Overcoming Obstacles: Barriers to Virtual Care Use Among Video-Enabled Tablet Recipients in the Veterans Health Administration.

INTRODUCTION: The Veterans Health Administration (VHA) distributes video-enabled tablets to individuals with barriers to accessing care. Data suggests that many tablets are under-used. We surveyed Veterans who received a tablet to identify barriers that are associated with lower use, and evaluated the impact of a telephone-based orientation call on reported barriers and future video use. METHODS: We used a national survey to assess for the presence of 13 barriers to accessing video-based care, and then calculated the prevalence of the barriers stratified by video care utilization in the 6 months after survey administration. We used multivariable modeling to examine the association between each barrier and video-based care use and evaluated whether a telephone-based orientation modified this association. RESULTS: The most prevalent patient-reported barriers to video-based care were not knowing how to schedule a visit, prior video care being rescheduled/canceled, and past problems using video care. Following adjustment, individuals who reported vision or hearing difficulties and those who reported that video care does not provide high-quality care had a 19% and 12% lower probability of future video care use, respectively. Individuals who reported no interest in video care, or did not know how to schedule a video care visit, had an 11% and 10% lower probability of being a video care user, respectively. A telephone-based orientation following device receipt did not improve the probability of being a video care user. DISCUSSION: Barriers to engaging in virtual care persist despite access to video-enabled devices. Targeted interventions beyond telephone-based orientation are needed to facilitate adoption and engagement in video visits.

Patient-, Provider-, and Facility-Level Contributors to the Use of Cardiology Telehealth Care in the Veterans Health Administration: Retrospective Cohort Study.

BACKGROUND: Telehealth (care delivered by phone or video) comprises a substantial proportion of cardiology care delivered in the Veterans Health Administration (VHA). Little is known about how factors specific to patients, clinicians, and facilities contribute to variation in cardiology telehealth use. OBJECTIVE: The aim of this study is to estimate the relative extent to which patient-, clinician-, and facility-level factors affect cardiology telehealth use in VHA. METHODS: This was a retrospective, nation-wide cohort study of veterans' use of VHA cardiology telehealth care during the first 2 years of the COVID-19 pandemic (March 11, 2020, to March 10, 2022). We constructed multilevel, multivariable, logistic regression models of patient-level cardiology telehealth use (telephone or video-based care). Models included random effects for the patient, the patient's main cardiology provider, and the patient's primary facility (ie, VHA medical center) for specialty care and fixed effects for patient sociodemographic and clinical characteristics. RESULTS: Our analytic cohort comprised 223,809 veterans with 989,271 encounters among 2235 unique clinicians. The veterans' average age was 70.2 years, and 3.4% (n=7616) were women. Of the 989,271 encounters, 4.2% (n=41,480) were video based and 34.3% (n=338,834) were phone based. Adjusted odds of telehealth use were slightly higher for women versus men (adjusted odds ratio [AOR] 1.08, 95% CI 1.05-1.10), individuals identifying as Hispanic or Latino versus not Hispanic or Latino (AOR 1.46, 95% CI 1.43-1.49), and those with medium and long drive times versus short drive time (AOR 1.11, 95% CI 1.10-1.12 and AOR 1.09, 95% CI 1.07-1.10, respectively). Further, 40.5% of the variation in a veteran's likelihood of using cardiology telehealth care was found at the patient level, 30.8% at the clinician level, and 7% at the facility level. CONCLUSIONS: The largest share of the attributable variability in VHA cardiology telehealth use in this cohort was explained by the patient, followed closely by the clinician. Little variability was attributed to the primary facility through which the veteran received their cardiology care. These results suggest that policy solutions intended to improve equity of cardiology telehealth care use in VHA may be most impactful when directed at patients and clinicians.

Evaluation of the Veterans Health Administration's Digital Divide Consult for Tablet Distribution and Telehealth Adoption: Cohort Study.

BACKGROUND: Video telehealth offers a mechanism to help Veterans Health Administration (VHA) patients overcome health care access barriers; however, many veterans lack a suitable device and sufficient internet connectivity. To address disparities in technology access, VHA established a Connected Device Program that offers veterans loaned video-capable tablets and internet service. In 2020, VHA introduced a national Digital Divide Consult to facilitate and standardize referrals for this resource. OBJECTIVE: We sought to evaluate the reach and impact of VHA's Connected Device Program, leveraging Digital Divide Consult data to determine whether resources are supporting veterans with health care needs and access barriers. METHODS: We examined the reach of VHA's Connected Device Program using national secondary data from VHA's electronic health records among 119,926 tablet recipients who received a tablet (April 1, 2020, to February 28, 2023) and 683,219 veterans from the general VHA population. We assessed changes in tablet recipients' demographic and clinical characteristics before and after implementation of the Digital Divide Consult compared with the general VHA population. We examined the impact of tablets and the consult on adoption of telehealth (ie, video visit use and number of visits) adjusting for differences between tablet recipients and the general VHA population. Finally, we evaluated consult implementation by assessing the use of video-based services by tablet referral reason. RESULTS: Common reasons for tablet referral included mental health diagnoses (50,367/79,230, 63.9%), distance from a VHA facility >30 miles (17,228/79,230, 21.7%), and social isolation (16,161/79,230, 20.4%). Moreover, 63.0% (49,925/79,230) of individuals who received a tablet after implementation of the Digital Divide Consult had a video visit in the first 6 months of tablet receipt. Some consult reasons were associated with a higher-than-average percentage of video telehealth use, including enrollment in evidence-based mental health programs (74.8% [830/1100] with video use), living >30 miles from a VHA facility (68.3% [10,557/17,228] with video use), and having a mental health diagnosis (68.1% [34,301/50,367] with video use). Tablet recipients had nearly 3 times the likelihood of having a video visit within a month once provided a tablet compared to the general VHA population, with an adjusted risk ratio of 2.95 (95% CI 2.91-2.99) before consult implementation and 2.73 (95% CI 2.70-2.76) after consult implementation. Analyses of telehealth adoption suggested that veterans receiving tablets for mental health care and evidence-based programs have higher rates of video visits, while those who are homebound or receiving tablets for hospice have higher rates of nonuse. CONCLUSIONS: This evaluation of VHA's Connected Device Program suggests that tablets are facilitating video-based care among veterans with complex needs. Standardization of referrals through the Digital Divide Consult has created opportunities to identify groups of tablet recipients with lower telehealth adoption rates who might benefit from a targeted intervention.

Adoption and Sustained Use of Primary Care Video Visits Among Veterans with VA Video-Enabled Tablets.

In 2020, the U.S. Department of Veterans Affairs (VA) expanded an initiative to distribute video-enabled tablets to Veterans with limited virtual care access. We examined patient characteristics associated with adoption and sustained use of video-based primary care among Veterans. We conducted a retrospective cohort study of Veterans who received VA-issued tablets between 3/11/2020-9/10/2020. We used generalized linear models to evaluate the sociodemographic and clinical factors associated with video-based primary care adoption (i.e., likelihood of having a primary care video visit) and sustained use (i.e., rate of video care) in the six months after a Veteran received a VA-issued tablet. Of the 36,077 Veterans who received a tablet, 69% had at least one video-based visit within six months, and 24% had a video-based visit in primary care. Veterans with a history of housing instability or a mental health condition, and those meeting VA enrollment criteria for low-income were significantly less likely to adopt video-based primary care. However, among Veterans who had a video visit in primary care (e.g., those with at least one video visit), older Veterans, and Veterans with a mental health condition had more sustained use (higher rate) than younger Veterans or those without a mental health condition. We found no differences in adoption of video-based primary care by rurality, age, race, ethnicity, or low/moderate disability and high disability priority groups compared to Veterans with no special enrollment category. VA's tablet initiative has supported many Veterans with complex needs in accessing primary care by video. While Veterans with certain social and clinical challenges were less likely to have a video visit, those who adopted video telehealth generally had similar or higher rates of sustained use. These patterns suggest opportunities for tailored interventions that focus on needs specific to initial uptake vs. sustained use of video care.

Overcoming Access Barriers for Veterans: Cohort Study of the Distribution and Use of Veterans Affairs' Video-Enabled Tablets Before and During the COVID-19 Pandemic.

BACKGROUND: During the COVID-19 pandemic, as health care services shifted to video- and phone-based modalities for patient and provider safety, the Veterans Affairs (VA) Office of Connected Care widely expanded its video-enabled tablet program to bridge digital divides for veterans with limited video care access. OBJECTIVE: This study aimed to characterize veterans who received and used US Department of VA-issued video-enabled tablets before versus during the COVID-19 pandemic. METHODS: We compared sociodemographic and clinical characteristics of veterans who received VA-issued tablets during 6-month prepandemic and pandemic periods (ie, from March 11, 2019, to September 10, 2019, and from March 11, 2020, to September 10, 2020). Then, we examined characteristics associated with video visit use for primary and mental health care within 6 months after tablet shipment, stratifying models by timing of tablet receipt. RESULTS: There was a nearly 6-fold increase in the number of veterans who received tablets in the pandemic versus prepandemic study periods (n=36,107 vs n=6784, respectively). Compared to the prepandemic period, tablet recipients during the pandemic were more likely to be older (mean age 64 vs 59 years), urban-dwelling (24,504/36,107, 67.9% vs 3766/6784, 55.5%), and have a history of housing instability (8633/36,107, 23.9% vs 1022/6784, 15.1%). Pandemic recipients were more likely to use video care (21,090/36,107, 58.4% vs 2995/6784, 44.2%) and did so more frequently (5.6 vs 2.3 average encounters) within 6 months of tablet receipt. In adjusted models, pandemic and prepandemic video care users were significantly more likely to be younger, stably housed, and have a mental health condition than nonusers. CONCLUSIONS: Although the COVID-19 pandemic led to increased distribution of VA-issued tablets to veterans with complex clinical and social needs, tablet recipients who were older or unstably housed remained less likely to have a video visit. The VA's tablet distribution program expanded access to video-enabled devices, but interventions are needed to bridge disparities in video visit use among device recipients.

Risk factors for meticillin-resistant Staphylococcus aureus (MRSA) carriage in MRSA-exposed household pets.

BACKGROUND: Household pets can carry meticillin-resistant Staphylococcus aureus (MRSA) introduced to the home by their human companions. Specific factors promoting pet carriage of this pathogen have not been fully elucidated. OBJECTIVE: This study evaluated MRSA cultured from pets and the home environment in households where a human infected with MRSA had been identified, and aimed to determine potential risk factors for pet MRSA carriage. MATERIALS AND METHODS: Humans diagnosed with community-associated MRSA (CA-MRSA) skin or soft-tissue infection (SSTI) in the mid-Atlantic United States were identified. One hundred forty-two dogs and cats from 57 affected households were identified of which 134 (94.4%) pets and the household environment were sampled for bacterial culture, PCR confirmation and spa-typing for MRSA strain determination. Samples were obtained 3 months later from 86 pets. RESULTS: At baseline, 12 (9.0%) pets carried MRSA. Potential risk factors associated with carriage included pet bed (environmental) MRSA contamination, flea infestation and prior antimicrobial use in the pet. Pets tended to carry human-adapted MRSA strains and spa-types of MRSA isolates cultured from pets were concordant with strains cultured from the home environment in seven of eight homes (87.5%) at baseline. CONCLUSIONS AND CLINICAL RELEVANCE: Results may inform risk-based veterinary clinical recommendations and provide evidence for selective pet testing as a possible alternative to early removal of pets from the homes of humans infected with MRSA. MRSA contamination of the home environment is likely an important risk factor for pet MRSA carriage, and household interventions should be considered to reduce risk of MRSA carriage in exposed pets.

The development and initial validation of a new working time scale for full-time workers with non-standard schedules.

BACKGROUND: Working time characteristics have been used to link work schedule features to health impairment; however, extant working time exposure assessments are narrow in scope. Prominent working time frameworks suggest that a broad range of schedule features should be assessed to best capture non-standard schedules. The purpose of this study was to develop a multi-dimensional scale that assesses working time exposures and test its reliability and validity for full-time workers with non-standard schedules. METHODS: A cross-sectional study was conducted using full-time, blue-collar worker population samples from three industries - transportation (n = 174), corrections (n = 112), and manufacturing (n = 99). Using a multi-phased approach including the review of scientific literature and input from an advisory panel of experts, the WorkTime Scale (WTS) was created and included multiple domains to characterize working time (length, time of day, intensity, control, predictability, and free time). Self-report surveys were distributed to workers at their workplace during company time. Following a comprehensive scale development procedure (Phase 1), exploratory factor analysis (EFA) (Phase 2) and, confirmatory factor analysis (CFA) (Phase 3; bivariate correlations were used to identify the core components of the WTS and assess the reliability and validity (Phase 4) in three samples. RESULTS: Phase 1 resulted in a preliminary set of 21 items that served as the basis for the quantitative analysis of the WTS. Phase 2 used EFA to yield a 14-item WTS measure with two subscales ("Extended and Irregular Work Days (EIWD)" and "Lack of Control (LOC)"). Phase 3 used CFA to confirm the factor structure of the WTS, and its subscales demonstrated good internal consistency: alpha coefficients were 0.88 for the EIWD factor and 0.76-0.81 for the LOC factor. Phase 4 used bivariate correlations to substantiate convergent, discriminant, and criterion (predictive) validities. CONCLUSIONS: The 14-item WTS with good reliability and validity is an effective tool for assessing working time exposures in a variety of full-time jobs with non-standard schedules.

Organizational and External Factors Associated with Video Telehealth Use in the Veterans Health Administration Before and During the COVID-19 Pandemic.

Objectives: To identify organizational and external factors associated with medical center video telehealth uptake (i.e., the proportion of patients using telemedicine) before and early in the coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: We conducted a retrospective, observational study using cross-sectional data for all 139 U.S. Veterans Affairs Medical Centers (VAMCs). We used logistic regression analyses to identify factors that predicted whether a VAMC was in the top quartile of VA Video Connect (VVC) telehealth uptake for primary care and mental health care. Results: All 139 VAMCs increased their VVC uptake at least 2-fold early in the pandemic, with most increasing uptake between 5- and 10-fold. Pre-COVID-19, higher VVC uptake in primary care was weakly and positively associated with having more high-risk patients, negatively associated with having more long-distance patients, and positively associated with the prior fiscal year's VVC uptake. During COVID-19, the positive association with high-risk patients and the negative association with long-distance patients strengthened, while weaker broadband coverage was negatively associated with VVC uptake. For mental health care, having more long-distance patients was positively associated with higher VVC uptake pre-COVID-19, but this relationship reversed during COVID-19. Discussion: Despite the marked increase in VVC uptake early in the COVID-19 pandemic, significant VAMC-level variation indicates that VVC adoption was more difficult for some medical centers, particularly those with poorer broadband coverage and less prior VVC experience. Conclusions and Relevance: These findings highlight opportunities for medical centers, VA Central Office, and other federal entities to ensure equitable access to video telehealth.

Changes in the associations of race and rurality with SARS-CoV-2 infection, mortality, and case fatality in the United States from February 2020 to March 2021: A population-based cohort study.

BACKGROUND: We examined whether key sociodemographic and clinical risk factors for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and mortality changed over time in a population-based cohort study. METHODS AND FINDINGS: In a cohort of 9,127,673 persons enrolled in the United States Veterans Affairs (VA) healthcare system, we evaluated the independent associations of sociodemographic and clinical characteristics with SARS-CoV-2 infection (n = 216,046), SARS-CoV-2-related mortality (n = 10,230), and case fatality at monthly intervals between February 1, 2020 and March 31, 2021. VA enrollees had a mean age of 61 years (SD 17.7) and were predominantly male (90.9%) and White (64.5%), with 14.6% of Black race and 6.3% of Hispanic ethnicity. Black (versus White) race was strongly associated with SARS-CoV-2 infection (adjusted odds ratio [AOR] 5.10, [95% CI 4.65 to 5.59], p-value <0.001), mortality (AOR 3.85 [95% CI 3.30 to 4.50], p-value < 0.001), and case fatality (AOR 2.56, 95% CI 2.23 to 2.93, p-value < 0.001) in February to March 2020, but these associations were attenuated and not statistically significant by November 2020 for infection (AOR 1.03 [95% CI 1.00 to 1.07] p-value = 0.05) and mortality (AOR 1.08 [95% CI 0.96 to 1.20], p-value = 0.21) and were reversed for case fatality (AOR 0.86, 95% CI 0.78 to 0.95, p-value = 0.005). American Indian/Alaska Native (AI/AN versus White) race was associated with higher risk of SARS-CoV-2 infection in April and May 2020; this association declined over time and reversed by March 2021 (AOR 0.66 [95% CI 0.51 to 0.85] p-value = 0.004). Hispanic (versus non-Hispanic) ethnicity was associated with higher risk of SARS-CoV-2 infection and mortality during almost every time period, with no evidence of attenuation over time. Urban (versus rural) residence was associated with higher risk of infection (AOR 2.02, [95% CI 1.83 to 2.22], p-value < 0.001), mortality (AOR 2.48 [95% CI 2.08 to 2.96], p-value < 0.001), and case fatality (AOR 2.24, 95% CI 1.93 to 2.60, p-value < 0.001) in February to April 2020, but these associations attenuated over time and reversed by September 2020 (AOR 0.85, 95% CI 0.81 to 0.89, p-value < 0.001 for infection, AOR 0.72, 95% CI 0.62 to 0.83, p-value < 0.001 for mortality and AOR 0.81, 95% CI 0.71 to 0.93, p-value = 0.006 for case fatality). Throughout the observation period, high comorbidity burden, younger age, and obesity were consistently associated with infection, while high comorbidity burden, older age, and male sex were consistently associated with mortality. Limitations of the study include that changes over time in the associations of some risk factors may be affected by changes in the likelihood of testing for SARS-CoV-2 according to those risk factors; also, study results apply directly to VA enrollees who are predominantly male and have comprehensive healthcare and need to be confirmed in other populations. CONCLUSIONS: In this study, we found that strongly positive associations of Black and AI/AN (versus White) race and urban (versus rural) residence with SARS-CoV-2 infection, mortality, and case fatality observed early in the pandemic were ameliorated or reversed by March 2021.

Chronic obstructive pulmonary disease mortality: The Diesel Exhaust in Miners Study (DEMS).

BACKGROUND: Miners are highly exposed to diesel exhaust emissions from powered equipment. Although biologically plausible, there is little evidence based on quantitative exposure assessment, that long-term diesel exposure increases risk of chronic obstructive pulmonary disease (COPD). To fill this gap, we examined COPD mortality and diesel exhaust exposure in the Diesel Exhaust in Miners Study (DEMS). METHODS: We fit Cox models to estimate hazard ratios (HRs) for COPD mortality and cumulative exposure (µg/m3-years) to respirable elemental carbon (REC), a key metric for diesel exhaust exposure. Separate models were fit for ever-underground and surface-only miners to allow for effect modification. Exposure was lagged by 0, 10 and 15 years. In a secondary analysis, we addressed the healthy worker survivor effect by applying the parametric g-formula to handle time-varying confounding affected by prior exposure among ever-underground workers. RESULTS: Based on 140 cases, the HRs for COPD mortality increased as categories of lagged REC exposure increased for all workers. Among surface-only workers, those in the middle exposure category (0 lag) had a significantly elevated hazard ratio of 2.34 (95% CI: 1.11-4.61) relative to those in the lowest category. Among the ever-underground, that ratio was 1.35, with wide confidence intervals. Using the g-formula, we estimated that the lifetime cumulative risk of COPD mortality would have been reduced from the observed 5.0%-3.1% under a hypothetical intervention where all ever-underground workers were always unexposed. CONCLUSIONS: Our results suggest long term exposure to diesel exhaust may increase risk of COPD in miners, though power was limited.

Biomarkers of Secondhand Smoke Exposure in Waterpipe Tobacco Venue Employees in Istanbul, Moscow, and Cairo.

Background: Most smoke-free legislation to reduce secondhand smoke (SHS) exposure exempts waterpipe (hookah) smoking venues. Few studies have examined SHS exposure in waterpipe venues and their employees. Methods: We surveyed 276 employees of 46 waterpipe tobacco venues in Istanbul, Moscow, and Cairo. We interviewed venue managers and employees and collected biological samples from employees to measure exhaled carbon monoxide (CO), hair nicotine, saliva cotinine, urine cotinine, urine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and urine 1-hydroxypyrene glucuronide (1-OHPG). We estimated adjusted geometric mean ratios (GMR) of each SHS biomarker by employee characteristics and indoor air SHS measures. Results: There were 73 nonsmoking employees and 203 current smokers of cigarettes or waterpipe. In nonsmokers, the median (interquartile) range concentrations of SHS biomarkers were 1.1 (0.2, 40.9) µg/g creatinine urine cotinine, 5.5 (2, 15) ng/mL saliva cotinine, 0.95 (0.36, 5.02) ng/mg hair nicotine, 1.48 (0.98, 3.97) pg/mg creatinine urine NNAL, 0.54 (0.25, 0.97) pmol/mg creatinine urine 1-OHPG, and 1.67 (1.33, 2.33) ppm exhaled CO. An 8-hour increase in work hours was associated with higher urine cotinine (GMR: 1.68, 95% CI: 1.20, 2.37) and hair nicotine (GMR: 1.22, 95% CI: 1.05, 1.43). Lighting waterpipes was associated with higher saliva cotinine (GMR: 2.83, 95% CI: 1.05, 7.62). Conclusions: Nonsmoking employees of waterpipe tobacco venues were exposed to high levels of SHS, including measurable levels of carcinogenic biomarkers (tobacco-specific nitrosamines and PAHs). Implications: Smoke-free regulation should be extended to waterpipe venues to protect nonsmoking employees and patrons from the adverse health effects of SHS.

Comparison of Culture-Based Methods for Identification of Colonization with Methicillin-Resistant and Methicillin-Susceptible Staphylococcus aureus in the Context of Cocolonization.

Two screening methods to detect staphylococcal colonization in humans were compared. Direct plating to CHROMagar (BD Diagnostics) was compared to a broth preenrichment followed by plating to Baird-Parker agar. The broth-enrichment method was comparable to CHROMagar for methicillin-resistant Staphylococcus aureas (MRSA) detection, but the enrichment method was optimum for recovery of coagulase-positive Staphylococcus spp.

Gender Differences in Adoption and Frequency of Virtual Primary Care Among Men and Women Veterans.

Background: Women Veterans have unique health care utilization patterns; however, video-based primary care utilization among and between women and men has not been well examined. Methods: In a retrospective cohort study, we calculated gender-stratified video visit adoption (i.e., likelihood) and frequency (i.e., rate of use among users) between April 1, 2020, and March 31, 2022, by demographic and clinical characteristics known to impact health care utilization. Results: Among 5,389,139 Veterans (9.2% women), 32% of women and 18.6% of men had a video-based primary care visit over the 2-year study period. Gender interacted with Veteran characteristics and the likelihood of any video care. Men often had associations stronger in magnitude (both positive and negative) than women, including by age, rurality, history of housing instability, mental health conditions, and marital status. The direction of effect never diverged by gender. A positive association among women always coincided with a positive association among men, and vice versa, across all characteristics assessed. Only the risk ratio for video care use comparing Veterans of Black race with White race was stronger among women. In contrast to the video care adoption differences by gender, we found few differences in the frequency of video-based care by gender. Conclusions: The findings suggest there are fewer disparities by demographic and clinical characteristics in any video care use among women compared with men and little to no disparities in the frequency of video care use by gender. Understanding the variation in video care utilization by gender could help improve acceptance, appropriate utilization, and uptake of video-based visits for all.

Diesel exhaust and respiratory dust exposure in miners and chronic obstructive pulmonary disease (COPD) mortality in DEMS II.

BACKGROUND: Diesel exhaust and respirable dust exposures in the mining industry have not been studied in depth with respect to non-malignant respiratory disease including chronic obstructive pulmonary disease (COPD), with most available evidence coming from other settings. OBJECTIVES: To assess the relationship between occupational diesel exhaust and respirable dust exposures and COPD mortality, while addressing issues of survivor bias in exposed miners. METHODS: The study population consisted of 11,817 male workers from the Diesel Exhaust in Miners Study II, followed from 1947 to 2015, with 279 observed COPD deaths. We fit Cox proportional hazards models for the relationship between respirable elemental carbon (REC) and respirable dust (RD) exposure and COPD mortality. To address healthy worker survivor bias, we leveraged the parametric g-formula to assess effects of hypothetical interventions on both exposures. RESULTS: Cox models yielded elevated estimates for the associations between average intensity of REC and RD and COPD mortality, with hazard ratios (HR) corresponding to an interquartile range width increase in exposure of 1.46 (95 % confidence interval (CI): 1.12, 1.91) and 1.20 (95 % CI: 0.96, 1.49), respectively for each exposure. HRs for cumulative exposures were negative for both REC and RD. Based on results from the parametric g-formula, the risk ratio (RR) for COPD mortality comparing risk under an intervention eliminating REC to the observed risk was 0.85 (95 % CI: 0.55, 1.06), equivalent to an attributable risk of 15 %. The corresponding RR comparing risk under an intervention eliminating RD to the observed risk was 0.93 (95 % CI: 0.56, 1.31). CONCLUSIONS: Our findings, based on data from a cohort of nonmetal miners, are suggestive of an increased risk of COPD mortality associated with REC and RD, as well as evidence of survivor bias in this population leading to negative associations between cumulative exposures and COPD mortality in traditional regression analysis.

The association of TNF inhibitor use with incident cardiovascular events in radiographic axial spondyloarthritis.

BACKGROUND: Whether tumor necrosis factor inhibitor (TNFi) use is cardioprotective among individuals with radiographic axial spondyloarthritis (r-axSpA), who have heightened cardiovascular (CV) risk, is unclear. We tested the association of TNFi use with incident CV outcomes in r-axSpA. METHODS: We identified a r-axSpA cohort within a Veterans Affairs database between 2002 and 2019 using novel phenotyping methods and secondarily using ICD codes. TNFi use was assessed as a time-varying exposure using pharmacy dispense records. The primary outcome was incident CV disease identified using ICD codes for coronary artery disease, myocardial infarction or stroke. We fit Cox models with inverse probability weights to estimate the risk of each outcome with TNFi use versus non-use. Analyses were performed in the overall cohort, and separately in two periods (2002-2010, 2011-2019) to account for secular trends. RESULTS: Using phenotyping we identified 26,928 individuals with an r-axSpA diagnosis (mean age 63.4 years, 94 % male); at baseline 3633 were TNFi users and 23,295 were non-users. During follow-up of a mean 3.3 ± 4.2 years, 674 (18.6 %) TNFi users had incident CVD versus 11,838 (50.8 %) non-users. In adjusted analyses, TNFi use versus non-use was associated with lower risk of incident CVD (HR 0.34, 95 % CI 0.29-0.40) in the cohort overall, and in the two time periods separately. CONCLUSION: In this r-axSpA cohort identified using phenotyping methods, TNFi use versus non-use had a lower risk of incident CVD. These findings provide reassurance regarding the CV safety of TNFi agents for r-axSpA treatment. Replication of these results in other cohorts is needed.

Distribution of working hour characteristics by race, age, gender, and shift schedule among U.S. manufacturing workers.

Shift work is a common occupational exposure, however, few studies have examined aspects of shift work beyond night work and long hours, such as rotational patterns or weekend work, which may contribute to poor health through disruption of the body's circadian rhythms. In this manuscript, we calculated the prevalence of working hour characteristics using algorithms for type (e.g., day), duration, intensity, rotational direction, and social aspects (e.g., weekend work) in a nationwide cohort of American manufacturing workers (N = 23,044) between 2003 and 2014. Distributions of working hour characteristics were examined by schedules (e.g., permanent day, day/night) and demographics, and were cross-classified in a matrix to examine co-occurrence. Approximately 55% of shifts may cause circadian rhythm disruption as they were non-day shifts or day shifts with a quick return or rotation, or were 13 h or longer. Older workers, female workers, and White workers worked permanent day shifts most often, while workers of color worked more day/night schedules. Night and evening shifts had more frequent shift rotations, quick returns, and longer hours than day shifts. Yet, day shifts, which are presumed to have little negative circadian impact, may cause circadian rhythm disruption as long hours, quick returns and rotations also occurred within day shifts.

Variation in initial and continued use of primary, mental health, and specialty video care among Veterans.

OBJECTIVE: To identify which Veteran populations are routinely accessing video-based care. DATA SOURCES AND STUDY SETTING: National, secondary administrative data from electronic health records at the Veterans Health Administration (VHA), 2019-2021. STUDY DESIGN: This retrospective cohort analysis identified patient characteristics associated with the odds of using any video care; and then, among those with a previous video visit, the annual rate of video care utilization. Video care use was reported overall and stratified into care type (e.g., primary, mental health, and specialty video care) between March 10, 2020 and February 28, 2021. DATA COLLECTION: Veterans active in VA health care (>1 outpatient visit between March 11, 2019 and March 10, 2020) were included in this study. PRINCIPAL FINDINGS: Among 5,389,129 Veterans in this evaluation, approximately 27.4% of Veterans had at least one video visit. We found differences in video care utilization by type of video care: 14.7% of Veterans had at least one primary care video visit, 10.6% a mental health video visit, and 5.9% a specialty care video visit. Veterans with a history of housing instability had a higher overall rate of video care driven by their higher usage of video for mental health care compared with Veterans in stable housing. American Indian/Alaska Native Veterans had reduced odds of video visits, yet similar rates of video care when compared to White Veterans. Low-income Veterans had lower odds of using primary video care yet slightly elevated rates of primary video care among those with at least one video visit when compared to Veterans enrolled at VA without special considerations. CONCLUSIONS: Variation in video care utilization patterns by type of care identified Veteran populations that might require greater resources and support to initiate and sustain video care use. Our data support service specific outreach to homeless and American Indian/Alaska Native Veterans.

Geographic and temporal variation in racial and ethnic disparities in SARS-CoV-2 positivity between February 2020 and August 2021 in the United States.

The coronavirus pandemic has disproportionally impacted racial and ethnic minority communities in the United States. Patterns of these disparities may be changing over time as outbreaks occur in different communities. Utilizing electronic health record data from the US Department of Veterans Affairs (VA), we estimated odds ratios, stratified by time period and region, for testing positive among 1,313,402 individuals tested for SARS-CoV-2 between February 12, 2020 and August 16, 2021 at VA medical facilities. We adjusted for personal characteristics (sex, age, rural/urban residence, VA facility) and a wide range of clinical characteristics that have been evaluated in prior SARS-CoV-2 reports and could potentially explain racial/ethnic disparities in SARS-CoV-2. Our study found racial and ethnic disparities for testing positive were most pronounced at the beginning of the pandemic and decreased over time. A key finding was that the disparity among Hispanic individuals attenuated but remained elevated, while disparities among Asian individuals reversed by March 1, 2021. The variation in racial and ethnic disparities in SARS-CoV-2 positivity by time and region, independent of underlying health status and other demographic characteristics in a nationwide cohort, provides important insight for strategies to prevent further outbreaks.