Adapting an Alcohol Care Linkage Intervention to US Military Veterans Presenting to Primary Care with Hazardous Drinking and PTSD and/or Depression Symptoms: A Qualitative Study.

There is a critical need to improve linkage to alcohol care for veterans in primary care with hazardous drinking and PTSD and/or depression symptoms (A-MH). We adapted an alcohol care linkage intervention, "Connect to Care" (C2C), for this population. We conducted separate focus groups with veterans with A-MH, providers, and policy leaders. Feedback centered on how psychologists and other providers can optimally inform veterans about their care options and alcohol use, and how to ensure C2C is accessible. Participants reported that veterans with A-MH may not view alcohol use as their primary concern but rather as a symptom of a potential co-occurring mental health condition. Veterans have difficulty identifying and accessing existing alcohol care options within the Veterans Health Administration. C2C was modified to facilitate alcohol care linkage for this population specific to their locality, provide concrete support and education, and offer care options to preserve privacy.

Connect To Care (C2C): protocol for two-site randomized controlled pilot trial to improve outcomes for patients with hazardous drinking and PTSD and/or depression symptoms.

BACKGROUND: In studies of the general population and of military veterans, many primary care patients with hazardous drinking and PTSD and/or depression (abbreviated here as HD +) do not initiate or engage with alcohol-related care. To address this gap in care, we identified and will pilot test a promising evidence-based intervention, Connect To Care (C2C). C2C is a strengths-based approach, delivered by a Care Coach by telephone and/or video, with four components: (1) identifying and leveraging patient strengths to facilitate care initiation, (2) collaborative decision-making around a menu of care options, (3) identifying and resolving barriers to care, and (4) monitoring and facilitating progress toward care initiation by, for example, checking on barriers, identifying solutions, and revisiting care options. METHODS/DESIGN: Aim 1 will involve adapting C2C for use in Veterans Affairs' (VA) primary care. We will use an iterative process that includes focus groups and semi-structured interviews with key stakeholders (patients, primary care providers, and VA national policy leaders). In Aim 2, we will conduct a two-site, pilot randomized controlled trial to determine the feasibility of conducting a larger scale trial to test C2C's effectiveness, ascertain the acceptability of C2C among primary care patients with HD + , and explore the efficacy of C2C to improve veteran patients' initiation of and engagement in alcohol care, and their alcohol and mental health (PTSD, depression) outcomes, at 3-month follow-up. We will explore explanatory mechanisms by which C2C is effective. DISCUSSION: Study findings are likely to have implications for clinical practice to enhance current approaches to linking patients with HD + to alcohol care by applying a practical intervention such as C2C. The results may improve treatment outcomes for people with HD + by drawing on patients' strengths to problem-solve barriers to care following a process of shared decision-making with a coach. In addition to possibly accelerating the translation of C2C into practice, study findings will also support additional research in terms of a planned effectiveness-implementation hybrid trial, adding to this study's potential for high impact. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05023317.

A Randomized Clinical Trial of Clinician-Supported PTSD Coach in VA Primary Care Patients.

BACKGROUND: Posttraumatic stress disorder (PTSD) is common in primary care patients; however, evidence-based treatments are typically only available in specialty mental healthcare settings and often not accessed. OBJECTIVE: To test the effectiveness of a brief primary care-based treatment, Clinician-Supported PTSD Coach (CS PTSD Coach) was compared with Primary Care Mental Health Integration-Treatment as Usual (PCMHI-TAU) in (1) reducing PTSD severity, (2) engaging veterans in specialty mental health care, and (3) patient satisfaction with care. DESIGN: Multi-site randomized pragmatic clinical trial. PARTICIPANTS: A total of 234 veterans with PTSD symptoms who were not currently accessing PTSD treatment. INTERVENTION: CS PTSD Coach was designed to be implemented in Veterans Affairs PCMHI and combines mental health clinician support with the "PTSD Coach" mobile app. Four 30-min sessions encourage daily use of symptom management strategies. MAIN MEASURES: PTSD severity was measured by clinician-rated interviews pre- and post-treatment (8 weeks). Self-report measures assessed PTSD, depression, and quality of life at pretreatment, posttreatment, and 16- and 24-week follow-ups, and patient satisfaction at post-treatment. Mental healthcare utilization was extracted from medical records. KEY RESULTS: Clinician-rated PTSD severity did not differ by condition at post-treatment. CS PTSD Coach participants improved more on patient-reported PTSD severity at post-treatment than TAU participants (D = .28, p = .021). Coach participants who continued to have problematic PTSD symptoms at post-treatment were not more likely to engage in 2 sessions of specialty mental health treatment than TAU participants. Coach participants engaged in 74% more sessions in the intervention and reported higher treatment satisfaction than TAU participants (p < .001). CONCLUSIONS: A structured 4-session intervention designed to align with patient preferences for care resulted in more patient-reported PTSD symptom relief, greater utilization of mental health treatment, and overall treatment satisfaction than TAU, but not more clinician-rated PTSD symptom relief or engagement in specialty mental health.

Medical Record Documentation of Goals-of-Care Discussions Among Older Veterans With Incident Kidney Failure.

RATIONALE & OBJECTIVE: Elicitation and documentation of patient preferences is at the core of shared decision making and is particularly important among patients with high anticipated mortality. The extent to which older patients with incident kidney failure undertake such discussions with their providers is unknown and its characterization was the focus of this study. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: A random sample of veterans 67 years and older with incident kidney failure receiving care from the US Veterans Health Administration between 2005 and 2010. EXPOSURES: Demographic and facility characteristics, as well as predicted 6-month mortality risk after dialysis initiation and documentation of resuscitation preferences. OUTCOMES: Documented discussions of dialysis treatment and supportive care. ANALYTICAL APPROACH: We reviewed medical records over the 2 years before incident kidney failure and up to 1 year afterward to ascertain the frequency and timing of documented discussions about dialysis treatment, supportive care, and resuscitation. Logistic regression was used to identify factors associated with these documented discussions. RESULTS: The cohort of 821 veterans had a mean age of 80.9±7.2 years, and 37.2% had a predicted 6-month mortality risk>20% with dialysis. Documented discussions addressing dialysis treatment and resuscitation were present in 55.6% and 77.1% of patients, respectively. Those addressing supportive care were present in 32.4%. The frequency of documentation varied by mortality risk and whether the patient ultimately started dialysis. In adjusted analyses, the frequency and pattern of documentation were more strongly associated with geographic location and receipt of outpatient nephrology care than with patient demographic or clinical characteristics. LIMITATIONS: Documentation may not fully reflect the quality and content of discussions, and generalizability to nonveteran patients is limited. CONCLUSIONS: Among older veterans with incident kidney failure, discussions of dialysis treatment are decoupled from other aspects of advance care planning and are suboptimally documented, even among patients at high risk for mortality.

Receptivity to alcohol-related care among U.S. women Veterans with alcohol misuse.

Previous research indicates women Veterans have a potentially large, unmet need for alcohol-related care but are under-represented in treatment settings. The purpose of this study was to identify factors associated with women Veterans' receptivity to a recommendation for alcohol-related care when they present to Veterans Affairs (VA) primary care with alcohol misuse. Semi-structured interviews were conducted from 2012-2013 with 30 women Veterans at two VA facilities who screened positive for alcohol misuse during a primary care visit and discussed their alcohol use with their primary-care provider. Qualitative analyses identified 9 themes women used to describe what affected their receptivity to a recommendation for alcohol-related care (i.e., VA specialty substance use disorder services). The most common themes positively associated with women's receptivity included self-appraisal of their drinking behavior as more severe, the provider's presentation of treatment options, availability of gender-specific services, and worse physical and mental health. The themes identified here may have important implications for the clinical strategies providers can use to present alcohol-related care options to women Veterans to facilitate their use of care. These strategies include educating women about the health effects of alcohol misuse and increasing providers' knowledge about available care options (within the care organization or the community), including the availability of gender-specific services.

Care utilization and patient characteristics of veterans who misuse alcohol.

Substance abuse treatment utilization and patient characteristics of veterans (N = 167) drinking alcohol at risky levels at a Department of Veterans Affairs hospital were examined. Rates of brief intervention and specialty care were higher than those found in national samples in 2010, but fall short of recommended guidelines. Veterans receiving more care were older, lower-income, and less likely to be in a relationship. Care-receiving veterans had higher rates of mental health comorbidities and mental health treatment in the prior year for an issue other than substance use. Understanding patients' recent care history may help primary care providers to deliver care effectively.

Facility-level analysis of PET scanning for staging among US veterans with non-small cell lung cancer.

BACKGROUND: PET scanning has been shown in randomized trials to reduce the frequency of surgery without cure among patients with potentially resectable non-small cell lung cancer (NSCLC). We examined whether more frequent use of PET scanning at the facility level improves survival among patients with NSCLC in real-world practice. METHODS: In this prospective cohort study of 622 US veterans with newly diagnosed NSCLC, we compared groups defined by the frequency of PET scan use measured at the facility level and categorized as low (<25%), medium (25%-60%), or high (>60%). RESULTS: The median age of the sample was 69 years. Ninety-eight percent were men, 36% were Hispanic or nonwhite, and 54% had moderate or severe comorbidities. At low-, medium-, and high-use facilities, PET scan was performed in 13%, 40%, and 72% of patients, respectively (P<.0001). Baseline characteristics were similar across groups, including clinical stage based on CT scanning. More frequent use of PET scanning was associated with more frequent invasive staging (P<.001) and nonsignificant improvements in downstaging (P=.13) and surgery without cure (P=.12). After a median of 352 days of follow-up, 22% of the sample was still alive, including 22% at low- and medium-use facilities and 20% at high-use facilities. After adjustment and compared with patients at low-use facilities, the hazard of death was greater for patients at high-use facilities (adjusted hazard ratio [HR], 1.35; 95% CI, 1.05-1.74) but not different for patients at medium-use facilities (adjusted HR, 1.14; 95% CI, 0.88-1.46). CONCLUSIONS: In this study of veterans with NSCLC, markedly greater use of PET scanning at the facility level was associated with more frequent use of invasive staging and possible improvements in downstaging and surgery without cure, but greater use of PET scanning was not associated with better survival.

A randomized controlled trial of a web-delivered brief alcohol intervention in Veterans Affairs primary care.

OBJECTIVE: This study sought to examine whether a web-delivered brief alcohol intervention (BAI) is effective for reducing alcohol misuse in U.S. military veterans presenting to primary care. METHOD: Veterans (N = 167) screening positive for alcohol misuse during a routine primary care visit were randomized to receive a BAI plus treatment as usual (TAU) or TAU alone. An assessment of alcohol-related outcomes was conducted at baseline and 3 and 6 months after treatment. RESULTS: Veterans in both study conditions showed a significant reduction in alcohol quantity and frequency and alcohol-related problems at 6-month follow-up. No differential treatment effects on outcomes were observed between the two treatment groups. CONCLUSIONS: This study is the first to explore whether a web-delivered BAI using normative feedback is effective for veterans with alcohol misuse. Our findings suggest that BAIs using normative feedback may not have any additional benefit beyond TAU for older veterans with high rates of comorbid mental health concerns.

Do normative perceptions of drinking relate to alcohol use in U.S. Military veterans presenting to primary care?

OBJECTIVE: The current cross sectional study sought to examine whether perceived social normative beliefs are associated with indicators of alcohol use in a sample of alcohol misusing veterans. METHOD: A sample of 107 U.S. Military Veterans presenting to primary care that screened positive for alcohol misuse on the alcohol use disorders identification test-consumption items (AUDIT-C) was recruited. Assessment measures were used to examine social normative beliefs and alcohol-related concerns as they relate to indicators of alcohol use at baseline. RESULTS: Our findings indicate mixed support for our two hypotheses in that perceived descriptive norms were associated with alcohol use indicators in the predicted direction; however, this was not the case for alcohol-related concerns. For perceived norms, we found that higher quantity beliefs were significantly related to greater alcohol consumption on a drinking day (p<.01), increased likelihood of dependence (p<.01), and frequency beliefs were significantly related to total number of drinking days (p<.01). Findings for alcohol-related concerns emerged contrary to our hypothesis, with results depicting increased alcohol-related concerns associated with higher alcohol consumption across indicators of use (ps<.01). SUMMARY: Findings of the current study suggest that social normative beliefs, specifically misperceptions about descriptive norms, are significantly associated with alcohol consumption in a sample of alcohol misusing veterans presenting to primary care.

Sexual assault and substance use in male veterans receiving a brief alcohol intervention.

OBJECTIVE: Many studies have documented the link between substance use and a history of sexual assault in women; however, few studies have examined this relationship in men. The purpose of this study was to explore the rates of sexual assault in a sample of male veterans reporting alcohol misuse and to further explore potential differences in alcohol use patterns and alcohol-related characteristics in those with and without a history of sexual assault. We also explored the types of illicit drugs being used in the past 90 days and whether a clinical sample of male veterans reporting sexual assault are at greater odds of using these substances when compared with their peers with no history of sexual assault. METHOD: Data were collected on a nationwide sample (N = 880) of male veterans receiving care in Veterans Administration outpatient mental health clinics. RESULTS: We found that 9.5% of our sample reported a history of sexual assault, and those with this history reported increased alcohol consumption, a greater number of alcohol-related consequences, and an increased likelihood of using an illicit substance in the past 90 days. The most commonly used illicit substances were cannabis, cocaine, and opiates. Those with sexual assault histories were also more likely to report risk factors that may exacerbate the negative effects of any level of alcohol consumption. CONCLUSIONS: Our findings highlight the burden of alcohol and illicit drug use among male veterans and suggest that substance use disorder treatment settings may be a context in which prevalence of a history of sexual assault is high. Our findings further support prior call for universal screening for sexual assault among this population.

Disparities in lung cancer staging with positron emission tomography in the Cancer Care Outcomes Research and Surveillance (CanCORS) study.

INTRODUCTION: Disparities in treatment exist for nonwhite and Hispanic patients with non-small cell lung cancer, but little is known about disparities in the use of staging tests or their underlying causes. METHODS: Prospective, observational cohort study of 3638 patients with newly diagnosed non-small cell lung cancer from 4 large, geographically defined regions, 5 integrated health care systems, and 13 VA health care facilities. RESULTS: Median age was 69 years, 62% were men, 26% were Hispanic or nonwhite, 68% graduated high school, 50% had private insurance, and 41% received care in the VA or another integrated health care system. After adjustment, positron emission tomography (PET) use was 13% lower among nonwhites and Hispanics than non-Hispanic whites (risk ratio [RR] 0.87, 95% confidence interval [CI] 0.77-0.97), 13% lower among those with Medicare than those with private insurance (RR 0.87, 95% CI 0.76-0.99), and 24% lower among those with an elementary school education than those with a graduate degree (RR 0.76, 95% CI 0.57-0.98). Disparate use of PET was not observed among patients who received care in an integrated health care setting, but the association between race/ethnicity and PET use was similar in magnitude across all other subgroups. Further analysis showed that income, education, insurance, and health care setting do not explain the association between race/ethnicity and PET use. CONCLUSIONS: Hispanics and nonwhites with non-small cell lung cancer are less likely to receive PET imaging. This finding is consistent across subgroups and not explained by differences in income, education, or insurance coverage.

Timeliness of care in veterans with non-small cell lung cancer.

BACKGROUND: Timeliness is an important dimension of quality of care for patients with lung cancer. METHODS: We reviewed the records of consecutive patients in whom non-small cell lung cancer (NSCLC) had been diagnosed between January 1, 2002, and December 31, 2003, at the Veterans Affairs Palo Alto Health Care System. We used multivariable statistical methods to identify independent predictors of timely care and examined the effect of timeliness on survival. RESULTS: We identified 129 veterans with NSCLC (mean age, 67 years; 98% men; 83% white), most of whom had adenocarcinoma (51%) or squamous cell carcinoma (30%). A minority of patients (18%) presented with a solitary pulmonary nodule (SPN). The median time from the initial suspicion of cancer to treatment was 84 days (interquartile range, 38 to 153 days). Independent predictors of treatment within 84 days included hospitalization within 7 days (odds ratio [OR], 8.2; 95% confidence interval [CI], 2.9 to 23), tumor size of > 3.0 cm (OR, 4.8; 95% CI, 1.8 to 12.4), the presence of additional chest radiographic abnormalities (OR, 3.0; 95% CI, 1.1 to 8.5), and the presence of one or more symptoms suggesting metastasis (OR, 2.6; 95% CI, 1.1 to 6.2). More timely care was not associated with better survival time (adjusted hazard ratio, 1.6; 95% CI, 1.3 to 1.9). However, in patients with SPNs, there was a trend toward better survival time when the time to treatment was < 84 days. CONCLUSIONS: The time to treatment for patients with NSCLC was often longer than recommended. Patients with larger tumors, symptoms, and other chest radiographic abnormalities receive more timely care. In patients with malignant SPNs, survival may be better when treatment is initiated promptly.