Benchmark findings from a veteran electronic patient-reported outcomes evaluation from a chronic pain management telehealth program.

BACKGROUND: Chronic pain is a leading cause of disability and negatively impacts biological/physical, psychological, and social aspects of life resulting in significant pain interference or disability. This project was part of a longitudinal mixed-methods implementation evaluation of the TelePain-Empower Veterans Program (EVP), a non-pharmacological chronic pain intervention. The purpose of this quality management project was to examine electronic patient-reported outcome measures (ePROs) including primary pain-related (intensity, interference, catastrophizing, kinesiophobia) and secondary outcomes (physical, psychological, acceptance, social) to determine TelePain-EVP effectiveness. Secondary purpose was to examine dosing effects to better understand potential dose relationships between EVP use and ePROs. METHODS: Standardized ePRO measures were examined at week 1 (baseline), week 10 (post-EVP), and week 26 (follow-up). Qualtrics, a cloud-based platform was used to collect ePRO data at each time point. Veterans that completed at-least one survey at any specified time point were categorized as responders (n = 221). Linear-mixed models (LMMs) were fit to assess changes for each primary and secondary ePRO. RESULTS: Participants ranged from 24 to 81 years old; veterans were typically male (65.16%), black or African American (76.47%), married or partnered (41.63%), attended at-least some college or vocational school (67.87%), and reported low back as their primary pain location (29.41%). There was a significant decrease in pain catastrophizing from baseline to post-TelePain-EVP (p < .001). However, pain catastrophizing improvement from baseline was not present at week 26 (p = .116). Pain interference also decreased from baseline to post-treatment (p = .05), but this improvement did not exceed the adjusted significance threshold. Additional pre-post improvements were also observed for certain secondary ePROs: psychological (anxiety, depression), acceptance (activities engagement). Only the activities engagement effect remained 26 weeks from baseline. Mixed results were observed for EVP dose across primary and secondary outcomes. CONCLUSIONS: Evidence from this evaluation indicate that TelePain-EVP has positive outcomes for certain pain (catastrophizing), psychological (anxiety, depression), and acceptance (activities engagement) for veterans with chronic pain. More TelePain related studies and enterprise-wide evaluations are needed along with comparative and cost effectiveness methods to determine patient benefits and the economic value gained of treatment options such as TelePain-EVP.

Qualitative Evaluation Informs the Implementation of a Telehealth Program to Manage Chronic Pain.

In response to the opioid epidemic and high rates of chronic pain among the veteran population, the U.S. Department of Veterans Affairs implemented the TelePain-Empower Veterans Program (EVP), a nonpharmacological pain management program for veterans. Delivered virtually, TelePain-EVP incorporates integrated health components (Whole Health, Acceptance and Commitment Therapy, and Mindful Movement) through interdisciplinary personalized coaching. The objective of this quality improvement project was to evaluate the implementation of TelePain-EVP to identify determinants to implementation, benefits and challenges to participation, and recommendations for future direction. We used a qualitative descriptive design to conduct semistructured telephone interviews with TelePain-EVP leaders (n = 3), staff (n = 10), and veterans (n = 22). The interview guides aligned with the Consolidated Framework for Implementation Research (CFIR). Thematic content analysis organized and characterized findings. Several CFIR domains emerged as determinants relevant to program implementation, including innovation (eg, design); individuals (eg, deliverers, recipients); inner (eg, communications) and outer settings (eg, local conditions); and implementation process (eg, reflecting and evaluating). Identified determinants included facilitators (eg, virtual delivery) and barriers (eg, staff shortages). Participants reported improvements in pain management coping skills, interpersonal relationships, and sense of community, but no self-reported reductions in pain or medication use. Program improvement recommendations included using centralized staff to address vacancies, collecting electronic data, offering structured training, and providing course materials to veteran participants. Qualitative data can inform the sustained implementation of TelePain-EVP and other similar telehealth pain management programs. These descriptive data should be triangulated with quantitative data to objectively assess participant TelePain-EVP outcomes and associated participant characteristics. PERSPECTIVE: A qualitative evaluation of a telehealth program to manage chronic pain, guided by the CFIR framework, identified determinants of program implementation. Additionally, participants reported improvements in pain management coping skills, interpersonal relationships, and sense of community, but no self-reported reductions in pain or medication use.

Utilization of whole health services among veterans with spinal cord injuries and disorders (SCI/D): Early insights from the VA SCI/D system of care.

CONTEXT/OBJECTIVE: Our objective was to describe early participation in Whole Health programs across the Veterans Health Administration (VHA) Spinal Cord Injuries and Disorders (SCI/D) System of Care. DESIGN: Retrospective analysis of VHA administrative data. SETTING: The VHA SCI/D System of Care. PARTICIPANTS: Veterans with SCI/D included in the FY2019 cumulative VHA SCI/D Registry cohort with living status during FY2017, FY2018, and FY2019. INTERVENTIONS: N/A. OUTCOME MEASURES: We assessed the number of encounters and unique Veterans with SCI/D, and the percent of Veterans with SCI/D, who utilized each Whole Health (WH) program available in VA. RESULTS: Utilization of WH Pathway and well-being Programs increased from 62 encounters to 1703 encounters between FY2017 and FY2019 (representing 0.09% to 3.13% of Veterans with SCI/D). Utilization of chiropractic care rose from 130 encounters to 418 encounters during the same time period. Similarly, utilization of complementary and integrative health programs increased from 886 encounters to 2655 encounters (representing 1.09% to 3.11% of Veterans; FY2017 to 2019). We also report utilization of specific WH programs. CONCLUSION: Participation in WH services has been increasing among Veterans with SCI/D who receive health care from the VHA SCI/D System of Care. However, utilization among Veterans with SCI/D remains low overall, and targeted efforts to increase WH program reach are needed. Additional information about the relative effectiveness of different strategies to support WH implementation is also needed, to ensure strategies likely to have the most impact are prioritized.

VHA Whole Health Services and Complementary and Integrative Health Therapies: a Gateway to Evidence-Based Mental Health Treatment.

BACKGROUND: Engagement in evidence-based psychotherapy (EBP) among veterans with behavioral health conditions is often low. The Veterans Health Administration (VHA) is implementing a "Whole Health (WH)" system of care, to identify veteran personal health goals, align care with those goals, and offer services designed to engage and empower veterans to achieve well-being. OBJECTIVE: To examine the relationship between veteran WH utilization and subsequent engagement in EBP. DESIGN: Retrospective analysis of VHA administrative records from 18 facilities implementing WH. SUBJECTS: Veterans (n = 265,364) with a diagnosis of depression, post-traumatic stress disorder (PTSD), and/or anxiety who had a mental healthcare encounter but no EBP use in fiscal year (FY) 2018. Among this cohort, 33,146 (12.5%) began using WH in FY2019. MAIN MEASURES: We examined use of an EBP for depression, anxiety, and/or PTSD within 1 year of the index date of WH use compared to use of an EBP anytime during FY2019 for veterans not identified as using WH. We used multiple logistic regression to examine the association between veteran WH use and EBP engagement. KEY RESULTS: Approximately 3.0% (n = 7,860) of the veterans in our overall cohort engaged in an EBP in the year following their index date. Controlling for key demographic, health, and utilization variables, WH users had 2.4 (95% CI: 2.2-2.5) times higher odds of engaging in an EBP the following year than those with no WH utilization. Associations between utilization of specific WH services (vs. no utilization of that service) and engagement in an EBP in the subsequent year ranged from 1.6 (95% CI: 1.0-2.6) to 3.5 (95% CI: 3.2-3.9) across the different types of WH services used. CONCLUSIONS: WH use was associated with increased engagement in EBPs among veterans with depression, anxiety, and/or PTSD. Future interventions intended to promote veteran engagement in EBPs may benefit from leveraging WH services and therapies.

Empower Veterans Program (EVP): a chronic pain management program demonstrates positive outcomes among veterans.

BACKGROUND: Chronic pain is a highly prevalent health condition among veterans. Traditional pharmacological interventions present unique challenges for chronic pain management including prescription opioid addiction and overdose. In alignment with the 2016 Comprehensive Addiction and Recovery Act and VA's Stepped Care Model to meet veterans' pain management needs, the Offices of Rural Health and Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP) funded an enterprise-wide initiative to implement a Step 3 integrated tele-pain program: Empower Veterans Program (EVP). EVP provides veterans with chronic pain self-care skills using a whole health driven approach to pain management. OBJECTIVES: The Comprehensive Addiction and Recovery Act prompted the strategic approach to offer non-pharmacological options to meet veterans' pain management needs. EVP, a 10-week interdisciplinary group medical appointment, leverages Acceptance and Commitment Therapy, Mindful Movement, and Whole Health to provide veterans with chronic pain self-care skills. This evaluation was conducted to describe participant characteristics, graduation, and satisfaction rates; and assess pre-post patient-reported outcomes (PRO) associated with EVP participation. METHODS: A sample of 639 veterans enrolled in EVP between May, 2015 and December, 2017 provided data to conduct descriptive analyses to assess participant demographics, graduation, and satisfaction rates. PRO data were analyzed using a within-participants pre-post design, and linear mixed-effects models were used to examine pre-post changes in PRO. RESULTS: Of 639 participants, 444 (69.48%) graduated EVP. Participant median program satisfaction rating was 8.41 (Interquartile Range: 8.20-9.20). Results indicate pre-post EVP improvements (Bonferroni-adjusted p < .003) in the three primary pain outcomes (intensity, interference, catastrophizing), and 12 of 17 secondary outcomes, including physical, psychological, health-related quality of life (HRQoL), acceptance, and mindfulness measures. DISCUSSION: Data suggest that EVP has significant positive outcomes in pain, psychological, physical, HRQoL, acceptance, and mindfulness measures for veterans with chronic pain through non-pharmacological means. Future evaluations of intervention dosing effect and long-term effectiveness of the program is needed.

Effect of a Machine Learning Recommender System and Viral Peer Marketing Intervention on Smoking Cessation: A Randomized Clinical Trial.

Importance: Novel data science and marketing methods of smoking-cessation intervention have not been adequately evaluated. Objective: To compare machine learning recommender (ML recommender) computer tailoring of motivational text messages vs a standard motivational text-based intervention (standard messaging) and a viral peer-recruitment tool kit (viral tool kit) for recruiting friends and family vs no tool kit in a smoking-cessation intervention. Design, Setting, and Participants: This 2 ×2 factorial randomized clinical trial with partial allocation, conducted between July 2017 and September 2019 within an online tobacco intervention, recruited current smokers aged 18 years and older who spoke English from the US via the internet and peer referral. Data were analyzed from March through May 2022. Interventions: Participants registering for the online intervention were randomly assigned to the ML recommender or standard messaging groups followed by partially random allocation to access to viral tool kit or no viral tool kit groups. The ML recommender provided ongoing refinement of message selection based on user feedback and comparison with a growing database of other users, while the standard system selected messages based on participant baseline readiness to quit. Main Outcomes and Measures: Our primary outcome was self-reported 7-day point prevalence smoking cessation at 6 months. Results: Of 1487 participants who smoked (444 aged 19-34 years [29.9%], 508 aged 35-54 years [34.1%], 535 aged ≥55 years [36.0%]; 1101 [74.0%] females; 189 Black [12.7%] and 1101 White [78.5%]; 106 Hispanic [7.1%]), 741 individuals were randomly assigned to the ML recommender group and 746 individuals to the standard messaging group; viral tool kit access was provided to 745 participants, and 742 participants received no such access. There was no significant difference in 6-month smoking cessation between ML recommender (146 of 412 participants [35.4%] with outcome data) and standard messaging (156 of 389 participants [40.1%] with outcome data) groups (adjusted odds ratio, 0.81; 95% CI, 0.61-1.08). Smoking cessation was significantly higher in viral tool kit (177 of 395 participants [44.8%] with outcome data) vs no viral tool kit (125 of 406 participants [30.8%] with outcome data) groups (adjusted odds ratio, 1.48; 95% CI, 1.11-1.98). Conclusions and Relevance: In this study, machine learning-based selection did not improve performance compared with standard message selection, while viral marketing did improve cessation outcomes. These results suggest that in addition to increasing dissemination, viral recruitment may have important implications for improving effectiveness of smoking-cessation interventions. Trial Registration: ClinicalTrials.gov Identifier: NCT03224520.

Dual utilization of Medicare and VA outpatient care among Veterans with spinal cord injuries and disorders.

OBJECTIVE: Veterans with spinal cord injuries and disorders (SCI/D) utilizing Veterans Affairs healthcare facilities are also Medicare eligible. Use of multiple health care systems potentially duplicates or fragments care in this population; yet little is known about those using multiple systems. This study describes dual use of services paid for by VA and Medicare among Veterans with SCI/D. DESIGN: Retrospective, cross-sectional, observational study. PARTICIPANTS: Veterans with SCI/D (n = 13,902) who received healthcare services within the VA SCI System of Care and were eligible for or enrolled in Medicare in 2011. INTERVENTIONS: N/A. OUTCOME MEASURES: Patient characteristics, average number of visits and patient level frequencies of reasons for visits were determined for individuals within healthcare utilization (VA only, Medicare only, or dual VA/Medicare) groups. Multinomial logistic regression analyses were used to investigate associations of patient variables on dual use. RESULTS: 65.3% of Veterans with SCI/D were VA only users for outpatient encounters, 4.4% had encounters paid for by Medicare only, and 30.3% were dual users. Veterans were less likely to be VA only users if they were older than 69 and if they had been injured for greater than ten years. African American Veterans with SCI (compared to white) were more likely to be VA only users. CONCLUSION: A substantial number (∼30%) of Veterans with SCI/D are dual users. These numbers highlight the importance of improved strategies to coordinate care and increase health information sharing across systems.

Modernization of a Large Spinal Cord Injuries and Disorders Registry: The Veterans Administration Experience.

Since the 1990s, Veterans Health Administration (VHA) has maintained a registry of Veterans with Spinal Cord Injuries and Disorders (SCI/Ds) to guide clinical care, policy, and research. Historically, methods for collecting and recording data for the VHA SCI/D Registry (VSR) have required significant time, cost, and staffing to maintain, were susceptible to missing data, and caused delays in aggregation and reporting. Each subsequent data collection method was aimed at improving these issues over the last several decades. This paper describes the development and validation of a case-finding and data-capture algorithm that uses primary clinical data, including diagnoses and utilization across 9 million VHA electronic medical records, to create a comprehensive registry of living and deceased Veterans seen for SCI/D services since 2012. A multi-step process was used to develop and validate a computer algorithm to create a comprehensive registry of Veterans with SCI/D whose records are maintained in the enterprise wide VHA Corporate Data Warehouse. Chart reviews and validity checks were used to validate the accuracy of cases that were identified using the new algorithm. An initial cohort of 28,202 living and deceased Veterans with SCI/D who were enrolled in VHA care from 10/1/2012 through 9/30/2017 was validated. Tables, reports, and charts using VSR data were developed to provide operational tools to study, predict, and improve targeted management and care for Veterans with SCI/Ds. The modernized VSR includes data on diagnoses, qualifying fiscal year, recent utilization, demographics, injury, and impairment for 38,022 Veterans as of 11/2/2022. This establishes the VSR as one of the largest ongoing longitudinal SCI/D datasets in North America and provides operational reports for VHA population health management and evidence-based rehabilitation. The VSR also comprises one of the only registries for individuals with non-traumatic SCI/Ds and holds potential to advance research and treatment for multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), and other motor neuron disorders with spinal cord involvement. Selected trends in VSR data indicate possible differences in the future lifelong care needs of Veterans with SCI/Ds. Future collaborative research using the VSR offers opportunities to contribute to knowledge and improve health care for people living with SCI/Ds.

Factors Associated With Self-reported Use of Web and Mobile Health Apps Among US Military Veterans: Cross-sectional Survey.

BACKGROUND: Despite their prevalence and reported patient interest in their use, uptake of health-related apps is limited. The Veterans Health Administration (VHA) has developed a variety of apps to support veterans; however, uptake remains low nationally. OBJECTIVE: We examined the prevalence of VHA health-related app use and how veterans learned about these apps in order to identify factors associated with their use. METHODS: As part of a VHA quality improvement initiative, we recruited a national cohort of veterans to obtain feedback on their use of technology for health and collected data from them via a cross-sectional survey. The survey data were supplemented with VHA administrative data. We used descriptive statistics to examine demographic and health characteristics, health-related technology use, and how veterans learned about apps. We assessed factors associated with app use using bivariate analyses and multiple logistic regression models. RESULTS: We had complete data on 1259 veterans. A majority of the sample was male (1069/1259, 84.9%), aged older than 65 years (740/1259, 58.8%), White (1086/1259, 86.3%), and non-Hispanic (1218/1259, 96.7%). Most respondents (1125/1259, 89.4%) reported being very comfortable and confident using computers, over half (675/1259, 53.6%) reported being an early adopter of technology, and almost half (595/1259, 47.3%) reported having used a VHA health-related app. Just over one-third (435/1259, 34.6%) reported that their VHA care team members encouraged them to use health-related apps. Respondents reported learning about available VHA health-related apps by reading about them on the VHA's patient portal (468/1259, 37.2%), being told about them by their VHA health care team (316/1259, 25.1%), and reading about them on the VHA's website (139/1259, 11%). Veterans who self-reported having used VHA health-related apps were more likely to receive care at the VHA (OR [odds ratio] 1.3, 95% CI 1.0-1.7), be in worse health (as assessed by Hierarchical Condition Community score; OR 1.1, 95% CI 1.0-1.2), report owning a desktop or laptop computer (OR 1.8, 95% CI 1.1-3.1), have posttraumatic stress disorder (OR 1.4, 95% CI 1.1-1.9), and report having VHA health care team members encourage them to use the apps (OR 2.7, 95% CI 2.1-3.4). CONCLUSIONS: We found strong associations between self-reported use by veterans of VHA health-related apps and multiple variables in our survey. The strongest association was observed between a veteran self-reporting app use and having received encouragement from their VHA health care team to use the apps. Veterans who reported receiving encouragement from their VHA care team members had nearly 3 times higher odds of using VHA apps than veterans who did not report receiving such encouragement. Our results add to growing evidence suggesting that endorsement of apps by a health care system or health care team can positively impact patient uptake and use.

Comparative effectiveness of antibiotic therapy for carbapenem-resistant Enterobacterales (CRE) bloodstream infections in hospitalized US veterans.

Background: Carbapenem-resistant Enterobacterales bloodstream infections (CRE-BSI) increase mortality three-fold compared with carbapenem-susceptible bloodstream infections. Because these infections are rare, there is a paucity of information on mortality associated with different treatment regimens. This study examines treatment regimens and association with in-hospital, 30 day and 1 year mortality risk for patients with CRE-BSI. Methods: This retrospective cohort study identified hospitalized patients within the Veteran Affairs (VA) from 2013 to 2018 with a positive CRE blood culture and started antibiotic treatment within 5 days of culture. Primary outcomes were in-hospital, 30 day and 1 year all-cause mortality. Secondary outcomes were healthcare costs at 30 days and 1 year and Clostridioides difficile infection 6 weeks post culture date. The propensity for receiving each treatment regimen was determined. Multivariable regression assessed the association between treatment and outcomes. Results: There were 393 hospitalized patients from 2013 to 2018 included in the study. The cohort was male (97%) and elderly (mean age 71.0 years). Carbapenems were the most prescribed antibiotics (47%). In unadjusted analysis, ceftazidime/avibactam was associated with a lower likelihood of 30 day and 1 year mortality. After adjusting, ceftazidime/avibactam had a 30 day mortality OR of 0.42 (95% CI 0.17-1.02). No difference was found in C. difficile incidence at 6 weeks post-infection or total costs at 30 days or 1 year post culture date by any treatments. Conclusions: In hospitalized veterans with CRE-BSI, none of the treatments were shown to be associated with all-cause mortality. Ceftazidime/avibactam trended towards protectiveness against 30 day and 1 year all-cause mortality. Use of ceftazidime/avibactam should be encouraged for treatment of CRE-BSI.

Understanding Adoption and Preliminary Effectiveness of a Mobile App for Chronic Pain Management Among US Military Veterans: Pre-Post Mixed Methods Evaluation.

BACKGROUND: The Veterans Health Administration Pain Coach mobile health app was developed to support veterans with chronic pain. OBJECTIVE: Our objective was to evaluate early user experiences with the Pain Coach app and preliminary impacts of app use on pain-related outcomes. METHODS: Following a sequential, explanatory, mixed methods design, we mailed surveys to veterans at 2 time points with an outreach program in between and conducted semistructured interviews with a subsample of survey respondents. We analyzed survey data using descriptive statistics among veterans who completed both surveys and examined differences in key outcomes using paired samples t tests. We analyzed semistructured interview data using thematic analysis. RESULTS: Of 1507 veterans invited and eligible to complete the baseline survey, we received responses from 393 (26.1%). These veterans received our outreach program; 236 (236/393, 60.1%) completed follow-up surveys. We conducted interviews with 10 app users and 10 nonusers. Among survey respondents, 10.2% (24/236) used Pain Coach, and 58% (14/24) reported it was easy to use, though interviews identified various app usability issues. Veterans who used Pain Coach reported greater pain self-efficacy (mean 23.1 vs mean 16.6; P=.01) and lower pain interference (mean 34.6 vs mean 31.8; P=.03) after (vs before) use. The most frequent reason veterans reported for not using the app was that their health care team had not discussed it with them (96/212, 45.3%). CONCLUSIONS: Our findings suggest that future efforts to increase adoption of Pain Coach and other mobile apps among veterans should include health care team endorsement. Our findings regarding the impact of Pain Coach use on outcomes warrant further study.

Effect of the Affordable Care Act on healthcare utilization for Veterans with spinal cord injuries and disorders.

Context/Objective: Provisions of the Affordable Care Act (ACA) potentially increase insurance options for Veterans with disabilities. We examined Veterans with spinal cord injuries and disorders (SCI/D) to assess whether the ACA was associated with changes in healthcare utilization from Department of Veterans Affairs (VA) healthcare facilities.Design: Using national VA data, we investigated impacts on VA healthcare utilization pre- (2012/13) and post-ACA (2014/15) implementation with negative binomial regression models.Setting: VA healthcare facilities.Participants: 8,591 VA users with SCI/D. Veterans with acute myelitis, Guillain-Barré syndrome, multiple sclerosis, or amyotrophic lateral sclerosis were excluded as were patients who died during the study period.Interventions: We assessed VA healthcare utilization before and after ACA implementation.Outcome Measures: Total numbers of VA visits for SCI/D care, diagnostic care, primary care, specialty care, and mental health care, and VA admissions.Results: The number of VA admissions was 7% higher in the post than pre-ACA implementation period (P < 0.01). The number of VA visits post-implementation increased for SCI/D care (8%; P < 0.01) and specialty care (12%; P < 0.001). Conversely, the number of mental health visits was 17% lower in the post-ACA period (P < 0.001). Veterans with SCI/D who live <5 miles from their nearest VA facility received VA care more frequently than those ≥40 miles from VA (P < 0.001).Conclusion: Counter to expectations, results suggest that Veterans with SCI/D sought more frequent VA care after ACA implementation, indicating Veterans with SCI/D continue to utilize the lifelong, comprehensive care provided at VA.

Health Insurance Coverage Among Veterans Receiving Care From VA Health Care Facilities.

Reasons for acquiring insurance outside Department of Veterans Affairs (VA) health care coverage among VA enrollees are incompletely understood. To assess Veterans' decision-making and acquisition of non-VA health care insurance in the Affordable Care Act era, we used mailed questionnaires and semistructured interviews in a stratified random sample of VA enrollees <65 years in the Midwest. Of the 3,666 survey participants, 32.1% reported non-VA insurance. Frequently reported reasons included wanting coverage for emergency situations or family members. Those without non-VA insurance cited unaffordability as the main obstacle. Analysis of the semistructured interview data revealed similar findings. In multivariable logistic regression analyses, characteristics associated with non-VA insurance included higher income (>$50,000 vs. <$10,000, odds ratio [OR] = 5.95, 95% confidence interval [CI]: 3.45-10.3, p < .001). As financial barriers exist for acquisition of non-VA insurance and hence community care, it is critically important that VA enrollees' health care needs are met through VA or community providers financed through VA.

Evaluating the use of a recommender system for selecting optimal messages for smoking cessation: patterns and effects of user-system engagement.

BACKGROUND: Motivational messaging is a frequently used digital intervention to promote positive health behavior changes, including smoking cessation. Typically, motivational messaging systems have not actively sought feedback on each message, preventing a closer examination of the user-system engagement. This study assessed the granular user-system engagement around a recommender system (a new system that actively sought user feedback on each message to improve message selection) for promoting smoking cessation and the impact of engagement on cessation outcome. METHODS: We prospectively followed a cohort of current smokers enrolled to use the recommender system for 6 months. The system sent participants motivational messages to support smoking cessation every 3 days and used machine learning to incorporate user feedback (i.e., user's rating on the perceived influence of each message, collected on a 5-point Likert scale with 1 indicating strong disagreement and 5 indicating strong agreement on perceiving the influence on quitting smoking) to improve the selection of the following message. We assessed user-system engagement by various metrics, including user response rate (i.e., the percent of times a user rated the messages) and the perceived influence of messages. We compared retention rates across different levels of user-system engagement and assessed the association between engagement and the 7-day point prevalence abstinence (missing outcome = smoking) by using multiple logistic regression. RESULTS: We analyzed data from 731 participants (13% Black; 73% women). The user response rate was 0.24 (SD = 0.34) and user-perceived influence was 3.76 (SD = 0.84). The retention rate positively increased with the user response rate (trend test P < 0.001). Compared with non-response, six-month cessation increased with the levels of response rates: low response rate (odds ratio [OR] = 1.86, 95% confidence interval [CI]: 1.07-3.23), moderate response rate (OR = 2.30, 95% CI: 1.36-3.88), high response rate (OR = 2.69, 95% CI: 1.58-4.58). The association between perceived message influence and the outcome showed a similar pattern. CONCLUSIONS: High user-system engagement was positively associated with both high retention rate and smoking cessation, suggesting that investigation of methods to increase engagement may be crucial to increase the impact of the recommender system for smoking cessation. TRIAL REGISTRATION: Registration Identifier: NCT03224520 . Registration date: July 21, 2017.

Web-based patient portal use and medication overlap from VA and private-sector pharmacies among older veterans.

BACKGROUND: The availability of Medicare Part D pharmacy coverage may increase veterans' options for obtaining medications outside of the Department of Veterans Affairs (VA) pharmacies. However, availability of Part D coverage raises the potential that veterans may be receiving similar medications from VA and non-VA pharmacies. The VA's personal health record portal, My HealtheVet, allows veterans to self-enter the non-VA medications that they obtained from community-based pharmacies, including those reimbursed by Medicare Part D. The Blue Button medication view feature of My HealtheVet allows veterans to view and download their VA and self-entered non-VA medication history. OBJECTIVE: To examine whether the use by veterans of the Blue Button feature of My HealtheVet was associated with less acquisition of similar medications from VA and community-based pharmacies reimbursed by Medicare Part D. METHODS: This study included a national sample of veterans who were new My HealtheVet users during fiscal year 2013 (October 1, 2012-September 30, 2013) and who used the Blue Button medication view feature of My HealtheVet at least once (users). We compared these veterans with a random sample of veterans who were not registered to use My HealtheVet (nonusers). From these groups, we identified veterans who were enrolled in Part D. We used multiple logistic regression analysis to assess the association of Blue Button medication view use with obtaining medications from the same drug classes (with overlap of 7 or more days) from VA and Part D-reimbursed pharmacies. RESULTS: There were 7,973 My HealtheVet medication view users and 65,985 nonusers. During a 12-month period, medication view users received more 30-day supplies of medications (one 90-day supply equals three 30-day supplies) than nonusers, on average (152.1 vs 71.3, P < 0.001). A larger percentage of users than nonusers obtained medications from VA and Part D-reimbursed pharmacies with overlapping days supply from the same drug classes (30% vs 23%, P < 0.001). However, for veterans who obtained greater numbers of 30-day supplies (82 or more), a significantly smaller percentage of users than nonusers obtained overlapping medications from VA and Part D-reimbursed pharmacies. Moreover, controlling for the total number of 30-day supplies that veterans received, the odds of obtaining medications from VA and Part D-reimbursed pharmacies with days supply that overlapped by at least 7 days for the same drug classes was 18% lower for users than nonusers (P=0.002). CONCLUSIONS: Veterans who used the Blue Button medication view feature of My HealtheVet obtained a larger number of 30-day supplies of medications from VA pharmacies than nonusers. For veterans who obtained a larger number of 30-day supplies of medications, use of the Blue Button medication view feature of My HealtheVet was associated with less overlap in days supply of medication from the same drug class from VA and Part D-reimbursed pharmacies. DISCLOSURES: This study was funded by the Department of Veterans Affairs, Office of Research and Development, Health Services Research and Development Service project IIR 14-041-2. The sponsor provided funding but was not involved in the development of the manuscript. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the Health Services Research and Development Service. All authors are employed in some capacity with the Department of Veterans Affairs and have no conflicts of interest to disclose.

Health-Related Goal Setting and Achievement Among Veterans with High Technology Adoption.

BACKGROUND: There is increasing recognition of the importance of supporting patients in their health-related goals. Patient-provider discussions and health-related mobile applications (apps) can support patients to pursue health goals; however, their impact on patient goal setting and achievement is not well understood. OBJECTIVE: To examine the relationships between the following: (1) patient demographics, patient-provider discussions, and health-related goal setting and achievement, and (2) patient mobile health app use and goal achievement. DESIGN: Cross-sectional survey. PARTICIPANTS: Veterans who receive Veterans Health Administration (VA) healthcare and are users of VA patient-facing technology. MAIN MEASURES: Veteran demographics, goal-related behaviors, and goal achievement. METHODS: Veterans were invited to participate in a telephone survey. VA administrative data were linked to survey data for additional health and demographic information. Logistic regression models were run to identify factors that predict health-related goal setting and achievement. KEY RESULTS: Among respondents (n=2552), 75% of patients indicated having set health goals in the preceding 6 months and approximately 42% reported achieving their goal. Men (vs. women) had lower odds of setting goals (OR: 0.71; CI95: 0.53-0.97), as did individuals with worse (vs. better) health (OR: 0.18; CI95: 0.04-0.88). Individuals with advanced education-some college/college degrees, and post-college degrees (vs. no college education)-demonstrated higher odds of setting goals (OR: 1.35; CI95: 1.01-1.79; OR: 1.71; CI95: 1.28-2.28, respectively). Those who reported having discussed their goals with their providers were more likely to set goals (OR: 3.60; CI95: 2.97-4.35). Patient mobile health app use was not statistically associated with goal achievement. CONCLUSIONS: Efforts to further promote patient-led goal setting should leverage the influence of patient-provider conversations. Use of patient-facing technologies, specifically mobile health apps, may facilitate goal-oriented care, but further work is needed to examine the potential benefits of apps to support patient goals, particularly if providers discuss and endorse use of those apps with patients.

Comparing recruitment strategies for a digital smoking cessation intervention: Technology-assisted peer recruitment, social media, ResearchMatch, and smokefree.gov.

BACKGROUND: Choosing the right recruitment strategy has implications for the successful conduct of a trial. Our objective was to compare a novel peer recruitment strategy to four other recruitment strategies for a large randomized trial testing a digital tobacco intervention. METHODS: We compared enrollment rates, demographic and baseline smoking characteristics, and odds of completing the 6-month study by recruitment strategy. Cost of recruitment strategies per retained participant was calculated using staff personnel time and advertisement costs. FINDINGS: We enrolled 1487 participants between August 2017 and March 2019 from: Peer recruitment n = 273 (18.4%), Facebook Ads n = 505 (34%), Google Ads = 200 (13.4%), ResearchMatch n = 356 (23.9%) and Smokefree.govn = 153 (10.3%). Mean enrollment rate per active recruitment month: 1) Peer recruitment, n = 13.9, 2) Facebook ads, n = 25.3, 3) Google ads, n = 10.51, 4) Research Match, n = 59.3, and 5) Smokefree.gov, n = 13.9. Peer recruitment recruited the greatest number of males (n = 110, 40.3%), young adults (n = 41, 14.7%), participants with a high school degree or less (n = 24, 12.5%) and smokers within one's social network. Compared to peer recruitment (retention rate = 57%), participants from Facebook were less likely (OR 0.46, p < 0.01, retention rate = 40%), and those from ResearchMatch were more likely to complete the study (OR 1.90, p < 0.01, retention rate = 70%). Peer recruitment was moderate in cost per retained participant ($47.18) and substantially less costly than Facebook ($173.60). CONCLUSIONS: Though peer recruitment had lower enrollment than other strategies, it may provide greater access to harder to reach populations and possibly others who smoke within one's social network while being moderately cost-effective. ClinicalTrials.gov: NCT03224520.

Challenges, Facilitators, and Recommendations for Implementation of Home Dialysis in the Veterans Health Administration: Patient, Caregiver, and Clinician Perceptions.

Background: Home dialysis confers similar survival and greater quality of life than in-center hemodialysis for adults with ESKD but remains underutilized. We examined challenges and facilitators to implementation of home dialysis and identified stakeholder-centered strategies for improving it. Methods: We conducted a qualitative, cross-sectional, multisite evaluation that included five geographically dispersed Veterans Health Administration (VHA) home dialysis programs. Participants included patients with ESKD receiving home dialysis, their informal caregivers, and home dialysis staff. Semistructured telephone interviews were conducted and audio-recorded from 2017 through 2018, to assess perceived barriers and facilitators to patient home dialysis use in VHA. Transcribed interviews were analyzed thematically by each participant group. Results: Participants included 22 patients receiving home dialysis (18 on peritoneal dialysis [PD] and four hemodialysis [HD]); 20 informal caregivers, and 19 home dialysis program staff. Ten themes emerged as challenges to implementing home dialysis, of which six (60%) spanned all groups: need for sterility, burden of home dialysis tasks, lack of suitable home environment, physical side effects of home dialysis, negative psychosocial effects of home dialysis, and loss of freedom. Four themes (40%), identified only by staff, were insufficient self-efficacy, diminished peer socialization, geographic barriers, and challenging health status. Twelve themes emerged as facilitators to implementing home dialysis, of which seven (58%) spanned all groups: convenience, freedom, avoidance of in-center HD, preservation of autonomy, adequate support, favorable disposition, and perceptions of improved health. Two themes (17%) common among patients and staff were adequate training and resources, and physical and cognitive skills for home dialysis. Recommendations to promote implementation of home dialysis common to all participant groups entailed incorporating mental health care services, offering peer-to-peer coaching, increasing home visits, providing health data feedback, and reducing patient burden. Conclusions: Stakeholder-centered challenges were rigorously identified. Facilitators and recommendations can inform efforts to support home dialysis implementation.

Characterization of Telehealth Use in Veterans With Spinal Cord Injuries and Disorders.

BACKGROUND: Individuals with spinal cord injuries and disorders (SCI/D) require frequent interdisciplinary health care to address impairments in mobility, autonomic function, and secondary complications. Telehealth has the capacity to substantially transform health care delivery and improve care by increasing access and communication. However, relatively little is known about telehealth use in this specific population. Here we attempt to fill part of this gap. OBJECTIVE: To investigate the frequency and characteristics associated with telehealth use in Veterans with SCI/D. DESIGN: Cross-sectional, descriptive project. SETTING: Veterans Health Administration (VHA) facilities. PARTICIPANTS: A total of 15 028 Veterans living with SCI/D who received services from the VHA SCI/D System of Care. INTERVENTION: Not applicable. OUTCOME MEASURES: Frequency and characteristics associated with VHA telehealth utilization. RESULTS: Of the 15 028 Veterans with SCI/D included in the evaluation, 17% used some form of telehealth in VHA Fiscal Year (FY)2017. Veterans older than 65 years of age had lower odds (odds ratio [OR] = 0.88, P < .05, confidence interval [CI] 0.80-0.98) of using telehealth. Being Caucasian (OR = 1.29, P < .01, CI 1.09-1.52), living in rural areas (OR = 1.16, P < .01, CI 1.05-1.28), living greater distances away from the VHA (P < .01 for all distances), and being in priority group 8, meaning that Veterans have higher copayment requirements (OR = 1.46, P < .001, CI 1.19-1.81), were all significantly associated with greater odds of telehealth use. The most frequent types of telehealth used were real-time clinical video and store-and-forward between a provider and patient within the same hub network. CONCLUSION: There are opportunities to increase telehealth adoption in the SCI/D arena. The findings from this project highlight which Veterans are currently using telehealth services, as well as gaps regarding telehealth adoption in this population.

Supporting the Implementation of Connected Care Technologies in the Veterans Health Administration: Cross-Sectional Survey Findings from the Veterans Engagement with Technology Collaborative (VET-C) Cohort.

BACKGROUND: Widespread adoption, use, and integration of patient-facing technologies into the workflow of health care systems has been slow, thus limiting the realization of their potential. A growing body of work has focused on how best to promote adoption and use of these technologies and measure their impacts on processes of care and outcomes. This body of work currently suffers from limitations (eg, cross-sectional analyses, limited patient-generated data linked with clinical records) and would benefit from institutional infrastructure to enhance available data and integrate the voice of the patient into implementation and evaluation efforts. OBJECTIVE: The Veterans Health Administration (VHA) has launched an initiative called the Veterans Engagement with Technology Collaborative cohort to directly address these challenges. This paper reports the process by which the cohort was developed and describes the baseline data being collected from cohort members. The overarching goal of the Veterans Engagement with Technology Collaborative cohort is to directly engage veterans in the evaluation of new VHA patient-facing technologies and in so doing, to create new infrastructure to support related quality improvement and evaluation activities. METHODS: Inclusion criteria for veterans to be eligible for membership in the cohort included being an active user of VHA health care services, having a mobile phone, and being an established user of existing VHA patient-facing technologies as represented by use of the secure messaging feature of VHA's patient portal. Between 2017 and 2018, we recruited veterans who met these criteria and administered a survey to them over the telephone. RESULTS: The majority of participants (N=2727) were male (2268/2727, 83.2%), White (2226/2727, 81.6%), living in their own apartment or house (2519/2696, 93.4%), and had completed some college (1176/2701, 43.5%) or an advanced degree (1178/2701, 43.6%). Cohort members were 59.9 years old, on average. The majority self-reported their health status as being good (1055/2725, 38.7%) or very good (524/2725, 19.2%). Most cohort members owned a personal computer (2609/2725, 95.7%), tablet computer (1616/2716, 59.5%), and/or smartphone (2438/2722, 89.6%). CONCLUSIONS: The Veterans Engagement with Technology Collaborative cohort is an example of a VHA learning health care system initiative designed to support the data-driven implementation of patient-facing technologies into practice and measurement of their impacts. With this initiative, VHA is building capacity for future, rapid, rigorous evaluation and quality improvement efforts to enhance understanding of the adoption, use, and impact of patient-facing technologies.