Predictors of Incident Stroke and Subsequent Mortality Among a Sample of Veterans with Experience of Housing Instability.

Homelessness is associated with poor health outcomes and early development of cardiovascular disease. This study investigated the correlates of incident stroke and its association with mortality among Veterans experiencing housing instability. Using a national sample of Veterans (n=565,608) with incident housing instability between 2014-2018, we compared characteristics of Veterans who did and did not experience incident stroke and conducted logistic regressions to assess two outcomes: incident stroke and mortality. Almost four percent experienced a first stroke and were more frequently male, older than 55 years, Black, and non-Hispanic. A higher rate of mortality was observed among those with a first stroke compared with those with no stroke (17.6% vs. 10.8%), although the difference was not statistically significant. Incident stroke was associated with triple the odds of death among unstably-housed Veterans compared with those who did not have an incident stroke. Implications include the need to screen and monitor for stroke risk among Veterans with experience of housing instability, particularly for those who are older.

Association between Services to Address Adverse Social Determinants of Health and Suicide Mortality among Veterans with Indicators of Housing Instability, Unemployment, and Justice Involvement.

Suicide among Veterans continues to be a priority issue addressed by the U.S. Department of Veterans Affairs (VA). In addition to a variety of services specifically intended to prevent suicide, VA also offers a number of services to address Veterans' social determinants of health (SDH), several of which may be associated with elevated risk for suicide. For the present study, we assessed whether participation in services to address adverse SDH is associated with a reduction in risk of suicide mortality among Veterans using secondary data from VA datasets (1/1/2014-12/31/2019) for Veterans with an indicator of housing instability, unemployment, or justice involvement. Logistic regressions modeled suicide mortality; use of services to address SDH was the primary predictor. There was not a statistically significant association between services use and suicide mortality; significant correlates included race other than African American, low or no compensation related to disability incurred during military service, and suicidal ideation/attempt during observation period. Suicide is a complex outcome, difficult to predict, and likely the result of many factors; while there is not a consistent association between services use related to adverse SDH and suicide mortality, providers should intervene with Veterans who do not engage in SDH-focused services but have risk factors for suicide mortality.

Insights for Conducting Large-Scale Surveys with Veterans Who Have Experienced Homelessness.

Surveys of underserved patient populations are needed to guide quality improvement efforts but are challenging to implement. The goal of this study was to describe recruitment and response to a national survey of Veterans with homeless experience (VHE). We randomly selected 14,340 potential participants from 26 U.S. Department of Veterans Affairs (VA) facilities. A survey contract organization verified/updated addresses from VA administrative data with a commercial address database, then attempted to recruit VHE through 4 mailings, telephone follow-up, and a $10 incentive. We used mixed-effects logistic regressions to test for differences in survey response by patient characteristics. The response rate was 40.2% (n=5,766). Addresses from VA data elicited a higher response rate than addresses from commercial sources (46.9% vs 31.2%, p<.001). Residential addresses elicited a higher response rate than business addresses (43.8% vs 26.2%, p<.001). Compared to non-respondents, respondents were older, less likely to have mental health, drug, or alcohol conditions, and had fewer VA housing and emergency service visits. Collectively, our results indicated a national mailed survey approach is feasible and successful for reaching VA patients who have recently experienced homelessness. These findings offer insight into how health systems can obtain perspectives of socially disadvantaged groups.

Change in Homeless and Health Services Use Following Migration Among Veterans with Experience of Homelessness.

BACKGROUND: Homelessness is associated with poor health outcomes, including lack of access to care. Homelessness experienced in rural areas is understudied but likely associated with difficulty accessing needed services. Prior studies have assessed the extent to which Veterans experiencing homelessness in rural areas "migrate" to urban areas, but have not focused on changes in services utilization following migration. OBJECTIVE: To determine whether Veterans with a history of homelessness experience changes in the use of homeless and health services following a migration from a rural to urban residence, and vice versa, and to assess the magnitude of those changes. DESIGN: Longitudinal retrospective analysis of services use among Veterans identified as experiencing homelessness and migrating at least 40 miles or from an urban to a rural area or vice versa. PARTICIPANTS: A total of 81,620 Veterans with incident homelessness who experienced a migration and for whom we could establish 2 quarters of both pre-migration and post-migration service utilization. MAIN MEASURES: In addition to sociodemographic and health-related factors, we assessed index location and destination using geographic descriptors both residential address and Veteran Affairs (VA) facility where Veterans were identified as experiencing homelessness. Outcomes included continuous measures of homeless services and outpatient care and dichotomous measures of emergency department use and inpatient admissions. KEY RESULTS: Regardless of a Veteran's index location, migration to or within a rural area was associated with a significant decrease in the number of homeless and outpatient services and reduced risk of emergency department use or inpatient admission relative to migration to or within an urban area. CONCLUSION: Controlling for sociodemographic and health-related factors, Veterans experiencing homelessness who had a residential migration to or within a rural area had a significant reduction in their use of VA health and homeless services compared to those who migrated to or within an urban area.

Higher Pain Catastrophizing and Preoperative Pain is Associated with Increased Risk for Prolonged Postoperative Opioid Use.

BACKGROUND: Prolonged postoperative opioid use (PPOU) is considered an unfavorable post-surgical outcome. Demographic, clinical, and psychosocial factors have been associated with PPOU, but methods to prospectively identify patients at increased risk are lacking. OBJECTIVES: Our objective was to determine whether an individual or a combination of several psychological factors could identify a subset of patients at increased risk for PPOU. STUDY DESIGN: Observational cohort study with prospective baseline data collection and passive outcomes data collection. SETTING: A single VA medical center in the United States. METHODS: Patients were recruited from a preoperative anesthesia clinic where they were undergoing evaluation prior to elective surgery, and they completed a survey before surgery. The primary outcome was PPOU, defined as outpatient receipt of a prescribed opioid 31 to 90 days after surgery as determined from pharmacy records. Primary covariates of interest were pain catastrophizing, self-efficacy, and optimism. Additional covariates included social and demographic factors, pain severity, medication use, depression, anxiety, and surgical fear. RESULTS: Of 123 patients included in the final analyses, 30 (24.4%) had PPOU. In bivariate analyses, preoperative opioid use and preoperative nonsteroidal anti-inflammatory drug use were significantly associated with PPOU. The combination of high pain catastrophizing and high preoperative pain (OR 3.32, 95% CI 1.41 - 7.79) was associated with higher odds of PPOU than either alone, and the association remained significant after adjusting for preoperative opioid use (OR 2.56, 95% CI 1.04 - 6.29). LIMITATIONS: Patients were recruited from a single site, and the sample was not large enough to include potentially important variables such as procedure type. CONCLUSIONS: A combination of high pain catastrophizing and high preoperative pain has the potential to be a clinically useful means of identifying patients at elevated risk of PPOU.

Sensitivity of health records for self-reported nonfatal drug and alcohol overdose.

BACKGROUND AND OBJECTIVES: Public health surveillance for overdose sometimes depends on nonfatal drug overdoses recorded in health records. However, the proportion of total overdoses identified through health record systems is unclear. Comparison of overdoses from health records to those that are self-reported may provide insight on the proportion of nonfatal overdoses that are not identified. METHODS: We conducted a cohort study linking survey data on overdose from a national survey of Veterans to United States Department of Veterans Affairs (VA) health records, including community care paid for by VA. Self-reported overdose in the prior 3 years was compared to diagnostic codes for overdoses and substance use disorders in the same time period. RESULTS: The sensitivity of diagnostic codes for overdose, compared to self-report as a reference standard for this analysis, varied by substance: 28.1% for alcohol, 23.1% for sedatives, 12.0% for opioids, and 5.5% for cocaine. There was a notable concordance between substance use disorder diagnoses and self-reported overdose (sensitivity range 17.9%-90.6%). DISCUSSION AND CONCLUSIONS: Diagnostic codes in health records may not identify a substantial proportion of drug overdoses. A health record diagnosis of substance use disorder may offer a stronger inference regarding the size of the population at risk. Alternatively, screening for self-reported overdose in routine clinical care could enhance overdose surveillance and targeted intervention. SCIENTIFIC SIGNIFICANCE: This study suggests that diagnostic codes for overdose are insensitive. These findings support consideration of alternative approaches to overdose surveillance in public health.

What do Veterans with homeless experience want us to know that we are not asking? A qualitative content analysis of comments from a national survey of healthcare experience.

Surveys of people who experience homelessness can portray their life and healthcare experiences with a level of statistical precision; however, few have explored how the very same surveys can deliver qualitative insights as well. In responding to surveys, people experiencing homelessness can use the margins to highlight health and social concerns that investigators failed to anticipate that standard question batteries miss. This study describes the unprompted comments of a large national survey of Veterans with homeless experiences. The Primary Care Quality-Homeless Services Tailoring (PCQ-HOST) survey presented 85 close-ended items to solicit social and psychological experiences, health conditions, and patient ratings of primary care. Amongst 5377 Veterans responding to the paper survey, 657 (12%) offered 1933 unprompted comments across nearly all domains queried. Using a team-based content analysis approach, we coded and organised survey comments by survey domain, and identified emergent themes. Respondents used comments for many purposes. They noted when questions called for more nuanced responses than those allowed, especially 'sometimes' or 'not applicable' on sensitive questions, such as substance use, where recovery status was not queried. On such matters, the options of 'no' and 'yes' failed to capture important contextual and historical information that mattered to respondents, such as being in recovery. Respondents also elaborated on negative and positive care experiences, often naming specific clinics or clinicians. This study highlights the degree to which members of vulnerable populations, who participate in survey research, want researchers to know the reasons behind their responses and topics (like chronic pain and substance use disorders) that could benefit from open-ended response options. Understanding patient perspectives can help improve care. Quantitative data from surveys can provide statistical precision but may miss key patient perspectives. The content that patients write into survey margins can highlight shortfalls of a survey and point towards future areas of inquiry. Veterans with homeless experience want to provide additional detail about their lives and care experiences in ways that transcend the boundaries of close-ended survey questions. Questions on substance use proved especially likely to draw comments that went beyond the permitted response options, often to declare that the respondent was in recovery. Respondents frequently clarified aspects of their care experiences related to pain, pain care, transportation and experiences of homelessness.

Characteristics Associated With Unsheltered Status Among Veterans.

INTRODUCTION: Unsheltered homelessness is a strongly debated public issue. The study objective is to identify personal and community characteristics associated with unsheltered homelessness in veterans and to test for interactions between these characteristics. METHODS: In a 2018 national survey of U.S. veterans with homeless experiences; investigators assessed unsheltered time; psychosocial characteristics; and community measures of shelter access, weather, and rental affordability. Associations between these characteristics and unsheltered status were tested in July-August 2020. This study also tested whether the count of personal risk factors interacted with community characteristics in predicting unsheltered status. RESULTS: Among 5,406 veterans, 481 (8.9%) reported ≥7 nights unsheltered over 6 months. This group was more likely to report criminal justice history, poor social support, medical and drug problems, financial hardship, and being unmarried. Their communities had poorer shelter access and warmer temperatures. The likelihood of unsheltered experience rose with risk factor count from 2.0% (0-1) to 8.4% (2-3) and to 24.2% (4-11). Interaction tests showed that the increase was greater for communities with warmer weather and higher rents (p<0.05). CONCLUSIONS: Among veterans experiencing homelessness, unsheltered experiences correlate with individual and community risk factors. Communities wishing to address unsheltered homelessness will need to consider action at both levels.

Comparison of Patient Experience Between Primary Care Settings Tailored for Homeless Clientele and Mainstream Care Settings.

BACKGROUND: More than 1 million Americans receive primary care from federal homeless health care programs yearly. Vulnerabilities that can make care challenging include pain, addiction, psychological distress, and a lack of shelter. Research on the effectiveness of tailoring services for this population is limited. OBJECTIVE: The aim was to examine whether homeless-tailored primary care programs offer a superior patient experience compared with nontailored ("mainstream") programs overall, and for highly vulnerable patients. RESEARCH DESIGN: National patient survey comparing 26 US Department of Veterans Affairs (VA) Medical Centers' homeless-tailored primary care ("H-PACT"s) to mainstream primary care ("mainstream PACT"s) at the same locations. PARTICIPANTS: A total of 5766 homeless-experienced veterans. MEASURES: Primary care experience on 4 scales: Patient-Clinician Relationship, Cooperation, Accessibility/Coordination, and Homeless-Specific Needs. Mean scores (range: 1-4) were calculated and dichotomized as unfavorable versus not. We counted key vulnerabilities (chronic pain, unsheltered homelessness, severe psychological distress, and history of overdose, 0-4), and categorized homeless-experienced veterans as having fewer (≤1) and more (≥2) vulnerabilities. RESULTS: H-PACTs outscored mainstream PACTs on all scales (all P<0.001). Unfavorable care experiences were more common in mainstream PACTs compared with H-PACTs, with adjusted risk differences of 11.9% (95% CI=6.3-17.4), 12.6% (6.2-19.1), 11.7% (6.0-17.3), and 12.6% (6.2-19.1) for Relationship, Cooperation, Access/Coordination, and Homeless-Specific Needs, respectively. For the Relationship and Cooperation scales, H-PACTs were associated with a greater reduction in unfavorable experience for patients with ≥2 vulnerabilities versus ≤1 (interaction P<0.0001). CONCLUSIONS: Organizations that offer primary care for persons experiencing homelessness can improve the primary care experience by tailoring the design and delivery of services.

Perceptions of Care Coordination Among Homeless Veterans Receiving Medical Care in the Veterans Health Administration and Community Care Settings: Results From a National Survey.

BACKGROUND: Initiatives to expand Veterans' access to purchased health care outside Veterans Health Administration (VHA) facilities ("community care") present care coordination challenges for Veterans experiencing homelessness. OBJECTIVE: Among Veterans with homeless experiences, to evaluate community care use and satisfaction, and compare perceptions of care coordination among Veterans using VHA services and community care to those using VHA services without community care. RESEARCH DESIGN: Cross-sectional analysis of responses to a 2018 mailed survey. SUBJECTS: VHA outpatients with homeless experiences. MEASURES: Self-reported use of community care, Likert-style ratings of satisfaction with that care, and Access/Coordination experiences from the Primary Care Quality-Homeless (PCQ-H) survey. RESULTS: Of 4777 respondents, 1325 (26.7%) reported using community care; most of this subsample affirmed satisfaction with the community care they received (83%) and its timeliness (75%). After covariate adjustment, Veteran characteristics associated with greater community care use included female sex, being of retirement age and nonmarried, and having higher education, more financial hardship, ≥3 chronic conditions, psychological distress, depression, and posttraumatic stress disorder. Satisfaction with community care was lower among patients with travel barriers, psychological distress, and less social support. Compared with those using the VHA without community care, Veterans using VHA services and community care were more likely to report unfavorable access/coordination experiences [odds ratio (OR)=1.34, confidence interval (CI)=1.15-1.57]. This included hassles following referral (OR=1.37, CI=1.14-1.65) and perceived delays in receiving health care (OR=1.38, CI=1.19-1.61). CONCLUSIONS: Veterans with homeless experiences value community care options. Potential access benefits are balanced with risks of unfavorable coordination experiences for vulnerable Veterans with limited resources.

Enhancing Primary Care Experiences for Homeless Patients with Serious Mental Illness: Results from a National Survey.

OBJECTIVES: Patients experiencing homelessness (PEH) with serious mental illness (SMI) have poor satisfaction with primary care. We assessed if primary care teams tailored for homeless patients (Homeless-Patient Aligned Care Teams (H-PACTs)) provide this population with superior experiences than mainstream primary care and explored whether integrated behavioral health and social services were associated with favorable experiences. METHODS: We surveyed VA PEH with SMI (n = 1095) to capture the valence of their primary care experiences in 4 domains (Access/Coordination, Patient-Clinician Relationships, Cooperation, and Homeless-Specific Needs). We surveyed clinicians (n = 52) from 29 H-PACTs to elucidate if their clinics had embedded mental health, addiction, social work, and/or housing services. We counted these services in each H-PACT (0-4) and classified H-PACTs as having high (3-4) versus low (0-2) service integration. We controlled for demographics, housing history, and needs in comparing H-PACT versus mainstream experiences; and experiences in high versus low integration H-PACTs. RESULTS: Among respondents, 969 (91%) had complete data and 626 (62%) were in H-PACTs. After covariate adjustment, compared to mainstream respondents, H-PACT respondents were more likely (P < .01) to report favorable experiences (AORs = 1.7-2.1) and less likely to report unfavorable experiences (AORs = 0.5-0.6) in all 4 domains. Of 29 H-PACTs, 27.6% had high integration. High integration H-PACT respondents were twice as likely as low integration H-PACT respondents to report favorable access/coordination experiences (AOR = 1.7). CONCLUSIONS: Homeless-tailored clinics with highly-integrated services were associated with better care experiences among PEH with SMI. These observational data suggest that tailored primary care with integrated services may improve care perceptions among complex patients.

Low Uptake of Secure Messaging Among Veterans With Experiences of Homelessness and Substance Use Disorders.

OBJECTIVES: Persons who are homeless have significant health challenges and barriers accessing care. Secure messaging supports communication between patients and their providers through a web-based portal, but the acceptability of this technology among patients with high prevalence of substance use disorders (SUDs) is unknown. We examined secure messaging use among veterans with experiences of homelessness (VEHs), and determined factors associated with messaging use. METHODS: We conducted a cross-sectional analysis of responses to a national survey of VEHs, administered by mail from March to October 2018 (response rate = 40.2%). One item assessed secure messaging use and satisfaction. We used multivariable logistic regressions to model secure messaging use, controlling for sociodemographics, medical conditions, housing indicators, and mental health and SUD diagnoses. RESULTS: Of 5072 VEHs, 21% had ever used secure messaging and 87% of the subsample found messaging to be useful. Secure messaging was more commonly used by VEHs who were female, had some college education, those with ≥3 chronic medical conditions, depression, or posttraumatic stress disorder (all P < 0.001). Messaging was much less common for VEHs ages 55 to 64 or older, non-Latino Blacks, those receiving homeless-tailored primary care, and those with SUDs (all P < 0.001). VEHs with opioid use disorder were even less likely than those with other SUDs to use secure messaging (P = 0.047). CONCLUSIONS: Persons with homeless experiences might require assistance to engage with secure messaging technology. As health systems limit in-person care during a national pandemic, alternative solutions may be needed to facilitate health communications and prevent care disruptions for patients experiencing homelessness and SUDs.

Prevalence of and Risk Factors Associated With Nonfatal Overdose Among Veterans Who Have Experienced Homelessness.

Importance: Individuals with a history of homelessness are at increased risk for drug or alcohol overdose, although the proportion who have had recent nonfatal overdose is unknown. Understanding risk factors associated with nonfatal overdose could guide efforts to prevent fatal overdose. Objectives: To determine the prevalence of recent overdose and the individual contributions of drugs and alcohol to overdose and to identify characteristics associated with overdose among veterans who have experienced homelessness. Design, Setting, and Participants: This survey study was conducted from November 15, 2017, to October 1, 2018, via mailed surveys with telephone follow-up for nonrespondents. Eligible participants were selected from the records of 26 US Department of Veterans Affairs medical centers and included veterans who had received primary care at 1 of these Veterans Affairs medical centers and had a history of experiencing homelessness according to administrative data. Preliminary analyses were conducted in October 2018, and final analyses were conducted in January 2020. Main Outcomes and Measures: Self-report of overdose (such that emergent medical care was obtained) in the previous 3 years and substances used during the most recent overdose. All percentages are weighted according to propensity to respond to the survey, modeled from clinical characteristics obtained in electronic health records. Results: A total of 5766 veterans completed the survey (completion rate, 40.2%), and data on overdose were available for 5694 veterans. After adjusting for the propensity to respond to the survey, the mean (SD) age was 56.4 (18.3) years; 5100 veterans (91.6%) were men, 2225 veterans (38.1%) were black, and 2345 veterans (40.7%) were white. A total of 379 veterans (7.4%) reported any overdose during the past 3 years; 228 veterans (4.6%) reported overdose involving drugs, including 83 veterans (1.7%) who reported overdose involving opioids. Overdose involving alcohol was reported by 192 veterans (3.7%). In multivariable analyses, white race (odds ratio, 2.44 [95% CI, 2.00-2.98]), self-reporting a drug problem (odds ratio, 1.66 [95% CI, 1.39-1.98]) or alcohol problem (odds ratio, 2.54 [95% CI, 2.16-2.99]), and having witnessed someone else overdose (odds ratio, 2.34 [95% CI, 1.98-2.76]) were associated with increased risk of overdose. Conclusions and Relevance: These findings suggest that nonfatal overdose is relatively common among veterans who have experienced homelessness. While overdose involving alcohol was more common than any specific drug, 1.7% of veterans reported overdose involving opioids. Improving access to addiction treatment for veterans who are experiencing homelessness or who are recently housed, especially for those who have experienced or witnessed overdose, could help to protect this population.

Exploring Quality of Primary Care for Patients Who Experience Homelessness and the Clinicians Who Serve Them: What Are Their Aspirations?

To develop and evaluate an effective model of patient-centered, high-quality, homeless-focused primary care, our team explored key domains of primary care that may be important to patients. We anchored our conceptual framework in two reports from the Institute of Medicine (IOM) that defined components of primary care and quality of care. Using questions developed from this framework, we conducted semistructured interviews with 36 homeless-experienced individuals with past-year primary care engagement and 24 health care professionals (clinicians and researchers) who serve homeless-experienced patients in the primary care setting. Template analysis revealed factors important to this population. These included stigma, respect, and perspectives on patient control of medical decision-making in regard to both pain and addiction. For patients experiencing homelessness, the results suggest that quality primary care may have different meanings for patients and professionals, and that services should be tailored to meet homeless-specific needs.

Perioperative beta blockers and statins for noncardiac surgery patients with coronary stents.

IMPORTANCE: Recent publications report that perioperative initiation of statin therapy is associated with improved outcomes particularly among patients with increased cardiac risk. However, findings on associations with beta blocker (BB) initiation are mixed. OBJECTIVE: This study examines associations between perioperative statin and BB use in a national sample of patients with cardiac stents. DESIGN: Retrospective cohort study. SETTING: VA Medical Centers nationwide. PARTICIPANTS: We identified Veterans Affairs (VA) patients undergoing non-cardiac surgery in the within two years after stent placement between October 2002 and September 2011 with BB and/or statin prescriptions within one year prior to surgery. Using VA inpatient data we identified major adverse cardiac or cerebrovascular events (MACCE) within 30 days of surgery. General usage patterns and percent of days covered by medication were calculated as additional markers of medication use. Adjusted logistic regression was used to examine associations between medication use and 30-day postoperative outcomes. RESULTS: 23,537 patients underwent surgery within 2 years following stent placement, of whom 20,566 (88.6%) had prescriptions for beta blockers and statins within 365 days prior to surgery. Of those, 13,501 (65.6%) used both BB and statins prior to surgery, while 2626 (12.8%) used only BB, 2346 (11.4%) used only statins, and 2093 (10.2%) used neither. In fully adjusted models, the only significant association was between perioperative statin use and decreased mortality (OR 0.65, 95% CI 0.48-0.87). CONCLUSIONS: Our results suggest that maintaining statin therapy perioperatively is associated with reduced 30 day mortality in stented patients undergoing non-cardiac surgery who have previously been prescribed both beta blockers and statins.

Racial disparities in length-of-stay persist even with no postoperative complications.

BACKGROUND: To determine the contribution of race to postoperative length-of-stay in elective colorectal surgery without complications. METHODS: The 2012-2013 National Surgical Quality Improvement Program Colectomy-Targeted Database was queried for patients undergoing elective colorectal surgery without complications. After stratifying by race, univariate/bivariate comparisons were made. On adjusted comparison, predictors of postoperative length-of-stay were identified along with incident rate ratios and Least Squares Means for predicted length-of-stays. RESULTS: Of 28,480 elective colorectal surgeries, 19,898 patients had no postoperative complications. Patients stratified to white (84%), black (8%), Hispanic (3%), and Asian (3%). Overall mean postoperative length-of-stay was 4.8 d, with black patients having the longest at 5.3 d (P < 0.05). After covariate adjustment, black race increased postoperative length-of-stay by 9%, 7%, and 6% compared to white, Hispanic, and Asian patients, respectively (P < 0.05). No statistical difference existed in postoperative length-of-stay for Hispanic and Asian patients versus white patients. Adjusted postoperative length-of-stay was 5.1 d for black patients compared to 4.7, 4.8, and 4.8 d for white, Hispanic, and Asian patients, respectively (P < 0.05). CONCLUSIONS: Black patients have significantly longer postoperative length-of-stay after elective colorectal surgery even if no postoperative complications occur. Further studies are needed to understand the mechanism(s) for these disparities.

Housing first on a large scale: Fidelity strengths and challenges in the VA's HUD-VASH program.

Housing First (HF) combines permanent supportive housing and supportive services for homeless individuals and removes traditional treatment-related preconditions for housing entry. There has been little research describing strengths and shortfalls of HF implementation outside of research demonstration projects. The U.S. Department of Veterans Affairs (VA) has transitioned to an HF approach in a supportive housing program serving over 85,000 persons. This offers a naturalistic window to study fidelity when HF is adopted on a large scale. We operationalized HF into 20 criteria grouped into 5 domains. We assessed 8 VA medical centers twice (1 year apart), scoring each criterion using a scale ranging from 1 (low fidelity) to 4 (high fidelity). There were 2 HF domains (no preconditions and rapidly offering permanent housing) for which high fidelity was readily attained. There was uneven progress in prioritizing the most vulnerable clients for housing support. Two HF domains (sufficient supportive services and a modern recovery philosophy) had considerably lower fidelity. Interviews suggested that operational issues such as shortfalls in staffing and training likely hindered performance in these 2 domains. In this ambitious national HF program, the largest to date, we found substantial fidelity in focusing on permanent housing and removal of preconditions to housing entry. Areas of concern included the adequacy of supportive services and adequacy in deployment of a modern recovery philosophy. Under real-world conditions, large-scale implementation of HF is likely to require significant additional investment in client service supports to assure that results are concordant with those found in research studies. (PsycINFO Database Record

Triple Antithrombotic Therapy and Outcomes in Post-PCI Patients Undergoing Non-cardiac Surgery.

BACKGROUND: Triple therapy, or the use of anticoagulants with dual antiplatelet therapy (DAPT), is often used to protect against ischemic events in post-percutaneous coronary intervention (PCI) patients with indications for anticoagulation, but is associated with increased bleeding. As both ischemic and bleeding risks increase in the perioperative period, the impact of triple therapy may be especially pronounced in patients undergoing surgery. Outcomes in this population are currently unknown. METHODS: We identified patients undergoing non-cardiac surgeries within 2 years of PCI in Veterans Affairs hospitals from 2004 to 2012. We compared perioperative major adverse cardiovascular and cerebrovascular events (MACCE: mortality, myocardial infarction, stroke, revascularization) and bleeding events (in-hospital bleeding, transfusion) between surgeries in patients prescribed triple therapy and DAPT, adjusting for clinical, demographic, and operative characteristics. RESULTS: Among 7811 surgeries, 391 (5.0 %) occurred in patients receiving triple therapy. 44 (11.3 %) MACCE and 107 (27.4 %) bleeding events occurred with surgeries in triple therapy patients, compared to 366 (4.9 %) MACCE and 980 (13.2 %) bleeding events in DAPT patients. After adjustment, surgery in triple therapy patients was associated with higher rates of MACCE [odds ratio (OR) 1.65, 95 % confidence interval (CI) 1.16-2.34] or bleeding (OR 1.52, 95 % CI 1.17-1.99) as compared to surgery in DAPT patients. CONCLUSIONS: One in twenty post-PCI patients undergoing non-cardiac surgery were on triple therapy. Surgery in these patients was associated with higher MACCE and bleeding events compared to surgery in patients on DAPT, independent of clinical and operative characteristics. These findings identify a high-risk population for surgery, which may warrant increased surveillance for adverse perioperative events.

Coronary angiography and failure to rescue after postoperative myocardial infarction in patients with coronary stents undergoing noncardiac surgery.

BACKGROUND: We evaluated coronary angiography use among patients with coronary stents suffering postoperative myocardial infarction (MI) and the association with mortality. METHODS: Patients with prior coronary stenting who underwent inpatient noncardiac surgery in Veterans Affairs hospitals between 2000 and 2012 and experienced postoperative MI were identified. Predictors of 30-day post-MI mortality were evaluated. RESULTS: Following 12,096 operations, 353 (2.9%) patients had postoperative MI and 58 (16.4%) died. Post-MI coronary angiography was performed in 103 (29.2%) patients. Coronary angiography was not associated with 30-day mortality (odds ratio [OR]: .70, 95% CI: .35-1.42). Instead, 30-day mortality was predicted by revised cardiac risk index ≥3 (OR 1.91, 95% CI: 1.04-3.50) and prior bare metal stent (OR 2.12, 95% CI: 1.04-4.33). CONCLUSIONS: Less than one-third of patients with coronary stents suffering postoperative MI underwent coronary angiography. Significant predictors of mortality were higher revised cardiac risk index and prior bare metal stent. These findings highlight the importance of comorbidities in predicting mortality following postoperative MI.

Racial Disparities in Readmissions for Patients with Inflammatory Bowel Disease (IBD) After Colorectal Surgery.

BACKGROUND: The incidence of inflammatory bowel disease (IBD) in minorities is increasing, and health outcome disparities are becoming more apparent. Our aim was to investigate the contribution of race to readmissions in IBD patients undergoing colorectal surgery. DESIGN: The National Surgical Quality Improvement Program database from 2012 to 2013 was queried for all patients with IBD undergoing elective colorectal surgery. After stratifying by race, unadjusted univariate and bivariate comparisons were made. Primary outcome was all-cause 30-day readmission. Predictors of readmission were identified using multivariable logistic regression. RESULTS: Of the 2523 patients with IBD who underwent elective colon surgery, 15.0 % were readmitted within 30 days of index operation. Black patients constituted 7.7 % of the entire cohort. Black patients were significantly different in smoking status (27 vs. 22 %) and Crohn's diagnosis (84 vs. 73 %) (p < 0.05). Black patients had significantly higher readmission rates (20 vs. 15 %) and longer length-of-stays (8 vs. 6 days) after surgery (p < 0.05). On multivariable analysis, black race remained a significant predictor for 30-day readmissions in patients with IBD (odds ratio 1.6, 95 % confidence interval 1.1-2.5). CONCLUSIONS: Black patients with IBD have an increased risk for readmission after colorectal surgery. Efforts to reduce readmissions need to target not only well-studied risk factors such as postoperative complications, but also investigate non-NSQIP-measured elements such as social and behavioral determinants of health.