VA Providers' Perceptions of Cannabis Use Policies in a Legalized and Nonlegalized State.

Background: Providers in the Department of Veterans Affairs (VA) system are caught between two opposing sets of laws regarding cannabis and cannabidiol (CBD) use by their patients. As VA is a federal agency, it must abide by federal regulations, including that the Food and Drug Administration classifies cannabis as a Schedule 1 drug and therefore cannot recommend or help Veterans obtain it. Meanwhile, 38 states have passed legislation, legalizing medical use of cannabis. Objective: The goal of this project is to examine how VA providers understand state and federal laws, and VA policies about cannabis and CBD use, and to learn more about providers' experiences with patients who use cannabis and CBD within a legalized and nonlegalized state. Materials and Methods: We identified 432 health care providers from two VA facilities in northern Illinois (IL) where medical and recreational cannabis is legal, and two VA facilities in southern Wisconsin (WI) where medical and recreational cannabis is illegal. Participants were invited via e-mail to complete an anonymous online survey, including 31 closed- and open-ended questions about knowledge of state and federal laws and VA policies regarding cannabis and CBD oil, thoughts about the value of cannabis or CBD for treating medical conditions, and behaviors regarding cannabis use by their patients. Results: We received 50 responses (IL N=20, WI N=30). Providers in both states were knowledgeable about cannabis laws in their state but unsure whether they could recommend cannabis. There were more providers who were unclear if they could have a conversation about cannabis with their VA patients in WI compared with IL. Providers were more likely to agree than disagree that cannabis can be beneficial, χ2 (1, 49)=4.74, p=0.030. Providers in both states (81.6%) believe cannabis use is acceptable for end-of-life care, but responses varied for other conditions and symptoms. Discussion: Findings suggest that VA providers could use more guidance on what is allowable within their VA facilities and how state laws affect their practice. Education about safety related to cannabis and other drug interactions would be helpful. There is limited information about possible interactions, warranting future research.

Cerner Millennium's Care Pathways for Specialty Care Referrals: Provider and Nurse Experiences, Perceptions, and Recommendations for Improvements.

BACKGROUND: Using structured templates to guide providers in communicating key information in electronic referrals is an evidence-based practice for improving care quality. To facilitate referrals in Veterans Health Administration's (VA) Cerner Millennium electronic health record, VA and Cerner have created "Care Pathways"-templated electronic forms, capturing needed information and prompting ordering of appropriate pre-referral tests. OBJECTIVE: To inform their iterative improvement, we sought to elicit experiences, perceptions, and recommendations regarding Care Pathways from frontline clinicians and staff in the first VA site to deploy Cerner Millennium. DESIGN: Qualitative interviews, conducted 12-20 months after Cerner Millennium deployment. PARTICIPANTS: We conducted interviews with primary care providers, primary care registered nurses, and specialty providers requesting and/or receiving referrals. APPROACH: We used rapid qualitative analysis. Two researchers independently summarized interview transcripts with bullet points; summaries were merged by consensus. Constant comparison was used to sort bullet points into themes. A matrix was used to view bullet points by theme and participant. RESULTS: Some interviewees liked aspects of the Care Pathways, expressing appreciation of their premise and logic. However, interviewees commonly expressed frustration with their poor usability across multiple attributes. Care Pathways were reported as being inefficient; lacking simplicity, naturalness, consistency, and effective use of language; imposing an unacceptable cognitive load; and not employing forgiveness and feedback for errors. Specialists reported not receiving the information needed for referral triaging. CONCLUSIONS: Cerner Millennium's Care Pathways, and their associated organizational policies and processes, need substantial revision across several usability attributes. Problems with design and technical limitations are compounding challenges in using standardized templates nationally, across VA sites having diverse organizational and contextual characteristics. VA is actively working to make improvements; however, significant additional investments are needed for Care Pathways to achieve their intended purpose of optimizing specialty care referrals for Veterans.

Point-of-care ultrasound in geriatrics: a national survey of VA medical centers.

BACKGROUND: Point-of-care ultrasound (POCUS) can aid geriatricians in caring for complex, older patients. Currently, there is limited literature on POCUS use by geriatricians. We conducted a national survey to assess current POCUS use, training desired, and barriers among Geriatrics and Extended Care ("geriatric") clinics at Veterans Affairs Medical Centers (VAMCs). METHODS: We conducted a prospective observational study of all VAMCs between August 2019 and March 2020 using a web-based survey sent to all VAMC Chiefs of Staff and Chiefs of geriatric clinics. RESULTS: All Chiefs of Staff (n=130) completed the survey (100% response rate). Chiefs of geriatric clinics ("chiefs") at 76 VAMCs were surveyed and 52 completed the survey (68% response rate). Geriatric clinics were located throughout the United States, mostly at high-complexity, urban VAMCs. Only 15% of chiefs responded that there was some POCUS usage in their geriatric clinic, but more than 60% of chiefs would support the implementation of POCUS use. The most common POCUS applications used in geriatric clinics were the evaluation of the bladder and urinary obstruction. Barriers to POCUS use included a lack of trained providers (56%), ultrasound equipment (50%), and funding for training (35%). Additionally, chiefs reported time utilization, clinical indications, and low patient census as barriers. CONCLUSIONS: POCUS has several potential applications for clinicians caring for geriatric patients. Though only 15% of geriatric clinics at VAMCs currently use POCUS, most geriatric chiefs would support implementing POCUS use as a diagnostic tool. The greatest barriers to POCUS implementation in geriatric clinics were a lack of training and ultrasound equipment. Addressing these barriers systematically can facilitate implementation of POCUS use into practice and permit assessment of the impact of POCUS on geriatric care in the future.

Evidence-Based Intervention Adaptations Within the Veterans Health Administration: a Scoping Review.

BACKGROUND: Veterans receiving care within the Veterans Health Administration (VA) are a unique population with distinctive cultural traits and healthcare needs compared to the civilian population. Modifications to evidence-based interventions (EBIs) developed outside of the VA may be useful to adapt care to the VA healthcare system context or to specific cultural norms among veterans. We sought to understand how EBIs have been modified for veterans and whether adaptations were feasible and acceptable to veteran populations. METHODS: We conducted a scoping review of EBI adaptations occurring within the VA at any time prior to June 2021. Eligible articles were those where study populations included veterans in VA care, EBIs were clearly defined, and there was a comprehensive description of the EBI adaptation from its original context. Data was summarized by the components of the Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME). FINDINGS: We retrieved 922 abstracts based on our search terms. Following review of titles and abstracts, 49 articles remained for full-text review; eleven of these articles (22%) met all inclusion criteria. EBIs were adapted for mental health (n = 4), access to care and/or care delivery (n = 3), diabetes prevention (n = 2), substance use (n = 2), weight management (n = 1), care specific to cancer survivors (n = 1), and/or to reduce criminal recidivism among veterans (n = 1). All articles used qualitative feedback (e.g., interviews or focus groups) with participants to inform adaptations. The majority of studies (55%) were modified in the pre-implementation, planning, or pilot phases, and all were planned proactive adaptations to EBIs. IMPLICATIONS FOR D&I RESEARCH: The reviewed articles used a variety of methods and frameworks to guide EBI adaptations for veterans receiving VA care. There is an opportunity to continue to expand the use of EBI adaptations to meet the specific needs of veteran populations.

Veterans Health Administration TeleSleep Enterprise-Wide Initiative 2017-2020: bringing sleep care to our nation's veterans.

STUDY OBJECTIVES: The Veterans Health Administration cares for many veterans with sleep disorders who live in rural areas. The Veterans Health Administration's Office of Rural Health funded the TeleSleep Enterprise-Wide Initiative (EWI) to improve access to sleep care for rural veterans through creation of national telehealth networks. METHODS: The TeleSleep EWI consists of (1) virtual synchronous care, (2) home sleep apnea testing, and (3) REVAMP (Remote Veterans Apnea Management Platform), a patient- and provider-facing web application that enabled veterans to actively engage with their sleep care and sleep care team. The TeleSleep EWI was designed as a hub-and-spoke model, where larger sites with established sleep centers care for smaller, rural sites with a shortage of providers. Structured formative evaluation for the TeleSleep EWI is supported by the Veterans Health Administration's Quality Enhancement Research Initiative and was critical in assessing outcomes and effectiveness of the program. RESULTS: The TeleSleep EWI launched with 7 hubs and 34 spokes (2017) and rapidly expanded to 13 hubs and 63 spokes (2020). The TeleSleep EWI resulted in a significant increase in rural veterans accessing sleep care by utilizing home sleep apnea testing to establish a diagnosis of obstructive sleep apnea and virtual care for follow-up. Rates of virtual care utilization were greater in hubs and spokes participating in the TeleSleep EWI compared with non-EWI sleep programs. Additionally, veterans expressed satisfaction with their virtual care TeleSleep experiences. CONCLUSIONS: The TeleSleep EWI successfully increased sleep care access for rural veterans, promoted adoption of virtual care services, and resulted in high patient satisfaction. CITATION: Chun VS, Whooley MA, Williams K, et al. Veterans Health Administration TeleSleep Enterprise-Wide Initiative 2017-2020: bringing sleep care to our nation's veterans. J Clin Sleep Med. 2023;19(5):913-923.

Evaluating the implementation of robotic thoracic surgery on a Veterans Administration Hospital.

Robotic thoracic surgery has demonstrated benefits. We aimed to evaluate implementation of a robotic thoracic surgery program on postoperative outcomes at our Veteran's Administration Medical Center (VAMC). We retrospectively reviewed our VAMC database from 2015 to 2021. Patients who underwent surgery with intention to treat lung nodules were included. Primary outcome was patient length of stay (LOS). Patients were grouped by surgical approach and stratified to before and after adoption of robotic surgery. Univariate comparison of postoperative outcomes was performed using Wilcoxon rank sums and chi-squared tests. Multivariate regression was performed to control for ASA class. P values < 0.05 were considered significant. Outcomes of 108 patients were assessed. 63 operations (58%) occurred before and 45 (42%) after robotic surgery implementation. There were no differences in patient preoperative characteristics. More patients underwent minimally invasive surgery (MIS) in the post-implementation era than pre-implementation (85% vs. 42%, p < 0.001). Robotic operations comprised 53% of operations post-implementation. On univariate analysis, patients in the post-implementation era had a shorter LOS vs. pre-implementation, regardless of surgical approach (mean 4.7 vs. 6.0 days, p = 0.04). On multivariate analysis, patients who underwent MIS had a shorter LOS [median 4 days (IQR 2-6 days) vs. 7 days (6-9 days), p < 0.001] and were more likely to be discharged home than to inpatient facilities [OR (95% CI) 13.00 (1.61-104.70), p = 0.02]. Robotic thoracic surgery program implementation at a VAMC decreased patient LOS and increased the likelihood of discharging home. Implementation at other VAMCs may be associated with improvement in some patient outcomes.

Heterogeneous Longitudinal Antibody Responses to Covid-19 mRNA Vaccination.

BACKGROUND: Public health measures to stem the coronavirus disease 2019 (COVID-19) pandemic are challenged by social, economic, health status, and cultural disparities that facilitate disease transmission and amplify its severity. Prior pre-clinical biomedical technologic advances in nucleic acid-based vaccination enabled unprecedented speed of conceptualization, development, production, and widespread distribution of mRNA vaccines that target SARS-CoV-2's Spike (S) protein. DESIGN: Twenty-five female and male volunteer fulltime employees at the Providence VA Medical Center participated in this study to examine longitudinal antibody responses to the Moderna mRNA-1273 vaccine. IgM-S and IgG-S were measured in serum using the Abbott IgM-S-Qualitative and IgG2-S-Quantitative chemiluminescent assays. RESULTS: Peak IgM responses after Vaccine Dose #1 were delayed in 6 (24%) and absent in 7 (28%) participants. IgG2-S peak responses primarily occurred 40 to 44 days after Vaccine Dose #1, which was also 11 to 14 days after Vaccine Dose #2. However, subgroups exhibited Strong (n = 6; 24%), Normal (n = 13; 52%), or Weak (n = 6; 24%) peak level responses that differed significantly from each other (P < .005 or better). The post-peak IgG2-S levels declined progressively, and within 6 months reached the mean level measured 1 month after Vaccine Dose #1. Weak responders exhibited persistently low levels of IgG2-S. Variability in vaccine responsiveness was unrelated to age or gender. CONCLUSION: Host responses to SARS-CoV-2-Spike mRNA vaccines vary in magnitude, duration and occurrence. This study raises concern about the lack of vaccine protection in as many as 8% of otherwise normal people, and the need for open dialog about future re-boosting requirements to ensure long-lasting immunity via mRNA vaccination versus natural infection.

Changes in alcohol use during the COVID-19 pandemic among American veterans.

BACKGROUND: The COVID-19 pandemic has had considerable behavioral health implications globally. One subgroup that may be of particular concern is U.S. veterans, who are susceptible to mental health and substance use concerns. The current study aimed to investigate changes in alcohol use and binge drinking before and during the first year of the pandemic among U.S. veterans, and how pre-pandemic mental health disorders, namely posttraumatic stress disorder (PTSD), and COVID-19-related factors like loneliness, negative reactions to COVID-19, and economic hardship influenced alcohol use trends. METHODS: 1230 veterans were recruited in February 2020 as part of a larger survey study on veteran health behaviors. Veterans were asked to complete follow-up assessments throughout the pandemic at 6, 9, and 12- months. RESULTS: Overall, veterans reported a significant decrease in alcohol use (IRR = 0.98) and binge drinking (IRR = 0.11) However, women, racial/ethnic minority veterans, and those with pre-existing PTSD exhibited smaller decreases in alcohol use and binge drinking and overall higher rates of use compared to men, White veterans, and those without PTSD. Both economic hardship and negative reactions to COVID-19 were associated with greater alcohol and binge drinking whereas loneliness showed a negative association with alcohol use and binge drinking. CONCLUSIONS: Veterans reported decreases in alcohol use and binge drinking throughout the pandemic, with heterogeneity in these outcomes noted for higher risk groups. Special research and clinical attention should be given to the behavioral health care needs of veterans in the post-pandemic period.

A Chaplain's Comprehensive Spiritual Assessment And Military Mission.

Commanders expect their Chaplains to care for their Soldiers and their Families. Given the number of Soldiers and their Families, this responsibility can be daunting. Between 2007 and 2012, a comprehensive spiritual assessment was developed and used within the 98th Training Division, which was able to identify issues before they became debilitating problems. Approved by the Commanding Generals, this spiritual assessment was essential for Chaplains to find the Soldiers and their Families who needed care.

Surgical Timing for Carpal Tunnel Syndrome: A Comparison of Health Care Delivery in the Veterans Administration and Private Sector.

PURPOSE: The U.S. Department of Veterans Affairs (VA) health care system monitors time from referral to specialist visit. We compared wait times for carpal tunnel release (CTR) at a VA hospital and its academic affiliate. METHODS: We selected patients who underwent CTR at a VA hospital and its academic affiliate (AA) (2010-2015). We analyzed time from primary care physician (PCP) referral to CTR, which was subdivided into PCP referral to surgical consultation and surgical consultation to CTR. Electrodiagnostic testing (EDS) was categorized in relation to surgical consultation (prereferral vs postreferral). Multivariable Cox proportional hazard models were used to examine associations between clinical variables and surgical location. RESULTS: Between 2010 and 2015, VA patients had a shorter median time from PCP referral to CTR (VA: 168 days; AA: 410 days), shorter time from PCP referral to surgical consultation (VA: 43 days; AA: 191 days), but longer time from surgical consultation to CTR (VA: 98 days; AA: 55 days). Using multivariable models, the VA was associated with a 35% shorter time to CTR (AA hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.52-0.82) and 75% shorter time to surgical consultation (AA HR, 0.25; 95% CI, 0.20-0.03). Receiving both prereferral and postreferral EDS was associated with almost a 2-fold prolonged time to CTR (AA HR, 0.49; 95% CI, 0.36-0.67). CONCLUSIONS: The VA was associated with shorter overall time to CTR compared with its AA. However, the VA policy of prioritizing time from referral to surgical consultation may not optimally incentivize time to surgery. Repeat EDS was associated with longer wait times in both systems. CLINICAL RELEVANCE: Given differences in where delays occur in each health care system, initiatives to improve efficiency will require targeting the appropriate sources of preoperative delay. Judicious use of EDS may be one avenue to decrease wait times in both systems.

Virtual Care in the Veterans Affairs Spinal Cord Injuries and Disorders System of Care During the COVID-19 National Public Health Emergency.

Telehealth reduces disparities that result from physical disabilities, difficulties with transportation, geographic barriers, and scarcity of specialists, which are commonly experienced by individuals with spinal cord injuries and disorders (SCI/D). The Department of Veterans Affairs (VA) has been an international leader in the use of virtual health. The VA's SCI/D System of Care is the nation's largest coordinated system of lifelong care for people with SCI/D and has implemented the use of telehealth to ensure that Veterans with SCI/D have convenient access to their health care, particularly during the restrictions that were imposed by the COVID-19 pandemic.

Implementation of low-dose CT screening in two different health care systems: Mount Sinai Healthcare System and Phoenix VA Health Care System.

Implementation of lung screening (LS) programs is challenging even among health care organizations that have the motivation, the resources, and more importantly, the goal of providing for life-saving early detection, diagnosis, and treatment of lung cancer. We provide a case study of LS implementation in different healthcare systems, at the Mount Sinai Healthcare System (MSHS) in New York City, and at the Phoenix Veterans Affairs Health Care System (PVAHCS) in Phoenix, Arizona. This will illustrate the commonalities and differences of the LS implementation process in two very different health care systems in very different parts of the United States. Underlying the successful implementation of these LS programs was the use of a comprehensive management system, the Early Lung Cancer Action Program (ELCAP) Management SystemTM. The collaboration between MSHS and PVAHCS over the past decade led to the ELCAP Management SystemTM being gifted by the Early Diagnosis and Treatment Research Foundation to the PVAHCS, to develop a "VA-ELCAP" version. While there remain challenges and opportunities to continue improving LS and its implementation, there is an increasing realization that most patients who are diagnosed with lung cancer as a result of annual LS can be cured, and that of all the possible risks associated with LS, the greater risk of all is for heavy cigarette smokers not to be screened. We identified 10 critical components in implementing a LS program. We provided the details of each of these components for the two healthcare systems. Most importantly, is that continual re-evaluation of the screening program is needed based on the ongoing quality assurance program and database of the actual screenings. At minimum, there should be an annual review and updating. As early diagnosis of lung cancer must be followed by optimal treatment to be effective, treatment advances for small, early lung cancers diagnosed as a result of screening also need to be assessed and incorporated into the entire screening and treatment program.

Sustained Improvements in Markers of Liver Disease Severity After Hepatitis C Treatment.

BACKGROUND & AIMS: Although serological markers of disease severity improve after hepatitis C virus (HCV) treatment, it is unclear if all patients experience sustained improvement. We aim to evaluate longitudinal changes in aspartate (AST), alanine (ALT) aminotransferase, platelet count (PLT), and fibrosis-4 (FIB-4) after HCV treatment. METHODS: All adult chronic HCV patients who received antiviral therapy from January 2011 to February 2017 at four large urban hospital systems were evaluated to assess changes in AST, ALT, PLT, and FIB-4 from pre-treatment to post-treatment annually up to 4 years after HCV therapy. Comparisons used Student's t-test and analysis of variance, and were stratified by sex, race, ethnicity, age, body mass index (BMI), and diabetes mellitus. RESULTS: Among 2691 patients (62.2% men, 76.9% aged 45-65 years, 56.5% white), all markers of disease severity demonstrated sustained improvements from pre-treatment to 4 years post-treatment (AST 53 U/L to 27.5 U/L, ALT 53 U/L to 29 U/L, PLT 168 × 103 to 176 × 103, FIB-4 2.51 to 1.68). However, Hispanics and patients with BMI >30 kg/m2 experienced rebound increases in AST, ALT, and FIB-4 at 4 years post-treatment after experiencing initial improvements in these serological markers in the first-year post-treatment. Sustained improvements in PLT were observed in all groups, including Hispanics and patients with BMI >30 kg/m2. CONCLUSION: HCV treatment in a large community-based cohort demonstrated sustained improvements in AST, ALT, PLT, and FIB-4. Rebound increases in AST, ALT, and FIB-4 observed in Hispanics and those with BMI >30 kg/m2 may reflect persisting nonalcoholic fatty liver disease.

Impact of opioid dose escalation on the development of substance use disorders, accidents, self-inflicted injuries, opioid overdoses and alcohol and non-opioid drug-related overdoses: a retrospective cohort study.

AIM: To understand the potential harmful effects of dose escalation among patients with chronic, non-cancer pain (CNCP) on chronic opioid therapy. DESIGN: Retrospective cohort study. SETTING: United States Veterans Healthcare Administration. PARTICIPANTS: Veterans with CNCP and on chronic opioid therapy were identified using data from fiscal years 2008-15. The Veteran sample was approximately 90% male and 70% white. MEASUREMENTS: Dose escalators [increase of > 20% average morphine milligram equivalent (MME) daily dose] were compared with dose maintainers (change of ±20% average MME daily dose). A composite measure of subsequent substance use disorders (SUDs: opioid, non-opioid and alcohol use disorders) and opioid-related adverse outcomes (AOs: accidents resulting in wounds/injuries, opioid-related and alcohol and non-opioid medication-related accidents and overdoses, self-inflicted injuries) as well as the individual SUDs and AOs was examined. The primary analyses were conducted among a 1 : 1 matched sample of escalators and maintainers matched on propensity score and index date. Propensity scores were generated using demographic characteristics, medical comorbidities, medication and health-care utilization characteristics. Subgroup analyses were conducted by quartile of the propensity score. Sensitivity analyses were conducted using adjusted logistic regression, logistic regression using stabilized inverse probability of treatment weighting (SIPTW) and instrumental variable (IV) models using geographic variation in opioid dose escalation as the IV. FINDINGS: There were 32 420 maintainers and 20 767 escalators resulting in 19 358 (93.2%) matched pairs. Composite AOs [odds ratio (OR) = 1.31, 95% confidence interval (CI) = 1.23, 1.40], composite SUDs (OR = 1.31, 95% CI = 1.22, 1.41) and individual SUD and AO subtypes were higher among dose escalators, except for opioid-related accidents and overdoses and violence-related injuries. Subgroup analyses within the propensity score quartiles found similar results. Sensitivity analyses with the adjusted and SIPTW logistic regressions found similar results to the primary analyses for all outcomes except for opioid-related accidents and overdoses, which were found to be significantly higher among escalators. Sensitivity analyses with IV models provided mixed results with SUDs and the individual types of AOs. CONCLUSION: Escalating the opioid dose for those with chronic, non-cancer pain is associated with increased risks of substance use disorder and opioid-related adverse outcomes.

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

BACKGROUND: Cannabis is increasingly available and used for medical and recreational purposes, but few studies have assessed provider knowledge, attitudes, and practice regarding cannabis. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Reporting of adverse drug events in the Veterans Health Administration for patients whose treatment with empagliflozin or apixaban was discontinued.

PURPOSE: To examine the reporting rates of adverse drug events (ADEs) with apixaban and empagliflozin as reports move up to the next level of spontaneous reporting. METHODS: This was a retrospective cohort study of outpatients who discontinued apixaban or empagliflozin within 3 years of Food and Drug Administration (FDA) approval. We enriched the sample using an active surveillance strategy to identify subsets of patients with International Classification of Diseases (ICD) codes possibly associated with an ADE. Stratified random samples of charts were reviewed to determine if patients discontinued the medication due to an ADE. If so, we ascertained whether these were uploaded into the Veterans Administration (VA) electronic health record reporting system (Adverse Reaction Tracking System [ARTS]), VA national Web-based system (VA Adverse Drug Event Reporting System [VA ADERS]), and FDA MedWatch. RESULTS: From the cohort of 2,973 patients who discontinued apixaban, 321 patients (10.8%) were randomly sampled for chart review (including 61 patients with relevant ICD codes). During chart review, 88 ADEs were identified, with 40/61 (65.6%) from the subset with ICD codes. Of the total of 88 ADEs, 18.2%, 10.2%, and 6.8% were reported in ARTS, VA ADERS, and MedWatch, respectively. Of the 1,555 patients who discontinued empagliflozin, 179 patients (11.5%) were randomly sampled for chart review (40 patients with relevant ICD codes). During chart review, 78 ADEs were identified, with 19/40 (47.5%) from the subset with ICD codes. Of the 78 ADEs, 28.2%, 19.2%, and 7.7% were reported in ARTS, VA ADERS, and MedWatch, respectively. CONCLUSION: We found substantial underreporting of apixaban and empagliflozin ADEs that became worse at each higher level of spontaneous reporting.

A novel approach to assess real-world efficacy of cancer therapy in metastatic prostate cancer. Analysis of national data on Veterans treated with abiraterone and enzalutamide.

BACKGROUND: With 1.3 million new cases in 2018 worldwide, prostate cancer remains a challenge. Development of novel therapies targeting the androgen pathway followed recognition of the continued importance of androgens in castrate-resistant prostate cancer. To assess abiraterone and enzalutamide efficacy we analyzed data from US Veterans Administration Medical Centers (VAMCs). METHODS: We used a novel method independent of assessment intervals and ideal for real-world analysis to estimate rates of tumor growth (g) and regression (d). FINDINGS: Using the VA Informatics and Computing Infrastructure, we collected data from 5,116 Veterans with castrate-resistant prostate cancer prescribed abiraterone, enzalutamide or both. We estimated values for g and d and demonstrated a correlation of g with overall survival (P < .0001). Abiraterone and enzalutamide slowed growth rates across age groups and across the entire VAMC system, although less so in Veterans previously treated with a taxane and those with Gleason grade group 5 tumors. Abiraterone and enzalutamide efficacy in first-line were comparable although abiraterone in first-line slowed growth rates significantly more in African Americans than in Caucasians; enzalutamide was a better salvage therapy. When abiraterone was first-line and g was low, switching to enzalutamide was associated with a faster g in 67%. INTERPRETATION: In the real-world g can be estimated using a novel analysis method indifferent to assessment intervals that correlates highly with OS. While we show excellent real-world outcomes with abiraterone and enzalutamide, 2 effective and tolerable therapies, our results in VAMCs suggest enzalutamide should follow abiraterone. Changing therapies may be detrimental and consideration should be given to continue monitoring of growth rates over time. Funding Support from the Prostate Cancer Foundation and the Blavatnik Family Foundation.

Reflections on and future of hematologic malignancies research in the Veterans Health Administration.

Research in the Veterans Health Administration (VHA) has played an integral part in learning about cancer biology and treatment. Here we provide examples of past research performed in the VHA focusing on hematologic malignancies, and identify future opportunities for areas of research in this group of uncommon diseases that have specific importance for Veterans and the VHA. Veterans treated in the VHA and in the private sector deserve information that is focused on them, and is not an extrapolation from the larger population. Only by building upon and expanding existing research within the VHA can Veteran-specific results be collected and best practices be developed. In turn, such advances will benefit Veterans affected by these cancers with an improved quality of life and a longer lifespan.

Measuring coordination of epilepsy care: A mixed methods evaluation of social network analysis versus relational coordination.

OBJECTIVES: Coordination of multidisciplinary care is critical to address the complex needs of people with neurological disorders; however, quality improvement and research tools to measure coordination of neurological care are not well-developed. This study explored and compared the value of social network analysis (SNA) and relational coordination (RC) in measuring coordination of care in a neurology setting. The Department of Veterans Affairs Healthcare System (VA) established an Epilepsy Centers of Excellence (ECOE) hub and spoke model of care, which provides a setting to measure coordination of care across networks of providers. METHODS: In a parallel mixed methods approach, we compared coordination of care of VA providers who formally engage the ECOE system to VA providers outside the ECOE system using SNA and RC. Coordination of care scores were compiled from provider teams across 66 VA facilities, and key informant interviews of 80 epilepsy care team members were conducted concurrently to describe the quality of epilepsy care coordinating in the VA healthcare system. RESULTS: On average, members of healthcare teams affiliated with the ECOE program rated quality of communication and respect higher than non-ECOE physicians. Connectivity between neurologist and primary care providers as well as between neurologists and mental health providers were higher within ECOE hub facilities compared to spoke referring facilities. Key informant interviews reported the important role of formal and informal programming, social support and social capital, and social influence on epilepsy care networks. CONCLUSION: For quality improvement and research purposes, SNA and RC can be used to measure coordination of neurological care; RC provides a detailed assessment of the quality of communication within and across healthcare teams but is difficult to administer and analyze; SNA provides large scale coordination of care maps and metrics to compare across large healthcare systems. The two measures provide complimentary coordination of care data at a local as well as population level. Interviews describe the mechanisms of developing and sustaining health professional networks that are not captured in either SNA or RC measures.