Veterans Health Administration Research Articles

Clinicians in the Veterans Health Administration initiate gender-affirming hormone therapy in concordance with clinical guideline recommendations

BackgroundGender-affirming hormone therapy (GAHT) is a common medical intervention sought by transgender and gender diverse (TGD) individuals. Initiating GAHT in accordance with clinical guideline recommendations ensures delivery of high-quality care. However, no prior studies have examined how current GAHT initiation compares to recommended GAHT initiation.ObjectiveThis study assessed guideline concordance around feminizing and masculinizing GAHT initiation in the Veterans Health Administration (VHA).MethodsThe sample included 4,676 veterans with a gender identity disorder diagnosis who initiated feminizing (n=3,547) and masculinizing (n=1,129) GAHT between 2007 and 2018 in VHA. Demographics and health conditions on veterans receiving feminizing and masculinizing GAHT were assessed. Proportion of guideline concordant veterans on six VHA guidelines on feminizing and masculinizing GAHT initiation were determined.ResultsCompared to veterans receiving masculinizing GAHT, a higher proportion of veterans receiving feminizing GAHT were older (≥60 years: 23.7% vs. 6.3%), White non-Hispanic (83.5% vs. 57.6%), and had a higher number of comorbidities (≥7: 14.0% vs. 10.6%). A higher proportion of veterans receiving masculinizing GAHT were Black non-Hispanic (21.5% vs. 3.5%), had posttraumatic stress disorder (43.0% vs. 33.9%) and positive military sexual trauma (33.5% vs.16.8%; all p-values<0.001) than veterans receiving feminizing GAHT. Among veterans who started feminizing GAHT with estrogen, 97.0% were guideline concordant due to no documentation of contraindication, including venous thromboembolism, breast cancer, stroke, or myocardial infarction. Among veterans who started spironolactone as part of feminizing GAHT, 98.1% were guideline concordant as they had no documentation of contraindication, including hyperkalemia or acute renal failure. Among veterans starting masculinizing GAHT, 90.1% were guideline concordant due to no documentation of contraindications, such as breast or prostate cancer. Hematocrit had been measured in 91.8% of veterans before initiating masculinizing GAHT, with 96.5% not having an elevated hematocrit (>50%) prior to starting masculinizing GAHT. Among veterans initiating feminizing and masculinizing GAHT, 91.2% had documentation of a gender identity disorder diagnosis prior to GAHT initiation.ConclusionWe observed high concordance between current GAHT initiation practices in VHA and guidelines, particularly for feminizing GAHT. Findings suggest that VHA clinicians are initiating feminizing GAHT in concordance with clinical guidelines. Future work should assess guideline concordance on monitoring and management of GAHT in VHA.

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.

Improving patient education in hospitalized patients with chronic obstructive pulmonary disease: A quality improvement initiative using LEAN methodology.

Chronic obstructive pulmonary disease (COPD) is a costly chronic disease affecting more than 15 million Americans. The prevalence among US veterans is 3 times higher than the general population. The Veteran Health Administration developed a standardized, evidence-based COPD educational tool called Green Light to Go (GLTG) designed to educate patients on managing their COPD symptoms at home. Despite the availability of this resource, inpatient education on COPD self-management practices is highly variable across different medical teams. This quality improvement (QI) initiative sought to standardize inpatient COPD patient education using the GLTG tool. This initiative also assessed whether patients receiving standardized patient education during their index hospitalization had lower COPD 30-day readmission rates. The QI initiative followed the LEAN methodology and the A3 framework. The team performed rapid tests of change (plan-do-study-act cycles) to increase the percentage of veterans receiving COPD education. The interventions implemented for this QI initiative focused on clinical, patient, and system improvements. This initiative standardized COPD patient education and increased the percentage of veterans receiving (a) daily COPD education from 0% to 66%, (b) verbal COPD education on discharge from a baseline of 20% to 100%, (c) receipt of written educational material on discharge from 20% to 100%, and (d) the cohort all-cause 30-day readmission rate declined from 19.3% to 14.3%. Given the substantial economic burden of COPD readmissions on the health care system and patients, evidence-based educational interventions may potentially improve outcomes and reduce hospital readmissions in this veteran population.

Adherence to buprenorphine-XR through hybrid telehealth contingency management procedures: a case series

ABSTRACT Background and objectives Contingency management (CM) for substance use disorders (SUD) is effective in strengthening recovery behaviors, however can be quite burdensome. When health facilities experience staff shortages, adapting current CM protocols to be less staff and time intensive may be one way to address this challenge. Methods Case series (N = 3). Results Three veterans with opioid use disorder (OUD) received CM for treatment adherence through a Veteran Health Administration Outpatient Substance Disorder program. Due to the COVID-19 pandemic, traditional CM procedures resulted in limited accessibility and staff, delayed appointments, and decreased patient satisfaction. In response, the hybrid telehealth contingency management (HTCM) procedure was developed and implemented. Flexibility offered by HTCM allowed for consecutive completion of appointments and maintained adherence to BUP-XR treatment. Conclusions This is a novel method of CM implementation. HTCM streamlined the process and was successful in increasing accessibility, reducing time-burden on patients and staff, while preserving fidelity to key components of the model. Considerations for future implementation and implications of HTCM are discussed.

Care cascades following low-value cervical cancer screening in dually enrolled Veterans.

Veterans dually enrolled in the Veterans Health Administration (VA) and Medicare commonly experience downstream services as part of a care cascade after an initial low-value service. Our objective was to characterize the frequency and cost of low-value cervical cancer screening and subsequent care cascades among Veterans dually enrolled in VA and Medicare. This retrospective cohort study used VA and Medicare administrative data from fiscal years 2015 to 2019. The study cohort was comprised of female Veterans aged >65 years and at low risk of cervical cancer who were dually enrolled in VA and Medicare. Within this cohort, we compared differences in the rates and costs of cascade services related to low-value cervical cancer screening for Veterans who received and did not receive screening in FY2018, adjusting for baseline patient- and facility-level covariates using inverse probability of treatment weighting. Among 20,972 cohort-eligible Veterans, 494 (2.4%) underwent low-value cervical cancer screening with 301 (60.9%) initial screens occurring in VA and 193 (39%) occurring in Medicare. Veterans who were screened experienced an additional 26.7 (95% CI, 16.4-37.0) cascade services per 100 Veterans compared to those who were not screened, contributing to $2919.4 (95% CI, -265 to 6104.7) per 100 Veterans in excess costs. Care cascades consisted predominantly of subsequent cervical cancer screening procedures and related outpatient visits with low rates of invasive procedures and occurred in both VA and Medicare. Veterans dually enrolled in VA and Medicare commonly receive related downstream tests and visits as part of care cascades following low-value cervical cancer screening. Our findings demonstrate that to fully capture the extent to which individuals are subject to low-value care, it is important to examine downstream care stemming from initial low-value services across all systems from which individuals receive care.

Barriers and Facilitators to Administering Burn Pit Registry Exams in VHA Facilities.

The Veterans Health Administration (VHA) established the Airborne Hazards and Open Burn Pit Registry (AHOBPR) in 2014 to address exposure concerns for veterans who have served in military operations in Southwest Asia and Afghanistan. By 2021, over 236,086 veterans completed the online questionnaire and 60% requested an AHOBPR examination. Of those requesting an exam, only 12% had an exam recorded in their medical record. This article summarizes barriers and facilitators to delivering AHOBPR exams and shares lessons learned from facilities who have successfully implemented burn pit exams for veterans. We (I.C.C and J.H.) constructed a key performance measure of AHOBPR examination (the ratio of examinations performed in facility over examinations assigned to a facility) to identify top performing facilities and then used stratified purposeful sampling among high-performing sites to recruit a diverse set of facilities for participation. We (P.V.C. and A.A.) recruited and interviewed key personnel at these facilities about their process of administering burn pit exams. Rapid qualitative methods were used to analyze interviews. The ratio of exams performed to exams assigned ranged from 0.00 to 14.50 for the 129 facilities with available information. Twelve interviews were conducted with a total of 19 participants from 10 different facilities. We identified 3 barriers: Unclear responsibility, limited incentives and competing duties for personnel involved, and constrained resources. Facilitators included the presence of an internal facilitator, additional staff support, and coordination across a facility's departments to provide care. Gaps across many VHA facilities to provide AHOBPR exams may be understood as stemming from organizational issues related to clear delegation of responsibility and staffing issues. VHA facilities that wish to increase AHOBPR exams for veterans may need additional administrative and medical staff.

Feeding Tube Clinic Effect on Nutrition.

Optimizing nutrition is essential for recovery after major surgery or severe illness. Feeding tubes (FT) can be placed in patients limited by oral enteral nutrition. Given the myriad of locations in which these procedures are performed (radiology, intensive care unit, and endoscopy suite), routine follow-up is challenging. The purpose of this study was to evaluate the impact of an FT clinic on nutrition. We hypothesized that enrollment in the FT clinic would result in improved nutritional outcomes. Retrospective review of Veteran Affairs Medical Center patients with FTs placed from January 2010 to January 2020. Demographics and body mass index (BMI) were recorded. Serum albumin recorded within 1 month of tube placement was compared to within 1 month of tube removal, death, or at the end of the study period. FT clinic participation required at least 2 visits. Indications for FT placement and duration were recorded. Patients were excluded when both BMI and albumin values were incomplete, and if FTs were placed for decompression. Ninety-three patients underwent FT placement during the study period; 5 (5%) were excluded. The average age was 64.8±9.7 years, with the majority being male, 85 patients (97%). Eighteen (20%) patients were seen in the FT clinic (FTC) and 70 (80%) were managed outside of FTC (nFTC). There were no differences in age, gender, or indication for FT. Mean albumin increased 0.42±0.85g/dL in the FTC group versus -0.07±0.72g/dL in the nFTC group (P=0.037). The FTC group BMI increased, 0.38kg/m2 vs. -1.48kg/m2 in nFTC patients, P=0.041. The FTC patients maintained their tubes longer (36.5 vs. 7.0mo, P=0.0014). Patients managed in a dedicated FT clinic experienced an improvement in their serum albumin values and increases in their BMI. In addition, they also maintained their FTs longer. To optimize nutrition and reduce weight loss, patients who require FTs should be enrolled in a dedicated FT clinic.

Lower comorbidity scores and severity levels in Veterans Health Administration hospitals: a cross-sectional study

BackgroundPrevious studies found that documentation of comorbidities differed when Veterans received care within versus outside Veterans Health Administration (VHA). Changes to medical center funding, increased attention to performance reporting, and expansion of Clinical Documentation Improvement programs, however, may have caused coding in VHA to change.MethodsUsing repeated cross-sectional data, we compared Elixhauser-van Walraven scores and Medicare Severity Diagnosis Related Group (DRG) severity levels for Veterans’ admissions across settings and payers over time, utilizing a linkage of VHA and all-payer discharge data for 2012–2017 in seven US states. To minimize selection bias, we analyzed records for Veterans admitted to both VHA and non-VHA hospitals in the same year. Using generalized linear models, we adjusted for patient and hospital characteristics.ResultsFollowing adjustment, VHA admissions consistently had the lowest predicted mean comorbidity scores (4.44 (95% CI 4.34–4.55)) and lowest probability of using the most severe DRG (22.1% (95% CI 21.4%-22.8%)). In contrast, Medicare-covered admissions had the highest predicted mean comorbidity score (5.71 (95% CI 5.56–5.85)) and highest probability of using the top DRG (35.3% (95% CI 34.2%-36.4%)).ConclusionsMore effective strategies may be needed to improve VHA documentation, and current risk-adjusted comparisons should account for differences in coding intensity.

Understanding pathways from implementation to sustainment: a longitudinal, mixed methods analysis of promising practices implemented in the Veterans Health Administration

BackgroundThe Veterans Health Administration (VHA) is the United States largest learning health system. The Diffusion of Excellence (DoE) program is a large-scale model of diffusion that identifies and diffuses evidence-informed practices across VHA. During the period of 2016-2021, 57 evidence-informed practices were implemented across 82 VHA facilities. This setting provides a unique opportunity to understand sustainment determinants and pathways. Our objective was to characterize the longitudinal pathways of practices as they transition from initial implementation to long-term sustainment at each facility.MethodsA longitudinal, mixed-methods evaluation of 82 VHA facilities. Eighty-two facility representatives, chosen by leadership as points-of-contact for 57 DoE practices, were eligible for post-implementation interviews and annual sustainment surveys. Primary outcomes (implementation, sustainment), and secondary outcomes (institutionalization, effectiveness, anticipated sustainment) at four time-points were collected. We performed descriptive statistics and directed content analysis using Hailemariam et al.’s factors influencing sustainment.ResultsAfter approximately five years post-implementation (e.g., 2021 sustainment outcomes), of the 82 facilities, about one-third fully sustained their practice compared to one-third that did not fully sustain their practice because it was in a “liminal” stage (neither sustained nor discontinued) or permanently discontinued. The remaining one-third of facilities had missing 2021 sustainment outcomes. A higher percentage of facilities (70%) had inconsistent primary outcomes (changing over time) compared to facilities (30%) with consistent primary outcomes (same over time). Thirty-four percent of facilities with sustained practices reported resilience since they overcame implementation and sustainment barriers. Facilities with sustained practices reported more positive secondary outcomes compared to those that did not sustain their practice. Key factors facilitating practice sustainment included: demonstrating practice effectiveness/benefit, sufficient organizational leadership, sufficient workforce, and adaptation/alignment with local context. Key factors hindering practice sustainment included: insufficient workforce, not able to maintain practice fidelity/integrity, critical incidents related to the COVID-19 pandemic, organizational leadership did not support sustainment of practice, and no ongoing support.ConclusionsWe identified diverse pathways from implementation to sustainment, and our data underscore that initial implementation outcomes may not determine long-term sustainment outcomes. This longitudinal evaluation contributes to understanding impacts of the DoE program, including return on investment, achieving learning health system goals, and insights into achieving high-quality healthcare in VHA.

Lifetime prevalence and correlates of colorectal cancer screening among low-income U.S. Veterans.

The Veterans Health Administration (VHA) is the largest integrated healthcare system in the U.S. While preventive healthcare services are high priority in the VHA, low-income U.S. Veterans experience adverse life circumstances that may negatively impact their access to these services. This study examined lifetime prevalence as well as demographic, socioeconomic, military-specific, and clinical correlates of colorectal cancer (CRC) screening among low-income U.S. Veterans ≥ 50years of age. Cross-sectional data on 862 participants were analyzed from the 2021-2022 National Veteran Homeless and Other Poverty Experiences study. Overall, 55.3% (95% confidence interval [CI] 51.3-59.3%) reported ever-receiving CRC-screening services. In a multivariable logistic regression model, never-receivers of CRC screening were twice as likely to reside outside of the Northeast, and more likely to be married (odds ratio [OR] = 1.86, 95% CI 1.02, 3.37), have BMI < 25kg/m2 [vs. 25- < 30kg/m2] (OR = 1.75, 95% CI 1.19, 2.58), or ≥ 1 chronic condition (OR = 1.46, 95% CI 1.06, 2.02). Never-receivers of CRC screening were less likely to be female (OR = 0.53, 95% CI 0.29, 0.96), aged 65-79y [vs. ≥ 80y] (OR = 0.61, 95% CI 0.40, 0.92), live in 5 + member households (OR = 0.33, 95% CI 0.13, 0.86), disabled (OR = 0.45, 0.22, 0.92), with purchased health insurance (OR = 0.56, 95% CI 0.33, 0.98), or report alcohol-use disorder (OR = 0.10, 95% CI 0.02, 0.49) and/or HIV/AIDS (OR = 0.28, 95% CI 0.12, 0.68). Nearly 55% of low-income U.S. Veterans reported ever screening for CRC. Variations in CRC-screening behaviors according to veteran characteristics highlight potential disparities as well as opportunities for targeted behavioral interventions.

Needs for Successful Engagement in Telemedicine Among Rural Older US Veterans and Their Caregivers: Qualitative Study.

Telemedicine is an important option for rural older adults who often must travel far distances to clinics or forgo essential care. In 2014, the Geriatric Research, Education, and Clinical Centers (GRECC) of the US Veterans Health Administration (VA) established a national telemedicine network called GRECC Connect. This network increased access to geriatric specialty care for the 1.4 million rural VA-enrolled veterans aged 65 years or older. The use of telemedicine skyrocketed during the COVID-19 pandemic, which disproportionately impacted older adults, exacerbating disparities in specialty care access as overburdened systems shut down in-person services. This surge presented a unique opportunity to study the supports necessary for those who would forgo telemedicine if in-person care were available. In spring 2021, we interviewed veterans and their informal caregivers to (1) elicit their experiences attempting to prepare for a video visit with a GRECC Connect geriatric specialist and (2) explore facilitators and barriers to successful engagement in a telemedicine visit. We conducted a cross-sectional qualitative evaluation with patients and their caregivers who agreed to participate in at least 1 GRECC Connect telemedicine visit in the previous 3 months. A total of 30 participants from 6 geographically diverse GRECC Connect hub sites agreed to participate. Semistructured interviews were conducted through telephone or the VA's videoconference platform for home telemedicine visits (VA Video Connect) per participant preference. We observed challenges and, when needed, provided real-time technical support to facilitate VA Video Connect use for interviews. All interviews were recorded with permission and professionally transcribed. A team of 5 researchers experienced in qualitative research analyzed interview transcripts using rapid qualitative analysis. From 30 participant interviews, we identified the following 4 categories of supports participants described regarding successful engagement in telemedicine, as defined by visit completion, satisfaction, and willingness to engage in telemedicine in the future: (1) caregiver presence to facilitate technology setup and communication; (2) flexibility in visit modality (eg, video from home or a clinic or telephone); (3) technology support (eg, determining device compatibility or providing instruction and on-demand assistance); and (4) assurance of comfort with web-based communication, including orientation to features like closed captioning. Supports were needed at multiple points before the visit, and participants stressed the importance of eliciting the varying needs and preferences of each patient-caregiver dyad. Though many initially agreed to a telemedicine visit because of pandemic-related clinic closures, participants were satisfied with telemedicine and willing to use it for other types of health care visits. To close gaps in telemedicine use among rural older adults, supports must be tailored to individuals, accounting for technology availability and comfort, as well as availability of and need for caregiver involvement. Comprehensive scaffolding of support starts well before the first telemedicine visit.

Identification of sleep phenotypes in COPD using machine learning-based cluster analysis

BackgroundDisturbed sleep in patients with COPD impact quality of life and predict adverse outcomes. Research questionTo identify distinct phenotypic clusters of patients with COPD using objective sleep parameters and evaluate the associations between clusters and all-cause mortality to inform risk stratification. Study design and methodsA longitudinal observational cohort study using nationwide Veterans Health Administration data of patients with COPD investigated for sleep disorders. Sleep parameters were extracted from polysomnography physician interpretation using a validated natural language processing algorithm. We performed cluster analysis using an unsupervised machine learning algorithm (K-means) and examined the association between clusters and mortality using Cox regression analysis, adjusted for potential confounders, and visualized with Kaplan-Meier estimates. ResultsAmong 9992 patients with COPD and a clinically indicated baseline polysomnogram, we identified five distinct clusters based on age, comorbidity burden and sleep parameters. Overall mortality increased from 9.4 % to 42 % and short-term mortality (<5.3 years) ranged from 3.4 % to 24.3 % in Cluster 1 to 5. In Cluster 1 younger age, in 5 high comorbidity burden and in the other three clusters, total sleep time and sleep efficiency had significant associations with mortality. InterpretationWe identified five distinct clinical clusters and highlighted the significant association between total sleep time and sleep efficiency on mortality. The identified clusters highlight the importance of objective sleep parameters in determining mortality risk and phenotypic characterization in this population.

Characterization of Post-COVID-19 Definitions and Clinical Coding Practices: Longitudinal Study.

Post-COVID-19 condition (colloquially known as "long COVID-19") characterized as postacute sequelae of SARS-CoV-2 has no universal clinical case definition. Recent efforts have focused on understanding long COVID-19 symptoms, and electronic health record (EHR) data provide a unique resource for understanding this condition. The introduction of the International Classification of Diseases, Tenth Revision (ICD-10) code U09.9 for "Post COVID-19 condition, unspecified" to identify patients with long COVID-19 has provided a method of evaluating this condition in EHRs; however, the accuracy of this code is unclear. This study aimed to characterize the utility and accuracy of the U09.9 code across 3 health care systems-the Veterans Health Administration, the Beth Israel Deaconess Medical Center, and the University of Pittsburgh Medical Center-against patients identified with long COVID-19 via a chart review by operationalizing the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) definitions. Patients who were COVID-19 positive with either a U07.1 ICD-10 code or positive polymerase chain reaction test within these health care systems were identified for chart review. Among this cohort, we sampled patients based on two approaches: (1) with a U09.9 code and (2) without a U09.9 code but with a new onset long COVID-19-related ICD-10 code, which allows us to assess the sensitivity of the U09.9 code. To operationalize the long COVID-19 definition based on health agency guidelines, symptoms were grouped into a "core" cluster of 11 commonly reported symptoms among patients with long COVID-19 and an extended cluster that captured all other symptoms by disease domain. Patients having ≥2 symptoms persisting for ≥60 days that were new onset after their COVID-19 infection, with ≥1 symptom in the core cluster, were labeled as having long COVID-19 per chart review. The code's performance was compared across 3 health care systems and across different time periods of the pandemic. Overall, 900 patient charts were reviewed across 3 health care systems. The prevalence of long COVID-19 among the cohort with the U09.9 ICD-10 code based on the operationalized WHO definition was between 23.2% and 62.4% across these health care systems. We also evaluated a less stringent version of the WHO definition and the CDC definition and observed an increase in the prevalence of long COVID-19 at all 3 health care systems. This is one of the first studies to evaluate the U09.9 code against a clinical case definition for long COVID-19, as well as the first to apply this definition to EHR data using a chart review approach on a nationwide cohort across multiple health care systems. This chart review approach can be implemented at other EHR systems to further evaluate the utility and performance of the U09.9 code.

Associations of Mortality Outcomes With Employment Status at Discharge From VA Vocational Rehabilitation Service Programs.

The authors evaluated associations between employment at discharge from Veterans Health Administration Vocational Rehabilitation Service (VR) programs and suicide and other causes of death. For veterans receiving VR between October 1, 2005, and September 30, 2014 (N=78,293), proportional hazards analyses were used to test associations of employment with suicide, drug overdose, and external and natural cause mortality rates over 1 and 5 years postdischarge and through December 31, 2019. The analyses were adjusted for clinical and sociodemographic characteristics and propensity for employment. Of the veterans, 94.1% had a psychiatric diagnosis, and 35.5% were employed at VR discharge. In proportional hazards analyses, employment was associated with lower mortality rates through 1 year (suicide, hazard ratio [HR]=0.54; overdose, HR=0.70; external causes, HR=0.62; and natural causes, HR=0.51) and 5 years postdischarge (overdose, HR=0.72; external causes, HR=0.81; and natural causes, HR=0.72). Through December 31, 2019, employment was associated with lower risks for overdose (HR=0.80) and death by external (HR=0.81) and natural (HR=0.80) causes. Employment at VR discharge was associated with lower mortality risk among veterans with psychiatric diagnoses.

Abstract PS04-06: Breast cancer recurrence among women with pre-diagnostic major depression and co-existing substance abuse disorder: A retrospective study in the United States Veterans Health Administration Cohort

Abstract Background: Our prior study observed a 34% higher risk of breast cancer (BC) recurrence among women with major depressive disorder (MDD) at the time of their BC diagnosis compared to women without MDD after adjusting for sociodemographic, clinical, and prognostic factors. Given the high prevalence of substance abuse disorders among individuals with MDD and the positive association between alcohol use and mortality among BC survivors, we were interested to examine whether the risk of BC recurrence was compounded for women with both conditions. Objective: To investigate whether pre-diagnostic substance abuse disorders modify the association between MDD and BC recurrence. Methods: We established a retrospective cohort of women (age ≥ 18 years) with incident, early-stage BC diagnosed from 2010 through 2019 using the VHA’s electronic medical record database. A two-year window was used to identify women with MDD and co-existing substance abuse disorders prior to their BC diagnosis. We examined potential interactions between MDD and alcohol abuse and MDD and other substance abuse using multivariable proportional hazards regression, accounting for competing risk of death. Our outcome of interest was BC recurrence. The reference group for all analyses was women with BC alone. The models were adjusted for patient characteristics including age, race, ethnicity, marital status, rurality of primary residence, priority group rating (proxy for socioeconomic status), any homelessness or economic problems, comorbidity burden, body mass index, smoking status, receipt of a screening mammography, year of BC diagnosis, cancer stage, cancer subtype, and cancer treatment. Subgroup analyses were conducted by cancer subtype. Results: Our cohort comprised 6,045 women with BC, of whom 1,754 (29%) had a pre-diagnostic MDD diagnosis and 1,509 (25%) had a substance abuse disorder. Among women with MDD, 386 (22%) abused alcohol and 336 (19%) abused other substances. The median length of follow-up from BC diagnosis was 4.5 years (IQR=4.8 years). The average age at BC diagnosis was 57 years (SD=11 years) overall, 56 years (SD=10 years) among women with MDD, and 57 years (SD=9 years) among women with substance abuse disorders. On multivariable analysis, MDD (HR=1.33; 95% CI: 1.14, 1.53), alcohol abuse disorder (HR=1.37; 95% CI: 1.12, 1.68), and other substance abuse disorders (HR=1.33; 95% CI: 1.13, 1.56) were independent risk factors for BC recurrence. Further, there was a statistically significant interaction between pre-diagnostic MDD and alcohol abuse disorder (p-interaction=0.003). Women with BC who had both pre-diagnostic MDD and alcohol abuse disorder were at a 65% (HR=1.65; 95% CI: 1.29, 2.11) higher risk of BC recurrence compared to women with BC alone. A statistically significant interaction was also observed between pre-diagnostic MDD and other substance abuse disorders (p-interaction &amp;lt; 0.001). Women with BC who had both pre-diagnostic MDD and other substance abuse disorders were at a 90% (HR=1.90; 95% CI: 1.50, 2.42) higher risk of BC recurrence compared to women with BC alone. In subgroup analyses, the interaction between MDD and alcohol abuse disorders (p-interaction=0.001) and MDD and other substance abuse disorders (p-interaction &amp;lt; 0.001) was limited to women with estrogen receptor positive cancer but not estrogen receptor negative cancer. Conclusion: Women with incident BC who have prior diagnoses of both MDD and substance abuse disorder are at higher risk of recurrence than women with either exposure independently. Further research is needed to examine the etiology of our findings and to evaluate whether this newly defined risk group would benefit from closer monitoring and more tailored treatment options. Citation Format: Maya Aboumrad, Kala Visvanathan. Breast cancer recurrence among women with pre-diagnostic major depression and co-existing substance abuse disorder: A retrospective study in the United States Veterans Health Administration Cohort [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PS04-06.

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.

Hepatitis delta testing trends in a US national cohort: An analysis of patient and provider-level predictive factors.

The low prevalence of HDV infection in the United States could be attributed to insufficient testing rate, which can result in an underestimation of the true burden of HDV. The primary objective of this study is to quantify the prevalence of and factors associated with HDV antibody (anti-HDV) or RNA testing, among participants with positive HBsAg in the Veterans Health Administration (VHA). We conducted a retrospective cohort study of participants who tested positive for HBsAg between January 2000 and December 2022 within the VHA. We identified those who were tested for HDV, and patient and provider-level factors associated with HDV testing. Of 41,658 participants with positive HBsAg who had follow-up, 4438 (10.7%) were tested at least once for HDV, of which 135 (3.0%) were positive. Participants in the Northeast (adjusted odds ratio [aOR]: 1.30, 95% CI: 1.17-1.44, p<0.001), and receiving hepatology care (aOR: 1.38, 95% CI: 1.24-1.54, p<0.001) were more likely, while those in the Midwest (aOR: 0.69, 95% CI: 0.60-0.79, p<0.001), under the care of a primary care provider (aOR: 0.61, 95% CI: 0.50-0.74, p<0.001), Blacks (aOR: 0.85, 95% CI: 0.77-0.94, p=0.001), participants who were HCV antibody-positive (aOR: 0.89, 95% CI: 0.81-0.99, p=0.03), and participants who were HIV-positive (aOR: 0.80, 95% CI: 0.71-0.90, p<0.001) were less likely to be tested for HDV. HDV screening rates in the VHA remain low overall. Participants who are Black, living in the Midwest, patients who are HIV-positive, and patients who are HCV-positive are less likely to be tested for HDV. These results suggest that risk-based screening strategies are ineffective in the VHA and highlight the need for refining testing strategies to increase HDV screening rates.

What Should Healthcare Systems Consider When Modernizing Call Centers? Early Considerations From the Veterans Health Administration.

Growing numbers of hospitals and payers are using call centers to answer patients' clinical and administrative questions, schedule appointments, address billing issues, and offer supplementary care during public health emergencies and national disasters. In 2020, the Veterans Health Administration (VA) implemented VA Health Connect, an enterprise-wide initiative to modernize call centers. VA Health Connect is designed to improve the care experience with the convenience, flexibility, and simplicity of a single toll-free number connected to a range of 24/7 virtual services. The services are organized into four areas: administrative guidance for scheduling and general inquiries; pharmacy support for medication matters; clinical triage for evaluation of symptoms and recommended care; and virtual visits with providers for urgent and episodic care. Through a qualitative evaluation of VA Health Connect, we sought to identify the factors that affected the development of this program and to compile considerations to support the implementation of other enterprise-wide initiatives. The evaluation team interviewed 29 clinical and administrative leads from across the VA. These leads were responsible for the modernization of their local service networks. PhD-level qualitative methodologists conducted the interviews, asking participants to reflect on barriers and facilitators to modernization and implementation. The team employed a rapid qualitative analytic approach commonly used in healthcare research to distill robust results. A review of the early implementation of VA Health Connect found: (1) deadlines proved challenging but provided momentum for the initiative; (2) a balance between standardized processes and local adaptations facilitated implementation; (3) attention to staffing, hiring, and training of call center staff before implementation expedited workflows; (4) establishing national and local leadership commitment to the innovation from the onset increased team cohesion and efficacy; and (5) anticipating information technology infrastructure needs prevented delays to modernization and implementation. Our findings suggest that healthcare systems would benefit from anticipating likely obstacles (e.g., delays in software implementations and negotiations with unions), thus providing ample time to secure leadership buy-in and identify local champions, communicating early and often, and supporting flexible implementation to meet local needs. VA leadership can use this evaluation to refine implementation, and it could also have important implications for regulators, federal health exchanges, insurers, and other healthcare systems when determining resource levels for call centers.

Physicians and Specialties in the Veterans Health Administration's Community Care Network.

Physicians and Specialties in the Veterans Health Administration's Community Care Network.

Evaluating feedback reports to support documentation of veterans’ care preferences in home based primary care

BackgroundTo evaluate the effectiveness of delivering feedback reports to increase completion of LST notes among VA Home Based Primary Care (HBPC) teams. The Life Sustaining Treatment Decisions Initiative (LSTDI) was implemented throughout the Veterans Health Administration (VHA) in the United States in 2017 to ensure that seriously ill Veterans have care goals and LST decisions elicited and documented.MethodsWe distributed monthly feedback reports summarizing LST template completion rates to 13 HBPC intervention sites between October 2018 and February 2020 as the sole implementation strategy. We used principal component analyses to match intervention to 26 comparison sites and used interrupted time series/segmented regression analyses to evaluate the differences in LST template completion rates between intervention and comparison sites. Data were extracted from national databases for VA HBPC in addition to interviews and surveys in a mixed methods process evaluation.ResultsLST template completion rose from 6.3 to 41.9% across both intervention and comparison HBPC teams between March 1, 2018, and February 26, 2020. There were no statistically significant differences for intervention sites that received feedback reports.ConclusionsFeedback reports did not increase documentation of LST preferences for Veterans at intervention compared with comparison sites. Observed increases in completion rates across intervention and comparison sites can likely be attributed to implementation strategies used nationally as part of the national roll-out of the LSTDI. Our results suggest that feedback reports alone were not an effective implementation strategy to augment national implementation strategies in HBPC teams.