Growing Concern About Unsheltered Homelessness Among Veterans: Clinical Characteristics and Engagement in Health Care Services.

OBJECTIVES: Veteran homelessness has declined in the past decade, but the proportion of unsheltered homeless veterans has increased. We identified characteristics of unsheltered homelessness in a large contemporary veteran cohort and examined outpatient and inpatient encounters before and after intake to US Department of Veterans Affairs (VA) homeless programs. METHODS: National data from the Homeless Operations Management Evaluation System (HOMES) database and the Corporate Data Warehouse were analyzed on 191 204 veterans experiencing housing instability from January 2018 through December 2021. We used hierarchical multivariate logistic regressions to model associations between sheltered status and veteran correlates. Repeated-measures analysis of variance assessed changes in care utilization after intake in homeless programs. RESULTS: Age <50 years (odds ratio [OR] = 1.3; 95% CI, 1.2-1.4), Hispanic ethnicity (OR = 1.2; 95% CI, 1.1-1.3), some college education (OR = 1.1; 95% CI, 1.0-1.1), and a bachelor's degree (OR = 1.2; 95% CI, 1.1-1.2) were associated with veteran unsheltered homelessness. Unsheltered veterans were more likely to have a VA service-connected disability (OR = 1.4; 95% CI, 1.4-1.5), military sexual trauma (OR = 1.1; 95% CI, 1.0-1.1), and/or combat exposure (OR = 1.1; 95% CI, 1.0-1.1). Unsheltered and sheltered homeless veterans had an increase in outpatient encounters and a decrease in inpatient care after intake to the VA homeless program. CONCLUSIONS: Contemporary unsheltered homeless veterans are younger and Hispanic with some college education. Innovative public health approaches that better engage and reduce barriers to entry need to be tested for a diverse unsheltered homeless population.

Systematic Review of Financial Interventions for Adults Experiencing Behavioral Health Conditions.

OBJECTIVE: The authors reviewed the literature on finance-based interventions used to improve clinical and psychosocial outcomes among adults experiencing mental disorders, substance use disorders, or both. METHODS: A systematic review of the peer-reviewed literature, published from 1900 to 2022, was conducted. Only studies with participants with a mental disorder or a substance use disorder, a structured finance-based intervention or program, a quantitative dependent variable in a behavioral health outcomes domain, and a defined research design were included. Studies were rated with a quality assessment tool, and overall evidence (levels I-VII) for the outcomes was rated. RESULTS: In total, 544 articles were identified, screened for eligibility, and reduced to 55 articles. These articles were rated by two independent raters, and 18 articles were ultimately included. Of these 18 articles, four reported findings of randomized controlled trials (RCTs), one conducted a secondary analysis of an RCT, and the remaining articles were observational studies. The most studied intervention was representative payeeship, which reduced substance use and enhanced money management, showing the strongest evidence for improving outcomes among adults with behavioral health conditions. Weaker evidence suggested that financial education and assistance interventions could improve health care utilization and other psychosocial outcomes among individuals with mental or substance use disorders. CONCLUSIONS: Level II-V evidence indicates that finance-based interventions can improve outcomes among adults experiencing behavioral health conditions. Further research is needed to assess the impact of interventions beyond representative payee programs on objectively measured outcomes.

Newborn Outcomes Among Veterans Utilizing VHA Maternity Benefits, 2016-2020.

INTRODUCTION: Public Law 111-163 Section 206 of the Caregivers and Veteran Omnibus Health Services Act amended the Veterans Health Administration's (VHA) medical benefits package to include 7 days of medical care for newborns delivered by Veterans. We examined the newborn outcomes among a cohort of women Veterans receiving VHA maternity benefits and care coordination. MATERIALS AND METHODS: We conducted a secondary analysis of phone interview data from Veterans enrolled in the COMFORT (Center for Maternal and Infant Outcomes Research in Translation) study 2016-2020. Multivariable regression estimated associations with newborn outcomes (preterm birth; low birthweight). RESULTS: During the study period, 829 infants were born to 811 Veterans. Mothers reported "excellent health" for 94% of infants. The prevalence of preterm birth was slightly higher in our cohort (11% vs. 10%), as were low birthweight (9%) deliveries, compared to the general population (8.28%). Additionally, 42% of infants in our cohort required follow-up care for non-routine health conditions; 11% were uninsured at 2 months of age. Adverse newborn outcomes were more common for mothers who were older in age, self-identified as non-white in race and/or of Hispanic ethnicity, had a diagnosis of posttraumatic stress disorder, or had gestational comorbidities. CONCLUSIONS: The current VHA maternity coverage appears to be an effective policy for ensuring the well-being and health care coverage for the majority of Veterans and their newborns in the first days of life, thereby reducing the risk of inadequate prenatal and neonatal care. Future research should examine costs associated with extending coverage to 14 days or longer, comparing those to the projected excess costs of neonatal health problems. VHA policy should continue to support expanding care and resources through the Maternity Care Coordinator model.

Evaluating an Enterprise-Wide Initiative to enhance healthcare coordination for rural women Veterans using the RE-AIM framework.

Introduction: The Veterans Health Administration (VA) Office of Rural Health (ORH) and Office of Women's Health Services (OWH) in FY21 launched a three-year Enterprise-Wide Initiative (EWI) to expand access to preventive care for rural, women Veterans. Through this program, women's health care coordinators (WHCC) were funded to coordinate mammography, cervical cancer screening and maternity care for women Veterans at selected VA facilities. We conducted a mixed-methods evaluation using the RE-AIM framework to assess the program implementation. Materials and methods: We collected quantitative data from the 14 program facilities on reach (i.e., Veterans served by the program), effectiveness (e.g., cancer screening compliance, communication), adoption, and maintenance of women's health care coordinators (WHCC) in FY2022. Implementation of the program was examined through semi-structured interviews with the facility WHCC funding initiator (e.g., the point of contact at facility who initiated the request for WHCC funding), WHCCs, and providers. Results: Reach. The number of women Veterans and rural women Veterans served by the WHCC program grew (by 50% and 117% respectively). The program demonstrated effectiveness as screening rates increased for cervical and breast cancer screening (+0.9% and +.01%, respectively). Also, maternity care coordination phone encounters with Veterans grew 36%. Adoption: All facilities implemented care coordinators by quarter two of FY22. Implementation. Qualitative findings revealed facilitators and barriers to successful program implementation and care coordination. Maintenance: The EWI facilitated the recruitment and retention of WHCCs at respective VA facilities over time. Implications: In rural areas, WHCCs can play a critical role in increasing Reach and effectiveness. The EWI demonstrated to be a successful care coordination model that can be feasibly Adopted, Implemented, and Maintained at rural VA facilities.

Exploring the Acceptability of Expanded Perinatal Depression Care Practices Among Women Veterans.

BACKGROUND: Veterans receive obstetrical care from community-based providers contracted through the Veterans Health Administration (VA); however, Veterans remain eligible for VA mental healthcare in the perinatal period. To date, few studies have focused specifically on the mental health needs of Veterans during the perinatal period. OBJECTIVE: To examine the acceptability of more comprehensive perinatal mental healthcare screening and treatment in VA care, we explored pregnant and postpartum Veteran perspectives of United States Preventive Services Task Force (USPSTF) recommendations that aim to expand mental health counseling for the prevention and treatment of perinatal depression. DESIGN: Semi-structured interviews with pregnant and postpartum Veterans enrolled in VA care, integrated with quantitative survey data. PARTICIPANTS: Pregnant and postpartum Veterans (n=27) who had delivered infants or were due by February 2020. APPROACH: Framework analysis with an inductive approach was utilized to understand our data, interpret and code our transcripts, and develop themes. KEY RESULTS: Fewer than half (44%) of the women reported seeing a mental health provider at the beginning of their pregnancy. We found that Veterans support USPSTF recommendations in the VA, consider mental healthcare to be very important during the perinatal period, would like better access to mental healthcare resources and peer support networks, and suggest that perinatal depression screening could be more extensive. CONCLUSIONS: These findings support the implementation of more comprehensive perinatal depression prevention policies and practices within VA care. Understanding the real-world feasibility and prevailing barriers to comprehensive perinatal depression care is needed to inform implementation of the USPSTF recommendations or a similar intervention tailored for VA care.

Medications with Potential for Fetal Risk Prescribed to Veterans.

Background: Women service members of the past 20 years experienced high rates of traumatizing events resulting in pharmacological treatment. Post-military lives may include having children. Typically, Veterans Health Administration (VHA) patients' pregnancies are managed outside the VHA. This study examined medication exposures during pregnancy. Materials and Methods: The Center for Maternal and Infant Outcomes Research in Translation (COMFORT) study collected primary survey data and linked secondary health care data from the VHA from 2015 to 2021. Medication fills and covariates were extracted for three 9-month periods: preconception, pregnancy, and postpartum. Multiple regression assessed factors associated with use during pregnancy of selective serotonin reuptake inhibitor (SSRI)/serotonin norepinephrine reuptake inhibitor (SNRI) or of non-recommended, potentially risky drugs, and of discontinuation of those medications from prepregnancy to pregnancy. Results: The cohort comprised 501 women-29% Black, 65% White, and 6% other races, of whom 63% had 50%-100% service-connected disability. During pregnancy, 36% had a pain-related disorder, 19% major depression, and 18% post-traumatic stress disorder. The median number of drug classes prescribed during pregnancy was 5. The use of SSRI/SNRI antidepressants dropped from 36% preconception to 26% during pregnancy including new starts; 15% discontinued SSRI/SNRI. Comorbidity predicted medication use. Depression predicted discontinuing SSRI/SNRI during pregnancy; no predictors of discontinuing potentially risky drugs were identified. Conclusions: Based on prescriptions filled within the VHA only-ignoring potential community-based fills-women veterans were prescribed numerous medications during pregnancy and discontinued antidepressants alarmingly. Veterans of childbearing potential should receive counseling about medication use before pregnancy occurs. Their non-VHA obstetricians and VHA providers should share information to optimize outcomes, reviewing medications as soon as pregnancy is detected as well as after pregnancy concludes.

Coordinating women's preventive health care for rural veterans.

PURPOSE: As the number of women veterans receiving care from the Veterans Health Administration (VHA) continues to increase, so does the need to access gender-specific preventive health care services through the VHA. In rural areas, women veterans are the numeric minority, so many preventive screenings are performed outside of the VA by community providers. As the numbers of veterans utilizing both VHA and non-VHA providers for their preventive care continue to increase, so does the need to coordinate this care. This research examines the role of the Women Veterans' Care Coordinator (WVCC) at rural facilities and their perceptions of coordinating preventive care. METHODS: Between March and July 2019, semi-structured telephone interviews were conducted with WVCCs at 26 rural VA facilities. Each interview was digitally recorded and transcribed verbatim. Transcripts were loaded into Atlas.ti for further analysis. Once the codes were refined, the investigators coded the 26 interviews independently and conferred to achieve consensus on the underlying themes. FINDINGS: Five themes arose from the WVCC interviews: (1) Rural women veterans have varying needs of coordination; (2) Fragmented communication between the VA and non-VA care settings hinders effective coordination; (3) Difficulties in prioritizing rural care coordination; (4) Care coordination impacts patient care; and (5) WVCC recommendations to improve rural care coordination. CONCLUSIONS: The recent addition of WVCCs to rural facilities has expanded the VA's reach to veterans living in the most rural areas. As a result, many of these women are now receiving timely, quality, and coordinated health care.

Prenatal Stress Exposure and Post-traumatic Stress Disorder Associated With Risk of Postpartum Alcohol Misuse Among Women Veterans.

OBJECTIVES: Maternal alcohol misuse during the postpartum period is associated with negative maternal and infant outcomes. This study examined whether greater stress exposure in the year before the baby's birth and maternal post-traumatic stress disorder (PTSD) were associated with postpartum alcohol misuse among a sample of women veterans. Maternal PTSD was also examined as a moderator of the association between stress exposure and postpartum alcohol misuse. METHODS: Data were drawn from the Center for Maternal and Infant Outcomes Research in Translation study, a multisite prospective cohort study of pregnant and postpartum women veterans. Interviews were conducted within 12 weeks after birth. At this post-birth interview, women reported whether they experienced stressful events (e.g., loss of job, military deployment, separation/divorce) in the year before birth. PTSD diagnosis and postpartum scores on the Alcohol Use Disorders Identification Test (AUDIT-C) were derived from the Department of Veterans Affairs medical records. RESULTS: Models testing main and interaction effects showed a statistically significant association of both PTSD (p = .02) and stress exposure (p = .04), as well as significant interaction of PTSD and stress exposure (p = .03) with AUDIT-C scores postpartum, after controlling for marital status, age, and race. Specifically, compared with women without PTSD, those with PTSD had higher overall AUDIT-C scores postpartum, regardless of stress exposure. For women without PTSD, more stress exposure before birth was associated with higher AUDIT-C scores during the postpartum phase. CONCLUSIONS: PTSD diagnosis and life stressors before infant birth predicted maternal alcohol misuse during the postpartum period. Identifying such risk factors is an initial step in preventing alcohol misuse, with the goal of enhancing postpartum health for the birthing parent and infant.

Factors Associated With Quitting Smoking During Pregnancy Among Women Veterans.

INTRODUCTION: Little is known about the rates of smoking among pregnant veterans. Our objective was to examine rates of smoking during pregnancy and factors associated with quitting smoking during pregnancy. METHODS: We used data from a cohort study of pregnant veterans from 15 Veterans Health Administration facilities nationwide. Veterans who reported smoking during pregnancy were included in this analysis. Poisson regression models were used to estimate the relative risk (RR) of quitting smoking during pregnancy. RESULTS: Overall, 133 veterans reported smoking during pregnancy. Among this group of women who smoked, the average age was 31.6 years, 20% were Black, and 14% were Hispanic/Latino. More than one-half of women (65%) who reported smoking at the start of pregnancy quit smoking during pregnancy. Multivariable models, adjusted for history of deployment and age, indicated that prenatal care initiation at 12 or fewer weeks compared with more than 13 weeks (relative risk [RR], 2.06; 95% confidence interval [CI], 1.18-3.58), living without household smokers compared with any household smokers (RR, 1.58; 95% CI, 1.14-2.17), and first pregnancy (RR, 1.51; 95% CI, 1.17-1.95) were significant predictors of quitting versus persistent smoking during pregnancy. CONCLUSIONS: Women veterans who quit smoking may be different than those who continue to smoke during pregnancy. Establishing prenatal care early in pregnancy, which likely includes counseling about smoking cessation, seems to be an important factor in quitting. Those for whom it is not a first pregnancy and who live with other smokers may especially benefit from such counseling.

Survivors of an Acute Coronary Syndrome With Lower Patient Activation Are More Likely to Experience Declines in Health-Related Quality of Life.

BACKGROUND: Patient activation comprises the knowledge, skills, and confidence for self-care and may lead to better health outcomes. OBJECTIVES: We examined the relationship between patient activation and changes in health-related quality of life (HRQOL) after hospitalization for an acute coronary syndrome (ACS). METHODS: We studied patients from 6 medical centers in central Massachusetts and Georgia who had been hospitalized for an ACS between 2011 and 2013. At 1 month after hospital discharge, the patients completed the 6-item Patient Activation Measure and were categorized into 4 levels of activation. Multinomial logistic regression analyses compared activation level with clinically meaningful changes (≥3.0 points, generic; ≥10.0 points, disease-specific) in generic physical (SF-36v2 Physical Component Summary [PCS]), generic mental (SF-36v2 Mental Component Summary [MCS]), and disease-specific (Seattle Angina Questionnaire [SAQ]) HRQOL from 1 to 3 and 1 to 6 months after hospitalization, adjusting for potential sociodemographic and clinical confounders. RESULTS: The patients (N = 1042) were, on average, 62 years old, 34% female, and 87% non-Hispanic white. A total of 10% were in the lowest level of activation. The patients with the lowest activation had 1.95 times (95% confidence interval, 1.05-3.62) and 2.18 times (95% confidence interval, 1.17-4.05) the odds of experiencing clinically significant declines in MCS and SAQ HRQOL, respectively, between 1 and 6 months than the most activated patients. The patient activation level was not associated with meaningful changes in PCS scores. CONCLUSIONS: Hospital survivors of an ACS with lower activation may be more likely to experience declines in mental and disease-specific HRQOL than more-activated patients, identifying a group at risk of poor outcomes.

Collective-Intelligence Recommender Systems: Advancing Computer Tailoring for Health Behavior Change Into the 21st Century.

BACKGROUND: What is the next frontier for computer-tailored health communication (CTHC) research? In current CTHC systems, study designers who have expertise in behavioral theory and mapping theory into CTHC systems select the variables and develop the rules that specify how the content should be tailored, based on their knowledge of the targeted population, the literature, and health behavior theories. In collective-intelligence recommender systems (hereafter recommender systems) used by Web 2.0 companies (eg, Netflix and Amazon), machine learning algorithms combine user profiles and continuous feedback ratings of content (from themselves and other users) to empirically tailor content. Augmenting current theory-based CTHC with empirical recommender systems could be evaluated as the next frontier for CTHC. OBJECTIVE: The objective of our study was to uncover barriers and challenges to using recommender systems in health promotion. METHODS: We conducted a focused literature review, interviewed subject experts (n=8), and synthesized the results. RESULTS: We describe (1) limitations of current CTHC systems, (2) advantages of incorporating recommender systems to move CTHC forward, and (3) challenges to incorporating recommender systems into CTHC. Based on the evidence presented, we propose a future research agenda for CTHC systems. CONCLUSIONS: We promote discussion of ways to move CTHC into the 21st century by incorporation of recommender systems.

Identification of Relationships Between Patients Through Elements in a Data Warehouse Using the Familial, Associational, and Incidental Relationship (FAIR) Initiative: A Pilot Study.

BACKGROUND: Over the last several years there has been widespread development of medical data warehouses. Current data warehouses focus on individual cases, but lack the ability to identify family members that could be used for dyadic or familial research. Currently, the patient's family history in the medical record is the only documentation we have to understand the health status and social habits of their family members. Identifying familial linkages in a phenotypic data warehouse can be valuable in cohort identification and in beginning to understand the interactions of diseases among families. OBJECTIVE: The goal of the Familial, Associational, & Incidental Relationships (FAIR) initiative is to identify an index set of patients' relationships through elements in a data warehouse. METHODS: Using a test set of 500 children, we measured the sensitivity and specificity of available linkage algorithm identifiers (eg, insurance identification numbers and phone numbers) and validated this tool/algorithm through a manual chart audit. RESULTS: Of all the children, 52.4% (262/500) were male, and the mean age of the cohort was 8 years old (SD 5). Of the children, 51.6% (258/500) were identified as white in race. The identifiers used for FAIR were available for the majority of patients: insurance number (483/500, 96.6%), phone number (500/500, 100%), and address (497/500, 99.4%). When utilizing the FAIR tool and various combinations of identifiers, sensitivity ranged from 15.5% (62/401) to 83.8% (336/401), and specificity from 72% (71/99) to 100% (99/99). The preferred method was matching patients using insurance or phone number, which had a sensitivity of 72.1% (289/401) and a specificity of 94% (93/99). Using the Informatics for Integrating Biology and the Bedside (i2b2) warehouse infrastructure, we have now developed a Web app that facilitates FAIR for any index population. CONCLUSIONS: FAIR is a valuable research and clinical resource that extends the capabilities of existing data warehouses and lays the groundwork for family-based research. FAIR will expedite studies that would otherwise require registry or manual chart abstraction data sources.

The association between patient activation and medication adherence, hospitalization, and emergency room utilization in patients with chronic illnesses: a systematic review.

OBJECTIVE: A systematic review of the published literature on the association between the PAM (Patient Activation Measure) and hospitalization, emergency room use, and medication adherence among chronically ill patient populations. METHODS: A literature search of several electronic databases was performed. Studies published between January 1, 2004 and June 30, 2014 that used the PAM measure and examined at least one of the outcomes of interest among a chronically ill study population were identified and systematically assessed. RESULTS: Ten studies met the eligibility criteria. Patients who scored in the lower PAM stages (Stages 1 and 2) were more likely to have been hospitalized. Patients who scored in the lowest stage were also more likely to utilize the emergency room. The relationship between PAM stage and medication adherence was inconclusive in this review. CONCLUSION: Chronically ill patients reporting low stages of patient activation are at an increased risk for hospitalization and ER utilization. PRACTICAL IMPLICATIONS: Future research is needed to further understand the relationship between patient activation and medication adherence, hospitalization and/or ER utilization in specific chronically ill (e.g. diabetic, asthmatic) populations. Research should also consider the role of patient activation in the development of effective interventions which seek to address the outcomes of interest.

An observational study of social and emotional support in smoking cessation Twitter accounts: content analysis of tweets.

BACKGROUND: Smoking continues to be the number one preventable cause of premature death in the United States. While evidence for the effectiveness of smoking cessation interventions has increased rapidly, questions remain on how to effectively disseminate these findings. Twitter, the second largest online social network, provides a natural way of disseminating information. Health communicators can use Twitter to inform smokers, provide social support, and attract them to other interventions. A key challenge for health researchers is how to frame their communications to maximize the engagement of smokers. OBJECTIVE: Our aim was to examine current Twitter activity for smoking cessation. METHODS: Active smoking cessation related Twitter accounts (N=18) were identified. Their 50 most recent tweets were content coded using a schema adapted from the Roter Interaction Analysis System (RIAS), a theory-based, validated coding method. Using negative binomial regression, the association of number of followers and frequency of individual tweet content at baseline was assessed. The difference in followership at 6 months (compared to baseline) to the frequency of tweet content was compared using linear regression. Both analyses were adjusted by account type (organizational or not organizational). RESULTS: The 18 accounts had 60,609 followers at baseline and 68,167 at 6 months. A total of 24% of tweets were socioemotional support (mean 11.8, SD 9.8), 14% (mean 7, SD 8.4) were encouraging/engagement, and 62% (mean 31.2, SD 15.2) were informational. At baseline, higher frequency of socioemotional support and encouraging/engaging tweets was significantly associated with higher number of followers (socioemotional: incident rate ratio [IRR] 1.09, 95% CI 1.02-1.20; encouraging/engaging: IRR 1.06, 95% CI 1.00-1.12). Conversely, higher frequency of informational tweets was significantly associated with lower number of followers (IRR 0.95, 95% CI 0.92-0.98). At 6 months, for every increase by 1 in socioemotional tweets, the change in followership significantly increased by 43.94 (P=.027); the association was slightly attenuated after adjusting by account type and was not significant (P=.064). CONCLUSIONS: Smoking cessation activity does exist on Twitter. Preliminary findings suggest that certain content strategies can be used to encourage followership, and this needs to be further investigated.

Predicting remission of diabetes after RYGB surgery following intensive management to optimize preoperative glucose control.

BACKGROUND: The purpose of the study is to investigate the association of preoperative glucose optimization prior to a Roux-en-Y gastric bypass (RYGB) and diabetes remission. METHODS: The study is a retrospective review of 245 patients with a history of diabetes type II and a RYGB from 2008 to 2012 at UMass Memorial Hospital. RESULTS: Patients that benefited from glucose optimization prior to RYGB were more likely to achieve diabetes remission 1 year after surgery. The preoperative glucose optimization intervention demonstrated that when patients decreased their HbA1c prior to surgery by 1 %, these individuals were 68 % more likely to remit (p = 0.015). Duration of diabetes (p = 0.005) and insulin use (p < 0.001) were also significant predictors of remission, whereas age, race, and gender were not. CONCLUSIONS: Our study results indicate that a greater degree of glycemic improvement in response to presurgical medical intervention is associated with higher rates of diabetes remission post-operatively among obese adults with diabetes type II. Conversely, the lack of favorable glycemic response to intensification of medical management predicts a poor glycemic response to bariatric surgery. Further research is needed to determine if this difference is due to physiological factors or is simply an indicator of patient behavior.

Perceived Stigma, Discrimination, and Disclosure of Sexual Orientation Among a Sample of Lesbian Veterans Receiving Care in the Department of Veterans Affairs.

PURPOSE: Many lesbian women experience stigma and discrimination from their healthcare providers as a result of their sexual orientation. Additionally, others avoid disclosure of their sexual orientation to their providers for fear of mistreatment. With the increasing number of lesbian, gay, bisexual, and transgender (LGBT) veterans seeking care from the Veterans Health Administration (VHA), it is important to understand lesbian veterans' experiences with stigma, discrimination, and disclosure of sexual orientation. This article examines lesbian veterans' experiences with perceived stigma and discrimination in VHA healthcare, their perspectives on disclosure of sexual orientation to VHA providers, and their recommendations for improvements in VHA healthcare to create a welcoming environment for lesbian veterans. METHODS: This is a mixed methods study of twenty lesbian veterans at four VHA facilities. The women veterans participated in a one-hour interview and then completed an anonymous survey. RESULTS: Ten percent of lesbian veterans had experienced mistreatment from VHA staff or providers, but nearly 50% feared that their Veterans Affairs (VA) providers would mistreat them if they knew about their sexual orientation. A majority of lesbian veterans (70%) believed that VHA providers should never ask about sexual orientation or should only ask if the veteran wanted to discuss it. A majority (80%) believed the VHA had taken steps to create a welcoming environment for LBGT veterans. CONCLUSION: Though many lesbian veterans have fears of stigma and discrimination in the context of VHA care, few have experienced this. Most lesbian veterans believed the VHA was trying to create a welcoming environment for its LGBT veterans. Future research should focus on expanding this study to include a larger and more diverse sample of lesbian, gay, bisexual, and transgender veterans receiving care at VA facilities across the country.

Psychometric evaluation of the Care Transition Measure in TRACE-CORE: do we need a better measure?

BACKGROUND: The quality of transitional care is associated with important health outcomes such as rehospitalization and costs. The widely used Care Transitions Measure (CTM-15) was developed with a classic test theory approach; its short version (CTM-3) was included in the CAHPS Hospital Survey. We conducted a psychometric evaluation of both measures and explored whether item response theory (IRT) could produce a more precise measure. METHODS AND RESULTS: As part of the Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education, 1545 participants were interviewed during an acute coronary syndrome hospitalization, providing information on general health status (Short Form-36), CTM-15, health utilization, and care process questions at 1 month postdischarge. We used classic and IRT analyses and compared the measurement precision of CTM-15-, CTM-3-, and CTM-IRT-based score using relative validity. Participants were 79% non-Hispanic white and 67% male, with an average age of 62 years. The CTM-15 had good internal consistency (Cronbach's α=0.95) but demonstrated acquiescence bias (8.7% participants responded "Strongly agree" and 19% responded "Agree" to all items) and limited score variability. These problems were more pronounced for the CTM-3. The CTM-15 differentiated between patient groups defined by self-reported health status, health care utilization, and care transition process indicators. Differences between groups were small (2 to 3 points). There was no gain in measurement precision from IRT scoring. The CTM-3 was not significantly lower for patients reporting rehospitalization or emergency department visits. CONCLUSION: We identified psychometric challenges of the CTM, which may limit its value in research and practice. These results are in line with emerging evidence of gaps in the validity of the measure.

Share2Quit: Web-Based Peer-Driven Referrals for Smoking Cessation.

BACKGROUND: Smoking is the number one preventable cause of death in the United States. Effective Web-assisted tobacco interventions are often underutilized and require new and innovative engagement approaches. Web-based peer-driven chain referrals successfully used outside health care have the potential for increasing the reach of Internet interventions. OBJECTIVE: The objective of our study was to describe the protocol for the development and testing of proactive Web-based chain-referral tools for increasing the access to Decide2Quit.org, a Web-assisted tobacco intervention system. METHODS: We will build and refine proactive chain-referral tools, including email and Facebook referrals. In addition, we will implement respondent-driven sampling (RDS), a controlled chain-referral sampling technique designed to remove inherent biases in chain referrals and obtain a representative sample. We will begin our chain referrals with an initial recruitment of former and current smokers as seeds (initial participants) who will be trained to refer current smokers from their social network using the developed tools. In turn, these newly referred smokers will also be provided the tools to refer other smokers from their social networks. We will model predictors of referral success using sample weights from the RDS to estimate the success of the system in the targeted population. RESULTS: This protocol describes the evaluation of proactive Web-based chain-referral tools, which can be used in tobacco interventions to increase the access to hard-to-reach populations, for promoting smoking cessation. CONCLUSIONS: Share2Quit represents an innovative advancement by capitalizing on naturally occurring technology trends to recruit smokers to Web-assisted tobacco interventions.

Who participates in Web-assisted tobacco interventions? The QUIT-PRIMO and National Dental Practice-Based Research Network Hi-Quit studies.

INTRODUCTION: Smoking is the most preventable cause of death. Although effective, Web-assisted tobacco interventions are underutilized and recruitment is challenging. Understanding who participates in Web-assisted tobacco interventions may help in improving recruitment. OBJECTIVES: To understand characteristics of smokers participating in a Web-assisted tobacco intervention (Decide2Quit.org). METHODS: In addition to the typical Google advertisements, we expanded Decide2Quit.org recruitment to include referrals from medical and dental providers. We assessed how the expanded recruitment of smokers changed the users' characteristics, including comparison with a population-based sample of smokers from the national Behavioral Risk Factors Surveillance Survey (BRFSS). Using a negative binomial regression, we compared demographic and smoking characteristics by recruitment source, in particular readiness to quit and association with subsequent Decide2Quit.org use. RESULTS: The Decide2Quit.org cohort included 605 smokers; the 2010 BRFSS dataset included 69,992. Compared to BRFSS smokers, a higher proportion of Decide2Quit.org smokers were female (65.2% vs 45.7%, P=.001), over age 35 (80.8% vs 67.0%, P=.001), and had some college or were college graduates (65.7% vs 45.9%, P=.001). Demographic and smoking characteristics varied by recruitment; for example, a lower proportion of medical- (22.1%) and dental-referred (18.9%) smokers had set a quit date or had already quit than Google smokers (40.1%, P<.001). Medical- and dental-referred smokers were less likely to use Decide2Quit.org functions; in adjusted analysis, Google smokers (predicted count 17.04, 95% CI 14.97-19.11) had higher predicted counts of Web page visits than medical-referred (predicted count 12.73, 95% CI 11.42-14.04) and dental-referred (predicted count 11.97, 95% CI 10.13-13.82) smokers, and were more likely to contact tobacco treatment specialists. CONCLUSIONS: Recruitment from clinical practices complimented Google recruitment attracting smokers less motivated to quit and less experienced with Web-assisted tobacco interventions.

Internet health information seeking is a team sport: analysis of the Pew Internet Survey.

BACKGROUND: Previous studies examining characteristics of Internet health information seekers do not distinguish between those who only seek for themselves, and surrogate seekers who look for health information for family or friends. Identifying the unique characteristics of surrogate seekers would help in developing Internet interventions that better support these information seekers. OBJECTIVE: To assess differences between self seekers versus those that act also as surrogate seekers. METHODS: We analyzed data from the cross-sectional Pew Internet and American Life Project November/December 2008 health survey. Our dependent variable was self-report of type of health information seeking (surrogate versus self seeking). Independent variables included demographics, health status, and caregiving. After bivariate comparisons, we then developed multivariable models using logistic regression to assess characteristics associated with surrogate seeking. RESULTS: Out of 1250 respondents who reported seeking health information online, 56% (N=705) reported being surrogate seekers. In multivariable models, compared with those who sought information for themselves only, surrogate seekers were more likely both married and a parent (OR=1.57, CI=1.08, 2.28), having good (OR=2.05, CI=1.34, 3.12) or excellent (OR=2.72, CI=1.70, 4.33) health status, being caregiver of an adult relative (OR=1.76, CI=1.34, 2.30), having someone close with a serious medical condition (OR=1.62, CI=1.21, 2.17) and having someone close to them facing a chronic illness (OR=1.55, CI=1.17, 2.04). CONCLUSIONS: Our findings provide evidence that information needs of surrogate seekers are not being met, specifically of caregivers. Additional research is needed to develop new functions that support surrogate seekers.