Practice Pattern Variation in Adoption of New and Evolving Percutaneous Coronary Intervention Procedures.

Objective: Assess factors contributing to variation in the use of new and evolving diagnostic and interventional procedures for percutaneous coronary intervention (PCI). Background: Evidence-based practices for PCI have the potential to improve outcomes but are variably adopted. Finding possible drivers of PCI procedure-use variability is key for efforts aimed at establishing more uniform practice. Methods: Veterans Affairs Clinical Assessment, Reporting, and Tracking Program data were used to estimate a proportion of variation attributable to hospital-, operator-, and patient-level factors across (a) radial arterial access, (b) intravascular imaging/optical coherence tomography, and (c) atherectomy for PCI. We used random-effects models with hospital, operator, and patient random effects. Overlap between levels generated cumulative variability estimates greater than 100%. Results: A total of 445 operators performed 95,391 PCI procedures across 73 hospitals from 2011 to 2018. The rates of all procedures increased over this time. 24.45% of variability in the use of radial access was attributable to the hospital, 53.04% to the operator, and 57.83% to patient-level characteristics. 9.06% of the variability in intravascular imaging use was attributable to the hospital, 43.92% to the operator, and 21.20% to the patient. Lastly, 20.16% of the variability in use of atherectomy was attributed to the hospital, 34.63% to the operator, and 57.50% to the patient. Conclusions: The use of radial access, intracoronary imaging, and atherectomy is influenced by patient, operator, and hospital factors, but patient and operator-level effects predominate. Efforts to increase the use of evidence-based practices for PCI should consider interventions at these levels.

Association Between Mental Health Staffing Level and Primary Care-Mental Health Integration Level on Provision of Depression Care in Veteran's Affairs Medical Facilities.

We examined the association of mental health staffing and the utilization of primary care/mental health integration (PCMHI) with facility-level variations in adequacy of psychotherapy and antidepressants received by Veterans with new, recurrent, and chronic depression. Greater likelihood of adequate psychotherapy was associated with increased (1) PCMHI utilization by recurrent depression patients (AOR 1.02; 95% CI 1.00, 1.03); and (2) staffing for recurrent (AOR 1.03; 95% CI 1.01, 1.06) and chronic (AOR 1.02; 95% CI 1.00, 1.03) depression patients (p < 0.05). No effects were found for antidepressants. Mental health staffing and PCMHI utilization explained only a small amount of the variance in the adequacy of depression care.

Recruiting Sexual and Gender Minority Veterans for Health Disparities Research: Recruitment Protocol of a Web-Based Prospective Cohort Study.

BACKGROUND: The Health for Every Veteran Study is the first Veterans Health Administration-funded, nationwide study on lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) veterans' health that relies exclusively on primary recruitment methods. This study aimed to recruit 1600 veterans with diverse sexual and gender identities to study the mental health and health risk behaviors of this population. A growing body of literature highlights the health inequities faced by LGBTQ+ veterans when compared with their heterosexual or cisgender peer groups. However, there is little to no guidance in the health disparities literature describing the recruitment of LGBTQ+ veterans. OBJECTIVE: This paper provides an overview of the recruitment methodology of Health for Every Veteran Study. We describe the demographics of the enrolled cohort, challenges faced during recruitment, and considerations for recruiting LGBTQ+ veterans for health research. METHODS: Recruitment for this study was conducted for 15 months, from September 2019 to December 2020, with the goal of enrolling 1600 veterans evenly split among 8 sexual orientation and gender identity subgroups: cisgender heterosexual women, cisgender lesbian women, cisgender bisexual women, cisgender heterosexual men, cisgender gay men, cisgender bisexual men, transgender women, and transgender men. Three primary recruitment methods were used: social media advertising predominantly through Facebook ads, outreach to community organizations serving veterans and LGBTQ+ individuals across the United States, and contracting with a research recruitment company, Trialfacts. RESULTS: Of the 3535 participants screened, 1819 participants met the eligibility criteria, and 1062 completed the baseline survey to enroll. At baseline, 25.24% (268/1062) were recruited from Facebook ads, 40.49% (430/1062) from community outreach, and 34.27% (364/1062) from Trialfacts. Most subgroups neared the target enrollment goals, except for cisgender bisexual men, women, and transgender men. An exploratory group of nonbinary and genderqueer veterans and veterans with diverse gender identities was included in the study. CONCLUSIONS: All recruitment methods contributed to significant portions of the enrolled cohort, suggesting that a multipronged approach was a critical and successful strategy in our study of LGBTQ+ veterans. We discuss the strengths and challenges of all recruitment methods, including factors impacting recruitment such as the COVID-19 pandemic, negative comments on Facebook ads, congressional budget delays, and high-volume surges of heterosexual participants from community outreach. In addition, our subgroup stratification offers important disaggregated insights into the recruitment of specific LGBTQ+ subgroups. Finally, the web-based methodology offers important perspectives not only for reaching veterans outside of the Veterans Health Administration but also for research studies taking place in the COVID-19-impacted world. Overall, this study outlines useful recruitment methodologies and lessons learned to inform future research that seeks to recruit marginalized communities. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/43824.

Depression and anxiety diagnoses are not associated with delayed resolution of abnormal mammograms and pap tests among vulnerable women.

BACKGROUND: Delays in care after abnormal cancer screening contribute to disparities in cancer outcomes. Women with psychiatric disorders are less likely to receive cancer screening and may also have delays in diagnostic resolution after an abnormal screening test. OBJECTIVE: To determine if depression and anxiety are associated with delays in resolution after abnormal mammograms and Pap tests in a vulnerable population of urban women. DESIGN: We conducted retrospective chart reviews of electronic medical records to identify women who had a diagnosis of depression or anxiety in the year prior to the abnormal mammogram or Pap test. We used time-to-event analysis to analyze the outcome of time to resolution after abnormal cancer screening, and Cox proportional hazards regression modeling to control for confounding. PARTICIPANTS: Women receiving care in six Boston-area community health centers 2004-2005: 523 with abnormal mammograms, 474 with abnormal Pap tests. RESULTS: Of the women with abnormal mammogram and pap tests, 19% and 16%, respectively, had co-morbid depression. There was no difference in time to diagnostic resolution between depressed and not-depressed women for those with abnormal mammograms (aHR = 0.9, 95 CI 0.7,1.1) or Pap tests (aHR = 0.9, 95 CI 0.7,1.3). CONCLUSIONS: An active diagnosis of depression and/or anxiety in the year prior to an abnormal mammogram or Pap test was not associated with a prolonged time to diagnostic resolution. Our findings imply that documented mood disorders do not identify an additional barrier to resolution after abnormal cancer screening in a vulnerable population of women.

Trends in Arterial Access Site Selection and Bleeding Outcomes Following Coronary Procedures, 2011-2018.

BACKGROUND: Prior studies of radial access for cardiac catheterization have focused on early adopters of the technique, and some have described a risk/treatment paradox of low radial access use among high bleeding risk patients. This study aimed to determine (1) trends in radial access use over time, (2) if increasing use of radial access is driven by new invasive and interventional cardiologists (operators) or existing operators changing their practice, and (3) if increasing radial rates are associated with lower bleeding rates and elimination of the risk/treatment paradox. METHODS: In this cross-sectional study using data from the Clinical Assessment, Reporting, and Tracking Program, we calculated radial access rates and risk-adjusted postprocedural bleeding rates of patients undergoing diagnostic angiography or percutaneous coronary intervention (PCI) between 2011 and 2018 in Veterans Affairs hospitals. We used separate bleeding risk models for diagnostic angiography and PCI and assessed temporal trends with the Kendall Tau-b test. RESULTS: Among 253 179 diagnostic angiograms and 93 614 PCIs, radial access rates increased over time for both diagnostic (17.5%-60.4%; P<0.01)) and PCI procedures (14.0%-51.8%; P<0.01). Existing operators and new operators increased their use at similar rates, but new operators entered practice with higher baseline rates. Nearly all operators used radial access at least once in 2018. Overall adjusted rates of bleeding declined, a trend that was significant for diagnostic angiography (2.4%-1.4%, P=0.02) but not PCI (3.4%-2.5%, P=0.20). Femoral access patients had a higher predicted risk for bleeding. CONCLUSIONS: A steady rise in radial access for diagnostic angiography and PCI was driven by increasing use among existing operators and high use by new operators. While this was associated with decreasing bleeding rates, a risk/treatment paradox for access site selection persists; patients at higher bleeding risk were still more likely to receive femoral access.

Disparities in Mental Health and Health Risk Behaviors for LGBT Veteran Subgroups in a National U.S. Survey.

Purpose: This study examined differences in mental health and health risk behaviors across sexual orientation and gender identity among U.S. veterans. Methods: Veterans were recruited through targeted social media advertising, community organizations, and listservs to complete an online survey (N = 1062). Generalized linear regression was used to evaluate differences in outcomes between subgroups, which included cisgender heterosexual men and women, lesbian women, gay men, bisexual men and women, transgender men and women, and veterans with other gender identities. Results: Transgender men and women reported a significantly higher prevalence of lifetime suicide plans and attempts compared to all other subgroups within the respective genders. Beyond this finding, patterns of all outcomes varied by gender. Compared to other subgroups of men, transgender men reported higher prevalence of posttraumatic stress disorder, whereas cisgender gay men reported higher prevalence of lifetime cocaine use and positive human immunodeficiency virus (HIV) status. Within the women subgroups, all LGBT subgroups reported higher prevalence of lifetime smoking and past-year marijuana use compared to heterosexual women. Cisgender lesbian women also reported higher prevalence of past-month heavy episodic drinking, and cisgender bisexual women reported higher prevalence of lifetime cocaine and stimulant use compared to other groups. Conclusion: Transgender women and men reported significantly higher prevalence of lifetime suicide plans and attempts than other groups, highlighting this as an area in need of urgent public health attention. Other disparity patterns indicated the importance of examining subgroups within the LGBT veteran community.

Patient navigation to increase mammography screening among inner city women.

BACKGROUND: Lower mammography screening rates among minority and low income women contribute to increased morbidity and mortality from breast cancer. OBJECTIVE: To evaluate the effect of a patient navigation intervention on adherence rates to biennial screening mammography among women engaged in primary care at an inner-city academic medical center. DESIGN: Quality improvement intervention with a concurrent control group, conducted from February to November of 2008. STUDY SUBJECTS: All women in a hospital-based primary care practice aged 51-70 years. Subjects were randomized at the level of their primary care provider, such that half of the patients in the practice received the intervention, while the other half received usual care. INTERVENTIONS: Intervention subjects whose last mammogram was >18 months prior received a combination of telephone calls and reminder letters from patient navigators trained to identify barriers to care. Navigators were integrated into primary care teams and interacted directly with patients, providers, and radiology to coordinate care. Navigators utilized an electronic report to track subjects. Adherence rates to biennial mammography were assessed in intervention and control groups at baseline and post-intervention. KEY RESULTS: A total of 3,895 women were randomized to intervention (n = 1,817) and control (n = 2,078) groups. Mean age was 60, 71% were racial/ethnic minorities, 23% were non-English speaking, and 63% had public or no health insurance. At baseline, there was no difference in mammography adherence between the control and intervention groups (78%, respectively, p = 0.55). After the 9-month intervention, mammogram adherence was higher in the intervention group compared with the control group (87% vs. 76%, respectively, p < 0.001). Except among Hispanic women who demonstrated high rates in both the intervention and control groups (85% and 83%, respectively), all racial/ethnic and insurance groups demonstrated higher adherence in the intervention group. CONCLUSIONS: Patient navigation improves biennial mammography rates for inner city, low income, minority populations.

Design and baseline results of a coaching intervention for implementation of trans-radial access in percutaneous coronary intervention.

Trans-radial artery access (TRA) for cardiac catheterization and percutaneous coronary intervention has many advantages over trans-femoral artery access (TFA), but implementation has been slow. The steep learning curve, logistical issues, and radiation exposure have been documented as barriers to implementation. Although many cardiac catheterization laboratories have overcome these barriers, we lack evidence on effective implementation strategies. Our objective is to test a team-based coaching intervention that targets the learning curve and other barriers to increase use of TRA. We use a stepped-wedge cluster-randomized trial to test a coaching intervention in Department of Veterans Affairs cardiac catheterization laboratories. The coaching intervention comprises team-based didactic instruction with live observation at a TRA-proficient lab, followed by a visit from a cardiologist and catheterization laboratory nurse coaching team. Interview and survey data are collected from participants to test and adapt an implementation science framework known as the Promoting Action on Research Implementation in Health Services (PARIHS) framework. This study is designed to test the effectiveness of the coaching intervention on TRA implementation, inform changes to the coaching intervention itself, and test and adapt the PARIHS framework in practice. While the benefits of TRA, including increased clinical efficiency, patient comfort, and reduced patient complications, are well understood, the underlying drivers of TRA adoption and sustained practice are not. Findings from this trial can inform future research to facilitate change in the cardiac catheterization laboratory.

Antidepressant adherence and risk of coronary artery disease hospitalizations in older and younger adults with depression.

OBJECTIVES: To assess whether the relationship between antidepressant adherence and coronary artery disease (CAD) hospitalizations varied between older and younger adults with depression. DESIGN: Retrospective cohort study. SETTING: Department of Veterans Affairs outpatient clinics nationwide. PARTICIPANTS: Chronically depressed individuals (n = 50,261; aged 20-97) who had been prescribed an antidepressant were identified from records indicating an outpatient clinic visit for depression (index depression visit) during fiscal years 2009 and 2010. Individuals were considered chronically depressed if they had had prior depression visits and treatment for depression within the previous 4 months. The sample was age-stratified into younger (<65) and older (≥ 65) groups. MEASUREMENTS: After the index depression visit, medication possession ratios were calculated from pharmacy refill data to determine whether participants had 80% or greater adherence to antidepressant refills during a 6-month treatment observation period. International Classification of Diseases, Ninth Revision, codes were used to derive CAD-related hospitalizations during the follow-up period. Mean follow-up was 24 months. Data were analyzed using Cox proportional hazard models. RESULTS: Older participants with 80% or greater antidepressant adherence had 26% lower risk of CAD hospitalizations (hazard ratio = 0.74, 95% confidence interval = 0.60-0.93). Antidepressant adherence was not significantly related to CAD hospitalizations in younger adults. CONCLUSION: Older adults with chronic depression with 80% or greater antidepressant adherence had significantly lower risk of CAD hospitalizations at follow-up than those with less than 80% adherence. These preliminary results suggest that older adults with depression may derive cardiovascular benefits from clinical efforts to increase antidepressant adherence.

Characteristics and well-being of informal caregivers: Results from a nationally-representative US survey.

OBJECTIVES: Given ongoing concerns about high levels of burden reported among some informal caregivers, the goal of this study was to characterize their sociodemographics, health, and well-being. METHODS: Using cross-sectional data from a large nationally representative survey in the United States (N = 438,712) we identified adults who provided informal care to friends or family members with a health problem, long-term illness, or disability. Descriptive statistics and propensity matching were used to characterize caregivers and compare their health and social support to sociodemographically-similar adults who were not caregivers. Logistic regression models examined associations between caregiving and respondents' mental health, general health, perceived social support, and sleep problems. RESULTS: A total of 111,156 (25.3%) participants reported being caregivers, most of whom reported good mental health (90%) good general health (83%), and adequate social support (77%). After adjusting for respondents' gender, caregivers reported worse mental health than non-caregivers (odds ratio (OR) = 1.35, 95% confidence interval (CI) = 1.31-1.39 for >15 days poor mental health in the past month) but better general health (OR = 0.96, 95%CI = 0.94-0.98 for fair or poor health). Men caregivers reported somewhat worse overall health than non-caregivers (OR = 1.09, 95%CI = 1.05-1.13) whereas women reported better overall health. DISCUSSION: Although reporting good overall well-being, caregivers remain vulnerable for worse outcomes than non-caregivers. Caregiving is associated with poor mental health, and may have additional impacts on the physical health of caregiving men.

Racial and ethnic differences in receipt of antidepressants and psychotherapy by veterans with chronic depression.

OBJECTIVE: This study characterized racial-ethnic differences in treatment of veterans with chronic depression by examining antidepressant and psychotherapy use among non-Hispanic black, non-Hispanic white, Hispanic, Asian, and American Indian-Alaska Native (AI/AN) veterans. METHODS: Logistic regression models were estimated with data from the U.S. Department of Veterans Affairs (VA) medical records for a sample of 62,095 chronically depressed patients. Data (2009-2010) were from the VA External Peer Review Program. Three primary outcome measures were used: receipt of adequate antidepressant therapy (≥80% medications on hand), receipt of adequate psychotherapy (at least six sessions in six months), and receipt of guideline-concordant treatment (either of these treatments). RESULTS: Compared with whites, nearly all minority groups had lower odds of adequate antidepressant use and guideline-concordant care in unadjusted and adjusted models (antidepressant adjusted odds ratio [AOR] range=.53-.82, p<.05; guideline-concordant AOR range=.59-.83, p<.05). Although receipt of adequate psychotherapy was more common among veterans from minority groups in unadjusted analyses, differences between Hispanic, AI/AN, and white veterans were no longer significant after covariate adjustment. After adjustment for distance to the VA facility, the difference between black and white veterans was no longer significant. CONCLUSIONS: A better understanding of how patient preferences and provider and system factors interact to generate differences in depression care is needed to improve care for patients from racial-ethnic minority groups. It will become increasingly important to differentiate between health service use patterns that stem from genuine differences in patient preferences and those that signify inequitable quality of depression care.

Recruitment and retention rates in behavioral trials involving patients and a support person: a systematic review.

BACKGROUND: Recruitment and retention challenges impede the study of behavioral interventions among patient-support person dyads. PURPOSE: The aim of the study was to characterize recruitment and retention rates of behavioral interventions involving dyads. METHODS: Using PRISMA guidelines and with the guidance of a medical librarian, we searched Medline, EMBASE, Cochrane Controlled Trials, PsycInfo, and CINAHL from inception until July 2011. Eligible articles involved RCTs of behavioral interventions targeting adult patients with a non-psychiatric illness and a support person. Sample and study characteristics, recruitment and retention strategies, and recruitment and retention rates were abstracted in duplicate. Quality of reporting was determined on a 5-point scale. Due to the heterogeneity in data reporting and missing data, a narrative synthesis was undertaken. RESULTS: 53 unique studies involving 8081 dyads were included. 9 studies were ascertained to have a "high quality" of reporting. A majority of the studies did not report target sample size, time to complete recruitment, and sample sizes at each follow-up time point. Strategies employed to recruit support persons were rarely reported. 16 studies did not report the number of dyads screened. The mean recruitment rate was 51.2% (range: 4.3%-95.4%), and mean retention rate was 77.5% (range: 36%-100%). CONCLUSIONS: Details regarding recruitment and retention methodology were sparse in these interventions. Where available, data suggests that resources need to be devoted towards recruitment of sample but that retention rates are generally adequate.