Reforming the veteran: propaganda and agency in the First World War Reconstruction hospitals.

The United States' entry into the First World War prompted progressives to reform veterans' entitlements in the hopes of creating a system insulated from corruption and capable of rehabilitating disabled veterans into productive members of society. The replacement of pensions with medical care for wounded and disabled soldiers through the Reconstruction Hospital System was originally intended as a temporary measure but resulted in establishing the foundations of the modern veterans' health care system. Yet, these reforms would not have been possible without the support from the community of war veterans to which these reforms applied. By examining the communal values expressed in publications produced by and for soldiers, this paper explores the ways in which the Great War's veteran community expressed agency in the process of reforming the US veteran entitlements.

Medications for opioid use disorder in the Department of Veterans Affairs (VA) health care system: Historical perspective, lessons learned, and next steps.

The US Department of Veterans Affairs (VA), the largest health care system in the US, has been confronted with the health care consequences of opioid disorder (OUD). Increasing access to quality OUD treatment, including pharmacotherapy, is a priority for the VA. We examine the history of medications (e.g., methadone, buprenorphine, injectable naltrexone) used in the treatment of OUD within VA, document early and ongoing efforts to increase access and build capacity, primarily through the use of buprenorphine, and summarize research examining barriers and facilitators to prescribing and medication receipt. We find that there has been a slow but steady increase in the use of medications for OUD and, despite system-wide mandates and directives, uneven uptake across VA facilities and within patient sub-populations, including some of those most vulnerable. We conclude with recommendations intended to support the greater use of medication for OUD in the future, both within VA as well as other large health care systems.

Great aspirations: the postwar American college counseling center.

In the decade after World War II, psychologists, eager to bring the benefits of counseling to larger numbers, convinced hundreds of American colleges and universities to establish counseling centers. Inspired by the educational-vocational counseling center founded by psychologists at the University of Minnesota in 1932, Carl R. Rogers's "client-centered" methods of personal adjustment counseling, and the 400-plus college counseling centers created by the Veterans Administration to provide the educational-vocational counseling benefit promised to returning World War II servicemen under the 1944 GI Bill, these counseling psychologists created a new place to practice where important currents in psychology, higher education, and federal policy converged and where they attempted to integrate educational-vocational counseling with personal adjustment counseling based on techniques from psychotherapy. By the mid-1960s, half of America's colleges and universities had established counseling centers, and more than 90% offered students educational, vocational, and psychological counseling services, a great achievement of the first generation of counseling psychologists.

Racial differences in trends of serious hypoglycemia among higher risk older adults in US Veterans Health Administration, 2004-2015: Relationship to comorbid conditions, insulin use, and hemoglobin A1c level.

AIMS: To evaluate temporal trends in racial/ethnic groups in rates of serious hypoglycemia among higher risk patients dually enrolled in Veterans Health Administration and Medicare fee-for-service and assess the relationship(s) between hypoglycemia rates, insulin/secretagogues and comorbid conditions. METHODS: Retrospective observational serial cross-sectional design. Patients were ≥65 years receiving insulin and/or secretagogues. The primary outcome was the annual (period prevalence) rates (2004-2015), per 1000 patient years, of serious hypoglycemic events, defined as hypoglycemic-related emergency department visits or hospitalizations. RESULTS: Subjects were 77-83% White, 7-10% Black, 4-5% Hispanic, <2% women; 38-58% were ≥75 years old; 72-75% had ≥1 comorbidity. In 2004-2015, rates declined from 63.2 to 33.6(-46.9%) in Blacks; 29.7 to 20.3 (-31.6%) in Whites; and 41.8 to 29.6 (-29.3%) in Hispanics. The Black-White rate differences narrowed regardless of insulin use, hemoglobin A1c level, and frequency and various combinations of comorbid conditions. Among insulin users, the Black-White contrast decreased from 34.7 (98.5 vs. 63.8) in 2004 to 13.2 (43.6 vs. 30.4) in 2015; in non-insulin users, the contrast was 25.7 (44.1 vs. 18.4) in 2004 and 10.1 (18.9 vs. 8.8) in 2015. CONCLUSION: Marked declines in serious hypoglycemia events occurred across race, medications, and comorbidities, suggesting significant changes in clinical practice.

The History of Urology at the Minneapolis Veterans Affairs Health Care System.

OBJECTIVE: The Section of Urology at the Minneapolis Veteran's Affairs (VA) Medical Center has a long history of contributions to Urology including the Gleason Score, Fuhrman Grading system, testicular tumor marker development and the birth of Endourology. The objective of this manuscript is to compile and present the Urologic history of the Minneapolis VA. METHODS: The Urologic literature and institutional records originating from the Minneapolis VA Medical Center from 1946-2017 were reviewed and presented herein. RESULTS: The Minneapolis VA Health Care System originated in 1921 and currently employs 5 Urologist who serve over 16,000 veterans per year. Historic achievements from the Minneapolis VA Section of Urology include the development of the Veteran's Affairs Cooperative Research Group (VACURG) which was instrumental to development of the Gleason grading system for prostate cancer in 1965. Additional urologic oncology achievements originating from the Minneapolis VA Section of Urology included the development of the diagnostic utility of tumor markers in testis cancer in 1976 and The Fuhrman Grading System in 1982. Perhaps the greatest contribution to the field of Urology was the birth of Endourology at the Minneapolis VA in the late 1970s under the direction of Dr. Paul Lange. Currently the Minneapolis VA is a premier center for Evidence Based Urology by housing Cochrane Urology and the U.S. Grading of Recommendations Assessment, Development and Evaluation network (US GRADE). CONCLUSION: Since 1946, the section of Urology at the Minneapolis VA has contributed basic science, clinical technique and evidence based medicine to the field of Urology while providing care to the nation's veterans.

Veterans Administration support for medical research: opinions of the endangered species of physician-scientists.

Over the past three decades the Veterans Affairs (VA) Research program has evolved into a powerful, peer-reviewed funding mechanism for basic and translational research that has resulted in numerous important contributions to medical science and improvements in patient care. Continuity in VA Merit Review funding has fostered and nurtured the scientific careers of a large number of physician-scientists who have remained devoted to the mission of performing creative and innovative research that affects the patient care mission of the VA. VA medical research policies have undergone a major overhaul in the past year. Although many of these changes (de-emphasizing bench research and revamping the peer review process) have recently been reversed, the future direction of VA research remains in flux. The goal of this manuscript is to demonstrate the importance of the Merit Review medical research funding mechanism not just to the VA, but to the entire nation's health care system. To achieve this goal, the opinions of 65 established VA medical investigators were obtained regarding the past success and future direction of VA research. The conclusions reached include the following. 1) Merit Review research funding has been essential to the training, recruitment, and retention of productive VA physician-scientists. 2) The VA research program has contributed both basic and clinical innovations that have led to improvements in medical care. Contributions of VA researchers to excellence in many aspects of patient care at VA hospitals have been extraordinary. 3) Development of initiatives that entice outstanding Ph.D.'s to develop their careers in the VA has been crucial to the success of the program. 4) The VA research program has fostered a mutually beneficial relationship with affiliated medical schools. 5) Better methods to quantify VA research contributions and outcomes are essential for future program development.

The VA's affiliation with academic medicine: an emergency post-war strategy becomes a permanent partnership.

The creation of a cabinet-level department for veterans' programs is an occasion to review medical care of American military veterans, which dates back to colonial times. To meet the medical care crisis caused by large numbers of returning World War II veterans, the Veterans Administration (VA) entered into affiliations with U.S. medical schools, a partnership that provided physicians for veterans and allowed residents to complete graduate medical education. Increasing medical care needs of veterans of World War II and successive conflicts, and legislatively expanded entitlements, have contributed to sustained growth of the VA workload--which in turn has led to an expanded partnership with schools of medicine and allied health sciences. The affiliations continue to serve both partners well and to contribute substantively to society at large by fostering the production of medical manpower and advances in biomedical research.

The "new VA": a national laboratory for health care quality management.

In 1995, the Veterans Health Administration (VHA) initiated the most radical redesign of the veterans health care system since the system was formally created in 1946. One of the goals of this reengineering effort has been to ensure the consistent and predictable provision of high-quality care everywhere in the system. To accomplish this goal, the VHA has organized more than 100 different quality improvement activities according to a structure-, process-, and outcomes-focused quality management accountability framework (QMAF) that targets 10 interrelated dimensions of quality management (QM). Each of these dimensions utilizes a defined strategy and employs a menu of quality assessment and assurance tactics. Organizing these many different quality improvement activities into an accountability framework should facilitate the development of policies and procedures that will systematize the VHA's QM. The VHA's new operational structure and its approach to quality improvement provide a unique national laboratory for health care QM.

The evolution of American Medical Association policies concerning health care of veterans.

Relationships between the American Medical Association (AMA) and the Department of Veterans Affairs (VA) have been reviewed from the perspective of evolving AMA policies regarding the care of veterans, including educational and research policies. During the first two decades of VA hospital development between 1925 and 1945, the AMA opposed government participation in the care of veterans. During the next three decades there was a reluctant acknowledgement by the AMA of the need for federally housed care of veterans with service-connected illnesses. At the same time, the AMA recognized the value of the mission of the VA in training specialists through postgraduate medical education. More recently the AMA has been especially supportive of VA-medical school affiliations and VA activities in education and research. The reluctance of the AMA to support veterans' health care was paralleled by reluctance of VA staff physicians to join the AMA. In recent years the AMA has recognized the need to diversify its membership as increasing numbers of physicians have been trained in part in VA medical centers. It appears to be a time of enhanced opportunity for the AMA to work more closely with the Department of Veterans Affairs.

The Nursing Research Committee: the James A. Haley Veterans' Hospital.

Nursing research has been a part of the culture at the James A. Haley Veterans' Hospital for many years. A Nursing Research Committee (NRC) has been an integral part of this success. The emphasis remains on involving the staff nurse in nursing research. By defining clear-cut goals and objectives, leadership of the NRC reaps substantial professional results.

Federal policy and the rise in disability enrollment: evidence for the Veterans Affairs' Disability Compensation Program.

The U.S. Department of Veterans Affairs compensates 13 percent of the nation's military veterans for service­related disabilities through the Disability Compensation (DC) program. In 2001, a legislative change made it easier for Vietnam veterans to receive benefits for diabetes associated with military service. In this paper, we investigate this policy's effect on DC enrollment and expenditures as well as the behavioral response of potential beneficiaries. Our findings demonstrate that the policy increased DC enrollment by 6 percentage points among Vietnam veterans and that an additional 1.7 percent experienced an increase in their DC benefits, which increased annual program expenditures by $2.85 billion in 2007. Using individual-level data from the Veterans Supplement to the Current Population Survey, we find that the induced increase in DC enrollment had little average impact on the labor supply or health status of Vietnam veterans but did reduce labor supply among their spouses.