Reducing Alcohol Misuse and Promoting Treatment Initiation Among Veterans Through a Brief Internet-Based Intervention: Protocol for a Randomized Controlled Trial.

BACKGROUND: Young adult veterans who served after the September 11 attacks on the United States in 2001 (ie, post-9/11) are at heightened risk for experiencing behavioral health distress and disorders including hazardous drinking, posttraumatic stress disorder, and depression. These veterans often face significant barriers to behavioral health treatment, and reaching them through brief mobile phone-based interventions may help reduce drinking and promote treatment engagement. OBJECTIVE: Following a successful pilot study, this randomized controlled trial (RCT) aims to further test the efficacy of a brief (ie, single session) mobile phone-delivered personalized normative feedback intervention enhanced with content to promote treatment engagement. METHODS: We will conduct an RCT with 800 post-9/11 young adult veterans (aged 18 to 40 years) with potentially hazardous drinking and who have not recently received treatment for any behavioral health problems. Participants will be randomly assigned to the personalized intervention or a control condition with resources for seeking care. The personalized normative feedback module in the intervention focuses on the correction of misperceived norms of peer alcohol use and uses empirically informed approaches to increase motivation to address alcohol use and co-occurring behavioral health problems. Past 30-day drinking, alcohol-related consequences, and treatment-seeking behaviors will be assessed at baseline and 3, 6, 9, and 12 months post intervention. Sex, barriers to care, posttraumatic stress disorder, depression, and severity of alcohol use disorder symptoms will be explored as potential moderators of outcomes. RESULTS: We expect recruitment to be completed within 6 months, with data collection taking 12 months for each enrolled participant. Analyses will begin within 3 months of the final data collection point (ie, 12 months follow-up). CONCLUSIONS: This RCT will evaluate the efficacy of a novel intervention for non-treatment-seeking veterans who struggle with hazardous drinking and possible co-occurring behavioral health problems. This intervention has the potential to improve veteran health outcomes and overcome significant barriers to treatment. TRIAL REGISTRATION: ClinicalTrials.gov NCT04244461; https://clinicaltrials.gov/study/NCT04244461. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/59993.

Concurrent Care and use of Advanced Cardiac Therapies for Hospitalized Veterans with Heart Failure.

CONTEXT: Concurrent care allows patients to receive hospice while continuing disease-directed therapies. This treatment model is available in the Veterans Administration (VA) medical system, but its use in Veterans with heart failure (HF) is unexplored. OBJECTIVE: To compare use of advanced HF therapies 30 days post-hospitalization in Veterans on hospice versus not on hospice following admission for HF exacerbation. METHODS: We evaluated Veterans admitted for HF exacerbation to VA hospitals between Jan 2011 and June 2019 who received advanced HF therapies, hospice services, or both post-discharge. Concurrent care was defined as receiving both hospice services and advanced HF therapies. Demographics, comorbidities, and prior healthcare utilization were compared. Secondary outcomes included burdensome transitions and mortality. RESULTS: Among 317,967 HF Veterans, 18,350 (5.8%) chose hospice post-hospitalization. Only 58 hospice-enrolled Veterans (0.3%) received advanced HF therapies (i.e. concurrent care) within 30 days post-discharge. Of 299,617 Veterans not on hospice, 6,083 (2.0%) received advanced HF therapies (0.3% vs 2.0%; p<0.001). Veterans receiving concurrent care had higher six-month mortality than those receiving advanced HF therapies alone (77.6% vs. 14.9%, SMD 1.61). Hazard of burdensome transitions was similar (adjusted HR 1.44, 95% CI 0.95-2.17). CONCLUSION: Veterans with HF receiving concurrent care were few and experienced higher mortality. Rate of burdensome transitions was similar between Veterans receiving concurrent care and those not on hospice. Further research may explore why Veterans infrequently utilize concurrent care at the end of life.

Equity and Inclusion for LGBTQ+ Residents: Lessons Learned From the Initial Long-Term Care Equality Index (LEI).

Most older adults with lesbian, gay, bisexual, queer, questioning, transgender, and related identities (LGBTQ+) are concerned about receiving lower-quality care and/or being mistreated in nursing homes. Older LGBTQ+ Veterans may have additional reservations about receiving care in Veterans Affairs (VA) nursing homes [Community Living Centers (CLCs)] because of experience with past discriminatory military policies (eg, bans on participating in military service, Don't Ask Don't Tell). The Human Rights Campaign developed the Long-Term Care Equality Index (LEI) as a facility benchmarking tool to support more inclusive environments for LGBTQ+ residents and employees. The LEI offers 4 evaluation criteria: (1) Non-Discrimination and Staff Training; (2) LGBTQ+ Resident Services and Support; (3) Employee Benefits and Policies; and (4) Resident and Community Engagement. Facilities receive ratings based on the number of requirements achieved in each criteria category. This article describes one of the first VA CLCs to participate in the LEI self-assessment and the formative evaluation process used to identify opportunities for growth. Older LGBTQ+ Veterans, current CLC residents, interdisciplinary CLC providers and leadership, and national Geriatrics and Extended Care program managers collaborated to pilot the LEI and develop tools and materials to support other VA facilities' participation in the LEI. Results of qualitative interviews with Veterans and CLC residents supported inclusion of gender identity and sexual orientation in resident handbooks, discussions about person-centered care, and opportunities for additional staff training and community engagement (eg, observing Pride Month in June). Resources to support other VA long-term care facilities' participation in the LEI were developed and are discussed. The LEI offers a structured approach to identifying areas for improvement in providing high-quality and equitable care in long-term care settings. We offer 6 practical suggestions for CLCs and other nursing home settings considering the LEI for the first time.

A rapid review of the barriers and facilitators of mental health service access among Veterans and their families.

Introduction: Transitioning to civilian life after military service can be challenging for both Veterans and their families. Accessible mental health services are crucial during this period to provide support. The objective of this review was to conduct a rapid review to capture the barriers and identify facilitators that influence access to mental health services for Veterans and their families during the post-service transition period. Methods: This review was conducted using the Cochrane Handbook for Systematic Reviews of Interventions as a methodological framework and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Rapid Review (PRISMA-RR). Results: A total of 60 articles and 67 independent samples were included in the final data analyses. Across the included articles, this review identified 23 barriers and 14 facilitator themes. Issues navigating the mental health care system was identified as the main challenge among Veterans and their families, and those who received support navigating the system identified this as a significant facilitator. Applying the Theoretical Domains Framework, most of the identified barriers and facilitators were categorized into environmental context and resources domain. Discussion: The heterogeneity in Veterans' and Veteran families' experiences with mental health care-seeking may suggest that access to mental health care for Veterans and Veteran families cannot be solved by addressing one type of barrier alone. Instead, coordinated efforts to address prioritized systemic, logistical, social, and inter-/intrapersonal obstacles are essential for improving access and optimizing mental health care outcomes. These insights underscore the complexity of considerations for Veterans and families accessing mental health care.

[Approach to acupuncture teaching with the integration of the cases of famous and veteran TCM doctors in the perspective].

In the context of curriculum ideological and political education reform, ideological and political education entering acupuncture professional courses has great advantages and development prospects. By introducing the cases of famous and veteran traditional Chinese medicine (TCM) doctors and their life stories into acupuncture teaching, the ideological and political elements related to caring for patients, loving the country, innovation and development, cultural confidence etc. were deeply explored. Through optimizing the course design in acupuncture teaching, the integration of acupuncture teaching and ideological and political education is better achieved. While interpreting the life stories and superb medical skills of famous TCM experts, students are encouraged to establish good medical ethics and values, build their cultural confidence and innovation consciousness, and achieve the teaching goal of educating students through the course.

Role of homelessness and psychiatric disorders in suicide deaths among veterans: A four-way decomposition analysis.

Homelessness and suicide are top priorities in the U.S. Department of Veterans Affairs (VA). This study examined the various pathways involving homelessness, substance use, and mental health disorders in relation to suicide deaths among veterans in the VA healthcare system. A retrospective cohort study was conducted among 6,128,921 veterans-399,125 homeless and 5,729,796 non-homeless-followed-up between 2017 and 2021 using VA/Department of Defense linked databases. Multivariable Cox regression was applied for homelessness and psychiatric disorders as predictor of suicide deaths, sequentially controlling for demographic, clinical, substance use, and mental health characteristics. Four-way decomposition analysis was used to calculate proportions of suicide deaths mediated and/or moderated by homelessness, substance use, and mental health disorders. The relationship between homelessness and suicide-specific mortality risk was reduced from 40 % greater risk in unadjusted to 9 % greater risk in fully-adjusted models. Nearly 26 % of the total effect of homelessness on suicide-specific mortality risk was mediated by substance use disorders, whereas 49 % was mediated and 36 % was moderated by mental health disorders. In conclusion, excess suicide-specific mortality risk in homeless veterans is partly explained by substance use and mental health disorders, highlighting the importance of wrap-around health and social services for homeless veterans in mitigating suicide risk.

Comparing Federal Communications Commission and Microsoft Estimates of Broadband Access for Mental Health Video Telemedicine Among Veterans: Retrospective Cohort Study.

BACKGROUND: The COVID-19 pandemic highlighted the importance of telemedicine in health care. However, video telemedicine requires adequate broadband internet speeds. As video-based telemedicine grows, variations in broadband access must be accurately measured and characterized. OBJECTIVE: This study aims to compare the Federal Communications Commission (FCC) and Microsoft US broadband use data sources to measure county-level broadband access among veterans receiving mental health care from the Veterans Health Administration (VHA). METHODS: Retrospective observational cohort study using administrative data to identify mental health visits from January 1, 2019, to December 31, 2020, among 1161 VHA mental health clinics. The exposure is county-level broadband percentages calculated as the percentage of the county population with access to adequate broadband speeds (ie, download >25 megabits per second) as measured by the FCC and Microsoft. All veterans receiving VHA mental health services during the study period were included and categorized based on their use of video mental health visits. Broadband access was compared between and within data sources, stratified by video versus no video telemedicine use. RESULTS: Over the 2-year study period, 1,474,024 veterans with VHA mental health visits were identified. Average broadband percentages varied by source (FCC mean 91.3%, SD 12.5% vs Microsoft mean 48.2%, SD 18.1%; P<.001). Within each data source, broadband percentages generally increased from 2019 to 2020. Adjusted regression analyses estimated the change after pandemic onset versus before the pandemic in quarterly county-based mental health visit counts at prespecified broadband percentages. Using FCC model estimates, given all other covariates are constant and assuming an FCC percentage set at 70%, the incidence rate ratio (IRR) of county-level quarterly mental video visits during the COVID-19 pandemic was 6.81 times (95% CI 6.49-7.13) the rate before the pandemic. In comparison, the model using Microsoft data exhibited a stronger association (IRR 7.28; 95% CI 6.78-7.81). This relationship held across all broadband access levels assessed. CONCLUSIONS: This study found FCC broadband data estimated higher and less variable county-level broadband percentages compared to those estimated using Microsoft data. Regardless of the data source, veterans without mental health video visits lived in counties with lower broadband access, highlighting the need for accurate broadband speeds to prioritize infrastructure and intervention development based on the greatest community-level impacts. Future work should link broadband access to differences in clinical outcomes.

Traumatic brain injury and sleep in military and veteran populations: A literature review.

BACKGROUND: Traumatic brain injury (TBI) is a hallmark of wartime injury and is related to numerous sleep wake disorders (SWD), which persist long term in veterans. Current knowledge gaps in pathophysiology have hindered advances in diagnosis and treatment. OBJECTIVE: We reviewed TBI SWD pathophysiology, comorbidities, diagnosis and treatment that have emerged over the past two decades. METHODS: We conducted a literature review of English language publications evaluating sleep disorders (obstructive sleep apnea, insomnia, hypersomnia, parasomnias, restless legs syndrome and periodic limb movement disorder) and TBI published since 2000. We excluded studies that were not specifically evaluating TBI populations. RESULTS: Highlighted areas of interest and knowledge gaps were identified in TBI pathophysiology and mechanisms of sleep disruption, a comparison of TBI SWD and post-traumatic stress disorder SWD. The role of TBI and glymphatic biomarkers and management strategies for TBI SWD will also be discussed. CONCLUSION: Our understanding of the pathophysiologic underpinnings of TBI and sleep health, particularly at the basic science level, is limited. Developing an understanding of biomarkers, neuroimaging, and mixed-methods research in comorbid TBI SWD holds the greatest promise to advance our ability to diagnose and monitor response to therapy in this vulnerable population.

Prevalence and Characteristics of Veterans with Severe Hearing Loss: A Descriptive Study.

Hearing loss is common among Veterans, and extensive hearing care resources are prioritized within the Veterans Administration (VA). Severe hearing loss poses unique communication challenges with speech understanding that may not be overcome with amplification. We analyzed data from the VA Audiometric Repository between 2005 and 2017 and the relationship between hearing loss severity with speech recognition scores. We hypothesized that a significant subset of Veterans with severe or worse hearing loss would have poor unaided speech perception outcomes even with adequate audibility. Sociodemographic characteristics and comorbidities were compiled using electronic medical records as was self-report measures of hearing disability. We identified a cohort of 137,500 unique Veterans with 232,789 audiograms demonstrating bilateral severe or worse hearing loss (four-frequency PTA > 70 dB HL). The median (IQR; range) age of Veterans at their first audiogram with severe or worse hearing loss was 81 years (74 to 87; 21-90+), and a majority were male (136,087 [99%]) and non-Hispanic white (107,798 [78.4%]). Among those with bilateral severe or worse hearing loss, 41,901 (30.5%) also had poor speech recognition scores (<50% words), with greater hearing loss severity correlating with worse speech perception. We observed variability in speech perception abilities in those with moderate-severe and greater levels of hearing loss who may derive limited benefit from amplification. Veterans with communication challenges may warrant alternative approaches and treatment strategies such as cochlear implants to support communication needs.

Inclination to pursue Veterans Health Administration for primary care practice: survey of medical residents.

Introduction: Health systems like the Veterans Health Administration (VA) face challenges in recruiting and retaining a primary care physician workforce. This cross-sectional study of recent or current VA medical residents sought to identify determinants of intent to pursue primary care practice in VA after residency training. Methods: Residents were identified from administrative data between 2020 and 2021 and recruited via an emailed self-administered survey. Multivariable logistic regression, accounting for survey non-response, was applied to examine the association between intent to pursue VA practice and two sets of measures: VA training experiences and individual preferences for work conditions. Results: Of 268 responses received, 141 (56%) of the sample reported inclination to consider VA employment post-residency. Experiences with training in VA were rated more positively in the VA-inclined group compared to the not-inclined group. In the multivariable model, intent to practice primary care was the strongest predictor (OR 4.04, p < 0001). Preceptors' modeling of work-life balance (OR 3.23, p = 0.009) and perceptions of quality of clinical staff and services (OR 2.64, p = 0.004), ability to get patients the care they need (OR 2.51, p = 0.017), and quality of patient care (OR 2.30, p = 0.075) were independent predictors of being in the VA inclined group. Conclusion: Overall, we found that intent to practice primary care and the quality of VA training experiences are important determinants of inclination to consider VA for employment. These results provide an important perspective relevant to medical education, the hiring and retention of the United States (U.S). primary care workforce.

"Just Food doesn't Do It": Understanding Food Insecurity Among Rural Veterans in the United States.

Food security among rural veteran populations is an understudied subject. This study uses qualitative data from 106 semi-structured interviews conducted with staff from programs at the United States Department of Veterans Affairs (VA) and other federal agencies, staff from non-governmental organizations (NGOs), food security researchers, and food insecure veterans to identify the barriers to and facilitators for rural veteran food security. Barriers identified included external, structural barriers that exist in rural areas; internal barriers to using food assistance, such as feeling stigmatized; and barriers related to other social determinants of health, including a lack of education, employment, or housing stability.

Emergency department utilization in Veterans with spinal cord injuries & disorders.

OBJECTIVE: To determine frequency that ED visits are needed, and the most common chief complaints and medications prescribed to Veterans with spinal cord injuries and disorders (SCI/D). METHODS: The Veterans Health Administration (VHA) SCI and Disorders (SCI/D) Registry (VHA SCIDR) was used to identify Veterans with SCI/D over a five-year period (fiscal years 2018-2022). The primary outcome was the proportion of Veterans with SCI/D who had visits to the ED during the study period. Secondary outcomes included diagnostic codes and medications prescribed in the ED, and other healthcare encounters. RESULTS: Overall, 18,464 Veterans with SCI/D, including 80,661 patient-years were included. Of these Veterans, 10,234 (55.4%) had at least one ED visit and 8230 (44.6%) did not. ED visits were consistent, ranging from 33.5% to 36.4% annually. The number of in-person healthcare encounters decreased over the study period. The most common ED diagnostic codes were paraplegia or quadriplegia, discharge counseling, UTI, neuromuscular dysfunction of the bladder and low back pain. The most common medications prescribed in the ED were analgesics (e.g., acetaminophen, ketorolac), antimicrobials (e.g., ceftriaxone, vancomycin) and ondansetron. Antibiotics were among the most prescribed discharge medications, including ciprofloxacin, sulfamethoxazole/trimethoprim, cephalexin, and doxycycline. CONCLUSION: This national study of Veterans with SCI/D characterized ED healthcare utilization. Overall, more than half of Veterans with SCI/D required an ED visit during the five-year study period and over one third of Veterans in each fiscal year required an ED visit. Interventions to target prevention of ED visits and subsequent hospitalizations could focus on these areas.

Cannabidiol (CBD) and hemp oil use in veterans using a VA Pain Clinic: a cross-sectional survey study.

BACKGROUND: Many United States veterans utilize prescription opioids to treat chronic pain symptoms and are subsequently at risk for opioid and alcohol misuse. As more states legalized the use of cannabis for medical use, increasing numbers of people are using cannabis pharmacotherapy for pain. The veterans Health Administration (VHA) Directive 1315, July 28, 2023 prohibits any medical staff on recommending, making referral to, and complete forms for a state approved program. Also, a veterans medical center does not provide marijuana to veterans. State laws do not change the status of CBD under federal law. CBD is illegal in the federal system. OBJECTIVES: Our aim was to investigate the prevalence of cannabidiol product usage in Veterans and the association with changes in self-reported pain. METHODS: We conducted a cross-sectional descriptive survey offering questionnaires to patients greater than 18 years of age receiving care at the Fargo Veteran Health Administration medical center Pain Clinic (2101 Elm St N, Fargo ND, 58102). RESULTS: A total of 218 veterans participated of which 81.2% were male and 52.3% were in the age range of 60-80 years. Twenty-one participants reported cannabidiol usage (9.6%), with 52.4% using to treat pain symptoms. Average pain scores pre-usage of 6.37 were reduced to 4.05 post-usage indicating a statistically significant reduction in pain (p < 0.001). CONCLUSION: Our study broadened the baseline knowledge of cannabidiol use in the Veteran population. Limitations include results being self-reported and the inability to verify cannabinoid constituents.

Protocol for a pragmatic trial of Cannabidiol (CBD) to improve chronic pain symptoms among United States Veterans.

BACKGROUND: Chronic pain affects over 100 million Americans, with a disproportionately high number being Veterans. Chronic pain is often difficult to treat and responds variably to medications, with many providing minimal relief or having adverse side effects that preclude use. Cannabidiol (CBD) has emerged as a potential treatment for chronic pain, yet research in this area remains limited, with few studies examining CBD's analgesic potential. Because Veterans have a high need for improved pain care, we designed a clinical trial to investigate CBD's effectiveness in managing chronic pain symptoms among Veterans. We aim to determine whether CBD oral solution compared to placebo study medication is associated with greater improvement in the Patient Global Impression of Change (PGIC). METHODS: We designed a randomized, double-blind, placebo-controlled, pragmatic clinical trial with 468 participants. Participants will be randomly assigned in a 1:1 ratio to receive either placebo or a CBD oral solution over a 4-week period. The trial is remote via a smartphone app and by shipping study materials, including study medication, to participants. We will compare the difference in PGIC between the CBD and placebo group after four weeks and impacts on secondary outcomes (e.g., pain severity, pain interference, anxiety, suicide ideation, and sleep disturbance). DISCUSSION: Once complete, this trial will be among the largest to date investigating the efficacy of CBD for chronic pain. Findings from this clinical trial will contribute to a greater knowledge of CBD's analgesic potential and guide further research. Given the relative availability of CBD, our findings will help elucidate the potential of an accessible option for helping to manage chronic pain among Veterans. TRIAL REGISTRATION: This protocol is registered at clinicaltrials.gov under study number NCT06213233.

Screening rates for hepatitis B and C among low-income US veterans: Data from the National Veteran Homeless and Other Poverty Experiences Study.

Screening for viral hepatitis is considered a high-priority area in the Veterans Health Administration (VHA). Yet, few studies have examined viral hepatitis screening test use among low-income veterans who are considered high-risk with limited healthcare access. Using cross-sectional data from 933 participants in the 2021-2022 National Veteran Homeless and Other Poverty Experiences (NV-HOPE) study, we examined rates and correlates of lifetime screening for hepatitis B (HBV) and hepatitis C (HCV) infections. Multivariable logistic regression models evaluated characteristics associated with HBV/HCV screening. Nearly 16% and 21% reported lifetime HBV and HCV screening, respectively. These rates are considerably lower than HBV (47.3%) and HCV (92.9%) screening rates documented among contemporaneous veterans in VHA electronic health records. In the NV-HOPE data, veterans 50-79 years were more likely than those ≥80 years of age to ever-screen for HBV/HCV. Whereas, household income was inversely related to lifetime screening behaviours, veterans reporting 'other' employment types (vs. full-time/part-time employment) were more likely to ever-screen for HBV/HCV. Ever-screening for HBV was more likely among veterans reporting non-Hispanic 'other' (vs. non-Hispanic 'white') race, housing instability, Medicaid insurance, as well as drug use and cognitive disorder histories. Living with ≥5 members (vs. alone), histories of alcohol use, cancer, and liver disorders were also correlated with ever-screening for HCV. HIV/AIDS history correlated with ever-screening for HBV/HCV. In conclusion, fewer than one-third of low-income US veterans ever-screened for HBV/HCV, with lower screening rates among those less likely to be exposed to viral hepatitis, thereby informing interventions aimed at promoting available screening, treatment and vaccinations for HBV/HCV.

Blast Exposure Associations With Hearing Loss and Self-Reported Hearing Difficulty.

OBJECTIVE: Examine associations between military blast exposures on hearing loss and self-reported hearing difficulties among Active-Duty Service Members (ADSM) and Veterans from the Noise Outcomes in Servicemembers Epidemiology (NOISE) study. STUDY DESIGN: Cross-sectional. SETTING: Multi-institutional tertiary referral centers. METHODS: Blast exposure was assessed with a comprehensive blast questionnaire. Outcome measures included pure-tone hearing thresholds; Speech Recognition in Noise Test; Hearing Handicap Inventory for Adults (HHIA); and Speech, Spatial and Qualities of Hearing Scale (SSQ)-12. RESULTS: Twenty-one percent (102/494) of ADSM and 36.8% (196/533) of Veterans self-reported blast exposure. Compared to ADSM without blast exposure, blast-exposed ADSM had increased odds of high frequency (3-8 kHz) and extended-high frequency (9-16 kHz) hearing loss (odds ratio [OR] = 2.5, CI: 1.3, 4.7; OR = 3.7, CI: 1.9, 7.0, respectively). ADSM and Veterans with blast exposure were more likely than their nonblast exposed counterparts to report hearing difficulty on the HHIA (OR = 1.9, CI: 1.1, 3.3; OR = 2.1, CI: 1.4, 3.2, respectively). Those with self-reported blast exposure also had lower SSQ-12 scores (ADSM mean difference = -0.6, CI: -1.0, -0.1; Veteran mean difference: -0.9, CI: -1.3, -0.5). CONCLUSION: Results suggest that blast exposure is a prevalent source of hearing injury in the military. We found that among ADSM, blast exposure was associated with hearing loss, predominately in the higher frequencies. Blast exposure was associated with poorer self-perceived hearing ability in ADSM and Veterans. IRB: #FWH20180143H Joint Base San Antonio (JBSA) Military Healthcare System; #3159/9495 Joint VA Portland Health Care System (VAPORHCS) Oregon Health and Science University (OHSU).

Life-sustaining treatment decisions and family evaluations of end-of-life care for Veteran decedents in Department of Veterans Affairs nursing homes.

BACKGROUND: Modeled after the Physician Orders for Life Sustaining Treatment program, the Veterans Health Administration (VA) implemented the Life-Sustaining Treatment (LST) Decisions Initiative to improve end-of-life outcomes by standardizing LST preference documentation for seriously ill Veterans. This study examined the associations between LST documentation and family evaluation of care in the final month of life for Veterans in VA nursing homes. METHODS: Retrospective, cross-sectional analysis of data for decedents in VA nursing homes between July 1, 2018 and January 31, 2020 (N = 14,575). Regression modeling generated odds for key end-of-life outcomes and family ratings of care quality. RESULTS: LST preferences were documented for 12,928 (89%) of VA nursing home decedents. Contrary to our hypothesis, neither receipt of wanted medications and medical treatment (adjusted odds ratio [OR]: 0.85, 95% confidence interval [CI] 0.63, 1.16) nor ratings of overall care in the last month of life (adjusted OR: 0.96, 95% CI 0.76, 1.22) differed significantly between those with and without completed LST templates in adjusted analyses. CONCLUSIONS: Among Community Living Center (CLC) decedents, 89% had documented LST preferences. No significant differences were observed in family ratings of care between Veterans with and without documentation of LST preferences. Interventions aimed at improving family ratings of end-of-life care quality in CLCs should not target LST documentation in isolation of other factors associated with higher family ratings of end-of-life care quality.

Racial disparities in colorectal cancer outcomes and access to care: a multi-cohort analysis.

Introduction: Non-Hispanic Black (NHB) Americans have a higher incidence of colorectal cancer (CRC) and worse survival than non-Hispanic white (NHW) Americans, but the relative contributions of biological versus access to care remain poorly characterized. This study used two nationwide cohorts in different healthcare contexts to study health system effects on this disparity. Methods: We used data from the Surveillance, Epidemiology, and End Results (SEER) registry as well as the United States Veterans Health Administration (VA) to identify adults diagnosed with colorectal cancer between 2010 and 2020 who identified as non-Hispanic Black (NHB) or non-Hispanic white (NHW). Stratified survival analyses were performed using a primary endpoint of overall survival, and sensitivity analyses were performed using cancer-specific survival. Results: We identified 263,893 CRC patients in the SEER registry (36,662 (14%) NHB; 226,271 (86%) NHW) and 24,375 VA patients (4,860 (20%) NHB; 19,515 (80%) NHW). In the SEER registry, NHB patients had worse OS than NHW patients: median OS of 57 months (95% confidence interval (CI) 55-58) versus 72 months (95% CI 71-73) (hazard ratio (HR) 1.14, 95% CI 1.12-1.15, p = 0.001). In contrast, VA NHB median OS was 65 months (95% CI 62-69) versus NHW 69 months (95% CI 97-71) (HR 1.02, 95% CI 0.98-1.07, p = 0.375). There was significant interaction in the SEER registry between race and Medicare age eligibility (p < 0.001); NHB race had more effect in patients <65 years old (HR 1.44, 95% CI 1.39-1.49, p < 0.001) than in those ≥65 (HR 1.13, 95% CI 1.11-1.15, p < 0.001). In the VA, age stratification was not significant (p = 0.21). Discussion: Racial disparities in CRC survival in the general US population are significantly attenuated in Medicare-aged patients. This pattern is not present in the VA, suggesting that access to care may be an important component of racial disparities in this disease.

US Military Veteran Perspectives on Eating Disorder Screening, Diagnosis, and Treatment: A Qualitative Study.

OBJECTIVE: We aimed to explore US veteran perspectives on eating disorder screening, diagnosis, patient-provider conversations, and care in the Veterans Health Administration (VHA). METHOD: Rapid qualitative analysis of 30-45 min phone interviews with 16 (N = 16) veterans with an electronic health record ICD-10 eating disorder diagnosis, who received care at one of two VHA healthcare systems in Connecticut or California. Topics covered included: conversations with providers about eating disorder symptoms, diagnosis, and referral to treatment; feedback about an eating disorder screener, and; reflections on eating disorders among veterans and VHA's effort to address them. RESULTS: Most veterans reported difficulty understanding and defining the problems they were experiencing and self-diagnosed their eating disorder before discussing it with a provider. Treatment referrals were almost universally for being overweight rather than for an eating disorder, often leading veterans to feel misunderstood or marginalized. Overall, veterans were enthusiastic about the screener, preferred screening to be conducted by primary care providers, and noted that conversations needed to be non-stigmatizing. There was consensus that VHA is not doing enough to address this issue, that group support and therapy could be beneficial, and that resources needed to be centralized and accessible. DISCUSSION: For the most part, veterans felt that, at best, eating disorders and disordered eating are overlooked, and at worst, conflated with overweight. The majority of veterans got referred for weight loss or weight management services but would welcome the opportunity to be screened for, and referred to, eating disorder treatment.

LIMBIC-CENC: Successfully conducting longitudinal mTBI research during the COVID-19 pandemic.

BACKGROUND: Conducting mild traumatic brain injury (mTBI) longitudinal studies across multiple sites is a challenging endeavor which has been made more challenging because of COVID-19. OBJECTIVE: This article briefly describes several concerns that need to be addressed during the conduct of research to account for COVID-19's impact. METHODS: The recent actions and steps taken by the Long-term Impact of Military-relevant Brain Injury Consortium (LIMBIC)-Chronic Effects of Neurotrauma Consortium (CENC) researchers are reviewed. RESULTS: COVID-19's effects on the conduct of LIMBIC-CENC for the short-term and long-term were considered to ensure the study continued safely for participants and researchers. COVID-19 may have long-lasting health and especially neurological effects which may confound the quantitative and qualitative measures of this any comparable longitudinal studies. CONCLUSION: The recognition, understanding, and preparation of COVID-19's impact on a longitudinal military and veteran mTBI population is crucial to successfully conducting LIMBIC-CENC and similar neurological research studies. Developing a plan based on the best available information while remaining agile as new information about COVID-19 emerge, is essential. Research presented in this special issue underscores the complexity of studying long-term effects of mTBI, in a population exposed to and symptomatic from COVID-19.