Administration (VHA), are increasingly adopting programs to address social determinants of health. As part of a comprehensive social risk screening and referral model, tailored resource guides can support efforts to address unmet social needs. However, limited guidance is available on best practices for the development of resource guides in health care settings. This article describes the development of geographically tailored resource guides for a national VHA quality improvement initiative, Assessing Circumstances and Offering Resources for Needs (ACORN), which aims to systematically screen for and address social needs among veterans. We outline the rationale for using resource guides as a social needs intervention and provide a pragmatic framework for resource guide development and maintenance. We offer guidance based on lessons learned from the development of ACORN resource guides, emphasizing a collaborative approach with VHA social workers and other frontline clinical staff, as well as with community-based organizations. Our how-to guide provides steps for identifying high-yield resources along with formatting considerations to maximize accessibility and usability among patients. Resource guides can serve as a valuable cross-cutting component of health care organizations' efforts to address social needs. We provide a practical approach to resource guide development that may support successful implementation within the VHA and other clinical settings.

Effect of Post-traumatic Amnesia Duration on Traumatic Brain Injury (TBI) First Year Hospital Costs: A Veterans Affairs Traumatic Brain Injury Model Systems Study

ObjectiveTo examine the association between severity of traumatic brain injury (TBI) as measured by duration of post-traumatic amnesia (PTA) and first year hospitalization costs for service members and veterans (SMVs) treated for TBI at Polytrauma Rehabilitation Centers (PRCs) within the Veterans Health Administration (VHA). DesignMultivariable models of merged datasets from the VA TBI Model Systems (VA TBIMS) national database containing TBI clinical characterization including PTA with VHA hospital cost data. SettingFive VA PRCs. ParticipantsVA TBIMS participants with known PTA who received inpatient rehabilitation within 1 year of their TBI at any of 5 PRCs between 2010 and 2020 (N=717). InterventionsN/A. Main Outcome MeasuresTotal, acute care, rehabilitation, intensive care unit (ICU), and surgery costs across all VA hospitals. ResultsA total of 717 SMVs (mean age 36.9 years, 94.1% men, 76.8% non-Hispanic White, 7.8% active duty) met inclusion criteria for the unadjusted analyses. Unadjusted mean total hospital costs in the first-year post TBI were approximately $201,214 higher for those with PTA duration ≥24 hours ($351,157) than PTA <24 hours ($149,943). In adjusted models (n=583), each additional day of PTA duration incrementally increased total ($1453), rehabilitation ($1324), ICU ($78), and surgery ($39) costs. Other significant covariates included age, acute care length of stay, Disability Rating Scale on rehabilitation admission, penetrating violent cause of injury, and drug abuse. ConclusionsThis study demonstrates that PTA as a quantitative measure of TBI severity significantly affects first-year hospitalization costs of SMVs treated at PRCs. Each additional day of PTA was associated with higher total, rehabilitation, ICU, and surgery costs. Mean first year hospital costs were also found to exceed the highest budget allocation to VHA facilities for a veteran treated at a PRC. These findings have possible implications for hospital care provision for those receiving inpatient rehabilitation in VHA settings.

P600 Democratic deliberation to assess Veteran preferences for biosimilar medication switching for the treatment of Inflammatory Bowel Disease in a resource-conscious setting.

Abstract Background Optimizing care while being resource-conscious, the Veterans Health Administration (VHA) must develop equitable policies incorporating Veterans’ values and beliefs. Switching patients with Inflammatory Bowel Disease (IBD) from biologic medications (originators) to less expensive biosimilars offers opportunities to explore potential policies. Unlike originators, the FDA did not require disease-specific randomized controlled trials for approval of biosimilars, raising provider and patient concerns about the safety of switching to these medications. Deliberative democratic (DD) methods allow us to assess Veteran views of switching programs, a necessary step in creating equitable policies. Methods We carried out two 2-day sessions with Veterans from the Ann Arbor VA (n=17) and Houston VA (n=12). Deliberation began with education about IBD, the use of biologics (including biosimilars), and related implementation challenges. Participants engaged in facilitated small group discussions to 1) identify Veterans views about biosimilar switching and Veteran preferences about switching, and 2) evaluate five approaches for switching: (a) “status quo”–switching policies vary by VHA facility, (b) “sickest last”–Veterans with severe IBD are switched last, (c) “opt-out”–Veterans may opt-out of switching, (d) “next appointment”–Veterans are switched at follow-up, and (e) “lottery”–patients are switched based on random selection. Participants ranked options (1=most preferred, 5=least preferred) and proposed modifications to these approaches. Participants completed pre- and post-DD session surveys. Transcripts were analysed using qualitative methods. Results Participant demographics are in Table 1. Most Veterans sessions preferred the “sickest last” (mean rank: 1.8, standard deviation: 0.9) or “opt-out” (2.4,1.4) approaches over the “status quo” (3.1,1.0) or “lottery” (4.6,0.9); preferences did not significantly change after deliberation (Figure 1). Preferences reflected Veterans’ concerns about the risk of switching to biosimilars for the most vulnerable Veterans and their strong preference for transparency around biosimilar switching. Participants emphasized the importance of informed choice, prioritizing based on health status, personalization, and shared decision-making. Conclusion DD methods are effective for soliciting Veterans' opinions and preferences for health policies. Veterans favoured policies that provided information and control, promoted shared decision-making, and reduced risk to vulnerable patients. Incorporating patient preferences and insights is critical when implementing health policies in the VHA and other resource-limited settings.

DEMOCRATIC DELIBERATION TO ASSESS VETERAN PREFERENCES FOR BIOSIMILAR MEDICATION SWITCHING FOR THE TREATMENT OF INFLAMMATORY BOWEL DISEASE IN A RESOURCE CONSCIOUS SETTING

Abstract BACKGROUND To optimize care while being resource conscious, the Veterans Health Administration (VHA) must develop equitable policies that incorporate Veterans’ values and beliefs. Switching patients with Inflammatory Bowel Disease (IBD) from biologic medications (originators) to less expensive biosimilars offers the opportunity to explore potential policies. Unlike originators, the FDA did not require disease-specific randomized controlled trials for approval of biosimilars, creating provider and patient concerns about the safety of switching to these medications. Deliberative democratic (DD) methods allow us to assess Veteran views of switching programs, a necessary step in creating equitable policy approaches. METHODS We carried out two 2-day sessions with Veterans from the Ann Arbor VA (n=17) and Houston VA (n=12). Deliberation began with education about IBD, use of biologics (including biosimilars), and related implementation challenges. Participants engaged in facilitated small group discussions designed to 1) identify Veterans views about biosimilar switching and their preferences for informing Veterans about switching, and 2) evaluate responses to five approaches for switching: (a) “status quo”–switching policies vary by VHA facility, (b) “sickest last”–Veterans with the most severe IBD are switched last, (c) “opt-out”–Veterans may opt-out of switching, (d) “next appointment”–Veterans are switched at their next appointment, and (e) “lottery”–patients are switched based on random selection. Participants ranked options (1=most preferred, 5=least preferred) and proposed modifications to these approaches. Participants completed pre- and post-DD session surveys. Discussion transcripts were analyzed using qualitative methods. RESULTS Participant demographics are in Table 1. Most Veterans sessions preferred the “sickest last” (mean rank: 1.8, standard deviation: 0.9) or “opt-out” (2.4,1.4) approaches over the “status quo” (3.1,1.0) or “lottery” (4.6,0.9); preferences did not significantly change after deliberation (Figure 1). Preferences reflected Veterans’ concerns about the risk of switching to biosimilars for the most vulnerable Veterans and their strong preference for information and transparency around biosimilar switching. Participants emphasized the importance of informed choice, prioritizing based on health status, personalization, and shared decision-making (e.g., treatment should be geared to individual patient in discussion with their provider). CONCLUSION DD methods are effective for soliciting Veterans' opinions and preferences for health policies. Veterans favored policies that provided information and control, promoted shared decision-making, and reduced risk to vulnerable patients. Incorporating patient preferences and insights is critical when implementing health policies in the VHA and other resource-limited settings.

Proactive, Recovery-Oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare (PARTNER-MH), a Peer-Led Patient Navigation Intervention for Racially and Ethnically Minoritized Veterans in Veterans Health Administration Mental Health Services: Protocol for a Mixed Methods Randomized Controlled Feasibility Study.

BackgroundMental health care disparities are persistent and have increased in recent years. Compared with their White counterparts, members of racially and ethnically minoritized groups have less access to mental health care. Minoritized groups also have lower engagement in mental health treatment and are more likely to experience ineffective patient-provider communication, which contribute to negative mental health care experiences and poor mental health outcomes. Interventions that embrace recovery-oriented practices to support patient engagement and empower patients to participate in their mental health care and treatment decisions may help reduce mental health care disparities. Designed to achieve this goal, the Proactive, Recovery-Oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare (PARTNER-MH) is a peer-led patient navigation intervention that aims to engage minoritized patients in mental health treatment, support them to play a greater role in their care, and facilitate their participation in shared treatment decision-making.ObjectiveThe primary aim of this study is to assess the feasibility and acceptability of PARTNER-MH delivered to patients over 6 months. The second aim is to evaluate the preliminary effects of PARTNER-MH on patient activation, patient engagement, and shared decision-making. The third aim is to examine patient-perceived barriers to and facilitators of engagement in PARTNER-MH as well as contextual factors that may inhibit or promote the integration, sustainability, and scalability of PARTNER-MH using the Consolidated Framework for Implementation Research.MethodsThis pilot study evaluates the feasibility and acceptability of PARTNER-MH in a Veterans Health Administration (VHA) mental health setting using a mixed methods, randomized controlled trial study design. PARTNER-MH is tested under real-world conditions using certified VHA peer specialists (peers) selected through usual VHA hiring practices and assigned to the mental health service line. Peers provide PARTNER-MH and usual peer support services. The study compares the impact of PARTNER-MH versus a wait-list control group on patient activation, patient engagement, and shared decision-making as well as other patient-level outcomes. PARTNER-MH also examines organizational factors that could impact its future implementation in VHA settings.ResultsParticipants (N=50) were Veterans who were mostly male (n=31, 62%) and self-identified as non-Hispanic (n=44, 88%) and Black (n=35, 70%) with a median age of 45 to 54 years. Most had at least some college education, and 32% (16/50) had completed ≥4 years of college. Randomization produced comparable groups in terms of characteristics and outcome measures at baseline, except for sex.ConclusionsRather than simply documenting health disparities among vulnerable populations, PARTNER-MH offers opportunities to evaluate a tailored, culturally sensitive, system-based intervention to improve patient engagement and patient-provider communication in mental health care for racially and ethnically minoritized individuals.Trial RegistrationClinicalTrials.gov NCT04515771; https://clinicaltrials.gov/ct2/show/NCT04515771International Registered Report Identifier (IRRID)DERR1-10.2196/37712

Implementation of Integrated Dual Disorder Treatment in Routine Veterans Health Administration Settings

Implementation of Integrated Dual Disorder Treatment in Routine Veterans Health Administration Settings

Pretreatment stabilization increases completion of trauma-focused evidence-based psychotherapies.

Veterans with posttraumatic stress disorder (PTSD) initiate and complete cognitive processing therapy (CPT) and prolonged exposure (PE) at low rates within Veterans Health Administration (VHA) despite substantial dissemination and training. This study investigated how trauma-informed, skills-based treatment ("stabilization") administered before CPT and PE was related to initiation and completion of trauma-focused evidence-based psychotherapies (TF-EBPs). Data were extracted from the VHA electronic medical record to identify veterans who initiated outpatient treatment in the PTSD Clinical Team (PCT) at a Veterans Affairs Health Care System. Treatment initiation was defined as three or more PCT visits with no prior PCT care for at least 18 months (N = 341). Before initiation of TF-EBP, veterans received either no stabilization or received individual and/or group stabilization. Twenty-eight percent of veterans without stabilization (n = 115) initiated TF-EBP, compared with 34% of veterans who completed individual-only stabilization (n = 82), and 10% of veterans who completed group-only stabilization (n = 29, p = .050). Compared with those with no stabilization, individual stabilization was associated with significantly higher TF-EBP completion (93% vs. 50%, p < .001). CPT completion was also significantly higher for veterans who received individual-only stabilization (90% vs. 43%, p = .001). Results for PE followed the same relationship, but did not reach significance (100% vs. 67%, p = .090). Findings suggest that individual stabilization may improve delivery of TF-EBPs in VHA settings by increasing TF-EBP completion without reducing initiation, while pretreatment with group-only stabilization may reduce initiation of TF-EBPs. Results inform how models of care can improve TF-EBP retention and completion among veterans with PTSD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Applying polyvictimization theory to veterans: Associations with substance use and mental health.

Prior work has linked exposure to multiple types of trauma (i.e., polyictimization) to increased risk of negative behavioral health outcomes compared with exposure to any single event. However, few studies have attempted to understand how polyvictimization theory relates specifically to veterans' experiences and behavioral health outcomes. The present study assessed heterogeneity in reports of childhood trauma, combat trauma, and military sexual trauma. We recruited 1,230 veterans outside of traditional Veterans Health Administration settings to participate in a study assessing behavioral health. On average, participants were 34.5 years old with the majority identifying as White (79.3%) and male (88.7%). We used latent class analysis to extract classes of traumatic experience exposure including childhood trauma, combat trauma, and military sexual trauma. Five classes emerged: (a) high all; (b) moderate combat trauma, high military sexual trauma; (c) high combat trauma, moderate military sexual harassment; (d) moderate childhood trauma and combat trauma; and (e) combat trauma only. Overall, veterans in profiles that endorsed multiple trauma types (i.e., polyvictimization) evidenced greater symptoms of depression, posttraumatic stress disorder, and hazardous alcohol or cannabis use. Further, women were overly represented in profiles that included multiple victimization typologies, especially when profiles included elevated endorsement of military sexual trauma. A polyvictimization framework was partially supported, with differential effects on behavioral health outcomes noted across trauma experiences. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Clinical Response to Positive Screens for Intimate Partner Violence in the Veterans Health Administration: Findings from Review of Medical Records

ABSTRACT The Veterans Health Administration (VHA) is a leader in implementing healthcare-based intimate partner violence (IPV) screening and response. This study examined the early implementation of this program to assess clinical response to positive IPV screenings. We conducted an in-depth review of medical records for the six months following a positive IPV screen for all women patients who screened positive within the observation period in two medical centers (n = 208). Data included patient’s race, age, screening location, screening provider, screening response, and documentation of follow-up to positive screening, including interaction with an IPV Assistance Program Coordinator (IPVAP-C). The analysis, along with consultation with local staff for each site, revealed implementation challenges in consistency of response to IPV screens. Most (but not all) patients accepted offers of referral to the IPVAP-C. Case examples highlight the process of connecting with services and the content of support. Findings can be useful for VHA and other healthcare settings implementing IPV screening and response programs. Lessons learned include a need for processes for ensuring appropriate follow-up to a positive screen and that having an on-site IPVAP-C appears to be beneficial, although the uptake of such services is not universal.

Racial/Ethnic Variation in Veterans Health Administration COVID-19 Vaccine Uptake

IntroductionEquitable COVID-19 vaccine access is imperative to mitigating negative COVID-19 impacts among racial/ethnic minorities. U.S. racial/ethnic minorities have lower COVID-19 vaccination rates than Whites despite higher COVID-19 death/case rates. The Veterans Health Administration provides the unique context of a managed care system with few access barriers. This study evaluates race/ethnicity as a predictor of Veterans Health Administration COVID-19 vaccination.MethodsThe cohort was composed of Veterans Health Administration outpatient users aged ≥65 years (N=3,474,874). COVID-19 vaccination was assessed between December 14, 2020 and February 23, 2021. Multivariable logistic regressions were conducted, controlling for demographics, medical comorbidity, and influenza vaccination history. Proximity to Indian Health Service Contract Health Service Delivery Areas was tested as a moderator. Data analyses were conducted during 2021.ResultsBlacks (OR=1.28, 95% CI=1.17, 1.40), Hispanics (OR=1.15, 95% CI=1.05, 1.25), and Asians (OR=1.21, 95% CI=1.02, 1.43) were more likely than Whites to receive Veterans Health Administration COVID-19 vaccinations. American Indian/Alaska Natives were less likely than Whites to receive Veterans Health Administration COVID-19 vaccinations, but only those residing in Contract Health Service Delivery Area counties (OR= 0.58, 95% CI= 0.47, 0.72). Influenza vaccine history positively predicted COVID-19 vaccine uptake (OR= 2.28, 95% CI=2.22, 2.34).ConclusionsIn the Veterans Health Administration, compared with the general U.S. population, COVID-19 vaccine receipt is higher among most racial/ethnic minority groups than Whites, suggesting reduced vaccination barriers . The Indian Health Service may provide a safety net for American Indian/Alaska Native populations. Addressing vaccination access barriers in non–Veterans Health Administration settings can potentially reduce racial/ethnic disparities.

An Initiative to Improve 30-Day Readmission Rates Using a Transitions-of-Care Clinic Among a Mixed Urban and Rural Veteran Population.

Hospital readmissions in the United States, especially in patients at high-risk, cost more than $17 billion annually. Although care transitions is an important area of research, data are limited regarding its efficacy, especially among rural patients. In this study, we describe a novel transitions-of-care clinic (TOCC) to reduce 30-day readmissions in a Veterans Health Administration setting that serves a high proportion of rural veterans. In this quality improvement initiative we conducted a pre-post study evaluating clinical outcomes in adult patients at high risk for 30-day readmission (Care Assessment Needs score > 85) discharged from the Iowa City Veterans Affairs (ICVA) Health Care System from 2017 to 2020. The ICVA serves 184,000 veterans across 50 counties in eastern Iowa, western Illinois, and northern Missouri, with more than 60% of these patients residing in rural areas. We implemented a multidisciplinary TOCC to provide in-person or virtual follow-up to high-risk veterans after hospital discharge. The main purpose of this study was to assess how TOCC follow-up impacted the monthly 30-day patient readmission rate. The TOCC resulted in a 19.2% relative reduction in 30-day readmission rates in the 12-month postimplementation period compared to the preimplementation period (9.2% vs 11.4%, P = .04). Virtual visits were more popular than in-person visits among both urban and rural veterans. There was no difference in outcomes between these two follow-up options, and both groups had reduced readmission rates compared to non-TOCC follow-up. A multidisciplinary TOCC within the ICVA featuring both virtual and in-person visits reduced the 30-day readmission rate. This reduction was particularly notable among patients with congestive heart failure.

Adaptation of a quality improvement approach to implement eScreening in VHA healthcare settings: innovative use of the Lean Six Sigma Rapid Process Improvement Workshop

BackgroundThe Veterans Health Administration (VHA) developed a comprehensive mobile screening technology (eScreening) that provides customized and automated self-report health screening via mobile tablet for veterans seen in VHA settings. There is agreement about the value of health technology, but limited knowledge of how best to broadly implement and scale up health technologies. Quality improvement (QI) methods may offer solutions to overcome barriers related to broad scale implementation of technology in health systems. We aimed to develop a process guide for eScreening implementation in VHA clinics to automate self-report screening of mental health symptoms and psychosocial challenges.MethodsThis was a two-phase, mixed methods implementation project building on an adapted quality improvement method. In phase one, we adapted and conducted an RPIW to develop a generalizable process guide for eScreening implementation (eScreening Playbook). In phase two, we integrated the eScreening Playbook and RPIW with additional strategies of training and facilitation to create a multicomponent implementation strategy (MCIS) for eScreening. We then piloted the MCIS in two VHA sites. Quantitative eScreening pre-implementation survey data and qualitative implementation process “mini interviews” were collected from individuals at each of the two sites who participated in the implementation process. Survey data were characterized using descriptive statistics, and interview data were independently coded using a rapid qualitative analytic approach.ResultsPilot data showed overall satisfaction and usefulness of our MCIS approach and identified some challenges, solutions, and potential adaptations across sites. Both sites used the components of the MCIS, but site 2 elected not to include the RPIW. Survey data revealed positive responses related to eScreening from staff at both sites. Interview data exposed implementation challenges related to the technology, support, and education at both sites. Workflow and staffing resource challenges were only reported by site 2.ConclusionsOur use of RPIW and other QI methods to both develop a playbook and an implementation strategy for eScreening has created a testable implementation process to employ automated, patient-facing assessment. The efficient collection and communication of patient information have the potential to greatly improve access to and quality of healthcare.

Preventing Suicide Among Homeless Veterans: A Consensus Statement by the Veterans Affairs Suicide Prevention Among Veterans Experiencing Homelessness Workgroup.

Preventing Suicide Among Homeless Veterans: A Consensus Statement by the Veterans Affairs Suicide Prevention Among Veterans Experiencing Homelessness Workgroup.

Female Veterans' Willingness to Seek Veterans Health Administration and Non-Veterans Health Administration Services for Suicidal Thoughts and Mental Health Concerns.

The extent to which female veterans are willing to seek Veterans Health Administration (VHA) and non-VHA care when they are suicidal or experiencing mental health (MH) concerns is unknown. The objectives of this study were to: (1) examine whether current, past, and never VHA using female veterans' willingness to seek VHA care differs from their willingness to seek non-VHA care if suicidal or experiencing MH symptoms; (2) examine if VHA use, military sexual trauma, and suicidal ideation and attempt are associated with female veterans' willingness to use VHA and non-VHA care when experiencing suicidal thoughts or MH symptoms. A cross-sectional anonymous survey. Four hundred thirty nine female veterans, including current, past, and never VHA users were included. General Help-Seeking Questionnaire, Self-Injurious Thoughts and Behaviors Interview, and the VA Military Sexual Trauma Screening Questions. Current VHA users reported more willingness to use VHA than non-VHA care; conversely, past and never VHA users reported less willingness to use VHA care relative to non-VHA care. Military sexual assault and none or past VHA use were associated with lower willingness to use VHA care if suicidal or experiencing MH symptoms. In contrast, those with none or past VHA use reported greater willingness to use non-VHA care if suicidal or experiencing MH symptoms, while prior suicide attempt was associated with lower willingness. Ensuring that acceptable and effective suicide prevention services are available to female veterans in both VHA and community settings is critical. Increasing help-seeking intentions among female veterans who have attempted suicide or experienced military sexual assault is also essential.

To Prescribe or Deprescribe Statins, That Is the Question

To Prescribe or Deprescribe Statins, That Is the Question

Implementing daily chlorhexidine gluconate (CHG) bathing in VA settings: The human factors engineering to prevent resistant organisms (HERO) project

Daily use of chlorhexidine gluconate (CHG) has been shown to reduce risk of healthcare-associated infections. We aimed to assess moving CHG bathing into routine practice using a human factors approach. We evaluated implementation in non-intensive care unit (ICU) settings in the Veterans Health Administration. Our multiple case study approach included non-ICU units from 4 Veterans Health Administration settings. Guided by the Systems Engineering Initiative for Patient Safety, we conducted focus groups and interviews to capture barriers and facilitators to daily CHG bathing. We measured compliance using observations and skin CHG concentrations. Barriers to daily CHG include time, concern of increasing antibiotic resistance, workflow and product concerns. Facilitators include engagement of champions and unit shared responsibility. We found shortfalls in patient education, hand hygiene and CHG use on tubes and drains. CHG skin concentration levels were highest among patients from spinal cord injury units. These units applied antiseptic using 2% CHG impregnated wipes vs 4% CHG solution/soap. Non-ICUs implementing CHG bathing must consider human factors and work system barriers to ensure uptake and sustained practice change. Well-planned rollouts and a unit culture promoting shared responsibility are key to compliance with daily CHG bathing. Successful implementation requires attention to staff education and measurement of compliance.

A preliminary review of the Beck Depression Inventory-II (BDI-II) in veterans: Are new norms and cut scores needed?

The Beck Depression Inventory-II (BDI-II) is used within the Veterans Health Administration (VHA) to measure depression symptom severity. This naturalistic study aimed to examine VHA-specific BDI-II use and establish normative data and psychometric properties. Initial BDI-II data for 152,260 individual veterans were extracted from preexisting medical records using the VA Informatics and Computing Infrastructure. BDI-II scores were compared against Beck, Steer, and Brown (1996)'s original sample, as well as across veteran subgroups. Exploratory and confirmatory factor analyses were also conducted. Similar to Beck et al.'s (1996) sample, the BDI-II was most frequently administered in outpatient psychiatric VHA settings, although it was also used in inpatient and medical settings. Veterans scored significantly higher on the BDI-II than the original comparison groups. This was true across diagnostic categories. The largest discrepancy was seen between nondepressed veterans and corresponding patients from the original sample (Cohen's d = 1.34). Older veterans endorsed less severe levels of depression symptomatology. Additionally, a 2-factor model similar to Beck et al.'s (1996) original solution provided the best fit to the data. Veterans reported higher levels of somatic-affective symptoms than cognitive symptoms. Although potentially useful, the BDI-II requires further investigation in veterans. Standard cut scores are not recommended for use in this population when evaluating severity of depression. A cut score of 27 or higher best differentiated between veterans with and without mood disorders in the current sample. Treatment providers should also consider using BDI-II factor scores, rather than the total score, to measure depressive symptom change. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Predictors of survival, healthcare resource utilization, and healthcare costs in veterans with non-metastatic castration-resistant prostate cancer

ObjectivesThe objective of this study was to evaluate the association of prostate-specific antigen doubling time (PSADT) with metastasis-free survival (MFS) and overall survival (OS), and to describe healthcare resource utilization (HRU) and costs among patients with non-metastatic castrate-resistant prostate cancer (nmCRPC) in the Veterans Health Administration setting. Methods and MaterialsPatients with nmCRPC were identified from the Veterans Health Administration electronic health record database (1/2007–8/2017). PSADT was categorized as <3 months, 3 to 9 months, 9 to 15 months, ≥15 months, and unknown. MFS and OS were assessed using multivariable Cox proportional hazards regression, including PSADT as a predictor. HRU and costs were described per-patient-per-year (PPPY). ResultsAmong 12,083 patients in the study, shorter PSADT was associated with shorter MFS and OS (PSADT <3 months vs. PSADT ≥15 months hazard ratio [HR] [95% confidence interval (CI)] = 0.307 [0.281, 0.335] and 0.371 [0.335, 0.410], respectively). Patients who developed metastasis had a 3-fold higher risk of death compared to those without metastasis (HR [95% CI] = 2.933 [2.763, 3.113]). Mean HRU increased following the onset of nmCRPC and metastatic castrate-resistant prostate cancer (mCRPC); mean inpatient stays more than doubled (0.2 vs. 0.5 and 0.6 vs. 2.8 PPPY, respectively). Similar increases in healthcare costs were observed; pharmacy costs more than tripled following nmCRPC ($2,074 vs. $6,839 PPPY). From nmCRPC to mCRPC, large increases were observed for inpatient costs ($7,257–$61,691), emergency room costs ($844–$1,958), and pharmacy costs ($4,115–$26,279) PPPY. ConclusionsIn Veterans with nmCRPC, shorter PSADT was significantly associated with shorter MFS and OS. Onset of nmCRPC and mCRPC was associated with substantial HRU and cost increases.

Making Implementation Science More Rapid: Use of the RE-AIM Framework for Mid-Course Adaptations Across Five Health Services Research Projects in the Veterans Health Administration.

Introduction: Implementation science frameworks have helped advance translation of research to practice. They have been widely used for planning and post-hoc evaluation, but seldom to inform and guide mid-course adjustments to intervention and implementation strategies.Materials and Methods: This study developed an innovative methodology using the RE-AIM framework and related tools to guide mid-course assessments and adaptations across five diverse health services improvement projects in the Veterans Health Administration (VA). Using a semi-structured guide, project team members were asked to assess the importance of and progress on each RE-AIM dimension (i.e., reach, effectiveness, adoption, implementation, maintenance) at the current phase of their project. Based on these ratings, each team identified one or two RE-AIM dimensions for focused attention. Teams developed proximal goals and implementation strategies to improve progress on their selected dimension(s). A follow-up meeting with each team occurred approximately 6 weeks after the goal setting meeting to evaluate the usefulness of the iterative process. Results were evaluated using both descriptive quantitative analyses and qualitative assessments from interviews and meeting notes.Results: A median of seven team members participated in the two meetings. Qualitative and descriptive data revealed that the process was feasible, understandable and useful to teams in adjusting their interventions and implementation strategies. The RE-AIM dimensions identified as most important were adoption and effectiveness, and the dimension that had the largest gap between importance and rated progress was reach. The dimensions most frequently selected for improvement were reach and adoption. Examples of action plans were summarizing stakeholder interviews for leadership, revising exclusion criteria, and conducting in-service trainings. Follow-up meetings indicated that teams found the process very useful and were able to implement the action plans they set.Discussion: The iterative use of RE-AIM to support adjustments during project implementation proved feasible and useful across diverse projects in the VA setting. Building on this and related examples, future research should replicate these findings and further develop the methodology, as well as explore the optimal frequency and timing for these iterative applications of RE-AIM. More generally, greater focus on more rapid and iterative use of implementation science frameworks is encouraged to facilitate successful translation of research to practice.