Advancing Pharmacological Treatments for Opioid Use Disorder (ADaPT-OUD): an Implementation Trial in Eight Veterans Health Administration Facilities.

BACKGROUND: Identifying effective strategies to improve access to medication treatments for opioid use disorder (MOUD) is imperative. Within the Veterans Health Administration (VHA), provision of MOUD varies significantly, requiring development and testing of implementation strategies that target facilities with low provision of MOUD. OBJECTIVE: Determine the effectiveness of external facilitation in increasing the provision of MOUD among VHA facilities with low baseline provision of MOUD compared to matched controls. DESIGN: Pre-post, block randomized study designed to compare facility-level outcomes in a stratified sample of eligible facilities. Four blocks (two intervention facilities in each) were defined by median splits of both the ratio of patients with OUD receiving MOUD and number of patients with OUD not currently receiving MOUD (i.e., number of actionable patients). Intervention facilities participated in a 12-month implementation intervention. PARTICIPANTS: VHA facilities in the lowest quartile of MOUD provision (35 facilities), eight of which were randomly assigned to participate in the intervention (two per block) with twenty-seven serving as matched controls by block. INTERVENTION: External facilitation included assessment of local barriers/facilitators, formation of a local implementation team, a site visit for action planning and training/education, cross-facility quarterly calls, monthly coaching calls, and consultation. MAIN MEASURES: Pre- to post-change in the facility-level ratio of patients with an OUD diagnosis receiving MOUD compared to control facilities. KEY RESULTS: Intervention facilities significantly increased the ratio of patients with OUD receiving MOUD from an average of 18% at baseline to 30% 1 year later, with an absolute difference of 12% (95% confidence interval [CI]: 6.6%, 17.0%). The difference in differences between intervention and control facilities was 3.0% (95% CI: - 0.2%. 6.7%). The impact of the intervention varied by block, with smaller, less complex facilities more likely to outperform matched controls. CONCLUSIONS: Intensive external facilitation improved the adoption of MOUD in most low-performing facilities and may enhance adoption beyond other interventions less tailored to individual facility contexts.

Taking ACTION to Reduce Pain: a Randomized Clinical Trial of a Walking-Focused, Proactive Coaching Intervention for Black Patients with Chronic Musculoskeletal Pain.

BACKGROUND: Black patients in the USA are disproportionately affected by chronic pain, yet there are few interventions that address these disparities. OBJECTIVE: To determine whether a walking-focused, proactive coaching intervention aimed at addressing contributors to racial disparities in pain would improve chronic pain outcomes among Black patients compared to usual care. DESIGN: Randomized controlled trial with masked outcome assessment ( Clinicaltrials.gov : NCT01983228). PARTICIPANTS: Three hundred eighty Black patients at the Atlanta VA Health Care System with moderate to severe chronic back, hip, or knee pain. INTERVENTION: Six telephone coaching sessions over 8-14 weeks, proactively delivered, using action planning and motivational interviewing to increase walking, or usual care. MAIN MEASURES: Primary outcome was a 30% improvement in pain-related physical functioning (Roland Morris Disability Questionnaire [RMDQ]) over 6 months among Black patients, using intention-to-treat. Secondary outcomes were improvements in pain intensity and interference, depression, anxiety, global impression of change in pain, and average daily steps. KEY RESULTS: The intervention did not produce statistically significant effects on the primary outcome (at 6 months, 32.4% of intervention participants had 30% improvement on the RMDQ vs. 24.7% of patients in usual care; aOR=1.61, 95% CI, 0.94 to 2.77), nor on other secondary outcomes assessed at 6 months, with the exception that intervention participants reported more favorable changes in pain relative to usual care (mean difference=-0.54, 95% CI, -0.85 to -0.23). Intervention participants also experienced a significant reduction in pain intensity and pain interference over 3 months (mean difference=-0.55, 95% CI, -0.88 to -0.22). CONCLUSIONS: A novel intervention to improve chronic pain among Black patients did not produce statistically significant improvements on the primary outcome relative to usual care. More intensive efforts are likely required among this population, many of whom were economically disadvantaged and had mental health comorbidities and physical limitations. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01983228.

Impact of different cover letter content and incentives on non-response bias in a sample of Veterans applying for Department of Veterans Affairs disability benefits: a randomized, 3X2X2 factorial trial.

BACKGROUND: Non-random non-response bias in surveys requires time-consuming, complicated, post-survey analyses. Our goal was to see if modifying cover letter information would prevent non-random non-response bias altogether. Our secondary goal tested whether larger incentives would reduce non-response bias. METHODS: A mailed, survey of 480 male and 480 female, nationally representative, Operations Enduring Freedom, Iraqi Freedom, or New Dawn (OEF/OIF/OND) Veterans applying for Department of Veterans Affairs (VA) disability benefits for posttraumatic stress disorder (PTSD). Cover letters conveyed different information about the survey's topics (combat, unwanted sexual attention, or lifetime and military experiences), how Veterans' names had been selected (list of OEF/OIF/OND Veterans or list of Veterans applying for disability benefits), and what incentive Veterans would receive ($20 or $40). The main outcome, non-response bias, measured differences between survey respondents' and sampling frame's characteristics on 8 administrative variables, including Veterans' receipt of VA disability benefits and exposure to combat or military sexual trauma. Analysis was intention to treat. We used ANOVA for factorial block-design, logistic, mixed-models to assess bias and multiple imputation and expectation-maximization algorithms to assess potential missing mechanisms (missing completely at random, missing at random, or not random) of two self-reported variables: combat and military sexual assault. RESULTS: Regardless of intervention, men with any VA disability benefits, women with PTSD disability benefits, and women with combat exposure were over-represented among respondents. Interventions explained 0.0 to 31.2% of men's variance and 0.6 to 30.5% of women's variance in combat non-response bias and 10.2 to 43.0% of men's variance and 0.4 to 31.9% of women's variance in military sexual trauma non-response bias. Non-random assumptions showed that men's self-reported combat exposure was overestimated by 19.0 to 28.8 percentage points and their self-reported military sexual assault exposure was underestimated by 14.2 to 28.4 percentage points compared to random missingness assumptions. Women's self-reported combat exposure was overestimated by 8.6 to 10.6 percentage points and military sexual assault exposure, by 1.2 to 6.9 percentage points. CONCLUSIONS: Our interventions reduced bias in some characteristics, leaving others unaffected or exacerbated. Regardless of topic, researchers are urged to present estimates that include all three assumptions of missingness.

Learning to Apply Mindfulness to Pain (LAMP): Design for a Pragmatic Clinical Trial of Two Mindfulness-Based Interventions for Chronic Pain.

BACKGROUND: Mindfulness-based interventions (MBIs) are evidence-based nonpharmacological treatments for treating chronic pain. However, the predominant MBI, mindfulness-based stress reduction, has features that pose significant implementation barriers. OBJECTIVES: This study will test two approaches to delivering MBIs for improving Veterans' chronic pain and mental health comorbidities. These two approaches address key implementation barriers. METHODS: We will conduct a four-site, three-arm pragmatic randomized controlled trial, Learning to Apply Mindfulness to Pain (LAMP), to test the effectiveness of two MBIs at improving pain and mental health comorbidities. Mobile+Group LAMP consists of prerecorded modules presented by a mindfulness instructor that are viewed in an online group setting and interspersed with discussions led by a facilitator. Mobile LAMP consists of the same prerecorded modules but does not include a group component. We will test whether either of these MBIs will be more effective than usual care at improving chronic pain and whether the Mobile+Group LAMP will be more effective than Mobile LAMP at improving chronic pain. Comparisons for the primary hypotheses will be conducted with continuous outcomes (Brief Pain Inventory interference score) repeated at 10 weeks, 6 months, and 12 months. The secondary hypotheses are that Mobile+Group LAMP and Mobile LAMP will be more effective than usual care at improving secondary outcomes (e.g., post-traumatic stress disorder, depression). We will also confirm the comparisons for the primary and secondary hypotheses in gender-specific strata. IMPLICATIONS: This trial is expected to result in two approaches for delivering MBIs that will optimize engagement, adherence, and sustainability and be able to reach large numbers of Veterans.

Persistent Serious Mental Illness Among Former Applicants for VA PTSD Disability Benefits and Long-Term Outcomes: Symptoms, Functioning, and Employment.

Millions of U.S. veterans have returned from military service with posttraumatic stress disorder (PTSD), for which a substantial number receive U.S. Department of Veterans Affairs (VA) disability benefits. Although PTSD is treatable, comorbid serious mental illness (defined here as schizophrenia, schizoaffective disorder, and bipolar spectrum disorders) could complicate these veterans' recovery. Using VA administrative data, we examined the burden of persistent serious mental illness in a nationally representative cohort of 1,067 men and 1,513 women who applied for VA PTSD disability benefits between 1994 and 1998 and served during or after the Vietnam conflict. Self-reported outcomes were restricted to the 713 men and 1,015 women who returned surveys at each of 3 collection points. More than 10.0% of men and 20.0% of women had persistent serious mental illness; of these, more than 80.0% also had persistent PTSD. On repeated measures modeling, those with persistent serious mental illness consistently reported more severe PTSD symptoms and poorer functioning in comparison to other participants (ps < .001); their employment rate did not exceed 21.0%. Interactions between persistent serious mental illness and PTSD were significant only for employment (p = .002). Persistent serious mental illness in this population was almost 2 to 19 times higher than in the general U.S. POPULATION: The implications of these findings are discussed.

Food insecurity among veterans of the US wars in Iraq and Afghanistan.

OBJECTIVE: Food insecurity, or lack of access to sufficient food for a healthful lifestyle, has been associated with many aspects of poor health. While the economic struggles among veterans of the wars in Iraq and Afghanistan have been documented, it is unknown how commonly this population struggles to afford food. Our purpose was to document the prevalence and correlates of food insecurity among US veterans of the wars in Iraq and Afghanistan. DESIGN: A cross-sectional survey. SUBJECTS: US military veterans who had served in the wars in Iraq and Afghanistan since October 2001. SETTING: Subjects responded to a survey mailed to them in summer 2012. Food security was measured by the US Household Food Security Module: Six Item Short Form. Demographic and behavioural health items were also included. Survey data were matched to medical record data from the Department of Veterans Affairs. RESULTS: Over one in four veterans reported past-year food insecurity with 12 % reporting very low food security. Food-insecure veterans tended to be younger, not married/partnered, living in households with more children, earning lower incomes, had a lower final military pay grade, were more likely to use tobacco, reported more frequent binge drinking and slept less, compared with those who were food secure (P<0.05 for all associations listed). CONCLUSIONS: Previously undocumented, the problem of hunger among our newest veterans deserves attention.

Impact of different privacy conditions and incentives on survey response rate, participant representativeness, and disclosure of sensitive information: a randomized controlled trial.

BACKGROUND: Anonymous survey methods appear to promote greater disclosure of sensitive or stigmatizing information compared to non-anonymous methods. Higher disclosure rates have traditionally been interpreted as being more accurate than lower rates. We examined the impact of 3 increasingly private mailed survey conditions-ranging from potentially identifiable to completely anonymous-on survey response and on respondents' representativeness of the underlying sampling frame, completeness in answering sensitive survey items, and disclosure of sensitive information. We also examined the impact of 2 incentives ($10 versus $20) on these outcomes. METHODS: A 3X2 factorial, randomized controlled trial of 324 representatively selected, male Gulf War I era veterans who had applied for United States Department of Veterans Affairs (VA) disability benefits. Men were asked about past sexual assault experiences, childhood abuse, combat, other traumas, mental health symptoms, and sexual orientation. We used a novel technique, the pre-merged questionnaire, to link anonymous responses to administrative data. RESULTS: Response rates ranged from 56.0% to 63.3% across privacy conditions (p = 0.49) and from 52.8% to 68.1% across incentives (p = 0.007). Respondents' characteristics differed by privacy and by incentive assignments, with completely anonymous respondents and $20 respondents appearing least different from their non-respondent counterparts. Survey completeness did not differ by privacy or by incentive. No clear pattern of disclosing sensitive information by privacy condition or by incentive emerged. For example, although all respondents came from the same sampling frame, estimates of sexual abuse ranged from 13.6% to 33.3% across privacy conditions, with the highest estimate coming from the intermediate privacy condition (p = 0.007). CONCLUSION: Greater privacy and larger incentives do not necessarily result in higher disclosure rates of sensitive information than lesser privacy and lower incentives. Furthermore, disclosure of sensitive or stigmatizing information under differing privacy conditions may have less to do with promoting or impeding participants' "honesty" or "accuracy" than with selectively recruiting or attracting subpopulations that are higher or lower in such experiences. Pre-merged questionnaires bypassed many historical limitations of anonymous surveys and hold promise for exploring non-response issues in future research.

Exploring Gender Differences in Veterans in a Secondary Analysis of a Randomized Controlled Trial of Mindfulness for Chronic Pain.

Background: Although studies have documented higher rates of chronic pain among women Veterans compared to men Veterans, there remains a lack of comprehensive information about potential contributors to these disparities. Materials and Methods: This study examined gender differences in chronic pain and its contributors among 419 men and 392 women Veterans, enrolled in a mindfulness trial for chronic pain. We conducted descriptive analyses summarizing distributions of baseline measures, obtained by survey and through the electronic health record. Comparisons between genders were conducted using chi-square tests for categorical variables and t-tests for continuous measures. Results: Compared to men, women Veterans were more likely to have chronic overlapping pain conditions and had higher levels of pain interference and intensity. Women had higher prevalence of psychiatric and sleep disorder diagnoses, greater levels of depression, anxiety, post-traumatic stress disorder, fatigue, sleep disturbance, stress and pain catastrophizing, and lower levels of pain self-efficacy and participation in social roles and activities. However, women were less likely to smoke or have a substance abuse disorder and used more nonpharmacological pain treatment modalities. Conclusion: Among Veterans seeking treatment for chronic pain, women differed from men in their type of pain, had greater pain intensity and interference, and had greater prevalence and higher levels of many known biopsychosocial contributors to pain. Results point to the need for pain treatment that addresses the comprehensive needs of women Veterans.Clinical Trial Registration Number: NCT04526158. Patient enrollment began on December 4, 2020.

Gender differences in PTSD severity and pain outcomes: Baseline results from the LAMP trial.

BACKGROUND: Post-traumatic stress disorder (PTSD) and chronic pain are highly prevalent comorbid conditions. Veterans dually burdened by PTSD and chronic pain experience more severe outcomes compared to either disorder alone. Few studies have enrolled enough women Veterans to test gender differences in pain outcomes [catastrophizing, intensity, interference] by the severity of PTSD symptoms. AIM: Examine gender differences in the association between PTSD symptoms and pain outcomes among Veterans enrolled in a chronic pain clinical trial. METHODS: Participants were 421 men and 386 women Veterans with chronic pain who provided complete data on PTSD symptoms and pain outcomes. We used hierarchical linear regression models to examine gender differences in pain outcomes by PTSD symptoms. RESULTS: Adjusted multivariable models indicated that PTSD symptoms were associated with higher levels of pain catastrophizing (0.57, 95% CI [0.51, 0.63]), pain intensity (0.30, 95% CI [0.24, 0.37]), and pain interference (0.46, 95% CI [0.39, 0.52]). No evidence suggesting gender differences in this association were found in either the crude or adjusted models (all interaction p-values<0.05). CONCLUSION: These findings may reflect the underlying mutual maintenance of these conditions whereby the sensation of pain could trigger PTSD symptoms, particularly if the trauma and pain are associated with the same event. Clinical implications and opportunities testing relevant treatments that may benefit both chronic pain and PTSD are discussed.

Feasibility of a prospective, longitudinal study of resilience among young military recruits with embedded laboratory sub-study: the ARMOR pilot trial.

Background: Multilevel, longitudinal studies are integral to resilience research; however, they are costly and present unique methodological challenges. The objective of this study was to examine the feasibility of study methods (recruitment, retention, data collection) for a large-scale prospective, longitudinal study of resilience among young National Guard recruits. Methods: This feasibility trial used a pre-test/post-test design with embedded laboratory sub-study. Participants were young military recruits who had recently enlisted in the Army National Guard and had not yet shipped to Basic Combat Training (BCT). Recruitment and baseline data collection (Time 1), which included a battery of computerized self-report measures and neurocognitive tests, were conducted at local armories. Participants completed an online follow-up (Time 2) survey outside of drill training after returning from BCT. A subset of participants was recruited to complete extensive laboratory procedures pre-and post-BCT, including clinical interview, additional self-report measures, and performance on a series of neurobehavioral tasks during electroencephalogram recordings and, at pre-BCT only, magnetic resonances imaging. Feasibility outcomes assessed our ability to recruit, retain, and collect data from participants. Analysis of outcomes was based on descriptive statistics and evaluation of the feasibility of the larger study was based on pre-determined go/no go progression criteria. Results: All pre-determined progression criteria were met. A total of 102 (97.1%) of eligible military service members consented to participate. Of these, 73 (73.7%) completed the Time 2 survey. Of the 24 participants approached, 14 agreed to participate in the laboratory sub-study, 13 completed follow-up laboratory visits. Overall, completion of online surveys and laboratory tasks was excellent. However, participants had difficulties completing online surveys during BCT and the computerized neurocognitive testing battery at Time 2. Conclusions: Study methods were feasible, and all predetermined criteria for progression to the large-scale longitudinal study were met. Some minor protocol adaptations were identified from this feasibility study. Lessons learned and recommendations for future research are discussed.

Sociodemographic and Geographic Risk Factors for All-Cause Mortality in Patients with COPD.

Background: Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality worldwide. Identifying both individual and community risk factors associated with higher mortality is essential to improve outcomes. Few population-based studies of mortality in COPD include both individual characteristics and community risk factors. Objective: We used geocoded, patient-level data to describe the associations between individual demographics, neighborhood socioeconomic status, and all-cause mortality. Methods: We performed a nationally representative retrospective cohort analysis of all patients enrolled in the Veteran Health Administration with at least one ICD-9 or ICD-10 code for COPD in 2016-2019. We obtained demographic characteristics, comorbidities, and geocoded residential address. Area Deprivation Index and rurality were classified using individual geocoded residential addresses. We used logistic regression models to assess the association between these characteristics and age-adjusted all-cause mortality. Results: Of 1,106,163 COPD patients, 33.4% were deceased as of January 2021. In age-adjusted models, having more comorbidities, Black/African American race (OR 1.09 [95% CI: 1.08-1.11]), and higher neighborhood disadvantage (OR 1.30 [95% CI: 1.28-1.32]) were associated with all-cause mortality. Female sex (OR 0.67 [95% CI: 0.65-0.69]), Asian race (OR 0.64, [95% CI: 0.59-0.70]), and living in a more rural area were associated with lower odds of all-cause mortality. After adjusting for age, comorbidities, neighborhood socioeconomic status, and rurality, the association with Black/African American race reversed. Conclusion: All-cause mortality in COPD patients is disproportionately higher in patients living in poorer neighborhoods and urban areas, suggesting the impact of social determinants of health on COPD outcomes. Black race was associated with higher age-adjusted all-cause mortality, but this association was abrogated after adjusting for gender, socioeconomic status, comorbidities, and urbanicity. Future studies should focus on exploring mechanisms by which disparities arise and developing interventions to address these.

Guideline-discordant inhaler regimens after COPD hospitalization: associations with rurality, drive time to care, and fragmented care - a United States cohort study.

Background: Many patients receive guideline-discordant inhaler regimens after chronic obstructive pulmonary disease (COPD) hospitalization. Geography and fragmented care across multiple providers likely influence prescription of guideline-discordant inhaler regimens, but these have not been comprehensively studied. We assessed patient-level differences in guideline-discordant inhaler regimens by rurality, drive time to pulmonary specialty care, and fragmented care. Methods: Retrospective cohort analysis using national Veterans Health Administration (VA) data among patients who received primary care and prescriptions from the VA. Patients hospitalized for COPD exacerbation between 2017 and 2020 were assessed for guideline-discordant inhaler regimens in the subsequent 3 months. Guideline-discordant inhaler regimens were defined as short-acting inhaler/s only, inhaled corticosteroid (ICS) monotherapy, long-acting beta-agonist (LABA) monotherapy, ICS + LABA, long-acting muscarinic antagonist (LAMA) monotherapy, or LAMA + ICS. Rural residence and drive time to the closest pulmonary specialty care were obtained from geocoded addresses. Fragmented care was defined as hospitalization outside the VA. We used multivariable logistic regression models to assess associations between rurality, drive time, fragmentated care, and guideline-discordant inhaler regimens. Models were adjusted for age, sex, race/ethnicity, Charlson Comorbidity Index, Area Deprivation Index, and region. Findings: Of 33,785 patients, 16,398 (48.6%) received guideline-discordant inhaler regimens 3 months after hospitalization. Rural residents had higher odds of guideline-discordant inhalers regimens compared to their urban counterparts (adjusted odds ratio [aOR] 1.18 [95% CI: 1.12-1.23]). The odds of receiving guideline-discordant inhaler regimens increased with longer drive time to pulmonary specialty care (aOR 1.38 [95% CI: 1.30-1.46] for drive time >90 min compared to <30 min). Fragmented care was also associated with higher odds of guideline-discordant inhaler regimens (aOR 1.56 [95% CI: 1.48-1.63]). Interpretation: Rurality, long drive time to care, and fragmented care were associated with greater prescription of guideline-discordant inhaler regimens after COPD hospitalization. These findings highlight the need to understand challenges in delivering evidence-based care. Funding: NIHNCATS grants KL2TR002492 and UL1TR002494.

Costs of implementing a multi-site facilitation intervention to increase access to medication treatment for opioid use disorder.

BACKGROUND: The United States has been grappling with the opioid epidemic, which has resulted in over 75,000 opioid-related deaths between April 2020 and 2021. Evidence-based pharmaceutical interventions (buprenorphine, methadone, and naltrexone) are available to reduce opioid-related overdoses and deaths. However, adoption of these medications for opioid use disorder has been stifled due to individual- and system-level barriers. External facilitation is an evidence-based implementation intervention that has been used to increase access to medication for opioid use disorder (MOUD), but the implementation costs of external facilitation have not been assessed. We sought to measure the facility-level direct costs of implementing an external facilitation intervention for MOUD to provide decision makers with estimates of the resources needed to implement this evidence-based program. METHODS: We performed a cost analysis of the pre-implementation and implementation phases, including an itemization of external facilitation team and local site labor costs. We used labor estimates from the Bureau of Labor and Statistics, and sensitivity analyses were performed using labor estimates from the Veterans Health Administration (VHA) Financial Management System general ledger data. RESULTS: The average total costs for implementing an external facilitation intervention for MOUD per site was $18,847 (SD 6717) and ranged between $11,320 and $31,592. This translates to approximately $48 per patient with OUD. Sites with more encounters and participants with higher salaries in attendance had higher costs. This was driven mostly by the labor involved in planning and implementation activities. The average total cost of the pre-implementation and implementation activities were $1031 and $17,816 per site, respectively. In the sensitivity analysis, costs for VHA were higher than BLS estimates likely due to higher wages. CONCLUSIONS: Implementing external facilitation to increase MOUD prescribing may be affordable depending on the payer's budget constraints. Our study reported that there were variations in the time invested at each phase of implementation and the number and type of participants involved with implementing an external facilitation intervention. Participant composition played an important role in total implementation costs, and decision makers will need to identify the most efficient and optimal number of stakeholders to involve in their implementation plans.

Levels and variation in overuse of fecal occult blood testing in the Veterans Health Administration.

BACKGROUND: Policy-makers have called for efforts to reduce overuse of cancer screening tests, including colorectal cancer screening (CRCS). Overuse of CRCS tests other than colonoscopy has not been well documented. OBJECTIVE: To estimate levels and correlates of fecal occult blood test (FOBT) overuse in a national Veterans Health Administration (VHA) sample. DESIGN: Observational PARTICIPANTS: Participants included 1,844 CRCS-eligible patients who responded to a 2007 CRCS survey conducted in 24 VHA facilities and had one or more FOBTs between 2003 and 2009. MAIN MEASURES: We combined survey data on race, education, and income with administrative data on region, age, gender, CRCS procedures, and outpatient visits to estimate overuse levels and variation. We coded FOBTs as overused if they were conducted <10 months after prior FOBT, <9.5 years after prior colonoscopy, or <4.5 years after prior barium enema. We used multinomial logistic regression models to examine variation in overuse by reason (sooner than recommended after prior FOBT; sooner than recommended after colonoscopy, barium enema, or a combination of procedures), adjusting for clustering of procedures within patients, and patients within facilities. KEY RESULTS: Of 4,236 FOBTs received by participants, 885 (21 %) met overuse criteria, with 323 (8 %) sooner than recommended after FOBT, and 562 (13 %) sooner than recommended after other procedures. FOBT overuse varied across facilities (9-32 %, p<0.0001) and region (12-23 %, p< .0012). FOBT overuse after prior FOBT declined between 2003 and 2009 (8 %-5 %, p= .0492), but overuse after other procedures increased (11-19 %, p= .0002). FOBT overuse of both types increased with number of outpatient visits (OR 1.15, p<0.001), but did not vary by patient demographics. More than 11 % of overused FOBTs were followed by colonoscopy within 12 months. CONCLUSIONS: Many FOBTs are performed sooner than recommended in the VHA. Variation in overuse by facility, region, and outpatient visits suggests addressing FOBT overuse will require system-level solutions.

Caregiver reports of subsequent injuries among veterans with traumatic brain injury after discharge from inpatient polytrauma rehabilitation programs.

OBJECTIVE: : We examined prevalence of, and potential risk factors for, nonfatal injuries among Veterans with traumatic brain injury (TBI) postdischarge from Veterans Affairs inpatient polytrauma rehabilitation programs. METHODS: : We surveyed caregivers of patients who had military service anytime from 2001 to 2009, sustained polytrauma including TBI, received Veterans Affairs inpatient care from 2001 to 2009, were discharged at least 3 months before the study, and were alive when the study was fielded about caregiver and patient health, including patients' medically treated "accidents/new injuries" since discharge. We examined prevalence and source(s) of subsequent injuries and estimated patients' injury risk in reference to hypothesized risk factors. Odds ratios and 95% confidence intervals were calculated using multivariate logistic regression. RESULTS: : Caregivers reported that nearly one-third (32%) of patients incurred medically treated injuries after discharge; most were associated with falls (49%) and motor vehicles (37%). Odds of subsequent injury were associated with select demographics, initial injury characteristics, and postdischarge health and functioning. Characteristics of caregivers, including physical and mental health, were also associated with patients' odds of subsequent injury. CONCLUSIONS: : A significant number of caregivers reported subsequent nonfatal injuries among patients treated for TBI/polytrauma in inpatient rehabilitation settings. Enhanced injury prevention efforts may be beneficial for this population.

The invisible side of war: families caring for US service members with traumatic brain injuries and polytrauma.

OBJECTIVES: : To (1) identify informal caregivers to injured US service members following acute rehabilitation for polytraumatic injuries, principally traumatic brain injury (TBI), and (2) describe the prevalence and variation of care recipient and caregiver experiences. DESIGN: : Cross-sectional survey of caregivers. PARTICIPANTS: : Caregivers (N = 564) of service members with TBI who received inpatient rehabilitation care in a Veterans Affairs' Polytrauma Rehabilitation Center between 2001 and 2009. MAIN OUTCOME MEASURES: : Questions about caregiver and patient characteristics, type, and quantity of care currently being provided. RESULTS: : Caregiving responsibilities fall primarily on women (79%), typically a parent (62%) or spouse (32%). After a median 4 years since injury, 22% of patients still required assistance with activities of daily living and instrumental activities of daily living. An additional 48% required assistance with only instrumental activities of daily living. Nearly 25% of caregivers reported more than 40 h/wk of care and another 20% reported 5 to 40 h/wk of care. Of caregivers providing assistance with activities of daily living, 49% provided care ≥ 80 h/wk. Nearly 60% of caregivers were solely responsible for the caregiving. Most caregivers also reported providing other help, including managing emotions and navigating health and legal systems. CONCLUSIONS: : Caregivers who provide assistance with either activities of daily living or instrumental activities of daily living may need additional resources to meet the long-term needs of their injured family member.

Beyond Access: Factors Associated With Spirometry Underutilization Among Patients With a Diagnosis of COPD in Urban Tertiary Care Centers.

Rationale: Many patients with suspected chronic obstructive pulmonary disease (COPD) do not undergo spirometry to confirm the diagnosis. Underutilization is often attributed to barriers to accessing spirometry. Objective: Our objective wasto identify factors associated with spirometry underutilization for patients who are less likely to face access barriers related to travel, insurance, and availability of spirometry. Methods: A retrospective analysis was conducted of patients enrolled in the Veterans Health Administration and living in urban areas with a new diagnosis of COPD between 2012 to 2015, reducing out-of-pocket cost and travel barriers, respectively. We included only patients whose primary care clinic was located in an academically affiliated tertiary level facility with spirometry available. We used logistic regression to estimate associations between patient characteristics and receipt of spirometry within 2 years before or after COPD diagnosis. Results: Of 24,300 patients, 59.7% had spirometry. Compared to patients <55 years, patients 75-84 years had an adjusted odds ratio (aOR) of undergoing spirometry of 0.80 (95% confidence interval [CI]:0.72-0.90), while patients ≥85 years had an aOR of 0.47 (95%CI: 0.40-0.54). Compared to patients with a Charlson Comorbidity Index (CCI) ≥3, patients with a CCI of 0 had an aOR of 0.60 (95%CI:0.54-0.67). Patients who had not seen a pulmonary specialist had lower odds of receiving spirometry (aOR 0.38 [95%CI:0.35-0.41]). Conclusion: Spirometry underutilization persists among patients who are less likely to have access barriers related to travel, insurance, and availability of spirometry. Spirometry underutilization is associated with older age, not having received pulmonary care, and having fewer comorbidities. COPD care quality initiatives will need to address these factors.

Drive Time and Receipt of Guideline-Recommended Screening, Diagnosis, and Treatment.

Importance: Many patients do not receive recommended services. Drive time to health care services may affect receipt of guideline-recommended care, but this has not been comprehensively studied. Objective: To assess associations between drive time to care and receipt of guideline-recommended screening, diagnosis, and treatment interventions. Design, Setting, and Participants: This cohort study used administrative data from the National Veterans Health Administration (VA) data merged with Medicare data. Eligible participants were patients using VA services between January 2016 and December 2019. Women ages 65 years or older without underlying bone disease were assessed for osteoporosis screening. Patients with new diagnosis of chronic obstructive pulmonary disease (COPD) indicated by at least 2 encounter codes for COPD or at least 1 COPD-related hospitalization were assessed for receipt of diagnostic spirometry. Patients hospitalized for ischemic heart disease were assessed for cardiac rehabilitation treatment. Exposures: Drive time from each patient's residential address to the closest VA facility where the service was available, measured using geocoded addresses. Main Outcomes and Measures: Binary outcome at the patient level for receipt of osteoporosis screening, spirometry, and cardiac rehabilitation. Multivariable logistic regression models were used to assess associations between drive time and receipt of services. Results: Of 110 780 eligible women analyzed, 36 431 (32.9%) had osteoporosis screening (mean [SD] age, 66.7 [5.4] years; 19 422 [17.5%] Black, 63 403 [57.2%] White). Of 281 130 patients with new COPD diagnosis, 145 249 (51.7%) had spirometry (mean [SD] age, 68.2 [11.5] years; 268 999 [95.7%] men; 37 834 [13.5%] Black, 217 608 [77.4%] White). Of 73 146 patients hospitalized for ischemic heart disease, 11 171 (15.3%) had cardiac rehabilitation (mean [SD] age, 70.0 [10.8] years; 71 217 [97.4%] men; 15 213 [20.8%] Black, 52 144 [71.3%] White). The odds of receiving recommended services declined as drive times increased. Compared with patients with a drive time of 30 minutes or less, patients with a drive time of 61 to 90 minutes had lower odds of receiving osteoporosis screening (adjusted odds ratio [aOR], 0.90; 95% CI, 0.86-0.95) and spirometry (aOR, 0.90; 95% CI, 0.88-0.92) while patients with a drive time of 91 to 120 minutes had lower odds of receiving cardiac rehabilitation (aOR, 0.80; 95% CI, 0.74-0.87). Results were similar in analyses restricted to urban patients or patients whose primary care clinic was in a tertiary care center. Conclusions and Relevance: In this retrospective cohort study, longer drive time was associated with less frequent receipt of guideline-recommended services across multiple components of care. To improve quality of care and health outcomes, health systems and clinicians should adopt strategies to mitigate travel burden, even for urban patients.

Post-deployment injury among new combat veterans enrolled in Veterans Affairs (VA) healthcare.

The purpose of this study was to examine prevalence and potential risk factors for post-deployment injury among Iraq and Afghanistan combat veterans enrolled in Veterans Affairs (VA) healthcare. A national, stratified sample of Iraq/Afghanistan combat Veteran VA users was surveyed in 2008. Mental and physical health, including medically-treated injuries sustained since deployment, were self-reported. Injury risk was estimated using survey logistic regression. Stratified ORs and 95% CIs were adjusted for potential confounders and non-response bias and weighted to represent the target population. Nearly half the population reported post-deployment injuries. In multivariate models, veterans with probable post-traumatic stress disorder (OR=2.1; 95% CI 1.3 to 3.5), self-reported diagnosed depression (OR=3.6; 95% CI 1.8 to 7.0) and anger problems (OR=2.4; 95% CI 1.4 to 4.2) had greater odds of post-deployment injury. Deployment-related injuries were also strongly associated with odds of post-deployment injury. Results suggest that mental health disorders increase the odds of post-deployment injury among combat veteran VA users. Longitudinal research examining these associations is warranted.

The interrelationships between and contributions of background, cognitive, and environmental factors to colorectal cancer screening adherence.

OBJECTIVES: We examined the interrelationships between and contributions of background, cognitive, and environmental factors to colorectal cancer (CRC) screening adherence. METHODS: In this study, 2,416 average risk patients aged 50-75 from 24 Veterans Affairs medical facilities responded to a mailed survey with phone follow-up (response rate 81%). Survey data (attitudes, behaviors, demographics) were linked to facility (organizational complexity) and medical records data (diagnoses, screening history). Patients with a fecal occult blood test within 15 months, sigmoidoscopy or barium enema within 5.5 years, or colonoscopy within 11 years of the survey were considered adherent. Logistic regressions estimated the association between adherence and background, cognitive, and environmental factors. Deviance ratios examined interrelationships between factors. Population attributable risks (PAR) were used to identify intervention targets. RESULTS: The association of background factors with adherence was partially explained by cognitive and environmental factors. The association of environmental factors with adherence was partially explained by cognitive factors. Cognitive and environmental factors contributed equally to adherence. Factors with the highest PARs for non-adherence were age 50-64, less than two comorbidities, and lack of physician recommendation. CONCLUSIONS: Efforts to increase physician screening recommendations for younger, healthy patients at facilities with the lowest screening rates may improve CRC adherence in this setting.