Physicians and Specialties in the Veterans Health Administration's Community Care Network.

This cross-sectional study of data from the US Veterans Health Administration examines the availability of services provided through community care networks by specialty and clinical characteristics.

Factors Impacting the Implementation of Mobile Integrated Health Programs for the Acute Care of Older Adults.

OBJECTIVE: Emergency services utilization is increasing in older adult populations. Many such encounters may be preventable with better access to acute care in the community. Mobile integrated health (MIH) programs leverage mobile resources to deliver care and services to patients in the out-of-hospital environment and have the potential to improve clinical outcomes and decrease health care costs; however, they have not been widely implemented. We assessed barriers, potential facilitators, and other factors critical to the implementation of MIH programs with key vested partners. METHODS: Professional and community-member partners were purposefully recruited to participate in recorded structured interviews. The study team used the Practical Robust Implementation and Sustainability Model (PRISM) framework to develop an interview guide and codebook. Coders employed a combination of deductive and inductive coding strategies to identify common themes across partner groups. RESULTS: The study team interviewed 22 participants (mean age 56, 68% female). A cohort of professional subject matter experts included physicians, paramedics, public health personnel, and hospital administrators. A cohort of lay community partners included patients and caregivers. Coders identified three prominent themes that impact MIH implementation. First, MIH is disruptive to existing clinical workflows. Second, using MIH to improve patients' experience during acute care encounters is key to intervention adoption. Finally, legislative action is needed to augment central financial and regulatory policies to ensure the adoption of MIH programs. CONCLUSIONS: Common themes impacting the implementation of MIH programs were identified across vested partner groups. Multilevel strategies are needed to address patient adoption, clinical partners' workflow, and legislative policies to ensure the success of MIH programs.

Musculoskeletal Pain During Pregnancy Among Veterans: Associations With Health and Health Care Utilization.

INTRODUCTION: Musculoskeletal (MSK) pain is more likely to be diagnosed in veterans compared with the general population; however, MSK pain during pregnancy has not been studied in veterans. This study examined health and health care use differences between pregnant veterans with and without MSK pain (MSK-). METHODS: Veterans who delivered a newborn before June 1, 2021, were identified from an existing cohort (n = 1,181). Survey and Veterans Health Administration (VA) electronic health record data were obtained on participants. Veterans meeting inclusion criteria were identified as those with MSK pain (MSK+) and were compared with MSK- participants. We examined differences between primary outcomes of VA health care engagement (including mental health diagnoses, health care visits, receipt of prescription opioids, and complementary and integrative health use) and secondary outcomes (including postpartum variables) between MSK pain groups. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated. RESULTS: There were 172 veterans (14.6%) who met MSK pain eligibility criteria. In adjusted models, MSK+ veterans were more likely to be diagnosed with major depressive disorder (aOR, 1.76; 95% CI, 1.22-2.53) and post-traumatic stress disorder (aOR, 1.79; 95% CI, 1.21-2.64) during pregnancy compared with MSK- veterans. The use of VA mental health care (aOR, 1.52; 95% CI, 1.09-2.12) and the odds of receiving an opioid prescription during pregnancy (aOR, 2.76; 95% CI, 1.53-5.00) was higher in MSK+ veterans compared with MSK- veterans. Only a small proportion (3.6%) of our entire cohort used complementary and integrative health approaches during pregnancy. MSK+ veterans were more likely to deliver by cesarean section compared with MSK- veterans (36% vs. 26%). CONCLUSIONS: MSK+ veterans were more likely to be diagnosed with mental health conditions and to use VA mental health care during pregnancy compared with MSK- veterans. Because veterans receive their obstetrical care in the community, understanding the unique needs of pregnant MSK+ veterans in comparison with MSK- veterans is important to provide comprehensive care during the perinatal period.

Using RE-AIM to examine implementation of a tele-nephrology program for veterans living in rural areas.

Introduction: Chronic kidney disease (CKD) and refractory hypertension (rHTN) are common, chronic conditions that affect 10%-16% of Veterans. Several small studies have suggested that tele-nephrology can deliver nephrology care effectively to rural Veterans. The purpose of this evaluation was to examine perceptions and experiences with this tele-nephrology program among spoke site staff and clinicians using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to guide our understanding of tele-nephrology implementation. Methods: We conducted semi-structured interviews with fourteen clinicians at five tele-nephrology spoke sites. We used content analysis to analyze the results using our RE-AIM framework. Results: Five major themes arose: (1) Active engagement of a centralized clinical champion was a key factor in early success of tele-nephrology program; (2) Transition from community-based nephrology to VA tele-nephrology was heralded as the most meaningful indicator of the effectiveness of the intervention; (3) Effective adoption strategies included bi-weekly training with Hub nephrology staff and engagement of a local renal champion; (4) Meeting the needs of Veterans through proper staffing during tele-nephrology examinations was a key priority in facility program implementation; and (5) Growing reliance on Hub nephrologists may give rise to insufficient availability of nephrology appointments in some Spoke sites. Discussion: This evaluation represents an important step forward as VA considers how to provide care to Veterans at facilities without VA specialty providers. The COVID-19 pandemic has drastically shifted options for Veterans, and increasingly, the VA is moving to shift care from community to VA via virtual care. Further research should examine how the VA manages potential problems related to access to virtual providers and examine Veteran perspectives on community in-person vs. virtual VA care.

Understanding the Mental Health Impact of Previous Pregnancy Loss Among Currently Pregnant Veterans.

BACKGROUND: Pregnancy loss, including miscarriage and stillbirth, is common and associated with an increased risk for prenatal and postnatal depression, as well as posttraumatic stress disorder (PTSD). Racial disparities have been observed in pregnancy loss, with Black women having higher rates of pregnancy loss and postnatal depression. However, no research to date has examined the mental health and demographic correlates of pregnancy loss within a veteran population. METHOD: The current study examined associations between pregnancy loss and mental health and demographic correlates among 1,324 pregnant veterans, of which 368 had a history of at least one stillbirth and/or miscarriage. RESULTS: Veterans with a history of pregnancy loss, compared with those without, were more likely to have a diagnosis of anxiety (52.7% vs. 46.4%, p = .04), depression (62.5% vs. 50.8%, p = .0001), or PTSD (46.5% vs. 37.6%, p = .003); were more likely to report receiving mental health care during pregnancy (23.1% vs. 16.8%, p = .01); and were more likely to have experienced military sexual trauma (harassment: 56.5% vs. 49.9%, p = .04; rape: 38.9% vs. 29.3%, p = .0004). Results also indicated that Black veterans were more likely to report a history of pregnancy loss (32.1% vs. 25.3%, p = .01). Further, Black veterans were more likely to experience clinically meaningful prenatal depression symptoms (adjusted odds ratio: 1.90; 95% confidence interval: 1.42-2.54) after accounting for past loss and age in logistic regression models. DISCUSSION: Taken together, findings from the present investigation corroborate previous research highlighting the deleterious impact of pregnancy loss and extend prior work by examining these associations among a diverse sample of pregnant veterans.

Compensation and Pension Exams for Military Sexual Trauma-Related Posttraumatic Stress Disorder: Examiner Perspectives, Clinical Impacts on Veterans, and Strategies.

BACKGROUND: It is estimated that in one in three women veterans experience military sexual trauma (MST), which is strongly associated with posttraumatic stress disorder (PTSD). A 2018 report indicated the Veterans Benefits Administration (VBA) processed approximately 12,000 disability claims annually for PTSD related to MST, most of which are filed by women. Part of the VBA adjudication process involves reviewing information from a Compensation and Pension (C&P) exam, a forensic diagnostic evaluation that helps determine the relationship among military service, diagnoses, and current psychosocial functioning. The quality and outcome of these exams may affect veteran well-being and use of Veterans Health Administration (VHA) mental health care, but no work has looked at examiner perspectives of MST C&P exams and their potential clinical impacts on veteran claimants. METHODS: Thirteen clinicians ("examiners") who conduct MST C&P exams through VHA were interviewed. Data were analyzed using rapid qualitative methods. RESULTS: Examiners described MST exams as more clinically and diagnostically complex than non-MST PTSD exams. Examiners noted that assessing "markers" of MST (indication that MST occurred) could make veterans feel disbelieved; others raised concerns related to malingered PTSD symptoms. Examiners identified unique challenges for veterans who underreport MST (e.g., men and lesbian, gay, bisexual, transgender, and queer [LGBTQ+] veterans), and saw evaluations as a conduit to psychotherapy referrals and utilization of VHA mental health care. Last, examiners used strategies to convey respect and minimize retraumatization, including a standardized process and validating the difficulty of the process. CONCLUSIONS: Examiners' responses offer insight into a process entered by thousands of veterans annually with PTSD. Strengthening the MST C&P process is a unique opportunity to enhance trust in the VBA claims process and increase likelihood of using VHA mental health care, especially for women veterans.

Infertility Services for Veterans Enrolled in Veterans Health Administration Care.

BACKGROUND: Infertility care is provided to Veterans through the Veterans Health Administration (VHA) medical benefits package and includes infertility evaluation and many infertility treatments. OBJECTIVE: Our objective was to examine the incidence and prevalence of infertility diagnoses and the receipt of infertility healthcare among Veterans using Veterans Health Administration (VHA) healthcare from 2018 to 2020. METHODS: Veterans using the VHA and diagnosed with infertility during October 2017-September 2020 (FY18-20) were identified in VHA administrative data and through VA-purchased care (i.e., community care) claims. Infertility was categorized among men as azoospermia, oligospermia, and other and unspecified male infertility, and among women as anovulation, infertility of tubal origin, infertility of uterine origin, and other and unspecified female infertility using diagnosis and procedure codes (ICD-10, CPT). KEY RESULTS: A total of 17,216 Veterans had at least one VHA infertility diagnosis in FY18, FY19, or FY20, including 8766 male Veterans and 8450 female Veterans. Incident diagnoses of infertility were observed in 7192 male Veterans (10.8/10,000 person (p)-years) and 5563 female Veterans (93.6/10,000 p-years). A large proportion of Veterans who were diagnosed with infertility received an infertility-related procedure in the year of their incident diagnosis (males: 74.7, 75.3, 65.0%, FY18-20 respectively; females: 80.9, 80.8, 72.9%, FY18-20 respectively). CONCLUSIONS: In comparison to a recent study of active duty servicemembers, we found a lower rate of infertility among Veteran men and a higher rate among Veteran women. Further work is needed to investigate military exposures and circumstances that may lead to infertility. Given the rates of infertility among Veterans and active duty servicemembers, enhancing communications between Department of Defense and VHA systems regarding sources of and treatment for infertility is essential to help more men and women benefit from infertility care during military service or as Veterans.

Examining Veterans' Experiences With In Vitro Fertilization Provided Under P.L. 114-223.

BACKGROUND: Until recently, the Department of Veterans Affairs (VA) medical benefits package has expressly excluded in vitro fertilization (IVF) services for Veterans experiencing fertility problems. However, P.L. 114-223 (2016) allows VHA to provide Assisted Reproductive Technology, including IVF, to certain eligible Veterans. Little is known regarding Veterans' experiences accessing IVF through VA Community Care contracts with IVF providers. OBJECTIVE: To examine Veterans' experiences with IVF services provided under the auspices of P.L. 114-223. RESEARCH DESIGN: Telephone or video interviews were conducted with male and female Veterans and opposite-sex spouses of Veterans who had been approved for IVF. Interviews were recorded, transcribed, and analyzed using content analysis techniques. Major themes and representative quotes were derived from the analyses. RESULTS: Ninety-six Veterans and 14 spouses participated in our interviews. Six major themes arose from these interviews, including (1) the need for improved communication regarding IVF benefits, (2) the need for expanded IVF benefits, (3) the lack of a comprehensive care coordination program, (4) poor access to IVF providers in some areas of the country, (5) special services needed for Veterans with spinal cord injuries, and (6) the IVF policy may be discriminatory in nature to single and LGBTQ Veterans. CONCLUSIONS: Many Veterans with service-connected conditions related to reproductive health have taken advantage of the IVF benefit, though limitations on these benefits have prevented other Veterans from taking advantage of the IVF benefit. Further attention needs to be paid to improving communication and coordination of IVF services with ongoing VA care and ensuring special populations, including those living in rural areas and Veterans with spinal cord injuries, have access to IVF services as needed.

Pre-implementation formative evaluation of cooperative pain education and self-management expanding treatment for real-world access: A pragmatic pain trial.

OBJECTIVE: Cognitive behavioral therapy for chronic pain (CBT-CP) is an evidence-based treatment for improving functioning and pain intensity for people with chronic pain with extensive evidence of effectiveness. However, there has been relatively little investigation of the factors associated with successful implementation and uptake of CBT-CP, particularly clinician and system level factors. This formative evaluation examined barriers and facilitators to the successful implementation and uptake of CBT-CP from the perspective of CBT-CP clinicians and referring primary care clinicians. METHODS: Qualitative interviews guided by the Consolidated Framework for Implementation Research were conducted at nine geographically diverse Veterans Affairs sites as part of a pragmatic clinical trial comparing synchronous, clinician-delivered CBT-CP and remotely delivered, technology-assisted CBT-CP. Analysis was informed by a grounded theory approach. RESULTS: Twenty-six clinicians (CBT-CP clinicians = 17, primary care clinicians = 9) from nine VA medical centers participated in individual qualitative interviews conducted by telephone from April 2019 to August 2020. Four themes emerged in the qualitative interviews: (1) the complexity and variability of referral pathways across sites, (2) referring clinician's lack of knowledge about CBT-CP, (3) referring clinician's difficulty identifying suitable candidates for CBT-CP, and (4) preference for interventions that can be completed from home. CONCLUSIONS: This formative evaluation identified clinician and system barriers to widespread implementation of CBT-CP and allowed for refinement of the subsequent implementation of two forms of CBT-CP in an ongoing pragmatic trial. Identification of relative difference in barriers and facilitators in the two forms of CBT-CP may emerge more clearly in a pragmatic trial that evaluates how treatments perform in real-world settings and may provide important information to guide future system-wide implementation efforts.

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.

Perinatal Symptoms and Treatment Engagement in Female Veterans.

INTRODUCTION: Women veterans using Veterans Health Care Administration maternity benefits have a high prevalence of mental health disorders, including depression, PTSD, and anxiety. Additionally, women with psychiatric histories often experience a relapse or worsening of symptoms during pregnancy and postpartum. Adequate perinatal mental healthcare engagement is critical to optimizing outcomes for mother and child. MATERIALS AND METHODS: This study evaluated psychiatric symptom severity and predictors of women veteran's mental health treatment engagement during pregnancy and postpartum at the VA North Texas Health Care System. Seventy women using Veterans Health Administration were assessed longitudinally via chart review and interviews (including the Edinburgh Postnatal Depression Scale) during pregnancy and postpartum. A Friedman test was used to evaluate the change in symptom severity during (1) the 6 months before pregnancy, (2) pregnancy, and (3) postpartum. Multivariate logistic regressions were used to determine predictors of attending outpatient mental health appointments. Potential predictors examined included sociodemographic factors, symptoms of depression, history of military sexual assault, presence of a pre-pregnancy psychiatric diagnosis, and attendance of mental health appointments before pregnancy. RESULTS: Approximately 40% of participants demonstrated at least mild psychiatric symptoms before pregnancy, and symptom severity did not significantly change across the perinatal period (pre-pregnancy, pregnancy, and postpartum) X2 (2, n = 70) = 3.56, P = .17. Depressive symptoms during the 2nd or 3rd trimester were a significant predictor for attendance of mental health appointments during both pregnancy (OR = 1.18, 95% CI, 1.04 to 1.34) and postpartum (OR = 1.18, 95% CI, 1.02 to 1.36). An active psychiatric diagnosis during the 6 months before pregnancy was also a significant predictor of attendance following delivery (OR = 14.63, 95% CI, 1.55 to 138.51). CONCLUSION: Our results demonstrate that women with prior histories of mental health conditions will continue to be symptomatic, and this is a good predictor of mental health treatment engagement during the perinatal period.

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.

Examining Pregnant Veterans' Acceptance and Beliefs Regarding the COVID-19 Vaccine.

BACKGROUND: Pregnant persons have received mixed messages regarding whether or not to receive COVID-19 vaccines as limited data are available regarding vaccine safety for pregnant and lactating persons and breastfeeding infants. OBJECTIVE: The aims of this study were to examine pregnant Veteran's acceptance of COVID-19 vaccines, along with perceptions and beliefs regarding vaccine safety and vaccine conspiracy beliefs. DESIGN AND PARTICIPANTS: We conducted a cross-sectional survey of pregnant Veterans enrolled in VA care who were taking part in an ongoing cohort study at 15 VA medical centers between January and May 2021. MAIN MEASURES: Pregnant Veterans were asked whether they had been offered the COVID-19 vaccine during pregnancy, and whether they chose to accept or refuse it. Additional questions focused on perceptions of COVID-19 vaccine safety and endorsements of vaccine knowledge and conspiracy beliefs. Logistic regression was utilized to examine predictors of acceptance of a vaccine during pregnancy. KEY RESULTS: Overall, 72 pregnant Veterans were offered a COVID-19 vaccine during pregnancy; over two-thirds (69%) opted not to receive a vaccine. Reasons for not receiving a vaccine included potential effects on the baby (64%), side effects for oneself (30%), and immunity from a past COVID-19 infection (12%). Those who received a vaccine had significantly greater vaccine knowledge and less belief in vaccine conspiracy theories. Greater knowledge of vaccines in general (aOR: 1.78; 95% CI: 1.2-2.6) and lower beliefs in vaccine conspiracies (aOR: 0.76; 95% CI: 0.6-0.9) were the strongest predictors of acceptance of a COVID-19 vaccine during pregnancy. CONCLUSIONS: Our study provides important insights regarding pregnant Veterans' decisions to accept the COVID-19 vaccine, and reasons why they may choose not to accept the vaccine. Given the high endorsement of vaccine conspiracy beliefs, trusted healthcare providers should have ongoing, open discussions about vaccine conspiracy beliefs and provide additional information to dispel these beliefs.

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.

Effects of Intimate Partner Violence During COVID-19 and Pandemic-Related Stress on the Mental and Physical Health of Women Veterans.

BACKGROUND: Little is known about women veterans' intimate partner violence (IPV) experiences during the COVID-19 pandemic or the impacts of pandemic-related stress on their mental and physical health. OBJECTIVES: To identify IPV experiences among women veterans prior to and during the pandemic, pandemic-related stressors, and examine their respective contributions to mental and physical health. DESIGN: National sample of women veterans drawn from a larger web-based longitudinal study. Relationships between recent IPV and pandemic-related stressors were tested with linear regressions, controlling for pre-pandemic IPV and mental and physical health symptoms, demographic, and military-related covariates. PARTICIPANTS: One hundred forty-two women veterans (Mage=58.8 years). MAIN MEASURES: We assessed IPV (CTS-2), PTSD (PCL-5), depression (CESD), anxiety (DASS-A), physical health (PHQ-15), and physical health-related quality of life (SF-12) prior to the pandemic (June 2016-December 2016/January 2017) and during the pandemic study period (March 2020-December 2020/January 2021). We assessed pandemic-related stressors (EPII) during the pandemic study period. KEY RESULTS: Over a third (38.7%) of participants experienced IPV during the pandemic study period (psychological: 35.9%, physical: 9.9%, sexual: 4.2%). Overall rates, frequency, and severity of IPV experience did not significantly differ between the pre-pandemic and pandemic study periods. Few participants tested positive for COVID-19 (4.2%); however, most participants reported experiencing pandemic-related stressors across life domains (e.g., social activities: 88%, physical health: 80.3%, emotional health: 68.3%). IPV during the pandemic and pandemic-related stressors were both associated with greater PTSD and depressive symptoms. Pandemic-related stressors were associated with worse anxiety and physical health symptoms. Neither IPV during the pandemic nor pandemic-related stressors were associated with physical health-related quality of life. CONCLUSIONS: IPV experiences during the pandemic were common among women veterans, as were pandemic-related stressors. Although IPV did not increase in the context of COVID-19, IPV experiences during the pandemic and pandemic-related stressors were linked with poorer mental and physical health.

Understanding opportunities and challenges with telemedicine-delivered buprenorphine during the COVID-19 pandemic.

INTRODUCTION: Opioid use disorder (OUD) is a debilitating illness that remains a serious public health issue in the United States. Use of telemedicine to deliver medications for the treatment of OUD (MOUD) was limited until the confluence of the COVID-19 and opioid addiction epidemics in spring 2020. Starting in spring 2020, the Department of Veterans Health Affairs (VHA) transitioned from in-person to mostly telemedicine-delivered OUD care to reduce COVID-19 transmission among veterans and providers. To gain a nuanced understanding of provider perspectives on MOUD care delivery using telemedicine, we conducted semi-structured interviews with VHA providers who were using telehealth to deliver MOUD care. METHODS: We conducted semi-structed Zoom interviews with VA clinicians at nine VA Medical Centers (VAMCs) in eight states. Potential study participants were identified as providers who were involved in referrals and provision of buprenorphine treatment for chronic pain and opioid addiction. Audio-recordings of all interviews were transcribed and entered into Atlas. Ti qualitative analysis software. The study team analyzed the transcripts for major themes related to tele-prescribing practices for buprenorphine. RESULTS: Twenty-three VA providers participated in the study, representing 32% of all providers invited to participate in the study. The research team identified the following four themes: (1) COVID-19 spurred a seismic shift in OUD treatment; (2) Video calls provided a rare window into veterans' lives; (3) Providers experienced numerous challenges to virtual visits; and (4) Providers wrestled with paternalism and trust. CONCLUSIONS: The pandemic accelerated the movement toward harm reduction approaches. Prior to the pandemic, stringent requirements existed for patients receiving MOUD care. Providers in this study reflected on the need for these requirements (e.g., in-person visits, toxicology screens) and how reducing this monitoring implied more trust in patients' autonomous decisions. Providers' observation that videoconferencing offered them a window into patients' lives may offer some ways to improve rapport, and research should explore how best to incorporate the additional information conveyed in virtual visits.

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.

Veterans' Perinatal Care and Mental Health Experiences During the COVID-19 Pandemic: An Examination of the Role of Prior Trauma and Pandemic-Related Stressors.

Background: Many pregnant and postpartum Veterans have experienced multiple lifetime traumas, including military sexual trauma, intimate partner violence, and combat trauma. These women may be particularly vulnerable to increased post-traumatic stress disorder and other mental health problems following additional trauma exposures or stressful events, such as Coronavirus disease 2019 (COVID-19). This study sought to examine the impact of prior trauma exposures on the lived experience of pregnant and postpartum Veterans during the COVID-19 pandemic. Materials and Methods: Pregnant Veterans at 15 VA medical centers were surveyed at 20 weeks of pregnancy and 3 months postpartum asked about their COVID-19-related perinatal and mental health experiences, as well as the stressors that impacted them as a result of the COVID-19 pandemic. Results: Overall, 111 women Veterans completed both the pregnancy and postpartum surveys that included COVID-19 items. Sixty percent of our sample had experienced at least one potentially traumatic lifetime event, with 22% of our sample experiencing two or more of the included exposures. Women with a trauma history had 3.5 times increased odds of reporting their mental health as "much worse" compared to before the COVID-19 pandemic (95% confidence interval [CI]: 1.06-11.75) and were more likely to report that COVID-19 negatively affected their mental or emotional health "a lot" compared with women without a trauma history (odds ratio: 8.5; 95% CI: 1.93-37.48). Conclusions: COVID-19 has had a significant impact on pregnant and postpartum Veterans' mental health. Obstetricians should consider strategies to ensure women have access to mental health care during pregnancy, especially as the COVID-19 pandemic continues. Hospitals should also consider the importance of labor support companions during the COVID-19 pandemic and examine adjusting policies to allow for at least one labor support companion during labor and delivery.

Racial Differences in Nontraditional Risk Factors Associated with Cardiovascular Conditions in Pregnancy Among U.S. Women Veterans.

Background: Pregnancy-related cardiovascular (CV) conditions are important predictors of future cardiovascular disease (CVD). Nontraditional factors, such as depression and chronic stress, have been associated with CVD, but their role in pregnancy-related CVD conditions (pCVD) remains unknown. To determine the association between nontraditional factors and CV conditions in pregnancy, and to explore if this risk varies by race. Methods: Using data from a prospective study of pregnant women within the veterans affairs health system (COMFORT study), we described the prevalence of nontraditional factors (e.g., depression, post-traumatic stress disorder [PTSD], chronic stress) and used logistic regression to determine the association between nontraditional factors and pregnancy-related CV conditions (pre-eclampsia/eclampsia, gestational hypertension, gestation diabetes, or preterm delivery). Analyses were then stratified by race. Results: Among 706 enrollees, 26% had pregnancy-related CV conditions. These women had significantly higher rates of depression (62% vs. 45%, p < 0.01), anxiety (50% vs. 37%, p = 0.01), PTSD (44% vs. 29%, p < 0.01), and high stress levels before pregnancy (22% vs. 16%, p = 0.05) compared with women with normal pregnancies. Overall, these factors were not associated with increased adjusted odds of pCVD. Overall, Black women had disproportionately higher rates of prepregnancy hypertension compared with White women (22% vs. 6%, p < 0.01). Conclusions: Women Veterans with pCVD are a high-risk group for future CVD, with disproportionately high rates of depression, anxiety, PTSD, and chronic stress. Racial disparities exist in pregnancy-related CV risk factors, which may further compound existing racial disparities in CVD among women Veterans.

Effect of Technology-Assisted Brief Abstinence Game on Long-term Smoking Cessation in Individuals Not Yet Ready to Quit: A Randomized Clinical Trial.

IMPORTANCE: Most trials of behavioral or pharmaceutical interventions for people who smoke are limited to individuals reporting they are ready to quit smoking. Engaging individuals who initially report they are not yet ready to quit in brief, precessation, skills-building interventions (eg, practice quit attempts or nicotine replacement therapy [NRT] sampling) is challenging. OBJECTIVE: To test an integrated behavioral plus NRT-sampling intervention using a gamification approach supported by mobile health. DESIGN, SETTING, AND PARTICIPANTS: A multisite randomized clinical trial with site-level 1-to-1 allocation into 2 conditions was conducted in 4 US health care systems. A total of 433 individuals who were currently smoking and reported at enrollment that they were not ready to quit smoking were enrolled. The study was conducted from November 7, 2016, to July 31, 2020. INTERVENTIONS: Take a Break (TAB) was a 3-week game experience and included 5 behavioral components (motivational messaging, challenge quizzes, brief abstinence goal setting, mobile health apps for cravings management, and reward points for participation) integrated with NRT sampling. TAB draws on social cognitive theory and game mechanics concepts to engage participants in health behavior change. The comparison included NRT sampling only. MAIN OUTCOMES AND MEASURES: Time to first quit attempt (duration from TAB experience to primary outcome) and carbon monoxide level-verified smoking cessation at 6-month follow-up. All analyses used an intention-to-treat approach. RESULTS: Of the 433 individuals included in the trial, 223 were women (52%); mean (SD) age was 54 (13) years. More than half (53% [112 of 213]) of the TAB participants completed 100% of the daily challenge quizzes in the first week, 73% (145 of 199) of participants who completed the goal-setting call set a brief abstinence goal (most frequently 1-2 days of abstinence from cigarettes), and 75% (159 of 213) of participants used the mobile health apps to manage nicotine cravings. Time to the first quit attempt was lower for the TAB vs comparison group (hazard ratio, 1.68; 95% CI, 1.09-2.60; P = .02). At the 6-month follow-up, 18% (28 of 160) of TAB participants and 10% (17 of 171) of the comparison (χ2 test, P = .045) participants obtained carbon monoxide level-verified smoking cessation (accounting for clustering of outcomes by site; odds ratio, 1.92; 95% CI, 1.01-3.68; P = .048). CONCLUSIONS AND RELEVANCE: The findings of this randomized clinical trial demonstrate that individuals not yet ready to quit smoking could be engaged in a brief abstinence game. Six months later, the TAB group had nearly double the rate of smoking cessation vs the NRT sampling comparison group. Integrating a skills-building game experience with brief NRT sampling can enhance long-term cessation among those not yet ready to quit smoking. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02973425.