Energy Dissipation of Fast Electrons in Polymethylmethacrylate: Toward a Universal Curve for Electron-Beam Attenuation in Solids between ∼0 eV and Relativistic Energies.

Spectroscopy of correlated electron pairs was employed to investigate the energy dissipation process, as well as the transport and the emission of low-energy electrons on a polymethylmethacrylate surface, providing secondary electron spectra causally related to the energy loss of the primary. Two groups are identified in the cascade of slow electrons, corresponding to different stages in the energy dissipation process. The characteristic lengths for attenuation due to collective excitations and momentum relaxation are quantified for both groups and are found to be distinctly different: λ_{1}=(12±2) Å and λ_{2}=(62±11) Å. The results strongly contradict the commonly employed model of exponential attenuation with the electron inelastic mean free path as characteristic length, but they essentially agree with a theory used for decades in astrophysics and neutron transport, albeit with characteristic lengths expressed in units of angstroms rather than light-years.

Enhancing Primary Care and Mental Health Integration for Women Veterans with Complex Healthcare Needs Using Evidence-Based Quality Improvement.

BACKGROUND: Women Veterans with co-morbid medical and mental health conditions face persistent barriers accessing high-quality health care. Evidence-based quality improvement (EBQI) offers a systematic approach to implementing new care models that can address care gaps for women Veterans. OBJECTIVE: This study examines factors associated with the successful deployment of EBQI within integrated health systems to improve primary care for women Veterans with complex mental health needs. DESIGN: Following a 12-site (8 EBQI, 4 control) cluster randomized study to evaluate EBQI effectiveness, we conducted an in-depth case study analysis of one women's health clinic that used EBQI to improve integrated primary care-mental health services for women Veterans. PARTICIPANTS: Our study sample included providers, program managers, and clinic staff at a women Veteran's health clinic that, at the time of the study, had one Primary Care and Mental Health Integration team and one women's health primary care provider serving 800 women. We analyzed interviews conducted 12 months, 24 months, and 4 years post-implementation and call summaries between the clinic and support team. MAIN MEASURES: We conducted qualitative thematic analysis of interview and call summary data to identify EBQI elements, clinic characteristics, and reported challenges and successes within project development and execution. KEY RESULTS: The clinic harnessed core EBQI elements (multi-level stakeholder engagement, data-driven progress-monitoring, PDSA cycles, sharing results) to accomplish pre-defined project goals, strengthen inter-disciplinary partnerships, and bolster team confidence. Clinic characteristics that facilitated implementation success included prior QI experience and an organizational culture responsive to innovation, while lack of pre-existing guidelines and limited access to centralized databases posed implementation challenges. CONCLUSIONS: Successful practice transformation emerges through the interaction of evidence-based methods and site-specific characteristics. Examining how clinic characteristics support or impede EBQI adaptation can facilitate efforts to improve care within integrated health systems.

Initial experience with a novel stent-based mechanical thrombectomy device for management of acute myocardial infarction cases with large thrombus burden.

BACKGROUND: Patients with acute myocardial infarction (AMI) and large thrombus burden (LTB) still represent a challenge. Afflicted patients have a high morbidity and mortality. Aspiration thrombectomy is often ineffective in those cases. Mechanical thrombectomy devices (MTDs), which are effective for management of ischemic strokes, were recently CE-approved for treatment of thrombotic coronary lesions. Real-world data about their performance in AMI cases with LTB are scarce. This study sought to summarize our early experience with a novel MTD device in this context. METHODS: We analyzed consecutive patients from the prospective OPTIMISER registry (NCT04988672), who have been managed with the NeVa™ MTD (Vesalio, USA) for AMI with LTB at a tertiary cardiology facility. Outcomes of interest included, among others, periprocedural complications, target lesion failure (TLF), target lesion revascularization (TLR) and target vessel myocardial infarction (TV-MI). RESULTS: Overall, 15 patients underwent thrombectomy with the NeVa™ device. Thrombectomy was successfully performed in 14 (93%) patients. Final TIMI 3 flow was achieved in 13 (87%) patients, while 2 (13%) patients had TIMI 2 flow. We encountered no relevant periprocedural complications, especially no stroke, stent thrombosis or vessel closure. After a mean follow-up time of 26 ± 2.9 months, 1 (7%) patient presented with TLR due to stent thrombosis (10 months after treatment with the MTD and stenting). CONCLUSIONS: In AMI patients with LTB, the deployment of the novel NeVa™ MTD seems efficient and safe. Further randomized trials are warranted to assess whether the use of the NeVa™ device in cases with LTB improves procedural and clinical outcomes.

Impact of Evidence-Based Quality Improvement on Tailoring VA's Patient-Centered Medical Home Model to Women Veterans' Needs.

BACKGROUND: Women Veterans' numerical minority, high rates of military sexual trauma, and gender-specific healthcare needs have complicated implementation of comprehensive primary care (PC) under VA's patient-centered medical home model, Patient Aligned Care Teams (PACT). OBJECTIVE: We deployed an evidence-based quality improvement (EBQI) approach to tailor PACT to meet women Veterans' needs and studied its effects on women's health (WH) care readiness, team-based care, and burnout. DESIGN: We evaluated EBQI effectiveness in a cluster randomized trial with unbalanced random allocation of 12 VAMCs (8 EBQI vs. 4 control). Clinicians/staff completed web-based surveys at baseline (2014) and 24 months (2016). We adjusted for individual-level covariates (e.g., years at VA) and weighted for non-response in difference-in-difference analyses for readiness and team-based care overall and by teamlet type (mixed-gender PC-PACTs vs. women-only WH-PACTs), as well as post-only burnout comparisons. PARTICIPANTS: We surveyed all clinicians/staff in general PC and WH clinics. INTERVENTION: EBQI involved structured engagement of multilevel, multidisciplinary stakeholders at network, VAMC, and clinic levels toward network-specific QI roadmaps. The research team provided QI training, formative feedback, and external practice facilitation, and support for cross-site collaboration calls to VAMC-level QI teams, which developed roadmap-linked projects adapted to local contexts. MAIN MEASURES: WH care readiness (confidence providing WH care, self-efficacy implementing PACT for women, barriers to providing care for women, gender sensitivity); team-based care (change-readiness, communication, decision-making, PACT-related QI, functioning); burnout. KEY RESULTS: Overall, EBQI had mixed effects which varied substantively by type of PACT. In PC-PACTs, EBQI increased self-efficacy implementing PACT for women and gender sensitivity, even as it lowered confidence. In contrast, in WH-PACTs, EBQI improved change-readiness, team-based communication, and functioning, and was associated with lower burnout. CONCLUSIONS: EBQI effectiveness varied, with WH-PACTs experiencing broader benefits and PC-PACTs improving basic WH care readiness. Lower confidence delivering WH care by PC-PACT members warrants further study. TRIAL REGISTRATION: The data in this paper represent results from a cluster randomized controlled trial registered in ClinicalTrials.gov (NCT02039856).

Practices Supporting Electronic Health Record Transitions: Lessons from Four US Healthcare Systems.

BACKGROUND: Electronic health record (EHR) transitions are common and complex organizational changes, yet limited published literature is available to guide health systems that are changing from one EHR to another. Clinicians and staff end users at sites that have undergone EHR transitions may have critical insights that could inform future transitions. OBJECTIVE: To assess end user perspectives on organizational practices that support successful EHR transitions. DESIGN: Multi-site qualitative study of end users at healthcare systems that transitioned to a new EHR (either Epic or Cerner) within the prior 3 years. PARTICIPANTS: Forty-two participants, including providers, clinical leaders, and informaticists at four geographically and organizationally diverse US healthcare systems. APPROACH: We conducted semi-structured telephone interviews, which were audio-recorded and transcribed. We used content analysis to identify key practices that influenced EHR transition success. KEY RESULTS: Participants described specific organizational practices that they found most helpful in supporting EHR transitions, and these practices transcended individual sites and EHR systems. We categorized practices based on how they were described relative to the stage of implementation. During pre-go-live, recommended practices included communicate rationale and anticipated outcomes of the EHR change; understand baseline workflows; and plan for appropriate customization. During go-live, recommended practices included personalize training and support; invest in robust internal support; reduce workload expectations; and proactively address challenges. The recommended post-go-live practice was to continue to invest in the change. CONCLUSIONS: Our findings may act as a roadmap for future EHR transitions by identifying specific and actionable organizational practices across stages of implementation. These recommendations highlight the role of health system leaders in preparing for the organizational change, working with and supporting end users, and addressing challenges that arise.

Software is Policy: Electronic Health Record Governance and the Implications of Clinical Standardization.

BACKGROUND: Electronic health record (EHR) implementations, whether replacing paper or electronic systems, are major social and organizational transformations. Yet studies of EHR-to-EHR transitions have largely neglected to elucidate accompanying social and organizational changes. One such underexplored change is the standardization of clinical practice in the context of EHR transitions. The Department of Veterans Affairs (VA) has begun a decade-long process of replacing the approximately 130 separate versions of its homegrown EHR with a single commercial EHR system. This provides an opportunity to explore the standardization of clinical practice amidst an EHR transition. OBJECTIVE: To identify, in the context of a large-scale EHR transition, (1) the scope and content of clinical standardization and (2) the anticipated implications of such standardization. DESIGN: Qualitative study. PARTICIPANTS: Twenty-nine members of VA councils established for the EHR transition. APPROACH: We conducted semi-structured interviews, which were professionally transcribed, and analyzed first using rapid analysis methods, followed by coding and content analysis. KEY RESULTS: Clinical standardization across facilities was a central goal of the EHR transition, encompassing computerized recommendations, order sets, professional roles/permissions, and clinical documentation. The anticipated implications of this standardization include (i) potential efficiency gains, with less duplicated effort across facilities; (ii) expanded bureaucracy; and (iii) increased uniformity, reducing both wanted and unwanted variation in care. CONCLUSIONS: EHR systems shape a wide range of clinical processes, particularly in a large organization like VA with a long history of EHR use. This makes standardization of EHR content a powerful mechanism for standardizing clinical practice itself, which can bring dramatic collateral consequences. Organizations undergoing EHR transitions need to recognize the important role that clinical standardization plays by treating EHR transitions as major organizational transformations in the governance of clinical practice.

Impacts of an Electronic Health Record Transition on Veterans Health Administration Health Professions Trainee Experience.

BACKGROUND: Adoption of electronic health care records (EHRs) has proliferated since 2000. While EHR transitions are widely understood to be disruptive, little attention has been paid to their effect on health professions trainees' (HPTs) ability to learn and conduct work. Veterans Health Administration's (VA) massive transition from its homegrown EHR (CPRS/Vista) to the commercial Oracle Cerner presents an unparalleled-in-scope opportunity to gain insight on trainee work functions and their ability to obtain requisite experience during transitions. OBJECTIVE: To identify how an organizational EHR transition affected HPT work and learning at the third VA go-live site. DESIGN: A formative mixed-method evaluation of HPT experiences with VHA's EHR transition including interviews with HPTs and supervisors at Chalmers P. Wylie VA Outpatient Clinic in Columbus, OH, before (~60 min), during (15-30 min), and after (~60 min) go-live (December 2021-July 2022). We also conducted pre- (March 2022-April 2022) and post-go live (May 2022-June 2022) HPT and employee surveys. PARTICIPANTS: We conducted 24 interviews with HPTs (n=4), site leaders (n=2), and academic affiliates (n=2) using snowball sampling. We recruited HPTs in pre- (n=13) and post-go-live (n=10) surveys and employees in pre- (n=408) and post-go-live (n=458) surveys. APPROACH: We conducted interviews using a semi-structured guide and grounded prompts. We coded interviews and survey free text data using a priori and emergent codes, subsequently conducting thematic analysis. We conducted descriptive statistical analysis of survey responses and merged interview and survey data streams. KEY RESULTS: Our preliminary findings indicate that the EHR transition comprehensively affected HPT experiences, disrupting processes from onboarding and training to clinical care contributions and training-to-career retention. CONCLUSIONS: Understanding HPTs' challenges during EHR transitions is critical to effective training. Mitigating the identified barriers to HPT training and providing patient care may lessen their dissatisfaction and ensure quality patient care during EHR transitions.

"Everything's so Role-Specific": VA Employee Perspectives' on Electronic Health Record (EHR) Transition Implications for Roles and Responsibilities.

BACKGROUND: Electronic health record (EHR) transitions are increasingly widespread and often highly disruptive. It is imperative we learn from past experiences to anticipate and mitigate such disruptions. Veterans Affairs (VA) is undergoing a large-scale transition from its homegrown EHR (CPRS/Vista) to a commercial EHR (Cerner), creating a unique opportunity of shedding light on large-scale EHR-to-EHR transition challenges. OBJECTIVE: To explore one facet of the organizational impact of VA's EHR transition: its implications for employees' roles and responsibilities at the first VA site to implement Cerner Millennium EHR. DESIGN: As part of a formative evaluation of frontline staff experiences with VA's EHR transition, we conducted brief (~ 15 min) and full-length interviews (~ 60 min) with clinicians and staff at Mann-Grandstaff VA Medical Center in Spokane, WA, before, during, and after transition (July 2020-November 2021). PARTICIPANTS: We conducted 111 interviews with 26 Spokane clinicians and staff, recruited via snowball sampling. APPROACH: We conducted audio interviews using a semi-structured guide with grounded prompts. We coded interview transcripts using a priori and emergent codes, followed by qualitative content analysis. KEY RESULTS: Unlike VA's previous EHR, Cerner imposes additional restrictions on access to its EHR functionality based upon "roles" assigned to users. Participants described a mismatch between established institutional duties and their EHR permissions, unanticipated changes in scope of duties brought upon by the transition, as well as impediments to communication and collaboration due to different role-based views. CONCLUSIONS: Health systems should anticipate substantive impacts on professional workflows when EHR role settings do not reflect prior workflows. Such changes may increase user error, dissatisfaction, and patient care disruptions. To mitigate employee dissatisfaction and safety risks, health systems should proactively plan for and communicate about expected modifications and monitor for unintended role-related consequences of EHR transitions, while vendors should ensure accurate role configuration and assignment.

From "Local Control" to "Dependency": Transitions to Single-Vendor Integrated Electronic Health Record Systems and Their Implications for the EHR Workforce.

BACKGROUND: Healthcare systems that previously used either a single legacy electronic health record (EHR) system or a "best-of-breed" combination of products from multiple vendors are increasingly adopting integrated, single-vendor EHR systems. Though healthcare leaders are beginning to recognize the dramatic collateral consequences of these transitions, their impact on the EHR workforce - internal actors most closely involved in governing and supporting the EHR - is poorly understood. OBJECTIVE: Identify perceived impacts of adopting single-vendor, integrated EHR systems on the institutional EHR workforce. DESIGN: In this qualitative study, we conducted semi-structured phone interviews in four healthcare systems in the USA that had adopted an integrated EHR within the previous five years. PARTICIPANTS: Forty-two staff members of four geographically and organizationally diverse healthcare systems, including 22 individuals with formal informatics roles. APPROACH: Transcribed interviews were coded and analyzed using qualitative content analysis methods. KEY RESULTS: Across organizations, participants described a loss of autonomy by the EHR workforce at the individual and institutional level following the adoption of an integrated EHR. We also identified references to transformations in four key professional functions of the EHR workforce: communication, governance, optimization, and education. CONCLUSIONS: Transitions to integrated EHR systems can have important implications for the autonomy and professional functions of the EHR workforce. These findings may help institutions embarking on similar transitions better anticipate and prepare for these changes through such practices as revising job descriptions, strengthening EHR governance structures, and reinforcing pathways to engage frontline clinicians in supporting the EHR. Findings may also help institutions structure vendor contracts in a way that anticipates and mitigates loss of autonomy.

Transitioning from One Electronic Health Record to Another: A Systematic Review.

BACKGROUND: Transitioning to a new electronic health record (EHR) presents different challenges than transitions from paper to electronic records. We synthesized the body of peer-reviewed literature on EHR-to-EHR transitions to evaluate the generalizability of published work and identify knowledge gaps where more evidence is needed. METHODS: We conducted a broad search in PubMed through July 2022 and collected all publications from two prior reviews. Peer-reviewed publications reporting on data from an EHR-to-EHR transition were included. We extracted data on study design, setting, sample size, EHR systems involved, dates of transition and data collection, outcomes reported, and key findings. RESULTS: The 40 included publications were grouped into thematic categories for narrative synthesis: clinical care outcomes (n = 15), provider perspectives (n = 11), data migration (n = 8), patient experience (n = 4), and other topics (n = 5). Many studies described single sites that are early adopters of technology with robust research resources, switching from a homegrown system to a commercial system, and emphasized the dynamic effect of transitioning on important clinical care and other outcomes over time. DISCUSSION: The published literature represents a heterogeneous mix of study designs and outcome measures, and while some of the stronger studies in this review used longitudinal approaches to compare outcomes across more sites, the current literature is primarily descriptive and is not designed to offer recommendations that can guide future EHR transitions. Transitioning from one EHR to another constitutes a major organizational change that requires nearly every person in the organization to change how they do their work. Future research should include human factors as well as diverse methodological approaches such as mixed methods and implementation science.

Cerner Millennium's Care Pathways for Specialty Care Referrals: Provider and Nurse Experiences, Perceptions, and Recommendations for Improvements.

BACKGROUND: Using structured templates to guide providers in communicating key information in electronic referrals is an evidence-based practice for improving care quality. To facilitate referrals in Veterans Health Administration's (VA) Cerner Millennium electronic health record, VA and Cerner have created "Care Pathways"-templated electronic forms, capturing needed information and prompting ordering of appropriate pre-referral tests. OBJECTIVE: To inform their iterative improvement, we sought to elicit experiences, perceptions, and recommendations regarding Care Pathways from frontline clinicians and staff in the first VA site to deploy Cerner Millennium. DESIGN: Qualitative interviews, conducted 12-20 months after Cerner Millennium deployment. PARTICIPANTS: We conducted interviews with primary care providers, primary care registered nurses, and specialty providers requesting and/or receiving referrals. APPROACH: We used rapid qualitative analysis. Two researchers independently summarized interview transcripts with bullet points; summaries were merged by consensus. Constant comparison was used to sort bullet points into themes. A matrix was used to view bullet points by theme and participant. RESULTS: Some interviewees liked aspects of the Care Pathways, expressing appreciation of their premise and logic. However, interviewees commonly expressed frustration with their poor usability across multiple attributes. Care Pathways were reported as being inefficient; lacking simplicity, naturalness, consistency, and effective use of language; imposing an unacceptable cognitive load; and not employing forgiveness and feedback for errors. Specialists reported not receiving the information needed for referral triaging. CONCLUSIONS: Cerner Millennium's Care Pathways, and their associated organizational policies and processes, need substantial revision across several usability attributes. Problems with design and technical limitations are compounding challenges in using standardized templates nationally, across VA sites having diverse organizational and contextual characteristics. VA is actively working to make improvements; however, significant additional investments are needed for Care Pathways to achieve their intended purpose of optimizing specialty care referrals for Veterans.

"Like One Long Battle:" Employee Perspectives of the Simultaneous Impact of COVID-19 and an Electronic Health Record Transition.

BACKGROUND: Healthcare organizations regularly manage external stressors that threaten patient care, but experiences handling concurrent stressors are not well characterized. OBJECTIVE: To evaluate the experience of Veterans Affairs (VA) clinicians and staff navigating simultaneous organizational stressors-an electronic health record (EHR) transition and the COVID-19 pandemic-and identify potential strategies to optimize management of co-occurring stressors. DESIGN: Qualitative case study describing employee experiences at VA's initial EHR transition site. PARTICIPANTS: Clinicians, nurses, allied health professionals, and local leaders at VA's initial EHR transition site. APPROACH: We collected longitudinal qualitative interview data between July 2020 and November 2021 once before and 2-4 times after the date on which the health system transitioned; this timing corresponded with local surges of COVID-19 cases. Interviewers conducted coding and analysis of interview transcripts. For this study, we focused on quotes related to COVID-19 and performed content analysis to describe recurring themes describing the simultaneous impact of COVID-19 and an EHR transition. KEY RESULTS: We identified five themes related to participants' experiences: (1) efforts to mitigate COVID-19 transmission led to insufficient access to EHR training and support, (2) clinical practice changes in response to the pandemic impacted EHR workflows in unexpected ways, (3) lack of clear communication and inconsistent enforcement of COVID-19 policies intensified pre-existing frustrations with the EHR, (4) managing concurrent organizational stressors increased work dissatisfaction and feelings of burnout, and (5) participants had limited bandwidth to manage competing demands that arose from concurrent organizational stressors. CONCLUSION: The expected challenges of an EHR transition were compounded by co-occurrence of the COVID-19 pandemic, which had negative impacts on clinician experience and patient care. During simultaneous organizational stressors, health care facilities should be prepared to address the complex interplay of two stressors on employee experience.

Improving primary care team functioning through evidence based quality improvement: A comparative case study.

BACKGROUND: Provision of team-based primary care (PC) is associated with improved care quality, but limited empirical evidence guides practices on how to optimize team functioning. We examined how evidence-based quality improvement (EBQI) was used to change PC team processes. EBQI activities were supported by research-clinical partnerships and included multilevel stakeholder engagement, external facilitation, technical support, formative feedback, QI training, local QI development and across-site collaboration to share proven practices. METHODS: We used a comparative case study in two VA medical centers (Sites A and B) that engaged in EBQI between 2014 and 2016. We analyzed multiple qualitative data sources: baseline and follow-up interviews with key stakeholders and provider team ("teamlet") members (n = 64), and EBQI meeting notes, reports, and supporting materials. RESULTS: Site A's QI project entailed engaging in structured daily huddles using a huddle checklist and developing a protocol clarifying team member roles and responsibilities; Site B initiated weekly virtual team meetings that spanned two practice locations. Respondents from both sites perceived these projects as improving team structure and staffing, team communications, role clarity, staff voice and personhood, accountability, and ultimately, overall team functioning over time. CONCLUSION: EBQI enabled local QI teams and other stakeholders to develop and implement innovations to improve PC team processes and characteristics in ways that improved teamlet members' perceptions of team functioning. IMPLICATIONS: EBQI's multi-level approach may empower staff and facilitate innovation by and within teams, making it an effective implementation strategy for addressing unique practice-based challenges and supporting improvements in team functioning across varied clinical settings. LEVEL OF EVIDENCE: VI.

Engaging Veterans With Serious Mental Illness in Primary Care.

Background: Veterans with serious mental illness (SMI) are at substantial risk for premature mortality. Engagement in primary care can mitigate these mortality risks. However, veterans with SMI often become disengaged from primary care. The US Department of Veterans Affairs (VA) measures and reports at VA facilities primary care engagement among enrolled veterans with SMI. This quarterly metric enables VA facilities to identify targets for quality improvement and track their progress. To inform quality improvement at our VA facility, we sought to identify promising practices for supporting engagement in primary care among veterans with SMI. Methods: We conducted semistructured telephone interviews from May 2019 through July 2019 with a purposeful sample of key informants at VA facilities with high levels of engagement in primary care among veterans with SMI. All interviews were recorded, summarized using a structured template, and summaries placed into a matrix. An interdisciplinary team reviewed and discussed matrices to identify and build consensus around findings. Results: We interviewed 18 key informants from 11 VA facilities. The strategies used to engage veterans with SMI fell into 2 general categories: targeted outreach and routine practices. Targeted outreach included proactive, deliberate, systematic approaches for identifying and contacting veterans with SMI who are at risk of disengaging from care. In targeted outreach, veterans were identified and prioritized for outreach independent of any visits with mental health or other VA services. Routine practices included activities embedded in regular clinical workflows at the time of veterans' mental health visits, assessing, and connecting/reconnecting veterans with SMI into primary care. In addition, we identified extensive formal and informal ties between mental health and primary care that facilitated engaging veterans with SMI in primary care. Conclusions: VA facilities with high levels of primary care engagement among veterans with SMI used extensive engagement strategies, including a diverse array of targeted outreach and routine practices. Intentionally designed organizational structures and processes and facilitating extensive formal and informal ties between mental health and primary care teams supported these efforts. Additional organizational cultural factors were especially relevant to routine practice strategies. The practices we identified should be evaluated empirically for their effects on establishing and maintaining engagement in primary care among veterans with SMI.

Women Veterans' Healthcare Needs, Utilization, and Preferences in Veterans Affairs Primary Care Settings.

BACKGROUND: The Veterans Health Administration (VA) is the largest integrated health system in the US and provides access to comprehensive primary care. Women Veterans are the fastest growing segment of new VA users, yet little is known about the characteristics of those who routinely access VA primary care in general or by age group. OBJECTIVE: Describe healthcare needs, utilization, and preferences of women Veterans who routinely use VA primary care. PARTICIPANTS: 1,391 women Veterans with 3+ primary care visits within the previous year in 12 VA medical centers (including General Primary Care Clinics, General Primary Care Clinics with designated space for women, and Comprehensive Women's Health Centers) in nine states. METHODS: Cross-sectional survey (45% response rate) of sociodemographic characteristics, health status (including chronic disease, mental health, pain, and trauma exposure), utilization, care preferences, and satisfaction. Select utilization data were extracted from administrative data. Analyses were weighted to the population of routine users and adjusted for non-response in total and by age group. KEY RESULTS: While 43% had health coverage only through VA, 62% received all primary care in VA. In the prior year, 56% used VA mental healthcare and 78% used VA specialty care. Common physical health issues included hypertension (42%), elevated cholesterol (39%), pain (35%), and diabetes (16%). Many screened positive for PTSD (41%), anxiety (32%), and depression (27%). Chronic physical and mental health burdens varied by age. Two-thirds (62%) had experienced military sexual trauma. Respondents reported satisfaction with VA women's healthcare and preference for female providers. CONCLUSIONS: Women Veterans who routinely utilize VA primary care have significant multimorbid physical and mental health conditions and trauma histories. Meeting women Veterans' needs across the lifespan will require continued investment in woman-centered primary care, including integrated mental healthcare and emphasis on trauma-informed, age-specific care, guided by women's provider preferences.

What Drives Women Veterans' Trust in VA Healthcare Providers?

INTRODUCTION: Little is known about women veterans' trust in Veterans Affairs (VA) health care and what factors promote trust in VA providers. We examined provider behaviors and characteristics of women veterans associated with trust in their VA providers. METHODS: We used a 2015 survey of women veterans who were routine users of primary care at 12 VA medical centers (n = 1,395). Patient trust in their VA provider was measured on a seven-item scale. We used multiple logistic regression to examine associations of patient-provider communication and gender appropriateness with complete trust in VA provider (100 [complete trust] vs. <100 [less than complete trust]), controlling for patient characteristics. RESULTS: On average, 39.7% of women veterans reported complete trust in their VA providers. Those with complete trust reported greater patient-provider communication and gender appropriateness of VA services than those with less-than-complete trust (all ps ≤ .001). In multiple logistic regression models, higher ratings of provider communication (adjusted odds ratio, 2.37), gender-appropriate care (adjusted odds ratio, 1.93), and trauma-sensitive communication (adjusted odds ratios, 1.79-6.08) were associated with a higher likelihood of reporting complete trust in their VA provider. CONCLUSIONS: Women veterans reported high levels of trust in their VA providers. Provider communication, gender-appropriate care, and trauma-sensitive communication were associated with greater patient trust. Although it is important to highlight the steps already taken by VA to increase the quality of care for women veterans, current findings suggest that women veterans' trust may be further increased by interventions to improve trauma-informed care by VA providers.

The Relationship Between Sexual Assault History and Cervical Cancer Screening Completion Among Women Veterans in the Veterans Health Administration.

Background: Sexual assault affects one in three U.S. women and may have lifelong consequences for women's health, including potential barriers to completing cervical cancer screening and more than twofold higher cervical cancer risk. The objective of this study was to determine whether a history of sexual assault is associated with reduced cervical cancer screening completion among women Veterans. Materials and Methods: We analyzed data from a 2015 survey of women Veterans who use primary care or women's health services at 12 Veterans Health Administration facilities (VA's) in nine states. We linked survey responses with VA electronic health record data and used logistic regression to examine the association of lifetime sexual assault with cervical cancer screening completion within a guideline-concordant interval. Results: The sample included 1049 women, of whom 616 (58.7%) reported lifetime sexual assault. Women with a history of sexual assault were more likely to report a high level of distress related to pelvic examinations, and to report ever delaying a gynecologic examination due to distress. However, in the final adjusted model, lifetime sexual assault was not significantly associated with reduced odds of cervical cancer screening completion (OR 1.35, 95% CI 0.93-1.97). Conclusions: Contrary to our expectations, sexual assault was not significantly associated with gaps in cervical cancer screening completion. Three- to five-year screening intervals may provide sufficient time to complete screening, despite barriers. Trauma-sensitive care practices promoted in the VA may allow women to overcome the distress and discomfort of pelvic examinations to complete needed screening. ClinicalTrials.gov (#NCT02039856).

Implementing clinical decision support for reducing women Veterans' cardiovascular risk in VA: A mixed-method, longitudinal study of context, adaptation, and uptake.

Evaluations of clinical decision support (CDS) implementation often struggle to measure and explain heterogeneity in uptake over time and across settings, and to account for the impact of context and adaptation on implementation success. In 2017-2020, the EMPOWER QUERI implemented a cardiovascular toolkit using a computerized template aimed at reducing women Veterans' cardiovascular risk across five Veterans Healthcare Administration (VA) sites, using an enhanced Replicating Effective Programs (REP) implementation approach. In this study, we used longitudinal joint displays of qualitative and quantitative findings to explore (1) how contextual factors emerged across sites, (2) how the template and implementation strategies were adapted in response to contextual factors, and (3) how contextual factors and adaptations coincided with template uptake across sites and over time. We identified site structure, staffing changes, relational authority of champions, and external leadership as important contextual factors. These factors gave rise to adaptations such as splitting the template into multiple parts, pairing the template with a computerized reminder, conducting academic detailing, creating cheat sheets, and using small-scale pilot testing. All five sites exhibited variability in utilization over the months of implementation, though later sites exhibited higher template utilization immediately post-launch, possibly reflecting a "preloading" of adaptations from previous sites. These findings underscore the importance of adaptive approaches to implementation, with intentional shifts in intervention and strategy to meet the needs of individual sites, as well as the value of integrating mixed-method data sources in conducting longitudinal evaluation of implementation efforts.

Nonclassical Recrystallization.

Applications in the fields of materials science and nanotechnology increasingly demand monodisperse nanoparticles in size and shape. Up to now, no general purification procedure exists to thoroughly narrow the size and shape distributions of nanoparticles. Here, we show by analytical ultracentrifugation (AUC) as an absolute and quantitative high-resolution method that multiple recrystallizations of nanocrystals to mesocrystals is a very efficient tool to generate nanocrystals with an excellent and so-far unsurpassed size-distribution (PDIc =1.0001) and shape. Similar to the crystallization of molecular building blocks, nonclassical recrystallization removes "colloidal" impurities (i.e., nanoparticles, which are different in shape and size from the majority) by assembling them into a mesocrystal. In the case of nanocrystals, this assembly can be size- and shape-selective, since mesocrystals show both long-range packing ordering and preferable crystallographic orientation of nanocrystals. Besides the generation of highly monodisperse nanoparticles, these findings provide highly relevant insights into the crystallization of mesocrystals.