Veterans Health Administration Survey Research Articles

Real-world impacts from a decade of Quality Enhancement Research Initiative-partnered projects to translate the Diabetes Prevention Program in the Veterans Health Administration.

To describe the impacts of four Veterans Health Administration (VA) Quality Enhancement Research Initiative (QUERI) projects implementing an evidence-based lifestyle intervention known as the Diabetes Prevention Program (DPP). 2012-2024 VA administrative and survey data. This is a summary of findings and impacts from four effectiveness-implementation projects focused on in-person and/or online DPP across VA sites. Patient demographics, participation data, and key findings and impacts were summarized across reports from the VA Diabetes-Mellitus Quality Enhancement Research Initiative (QUERI-DM) Diabetes Prevention Program (VA DPP) Trial, QUERI-DM Online DPP Trial, the Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) QUERI DPP Project, and EMPOWER 2.0 QUERI Program. Between 2012 and 2024, four VA QUERI studies enrolled 963 Veterans in DPP across 16 VA sites. All participants had overweight/obesity with one additional risk factor for type 2 diabetes (i.e., prediabetes, elevated risk score, or history of gestational diabetes) and 56% (N = 536) were women. In addition to enhancing the reach of and engagement in diabetes prevention services among Veterans, these projects resulted in three key impacts as follows: (1) informing the national redesign of VA MOVE! including recommendations to increase the number of MOVE! sessions and revise guidelines across 150+ VA sites, (2) enhancing the national evidence base to support online DPP delivery options with citations in national care guidelines outside VA, and (3) demonstrating the importance of gender-tailoring of preventive care services by and for women Veterans to enhance engagement in preventive services. Over the past decade, the evolution of VA QUERI DPP projects increased the reach of and engagement in diabetes prevention services among Veterans, including women Veterans who have been harder to engage in lifestyle change programs in VA, and resulted in three key impacts informing type 2 diabetes and obesity prevention efforts within and outside of VA.

Racial and Ethnic Differences in Health Care Experiences for Veterans Receiving VA Community Care from 2016 to 2021

BackgroundPrior research documented racial and ethnic disparities in health care experiences within the Veterans Health Administration (VA). Little is known about such differences in VA-funded community care programs, through which a growing number of Veterans receive health care. Community care is available to Veterans when care is not available through the VA, nearby, or in a timely manner.ObjectiveTo examine differences in Veterans’ experiences with VA-funded community care by race and ethnicity and assess changes in these experiences from 2016 to 2021.DesignObservational analyses of Veterans’ ratings of community care experiences by self-reported race and ethnicity. We used linear and logistic regressions to estimate racial and ethnic differences in community care experiences, sequentially adjusting for demographic, health, insurance, and socioeconomic factors.ParticipantsRespondents to the 2016–2021 VA Survey of Healthcare Experiences of Patients-Community Care Survey.MeasuresCare ratings in nine domains.Key ResultsThe sample of 231,869 respondents included 24,306 Black Veterans (mean [SD] age 56.5 [12.9] years, 77.5% male) and 16,490 Hispanic Veterans (mean [SD] age 54.6 [15.9] years, 85.3% male). In adjusted analyses pooled across study years, Black and Hispanic Veterans reported significantly lower ratings than their White and non-Hispanic counterparts in five of nine domains (overall rating of community providers, scheduling a recent appointment, provider communication, non-appointment access, and billing), with adjusted differences ranging from − 0.04 to − 0.13 standard deviations (SDs) of domain scores. Black and Hispanic Veterans reported higher ratings with eligibility determination and scheduling initial appointments than their White and non-Hispanic counterparts, and Black Veterans reported higher ratings of care coordination, with adjusted differences of 0.05 to 0.21 SDs. Care ratings improved from 2016 to 2021, but differences between racial and ethnic groups persisted.ConclusionsThis study identified small but persistent racial and ethnic differences in Veterans’ experiences with VA-funded community care, with Black and Hispanic Veterans reporting lower ratings in five domains and, respectively, higher ratings in three and two domains. Interventions to improve Black and Hispanic Veterans’ patient experience could advance equity in VA community care.

Developing a brief assessment of social risks for the Veterans Health Administration Survey of Healthcare Experiences of Patients.

To determine whether a 6- or 12-month look-back period affected rates of reported social risks in a social risk survey for use in the Veterans Health Administration and to assess associations of social risks with overall health and mental health. Cross-sectional survey of respondents randomized to 6- or 12-month look-back period. Online survey with a convenience sample of Veterans in June and July 2021. Veteran volunteers were recruited by email to complete a survey assessing social risks, including financial strain, adult caregiving, childcare, food insecurity, housing, transportation, internet access, loneliness/isolation, stress, discrimination, and legal issues. Outcomes included self-reported overall health and mental health. Chi-squared tests compared the prevalence of reported social risks between 6- and 12-month look-back periods. Spearman correlations assessed associations among social risks. Bivariate and multivariable logistic regression models estimated associations between social risks and fair/poor overall and mental health. Of 3418 Veterans contacted, 1063 (31.10%) responded (87.11% male; 85.61% non-Hispanic White; median age = 70, interquartile range [IQR] = 61-74). Prevalence of most reported social risks did not significantly differ by look-back period. Most social risks were weakly intercorrelated (median |r| = 0.24, IQR = 0.16-0.31). Except for legal issues, all social risks were associated with higher odds of fair/poor overall health and mental health in bivariate models. In models containing all significant social risks from bivariate models, adult caregiving and stress remained significant predictors of overall health; food insecurity, housing, loneliness/isolation, and stress remained significant for mental health. Six- and 12-month look-back periods yielded similar rates of reported social risks. Although most individual social risks are associated with fair/poor overall and mental health, when examined together, only adult caregiving, stress, loneliness/isolation, food, and housing remain significant.

Association Between Availability of Women's Health Services and Women Veterans' Care Experiences.

Few studies have focused on determinants of women's ratings of care experiences in primary care. We assessed associations between availability of women's health services and women veterans' ratings of care experiences. In a cross-sectional analysis, we linked Fiscal Year (FY) 2017 (October 1, 2016, to September 30, 2017) survey data from 126 Veterans Health Administration (VA) primary care leaders to 4,254 women veterans' ratings of care from VA's Survey of Healthcare Experiences of Patients-Patient Centered Medical Home (FY 2017). The dependent variables were ratings of optimal access (appointments, information), care coordination, comprehensiveness (behavioral health assessment), patient-provider communication, and primary care provider. Key independent variables were number of women's health services 1) routinely available all weekday hours (compared with some hours or not available) and 2) available in VA general primary care vs. other arrangements. In multilevel logistic regression models, we adjusted for patient-, facility-, and area-level characteristics. A greater number of women's health services routinely available in VA primary care was associated with a higher likelihood of optimal ratings of care coordination (adjusted odds ratio [AOR], 1.06; 95% confidence interval [CI], 1.01-1.10), provider communication (AOR, 1.08; 95% CI, 1.002-1.16), and primary care provider (AOR, 1.07; 95% CI,1.02-1.13). A greater number of services available in VA primary care was associated with a lower likelihood of optimal ratings for access (AOR, 0.94; 95% CI, 0.88-0.99). For the most part, routine availability of women's health services in VA primary care clinics enhanced women's healthcare experiences. These empirical findings offer healthcare leaders evidence-based approaches for improving women's care experiences.

Effect of mental health staffing inputs on suicide-related events.

To estimate the effects of changes in Veterans Health Administration (VHA) mental health services staffing levels on suicide-related events among a cohort of Veterans. Data were obtained from the VHA Corporate Data Warehouse, the Department of Defense and Veterans Administration Infrastructure for Clinical Intelligence, the VHA survey of enrollees, and customized VHA databases tracking suicide-related events. Geographic variables were obtained from the Area Health Resources Files and the Centers for Medicare and Medicaid Services. We used an instrumental variables (IV) design with a Heckman correction for non-random partial observability of the use of mental health services. The principal predictor was a measure of provider staffing per 10,000 enrollees. The outcome was the probability of a suicide-related event. Data were obtained for a cohort of Veterans who recently separated from active service. From 2014 to 2018, the per-pay period probability of a suicide-related event among our cohort was 0.05%. We found that a 1% increase in mental health staffing led to a 1.6 percentage point reduction in suicide-related events. This was driven by the first tertile of staffing, suggesting diminishing returns to scale for mental health staffing. VHA facilities appear to be staffing-constrained when providing mental health care. Targeted increases in mental health staffing would be likely to reduce suicidality.

Antibiotic Stewardship Implementation at Hospitals Without On-Site Infectious Disease Specialists: A Mixed-Methods Study

Background: Hospitals are required to have antibiotic stewardship programs (ASPs), but there are few models for implementing ASPs without the support of an infectious disease (ID) specialist, defined as an ID physician and/or ID pharmacist. In this study, we sought to understand ASP implementation at hospitals within the Veterans’ Health Administration (VHA) that lack on-site ID support. Methods: Using a mandatory 2016 VHA survey, we identified acute-care hospitals that lacked an on-site ID specialist. For each hospital, antibiotic use (2018–2019) was quantified as days of therapy (DOT) per 1,000 days present, based on NHSN methodology for tracking all antibacterial agents. From July 2019 through April 2020, we conducted semistructured interviews with personnel involved in or affected by ASP activities at 7 qualifying hospitals. All interview transcripts were analyzed using thematic content analysis. Results: Of the 7 acute-care hospitals, 6 (86%) had a long-term care unit; 3 (43%) had an intensive care unit; and 2 (29%) had full-time employment equivalents dedicated to stewardship. Sites averaged 1,075 (SD, ±654) and 148 (SD, ±96) admissions per year in acute-care and long-term care, respectively. At the site-level, mean antibiotic use was 486 DOT (SD, ±98) per 1,000 days-present in acute-care and 207 DOT (SD, ±74) per 1,000 days present in long-term care. We interviewed 42 personnel across the 7 sites. Although sites reported using similar interventions to promote antibiotic stewardship, the shape of these interventions varied. The following 4 common themes were identified: (1) The primary responsibility for ASPs fell on the pharmacist champions, who were typically assigned multiple other non-ASP responsibilities. (2) The pharmacist champions were more successful at gaining buy-in for stewardship initiatives when they had established rapport with clinicians, but at some sites, the use of contract physicians and frequent staff turnover were potential barriers. (3) Some sites felt that having access to an off-site ID specialist was important for overcoming institutional barriers to stewardship and improving the acceptance of their stewardship interventions. (4) In general, stewardship champions struggled to mobilize institutional resources, which made it difficult to advance their programmatic goals. Conclusions: In this study of 7 hospitals without local ID support, we found that ASPs are largely a pharmacy-driven process. Remote ID support, if available, was seen as helpful for implementing stewardship interventions. These findings may inform the future implementation of ASPs in settings lacking local ID expertise.Funding: NoDisclosures: None

Antibiotic stewardship implementation at hospitals without on-site infectious disease specialists: A qualitative study.

Hospitals are required to have antibiotic stewardship programs (ASPs), but there are few models for implementing ASPs without the support of an infectious disease (ID) specialist, defined as an ID physician and/or ID pharmacist. In this study, we sought to understand ASP implementation at hospitals that lack on-site ID support within the Veterans' Health Administration (VHA). Using a mandatory VHA survey, we identified acute-care hospitals that lacked an on-site ID specialist. We conducted semistructured interviews with personnel involved in ASP activities. The study was conducted across 7 VHA hospitals. In total, 42 hospital personnel were enrolled in the study. The primary responsibility for ASPs fell on the pharmacist champions, who were typically assigned multiple other non-ASP responsibilities. The pharmacist champions were more successful at gaining buy-in when they had established rapport with clinicians, but at some sites, the use of contract physicians and frequent staff turnover were potential barriers. Some sites felt that having access to an off-site ID specialist was important for overcoming institutional barriers and improving the acceptance of their stewardship recommendations. In general, stewardship champions struggled to mobilize institutional resources, which made it difficult to advance their programmatic goals. In this study of 7 hospitals without on-site ID support, we found that ASPs are largely a pharmacy-driven process. Remote ID support, if available, was seen as helpful for implementing stewardship interventions. These findings may inform the future implementation of ASPs in settings lacking local ID expertise.

Clinician Knowledge, Attitudes, and Practice Regarding Cannabis: Results from a National Veterans Health Administration Survey.

Cannabis is increasingly available and used for medical and recreational purposes, but few studies have assessed provider knowledge, attitudes, and practice regarding cannabis. We administered a 47-item electronic survey to assess nationwide Veterans Health Administration (VHA) clinician knowledge, beliefs, attitudes, and practice regarding patients' use of cannabis. We received 249 completed surveys from 39 states and the District of Columbia. Fifty-five percent of respondents were female, 74% were white, and the mean age was 50 years. There were knowledge gaps among a substantial minority of respondents in specific areas: terminology, psychoactive effects of cannabis components, VHA policy, and evidence regarding benefits and harms of cannabis. Most respondents were likely or very likely to plan to taper opioids if urine drug testing was positive for tetra-hydro cannabinol (THC; 73%). A significantly greater proportion of respondents from states in which cannabis is illegal for any purpose (odds ratio [OR] = 4.9, 95% confidence interval [CI] = 2.0-10.8) or is recreationally illegal (OR = 5.0, 95% CI = 2.4-10.8) reported being likely or very likely to taper opioids as compared with respondents from states in which cannabis is legal for medical and recreational purposes. Among the sample, we found knowledge gaps, areas of discomfort discussing key aspects of cannabis use with their patients, and variation in practice regarding opioids in patients also using THC. These results suggest a need for more widespread clinician education about cannabis, as well as an opportunity to develop more robust guidance and evidence regarding management of patients using prescription opioids and cannabis concomitantly.

Developing an Algorithm for Combining Race and Ethnicity Data Sources in the Veterans Health Administration.

Racial/ethnic disparities exist in the Veterans Health Administration (VHA), despite financial barriers to care being largely mitigated and Veterans Administration's (VA) organizational commitment to health equity. Accurately identifying minority veterans is critical to monitoring progress toward equity as the VHA treats an increasingly racially and ethnically diverse veteran population. Although the VHA's completeness of race and ethnicity data is generally better than its public sector and private counterparts, the accuracy of the race and ethnicity in the various databases available to VHA is variable, as is the accuracy in identifying specific minority groups. The purpose of this article was to develop an algorithm for constructing race and ethnicity variables from data sources available to VHA researchers, to present demographic differences cross the data sources, and to apply the algorithm to one study year. We used existing VHA survey data from the Survey of Healthcare Experiences of Patients (SHEP) and three commonly used administrative databases from 2003 to 2015: the VA Corporate Data Warehouse (CDW), VA Defense Identity Repository (VADIR), and Medicare. Using measures of agreement such as sensitivity, specificity, positive and negative predictive values, and Cohen kappa, we compared self-reported race and ethnicity from the SHEP and each of the other data sources. Based on these results, we propose an algorithm for combining data on race and ethnicity from these datasets. We included VHA patients who completed a SHEP and had race/ethnicity recorded in CDW, VADIR, and/or Medicare. Agreement between SHEP and other sources was high for Whites and Blacks and substantially lower for other minority groups. The CDW demonstrated better agreement than VADIR or Medicare. We developed an algorithm of data source precedence in the VHA that improves the accuracy of the identification of historically under-identified minorities: (1) SHEP, (2) CDW, (3) Department of Defense's VADIR, and (4) Medicare.

Inpatient Fluoroquinolone Stewardship Improves the Quantity and Quality of Fluoroquinolone Prescribing at Hospital Discharge: A Retrospective Analysis Among 122 Veterans Health Administration Hospitals.

Despite increasing awareness of harms, fluoroquinolones are still frequently prescribed to inpatients and at hospital discharge. Our goal was to describe fluoroquinolone prescribing at hospital discharge across the Veterans Health Administration (VHA) and to contrast the volume and appropriateness of fluoroquinolone prescribing across 3 antimicrobial stewardship strategy types. We analyzed a retrospective cohort of patients hospitalized at 122 VHA acute-care hospitals during 2014-2016. Data from a mandatory VHA survey were used to identify 9 hospitals that self-reported 1 of 3 strategies for optimizing fluoroquinolone prescribing: prospective audit and feedback (PAF), restrictive policies (RP), and no strategy. Manual chart reviews to assess fluoroquinolone appropriateness at hospital discharge (ie, postdischarge) were performed across the 9 hospitals (3 hospitals and 125 cases per strategy type). There were 1.7 million patient admissions. Overall, there were 1 727 478 fluoroquinolone days of therapy (DOTs), with 674 918 (39.1%) DOTs prescribed for inpatients and 1 052 560 (60.9%) DOTs prescribed postdischarge. Among the 9 reviewed hospitals, postdischarge fluoroquinolone exposure was lower at hospitals using RP, compared to no strategy (3.8% vs 9.3%, respectively; P = .012). Postdischarge fluoroquinolones were deemed inappropriate in 154 of 375 (41.1%) patients. Fluoroquinolones were more likely to be inappropriate at hospitals without a strategy (52.8%) versus those using either RP or PAF (35.2%; P = .001). In this retrospective cohort, the majority of fluoroquinolone DOTs occurred after hospital discharge. A large proportion of postdischarge fluoroquinolone prescriptions were inappropriate, especially in hospitals without a strategy to manage fluoroquinolone prescribing. Our findings suggest that stewardship efforts to minimize and improve fluoroquinolone prescribing should also focus on antimicrobial prescribing at hospital discharge.

Obesity and Health Care Experiences among Women and Men Veterans.

Obesity is highly stigmatized, especially for women, and therefore may negatively affect health care experiences. Past findings on the relationship between obesity and health care experiences are mixed, perhaps because few studies examine relationships by gender and obesity class. Our objective was to evaluate whether women and men with more severe obesity report worse health care experiences related to Veterans Health Administration (VA) care. Health care experiences (self-management support, mental health assessments, office staff courtesy, communication with providers) and overall provider ratings were assessed with the 2014 VA Survey of Health Care Experiences of Patients. Using multiple regression analyses (n=13,462 women, n=268,180 men), we assessed associations among obesity classes, health care experiences, and overall provider ratings, adjusting for sociodemographic, health, and primary care use characteristics. The greatest differences in health care experiences between patients with and without obesity were in self-management support experiences, which were more favorable among women and men of all obesity classes. There were gender differences in associations between obesity and mental health assessments: for men, but not women, those in any obesity class gave higher ratings than those without obesity. For most other health care experiences and provider ratings, men with obesity reported slightly less favorable experiences than those without. There was no consistent pattern for women. It is promising that VA patients with obesity report more self-management support, given the behavior change required for weight management. Lower health care experience and provider ratings among men with obesity suggest a need to further investigate possible obesity-related stigma in VA primary care.

Differences in Experiences With Care Between Homeless and Nonhomeless Patients in Veterans Affairs Facilities With Tailored and Nontailored Primary Care Teams.

Homeless patients describe poor experiences with primary care. In 2012, the Veterans Health Administration (VHA) implemented homeless-tailored primary care teams (Homeless Patient Aligned Care Team, HPACTs) that could improve the primary care experience for homeless patients. To assess differences in primary care experiences between homeless and nonhomeless Veterans receiving care in VHA facilities that had HPACTs available (HPACT facilities) and in VHA facilities lacking HPACTs (non-HPACT facilities). We used multivariable multinomial regressions to estimate homeless versus nonhomeless patient differences in primary care experiences (categorized as negative/moderate/positive) reported on a national VHA survey. We compared the homeless versus nonhomeless risk differences (RDs) in reporting negative or positive experiences in 25 HPACT facilities versus 485 non-HPACT facilities. Survey respondents from non-HPACT facilities (homeless: n=10,148; nonhomeless: n=309,779) and HPACT facilities (homeless: n=2022; nonhomeless: n=20,941). Negative and positive experiences with access, communication, office staff, provider rating, comprehensiveness, coordination, shared decision-making, and self-management support. In non-HPACT facilities, homeless patients reported more negative and fewer positive experiences than nonhomeless patients. However, these patterns of homeless versus nonhomeless differences were reversed in HPACT facilities for the domains of communication (positive experience RDs in non-HPACT versus HPACT facilities=-2.0 and 2.0, respectively); comprehensiveness (negative RDs=2.1 and -2.3), shared decision-making (negative RDs=1.2 and -1.8), and self-management support (negative RDs=0.1 and -4.5; positive RDs=0.5 and 8.0). VHA facilities with HPACT programs appear to offer a better primary care experience for homeless versus nonhomeless Veterans, reversing the pattern of relatively poor primary care experiences often associated with homelessness.

Primary Care Tasks Associated with Provider Burnout: Findings from a Veterans Health Administration Survey.

The patient-centered medical home (PCMH) is a primary care delivery model predicated on shared responsibility for patient care among members of an interprofessional team. Effective task sharing may reduce burnout among primary care providers (PCPs). However, little is known about the extent to which PCPs share these responsibilities, and which, if any, of the primary care tasks performed independently by the PCPs (vs. shared with the team) are particularly associated with PCP burnout. A better understanding of the relationship between these tasks and their effects on PCP burnout may help guide focused efforts aimed at reducing burnout. To investigate (1) the extent to which PCPs share responsibility for 14 discrete primary care tasks with other team members, and (2) which, if any, of the primary care tasks performed by the PCPs (without reliance on team members) are associated with PCP burnout. Secondary data analysis of Veterans Health Administration (VHA) survey data from two time periods. 327 providers from 23 VA primary care practices within one VHA regional network. The dependent variable was PCP report of burnout. Independent variables included PCP report of the extent to which they performed 14 discrete primary care tasks without reliance on team members; team functioning; and PCP-, clinic-, and system-level variables. In adjusted models, PCP reports of intervening on patient lifestyle factors and educating patients about disease-specific self-care activities, without reliance on their teams, were significantly associated with burnout (intervening on lifestyle: b=4.11, 95% CI=0.39, 7.83, p=0.03; educating patients: b=3.83, 95% CI=0.33, 7.32, p=0.03). Performing behavioral counseling and self-management education tasks without relying on other team members for assistance was associated with PCP burnout. Expanding the roles of nurses and other healthcare professionals to assume responsibility for these tasks may ease PCP burden and reduce burnout.

Surveyed Enrollees in Veterans Affairs Health Care: How They Differ From Eligible Veterans Surveyed by BRFSS.

We described differences in demographic and socioeconomic characteristics between Veterans enrolled in the Veterans Health Administration (VHA) and Veterans eligible to enroll for Veterans Affairs health care. Knowledge of these differences is important in planning better services for Veterans who enroll and in encouraging additional enrollment. We compared characteristics of enrollees and eligible Veterans in 2012. To describe enrollees, we used aggregate data from administrative records and results from VHA's Survey of Veteran Enrollees' Health and Reliance Upon VA. To describe eligible Veterans, we analyzed individual-level data from the Behavioral Risk Factor Surveillance System. Elderly individuals are more heavily represented among enrollees than eligible Veterans, and elderly enrollees are less likely to describe their health as good to excellent. Enrollees are more than twice as likely as eligible Veterans to have annual household incomes below $16,000. Representation of minorities is roughly the same among enrollees as eligible Veterans. Our results are consistent with VHA as a safety net provider with respect to income, age, and disease burden.

VA Location and Structural Factors Associated with On-Site Availability of Reproductive Health Services

ABSTRACTINTRODUCTIONWith the increasing number of women Veterans enrolling in the Veterans Health Administration (VA), there is growing demand for reproductive health services. Little is known regarding the on-site availability of reproductive health services at VA and how this varies by site location and type.OBJECTIVETo describe the on-site availability of hormonal contraception, intrauterine device (IUD) placement, infertility evaluation or treatment, and prenatal care by site location and type; the characteristics of sites providing these services; and to determine whether, within this context, site location and type is associated with on-site availability of these reproductive health services.METHODSWe used data from the 2007 Veterans Health Administration Survey of Women Veterans Health Programs and Practices, a national census of VA sites serving 300 or more women Veterans assessing practice structure and provision of care for women. Hierarchical models were used to test whether site location and type (metropolitan hospital-based clinic, non-metropolitan hospital-based clinic, metropolitan community-based outpatient clinic [CBOC]) were associated with availability of IUD placement and infertility evaluation/treatment. Non-metropolitan CBOCs were excluded from this analysis (n = 2).RESULTSOf 193 sites, 182 (94 %) offered on-site hormonal contraception, 97 (50 %) offered on-site IUD placement, 57 (30 %) offered on-site infertility evaluation/treatment, and 11 (6 %) offered on-site prenatal care. After adjustment, compared with metropolitan hospital based-clinics, metropolitan CBOCs were less likely to offer on-site IUD placement (OR 0.33; 95 % CI 0.14, 0.74).CONCLUSIONCompared with metropolitan hospital-based clinics, metropolitan CBOCs offer fewer specialized reproductive health services on-site. Additional research is needed regarding delivery of specialized reproductive health care services for women Veterans in CBOCs and clinics in non-metropolitan areas.

Demographic Question Placement: Effect on Item Response Rates and Means of a Veterans Health Administration Survey

Purpose This study examined whether demographic question placement affects demographic and non-demographic question completion rates, non-demographic item means, and blank questionnaire rates using a web-based survey of Veterans Health Administration employees.

Receipt of opioid agonist treatment in the Veterans Health Administration: Facility and patient factors

BackgroundOpioid agonist treatment (OAT)—through licensed clinic settings (C-OAT) using methadone or buprenorphine or office-based settings with buprenorphine (O-OAT)—is an evidence-based treatment for opioid dependence. Because of limited availability of on-site C-OAT (n=28 of 128 facilities) in the Veterans Health Administration (VHA), O-OAT use has been encouraged. This study examined OAT utilization across VHA facilities and the patient and facility factors related to variability in utilization. MethodWe examined 12 months of VHA administrative data (fiscal year [FY] 2008, October 2007 through September 2008) for evidence of OAT utilization and substance use disorder program data from an annual VHA survey. Variability in OAT utilization across facilities and patient and facility factors related to OAT utilization were examined using mixed-effects, logistic regression models. ResultsAmong 128 VHA facilities, 35,240 patients were diagnosed with an opioid use disorder. Of those, 27.3% received OAT: 22.2% received C-OAT and 5.1% received O-OAT with buprenorphine. Substantial facility-level variability in proportions of patients treated with OAT was found, ranging from 0% to 66% with 44% of facilities treating <5%. Significant patient-level predictors of OAT receipt included being male, age ≥56, and without another mental health diagnosis. Significant facility-level predictors included offering any OAT services (C-OAT or O-OAT) and specialty substance abuse treatment services on weekends. ConclusionIn FY2008, prior to the VHA national mandate of access to buprenorphine OAT, substantial variation in the use of OAT existed, partially explained by patient- and facility-level factors. Implementation efforts should focus on increasing access to this evidence-based treatment, especially in facilities at the low end of the distribution.

National Variations in VA Mental Health Care for Women Veterans

Objectives Although the Veterans Health Administration (VA) has recently adopted new policies encouraging gender-specific mental health (MH) care delivery to women veterans, little is known about the potential difficulties local facilities may face in achieving compliance. We assessed variations in women’s mental health care delivery arrangements in VA facilities nationwide. Methods We used results from the VA Survey of Women Veterans Health Programs, a key informant survey of senior women’s health clinicians representing all VA facilities serving more than 300 women veterans, to assess the array of gender-sensitive mental health care arrangements (response rate, 86%; n = 195). We also examined organizational and area factors related to availability of women’s specialty mental health arrangements using multivariable logistic regression. Results Nationally, over half (53%) of VA facilities had some form of gender-sensitive mental health care arrangements. Overall, 34% of sites reported having designated women’s mental health providers in general outpatient mental health clinics (MHCs). Almost half (48%) had therapy groups for women in their MHCs. VAs with women’s primary care clinics also delivered mental health services (24%), and 12% of VAs reported having a separate women’s MHC, most of which (88%) offered sexual trauma group counseling. Assignment to same-gender mental health providers is not routine. VAs with comprehensive women’s primary care clinics were more likely to integrate mental health care for women as well. Conclusion Local implementation of gender-sensitive mental health care in VA settings is highly variable. Although this variation may reflect diverse local needs and resources, women veterans may also sometimes face challenges in accessing needed services.

Comparison of Paper, Web, and IVR Responses in the Veterans Health Administration Survey

Comparison of Paper, Web, and IVR Responses in the Veterans Health Administration Survey

Veterans' perceptions of care by nurse practitioners, physician assistants, and physicians: A comparison from satisfaction surveys

To examine the differences in patient satisfaction with care provided by nurse practitioners (NPs), physician assistants (PAs), and physicians in the Veterans Health Administration (VHA) system. Secondary data was obtained from the VHA's Survey of Healthcare Experience of Patients (SHEP), a monthly survey designed to measure patient satisfaction. Descriptive statistics were calculated and categorical variables were summarized with frequency counts. Of the 2,164,559 surveys mailed to the veterans, 1,601,828 (response rate 64%) were returned. The study found that satisfaction scores increased by 5% when the number of NPs was increased compared to 1.8% when the number of physicians was increased and slightly increased or remained the same when the number of PAs was increased. Physician to PA/NP ratio was 7:3. The VHA is the largest healthcare system and the single largest employer of NPs and PAs in the country. This study shows that a majority of the primary care clinic patients prefer to see NPs as compared with PAs and physicians. Besides clinical care, NPs focus on health promotion, disease prevention, health education, attentiveness, and counseling. Physicians and PAs should be educated on these characteristics to promote patient satisfaction and expected outcomes.