Veterans Health Administration Research Articles

Personalizing Cognitive Processing Therapy with a Case Formulation Approach to Intentionally Target Impairment in Psychosocial Functioning Associated with PTSD

Posttraumatic stress disorder (PTSD) is a debilitating condition often accompanied by significant functional impairments affecting quality of life and well-being. While Cognitive Processing Therapy (CPT) is a leading, evidence-based psychotherapy for PTSD, demonstrating substantial efficacy in core symptom reduction, its impact on psychosocial functioning is less well-established. The Personalizing Cognitive Processing Therapy with a Case Formulation Approach (Personalizing Approaches to Therapy: PATh) study aims to enhance CPT by explicitly targeting functional impairments and idiosyncratic challenges to optimal therapy outcomes (COTOs), comparing its efficacy against standard CPT in improving psychosocial functioning, quality of life, well-being, and core PTSD and depression symptoms. This randomized controlled trial involves 200 Veterans across eight Veterans Health Administration clinical sites, assigned to either Case Formulation CPT (CF-CPT) or standard CPT. Providers will deliver up to 20 sessions per patient, with assessments at baseline, mid-treatment, post-treatment, and three months follow-up. It is hypothesized that Veterans receiving CF-CPT will show greater improvements in functioning, quality of life, well-being, and symptom reduction, alongside higher treatment completion rates compared to standard CPT. Secondary outcomes will examine specific clinical challenges and their influence on treatment outcomes. This study investigates whether a personalized, flexible CPT protocol can enhance functional recovery in PTSD treatment without compromising the efficacy of the traditional approach, potentially impacting clinical practices and patient outcomes by promoting holistic recovery for veterans with PTSD.

Barriers to Perioperative Palliative Care Across Veterans Health Administration Hospitals: A Qualitative Evaluation

Barriers to Perioperative Palliative Care Across Veterans Health Administration Hospitals: A Qualitative Evaluation

Prostate-Specific Antigen Stratification for Predicting Advanced Prostate Cancer Events in Men Approaching Age Limits for Recommended Screening.

Our goal was to quantify the ability of various PSA values in predicting the likelihood of developing metastatic or fatal prostate cancer in older men. We used a random sample of patients in the US Veterans Health Administration to identify 80,706 men who had received PSA testing between ages 70 to 75. Our primary end point was time to development of either metastatic prostate cancer or death from prostate cancer. We used cumulative/dynamic modeling to account for competing events (death from non-prostate cancer causes) in studying both the discriminative ability of PSA as well as for positive predictive value and negative predictive value at 3 time points. PSA demonstrated time-dependent predictive discrimination, with receiver operating characteristic area under the curve at 5, 10, and 14 years decreasing from 0.83 to 0.77 to 0.73, respectively, but without statistically significant difference when stratified by race. At PSA thresholds between 1 and 8 ng/mL, the positive predictive value of developing advanced prostate cancer was significantly greater in Black than White patients. For instance, at a PSA > 3, at 5, 10, and 14 years, White patients had 2.4%, 2.9%, and 3.7% risk of an event, whereas Black patients had 4.3%, 6.5%, and 8.3% risk. In men aged 70 to 75 deciding whether to cease PSA testing with borderline-elevated PSA values, the risk of developing metastatic or fatal prostate cancer is quantifiable and relatively low. Risk assessment in this setting must account for the higher incidence of prostate cancer in Black men.

Impact of Home Telehealth Expansion on High-Cost Utilization Among Veterans Health Administration Patients with Diabetes.

Home telehealth (HT) services have rapidly expanded in the Veterans Health Administration (VHA), but little is known about the real-world impact of the expansion of these services on utilization. To evaluate the impact of expanding HT diabetes services in VHA on high-cost utilization. This cohort study used cross-temporal propensity score matching to identify patients with diabetes who would receive HT services (treatment group) with program expansion (treatment group) with a comparison group of patients with diabetes who did not receive HT services (control group) between 2010 and 2018. A difference-in-differences design was used to compare pre-post changes in high-cost utilization between propensity-matched groups. Data used was from the VHA's Corporate Data Warehouse. VHA patients with diabetes, n=7214 in the treatment group who received HT services, and n=1,067,138 in the control group who did not receive HT services. Emergency department (ED) visits, all-cause hospitalization, and hospitalizations for ambulatory care sensitive conditions (ACSCs). In the baseline period, patients in our sample had a mean age of 67 years old (SD=11 years), were 97% male, and 78% had a hemoglobin A1c (HbA1c) < 8%. The increase in HT use was associated with a net increase of ED visits per patient (0.215 95% CI [0.152, 0.279]), all-cause hospitalization (0.053 95% CI [0.032, 0.074]), and ACSC hospitalization (0.032 95% CI [0.019, 0.045]). Expanding HT or remote monitoring services may lead to additional needs being identified for patients, including increased access to in-person care, such as ED or hospital services.

Emergency department visits, inpatient hospitalizations, and non-fatal and fatal drug overdoses during COVID-19 among Veterans with opioid use disorder.

The COVID-19 pandemic had dramatic adverse impacts on people with opioid use disorder (OUD), as evidenced by significant disruptions to care and unprecedented increases in drug overdoses. In this study, we evaluated the impacts of COVID-19 on utilization of emergency and inpatient care, and fatal and non-fatal overdoses among veterans with OUD. We used Veterans Health Administration (VHA) electronic medical record and mortality data to compare emergency department (ED) visits, inpatient hospitalizations, and fatal and non-fatal overdoses between a pandemic-exposed cohort of veterans with OUD observed both pre- and post-pandemic onset (n = 53,803; observed January 2019-March 2021) to a matched pre-pandemic control group (n = 53,803; observed October 2017-December 2019). Compared to pre-pandemic trends, there were significant decreases in the odds of ED and inpatient admissions and total number of ED and inpatient admissions during COVID-19. There was a significant decrease in the odds of having a recorded non-fatal overdose. The odds of overdose death increased during the pandemic compared to pre-pandemic trends. We observed significant decreases in the utilization of ED and inpatient care services, and fewer non-fatal overdoses, post-pandemic onset. Healthcare disruptions limiting access to emergency and inpatient care could account for the lower number of recorded non-fatal overdoses, potentially reflecting an underestimate of risk. In contrast, fatal overdoses increased during the pandemic compared to pre-pandemic trends. Lower utilization of emergency and inpatient care, and higher rates of fatal overdoses during the pandemic, suggest an exacerbation of unmet treatment need post-pandemic onset.

A Validated Algorithm to Identify Hepatic Decompensation in the Veterans Health Administration Electronic Health Record System.

Accurate identification of hepatic decompensation is essential for pharmacoepidemiologic research among patients with chronic liver disease. An algorithm using ≥ 1 inpatient or ≥ 2 outpatient International Classification of Diseases, 10th revision (ICD-10) codes for hepatic decompensation was developed in Veterans Health Administration data from October 2015 through July 2019. Medical records were reviewed by hepatologists to confirm cases. The positive predictive value (PPV) of the coding algorithm for confirmed hepatic decompensation was calculated. Hepatic decompensation was confirmed in 149/185 records meeting the algorithm (PPV 81%; 95% CI, 70%, 90%). The most common hepatic decompensation diagnosis was ascites. Only 56% of confirmed cases had an accompanying diagnosis code for cirrhosis. Our ICD-10-based coding algorithm identified hepatic decompensation with high PPV in Veterans Health Administration data.

A Virtual Breakthrough Series Collaborative for Missed Test Results

Missed test results, defined as test results not followed up within an appropriate time frame, are common and lead to delays in diagnosis and treatment. To evaluate the effect of a quality improvement collaborative, the Virtual Breakthrough Series (VBTS), on the follow-up rate of 2 types of test results prone to being missed: chest imaging suspicious for lung cancer and laboratory findings suggestive of colorectal cancer. This stepped-wedge cluster-randomized clinical trial was conducted between February 2020 and March 2022 at 12 Department of Veterans Affairs (VA) medical centers, with a predefined 3-cohort roll-out. Each cohort was exposed to 3 phases: preintervention, action, and continuous improvement. Follow-up ranged from 0 to 12 months, depending on cohort. Teams at each site were led by a project leader and included diverse interdisciplinary representation, with a mix of clinical and technical experts, senior leaders, nursing champions, and other interdisciplinary team members. Analysis was conducted per protocol, and data were analyzed from April 2022 to March 2024. All teams participated in a VBTS, which included instruction on reducing rates of missed test results at their site. The primary outcome was changes in the percentage of abnormal test result follow-up, comparing the preintervention phase with the action phase. Secondary outcomes were effects across cohorts and the intervention's effect on sites with the highest and lowest preintervention follow-up rates. Previously validated electronic algorithms measured abnormal imaging and laboratory test result follow-up rates. A total of 11 teams completed the VBTS and implemented 47 (mean, 4 per team; range, 3-8 per team; mode, 3 per team) unique interventions to improve missed test results. A total of 40 027 colorectal cancer-related tests were performed, with 5130 abnormal results, of which 1286 results were flagged by the electronic trigger (e-trigger) algorithm as being missed. For lung cancer-related studies, 376 765 tests were performed, with 7314 abnormal results and 2436 flagged by the e-trigger as being missed. There was no significant difference in the percentage of abnormal test results followed up by study phase, consistent across all 3 cohorts. The estimated mean difference between the preintervention and action phases was -0.78 (95% CI, -6.88 to 5.31) percentage points for the colorectal e-trigger and 0.36 (95% CI, -5.19 to 5.9) percentage points for the lung e-trigger. However, there was a significant effect of the intervention by site, with the site with the lowest follow-up rate at baseline increasing its follow-up rate from 27.8% in the preintervention phase to 55.6% in the action phase. In this cluster-randomized clinical trial of the VBTS intervention, there was no improvement in the percentage of test results receiving follow-up. However, the VBTS may offer benefits for sites with low baseline performance. ClinicalTrials.gov Identifier: NCT04166240.

Analysis of Mortality Causes and Locations in Veterans with ALS: A Decade Review.

BACKGROUND Amyotrophic lateral sclerosis (ALS) is a motor neuron disease that leads to rapid degeneration of nerves in the brain and spinal cord, with eventual loss of voluntary movements, including breathing. This retrospective study of medical record data from 105 US veterans diagnosed with ALS at the Oklahoma City VA Medical Center between 2010 and 2021 aimed to identify patient demographics, and the causes and places of death for these veterans. MATERIAL AND METHODS Data from 105 US veterans diagnosed with ALS by the El Escorial criteria and supported by neurophysiology testing was reviewed. The information about the place and cause of death was obtained from each patient's care provider and death certificate. Crude mortality rates (per 100 person-years) and standardized mortality ratios (SMRs) were calculated for the causes of death, by sex, age group, and location of death. RESULTS During the 11-year follow-up period, 80 (76.2%) veterans with ALS died. The mean (SD) follow-up time was 4.53 (4.55) years. Most of the deaths were due to respiratory failure and pneumonia (n=43, mortality rate=9.21 per 100 person-years). Most patients died at home (n=71, 88.7%). The annual crude mortality rate was 16.7 and the all-cause death SMR was 25.63 (95% CI, 20.32-31.55). CONCLUSIONS This study's findings are that in veterans with ALS, the main cause of death is respiratory disease (failure). The main location of death was the home, with their family members. The all-cause mortality rate among veterans with ALS was 26 times greater than for the general Oklahoma population.

Co-designing a blueprint for spreading person-centered, Whole Health care to HIV specialty care settings: a mixed methods protocol

BackgroundSince 2013, the Veterans Health Administration (VHA) has advanced a person-centered, Whole Health (WH) System of Care, a shift from a disease-oriented system to one that prioritizes “what matters most” to patients in their lives. Whole Health is predicated on patient-provider interactions marked by a multi-level understanding of health and trusted relationships that promote well-being. Presently, WH implementation has been focused largely in primary care settings, yet the goal is to effect a system-wide transformation of care so that Veterans receive WH across VHA clinical settings, including specialty care. This sort of system-wide cultural transformation is difficult to implement.MethodsThis three-aim mixed methods study will result in a co-designed implementation blueprint for spreading WH from primary to specialty care settings. Taking HIV specialty care as an illustrative case- because of its diverse models of relationships to primary care - to explore how to spread WH through specialty care settings. We will use the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to organize quantitative and qualitative data and identify key determinants of WH receipt among Veterans living with HIV. Through a co-design process, we develop an adaptable implementation blueprint that identifies and matches implementation strategies to different HIV specialty care configurations.DiscussionThis study will co-design a flexible implementation blueprint for spreading WH from VHA primary care throughout HIV specialty care settings. This protocol contributes to the science of end-user engagement while also answering calls for greater transparency in how implementation strategies are identified, tailored, and spread.

Characteristics of incident benzodiazepine recipients among US veterans with posttraumatic stress disorder.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. While benzodiazepine prescribing among veterans with posttraumatic stress disorder (PTSD) declined substantially in the Veterans Health Administration over the past decade, little is known about current incident prescribing. Our objective was therefore to describe patient, provider, facility, and prescribing characteristics among veterans with PTSD who were incident benzodiazepine recipients in 2022 and contrast these to the characteristics for incident recipients in 2012. This retrospective observational study included all veterans with PTSD who received an incident benzodiazepine prescription during calendar year 2022 and separately for 2012. The distribution of patient, provider, facility, and benzodiazepine prescribing characteristics was contrasted between years. Stratified subanalyses were conducted by potential non-PTSD benzodiazepine indication, including anxiety and sleep disorders. A total of 28,310 (6.6%) incident benzodiazepine recipients were identified in 2012, which decreased to 16,776 (1.9%) incident recipients in 2022. The proportion of initial prescriptions written for a days' supply of 30 or more days decreased from 75.6% to 51.7%, and the proportion who received a second prescription within 6 months decreased from 68.7% to 53.5%. The proportion of patients with diagnoses for potential benzodiazepine indications also increased, including for generalized anxiety disorder (15.1% increase), obsessive compulsive disorders (0.6% increase), panic disorder (6.7% increase), and sleep disorders (22.9% increase). As incident benzodiazepine prescribing among veterans with PTSD decreased over the past decade, so did the volume of drug dispensed and duration of therapy, while the prevalence of documented prescriptions for non-PTSD indications increased.

Insomnia and Chronic Pain Mediate the Relationship Between Traumatic Brain Injury and Reduced Positive Airway Pressure Adherence Among Veterans.

To examine whether co-morbid insomnia, post-traumatic stress disorder (PTSD), depression, and chronic pain mediate the relationship between traumatic brain injury (TBI) and positive airway pressure (PAP) treatment adherence. One Veterans Health Administration (VHA) sleep medicine site. Veterans (n =8836) who were prescribed a modem-enabled PAP device. Secondary analysis of clinical data. We used path analysis to examine: (1) whether Veterans with a history of TBI were more likely to experience insomnia, PTSD, depression, and chronic pain; (2) in turn, whether Veterans with these co-morbid conditions exhibited lesser PAP adherence; and (3) whether Veterans with a history of TBI will exhibit lesser PAP adherence, even while accounting for such co-morbid conditions. Model estimates were adjusted for sociodemographic (eg, race/ethnicity) and clinical characteristics (eg, mask leakage). Health conditions were abstracted from the VHA medical record. PAP adherence was measured using average nightly use (hours). Among 8836 Veterans, 12% had a history of TBI. TBI history was not associated with PAP adherence when accounting for the presence of insomnia, PTSD, depression, and chronic pain. Indirect effect estimates indicated that a history of mild, moderate-severe, or unclassified TBI was associated with lesser PAP adherence, as mediated by the presence of co-morbid insomnia and chronic pain. Generally, TBI was associated with an increased likelihood of co-morbid insomnia, PTSD, depression, and chronic pain. In turn, insomnia and chronic pain, but not PTSD or depression, were associated with lesser PAP adherence. Our study offers empirical support for insomnia and chronic pain as potential explanatory mechanisms underlying the relationship between TBI history and suboptimal PAP adherence. While additional research is needed to confirm causality, findings offer preliminary evidence that can inform the development of tailored PAP adherence interventions for Veterans with TBI and obstructive sleep apnea.

A Qualitative Study of Patient and Interprofessional Healthcare Team Member Experiences of Bedside Interdisciplinary Rounds at a VA: Language, Teamwork, and Trust.

Patient and interprofessional healthcare team member experiences of bedside interdisciplinary rounds (BIDR) are generally positive. Overall, there is large heterogeneity in existingBIDR frameworks, and best practices have not been defined. Understand patients' and interprofessional healthcare team members' experiences of BIDR. Academic VA Medical Center (VAMC) with daily structured BIDR. Inpatients, nurses, pharmacists, and care coordinators who participated in BIDR. We conducted semi-structured qualitative interviews with study participants about their experiences with BIDR between January and June 2020. All interviews were recorded and professionally transcribed. We used thematic analysis to identify key themes. We interviewed 14 inpatients and 18 interprofessional healthcare team members, including nurses, pharmacists, and care coordinators. Patients participating in BIDR reported positive perceptions of being included in the discussion of their healthcare plans and increased trust in providers; patient discomfort resulted from physician use of technical language and frombeing presented with unclear, vague careplans. Interdisciplinary healthcare team members participating in BIDR reported an increased understanding, respect, and trust for other team members and improved patient care; challenges were posed by lack of supportive structural elements to interprofessional workflow and prolonged physician presentations. BIDR can build trust between patients andhealthcare providers and within the interprofessional team by creating a setting where teamwork interactions can be observed. Based on our findings, we recommend trust-building practices for BIDR, which include sharing BIDR goals with patients, using patient-centered language, creating structures for interprofessional inclusion, defining team roles, using standardized communication, and addressing interprofessional inputs in real time.

Developing a multi-center registry of peripheral artery disease using natural language processing: unlocking the power of the electronic health record

Abstract Background Although peripheral artery disease (PAD) is common and associated with a high risk of mortality, contemporary PAD research remains limited due to poor accuracy of diagnosis codes in the electronic health record (EHR). We previously developed and validated a novel natural language processing (NLP) algorithm that can extract ankle brachial index (ABI) and toe-brachial index (TBI) values from clinical documents and identify patients with PAD with high accuracy (positive predictive value 92.4%). Purpose Scale the NLP system for developing a nationwide registry of PAD in the Veterans Health Administration (VHA), the largest integrated health system in the U.S. that provides care to ~9 million Veterans across 130 sites. Describe the baseline characteristics and mortality outcomes among participants and identify predictors of long-term mortality. Methods A total of 1,182,025 documents from vascular and radiology procedures during 2013-2020 were processed by the NLP system. After excluding non-ABI vascular studies, patients with a known diagnosis of PAD prior to 2015, patients younger than 40 years of age, and those who do not regularly follow-up in the VHA, we identified 107,711 patients with newly diagnosed PAD during 2015-2020. Patients were followed longitudinally using the VA’s electronic health record data. The primary outcome was all-cause mortality. We used Cox proportional hazards regression to examine predictors of long-term mortality. Results The mean age was 70.5 years; 97.3% were males, and 18.5% were of Black race. The mean ABI value was 0.78 (SD: 0.26) and the mean TBI value was 0.51 (SD: 0.19). There was a high prevalence of hypertension (83.6%), heart failure (20.8%), diabetes (53.6%), renal failure (22.1%) and chronic obstructive pulmonary disease (32.4%, Table 1). At 1-year, 9.6% of patients had died and this proportion increased to 25.4% at 3 years. Although nearly all patient variables were significantly associated with mortality, older age, severe PAD at diagnosis, diabetes, heart failure, renal failure and COPD were the strongest predictors of long-term mortality. Black race was associated with lower hazard of long-term mortality. Conclusions Using a previously validated novel NLP algorithm that extracts ABI and TBI values from clinical documents, we have successfully developed a registry of newly diagnosed PAD in the VHA. Ongoing studies from our cohort will yield important insights into the association between clinical management of PAD and clinical outcomes, with the goal of identifying opportunities for improving care.

Racial and ethnic disparities in the incidence of stroke and mortality in atrial fibrillation: a US nationwide study

Abstract Background Atrial fibrillation (AF) is the most common arrhythmia globally and is associated with increased risks of cardiovascular mortality and ischemic stroke. Prior research has demonstrated racial/ethnic disparities in AF outcomes yet this work has been limited to small cohorts and did not adjust for anticoagulant therapy. Purpose We compared incidence of ischemic stroke and death by race/ethnicity for patients with AF in the Veterans Health Administration (VA), the largest integrated, low-cost, national healthcare system in the US. Methods In this retrospective cohort study we identified those with an outpatient diagnosis of AF and a confirmatory diagnosis ≦ 180 days of their index AF diagnosis enrolled in VA from January 1, 2014 to December 31, 2021, with follow-up for outcomes from the index AF diagnosis date until May 31, 2022. To create a cohort of incident AF cases, we excluded patients with an AF diagnosis or anticoagulant therapy in the 2 years prior to their index AF diagnosis. We also excluded patients with pre-existing valvular heart disease, prior stroke, receiving hospice care or who died within 180 days of index AF diagnosis. We categorized our independent variable as race (i.e., non-Hispanic American Indian / Alaska Native [AI/AN], Asian, Black, or White [reference group]), and ethnicity (i.e., Hispanic). Our primary outcomes were incidence of stroke or death at any point within the study follow-up period. To compare these outcomes by race/ethnicity we conducted a survival analysis, adjusting for anticoagulant use as a time-varying covariate along with sociodemographic factors (age, sex, region, area deprivation index), clinical factors (CHADS2VA2Sc stroke risk and HAS-BLED bleeding risk), and facility type. Results There were 187,080 patients in the final cohort including 0.5% AI/AN, 1% Asian, 9% Black, 4% Hispanic, 85% White; mean age was 73 years. Over a mean study follow-up period of 4.43 years, 65,375 (34.9%) patients died and 24,910 (13.3%) developed stroke. The adjusted hazard ratio [95% CI] for death was lower for Hispanic (0.84 [0.78, 0.91]) and Black (0.94 [0.91, 0.97]) patients than White patients. In contrast, the adjusted hazard ratio for stroke incidence was higher for Black (1.21 [1.16, 1.27]) and Hispanic (1.10 [1.03, 1.17]) patients than White patients. There was no difference observed between AI/AN or Asian and White patients in either outcome. Conclusions In a national cohort of patients with incident AF, we identified significantly higher rates of stroke in Black and Hispanic than White patients even controlling for myriad factors including anticoagulant use. Conversely, racial/ethnic disparities in mortality appear to be eliminated in VA, counter to prior data. Understanding the factors, beyond anticoagulation, driving disparities in stroke outcomes and identifying factors reducing mortality among minority groups is critical to improving overall AF care in the largest integrated US health system.Adjusted Hazard Ratios of Study Outcomes

Burnout and Turnover Among Veterans Health Administration Primary Care Providers From Fiscal Years 2017-2021.

We examined how individual-level turnover among Veterans Health Administration primary care providers (PCPs) from fiscal years 2017 to 2021 was associated with health care system-level burnout and turnover intent. Burnout among PCPs has been well documented in recent studies, but less is known about the potential relationship between burnout and turnover. We identified a national cohort of 6444 PCPs (physicians, nurse practitioners, and physician assistants) in 129 Veterans Health Administration health care systems in the first quarter of fiscal year 2017 and tracked their employment status for 20 quarters. PCP employment data on turnover were linked to annual health care system-level employee survey data on burnout, turnover intent, and other covariates. We performed logistic regression to estimate the impact of health care system-level burnout and turnover intent on individual PCP turnover, controlling for individual and health care system-level covariates and adjusting for clustering at the health care system level. Median health care system-level burnout ranged from 42.5% to 52.0% annually, and turnover among PCPs ranged from 6.3% to 8.4% (mean = 7.0%; SD = 0.9%). Separation from employment was higher among employees at health care systems with the highest burnout (odds ratio =1.14; 95% CI = 1.01-1.29) and turnover intent (OR = 1.18; 95% CI = 1.03-1.35). PCPs in health care systems with high burnout are more likely to separate from employment. Policymakers and administrators seeking to improve retention should consider system-level interventions to address organizational drivers of burnout.

Escalation to Biologics After Methotrexate Among US Veterans with Rheumatoid Arthritis Grouped by Rural Versus Urban Areas.

Racial and ethnic disparities in rheumatoid arthritis (RA) outcomes are well recognized. However, whether disparities in RA treatment selection and outcomes differ by urban versus rural residence, independent of race, have not been studied. Our objective was to evaluate whether biologic disease modifying anti-rheumatic drugs (bDMARD) initiation after methotrexate use differs by rural versus urban residence among Veterans with RA. In this retrospective cohort study utilizing national U.S. Veterans Affairs databases, we identified adult patients with RA based on presence of diagnostic codes and DMARD use. We included patients receiving an initial prescription of methotrexate (index date) between 2005 and 2014, with data through 2016 used for follow-up. Urban-rural status was categorized using the Veteran Health Administration's Urban/Rural classification. Our primary outcome of interest was time to biologic initiation within two years of starting methotrexate. Multivariable Cox proportional hazards models were conducted adjusting for demographics, comorbidities, and rheumatoid factor or anti-CCP positivity. Among 17,395 veterans with RA (88% male, 42% with rural residence) fulfilling eligibility criteria, 3,259 (19%) initiated a biologic within the first two years of follow up. In multivariable models, residence in an urban area was associated with a statistically significant higher biologic use compared to rural areas (adjusted hazard ratio (aHR) 1.10, 95% CI 1.02-1.18). Our study found only modest differences in initiation of biologic therapies among rural versus urban residing Veterans with RA in the VA healthcare system. These findings suggest that disparities are not easily explained by rurality within the VA healthcare system.

Differing needs for Advance Care Planning in the Veterans Health Administration: use of latent class analysis to identify subgroups to enhance Advance Care Planning via Group Visits for veterans

BackgroundAdvance Care Planning via Group Visits (ACP-GV) is a patient-centered intervention facilitated by a clinician using a group modality to promote healthcare decision-making among veterans. Participants in the group document a “Next Step” to use in planning for their future care needs. The next step may include documentation of preferences in an advance directive, discussing plans with family, or anything else to fulfill their ACP needs. This evaluation seeks to determine whether there are identifiable subgroups of group participants with differing needs prior to delivery of the ACP-GV program and, if so, to use information about the subgroups to enhance the program offered to veterans in United States Department of Veterans Affairs (VA) healthcare settings.MethodsWe conducted a secondary analysis of national data from a quality improvement evaluation. Patient- and provider-level data from administrative healthcare records for VA users in all 50 states, territories, and the District of Columbia provides data on veterans attending ACP-GV during federal fiscal years 2018–2022 (N = 26,857). Latent class analysis seeks to identify the various subgroups of veterans based on their level of ACP self-efficacy before attending ACP-GV and any demographic differences across the resulting subgroups of veterans attending ACP-GV. ACP self-efficacy is derived from seven items obtained from a participant worksheet used during the group.ResultsAnalysis revealed two distinct groups of veterans, distinguishable by their pre-ACP-GV levels of one aspect of ACP self-efficacy: prior knowledge of ACP. Veterans with higher prior knowledge of ACP are associated with an identified next step focused on checking their current AD status and updating it, and veterans with lower ACP prior knowledge are associated with identifying a next step to discuss ACP more fully with family. Differences in age, sex, race, ethnicity, and marital status exist across subgroups of veterans.ConclusionGreater attention must be paid to ACP and veterans’ prior knowledge of ACP to consistently encourage annual review and status updates.

Provider Perspectives on Healthcare System Barriers to Engaging Caregivers of Rural US Veterans in Firearm Suicide Prevention.

Firearms account for the majority of US Veteran suicides. Studies demonstrate that secure firearm storage can decrease risk of suicide. Veterans prefer to have discussions about secure firearm storage with familiar individuals, such as their caregivers. Providers in the Department of Veterans Affairs (VA) are well-positioned to engage caregivers of Veterans in firearm suicide prevention; however, challenges remain. Elucidate healthcare system barriers to caregiver engagement in firearm suicide prevention, as seen by Suicide Prevention and Caregiver Support Program staff, to inform development of an intervention to increase involvement of caregivers in efforts to reduce Veteran firearm suicides. An Advisory Board consisting of key stakeholders provided input regarding study methods and interpretation of findings. Participants included 16 Caregiver Support Program and 14 Suicide Prevention staff recruited from 8 geographically diverse rural VA medical centers. Interview topics and data analyses were guided by the Consolidated Framework for Implementation Research (CFIR). Rapid analysis and a team-based approach were employed to identify key barriers; emergent themes were mapped onto relevant constructs of the CFIR inner setting domain. Healthcare system barriers included structural characteristics (e.g., understaffing and heavy workloads), relational connections and communications (e.g., poor channels of communication between Caregiver Support Program and Suicide Prevention staff), culture (e.g., lack of recipient-centered care), and access to knowledge and information (e.g., lack of training in how to incorporate caregivers in Veteran care). The present study provides much needed perspective from VA staff in Suicide Prevention and Caregiver Support programs regarding barriers to involving caregivers in firearm suicide prevention efforts within the VA healthcare setting. Identifying these barriers and potential solutions is a critical step towards increasing engagement of caregivers in reducing firearm suicide among Veterans.

The Management of Non-Muscle-Invasive Bladder Cancer in a Veteran Patient Population: Issues and Recommendations

The ability of the Veterans Health Administration System to care for veterans with bladder cancer is influenced by the increased complexity of both veterans and the system’s capacity to do so, which is determined by personnel and equipment allocation. Herein, we review the guidelines for bladder cancer management in the context of this population and highlight unique veteran characteristics that impact the delivery of bladder cancer care within the Veterans Health Administration System. There are opportunities for standardization and implementation, which can improve the quality of this care, and we summarize the questions for which coordinated research efforts may provide answers.

Comparison of risk factors and mortality in veterans with HIV and those without HIV suffering first major acute cardiovascular events.

Previous studies have demonstrated that people with HIV have an increased atherosclerotic plaque vulnerability, making them more susceptible to severe cardiovascular complications. This study aimed to examine the clinical characteristics of people with HIV in comparison to people without HIV admitted to Veterans Health Administration (VHA) with their first major acute cardiovascular events (MACE) and compare their total mortality. We used national VHA data to extract data of those admitted to VHA hospitals with MACE defined as acute myocardial infarction (AMI), acute cerebrovascular accident (CVA) or cardiac arrest during the fiscal years 2003-2021. The hazard ratio (HR) of mortality for people with HIV versus people without HIV was estimated using Cox proportional hazard regression analysis. Out of 280 311 veterans, 2510 people with HIV and 277 801 people without HIV had their first MACE during the study period. People with HIV were younger, more likely to be African American, had a lower prevalence of diabetes mellitus and hypertension, similar total cholesterol levels and a lower mean 10-year cardiovascular risk score (25.4 in people with HIV vs. 28.7 in people without HIV). Among MACE components, people with HIV had a higher proportion of CVA (27% vs. 21.3%, p < 0.001) and cardiac arrest (13.0% vs. 8.4%, p < 0.001) but a lower incidence of AMI (62.4% vs. 72.5%, p < 0.001) than people without HIV. Additionally, people with HIV had a higher risk of total mortality (adjusted HR: 2.05, 95% confidence interval: 1.90-2.22) compared with people without HIV. People with HIV experience MACE at younger ages despite lower cardiovascular risks and similar baseline cholesterol and blood pressure levels. People with HIV had higher mortality and a higher risk of having ventricular fibrillation arrest and stroke as their first MACE.