Development and Psychometric Assessment of the Weight and Eating Quality of Life (WE-QOL) Scale in US Military Veterans.

BACKGROUND: The Veterans Health Administration (VHA) is in need of population health approaches to address overweight and obesity-related diseases. BMI serves as a simple, blunt metric to monitor these efforts. However, emerging research has demonstrated that healthcare weigh-ins contribute to weight stigma which paraodoxically is associated with weight gain. An alternative metric is urgently needed for VHA's MOVE!® Weight Management Program and other eating- and weight-related services. OBJECTIVE: To develop a brief population health metric called the Weight and Eating Quality of Life (WE-QOL) Scale and assess its psychometric properties. DESIGN: The literature was reviewed for relevant weight- and eating-specific QOL measures to identify unique and overlapping constructs. Eight items, representing these constructs, comprised the new brief WE-QOL Scale. A survey study was conducted with data analyzed in STATA. PARTICIPANTS: A total of 213 consecutively evaluated US Veterans attending an orientation session for MOVE!. MAIN MEASURES: The WE-QOL Scale, as well as a widely used generic health-related QOL measure, the European Quality of Life Screener (EQ-ED-5L), and relevant validated measures. KEY RESULTS: WE-QOL descriptive findings demonstrated severe impacts on physical activity and physical discomfort for approximately 30% of the sample each; moderate-to-severe impacts on daily responsibilities, emotional distress, and shame and guilt for one-third of the sample each and public distress for one-fourth of the sample. The WE-QOL Scale performed as well as, or better than, the EQ-ED-5L for internal consistency (Cronbach's alpha = 0.91) and associations to relevant constructs (BMI, eating pathology, and physical activity). CONCLUSIONS: Findings support the reliability and construct validity of the WE-QOL Scale. The WE-QOL Scale has potential to provide a standardized population health metric that could be used as a screening tool and clinical reminder to identify, refer, and assess outcomes for Veterans with weight and disordered eating issues. Future research could be targeted at using this measure to improve patient care and quality of care.

Addressing COVID-19 Vaccine Acceptance Within a Large Healthcare System: a Population Health Model.

BACKGROUND: The COVID-19 pandemic, and vaccine hesitancy, pose a significant public health threat. The Veterans Health Administration system is uniquely situated to provide insights into the implementation of a population health approach to vaccine acceptance. AIM: We describe the VA Connecticut Healthcare System's (VACHS) quality improvement project to improve rates of vaccine uptake. SETTING AND PARTICIPANTS: VACHS consists of eight primary care sites with 80 primary care providers delivering care to 47,000 enrolled veterans. PROGRAM DESCRIPTION: Our program involved identification of a local champion, education sessions, development of vaccine acceptance tools (including the templated "COVID-19 Prevention Letter" and the "COVID-19 Prevention Telephone Note"), and application of a population health approach (use of a prioritization scheme and playbook) by primary care patient-aligned care (PACT) medical home teams. PROGRAM EVALUATION: We found increased rates of vaccination at VACT compared to the surrounding region 6 months after implementation (65.16% vs 61.89%). Use of vaccine acceptance tools were associated with a statistically significant increase in vaccination (24.1% vs 13.6%, P = 0.036) in unvaccinated veterans. DISCUSSION: A population health approach to vaccine acceptance using EHR-based tools can impact vaccination rates, and this approach may be of practical utility to other large healthcare systems with EHR.

ICD-10 Coding of Musculoskeletal Conditions in the Veterans Health Administration.

OBJECTIVE: We describe the most frequently used musculoskeletal diagnoses in Veterans Health Administration care. We report the number of visits and patients associated with common musculoskeletal International Classification of Diseases (ICD)-10 codes and compare trends across primary and specialty care settings. DESIGN: Secondary analysis of a longitudinal cohort study. SUBJECTS: Veterans included in the Musculoskeletal Diagnosis Cohort with a musculoskeletal diagnosis from October 1, 2015, through September 30, 2017. METHODS: We obtained counts and proportions of all musculoskeletal diagnosis codes used and the number of unique patients with each musculoskeletal diagnosis. Diagnosis use was compared between primary and specialty care settings. RESULTS: Of more than 6,400 possible ICD-10 M-codes describing "Diseases of the Musculoskeletal System and Connective Tissue," 5,723 codes were used at least once. The most frequently used ICD-10 M-code was "Low Back Pain" (18.3%), followed by "Cervicalgia" (3.6%). Collectively, the 100 most frequently used codes accounted for 80% of M-coded visit diagnoses, and 95% of patients had at least one of these diagnoses. The most common diagnoses (spinal pain, joint pain, osteoarthritis) were used similarly in primary and specialty care settings. CONCLUSION: A diverse sample of all available musculoskeletal diagnosis codes were used; however, less than 2% of all possible codes accounted for 80% of the diagnoses used. This trend was consistent across primary and specialty care settings. The most frequently used diagnosis codes describe the types of musculoskeletal conditions, among a large pool of potential diagnoses, that prompt veterans to present to the Veterans Health Administration for musculoskeletal care.

A Model for Rapid Transition to Virtual Care, VA Connecticut Primary Care Response to COVID-19.

INTRODUCTION: Traditionally, health care delivery in the USA has been structured around in-person visits. The COVID-19 pandemic has forced a shift to virtual care models in order to reduce patient exposure to high-risk environments and to preserve valuable health care resources. This report describes one large primary care system's model for rapid transition to virtual care (RTVC). SETTING AND PARTICIPANTS: A RTVC model was implemented at the VA Connecticut Health Care System (VACHS), which delivers care to over 58,000 veterans. PROGRAM DESCRIPTION: The RTVC model included immediate virtual care conversion, telework expansion, implementation of virtual respiratory urgent care clinics, and development of standardized note templates. PROGRAM EVALUATION: Outcomes include the rates of primary encounter types, staff teleworking, and utilization of virtual respiratory urgent care clinics. In under 2 weeks, most encounters were transitioned from in-person to virtual care, enabling telework for over half of the medical staff. The majority of virtual visits were telephone encounters, though rates of video visits increased nearly 18-fold. DISCUSSION: The RTVC model demonstrates expeditious and sustained transition to virtual care during the COVID-19 pandemic. Our experiences help inform institutions still reliant on traditional in-person visits, and future pandemic response.

Sequelae of an Evidence-based Approach to Management for Access to Care in the Veterans Health Administration.

BACKGROUND: Access to health care is a critical concept in the design, delivery, and evaluation of high quality care. Meaningful evaluation of access requires research evidence and the integration of perspectives of patients, providers, and administrators. OBJECTIVE: Because of high-profile access challenges, the Department of Veterans Affairs (VA) invested in research and implemented initiatives to address access management. We describe a 2-year evidence-based approach to improving access in primary care. METHODS: The approach included an Evidence Synthesis Program (ESP) report, a 22-site in-person qualitative evaluation of VA initiatives, and in-person and online stakeholder panel meetings facilitated by the RAND corporation. Subsequent work products were disseminated in a targeted strategy to increase impact on policy and practice. RESULTS: The ESP report summarized existing research evidence in primary care management and an evaluation of ongoing initiatives provided organizational data and novel metrics. The stakeholder panel served as a source of insights and information, as well as a knowledge dissemination vector. Work products included the ESP report, a RAND report, peer-reviewed manuscripts, presentations at key conferences, and training materials for VA Group Practice Managers. Resulting policy and practice implications are discussed. CONCLUSIONS: The commissioning of an evidence report was the beginning of a cascade of work including exploration of unanswered questions, novel research and measurement discoveries, and policy changes and innovation. These results demonstrate what can be achieved in a learning health care system that employs evidence and expertise to address complex issues such as access management.

Self-report versus objective measurement of weight history: implications for pre-treatment weight gain.

There is increasing concern that patients gain considerable weight in the year prior to treatment and that outcomes may not reflect true treatment losses. To date, we know little about the accuracy of self-reported weight change prior to treatment. To investigate weight gain, and accuracy of self-reported recent weight history, Veterans (n = 126) reported their current weight and one-year weight history prior to entering treatment. These weights were compared to electronic medical record weights. Patients gained an average of 2.03 kg (4.5 lbs) in the year prior to treatment. Self-report and objective weight assessments showed high concurrent validity at the group level. However, standard deviations for the absolute difference scores revealed high individual variability in historical reporting, suggesting that weight loss seeking patients are inaccurate reporters of recent weight. Our findings have implications for the emerging area of pre-treatment weight gain research and processes for clinical care.

"Making weight" during military service is related to binge eating and eating pathology for veterans later in life.

PURPOSE: "Making weight" behaviors are unhealthy weight control strategies intended to reduce weight in an effort to meet weight requirements. This study aimed to examine a brief measure of making weight and to investigate the relationship between making weight and weight, binge eating, and eating pathology later in life. METHODS: Participants were veterans [N = 120, mean age 61.7, mean body mass index (BMI) 38.0, 89.2% male, 74.2% Caucasian] who were overweight/obese and seeking weight management treatment. Participants completed the making weight inventory (MWI), a measure of making weight behaviors engaged in during military service, and validated measures of eating behavior. Analyses compared participants who engaged in at least one making weight behavior (MWI+) versus those who did not (MWI-). RESULTS: The MWI had good internal consistency. One-third of participants were MWI+ and two-thirds were MWI-. The most frequently reported behavior was excessive exercise, reported in one-quarter of the sample, followed by fasting/skipping meals, sauna/rubber suit, laxatives, diuretics, and vomiting. MWI+ participants were significantly more likely to be in a younger cohort of veterans, to be an ethnic/racial minority, and to engage in current maladaptive eating behaviors, including binge eating, vomiting, emotional eating, food addiction, and night eating, compared to the MWI- group. Groups did not differ on BMI. CONCLUSIONS: One-third of veterans who were overweight/obese screened positive for engaging in making weight behaviors during military service. Findings provide evidence that efforts to "make weight" are related to binge eating and eating pathology later in life. Future research and clinical efforts should address how to best eliminate unhealthy weight control strategies in military service while also supporting healthy weight management efforts.

Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care.

Objective: To examine patient sociodemographic and clinical characteristics associated with opioid use among Veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who receive chiropractic care, and to explore the relationship between timing of a chiropractic visit and receipt of an opioid prescription. Methods: Cross-sectional analysis of administrative data on OEF/OIF/OND veterans who had at least one visit to a Veterans Affairs (VA) chiropractic clinic between 2004 and 2014. Opioid receipt was defined as at least one prescription within a window of 90 days before to 90 days after the index chiropractic clinic visit. Results: We identified 14,025 OEF/OIF/OND veterans with at least one chiropractic visit, and 4,396 (31.3%) of them also received one or more opioid prescriptions. Moderate/severe pain (odds ratio [OR] = 1.87, 95% confidence interval [CI] = 1.72-2.03), PTSD (OR = 1.55, 95% CI = 1.41-1.69), depression (OR = 1.40, 95% CI = 1.29-1.53), and current smoking (OR = 1.39, 95% CI = 1.26-1.52) were associated with a higher likelihood of receiving an opioid prescription. The percentage of veterans receiving opioid prescriptions was lower in each of the three 30-day time frames assessed after the index chiropractic visit than before. Conclusions: Nearly one-third of OEF/OIF/OND veterans receiving VA chiropractic services also received an opioid prescription, yet the frequency of opioid prescriptions was lower after the index chiropractic visit than before. Further study is warranted to assess the relationship between opioid use and chiropractic care.

Project STEP: Implementing the Veterans Health Administration's Stepped Care Model of Pain Management.

Objective: The "stepped care model of pain management" (SCM-PM) prioritizes the role of primary care providers in optimizing pharmacological management and timely and equitable access to patient-centered, evidence-based nonpharmacological approaches, when indicated. Over the past several years, the Veterans Health Administration (VHA) has supported implementation of SCM-PM, but few data exist regarding changes in pain care resulting from implementation. We examined trends in prescribing and referral practices of primary care providers with hypotheses of decreased opioid prescribing, increased nonopioid prescribing, and increased referrals to specialty care for nonpharmacological services. Design: An initiative was designed to foster implementation and systematic evaluation of the SCM-PM over a five-year period at the VA Connecticut Healthcare System (VACHS) while fostering collaborative, partnered initiatives to promote organizational improvements in the delivery of pain care. Subjects: Participants were veterans receiving care at VACHS with at least one pain intensity rating ≥4/10 over the course of the study period (7/2008-6/2013). Methods: We used electronic health record data to examine changes in indicators of pain care including pharmacy and health care utilization data. Results: We observed hypothesized changes in long-term opioid and nonopioid analgesic prescribing and increased utilization of nonpharmacological treatments such as physical therapy, occupational therapy, and clinical health psychology. Conclusions: Through a multifaceted comprehensive implementation approach, primary care providers demonstrated increases in guideline-concordant pain care practices. Findings suggest that engagement of interdisciplinary teams and partnerships to promote organizational improvements is a useful strategy to increase the use of integrated, multimodal pain care for veterans, consistent with VHA's SCM-PM.

Does food addiction contribute to excess weight among clinic patients seeking weight reduction? Examination of the Modified Yale Food Addiction Survey.

BACKGROUND: Despite controversy surrounding the construct of food addiction, its relationship with obesity and the validity of the Yale Food Addiction Scale (YFAS), have become emerging fields of study. No prior research has examined the prevalence and correlates of food addiction, and validation of the Modified Yale Food Addiction Scale (mYFAS), in a non-research based weight management clinic setting. OBJECTIVE: The current study sought to examine the validity of a brief version of the Yale Food Addiction Scale in weight loss seeking patients, and to determine whether food addiction contributes to excess weight in this patient population. PARTICIPANTS: The sample consisted of 126 Veterans with overweight/obesity who attended an orientation session for a weight management program. Participants (mean age = 61.8 years, mean BMI = 38.0, male = 89.7%, Caucasian = 76.0%) completed questionnaires related to food addiction, weight and eating, and mental health and behavior. RESULTS: Ten percent of the sample met diagnostic threshold for food addiction. Correlational analysis revealed that food addiction was significantly and highly correlated with BMI, emotional eating, night eating and screens for depression and insomnia (p's < 0.001); significantly correlated with eating pathology, and screening for PTSD (p's < 0.05); and inversely correlated with screening for alcohol use disorders (p < 0.01). The prevalence of food addiction was significantly higher in participants with Binge Eating Disorder (75%) compared to participants without (5.4%; p < 0.001). Food addiction uniquely accounted for 15% of the variance of BMI, almost three times more than general eating disorder pathology. DISCUSSION: This study provides further evidence for the validity of the mYFAS, and clinical significance of the food addiction construct among weight loss seeking patients in non-research based weight management settings. Findings confirm that food addiction contributes to excess weight among clinic patients seeking weight reduction above and beyond the effects of disordered eating. It is recommended that clinicians and researchers consider an addiction framework for addressing comorbid overweight and food addiction among afflicted individuals seeking weight loss.

Pain and modifiable risk factors among weight loss seeking Veterans with overweight.

OBJECTIVE: Overweight/obesity and chronic pain frequently co-occur and demonstrate a bidirectional relationship. Modifiable risk factors, such as eating behaviors and mental health symptoms, may be important to understand this relationship and improve interventions in Veterans. DESIGN: Cross-sectional. SETTING: Veterans Health Administration Medical Center outpatient clinic. SUBJECTS: The sample of Veterans (N = 126) was mostly male (89.7%), White (76%), and non-Hispanic (94%) with average age of 61.9 years (SD = 8.5) and average body mass index (BMI) of 38.5 (SD = 7.5). METHODS: Veterans referred for weight loss treatment (MOVE!) at VA Connecticut completed self-report questionnaires, and electronic medical records were reviewed. RESULTS: Mean self-reported pain rating was 4.5 out of 10 (SD = 2.3). Moderate to severe pain was endorsed by 60% of the sample. Veterans with higher pain intensity and interference reported higher global eating disorder symptoms, emotional overeating, night eating, insomnia severity, and mental health symptoms (all p's < 0.01). However, pain intensity and interference were not associated with BMI. CONCLUSIONS: For Veterans seeking behavioral weight loss treatment, higher pain intensity and interference were associated with more severe eating disorder, sleep, and mental health symptoms. A better description of the clinical characteristics of Veterans with pain who participate in MOVE! highlights their unique needs and may improve treatments to address pain in the context of weight loss treatment.

Night eating among veterans with obesity.

The obesity rate is higher among veterans than the general population, yet few studies have examined their eating behaviors, and none have examined the presence of night eating and related comorbidities. This study examines night eating syndrome (NES) among veterans seeking weight management treatment, and relationships between NES and weight, insomnia, disordered eating, and psychological variables. The sample consisted of 110 veterans referred to a weight management program at VA Connecticut Healthcare System. More than one out of ten veterans screened positive for NES, and one-third screened positive for insomnia. Most individuals screening positive for NES also screened positive for insomnia. Night eating was associated with higher BMI, and with higher scores on measures of binge eating, emotional overeating, and eating disorder symptomatology. Veterans screening positive for NES were also significantly more likely to screen positive for depression and PTSD. When controlling for insomnia, only the relationships between night eating and binge and emotional eating remained significant. Those screening positive for PTSD were more likely to endorse needing to eat to return to sleep. Findings suggest that both NES and insomnia are common among veterans seeking weight management services, and that NES is a marker for additional disordered eating behavior, specifically binge eating and overeating in response to emotions. Additional studies are needed to further delineate the relationships among NES, insomnia, and psychological variables, as well as to examine whether specifically addressing NES within behavioral weight management interventions can improve weight outcomes and problematic eating behaviors.

Weight change after antiretroviral therapy and mortality.

BACKGROUND: Weight gain after antiretroviral therapy (ART) initiation is common, but its implication for mortality is unknown. We evaluated weight change in the first year after ART initiation and its association with subsequent mortality. METHODS: Human immunodeficiency virus-infected patients from the Veterans Aging Cohort Study (VACS) who initiated ART between 2000 and 2008, with weight recorded at baseline and 1 year later, were followed another 5 years for mortality. Baseline body mass index (BMI) was classified as underweight (<18.5 kg/m(2)), normal (18.5-24.9 kg/m(2)), overweight (25-29.9 kg/m(2)), and obese (≥30 kg/m(2)). We used multivariable Cox models to assess mortality risk with adjustment for disease severity using the VACS Index. RESULTS: The sample consisted of 4184 men and 127 women with a mean age of 47.9 ± 10.0 years. After 1 year of ART, median weight change was 5.9 pounds (2.7 kg) (interquartile range, -2.9 to 17.0 pounds, -1.3 to 7.7 kg). Weight gain after ART initiation was associated with lower mortality among underweight and normal-weight patients. A minimum threshold of 10- to 19.9-pound (4.5 to 9.0 kg) weight gain was beneficial for normal-weight patients (hazard ratio, 0.56; 95% confidence interval, .41-.78), but there was no clear benefit to weight gain for overweight/obese patients. Baseline weight, CD4 cell count status, and hemoglobin level were strongly associated with weight gain. Risk for weight gain was higher among those with greater disease severity, regardless of weight at initiation. CONCLUSIONS: The survival benefits of weight gain after ART initiation are dependent on starting BMI. Weight gain after ART is associated with lower mortality for those who are not initially overweight.

Implementing the patient-centered medical home in residency education.

BACKGROUND: In recent years, physician groups, government agencies and third party payers in the United States of America have promoted a Patient-centered Medical Home (PCMH) model that fosters a team-based approach to primary care. Advocates highlight the model's collaborative approach where physicians, mid-level providers, nurses and other health care personnel coordinate their efforts with an aim for high-quality, efficient care. Early studies show improvement in quality measures, reduction in emergency room visits and cost savings. However, implementing the PCMH presents particular challenges to physician training programs, including institutional commitment, infrastructure expenditures and faculty training. DISCUSSION: Teaching programs must consider how the objectives of the PCMH model align with recent innovations in resident evaluation now required by the Accreditation Council of Graduate Medical Education (ACGME) in the US. This article addresses these challenges, assesses the preliminary success of a pilot project, and proposes a viable, realistic model for implementation at other institutions.

Integrating interdisciplinary pain management into primary care: development and implementation of a novel clinical program.

OBJECTIVES: The aims of this study were to develop and implement an interdisciplinary pain program integrated in primary care to address stakeholder-identified gaps. DESIGN: Program development and evaluation project utilizing a Plan-Do-Study-Act (PDSA) approach to address the identified problem of insufficient pain management resources within primary care. SETTING: A large Healthcare System within the Veterans Health Administration, consisting of two academically affiliated medical centers and six community-based outpatients clinics. METHODS: An interprofessional group of stakeholders participated in a Rapid Process Improvement Workshop (RPIW), a consensus-building process to identify systems-level gaps and feasible solutions and obtain buy-in. Changes were implemented in 2012, and in a 1-year follow-up, we examined indicators of engagement in specialty and multimodal pain care services as well as patient and provider satisfaction. RESULTS: In response to identified barriers, RPIW participants proposed and outlined two readily implementable, interdisciplinary clinics embedded within primary care: 1) the Integrated Pain Clinic, providing in-depth assessment and triage to targeted resources; and 2) the Opioid Reassessment Clinic, providing assessment and structured monitoring of patients with evidence of safety, efficacy, or misuse problems with opioids. Implementation of these programs led to higher rates of engagement in specialty and multimodal pain care services; patients and providers reported satisfaction with these services. CONCLUSIONS: Our PDSA cycle engaged an interprofessional group of stakeholders that recommended introduction of new systems-based interventions to better integrate pain resources into primary care to address reported barriers. Early data suggest improved outcomes; examination of additional outcomes is planned.

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

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

The Effect of Primary Care Visits on Total Patient Care Cost: Evidence From the Veterans Health Administration.

BACKGROUND: Since the 1980s, primary care (PC) in the US has been recognized as the backbone of healthcare providing comprehensive care to complex patients, coordinating care among specialists, and rendering preventive services to contain costs and improve clinical outcomes. However, the effect of PC visits on total patient care cost has been difficult to quantify. OBJECTIVE: To assess the effect of PC visits on total patient care cost. METHODS: This is a retrospective study of over 5 million patients assigned to a PC provider in the Veterans Health Administration (VHA) in each of the 4 fiscal years (FY 2016-2019). The main outcome of interest is total annual patient care cost. We assessed the effect of primary care visits on total patient care cost first by descriptive statistics, and then by multivariate regressions adjusting for severity of illness and other confounders. We conducted in-depth sensitivity analyses to validate the findings. RESULTS: On average, each additional in-person PC visit was associated with a total cost reduction of $721 (per patient per year). The first PC visit was associated with the largest savings, $3976 on average, and a steady diminishing return was observed. Further, the higher the patient risk (severity of illness), the larger the cost reduction: Among the top 10% of high-risk patients, the first PC in-person visit was associated with a reduction of $16 406 (19%). CONCLUSIONS: These findings, substantiated by our exhaustive sensitivity analyses, suggest that expanding PC capacity can significantly reduce overall health care costs and improve patient care outcomes given the former is a strong proxy of the latter.

Usability Testing of the Kidney Score Platform to Enhance Communication About Kidney Disease in Primary Care Settings: Qualitative Think-Aloud Study.

BACKGROUND: Patient awareness of chronic kidney disease (CKD) is low in part due to suboptimal testing for CKD among those at risk and lack of discussions about kidney disease between patients and clinicians. To bridge these gaps, the National Kidney Foundation developed the Kidney Score Platform, which is a web-based series of tools that includes resources for health care professionals as well as an interactive, dynamic patient-facing component that includes a brief questionnaire about risk factors for kidney disease, individualized assessment of risk for developing CKD, and self-management tools to manage one's kidney disease. OBJECTIVE: The aim of this study is to perform usability testing of the patient component of the Kidney Score platform among veterans with and at risk for kidney disease and among clinicians working as primary care providers in Veterans Affairs administration. METHODS: Think-aloud exercises were conducted, during which participants (veterans and clinicians) engaged with the platform while verbalizing their thoughts and making their perceptions, reasonings, and decision points explicit. A usability facilitator observed participants' behaviors and probed selectively to clarify their comprehension of the tool's instructions, content, and overall functionality. Thematic analysis on the audio-recording transcripts was performed, focusing on positive attributes, negative comments, and areas that required facilitator involvement. RESULTS: Veterans (N=18) were 78% (14/18) male with a mean age of 58.1 years. Two-thirds (12/18) were of non-White race/ethnicity, 28% (5/18) had laboratory evidence of CKD without a formal diagnosis, and 50% (9/18) carried a diagnosis of hypertension or diabetes. Clinicians (N=19) were 29% (5/17) male, 30% (5/17) of non-White race/ethnicity, and had a mean of 17 (range 4-32) years of experience. Veterans and clinicians easily navigated the online tool and appreciated the personalized results page as well as the inclusion of infographics to deliver key educational messages. Three major themes related to content and communication about risk for CKD emerged from the think-aloud exercises: (1) tension between lay and medical terminology when discussing kidney disease and diagnostic tests, (2) importance of linking general information to concrete self-management actions, and (3) usefulness of the tool as an adjunct to the office visit to prepare for patient-clinician communication. Importantly, these themes were consistent among interviews involving both veterans and clinicians. CONCLUSIONS: Veterans and clinicians both thought that the Kidney Score Platform would successfully promote communication and discussion about kidney disease in primary care settings. Tension between using medical terminology that is used regularly by clinicians versus lay terminology to promote CKD awareness was a key challenge, and knowledge of this can inform the development of future CKD educational materials.

Virtual Respiratory Urgent Clinics for COVID-19 Symptoms.

BACKGROUND: The COVID-19 pandemic has forced a shift from in-person to virtual care to reduce exposure risks to patients and health care workers. This report aims to describe a large primary care system's implementation of virtual respiratory urgent care clinics (VRUCs). METHODS: The VA Connecticut Healthcare System (VACHS) delivers care to more than 58,000 veterans in at 8 primary care sites. VRUCs were established as part of the VACHS primary care rapid transition to virtual care model. Retrospective analysis and qualitative chart reviews were performed from February 2020 through May 2020 to describe characteristics of patients who received care through the VRUCs. RESULTS: VRUCs were used by > 445 patients, 51% received COVID-19 testing, 10% tested positive, 5% were admitted to the hospital, and 18% had ≥ 1 subsequent emergency department visits. Chart documentation rates of discussion of isolation precautions, high occupational risk, and goals of care were 71%, 25%, and 14%, respectively. CONCLUSIONS: Average wait time for health care provider evaluation was 104 minutes, suggesting VRUCs are an expedient means to provide assessment of COVID-19 symptoms. Use of templated notes may ensure routine counseling about isolation, occupation, and goals of care.

Associations between adverse childhood experiences and weight, weight control behaviors and quality of life in Veterans seeking weight management services.

INTRODUCTION: A neglected area of trauma research with Veterans is the study of Adverse Childhood Experiences (ACEs). The present study aimed to examine the prevalence of ACEs, and to explore relationships between ACEs and measures of weight, eating behaviors and quality of life in weight loss seeking Veterans. METHODS: Participants were 191 Veterans [mean age 58.9 (SD = 12.8), mean Body Mass Index (BMI) 35.4 (SD = 6.1), 86.9% male, 33.7% racial/ethnic minority] receiving care at VA Connecticut Healthcare System (VA CT) who attended an orientation session of VA's behavioral weight management program. Participants completed a measure of ACEs and measures related to weight, eating and health. RESULTS: Among completers, 68.6% endorsed at least one ACE. The average number of reported ACEs was 2.2 (SD = 2.5), with 48.7% of Veterans reporting more than one type of ACE. Women were more likely to report any ACE (88.0% vs. 65.6%, p = .025) and reported significantly more ACEs compared to males (4.2 vs. 1.9, p < .001). ACEs were associated with lower physical activity (p = .05), lower quality of life (p's < 0.05), and lower weight-related quality of life (p < .01), but not weight, weight control strategies, binge eating, or alcohol use. CONCLUSION: ACEs are common among weight loss seeking Veterans, particularly among female Veterans. Findings suggest that there is a high rate of ACEs in Veterans, which are associated with exercise and quality of life outcomes, but not diet and weight outcomes.