Extracorporeal cardiopulmonary resuscitation outcomes for children with out-of-hospital and emergency department cardiac arrest.

OBJECTIVE: Data suggest extracorporeal cardiopulmonary resuscitation (ECPR) improves survival in adult patients with refractory cardiac arrest; however, ECPR outcomes in pediatric patients with out-of-hospital cardiac arrest (OHCA) is lacking. The primary aim of this study was to characterize pediatric patients who experience OHCA or cardiac arrest in the ED (EDCA). The secondary aim was to examine associations of cardiac arrest and location of ECPR cannulation with mortality. METHODS: We performed a retrospective analysis of the Extracorporeal Life Support Organization registry. We included pediatric patients (age > 28 days to <18 years) who received ECPR for refractory OHCA or EDCA between 2010 and 2019. Patient, cardiac arrest, and ECPR cannulation characteristics were summarized. We examined associations of location of cardiac arrest and ECPR cannulation with in-hospital mortality using multivariable logistic regression. RESULTS: We analyzed data from 140 pediatric patients. 66 patients (47%) experienced OHCA and 74 patients (53%) experienced EDCA. Overall survival to hospital discharge was 31% (20% OHCA survival vs. 41% EDCA survival, p = 0.008). In adjusted analyses, OHCA was associated with 3.9 times greater odds of mortality (95% confidence interval [CI] 1.61, 9.81) when compared to compared to EDCA. The location of ECPR cannulation was not associated with mortality (odds ratio 1.8, 95% CI 0.75, 4.3). CONCLUSIONS: The use of ECPR for pediatric patients with refractory OHCA is associated with poor survival compared to patients with EDCA. Location of ECPR cannulation does not appear to be associated with mortality.

Outcomes from Partner2Lose: a randomized controlled trial to evaluate 24-month weight loss in a partner-assisted intervention.

BACKGROUND: Partner support is associated with better weight loss outcomes in observational studies, but randomized trials show mixed results for including partners. Unclear is whether teaching communication skills to couples will improve weight loss in a person attempting weight loss (index participant). PURPOSE: To compare the efficacy of a partner-assisted intervention versus participant-only weight management program on 24-month weight loss. METHODS: This community-based study took place in Madison, WI. Index participants were eligible if they met obesity guideline criteria to receive weight loss counseling, were aged 18-74 years, lived with a partner, and had no medical contraindications to weight loss; partners were aged 18-74 years and not underweight. Couples were randomized 1:1 to a partner-assisted or participant-only intervention. Index participants in both arms received an evidence-based weight management program. In the partner-assisted arm, partners attended half of the intervention sessions, and couples were trained in communication skills. The primary outcome was index participant weight at 24 months, assessed by masked personnel; secondary outcomes were 24-month self-reported caloric intake and average daily steps assessed by an activity tracker. General linear mixed models were used to compare group differences in these outcomes following intent-to-treat principles. RESULTS: Among couples assigned to partner-assisted (n = 115) or participant-only intervention (n = 116), most index participants identified as female (67%) and non-Hispanic White (87%). Average baseline age was 47.27 years (SD 11.51 years) and weight was 106.55 kg (SD 19.41 kg). The estimated mean 24-month weight loss was similar in the partner-assisted (2.66 kg) and participant-only arms (2.89 kg) (estimated mean difference, 0.23 kg [95% CI, -1.58, 2.04 kg], p=0.80). There were no differences in 24-month average daily caloric intake (estimated mean difference 50 cal [95% CI: -233, 132 cal], p=0.59) or steps (estimated mean difference 806 steps [95% CI: -1675, 64 steps], p=0.07). The percentage of participants reporting an adverse event with at least possible attribution to the intervention did not differ by arm (partner-assisted: 9%, participant-only, 3%, p = 0.11). CONCLUSIONS: Partner-assisted and individual weight management interventions led to similar outcomes in index participants. TRIAL REGISTRATION: Clinicaltrials.gov NCT03801174, January 11, 2019.

Home Telehealth in the Veterans Health Administration: Trends and Correlates of Length of Enrollment from 2010 to 2017.

BACKGROUND: Home telehealth (HT) programs enable communication and remote monitoring of patient health data between clinician visits, with the goal of improving chronic disease self-management and outcomes. The Veterans Health Administration (VHA) established one of the earliest HT programs in the country in 2003; however, little is known about how these services have been utilized and expanded over the last decade. OBJECTIVE: To describe trends in use of VHA's HT program from 2010 through 2017 and correlates of length of enrollment in HT services. DESIGN: Retrospective observational cohort study. PARTICIPANTS: Patients enrolled in HT between January 1, 2010 and December 31, 2017. MAIN MEASURES: We described the number and characteristics of patients enrolled in HT, including the chronic conditions managed. We also identified length of HT enrollment and examined patient and facility characteristics associated with longer enrollment. KEY RESULTS: The total number of patients enrolled in HT was 402,263. At time of enrollment, half were >65 years old, 91% were male, and 59.3% lived in urban residences. The most common conditions addressed by HT were hypertension (28.8%), obesity (23.9%), and diabetes (17.0%). The median time to disenrollment in HT was 261 days (8.6 months) but varied by chronic condition. In a multivariable Cox proportional hazards model, covariates associated with higher likelihood of staying enrolled were older age, male gender, non-Hispanic Black race/ethnicity, lower neighborhood socioeconomic status, living in a more rural setting, and a greater burden of comorbidities per the Gagne index. CONCLUSIONS: Across 8 years, over 400,000 veterans engaged in HT services for chronic disease management and over half remained in the program for longer than 8 months. Our work provides a real-world evaluation of HT service expansion in the VHA. Additional studies are necessary to identify optimal enrollment duration and patients most likely to benefit from HT services.

National Veterans Health Administration MOVE! Weight Management Program Participation During the COVID-19 Pandemic.

INTRODUCTION: In response to COVID-19, the Veterans Health Administration (VHA) converted appropriate outpatient visits to virtual care, including MOVE! Weight Management Program for Veterans (MOVE!) visits. Before the pandemic, most veterans participated in MOVE! in person, with several telehealth modalities available. We sought to describe national trends in MOVE! participation during the pandemic (March 2020-January 2021) overall and by modality and to compare participation to prepandemic levels. METHODS: We conducted a national retrospective cohort study of veterans who participated in MOVE! from January 2018 through January 2021. We examined MOVE! participation across VHA aggregated at the national level by month, including the number of visits, participants, and new participants in person and via telehealth, including telephone, clinic-to-clinic synchronous video, anywhere-to-anywhere (eg, provider home to patient home) synchronous video, and remote education and monitoring. We also determined the percentage of all MOVE! visits attributable to each modality and the monthly percentage change in participation during the pandemic compared with monthly averages in prior years. RESULTS: Before March 2020, 20% to 30% of MOVE! was delivered via telehealth, which increased to 90% by April 2020. Early in the pandemic, telephone-delivered MOVE! was the most common modality, but anywhere-to-anywhere synchronous video participation increased over time. Compared with the same months in prior years, total monthly MOVE! participation remained 20% to 40% lower at the end of 2020 and into January 2021. CONCLUSION: The VHA MOVE! program rapidly shifted to telehealth delivery of weight management services in response to the pandemic. However, a gap remained in the number of veterans receiving these services compared with prior years, suggesting potential unmet needs for weight management.

Differences in functional and structural social support among female and male veterans and civilians.

PURPOSE: Social support is an important correlate of health behaviors and outcomes. Studies suggest that veterans have lower social support than civilians, but interpretation is hindered by methodological limitations. Furthermore, little is known about how sex influences veteran-civilian differences. Therefore, we examined veteran-civilian differences in several dimensions of social support and whether differences varied by sex. METHODS: We performed a cross-sectional analysis of the 2012-2013 National Epidemiologic Survey of Alcohol and Related Conditions-III, a nationally representative sample of 34,331 respondents (male veterans = 2569; female veterans = 356). We examined veteran-civilian differences in functional and structural social support using linear regression and variation by sex with interactions. We adjusted for socio-demographics, childhood experiences, and physical and mental health. RESULTS: Compared to civilians, veterans had lower social network diversity scores (difference [diff] = - 0.13, 95% confidence interval [CI] - 0.23, - 0.03). Among women but not men, veterans had smaller social network size (diff = - 2.27, 95% CI - 3.81, - 0.73) than civilians, attributable to differences in religious groups, volunteers, and coworkers. Among men, veterans had lower social network diversity scores than civilians (diff = - 0.13, 95% CI - 0.23, - 0.03); while among women, the difference was similar but did not reach statistical significance (diff = - 0.13, 95% CI - 0.23, 0.09). There was limited evidence of functional social support differences. CONCLUSION: After accounting for factors that influence military entry and social support, veterans reported significantly lower structural social support, which may be attributable to reintegration challenges and geographic mobility. Findings suggest that veterans could benefit from programs to enhance structural social support and improve health outcomes, with female veterans potentially in greatest need.

Contributors to Racial Disparities in Minimally Invasive Hysterectomy in the US Department of Veterans Affairs.

BACKGROUND: Minimally invasive hysterectomy for fibroids decreases recovery time and risk of postoperative complications compared with abdominal hysterectomy. Within Veterans Affair (VA), black women with uterine fibroids are less likely to receive a minimally invasive hysterectomy than white women. OBJECTIVE: To quantify the contributions of patient, facility, temporal and geographic factors to VA black-white disparity in minimally invasive hysterectomy. RESEARCH DESIGN: A cross-sectional study. SUBJECTS: Veterans with fibroids and hysterectomy performed in VA between October 1, 2012 and September 30, 2015. MEASURES: Hysterectomy mode was defined using ICD-9 codes as minimally invasive (laparoscopic, vaginal, or robotic-assisted) versus abdominal. The authors estimated a logistic regression model with minimally invasive hysterectomy modeled as a function of 4 sets of factors: sociodemographic characteristics other than race, health risk factors, facility, and temporal and geographic factors. Using decomposition techniques, systematically substituting each white woman's characteristics for each black woman's characteristics, then recalculating the predicted probability of minimally invasive hysterectomy for black women for each possible combination of factors, we quantified the contribution of each set of factors to observed disparities in minimally invasive hysterectomy. RESULTS: Among 1255 veterans with fibroids who had a hysterectomy at a VA, 61% of black women and 39% of white women had an abdominal hysterectomy. Our models indicated there were 99 excess abdominal hysterectomies among black women. The majority (n=77) of excess abdominal hysterectomies were unexplained by measured sociodemographic factors beyond race, health risk factors, facility, and temporal or geographic trends. CONCLUSION: Closer examination of the equity of VA gynecology care and ways in which the VA can work to ensure equitable care for all women veterans is necessary.

Shoe and Field Surface Risk Factors for Acute Lower Extremity Injuries Among Female Youth Soccer Players.

OBJECTIVE: To describe acute lower extremity injuries and evaluate extrinsic risk factors in female youth soccer. DESIGN: Nested case-control study. SETTING: Youth soccer clubs in Seattle, WA. PARTICIPANTS: Female soccer players (n = 351) ages 11 to 15 years randomly selected from 4 soccer clubs from which 83% of their players were enrolled with complete follow-up for 92% of players. INTERVENTIONS: Injured players were interviewed regarding injury, field surface, shoe type, and position. Uninjured controls, matched on game or practice session, were also interviewed. MAIN OUTCOME MEASURES: The association between risk factors and acute lower extremity injury using logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI). RESULTS: One hundred seventy-three acute lower extremity injuries occurred involving primarily the ankle (39.3%), knee (24.9%), and thigh (11.0%). Over half (52.9%) recovered within 1 week, whereas 30.2% lasted beyond 2 weeks. During practices, those injured were approximately 3-fold (OR, 2.83; 95% CI, 1.49-5.31) more likely to play on grass than artificial turf and 2.4-fold (95% CI, 1.03-5.96) more likely to wear cleats on grass than other shoe and surface combinations. During games, injured players were 89% (95% CI, 1.03-4.17) more likely to play defender compared with forward. CONCLUSIONS: Half of the acute lower extremity injuries affected the ankle or knee. Grass surface and wearing cleats on grass increased training injuries. CLINICAL RELEVANCE: The majority, 64%, of female youth soccer players' acute injuries involve the ankle and knee and injury prevention strategies in this age group should target these areas. When considering playing surfaces for training, communities and soccer organizations should consider the third-generation artificial turf a safe alternative to grass.

Observed child and parent toothbrushing behaviors and child oral health.

BACKGROUND: Parent-led toothbrushing effectively reduces early childhood caries. Research on the strategies that parents use to promote this behavior is, however, lacking. AIM: To examine associations between parent-child toothbrushing interactions and child oral health using a newly developed measure, the Toothbrushing Observation System (TBOS). DESIGN: One hundred children ages 18-60 months and their parents were video-recorded during toothbrushing interactions. Using these recordings, six raters coded parent and child behaviors and the duration of toothbrushing. We examined the reliability of the coding system and associations between observed parent and child behaviors and three indices of oral health: caries, gingival health, and history of dental procedures requiring general anesthesia. RESULTS: Reliabilities were moderate to strong for TBOS child and parent scores. Parent TBOS scores and longer duration of parent-led toothbrushing were associated with fewer decayed, missing or filled tooth surfaces and lower incidence of gingivitis and procedures requiring general anesthesia. Associations between child TBOS scores and dental outcomes were modest, suggesting the relative importance of parent versus child behaviors at this early age. CONCLUSIONS: Parents' child behavior management skills and the duration of parent-led toothbrushing were associated with better child oral health. These findings suggest that parenting skills are an important target for future behavioral oral health interventions.

Gynecologists in the VA: do they enhance availability of sex-specific services and policies in the emergency department?

OBJECTIVES: To examine the association between on-site gynecology and availability of sex-specific services and policies in Department of Veterans Affairs (VA) emergency departments (EDs). RESEARCH DESIGN: Cross-sectional analysis using data from a VA national inventory of emergency services for women and gynecologist staffing information from the VA Office of Productivity, Efficiency, and Staffing. SUBJECTS: ED directors from all VA medical centers (N=120). MEASURES: We used logistic regression to evaluate the association between on-site gynecologist full-time equivalents (FTEs, <0.5 and ≥0.5), and availability of sex-specific ED services, such as consult and follow-up within VA by a gynecologist, emergency contraception, rho (D) immunoglobulin, pelvic ultrasound, and transfer policies for obstetric and gynecologic emergencies. All analyses were adjusted for number of ED encounters by women. RESULTS: Greater gynecologist FTE (≥0.5 vs. <0.5) was associated with increased odds of on-site availability of a gynecology consultation in the ED [odds ratio (OR)=10.9; 95% confidence interval (CI): 3.2, 36.6] and gynecologist follow-up within VA after an ED encounter (OR=2.5; 95% CI: 1.0, 6.2). A positive trend was seen in availability of rho (D) immunoglobulin (OR=1.4; 95% CI: 0.6, 3.5) and presence of transfer policies for obstetric (OR=1.7; 95% CI: 0.7, 4.5) and gynecologic emergencies (OR=1.6; 95% CI: 0.6, 4.2). Half of the facilities with <0.5 FTE did not have transfer policies in place or under development. CONCLUSIONS: On-site gynecologist FTE is associated with improved availability of sex-specific care in EDs. Development of transfer processes for obstetric and gynecologic emergencies in settings with limited on-site gynecology is needed.

Predicting developmental delay in a longitudinal cohort of preschool children with single-suture craniosynostosis: is neurobehavioral assessment important?

AIM: The aim of this study was to determine whether neurobehavioral assessment before and after cranial vault surgery can improve prediction of developmental delay in children with single-suture craniosynostosis (SSC), after accounting for 'baseline' demographic and clinical variables (SSC diagnosis and surgery age). METHOD: Children with SSC were referred by the treating surgeon or pediatrician before surgery. Neurobehavioral assessments were performed at ages of approximately 6, 18, and 36 months. Iterative models were developed to predict delay, as determined by one or more tests of cognitive, motor, and language skills at 36 months. We selected from groups of variables entered in order of timing (before or after corrective surgery), and source of information (parent questionnaire or psychometric testing). RESULTS: Good predictive accuracy as determined by area under the receiver operating characteristic curve (AUC), was obtained with the baseline model (AUC=0.66), which incorporated age at surgery, sex, and socio-economic status. However, predictive accuracy was improved by including pre- and post-surgery neurobehavioral assessments. Models incorporating post-surgery neurobehavioral testing (AUC=0.79), pre-surgery testing (AUC=0.74), or both pre- and post-surgery testing (AUC=0.79) performed similarly. However, the specifity of all models was considered to be moderate (≤0.62). INTERPRETATION: Prediction of delay was enhanced by assessment of neurobehavioral status. Findings provide tentative support for guidelines of care that call for routine testing of children with SSC.

Sex differences in the neurodevelopment of school-age children with and without single-suture craniosynostosis.

PURPOSE: Previous studies have indicated that infants and school-age children with single-suture craniosynostosis (SSC, cases) score modestly but consistently lower than unaffected children (controls) on neurodevelopmental tests. However, sex differences in these functions rarely have been examined, and it is unknown whether potential sex differences vary by case status (cases vs. controls) or location of suture fusion. METHODS: We tested 182 cases and 183 demographically matched controls at a mean age of 7.4 years. We measured intellectual abilities with the Wechsler Scale of Intelligence for Children-Fourth Edition. We assessed reading, spelling, and math with a combination of the Wide Range Assessment Test-Fourth Edition, the Test of Word Reading Efficiency, and the Comprehensive Test of Phonological Processing. RESULTS: Among both cases and controls, males scored lower on all measures than females with standard score differences ranging from -1.2 to -7.8 for controls (p values from <0.001 to 0.55) and -2.3 to -8.5 for cases (p values from <0.001 to 0.33). For all but one measure, sex differences were slightly larger for cases than controls. Among cases, males were more likely than females to have learning problems (50 vs. 30%, respectively), with the highest level observed among males with unicoronal synostosis (86%). CONCLUSIONS: Sex differences in neurodevelopmental abilities among children with SSC are substantial, but not a unique correlate of this disorder as similar differences were observed among controls. Girls and those with sagittal synostosis have the lowest risk for academic problems. Boys with unicoronal synostosis warrant close developmental surveillance.

Longitudinal analysis of parenting stress in mothers and fathers of infants with and without single-suture craniosynostosis.

OBJECTIVE: To examine longitudinal differences in reported stress between parents of children with and without single-suture craniosynostosis and to compare the stress reports of mothers and fathers. DESIGN: Multi-site, nonrandomized prospective study. SETTING/PARTICIPANTS: Children with single-suture craniosynostosis (cases) were identified via referral of the treating surgeon or physician at the time of diagnosis, and those without single-suture craniosynostosis (controls) were recruited from pediatric practices, birthing centers, and announcements in print media. When children were aged 6, 18, and 36 months (on average), mothers and fathers of children with and without single-suture craniosynostosis completed the Parenting Stress Index. For cases, 247 mothers and 211 fathers completed the Parenting Stress Index at the first visit; corresponding numbers for controls were 254 and 220, respectively. MAIN OUTCOME MEASURES: The Parenting Stress Index Parent and Child Domains and subscales scores. RESULTS: We found few differences between parents of infants with and without single-suture craniosynostosis, regardless of parent gender. Irrespective of case status, mothers consistently reported higher stress than fathers on the Parent Domain. Within the Parent Domain, mothers reported more stress than fathers on the Role Restriction and Spousal Support subscales. CONCLUSIONS: The parents of children with single-suture craniosynostosis reported levels of stress similar to those reported by parents of same-aged, unaffected children. Mothers reported greater stress than fathers, and these differences remained remarkably stable over time. This may reflect widely held perceptions of gender differences in parenting roles.

Leukocyte telomere length and age at menopause.

BACKGROUND: Telomere length is a marker of cellular aging that varies with the individual, is inherited, and is highly correlated across somatic cell types within persons. Interindividual variability of telomere length may partly explain differences in reproductive aging rates. We examined whether leukocyte telomere length was associated with menopausal age. METHODS: We evaluated the relationship between leukocyte telomere length and age at natural menopause in 486 white women ≥65 years of age. We fit linear regression models adjusted for age, income, education, body mass index, physical activity, smoking, and alcohol intake. We repeated the analysis in women with surgical menopause. We also performed sensitivity analyses excluding women (1) with unilateral oophorectomy, (2) who were nulliparous, or (3) reporting menopausal age <40 years, among other exclusions. RESULTS: For every 1-kb increase in leukocyte telomere length, average age at natural menopause increased by 10.2 months (95% confidence interval = 1.3 to 19.0). There was no association among 179 women reporting surgical menopause. In all but one sensitivity analysis, the association between leukocyte telomere length and age at menopause became stronger. However, when excluding women with menopausal age <40 years, the association decreased to 7.5 months (-0.4 to 15.5). CONCLUSIONS: Women with the longest leukocyte telomere length underwent menopause 3 years later than those with the shortest leukocyte telomere length. If an artifact, an association would likely also have been observed in women with surgical menopause. If these results are replicated, leukocyte telomere length may prove to be a useful predictor of age at menopause.

Factors Associated With Use of the Preventive Health Inventory in US Veterans.

Importance: The COVID-19 pandemic caused significant declines in the quality of preventive and chronic disease care. The Veterans Health Administration (VHA) used the Preventive Health Inventory (PHI), a multicomponent care management intervention, to catch up on care disrupted by the pandemic. Objective: To identify key factors associated with PHI use. Design, Setting, and Participants: This cohort study of veterans receiving primary care used administrative data from national VHA primary care clinics for February 1, 2021, through February 1, 2022. Exposure: Patient PHI receipt. Main Outcomes and Measures: The main outcomes were patient, practitioner, and clinic factors associated with PHI receipt. Binomial generalized linear models with fixed effects for clinic were used to analyze factors associated with receipt of PHI. Least absolute shrinkage and selection operator procedures were used for variable selection. Results: A total of 4 358 038 veterans (mean [SD] age, 63.7 [16.0] years; 90% male; 76% non-Hispanic White) formed the study cohort, of whom 389 757 (9%) received the PHI. Veterans who received the PHI had higher mean Care Assessment Need (CAN) scores, which indicate the likelihood of hospitalization or death within 1 year (mean [SD], 51.9 [28.6] vs 47.2 [28.6]; standardized mean difference [SMD], -0.16). They were also more likely to live in urban areas (77% vs 64%; SMD, 0.28) and have a shorter drive distance to primary care (mean [SD], 13.2 [12.4] vs 15.7 [14.6] miles; SMD, 0.19). The mean outpatient use was higher among PHI recipients compared with non-PHI recipients (mean [SD], 18.4 [27.8] vs 15.1 [24.1] visits; SMD, -0.13). In addition, veterans with primary care practitioners with higher caseloads were more likely to receive the PHI (mean [SD], 778 [231] vs 744 [249] patients; SMD, -0.14), and they were more likely to be seen at larger clinics (mean [SD], 9670 [6876] vs 8786 [6892] patients; SMD, -0.13). Prior outpatient use and CAN score were associated with PHI receipt in the final model. Conclusions and Relevance: In this cohort study of the VHA's PHI, patients with higher CAN scores and more outpatient use in the previous year were more likely to receive the PHI. This study identifies potential intervention points to improve care coordination for veterans.

Women's Health Care Delivery and Coordination After Transitioning From One Electronic Health Record to Another: Perspectives From Staff in the Veterans Health Administration.

OBJECTIVES: The Veterans Health Administration (VA) is transitioning its 1,300 health care facilities from one electronic health record (EHR) to another. The transition aims to improve care delivery and interoperability; however, specific effects on women veterans, who comprise only 7.5% of the patient population, may be obscured without focused evaluation. We aimed to characterize the perspectives of VA staff regarding the impact of transitioning EHRs on women's health care delivery. METHODS: We conducted semistructured interviews with VA staff members involved in delivering or coordinating care for women at three sites that had transitioned EHRs within the past year. Interviews were audio-recorded and transcribed. We used a rapid, templated qualitative analytic approach to identify salient themes in the data. RESULTS: We interviewed 16 staff members across VA departments and roles. Although some participants felt the new EHR held promise, most identified challenges with the EHR rollout and implementation (e.g., insufficient training) and the EHR product (e.g., system inefficiencies and latency). Participants highlighted several ways the EHR transition disproportionately affected care delivery for women veterans, including via backlogs of community care referrals, insufficient opportunities for providers to gain proficiency with sex-specific workflows in the new EHR, and outdated listings for veterans who have changed their names. Participants reported that these issues affected their morale and contributed to decreases in productivity and delayed care. CONCLUSIONS: Many of our findings reflect challenges that affect VA staff broadly, whereas others may be compounded among women veterans and the VA staff who serve them. To achieve the goal of delivering timely, equitable, high-quality, comprehensive health care services to women veterans, continued efforts to monitor and address the impacts of the EHR transition on this population are needed.

"You want people to listen to you": Patient experiences of women's healthcare within the Veterans Health Administration.

OBJECTIVE: To identify constructs that are critical in shaping Veterans' experiences with Veterans Health Administration (VA) women's healthcare, including any which have been underexplored or are not included in current VA surveys of patient experience. DATA SOURCES AND STUDY SETTING: From June 2022 to January 2023, we conducted 28 semi-structured interviews with a diverse, national sample of Veterans who use VA women's healthcare. STUDY DESIGN: Using VA data, we divided Veteran VA-users identified as female into four groups stratified by age (dichotomized at age 45) and race/ethnicity (non-Hispanic White vs. all other). We enrolled Veterans continuously from each recruitment strata until thematic saturation was reached. DATA COLLECTION/EXTRACTION METHODS: For this qualitative study, we asked Veterans about past VA healthcare experiences. Interview questions were guided by a priori domains identified from review of the literature, including trust, safety, respect, privacy, communication and discrimination. Analysis occurred concurrently with interviews, using inductive and deductive content analysis. PRINCIPAL FINDINGS: We identified five themes influencing Veterans' experiences of VA women's healthcare: feeling valued and supported, bodily autonomy, discrimination, past military experiences and trauma, and accessible care. Each emergent theme was associated with multiple of the a priori domains we asked about in the interview guide. CONCLUSIONS: Our findings underscore the need for a measure of patient experience tailored to VA women's healthcare. Existing patient experience measures used within VA fail to address several aspects of experience highlighted by our study, including bodily autonomy, the influence of past military experiences and trauma on healthcare, and discrimination. Understanding distinct factors that influence women and gender-diverse Veterans' experiences with VA care is critical to advance efforts by VA to measure and improve the quality and equity of care for all Veterans.

A non-randomized comparison of engagement and outcomes for in-person versus virtual delivery of the Partner2Lose weight management trial.

Objective: Existing behavioral weight management interventions produce clinically meaningful weight loss. The onset of the COVID-19 pandemic led to the quick transition of such interventions from in-person to virtual platforms. This provided a unique opportunity to compare engagement and outcomes for an in-person versus virtually delivered weight management intervention. Methods: A non-randomized comparison of engagement and weight outcomes was performed between two cohorts who participated in a weight management intervention in person (N = 97) versus three who participated virtually via videoconference (N = 134). Various metrics of engagement were examined, including group class and individual phone call attendance and duration, and retention for weight assessments. Behavioral targets of daily caloric intake and step-counts and the clinical weight outcome were explored. Results: Cohorts (mean [standard deviation] age 47.3 (11.5), 67.1% women: 86.8% White) that participated virtually attended more group sessions (p < 0.001) and had maintenance telephone calls that were of a longer duration (p < 0.001). No other engagement or weight outcomes significantly differed by delivery modality. Conclusions: Virtual weight management programs are promising and may generate similar outcomes to those delivered in-person. Future research should seek to understand how best to promote and sustain engagement in virtual interventions.

"Veteran to Veteran, There's Automatically a Trust": A Qualitative Study of Veterans' Experiences in a Peer Health-Coaching Program for Hypertension.

Introduction: Veteran peer Coaches Optimizing and Advancing Cardiac Health was an randomized controlled trial (RCT) to test the effectiveness of a peer support intervention to reduce blood pressure among veterans with hypertension and 1 or more cardiovascular risks. The authors studied participant perceptions of the intervention, including barriers and facilitators to participation, factors promoting behavior change, and disease self-management practices. Methods: The authors enrolled participants at their exit visit for the Veteran peer Coaches Optimizing and Advancing Cardiac Health study. Participants received primary care at the Veterans Administration healthcare system and had multiple cardiovascular disease risks, including a diagnosis of hypertension. The authors conducted a qualitative content analysis of semistructured interviews about their experience with the Veteran peer Coaches Optimizing and Advancing Cardiac Health intervention. Results: Interview participants (N=29) were aged 60 years on average (SD=8.6), were 71% male, and were 55% White. They had mean systolic blood pressure of 138 mmHg (SD=18) at baseline. Authors identified themes across 3 major categories, which follow the general progression of the intervention: participation, relationship building, and behavior change. Scheduling flexibility, shared identity and experiences with the coach, acquisition of new knowledge and skills, and goal setting were important determinants of participants' experiences in the program. In the participation category, the themes were scheduling, visit modality, life circumstances, and staffing. In the relationship category, the themes were the coach's professional role, shared identity and experiences, and social support. In the behavior change category, the themes were memory, attention, and decision processes; goal setting; skills and knowledge; and environmental context and resources. Authors report differences across patients varying by blood pressure reduction after the intervention and number of coaching visits. Conclusions: Participants generally reported positive experiences in a peer support intervention for veterans with hypertension. Participant perceptions provide important insights into the intervention design and implementation. These findings may inform future implementation of peer support among veterans in hypertension and chronic disease self-management more generally. Trial registration: This study was registered at Clinicaltrial.gov with the identifier NCT02697422.

Laypersons' ratings of appearance in children with and without single-suture craniosynostosis.

BACKGROUND: Single-suture craniosynostosis (SSC) results in head shape anomalies that likely affect social perceptions of appearance. The purpose of this study was to evaluate laypersons' ratings of attractiveness in children with and without SSC. Among cases, we also examined differences by suture fused and age at surgery. METHODS: We collected photographs of 196 children with SSC and 186 children without SSC as infants (before surgery, for cases) and at ages 18 and 36 months. Photographs were rated by 8 raters, who were blinded to the population being studied. We used linear regression to compare appearance ratings for the 2 groups at each visit and to evaluate changes over time. Regression analyses were used to examine the association between age at surgery and appearance ratings. RESULTS: Children with SSC received lower appearance ratings than unaffected controls at each visit (all P < 0.001). Appearance ratings decreased over time, with a similar trajectory for children with and without SSC. Among cases, those with unicoronal and lambdoid synostosis had the lowest ratings and those with sagittal synostosis had the highest. Age at surgery was inversely associated with appearance ratings. CONCLUSIONS: Children with SSC received lower appearance ratings than unaffected controls, with minimal change after surgery. Better outcomes were associated with earlier surgery. These findings do not indicate that children with SSC failed to benefit from surgery, as without surgical intervention, asymmetrical head shape would likely have worsened over time. However, our data suggest that appearance does not fully "normalize."

Gender differences in social support for diabetes self-management: A qualitative study among veterans.

OBJECTIVE: Describe the role of social support in veterans' diabetes self-management and examine gender differences. METHODS: We conducted semi-structured interviews among veterans with diabetes from one Veterans Health Administration Health Care System. Participants described how support persons influenced their diabetes self-management and perspectives on a proposed self-management program incorporating a support person. We used thematic analysis to identify salient themes and examine gender differences. RESULTS: Among 18 women and 18 men, we identified four themes: 1) women felt responsible for their health and the care of others; 2) men shared responsibility for managing their diabetes, with support persons often attempting to correct behaviors (social control); 3) whereas both men and women described receiving instrumental and informational social support, primarily women described emotional support; and 4) some women's self-management efforts were hindered by support persons. Regarding programs incorporating a support person, some participants endorsed including family/friends and some preferred programs including other individuals with diabetes. CONCLUSIONS: Notable gender differences in social support for self-management were observed, with women assuming responsibility for their diabetes and their family's needs and experiencing interpersonal barriers. PRACTICE IMPLICATIONS: Gender differences in the role of support persons in diabetes self-management should inform support-based self-management programs.