Postacute Sequelae of SARS-CoV-2 Infection in the Pre-Delta, Delta, and Omicron Eras.

BACKGROUND: Postacute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PASC) can affect many organ systems. However, temporal changes during the coronavirus disease 2019 (Covid-19) pandemic, including the evolution of SARS-CoV-2, may have affected the risk and burden of PASC. Whether the risk and burden of PASC have changed over the course of the pandemic is unclear. METHODS: We used health records of the Department of Veterans Affairs to build a study population of 441,583 veterans with SARS-CoV-2 infection between March 1, 2020, and January 31, 2022, and 4,748,504 noninfected contemporaneous controls. We estimated the cumulative incidence of PASC at 1 year after SARS-CoV-2 infection during the pre-delta, delta, and omicron eras of the Covid-19 pandemic. RESULTS: Among unvaccinated persons infected with SARS-CoV-2, the cumulative incidence of PASC during the first year after infection was 10.42 events per 100 persons (95% confidence interval [CI], 10.22 to 10.64) in the pre-delta era, 9.51 events per 100 persons (95% CI, 9.26 to 9.75) in the delta era, and 7.76 events per 100 persons (95% CI, 7.57 to 7.98) in the omicron era (difference between the omicron and pre-delta eras, -2.66 events per 100 persons [95% CI, -2.93 to -2.36]; difference between the omicron and delta eras, -1.75 events per 100 persons [95% CI, -2.08 to -1.42]). Among vaccinated persons, the cumulative incidence of PASC at 1 year was 5.34 events per 100 persons (95% CI, 5.10 to 5.58) during the delta era and 3.50 events per 100 persons (95% CI, 3.31 to 3.71) during the omicron era (difference between the omicron and delta eras, -1.83 events per 100 persons; 95% CI, -2.14 to -1.52). Vaccinated persons had a lower cumulative incidence of PASC at 1 year than unvaccinated persons (difference during the delta era, -4.18 events per 100 persons [95% CI, -4.47 to -3.88]; difference during the omicron era, -4.26 events per 100 persons [95% CI, -4.49 to -4.05]). Decomposition analyses showed 5.23 (95% CI, 4.97 to 5.47) fewer PASC events per 100 persons at 1 year during the omicron era than during the pre-delta and delta eras combined; 28.11% of the decrease (95% CI, 25.57 to 30.50) was attributable to era-related effects (changes in the virus and other temporal effects), and 71.89% (95% CI, 69.50 to 74.43) was attributable to vaccines. CONCLUSIONS: The cumulative incidence of PASC during the first year after SARS-CoV-2 infection decreased over the course of the pandemic, but the risk of PASC remained substantial even among vaccinated persons who had SARS-CoV-2 infection in the omicron era. (Supported by the Department of Veterans Affairs.).

High-dimensional characterization of post-acute sequelae of COVID-19.

The acute clinical manifestations of COVID-19 have been well characterized1,2, but the post-acute sequelae of this disease have not been comprehensively described. Here we use the national healthcare databases of the US Department of Veterans Affairs to systematically and comprehensively identify 6-month incident sequelae-including diagnoses, medication use and laboratory abnormalities-in patients with COVID-19 who survived for at least 30 days after diagnosis. We show that beyond the first 30 days of illness, people with COVID-19 exhibit a higher risk of death and use of health resources. Our high-dimensional approach identifies incident sequelae in the respiratory system, as well as several other sequelae that include nervous system and neurocognitive disorders, mental health disorders, metabolic disorders, cardiovascular disorders, gastrointestinal disorders, malaise, fatigue, musculoskeletal pain and anaemia. We show increased incident use of several therapeutic agents-including pain medications (opioids and non-opioids) as well as antidepressant, anxiolytic, antihypertensive and oral hypoglycaemic agents-as well as evidence of laboratory abnormalities in several organ systems. Our analysis of an array of prespecified outcomes reveals a risk gradient that increases according to the severity of the acute COVID-19 infection (that is, whether patients were not hospitalized, hospitalized or admitted to intensive care). Our findings show that a substantial burden of health loss that spans pulmonary and several extrapulmonary organ systems is experienced by patients who survive after the acute phase of COVID-19. These results will help to inform health system planning and the development of multidisciplinary care strategies to reduce chronic health loss among individuals with COVID-19.

Developing an individualized treatment rule for Veterans with major depressive disorder using electronic health records.

Efforts to develop an individualized treatment rule (ITR) to optimize major depressive disorder (MDD) treatment with antidepressant medication (ADM), psychotherapy, or combined ADM-psychotherapy have been hampered by small samples, small predictor sets, and suboptimal analysis methods. Analyses of large administrative databases designed to approximate experiments followed iteratively by pragmatic trials hold promise for resolving these problems. The current report presents a proof-of-concept study using electronic health records (EHR) of n = 43,470 outpatients beginning MDD treatment in Veterans Health Administration Primary Care Mental Health Integration (PC-MHI) clinics, which offer access not only to ADMs but also psychotherapy and combined ADM-psychotherapy. EHR and geospatial databases were used to generate an extensive baseline predictor set (5,865 variables). The outcome was a composite measure of at least one serious negative event (suicide attempt, psychiatric emergency department visit, psychiatric hospitalization, suicide death) over the next 12 months. Best-practices methods were used to adjust for nonrandom treatment assignment and to estimate a preliminary ITR in a 70% training sample and to evaluate the ITR in the 30% test sample. Statistically significant aggregate variation was found in overall probability of the outcome related to baseline predictors (AU-ROC = 0.68, S.E. = 0.01), with test sample outcome prevalence of 32.6% among the 5% of patients having highest predicted risk compared to 7.1% in the remainder of the test sample. The ITR found that psychotherapy-only was the optimal treatment for 56.0% of patients (roughly 20% lower risk of the outcome than if receiving one of the other treatments) and that treatment type was unrelated to outcome risk among other patients. Change in aggregate treatment costs of implementing this ITR would be negligible, as 16.1% fewer patients would be prescribed ADMs and 2.9% more would receive psychotherapy. A pragmatic trial would be needed to confirm the accuracy of the ITR.

The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline.

DESCRIPTION: The U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) worked together to revise the 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. This article summarizes the 2023 clinical practice guideline (CPG) and its development process, focusing on assessments and treatments for which evidence was sufficient to support a recommendation for or against. METHODS: Subject experts from both departments developed 12 key questions and reviewed the published literature after a systematic search using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) method. The evidence was then evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Recommendations were made after consensus was reached; they were based on quality and strength of evidence and informed by other factors, including feasibility and patient perspectives. Once the draft was peer reviewed by an external group of experts and their inputs were incorporated, the final document was completed. RECOMMENDATIONS: The revised CPG includes 34 recommendations in the following 5 topic areas: assessment and diagnosis, prevention, treatment, treatment of nightmares, and treatment of posttraumatic stress disorder (PTSD) with co-occurring conditions. Six recommendations on PTSD treatment were rated as strong. The CPG recommends use of specific manualized psychotherapies over pharmacotherapy; prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy; paroxetine, sertraline, or venlafaxine; and secure video teleconferencing to deliver recommended psychotherapy when that therapy has been validated for use with video teleconferencing or when other options are unavailable. The CPG also recommends against use of benzodiazepines, cannabis, or cannabis-derived products. Providers are encouraged to use this guideline to support evidence-based, patient-centered care and shared decision making to optimize individuals' health outcomes and quality of life.

A Novel Risk-Adjusted Metric to Compare Hospitals on Their Antibiotic Prescribing at Hospital Discharge.

BACKGROUND: Antibiotic overuse at hospital discharge is common, but there is no metric to evaluate hospital performance at this transition of care. We built a risk-adjusted metric for comparing hospitals on their overall post-discharge antibiotic use. METHODS: This was a retrospective study across all acute-care admissions within the Veterans Health Administration during 2018-2021. For patients discharged to home, we collected data on antibiotics and relevant covariates. We built a zero-inflated, negative, binomial mixed model with 2 random intercepts for each hospital to predict post-discharge antibiotic exposure and length of therapy (LOT). Data were split into training and testing sets to evaluate model performance using absolute error. Hospital performance was determined by the predicted random intercepts. RESULTS: 1 804 300 patient-admissions across 129 hospitals were included. Antibiotics were prescribed to 41.5% while hospitalized and 19.5% at discharge. Median LOT among those prescribed post-discharge antibiotics was 7 (IQR, 4-10) days. The predictive model detected post-discharge antibiotic use with fidelity, including accurate identification of any exposure (area under the precision-recall curve = 0.97) and reliable prediction of post-discharge LOT (mean absolute error = 1.48). Based on this model, 39 (30.2%) hospitals prescribed antibiotics less often than expected at discharge and used shorter LOT than expected. Twenty-eight (21.7%) hospitals prescribed antibiotics more often at discharge and used longer LOT. CONCLUSIONS: A model using electronically available data was able to predict antibiotic use prescribed at hospital discharge and showed that some hospitals were more successful in reducing antibiotic overuse at this transition of care. This metric may help hospitals identify opportunities for improved antibiotic stewardship at discharge.

Success of the US Veterans Health Administration's Hepatitis C Virus Care Continuum in the Direct-acting Antiviral Era.

BACKGROUND: Estimated hepatitis C prevalence within the Veterans Health Administration is higher than the general population and is a risk factor for advanced liver disease and subsequent complications. We describe the hepatitis C care continuum within the Veterans Health Administration 1 January 2014 to 31 December 2022. METHODS: We included individuals in Veterans Health Administration care 2021-2022 who were eligible for direct-acting antiviral treatment 1 January 2014 to 31 December 2022. We evaluated the proportion of Veterans who progressed through each step of the hepatitis C care continuum, and identified factors associated with initiating direct-acting antivirals, achieving sustained virologic response, and repeat hepatitis C viremia. RESULTS: We identified 133 732 Veterans with hepatitis C viremia. Hepatitis C treatment was initiated in 107 134 (80.1%), with sustained virologic response achieved in 98 136 (91.6%). In those who achieved sustained virologic response, 1097 (1.1%) had repeat viremia and 579 (52.8%) were retreated for hepatitis C. Veterans of younger ages were less likely to initiate treatment and achieve sustained virologic response, and more likely to have repeat viremia. Stimulant use and unstable housing were negatively associated with each step of the hepatitis C care continuum. CONCLUSIONS: The Veterans Health Administration has treated 80% of Veterans with hepatitis C in care 2021-2022 and achieved sustained virologic response in more than 90% of those treated. Repeat viremia is rare and is associated with younger age, unstable housing, opioid use, and stimulant use. Ongoing efforts are needed to reach younger Veterans, and Veterans with unstable housing or substance use disorders.

Real-world evidence of 18F-fluciclovine Positron emission tomography/computed tomography performance for recurrent prostate cancer in the Veterans Affairs Health System.

BACKGROUND: There are no population-level studies assessing 18F-fluciclovine (fluciclovine) utilization of Positron emission tomography/computed tomography (PET/CT) for biochemically recurrent prostate cancer (PC). We assessed fluciclovine PET/CT in the Veterans Affairs Health Care System. METHODS: Of 1153 men with claims suggesting receipt of fluciclovine PET/CT, we randomly reviewed charts of 300 who indeed underwent fluciclovine PET/CT. The primary outcome was fluciclovine PET/CT result (positive or negative). Comparison among groups stratified by androgen deprivation therapy (ADT) (yes vs. no) and prostate-specific antigen (PSA) (≤1 vs. >1 ng/mL) at imaging were performed. Logistic regression tested associations between PSA, ADT receipt, and race with fluciclovine PET/CT positive imaging. RESULTS: Fluciclovine PET/CT positivity rate was 33% for patients with PSA 0-0.5 ng/mL, 21% for >0.5-1.0, 54% for >1.0-2.0, and 66% for >2.0 (p < 0.01). A 59% positivity rate ocurred in patients treated with concurrent ADT versus 37% in those not on ADT (p < 0.01). White were more likely to have a positive scan versus Black patients (55% vs. 38%; p = 0.02). Patients whose primary treatment was radical prostatectomy had a lower positivity rate (33%) versus those treated with radiotherapy (55%) (p < 0.001). On multivariable logistic regression, PSA > 1 ng/mL (all men odds ratio [OR]: 4.06, 95% confidence interval [CI]: 2.07-7.96; men on ADT only OR: 4.42, 95% CI: 1.73-11.26) and use of ADT (OR: 3.94, 95% CI: 1.32-11.75), and White (all men OR: 2.22, 95% CI: 1.20-4.17) predicted positive fluciclovine PET/CT. CONCLUSION: This real-world study assessing 18F-fluciclovine PET/CT performance in an equal access health care system confirms higher detection rates than traditional imaging methods, but positivity is highly influenced by PSA at time of imaging. Additionally, patients currently receiving ADT have at least four times higher likelihood of a positive scan, showing that scan positivity isn't negatively affected by ADT status in this study. Finally, White men were more likely to have a positive scan, the reasons for which should be explored in future studies.

Impact of lung cancer screening on stage migration and mortality among the national Veterans Health Administration population with lung cancer.

BACKGROUND: Despite randomized trials demonstrating a mortality benefit to low-dose computed tomography screening to detect lung cancer, uptake of lung cancer screening (LCS) has been slow, and the benefits of screening remain unclear in clinical practice. METHODS: This study aimed to assess the impact of screening among patients in the Veterans Health Administration (VA) health care system diagnosed with lung cancer between 2011 and 2018. Lung cancer stage at diagnosis, lung cancer-specific survival, and overall survival between patients with cancer who did and did not receive screening before diagnosis were evaluated. We used Cox regression modeling and inverse propensity weighting analyses with lead time bias adjustment to correlate LCS exposure with patient outcomes. RESULTS: Of 57,919 individuals diagnosed with lung cancer in the VA system between 2011 and 2018, 2167 (3.9%) underwent screening before diagnosis. Patients with screening had higher rates of stage I diagnoses (52% vs. 27%; p ≤ .0001) compared to those who had no screening. Screened patients had improved 5-year overall survival rates (50.2% vs. 27.9%) and 5-year lung cancer-specific survival (59.0% vs. 29.7%) compared to unscreened patients. Among screening-eligible patients who underwent National Comprehensive Cancer Network guideline-concordant treatment, screening resulted in substantial reductions in all-cause mortality (adjusted hazard ratio [aHR], 0.79; 95% confidence interval [CI], 0.67-0.92; p = .003) and lung-specific mortality (aHR, 0.61; 95% CI, 0.50-0.74; p < .001). CONCLUSIONS: While LCS uptake remains limited, screening was associated with earlier stage diagnoses and improved survival. This large national study corroborates the value of LCS in clinical practice; efforts to widely adopt this vital intervention are needed.

Clinical Characteristics, Treatment Patterns, and Outcomes of Patients With Locally Advanced/Metastatic Hepatocellular Carcinoma Treated at the Veterans Health Administration.

PURPOSE: This study retrospectively reviewed the outcomes of patients with advanced hepatocellular carcinoma (HCC) receiving atezolizumab with bevacizumab (A + B) therapy at the Veterans Health Administration (VHA). PATIENTS AND METHODS: Patients with advanced HCC who received first-line systemic therapy with A + B at the VHA between December 1, 2019, and March 1, 2022, were selected from electronic medical records (EMR) using ICD-9 and ICD-10 codes. Abstractors reviewed the EMR of the patients from their index date of A + B initiation until death or their last VHA visit, with the study period ending on January 31, 2023. The chi-square test was used to compare rates, and the Mann-Whitney test was used to compare medians. RESULTS: A total of 332 patients met the study criteria. The median age was 67 years; 99% were male, 63% were non-Hispanic Whites, 26% were Black, and 66% had an Eastern Cooperative Oncology Group performance status of ≥1. 84% had child Pugh score (CPS) class A, 16% had CPS classes B and C, 62% had a grade 2 albumin-bilirubin score, 56% had HCC caused by viral hepatitis, 80% had cirrhosis, and 67% had received prior local therapies. The 6-month progression-free survival (PFS) was 59%, while the 1-year PFS rate was 36%. Overall survival (OS) at 1-year was 52% in our study. CONCLUSION: In real world, despite having similar PFS as the phase III IMbrave 150 trial, our OS at 12 months was lower (52% vs. 67%) because our study included a higher proportion of elderly patients with moderate liver dysfunction and a 40% non-White. This study provided real-world outcomes that differed from the study population in a pivotal trial.

Lifetime prevalence and correlates of colorectal cancer screening among low-income U.S. Veterans.

PURPOSE: The Veterans Health Administration (VHA) is the largest integrated healthcare system in the U.S. While preventive healthcare services are high priority in the VHA, low-income U.S. Veterans experience adverse life circumstances that may negatively impact their access to these services. This study examined lifetime prevalence as well as demographic, socioeconomic, military-specific, and clinical correlates of colorectal cancer (CRC) screening among low-income U.S. Veterans ≥ 50 years of age. METHODS: Cross-sectional data on 862 participants were analyzed from the 2021-2022 National Veteran Homeless and Other Poverty Experiences study. RESULTS: Overall, 55.3% (95% confidence interval [CI] 51.3-59.3%) reported ever-receiving CRC-screening services. In a multivariable logistic regression model, never-receivers of CRC screening were twice as likely to reside outside of the Northeast, and more likely to be married (odds ratio [OR] = 1.86, 95% CI 1.02, 3.37), have BMI < 25 kg/m2 [vs. 25- < 30 kg/m2] (OR = 1.75, 95% CI 1.19, 2.58), or ≥ 1 chronic condition (OR = 1.46, 95% CI 1.06, 2.02). Never-receivers of CRC screening were less likely to be female (OR = 0.53, 95% CI 0.29, 0.96), aged 65-79y [vs. ≥ 80y] (OR = 0.61, 95% CI 0.40, 0.92), live in 5 + member households (OR = 0.33, 95% CI 0.13, 0.86), disabled (OR = 0.45, 0.22, 0.92), with purchased health insurance (OR = 0.56, 95% CI 0.33, 0.98), or report alcohol-use disorder (OR = 0.10, 95% CI 0.02, 0.49) and/or HIV/AIDS (OR = 0.28, 95% CI 0.12, 0.68). CONCLUSION: Nearly 55% of low-income U.S. Veterans reported ever screening for CRC. Variations in CRC-screening behaviors according to veteran characteristics highlight potential disparities as well as opportunities for targeted behavioral interventions.

Uptake of Sodium-Glucose Cotransporter-2 Inhibitors in Hospitalized Patients With Heart Failure: Insights From the Veterans Affairs Healthcare System.

BACKGROUND: The use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) in Veterans Affairs (VA) patients hospitalized with heart failure (HF) has not been reported previously. METHODS: VA electronic health record data were used to identify patients hospitalized for HF (primary or secondary diagnosis) from 01/2019-11/2022. Patients with SGLT2i allergy, advanced/end-stage chronic kidney disease (CKD) or advanced HF therapies were excluded. We identified factors associated with discharge SGLT2i prescriptions for patients hospitalized due to HF in 2022. We also compared SGLT2i and angiotensin receptor-neprilysin inhibitor (ARNI) prescription rates. Hospital-level variations in SGLT2i prescriptions were assessed via the median odds ratio. RESULTS: A total of 69,680 patients were hospitalized due to HF; 10.3% were prescribed SGLT2i at discharge (4.4% newly prescribed, 5.9% continued preadmission therapy). SGLT2i prescription increased over time and was higher in patients with HFrEF and primary HF. Among 15,762 patients hospitalized in 2022, SGLT2i prescription was more likely in patients with diabetes (adjusted odds ratio [aOR] 2.27; 95% confidence interval [CI]: 2.09-2.47) and ischemic heart disease (aOR 1.14; 95% CI: 1.03-1.26). Patients with increased age (aOR 0.77 per 10 years; 95% CI: 0.73-0.80) and lower systolic blood pressure (aOR 0.94 per 10 mmHg; 95% CI: 0.92-0.96) were less likely to be prescribed SGLT2i, and SGLT2i prescription was not more likely in patients with CKD (aOR 1.07; 95% CI 0.98-1.16). The adjusted median odds ratio suggested a 1.8-fold variation in the likelihood that similar patients at 2 random VA sites were prescribed SGLT2i (range 0-21.0%). In patients with EF ≤ 40%, 30.9% were prescribed SGLT2i while 26.9% were prescribed ARNI (P < 0.01). CONCLUSION: One-tenth of VA patients hospitalized for HF were prescribed SGLT2i at discharge. Opportunities exist to reduce variation in SGLT2i prescription rates across hospitals and to promote its use in patients with CKD and older age.

Follow-up compliance in patients undergoing abdominal aortic aneurysm repair at Veterans Affairs hospitals.

OBJECTIVE: The Society for Vascular Surgery guidelines recommend annual imaging surveillance following endovascular aneurysm repair (EVAR) and every 5 years following open surgical repairs (OSR) of abdominal aortic aneurysms (AAAs). Adherence to these guidelines is low outside of clinical trials, and compliance at Veterans Affairs (VA) hospitals is not yet well-established. We examined imaging follow-up compliance and mortality rates after AAA repair at VA hospitals. METHODS: We queried the VA Surgical Quality Improvement Program database for elective infrarenal AAA repairs, EVAR and OSR, then merged in follow-up imaging and mortality information. Mortality rate over time was derived using Kaplan-Meier estimation. Generalized estimating equation with a logit link and a sandwich standard error estimate was performed to compare the probability of having annual follow-up imaging over time between procedure types and to identify variables associated with follow-up imaging for EVAR patients. RESULTS: Our analysis included 11,668 patients who underwent EVAR and 4507 patients who underwent OSR at VA hospitals between the years 2000 and 2019. The 30-day mortality rate for EVAR and OSR was 0.37% and 0.82%, respectively. OSR was associated with lower long-term mortality after adjusting age, sex, American Society of Anesthesiologists classification and preoperative renal failure with an adjusted hazard ratio of 0.88 (95% confidence interval, 0.84-0.92; P < .01). Of surviving patients, the follow-up imaging rate was 69.1% by 1 year post-EVAR. The follow-up rate after 5 years was 45.6% post-EVAR compared with 63.6% post-OSR of surviving patients. A history of smoking or drinking, baseline hypertension, and known cardiac disease were independently associated with poor follow-up after EVAR. CONCLUSIONS: Patients undergoing elective open AAA repair in the VA hospital system had lower long-term mortality compared with patients who underwent endovascular repair. Compliance with post-EVAR imaging is low. Patient factors associated with poor post-EVAR imaging surveillance were smoking within the last year, excess alcohol consumption, and cardiac risk factors including hypertension, prior myocardial infarction, and congestive heart failure.

Impact of Nurse Residency Program on Time-to-Fill Nurse Vacancies at the Veterans Health Administration.

BACKGROUND: The Department of Veterans Affairs (VA) offers a 1-year Post-Baccalaureate-Registered Nurse Residency (PB-RNR) Program. The impact of the PB-RNR program on local RN recruitment was unknown. OBJECTIVES: We aimed to evaluate the effect of the size of the PB-RNR program at a VA facility on its time-to-fill RN vacancies. PROJECT DESIGN: We used an instrumental variable approach with a 2-stage residual inclusion specification. SUBJECTS: We included RN filled vacancies in the VA that were posted nationwide between 2020 and 2021. MEASURES: Our independent variable was the facility-year level number of PB-RNR program allocations. The 3 binary outcomes were whether the RN vacancy was filled within 90, 60, or 30 days. RESULTS: An increase of one training allocation was significantly associated with a 5.60 percentage point (PP) (95% CI: 2.74-8.46) higher likelihood of filling a vacancy within 90 days, 7.34 PP (95% CI: 4.66-10.03) higher likelihood of filling a vacancy within 60 days, and 5.32 PP (95% CI: 3.18-7.46) higher likelihood of filling a vacancy within 30 days. The impact was significant in both 2020 and 2021 positions, and in facilities located in areas with lower social deprivation scores, higher-quality public schools, or with either no or partial primary care physician shortages. CONCLUSIONS: We found favorable impacts of the size of the PB-RNR program at a VA facility on filling RN vacancies.

Impact of Medical Training Programs on Time-to-Fill Physician Vacancies at the Veterans Health Administration.

BACKGROUND: The Department of Veterans Affairs (VA) provides the largest Graduate Medical Education (GME) training platform for health professionals in the United States. Studies on the impact of VA GME programs on physician recruitment were lacking. OBJECTIVES: To examine the impact of the size of residency training programs at a VA facility on the facility's time-to-fill physician vacancies, and whether the impact differs by the socioeconomic deprivation and public school quality of the geographic area. PROJECT DESIGN: We constructed an instrumental variable for training program size by interacting the facility clinicians share with the total training allocation nationally. SUBJECTS: Our evaluation used national data on filled physician vacancies in the VA that were posted between 2020 and 2021. MEASURES: The outcome evaluated was time-to-fill physician vacancies. Our explanatory variable was the facility-year level number of physician residency slots. RESULTS: For positions posted in 2020, an increase of one training slot was significantly associated with a decrease of 1.33 days to fill physician vacancies (95% CI, 0.38-2.28) in facilities in less deprived areas, a decrease of 1.50 days (95% CI, 0.75-2.25) in facilities with better public schools, a decrease of 3.30 days (95% CI, 0.85-5.76) in facilities in both less deprived areas and better public schools. We found similar results for positions posted in 2020 and 2021 when limiting time-to-fill to <500 days. CONCLUSIONS: We found that increasing the size of the residency program at a VA facility could decrease the facility's time-to-fill vacant physician positions in places with less socioeconomic deprivation or better public schools.

Intensity, Characteristics, and Factors Associated With Receipt of Care Coordination Among High-Risk Veterans in the Veterans Health Administration.

BACKGROUND: The Veterans Health Administration (VHA) has initiatives underway to enhance the provision of care coordination (CC), particularly among high-risk Veterans. Yet, evidence detailing the characteristics of and who receives VHA CC is limited. OBJECTIVES: We examined intensity, timing, setting, and factors associated with VHA CC among high-risk Veterans. RESEARCH DESIGN: We conducted a retrospective observational cohort study, following Veterans for 1 year after being identified as high-risk for hospitalization or mortality, to characterize their CC. Demographic and clinical factors predictive of CC were identified via multivariate logistic regression. SUBJECTS: A total of 1,843,272 VHA-enrolled high-risk Veterans in fiscal years 2019-2021. MEASURES: We measured 5 CC variables during the year after Veterans were identified as high risk: (1) receipt of any service, (2) number of services received, (3) number of days to first service, (4) number of days between services, and (5) type of visit during which services were received. RESULTS: Overall, 31% of high-risk Veterans in the sample received CC during one-year follow-up. Among Veterans who received ≥1 service, a median of 2 [IQR (1, 6)] services were received. Among Veterans who received ≥2 services, there was a median of 26 [IQR (10, 57)] days between services. Most services were received during outpatient psychiatry (46%) or medicine (16%) visits. Veterans' sociodemographic and clinical characteristics were associated with receipt of CC. CONCLUSIONS: A minority of Veterans received CC in the year after being identified as high-risk, and there was variation in intensity, timing, and setting of CC. Research is needed to examine the fit between Veterans' CC needs and preferences and VHA CC delivery.

Association Between a National Behavioral Weight Management Program and Veterans Affairs Health Expenditures.

OBJECTIVE: The association between participation in a behavioral weight intervention and health expenditures has not been well characterized. We compared Veterans Affairs (VA) expenditures of individuals participating in MOVE!, a VA behavioral weight loss program, and matched comparators 2 years before and 2 years after MOVE! initiation. METHODS: Retrospective cohort study of Veterans who had one or more MOVE! visits in 2008-2017 who were matched contemporaneously to up to 3 comparators with overweight or obesity through sequential stratification on an array of patient characteristics, including sex. Baseline patient characteristics were compared between the two cohorts through standardized mean differences. VA expenditures in the 2 years before MOVE! initiation and 2 years after initiation were modeled using generalized estimating equations with a log link and distribution with variance proportional to the standard deviation (gamma). RESULTS: MOVE! participants (n=499,696) and comparators (n=1,336,172) were well-matched, with an average age of 56, average body mass index of 35, and similar total VA expenditures in the fiscal year before MOVE! initiation ($9662 for MOVE! participants and $10,072 for comparators, standardized mean difference=-0.019). MOVE! participants had total expenditures that were statistically lower than matched comparators in the 6 months after initiation but modestly higher in the 6 months to 2 years after initiation, though differences were small in magnitude (1.0%-1.6% differences). CONCLUSIONS: The VA's system-wide behavioral weight intervention did not realize meaningful short-term health care cost savings for participants.

Medication Safety Events After Acute Myocardial Infarction Among Veterans Treated at VA Versus Non-VA Hospitals.

INTRODUCTION: Fragmentation of health care across systems can contribute to mistakes in prescribing and filling medications among patients treated for myocardial infarction (MI). We sought to compare omissions, duplications, and delays in outpatient medications used for secondary prevention among veterans treated for MI at Veterans Affairs (VA) versus non-VA hospitals. METHODS: We utilized national VA and Centers for Medicare and Medicaid Services data (2012-2018) to identify veterans 65 years or older hospitalized for MI and measured the use of outpatient medications for secondary prevention in the 30 days after MI among those treated at VA versus non-VA hospitals. RESULTS: A total of 118,456 veterans experiencing MI were included; of which 102,209 were hospitalized at non-VA hospitals. An omission in any medication class occurred more frequently among veterans treated at non-VA versus VA hospitals (82.8% vs 67.8%, P < 0.001). In multivariable modeling, the odds of omissions in any medication class were higher among those treated at non-VA versus VA hospitals (odds ratio: 3.04; 95% CI: 2.88-3.20). Duplications occurred more frequently in veterans treated at non-VA versus VA hospitals: 1.9% versus 1.6% had 1 or more for non-VA versus VA hospitals ( P < 0.001). Veterans treated at non-VA hospitals were more likely to have delays of 3 days or more in prescription fills after hospital discharge (88.4% vs 70.6% across all classes, P < 0.001). CONCLUSIONS: Omissions, duplications, and delays in outpatient prescribing of secondary prevention medications were more common among 118,456 veterans treated at non-VA versus VA hospitals for MI. Interventions aimed at improving care transitions and optimizing medication use among veterans treated at non-VA hospitals should be implemented.

Trajectories and Transitions in Service Use Among Older Veterans at High Risk of Long-Term Institutional Care.

BACKGROUND: We aimed to identify combinations of long-term services and supports (LTSS) Veterans use, describe transitions between groups, and identify factors influencing transition. METHODS: We explored LTSS across a continuum from home to institutional care. Analyses included 104,837 Veterans Health Administration (VHA) patients 66 years and older at high-risk of long-term institutional care (LTIC). We conduct latent class and latent transition analyses using VHA and Medicare data from fiscal years 2014 to 2017. We used logistic regression to identify variables associated with transition. RESULTS: We identified 5 latent classes: (1) No Services (11% of sample in 2015); (2) Medicare Services (31%), characterized by using LTSS only in Medicare; (3) VHA-Medicare Care Continuum (19%), including LTSS use in various settings across VHA and Medicare; (4) Personal Care Services (21%), characterized by high probabilities of using VHA homemaker/home health aide or self-directed care; and (5) Home-Centered Interdisciplinary Care (18%), characterized by a high probability of using home-based primary care. Veterans frequently stayed in the same class over the three years (30% to 46% in each class). Having a hip fracture, self-care impairment, or severe ambulatory limitation increased the odds of leaving No Services, and incontinence and dementia increased the odds of entering VHA-Medicare Care Continuum. Results were similar when restricted to Veterans who survived during all 3 years of the study period. CONCLUSIONS: Veterans at high risk of LTIC use a combination of services from across the care continuum and a mix of VHA and Medicare services. Service patterns are relatively stable for 3 years.

Reexamining Differences Between Black and White Veterans in Hospital Mortality and Other Outcomes in Veterans Affairs and Other Hospitals.

OBJECTIVES: To examine Black-White patient differences in mortality and other hospital outcomes among Veterans treated in Veterans Affairs (VA) and non-VA hospitals. BACKGROUND: Lower hospital mortality has been documented in older Black patients relative to White patients, yet the mechanisms have not been determined. Comparing other hospital outcomes and multiple hospital systems may help inform the reasons for these differences. METHODS: Repeated cross-sectional analysis of hospitalization records was conducted for Veterans discharged in VA and non-VA hospitals from January 1, 2013 to December 31, 2017 in 11 states. Hospital outcomes included 30-day mortality, 30-day readmissions, inpatient costs, and length of stay. Hospitalizations were for acute myocardial infarction, coronary artery bypass graft surgery, gastrointestinal bleeding, heart failure, pneumonia, and stroke. Differences in outcomes were estimated between Black and White patients for VA and non-VA hospitals and age groups younger than 65 years or 65 years and older in regression models adjusting for patient and hospital factors. RESULTS: There were a total of 459,574 study patients. Older Black patients had lower adjusted mortality for acute myocardial infarction, gastrointestinal bleeding, heart failure, and pneumonia. Adjusted probability of readmission was higher and adjusted mean length of stay and costs were greater for older Black patients relative to White patients in non-VA hospitals for several conditions. Fewer differences were observed in younger patients and in VA hospitals. CONCLUSION: While older Black patients had lower mortality, other outcomes compared poorly with White patients. Differences were not fully explained by observable patient and hospital factors although social determinants may contribute to these differences.

Leveraging Electronic Health Records to Assess Residential Mobility Among Veterans in the Veterans Health Administration.

BACKGROUND: Residential mobility, or a change in residence, can influence health care utilization and outcomes. Health systems can leverage their patients' residential addresses stored in their electronic health records (EHRs) to better understand the relationships among patients' residences, mobility, and health. The Veteran Health Administration (VHA), with a unique nationwide network of health care systems and integrated EHR, holds greater potential for examining these relationships. METHODS: We conducted a cross-sectional analysis to examine the association of sociodemographics, clinical conditions, and residential mobility. We defined residential mobility by the number of VHA EHR residential addresses identified for each patient in a 1-year period (1/1-12/31/2018), with 2 different addresses indicating one move. We used generalized logistic regression to model the relationship between a priori selected correlates and residential mobility as a multinomial outcome (0, 1, ≥2 moves). RESULTS: In our sample, 84.4% (n=3,803,475) veterans had no move, 13.0% (n=587,765) had 1 move, and 2.6% (n=117,680) had ≥2 moves. In the multivariable analyses, women had greater odds of moving [aOR=1.11 (95% CI: 1.10,1.12) 1 move; 1.27 (1.25,1.30) ≥2 moves] than men. Veterans with substance use disorders also had greater odds of moving [aOR=1.26 (1.24,1.28) 1 move; 1.77 (1.72,1.81) ≥2 moves]. DISCUSSION: Our study suggests about 16% of veterans seen at VHA had at least 1 residential move in 2018. VHA data can be a resource to examine relationships between place, residential mobility, and health.