Clinician and Family Caregiver Perspectives on Deprescribing Chronic Disease Medications in Older Nursing Home Residents Near the End of Life.

INTRODUCTION: Nursing home (NH) residents with limited life expectancy (LLE) who are intensely treated for hyperlipidemia, hypertension, or diabetes may benefit from deprescribing. OBJECTIVE: This study sought to describe NH clinician and family caregiver perspectives on key influences on deprescribing decisions for chronic disease medications in NH residents near the end of life. METHODS: We recruited family caregivers of veterans who recently died in a Veterans Affairs (VA) NH, known as community living centers (CLCs), and CLC healthcare clinicians (physicians, nurse practitioners, physician assistants, pharmacists, registered nurses). Respondents completed semi-structured interviews about their experiences with deprescribing statin, antihypertensive, and antidiabetic medications for residents near end of life. We conducted thematic analysis of interview transcripts to identify key themes regarding influences on deprescribing decisions. RESULTS: Thirteen family caregivers and 13 clinicians completed interviews. Key themes included (1) clinicians and caregivers both prefer to minimize drug burden; (2) clinical factors strongly influence deprescribing of chronic disease medications, with differences in how clinicians and caregivers weigh specific factors; (3) caregivers trust and rely on clinicians to make deprescribing decisions; (4) clinicians perceive caregiver involvement and buy-in as essential to deprescribing decisions, which requires time and effort to obtain; and (5) clinicians perceive conflicting care from other clinicians as a barrier to deprescribing. CONCLUSIONS: Findings suggest a need for efforts to encourage communication with and education for family caregivers of residents with LLE about deprescribing, and to foster better collaboration among clinicians in CLC and non-CLC settings.

Exploring Research Engagement and Priorities of Transgender and Gender Diverse Veterans.

INTRODUCTION: In recent years, the U.S. Veterans Health Administration (VHA) has seen an increasing population of transgender and gender diverse (TGD) veterans accessing care. Approximately 139 per 100,000 VHA users had a gender identity disorder diagnosis documented in 2018 compared to 32.9 per 100,000 in 2013. Despite TGD patients being overrepresented within VHA, TGD veterans may distrust or face unique barriers with various aspects of the VHA, including health services research. Existing VHA health research focused on TGD populations is largely limited to secondary analyses of electronic health record data. Identifying strategies to enhance primary data collection is crucial for more deeply investigating health care challenges experienced by TGD veterans using VHA care. Additionally, describing health topics of importance for TGD veterans is important for making the research agenda more patient-centered. In this study, we offer veterans' recommendations for researchers working with underrepresented populations based on our findings. MATERIALS AND METHODS: From September through October 2019, 30 TGD veterans were recruited through VHA lesbian, gay, bisexual, transgender, and queer/questioning Veteran Care Coordinators (LGBTQ+ VCC) located nationwide. Semi-structured interviews were used to explore barriers and facilitators to research participation, recommendations for improving outreach and engagement, and overall perspectives about priorities in health services research. Transcripts were independently and jointly reviewed and coded by two TGD research analysts, including a veteran using VHA care. Codes were derived inductively. Themes were identified using conventional content analysis. The VA Pittsburgh Healthcare System institutional review board approved this study. RESULTS: Participants cited privacy concerns of being "outed" and potentially having VHA benefits revoked, in addition to a level of distrust in researchers' intentions as barriers to participating in studies. Facilitators for participating included feeling a sense of serving the TGD community and accessibility to study locations, especially VHA-affiliated sites. Suggestions for recruitment included tailored messaging and using other TGD peers or affirming VHA staff (e.g., LGBTQ+ VCCs) for study outreach. Mental health and gender-affirming hormone therapy were the most understudied topics identified by participants. Additionally, participants prioritized the inclusion and study of underrepresented subpopulations, such as transgender women of color, transgender men, and non-binary/gender diverse veterans, in future research. CONCLUSIONS: By harnessing the VHA LGBTQ+ VCC network, this study recruited a national sample of TGD veterans to provide insight on methods for more effectively engaging TGD veterans in research and elicited their suggestions for health services research topics. The findings provide numerous suggestions for medicine and public health that are ripe for future research endeavors. Despite the study's lack of gender, racial, and ethnic diversity, findings highlight the need for engagement and study of underrepresented veteran populations. These suggested areas of focus for research in combination with valuable insight on research participation provide researchers with guidance for developing research agendas and designing recruitment and data collection methods that can facilitate future primary research advancing health services research involving TGD patients. Similarly, VHA and non-VHA researchers conducting research involving other underrepresented populations can also gain insight from these findings.

Using Intervention Mapping to Develop a Novel Pain Self-Management Intervention for People with Cirrhosis.

BACKGROUND: Chronic pain is common among patients with cirrhosis and is challenging to treat. While promising, pain self-management (PSM) interventions have not been tailored to this population's needs. AIMS: To design a PSM intervention for patients with cirrhosis. METHODS: Semi-structured interviews with 17 patients with cirrhosis, 12 hepatologists, and 6 administrators from two medical centers were conducted to inform a rigorous, structured intervention mapping (IM) process. Qualitative content analysis was guided by social cognitive theory (SCT) and the Consolidated Framework for Implementation Research (CFIR) and incorporated into intervention development. A planning group met regularly throughout the intervention, to reach consensus about how to use data and theory to develop the intervention through IM. RESULTS: Participants described barriers to PSM behaviors, including the absence of simple, evidence-based interventions for pain for patients with cirrhosis, inadequate provider knowledge, time, and training, and lack of champions, funding, and communication. Patients described high motivation to treat pain using behavioral methods including meditation, prayer, and exercise. The intervention was designed to address barriers to PSM behaviors for patients with cirrhosis, using behavior change methods that address knowledge, self-efficacy, and outcome expectations. The LEAP (Liver Education About Pain) intervention is a 12-week, modular intervention delivered by phone via individual and group sessions with a health coach. CONCLUSIONS: People with cirrhosis, hepatologists, and administrators informed this theory-driven, tailored PSM intervention, which was designed to be implementable in the real world.

Tracking the randomized rollout of a Veterans Affairs opioid risk management tool: A multi-method implementation evaluation using the Consolidated Framework for Implementation Research (CFIR).

Background: The Veterans Health Administration (VHA) developed the Stratification Tool for Opioid Risk Mitigation (STORM) dashboard to assist in identifying Veterans at risk for adverse opioid overdose or suicide-related events. In 2018, a policy was implemented requiring VHA facilities to complete case reviews of Veterans identified by STORM as very high risk for adverse events. Nationally, facilities were randomized in STORM implementation to four arms based on required oversight and by the timing of an increase in the number of required case reviews. To help evaluate this policy intervention, we aimed to (1) identify barriers and facilitators to implementing case reviews; (2) assess variation across the four arms; and (3) evaluate associations between facility characteristics and implementation barriers and facilitators. Method: Using the Consolidated Framework for Implementation Research (CFIR), we developed a semi-structured interview guide to examine barriers to and facilitators of implementing the STORM policy. A total of 78 staff from 39 purposefully selected facilities were invited to participate in telephone interviews. Interview transcripts were coded and then organized into memos, which were rated using the -2 to + 2 CFIR rating system. Descriptive statistics were used to evaluate the mean ratings on each CFIR construct, the associations between ratings and study arm, and three facility characteristics (size, rurality, and academic detailing) associated with CFIR ratings. We used the mean CFIR rating for each site to determine which constructs differed between the sites with highest and lowest overall CFIR scores, and these constructs were described in detail. Results: Two important CFIR constructs emerged as barriers to implementation: Access to knowledge and information and Evaluating and reflecting. Little time to complete the CASE reviews was a pervasive barrier. Sites with higher overall CFIR scores showed three important facilitators: Leadership engagement, Engaging, and Implementation climate. CFIR ratings were not significantly different between the four study arms, nor associated with facility characteristics.Plain Language Summary: The Veterans Health Administration (VHA) created a tool called the Stratification Tool for Opioid Risk Mitigation dashboard. This dashboard shows Veterans at risk for opioid overdose or suicide-related events. In 2018, a national policy required all VHA facilities to complete case reviews for Veterans who were at high risk for these events. To evaluate this policy implementation, 78 staff from 39 facilities were interviewed. The Consolidated Framework for Implementation Research (CFIR) implementation framework was used to create the interview. Interview transcripts were coded and organized into site memos. The site memos were rated using CFIR's -2 to +2 rating system. Ratings did not differ for four study arms related to oversight and timing. Ratings were not associated with facility characteristics. Leadership, engagement and implementation climate were the strongest facilitators for implementation. Lack of time, knowledge, and feedback were important barriers.

Veterans' experiences with and perspectives on insomnia treatment: A qualitative study.

Qualitative interviews were conducted with veterans to understand their experiences and perceptions about insomnia and its treatment, with a focus on cognitive-behavioral therapy for insomnia (CBT-I) and brief behavioral treatment for insomnia (BBTI). There is a lack of knowledge about veterans' understanding of this prevalent disorder, yet their experiences and perceptions can influence treatment delivery and treatment outcomes. The Department of Veterans Affairs (VA) can improve insomnia care by considering and responding to this valuable information from veteran stakeholders. Twenty veterans with an insomnia diagnosis or complaint were interviewed about their experiences with insomnia, its treatment, and their preferences for care. Transcripts from the audio-recorded interviews were independently analyzed by 2 coders using content analysis, and discrepancies were resolved through negotiated consensus. The 20 veterans were mostly male (85%), older (60.4 years ± 9.0), and white (60%). Experiences with insomnia and perspectives regarding treatment focused on (a) insomnia symptoms, (b) comorbid symptoms, (c) seeking treatment, (d) intervention experiences, (e) intervention preferences and expectations, and (f) patient attributes. Barriers to care included a lack of knowledge about treatment and a lack of options that fit veterans' preference for delivery. These results provide insight into veterans' experiences with and perspectives on insomnia treatment that is crucial to the support, development, and implementation of interventions. A focus on increasing knowledge of, and expectations for, insomnia treatments as well as offering multiple delivery options has the potential to improve utilization and access to quality insomnia care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The "S" Allele of the Serotonin Transporter Is Not Associated with Major Depression or Alcohol Use Disorders in a Veteran Sample.

The results of some studies suggest that the serotonin transporter-linked polymorphic region (5-HTTLPR) short (S) allele, relative to the long (L) allele, is associated with risk for Major Depressive Disorder (MDD) and for Alcohol Use Disorder (AUD), and thus serves as biomarker for those disorders, while results from other studies do not support that conclusion. Persons with an S allele demonstrate a 2- to 2.5 fold decrease in serotonin transcription rate compared to the L-allele, which may increase their risk for MDD. Differences in study populations may help explain the differences in findings between those meta-analyses. To date, there have been no published reports which have addressed the possible association between the S allele and MDD among military veterans. This manuscript describes a first study to assess the possible association of the S allele with MDD or with AUD among a study population of veterans in treatment for a substance use disorder. We hypothesized that the S allele would be associated with MDD in our study sample. Subjects signing informed consent were 101 Veterans recruited from VA behavioral health and substance use treatment clinics in the VA Pittsburgh Healthcare System, and 91 of those subjects were genotyped for 5-HTTLPR polymorphisms. The study sample from whom genetic material was collected included 82 males and 9 females, of whom 53 were white, 38 were black, and one was "other". Fifty-four members of the study sample (59%) met DSM-IV criteria for an MDD on the SCID. Forty-five of the subjects demonstrated one or two S alleles, while 46 did not do so. The presence of the S allele of the serotonin transporter was not found to be significantly associated with the diagnosis of major depressive disorder or with alcohol use disorders in our sample. Those findings, in combination with other recent negative findings from other researchers involving non-veterans, raise questions regarding the clinical utility of utilizing genetics tests involving the assessment of the alleles of the serotonin transporter as a possible biomarker for MDD or for AUD.