Factors Associated with Delayed Care Among Women Veterans Actively Engaged in Primary Care.

Background: Delaying needed medical care contributes to greater health risks and higher long-term medical costs. Women Veterans with complex medical and mental health needs face increased barriers to timely care access. Objectives: In a sample of women Veterans with recent engagement in Veterans Administration (VA) primary care, we aimed to compare characteristics of women Veterans who delayed care in the past 6 months with those who did not and examine factors associated with self-reported delayed care. Our study aims to inform interventions focused on eliminating health care access disparities among women Veterans. Materials and Methods: An innovation to improve women Veterans' engagement and retention in evidence-based health care for cardiovascular (CV) risk reduction (CV Toolkit) was implemented across five primary care sites within the VA. Women Veterans who were exposed to at least one CV Toolkit component participated in a mailed survey (n = 253). We used multivariate logistic regression to model factors associated with delaying care, including trust in VA providers, positive mental health screening (i.e., positive screen for either depression or anxiety), traumatic experience, self-rated health, and age. Results: Women with any mental health symptoms (odds ratio [OR] 2.42, 95% confidence interval [CI]: 1.23-4.74) and women who had experienced a traumatic event (OR 2.61, 95%CI: 1.11-6.14) were significantly more likely to report delaying care. Conclusions: Our study identified high rates of delayed care-over one-third of respondents-among women Veterans with recent primary care engagement. Mental health symptoms were the most common reported reason for delay among those who delayed care. Clinical Trial registration: NCT02991534.

Racial, Ethnic, and Rural Disparities in US Veteran COVID-19 Vaccine Rates.

Background: Race, ethnicity, and rurality-related disparities in coronavirus disease 2019 (COVID-19) vaccine uptake have been documented in the United States (US). Objective: We determined whether these disparities existed among patients at the Department of Veterans Affairs (VA), the largest healthcare system in the US. Design Settings Participants Measurements: Using VA Corporate Data Warehouse data, we included 5,871,438 patients (9.4% women) with at least one primary care visit in 2019 in a retrospective cohort study. Each patient was assigned a single race/ethnicity, which were mutually exclusive, self-reported categories. Rurality was based on 2019 home address at the zip code level. Our primary outcome was time-to-first COVID-19 vaccination between December 15, 2020-June 15, 2021. Additional covariates included age (in years), sex, geographic region (North Atlantic, Midwest, Southeast, Pacific, Continental), smoking status (current, former, never), Charlson Comorbidity Index (based on ≥1 inpatient or two outpatient ICD codes), service connection (any/none, using standardized VA-cutoffs for disability compensation), and influenza vaccination in 2019-2020 (yes/no). Results: Compared with unvaccinated patients, those vaccinated (n=3,238,532; 55.2%) were older (mean age in years vaccinated=66.3, (standard deviation=14.4) vs. unvaccinated=57.7, (18.0), p<.0001)). They were more likely to identify as Black (18.2% vs. 16.1%, p<.0001), Hispanic (7.0% vs. 6.6% p<.0001), or Asian American/Pacific Islander (AA/PI) (2.0% vs. 1.7%, P<.0001). In addition, they were more likely to reside in urban settings (68.0% vs. 62.8, p<.0001). Relative to non-Hispanic White urban Veterans, the reference group for race/ethnicity-urban/rural hazard ratios reported, all urban race/ethnicity groups were associated with increased likelihood for vaccination except American Indian/Alaskan Native (AI/AN) groups. Urban Black groups were 12% more likely (Hazard Ratio (HR)=1.12 [CI 1.12-1.13]) and rural Black groups were 6% more likely to receive a first vaccination (HR=1.06 [1.05-1.06]) relative to white urban groups. Urban Hispanic, AA/PI and Mixed groups were more likely to receive vaccination while rural members of these groups were less likely (Hispanic: Urban HR=1.17 [1.16-1.18], Rural HR=0.98 [0.97-0.99]; AA/PI: Urban HR=1.22 [1.21-1.23], Rural HR=0.86 [0.84-0.88]). Rural White Veterans were 21% less likely to receive an initial vaccine compared with urban White Veterans (HR=0.79 [0.78-0.79]). AI/AN groups were less likely to receive vaccination regardless of rurality: Urban HR=0.93 [0.91-0.95]; AI/AN-Rural HR=0.76 [0.74-0.78]. Conclusions: Urban Black, Hispanic, and AA/PI Veterans were more likely than their urban White counterparts to receive a first vaccination; all rural race/ethnicity groups except Black patients had lower likelihood for vaccination compared with urban White patients. A better understanding of disparities and rural outreach will inform equitable vaccine distribution.

Documentation of Screening for Firearm Access by Healthcare Providers in the Veterans Healthcare System: A Retrospective Study.

INTRODUCTION: Presence of a firearm is associated with increased risk of violence and suicide. United States military veterans are at disproportionate risk of suicide. Routine healthcare provider screening of firearm access may prompt counseling on safe storage and handling of firearms. The objective of this study was to determine the frequency with which Veterans Health Administration (VHA) healthcare providers document firearm access in electronic health record (EHR) clinical notes, and whether this varied by patient characteristics. METHODS: The study sample is a post-9-11 cohort of veterans in their first year of VHA care, with at least one outpatient care visit between 2012-2017 (N = 762,953). Demographic data, veteran military service characteristics, and clinical comorbidities were obtained from VHA EHR. We extracted clinical notes for outpatient visits to primary, urgent, or emergency clinics (total 105,316,004). Natural language processing and machine learning (ML) approaches were used to identify documentation of firearm access. A taxonomy of firearm terms was identified and manually annotated with text anchored by these terms, and then trained the ML algorithm. The random-forest algorithm achieved 81.9% accuracy in identifying documentation of firearm access. RESULTS: The proportion of patients with EHR-documented access to one or more firearms during their first year of care in the VHA was relatively low and varied by patient characteristics. Men had significantly higher documentation of firearms than women (9.8% vs 7.1%; P < .001) and veterans >50 years old had the lowest (6.5%). Among veterans with any firearm term present, only 24.4% were classified as positive for access to a firearm (24.7% of men and 20.9% of women). CONCLUSION: Natural language processing can identify documentation of access to firearms in clinical notes with acceptable accuracy, but there is a need for investigation into facilitators and barriers for providers and veterans to improve a systemwide process of firearm access screening. Screening, regardless of race/ethnicity, gender, and age, provides additional opportunities to protect veterans from self-harm and violence.

Tailoring an evidence-based lifestyle intervention to meet the needs of women Veterans with prediabetes.

Prediabetes affects one-third of U.S. adults. Lifestyle change interventions, such as the Diabetes Prevention Program (DPP), can significantly lower type 2 diabetes risk, but little is known about how the DPP could be best adapted for women. This mixed-methods study assessed the impact of gender-tailoring and modality choice on DPP engagement among women Veterans with prediabetes. Participants were offered women-only groups and either in-person/peer-led or online modalities. Implementation outcomes were assessed using attendance logs, recruitment calls, and semi-structured interviews about patient preferences. Between June 2016 and March 2017, 119 women Veterans enrolled in the DPP (n = 51 in-person, n = 68 online). We conducted 22 interviews between August and September 2016 (n = 10 early-implementation) and March and July 2017 (n = 12 follow-up). Most interviewees preferred women-only groups, citing increased comfort, camaraderie, and mutual understanding of gender-specific barriers to lifestyle change. More women preferred online DPP, and those using this modality participated at higher rates. Most endorsed the importance of modality choice and were satisfied with their selection; however, selection was frequently based on participants' personal circumstances and access barriers and not on a "preferred choice" of two equally accessible options. Patient engagement and program reach can be expanded by tailoring the DPP for population-specific needs.

Assessment of the healthcare needs and barriers to VA use experienced by women veterans: findings from the national survey of women Veterans.

BACKGROUND: Prior regional studies of women Veterans identified barriers to Veterans Affairs (VA) healthcare use. However, these studies do not reflect the demographic profile of women Veterans nationally, recent advances in VA women's healthcare, and the national context of expanded healthcare alternatives. OBJECTIVE: To characterize health, VA perceptions, barriers, healthcare delivery preferences, and reasons for VA or non-VA healthcare use in a national women Veteran sample. METHODS: Cross-sectional, population-based 2008-2009 National Survey of Women Veterans (n=3611). RESULTS: VA users had worse physical and mental health than non-VA-only users and healthcare nonusers. Older women Veterans had worse physical health, whereas younger groups had worse mental health. Healthcare use was highest for dual users, followed by VA-only users, but did not differ by age group. Healthcare nonusers were most likely to lack a regular source for healthcare. Perceptions of VA care quality and sex-appropriateness were highest for VA-only, followed by dual, then non-VA-only users. VA perceptions were guided by personal experience for 90% of VA users, versus media or other secondhand sources for 70% of other groups. Non-VA-only users and healthcare nonusers had more knowledge gaps about VA and misperceptions about VA eligibility and services; non-VA-only users more likely encountered VA enrollment barriers. CONCLUSIONS: Many nonusers had healthcare needs that were not met. Positive VA perceptions by women with first-hand VA experience, contrasted with VA knowledge gaps by those without such exposure, suggests the need for more education about available VA healthcare services. VA planning should account for mental health needs and healthcare use by younger women Veterans.

Clinician advice to quit smoking among seniors.

OBJECTIVE: Little smoking research in the past 20years includes persons 50 and older; herein we describe patterns of clinician cessation advice to US seniors, including variation by Medicare beneficiary characteristics. METHOD: In 2012-4, we analyzed 2010 Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data from Medicare beneficiaries over age 64 (n=346,674). We estimated smoking rates and the proportion of smokers whose clinicians encouraged cessation. RESULTS: 12% of male and 8% of female respondents aged 65 and older smoke. The rate decreases with age (14% of 65-69, 3% of 85+) and education (12-15% with no high school degree, 5-6% with BA+). Rates are highest among American Indian/Alaskan Native (16%), multiracial (14%), and African-American (13%) seniors, and in the Southeast (14%). Only 51% of smokers say they receive cessation advice "always" or "usually" at doctor visits, with advice more often given to the young, those in low-smoking regions, Asians, and women. For all results cited p<0.05. CONCLUSIONS: Smoking cessation advice to seniors is variable. Providers may focus on groups or areas in which smoking is less common or when they are most comfortable giving advice. More consistent interventions are needed, including cessation advice from clinicians.

Gender differences in smoking and smoking cessation treatment: an examination of the organizational features related to care.

OBJECTIVES: Veterans experience a particularly heavy burden with smoking rates higher than the general population, and the smoking prevalence for women Veterans has increased in recent years. We examined differences in smoking prevalence and treatment by gender for Veterans receiving at least some of their care at a VA facility, and examined the degree to which organizational factors may be associated with reductions in gender disparities in smoking cessation treatment. METHODS: We merged national organizational-level data focused on primary care (sites = 225) and women's health (sites = 195) with patient-level survey data (n = 15,033 smokers). Organizational measures focused on smoking cessation-specific structure and processes in primary care and women's health. Primary outcomes were patient-reported receipt of smoking cessation treatments-advised to quit, medication recommendation, and other treatment recommendation. We used multi-level, random-intercept logistic regression. RESULTS: In 2007, 29% of women and 23% of men were smokers. Overall, 83% of smokers reported they had been advised to quit, 62% recommended medications, and 60% recommended other treatments. Women were more likely to report being advised to quit (odds ratio, 1.33; 95% confidence interval, 1.07-1.64) but equally likely as men to have medications or other treatment recommended. Organizational factors did not eliminate the gender differences in being advised to quit. CONCLUSION: Despite having equivalent or higher smoking cessation treatment rates, women Veterans were more likely to smoke than men. With the rapid growth of women entering VA care, the need for effective gender-focused and gender-sensitive smoking cessation care arrangements is critical for the future health of women who have served.

Targeting primary care referrals to smoking cessation clinics does not improve quit rates: implementing evidence-based interventions into practice.

OBJECTIVE: To evaluate the impact of a locally adapted evidence-based quality improvement (EBQI) approach to implementation of smoking cessation guidelines into routine practice. DATA SOURCES/STUDY SETTING: We used patient questionnaires, practice surveys, and administrative data in Veterans Health Administration (VA) primary care practices across five southwestern states. STUDY DESIGN: In a group-randomized trial of 18 VA facilities, matched on size and academic affiliation, we evaluated intervention practices' abilities to implement evidence-based smoking cessation care following structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback, and monitoring. Control practices received mailed guidelines and VA audit-feedback reports as usual care. DATA COLLECTION: To represent the population of primary care-based smokers, we randomly sampled and screened 36,445 patients to identify and enroll eligible smokers at baseline (n=1,941) and follow-up at 12 months (n=1,080). We used computer-assisted telephone interviewing to collect smoking behavior, nicotine dependence, readiness to change, health status, and patient sociodemographics. We used practice surveys to measure structure and process changes, and administrative data to assess population utilization patterns. PRINCIPAL FINDINGS: Intervention practices adopted multifaceted EBQI plans, but had difficulty implementing them, ultimately focusing on smoking cessation clinic referral strategies. While attendance rates increased (p<.0001), we found no intervention effect on smoking cessation. CONCLUSIONS: EBQI stimulated practices to increase smoking cessation clinic referrals and try other less evidence-based interventions that did not translate into improved quit rates at a population level.

Predictors of colorectal cancer screening from patients enrolled in a managed care health plan.

BACKGROUND: Despite the growing recognition of the importance of colorectal cancer (CRC) screening in reducing cancer mortality, national screening rates are low, indicating a critical need to understand the barriers and remedies for underutilization of CRC screening tests. METHODS: Using results from independent cross-sectional telephone surveys with patients aged>or=50 years performed before (2000; n=498) and after (2003; n=482) a quality improvement intervention for CRC screening within a large managed care health plan, the trends and predictors of CRC screening with fecal occult blood test (FOBT) and/or endoscopy (flexible sigmoidoscopy/colonoscopy) were examined from a patient perspective. RESULTS: In 2000, patient reported screening rates within guidelines were 38% for any test, 23% for endoscopy, and 22% for FOBT. In 2003, screening rates increased to 50% for any test, 39% for endoscopy, and 24% for FOBT. Having discussed CRC with a doctor significantly increased the odds of being screened (FOBT: odds ratio [OR], 2.09 [95% confidence interval (95% CI), 1.47-2.96]; endoscopy: OR, 2.33 [95% CI, 1.67-3.26]; and any test: OR, 2.86 [95% CI, 2.06-3.96]), and reporting barriers to CRC in general decreased the odds of being screened (FOBT: OR, 0.76 [95% CI, 0.60-0.95]; endoscopy: OR, 0.74 [95% CI, 0.60-0.92]; and any test: OR, 0.66 [95% CI, 0.54-0.80]). CONCLUSIONS: Although screening rates increased over the 3-year period, evidence was found of ongoing underutilization of CRC screening. The 2 strongest determinants of obtaining CRC screening were provider influence and patient barriers related to CRC screening in general, pointing to the need for multilevel interventions that target both the provider and patient.

Results of a randomized controlled trial to increase colorectal cancer screening in a managed care health plan.

BACKGROUND: Colorectal cancer (CRC) is the third most common cause of cancer deaths; however, rates of regular screening for this cancer are low. A quality improvement (QI) program to increase CRC screening was developed for use in a managed care health plan. METHODS: Thirty-six provider organizations (POs) contracting with the health plan were recruited for a randomized controlled effectiveness trial testing the QI program. The intervention was delivered over a 2-year period, and its effectiveness was assessed by chart review of a random sample of patients from each PO. RESULTS: Thirty-two of the 36 POs were evaluable for outcome assessment. During the 2-year intervention period, only 26% of the eligible patients received any CRC screening test. Twenty-nine percent of patients had any CRC screening test within guidelines, with no differences between the intervention or control POs. Significant predictors of having received CRC screening within guidelines were older age (P = 0.0004), receiving care in an integrated medical group (P < 0.0001) and having had a physical examination within the past 2 years (P < 0.0001). CONCLUSIONS: A facilitated QI intervention program for CRC screening that focused on the PO did not increase rates of CRC screening. Overall CRC screening rates are low and are in need of improvement.

Are racial disparities in health conditional on socioeconomic status?

Racial health inequality is related to socioeconomic status (SES), but debate ensues on the nature of the relationship. Using the US National Health and Nutrition Examination Survey I and the subsequent follow-up interviews, this research examines health disparities between white and black adults and whether the SES/health gradient differs across the two groups in the USA. Two competing mechanisms for the conditional or interactive relationship between race and SES on health are examined during a 20-year period for black and white Americans. Results show that black adults began the study with more serious illnesses and poorer self-rated health than white adults and that the disparity continued over the 20 years. Significant interactions were found between race and education as well as race and employment status on health outcomes. The interaction effect of race and education showed that the racial disparity in self-rated health was largest at the higher levels of SES, providing some evidence for the "diminishing returns" hypothesis; as education levels increased, black adults did not have the same improvement in self-rated health as white adults. Overall, the findings provide evidence for the continuing significance of both race and SES in determining health status over time.

Primary care provider perceptions of barriers to and facilitators of colorectal cancer screening in a managed care setting.

BACKGROUND: Colorectal cancer (CRC) screening tests (e.g., fecal occult blood testing [FOBT], flexible sigmoidoscopy [FS], etc.) are underused. Primary care providers (PCPs) play a critical role in screening, but barriers to and facilitators of screening as perceived by PCPs in managed care settings are poorly understood. The objectives of the current study were to describe current CRC screening practices and to explore determinants of test use by PCPs in a managed care setting. METHODS: In 2000, a self-administered survey was mailed to a stratified, random sample of 1340 PCPs in a large, network model health maintenance organization in California. RESULTS: The survey response rate was 67%. PCPs indicated that 79% of their standard-risk patients were screened for CRC. PCP-reported median rates of recommendation for the use of specific screening tests were 90% for FOBT and 70% for FS. In logistic regression models, perceived barriers to the use of FOBT and FS included patient characteristics (e.g., education) and PCP-related barriers (e.g., failure to recall that patients were due for testing). Perceived facilitators of the use of FOBT and FS included interventions targeting certain aspects of the health care system (e.g., reimbursement) and interventions targeting certain aspects of the tests themselves (e.g., provision of evidence of a test's effectiveness). Assignment of high priority to screening, integrated medical group (as opposed to independent practice association) affiliation, and the proportion of patients receiving routine health maintenance examinations were positively associated with reported test use. CONCLUSIONS: CRC screening tests appear to be underused in the managed care setting examined in the current study. The perceived barriers and facilitators that were identified can be used to guide interventions aimed at increasing recommendations for, as well as actual performance of, CRC screening.

Improving colorectal cancer screening rates in a managed care health plan: recruitment of provider organizations for a randomized effectiveness trial.

Evidence-based guidelines recommend regular colorectal cancer (CRC) screening for adults 50 years and older, yet screening rates remain very low. In this paper we describe the challenges associated with recruitment and retention of provider organizations (POs) for a group randomized, controlled effectiveness trial to increase CRC screening, among patients in a managed care health insurance plan. Using the health plan as the sampling frame, we recruited POs to test a facilitated quality improvement program to increase CRC screening. Defined eligibility and recruitment procedures were used as part of this process. We successfully recruited 36 POs over the course of 9 months; however, there were many challenges associated with the recruitment and retention process, including difficulties in (a) identifying the PO medical director and the individual authorized to agree to study participation, (b) making contact with the medical director, and (c) obtaining the materials necessary to initiate the study. All of these factors delayed the research substantially. Retention activities were also a major challenge in that one-third of the medical directors changed during the course of the intervention. This study benefited from a strong partnership between the health plan and the research group. Although many challenges exist, there are tremendous opportunities that result from the design and conduct of effectiveness research in existing POs. Successful implementation of programs that are feasible and take advantage of existing quality improvement mechanisms within the PO has potential to improve CRC screening rates and can have a major public health impact.