A Clinical Decision Support Tool for Intimate Partner Violence Screening Among Women Veterans: Development and Qualitative Evaluation of Provider Perspectives.

BACKGROUND: Women veterans, compared to civilian women, are especially at risk of experiencing intimate partner violence (IPV), pointing to the critical need for IPV screening and intervention in the Veterans Health Administration (VHA). However, implementing paper-based IPV screening and intervention in the VHA has revealed substantial barriers, including health care providers' inadequate IPV training, competing demands, time constraints, and discomfort addressing IPV and making decisions about the appropriate type or level of intervention. OBJECTIVE: This study aimed to address IPV screening implementation barriers and hence developed and tested a novel IPV clinical decision support (CDS) tool for physicians in the Women's Health Clinic (WHC), a primary care clinic within the Veterans Affairs Palo Alto Health Care System. This tool provides intelligent, evidence-based, step-by-step guidance on how to conduct IPV screening and intervention. METHODS: Informed by existing CDS development frameworks, developing the IPV CDS tool prototype involved six steps: (1) identifying the scope of the tool, (2) identifying IPV screening and intervention content, (3) incorporating IPV-related VHA and clinic resources, (4) identifying the tool's components, (5) designing the tool, and (6) conducting initial tool revisions. We obtained preliminary physician feedback on user experience and clinical utility of the CDS tool via the System Usability Scale (SUS) and semistructured interviews with 6 WHC physicians. SUS scores were examined using descriptive statistics. Interviews were analyzed using rapid qualitative analysis to extract actionable feedback to inform design updates and improvements. RESULTS: This study includes a detailed description of the IPV CDS tool. Findings indicated that the tool was generally well received by physicians, who indicated good tool usability (SUS score: mean 77.5, SD 12.75). They found the tool clinically useful, needed in their practice, and feasible to implement in primary care. They emphasized that it increased their confidence in managing patients reporting IPV but expressed concerns regarding its length, workflow integration, flexibility, and specificity of information. Several physicians, for example, found the tool too time consuming when encountering patients at high risk; they suggested multiple uses of the tool (eg, an educational tool for less-experienced health care providers and a checklist for more-experienced health care providers) and including more detailed information (eg, a list of local shelters). CONCLUSIONS: Physician feedback on the IPV CDS tool is encouraging and will be used to improve the tool. This study offers an example of an IPV CDS tool that clinics can adapt to potentially enhance the quality and efficiency of their IPV screening and intervention process. Additional research is needed to determine the tool's clinical utility in improving IPV screening and intervention rates and patient outcomes (eg, increased patient safety, reduced IPV risk, and increased referrals to mental health treatment).

The use of online methods to recruit and follow a hard-to-reach population in the Peer Alternatives for Addiction Study 2021 Cohort.

BACKGROUND: Although studies are increasingly adopting online protocols, few such studies in the addiction field have comprehensively described their data review procedures and successes in detecting low-quality/fraudulent data. The current study describes data collection protocols and outcomes of a large, longitudinal study (the PAL Study 2021) that implemented online design elements to study individuals seeking peer support for an alcohol use disorder. METHODS: In 2021, the PAL Study collaborated with mutual-help group (MHG) partners and recovery-related organizations to recruit individuals attending a 12-step group, Women for Sobriety (WFS), LifeRing Secular Recovery, and/or SMART Recovery for an alcohol problem in-person and/or online in the prior 30 days. Participation was solicited both online and in-person. Individuals accessed baseline surveys via an open web link; follow-ups occurred at 6 and 12 months. Analyses included calculating the proportion of surveys eliminated in data quality review; comparing MHG subsamples to internal survey (benchmark) data for Alcoholics Anonymous (AA), WFS, LifeRing, and SMART; and examining response rates and attrition. RESULTS: Although 93% of respondents who opened the baseline survey completed it, 87% of baseline surveys were eliminated in data quality review (final N = 531). Nonetheless, cleaned MHG subsamples were generally similar to benchmark samples on gender, age, race/ethnicity, and education. Follow-up rates for the cleaned sample were 88% (6 months) and 85% (12 months). Analyses revealed some differences in attrition by gender, primary MHG, and lifetime drug problems, but there was no evidence of greater attrition among those in earlier/less stable recovery. CONCLUSIONS: Study methods appear to have produced a valid, largely representative sample of the hard-to-reach target population that was successfully followed across 12 months. However, given the high survey elimination rate and need for extensive data review, we recommend that researchers avoid open-link designs and include comprehensive data review when incorporating online design elements.

Validation of an ultra-short global quality of life scale in a large population-based health survey.

INTRODUCTION: Quality of life (QoL) assessment is essential in health-related research and clinical settings, offering insights into individuals' well-being and functioning. This study validated the Essential QoL-3 (EQoL-3), an ultra-short scale assessing essential dimensions of QoL, for use in epidemiological research and clinical settings. METHODS: Data from a 2021 national survey in Norway (N = 17,487) were used. Three items on the EQoL-3 assess life satisfaction, happiness, and meaningfulness on a 0-10 scale. Discriminant validity was assessed by comparing the EQoL-3 with the Satisfaction with Life Scale (SWLS) and by examining latent mean differences between individuals with adverse life experiences (ALE+) and those without such experiences (ALE-). Convergent validity was evaluated through latent regression analyses comparing the EQoL-3 with a perceived mastery scale and a mental distress scale. RESULTS: The discriminant validity of the EQoL-3 was less than optimal when compared with the SWLS. Nonetheless, a multigroup confirmatory factor analysis revealed that the EQoL-3 score was 1.42 (95% CI = 1.33-1.50, p < 0.001) lower in the ALE+ group compared to the ALE- group, providing support for discriminant validity. Convergent validity was established with a positive association between EQoL-3 and mastery (ß = 1.75, 95% CI = 1.70-1.80, p < 0.001) and a negative association between the EQoL-3 and mental distress (ß = -2.64, 95% CI = -2.71/-2.59, p < 0.001). CONCLUSIONS: The EQoL-3 is a reliable measure of QoL. Its streamlined nature facilitates quick administration, making it a valuable tool for clinicians and researchers in diverse settings. Its inclusion of the eudaimonic dimension, as well as its exclusion of health items in the measure itself, distinguishes it from traditional HQoL measures, making it suitable for mental health and substance use disorder research.

Predictors of concerned others' mental health and quality of life over 12 months following adults' entry into treatment for an alcohol use disorder.

INTRODUCTION: People in treatment for alcohol use disorders (AUDs) can negatively impact their Concerned Others (COs). This longitudinal study examined patient and CO characteristics associated with CO outcomes. METHOD: Participants were 279 dyads of patients entering residential treatment and their CO. Outcomes were COs' mental health and quality of life. The study collected patient and CO predictors and CO outcomes at baseline and 3-, 6-, and 12-month follow-ups as part of a randomized controlled trial. In the first set of models, the analytic approach identified baseline patient predictors associated with COs' outcomes measured at baseline and follow-ups. In the second set of models, we examined whether those effects remained after adding baseline CO characteristics. RESULTS: In the first set of models, COs of older age and whose patient reported less CO-patient relationship stress had better mental health. Also, married COs and those with higher income and whose patient reported no violence in the CO-patient relationship had better quality of life. In the second set of models, COs whose patient entered treatment due to criminal justice involvement, with more social support, less reported stigma, and less use of avoidance coping had better mental health. Also, married COs, those with higher income, and less reported discrimination stigma had better quality of life. CONCLUSIONS: Understanding patient and CO characteristics that are associated with COs' outcomes may inform AUD treatment programs' efforts to help COs. Identifying modifiable determinants of CO outcomes is important to clinical practice regardless of whether the patient chooses to obtain treatment.

Mode of mutual-help group attendance: Predictors and outcomes in a US national longitudinal survey of adults with lifetime alcohol use disorder.

INTRODUCTION: Although attending substance use-focused mutual-help meetings online may reduce attendance barriers, associations of attendance mode with group participation and outcomes are unknown. Using longitudinal data from mutual-help group attendees, this study, after identifying differences in baseline characteristics by attendance mode, examined associations of attendance mode with mutual-help participation (number of meetings attended, involvement) and outcomes (alcohol abstinence, heavy drinking, alcohol problems). METHODS: The Peer Alternatives for Addiction Study 2021 Cohort sampled attendees of 12-step groups (e.g., Alcoholics Anonymous), Women for Sobriety, LifeRing Secular Recovery, and/or SMART Recovery in-person and/or online within 30 days before baseline. The baseline sample, recruited in fall 2021, was 531 adults with lifetime alcohol use disorder, followed at 6 (88 %) and 12 months (85 %). Differences in baseline characteristics by attendance mode were tested using Chi-squares and ANOVAs. GEE models examined associations of attendance mode, time, and their interactions with mutual-help group participation and alcohol outcomes. The in-person only mode was compared to the online-only, and to the in-person plus online, modes. RESULTS: At baseline, 53.7 % of participants had attended only online meetings in the past 30 days, 33.7 % had attended both in-person and online meetings, and 12.6 % had attended only in-person meetings. Online meeting attendees were less likely to endorse lifetime abstinence as an alcohol recovery goal than in-person-only meeting attendees. In adjusted models (including for recovery goal), those attending online meetings only, or both online and in-person meetings, attended a greater number of meetings compared to those attending only in-person meetings. However, online-only attendance was associated with less involvement than in-person-only attendance. In adjusted models, compared to baseline, involvement increased and outcomes improved at follow-ups. Adjusted models examining alcohol outcomes found that no attendance at mutual-help groups at follow-ups was associated with more heavy drinking compared to in-person-only attendance. CONCLUSIONS: Findings inform efforts to ascertain benefits of mutual-help group participation by suggesting that online attendance is associated with attending more meetings, less involvement, and lower endorsement of abstinence as a recovery goal, and is comparable to in-person attendance on alcohol outcomes. In-person attendance may be more beneficial for less heavy drinking than terminating attendance.

Scoping review of military veterans involved in the criminal legal system and their health and healthcare: 5-year update and map to the Veterans-Sequential Intercept Model.

BACKGROUND: A previous scoping review of legal-involved veterans' health and healthcare (1947-2017) identified studies and their limitations. Given the influx of literature published recently, this study aimed to update the previous review and map articles to the Veterans-Sequential Intercept Model (V-SIM) - a conceptual model used by key partners, including Veterans Health Administration, veteran advocates, criminal justice practitioners, and local governments to identify intercept points in the criminal legal system where resources and programming can be provided. Developing an updated resource of literature is essential to inform current research, discover gaps, and highlight areas for future research. METHODS: A systematic search of 5 databases identified articles related to legal-involved veterans' health and healthcare published between December 2017 through December 2022. The first and senior authors conducted abstract reviews, full-text reviews, and data extraction of study characteristics. Finally, each article was sorted by the various intercept points from the V-SIM. RESULTS: Of 903 potentially relevant articles, 107 peer-reviewed publications were included in this review, most related to mental health (66/107, 62%) and used an observational quantitative study design (95/107, 89%). Although most articles did not explicitly use the V-SIM to guide data collection, analyses, or interpretation, all could be mapped to this conceptual model. Half of the articles (54/107, 50%) collected data from intercept 5 (Community Corrections and Support Intercept) of the V-SIM. No articles gathered data from intercepts 0 (Community and Emergency Services Intercept), 1 (Law Enforcement Intercept), or 2 (Initial Detention and Court Hearings Intercept). CONCLUSIONS: There were 107 articles published in the last five years compared to 190 articles published in 70 years covered in the last review, illustrating the growing interest in legal-involved veterans. The V-SIM is widely used by front-line providers and clinical leadership, but not by researchers to guide their work. By clearly tying their research to the V-SIM, researchers could generate results to help guide policy and practice at specific intercept points. Despite the large number of publications, research on prevention and early intervention for legal-involved veterans is lacking, indicating areas of great need for future studies.

Behavioral weight management use in the Veterans Health Administration: Sociodemographic and health correlates.

INTRODUCTION: Over 40 % of United States Veterans Health Administration (VHA) primary care patients have obesity. Few patients use VHA's flagship weight management program, MOVE! and there is little information on other behavioral weight management program use. METHODS: The national United States cohort included over 1.5 million primary care patients with obesity, age 18-79, based on VHA administrative data. Gender stratified multivariable logistic regression identified correlates of weight management use in the year after a patient's first primary care appointment (alpha of 0.05). Weight management use was defined as MOVE! or nutrition clinic visits. RESULTS: The cohort included 121,235 women and 1,521,547 men with 13 % and 7 % using weight management, respectively. Point estimates for specific correlates of use were similar between women and men, and across programs. Black patients were more likely to use weight management than White patients. Several physical and mental health diagnoses were also associated with increased use, such as sleep apnea and eating disorders. Age and distance from VHA were negatively associated with weight management use. CONCLUSIONS: When assessing multiple types of weight management visits, weight management care in VHA appears to be used more often by some populations at higher risk for obesity. Other groups may need additional outreach, such as those living far from VHA. Future work should focus on outreach and prevention efforts to increase overall use rates. This work could also examine the benefits of tailoring care for populations in greatest need.

Medical-surgical patients with untreated hazardous drinking: Randomized controlled trial of the DO-MoST intervention to improve health outcomes over 12-month follow-up.

INTRODUCTION: High prevalence and harmful consequences of hazardous drinking among medical-surgical patients underscore the importance of intervening with drinking to improve patients' health. This study evaluated a novel intervention, "Drinking Options - Motivate, Shared Decisions, Telemonitor" (DO-MoST). METHODS: In a randomized design, 155 medical-surgical patients with untreated hazardous drinking were assigned to enhanced usual care or DO-MoST, and followed 3, 6, and 12 months later. We conducted intent-to-treat and per-protocol analyses. RESULTS: For the primary outcome, percent days of alcohol abstinence in the past 30 days, intent-to-treat analyses did not find superior effectiveness of DO-MoST. However, per-protocol analyses found abstinence increased between 3 and 12 months among participants assigned to DO-MoST who engaged with the intervention (n=46). Among DO-MoST-assigned participants who did not engage (n=27), abstinence stayed stable during follow-up. Group comparisons showed an advantage on abstinence for Engaged compared to Non-Engaged participants on change over time. Intent-to-treat analyses found that DO-MoST was superior to usual care on the secondary outcome of physical health at 12 months; per-protocol analyses found that Engaged DO-MoST-assignees had better physical health at 12 months than Non-Engaged DO-MoST-assignees. DO-MoST-assignees had lower odds of receiving substance use care during follow-up than usual care-assignees. DISCUSSION: Patients engaged in DO-MoST showed a greater degree of abstinence and better physical health relative to the non-engaged or usual care group. DO-MoST may be a source of alcohol help in itself rather than only a linkage intervention. Work is needed to increase DO-MoST engagement among medical-surgical patients with untreated hazardous drinking.

Health Conditions and Treatment Utilization Among Older Male Veterans Incarcerated in Prisons.

BACKGROUND: More than 50,000 older male veterans incarcerated in prisons are expected to return to their communities and utilize the Veterans Health Administration (VHA) and community healthcare systems. To support the continuity of healthcare and overall successful community reentry of older incarcerated veterans, an understanding of their health profiles and treatment utilization while in correctional care is needed. OBJECTIVE: To assess the health status of older male veterans incarcerated in state prisons and explore demographic, military, and VHA-related factors associated with medical conditions, disabilities, behavioral conditions, and medical and behavioral treatment utilization. DESIGN/PARTICIPANTS: Cross-sectional observational study of 880 male veterans aged 50 + incarcerated in state prisons using data from the 2016 Bureau of Justice Statistics Survey of Prison Inmates. MAIN MEASURES: Veteran status, self-report health status, and treatment utilization since prison admission. Prevalence rates for conditions and treatment utilization were calculated. Logistic regression models were used to examine the association of characteristics with conditions and treatment utilization. KEY RESULTS: Among the 880 older male veterans in state prisons, the majority reported having a current medical condition (79.3%) or disability (61.6%), almost half had history of a mental health condition (44.5%), and more than a quarter (29%) had a substance use disorder. Compared to White veterans, Black veterans were less likely to report a disability or mental health condition. Few demographic, military, and VA-related characteristics were associated with medical or behavioral conditions or treatment utilization. CONCLUSION: Our results suggest that the VHA and community healthcare systems need to be prepared to address medical and disability conditions among the majority of older male veterans who will be leaving prison and returning to their communities. Integrated medical and behavioral healthcare delivery models may be especially important for these veterans as many did not receive behavioral health treatment while in prison.

Disparities in Alcoholics Anonymous Participation from 2000 to 2020 Among U.S. Residents With an Alcohol Use Disorder in the National Alcohol Survey.

OBJECTIVE: Mutual-help groups (MHGs) like Alcoholics Anonymous (AA) are effective for resolving alcohol use disorders (AUDs), but few studies have examined disparities in MHG participation, particularly recently. We used five waves of National Alcohol Survey data to investigate whether prevalence of AA attendance among those with a lifetime AUD differed by race/ethnicity, age, and sex, directly testing whether these associations varied with time. METHOD: Analyses pooled weighted data from 2000 to 2020, including only participants with a lifetime AUD and identifying as non-Hispanic White, Latinx/Hispanic, or non-Hispanic Black/African American (N = 8,876). Logistic regression models examined associations between lifetime AA attendance and survey year, race/ethnicity, age, and sex; models also tested for differences in demographic effects across survey year using interaction terms. RESULTS: In bivariate models, AA attendance was significantly less prevalent among participants identifying as Latinx/Hispanic (vs. White); ages 18-29 (vs. 30-64); and female (vs. male). Survey year was unrelated to AA attendance, and all interactions involving survey year were nonsignificant. In the final multivariate model (which controlled for severity and other help-seeking), disparities persisted for those identifying as Latinx/Hispanic (vs. White; adjusted odds ratio [aOR] = 0.63) and ages 18-29 (vs. 30-64; aOR = 0.35); AA attendance was also less prevalent among Black/African American (vs. White) participants (aOR = 0.59), but sex became nonsignificant. CONCLUSIONS: Results replicate and extend sparse findings regarding disparities in MHG attendance and suggest a stagnation in AA's growth and reach to underserved populations. Findings highlight the need to more effectively facilitate MHG attendance (and perhaps broader social network change) among racial/ethnic minorities and emerging adults.

Hazardous Drinking Interventions Delivered During Medical-Surgical Care: Patient and Provider Views.

Addressing hazardous drinking during medical-surgical care improves patients' health. This formative evaluation examined patients' consideration of options to change drinking and engage in treatment. It explored whether interventions such as "DO-MoST" overcome treatment barriers. We interviewed 20 medical-surgical patients with hazardous drinking in a trial of DO-MoST, and 16 providers. Analyses used a directed content approach. Patients were receptive to and comfortable discussing drinking during medical-surgical care. Interventions like DO-MoST (patient-centered, motivational approach to shared decision making) addressed some treatment barriers. Patients and providers viewed such interventions as helpful by building a relationship with a psychologist who facilitated self-awareness of drinking behaviors, and discussing connections between alcohol- and physical health-related problems and potential strategies to address drinking. However, both groups expressed concerns about individual and system-level barriers to long-term change. Interventions like DO-MoST bridge the gap between the patient's medical treatment episode and transition to other health care settings. TRIAL REGISTRATION: The study is registered on ClinicalTrials.gov (ID: NCT03258632).

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

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

The EMBER trial for weight management engagement: A hybrid type 1 randomized controlled trial protocol.

BACKGROUND: Almost 40% of Veterans Health Administration (VHA) users have obesity. VHA's national weight management program is associated with weight loss and improved health. However, while 94% of eligible VHA users are offered weight management programs, <8% use them. We developed EMBER - a novel, Motivational Interviewing-based, self-help tool - with the goal of Enhancing Motivation for Better Engagement and Reach for weight management. EMBER is not a weight management program; instead it engages people in existing programs by informing and guiding choices about weight management. METHODS: The EMBER Trial is a randomized hybrid type 1 effectiveness implementation trial. Participants are Palo Alto or Houston VA Health Care System users with obesity who have not used a VHA weight management program in the past two years (target N = 470). Participants are randomly assigned to EMBER or an information-only control condition, after which they receive materials on paper or digitally, per their preference. The trial's primary goal is to determine whether participants randomized to EMBER are more likely to have any weight management engagement at two-month follow-up compared to those in the control condition. Secondary outcomes include 6-month retention in weight management, weight management behaviors, weight loss, quality of life, and implementation outcomes (e.g., reach, appropriateness). CONCLUSION: EMBER is the first self-directed, Motivational Interviewing-based intervention designed to increase weight management program engagement. The study takes a low-touch, population health approach that could be modified for other programs if effective. The Hybrid Type 1 design will ensure results can be scaled and sustained.

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

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

Adapting a Telephone-Based, Dyadic Self-management Program to Be Delivered Over the Web: Methodology and Usability Testing.

BACKGROUND: The COVID-19 pandemic has amplified the need for web-based behavioral interventions to support individuals who are diagnosed with chronic conditions and their informal caregivers. However, most interventions focus on patient outcomes. Dyadic technology-enabled interventions that simultaneously improve outcomes for patients and caregivers are needed. OBJECTIVE: This study aimed to describe the methodology used to adapt a telephone-based, facilitated, and dyadic self-management program called Self-care Using Collaborative Coping Enhancement in Diseases (SUCCEED) into a self-guided, web-based version (web-SUCCEED) and to conduct usability testing for web-SUCCEED. METHODS: We developed web-SUCCEED in 6 steps: ideation-determine the intervention content areas; prototyping-develop the wireframes, illustrating the look and feel of the website; prototype refinement via feedback from focus groups; finalizing the module content; programming web-SUCCEED; and usability testing. A diverse team of stakeholders including content experts, web designers, patients, and caregivers provided input at various stages of development. Costs, including full-time equivalent employee, were summarized. RESULTS: At the ideation stage, we determined the content of web-SUCCEED based on feedback from the program's original pilot study. At the prototyping stage, the principal investigator and web designers iteratively developed prototypes that included inclusive design elements (eg, large font size). Feedback about these prototypes was elicited through 2 focus groups of veterans with chronic conditions (n=13). Rapid thematic analysis identified two themes: (1) web-based interventions can be useful for many but should include ways to connect with other users and (2) prototypes were sufficient to elicit feedback about the esthetics, but a live website allowing for continual feedback and updating would be better. Focus group feedback was incorporated into building a functional website. In parallel, the content experts worked in small groups to adapt SUCCEED's content, so that it could be delivered in a didactic, self-guided format. Usability testing was completed by veterans (8/16, 50%) and caregivers (8/16, 50%). Veterans and caregivers gave web-SUCCEED high usability scores, noting that it was easy to understand, easy to use, and not overly burdensome. Notable negative feedback included "slightly agreeing" that the site was confusing and awkward. All veterans (8/8, 100%) agreed that they would choose this type of program in the future to access an intervention that aims to improve their health. Developing and maintaining the software and hosting together cost approximately US $100,000, excluding salary and fringe benefits for project personnel (steps 1-3: US $25,000; steps 4-6: US $75,000). CONCLUSIONS: Adapting an existing, facilitated self-management support program for delivery via the web is feasible, and such programs can remotely deliver content. Input from a multidisciplinary team of experts and stakeholders can ensure the program's success. Those interested in adapting programs should have a realistic estimate of the budget and staffing requirements.

Telephone monitoring and 15-month outcomes for patients with co-occurring substance use and mental health disorders: Moderating effects of high-risk patient characteristics.

INTRODUCTION: Telephone monitoring interventions for substance use disorders are an important component of continuing care to reduce relapse and connect patients to services. However, a knowledge gap still exists as to which patient groups benefit most from them. This secondary analysis of a randomized controlled trial examined moderators of associations between telephone monitoring and 15-month substance use outcomes among patients with co-occurring substance use and mental health disorders. High-risk patient characteristics at baseline were examined as potential moderators of the effectivness of telephone monitoring, including history of incarceration, severity of depression symptoms, and suicide risk. METHODS: Participants were 406 psychiatry inpatients with documented substance use and mental health disorders who were randomized to treatment as usual (TAU; n = 199) or TAU plus telephone monitoring (TM; n = 207). Outcomes included abstinence self-efficacy (Brief Situational Confidence Questionnaire) and alcohol and drug use severity (Addiction Severity Index composites) at 15-month follow-up. Analyses examined main effects of treatment condition and moderators, and interactions between treatment condition and moderators. RESULTS: The study found five significant main effects, three of which were qualified by significant interactions. Incarceration history was associated with higher drug use severity; higher suicide risk was associated with higher abstinence self-efficacy. Regarding interaction effects, among participants with an incarceration history, TM compared to TAU was associated with significantly lower alcohol use severity at 15-month follow-up; this finding did not hold for never-incarcerated participants. For participants with less severe depression symptoms, TM compared to TAU was associated with significantly lower alcohol use severity and higher abstinence self-efficacy at follow-up; this did not hold for participants with more severe depression symptoms. Suicide risk was not a significant moderator of any outcome. CONCLUSIONS: Results indicate that TM is effective in improving alcohol use severity and abstinence self-efficacy for some subgroups of patients, including patients with an incarceration history or less severe depression. Results inform the clinical provision of substance use disorder care by means of telehealth, which increased due to the COVID-19 pandemic.

Patient-Concerned Other Dyads' 12-Step Involvement and Patients' Substance Use: A Latent Class Growth Model Analysis.

OBJECTIVE: This study aimed to inform clinical practice by identifying subgroups of patient-concerned other (CO) dyads. Patients with alcohol use disorders (AUDs) were characterized on Alcoholics Anonymous (AA) involvement and substance use together with COs' Al-Anon involvement. Predictors and recovery maintenance outcomes of subgroup membership were examined. METHOD: Participants were 279 patient-CO dyads. Patients were in residential treatment for AUD. Parallel latent class growth model analysis characterized 12-step involvement and substance use at treatment entry and 3-, 6-, and 12-month follow-ups. RESULTS: Three classes were as follows: 38% Low AA/Low Al-Anon (patients' low AA and COs' low Al-Anon involvement, and patients' high-to-moderate substance use), 10% High AA/High Al-Anon (patients' high AA and COs' high Al-Anon involvement, and patients' moderate-to-low substance use), and 52% High AA/Low Al-Anon (patients' high AA and COs' low Al-Anon involvement, and patients' moderate-to-low substance use). At follow-up, the Low AA/Low Al-Anon classes' patients were less likely to have spirituality as recovery support, confidence about staying abstinent, and satisfaction with recovery progress. The High AA classes' COs had less concern about patients' drinking and scored higher on positive aspects of relationships with patients. CONCLUSIONS: Clinicians should encourage patients' and COs' 12-step group involvement (12-step practices' engagement). Among patients treated for AUD, AA involvement was related to better outcomes, and to COs' lessened concern about the patients' drinking. COs' Al-Anon involvement was associated with having a more positive view of their relationship with the patient. That more than one third of dyads had low 12-step group involvement suggests that treatment programs may need to facilitate involvement in non-12-step mutual-help groups.

Stand Down-Think Before You Drink: protocol for an effectiveness-implementation trial of a mobile application for unhealthy alcohol use with and without peer support.

INTRODUCTION: Mobile apps can increase access to alcohol-related care but only if patients actively engage with them. Peers have shown promise for facilitating patients' engagement with mobile apps. However, the effectiveness of peer-based mobile health interventions for unhealthy alcohol use has yet to be evaluated in a randomised controlled trial. The goal of this hybrid I effectiveness-implementation study is to test a mobile app ('Stand Down-Think Before You Drink'), with and without peer support, to improve drinking outcomes among primary care patients. METHODS AND ANALYSIS: In two US Veterans Health Administration (VA) medical centres, 274 primary care patients who screen positive for unhealthy alcohol use and are not currently in alcohol treatment will be randomised to receive usual care (UC), UC plus access to Stand Down (App), or UC plus Peer-Supported Stand Down (PSSD-four peer-led phone sessions over the initial 8 weeks to enhance app engagement). Assessments will occur at baseline and 8-, 20- and 32-weeks postbaseline. The primary outcome is total standard drinks; secondary outcomes include drinks per drinking day, heavy drinking days and negative consequences from drinking. Hypotheses for study outcomes, as well as treatment mediators and moderators, will be tested using mixed effects models. Semi-structured interviews with patients and primary care staff will be analysed using thematic analysis to identify potential barriers and facilitators to implementation of PSSD in primary care. ETHICS AND DISSEMINATION: This protocol is a minimal risk study and has received approval from the VA Central Institutional Review Board. The results have the potential to transform the delivery of alcohol-related services for primary care patients who engage in unhealthy levels of drinking but rarely seek treatment. Study findings will be disseminated through collaborations with healthcare system policymakers as well as publications to scholarly journals and presentations at scientific conferences. TRIAL REGISTRATION NUMBER: NCT05473598.

Research and policy recommendations from the SOTA XVI: State of the Art Conference on VA Emergency Medicine.

To better understand and prioritize research on emergency care for Veterans, the Department of Veteran Affairs (VA) Health Services Research and Development convened the 16th State of the Art Conference on VA Emergency Medicine (SAVE) in Winter 2022 with emergency clinicians, researchers, operational leaders, and additional stakeholders in attendance. Three specific areas of focus were identified including older Veterans, Veterans with mental health needs, and emergency care in the community (non-VA) settings. Among older Veterans, identified priorities included examination of variation in care and its impact on patient outcomes, utilization, and costs; quality of emergency department (ED) care transitions and strategies to improve them; impact of geriatric ED care improvement initiatives; and use of geriatric assessment tools in the ED. For Veterans with mental health needs, priorities included enhancing the reach of effective, multicomponent suicide prevention interventions; development and evaluation of interventions to manage substance use disorders; and identifying and examining safety and effective acute psychosis practices. Community (non-VA) emergency care priorities included examining changes in patterns of use and costs in VA and the community care settings as a result of recent policy and coverage changes (with an emphasis on modifiable factors); understanding quality, safety, and Veteran experience differences between VA and community settings; and better understanding follow-up needs among Veterans who received emergency care (or urgent care) and how well those needs are being coordinated, communicated, and met. Beyond these three groups, cross-cutting themes included the use of telehealth and implementation science to refine multicomponent interventions, care coordination, and data needs from both VA and non-VA sources. Findings from this conference will be disseminated through multiple mechanisms and contribute to future funding applications focused on improving Veteran health.

Weight Management Treatment Representations: A Novel Use of the Common Sense Model.

We used the Common Sense Model to understand weight management treatment representations of diverse patients, conducting semistructured interviews with 24 veterans with obesity, recruited from multiple U.S. Veterans Health Administration facilities. We performed a directed content analysis to summarize representations and assess differences across demographic groups. Patients' representations were impacted by gender, socioeconomic status, and disability status, creating group differences in available treatment (e.g., disability-related limitations), negative consequences (e.g., expense), treatment timeline (e.g., men emphasized long-term lifestyle changes), and treatment models (e.g., women described medically driven models). Patients identified conventional representations aligning with medical recommendations and relating to positive consequences, long-term treatment timelines, and medically driven models. Finally, patients discussed risky representations, including undesirable attitudes related to short-term positive and negative consequences and long-term negative consequences. Applying the Common Sense Model emphasized diverse representations, influenced by patients' identities. Understanding representations may improve treatment to meet the needs of diverse preferences.