Providers' Shift to Telerehabilitation at the U.S. Veterans Health Administration During COVID-19: Practical Applications.

Telerehabilitation provides Veteran patients with necessary rehabilitation treatment. It enhances care continuity and reduces travel time for Veterans who face long distances to receive care at a Veterans Health Administration (VHA) medical facility. The onset of the COVID-19 pandemic necessitated a sudden shift to telehealth-including telerehabilitation, where a paucity of data-driven guidelines exist that are specific to the practicalities entailed in telerehabilitation implementation. This paper explicates gains in practical knowledge for implementing telerehabilitation that were accelerated during the rapid shift of VHA healthcare from out-patient rehabilitation services to telerehabilitation during the COVID-19 pandemic. Group and individual interviews with 12 VHA rehabilitation providers were conducted to examine, in-depth, the providers' implementation of telerehabilitation. Thematic analysis yielded nine themes: (i) Willingness to Give Telerehabilitation a Chance: A Key Ingredient; (ii) Creativity and Adaptability: Critical Attributes for Telerehabilitation Providers; (iii) Adapting Assessments; (iv) Adapting Interventions; (v) Role and Workflow Adaptations; (vi) Appraising for Self the Feasibility of the Telerehabilitation Modality; (vii) Availability of Informal, In-Person Support Improves Feasibility of Telerehabilitation; (viii) Shifts in the Expectations by the Patients and by the Provider; and (ix) Benefit and Anticipated Future of Telerehabilitation. This paper contributes an in-depth understanding of clinical reasoning considerations, supportive strategies, and practical approaches for engaging Veterans in telerehabilitation.

Feasibility and acceptability of a telephone and web-based stroke caregiver intervention: a pilot randomized controlled trial of the RESCUE intervention.

OBJECTIVE: Assess the feasibility and acceptability of an Internet and telephone support and problem-solving intervention for stroke caregivers. DESIGN: Randomized controlled pilot trial with four arms: four-week intervention (n = 13), eight-week intervention (n = 13), eight-week attention control (n = 13), and standard care (n = 14). SETTING: Southeastern U.S. Veterans Health System. PARTICIPANTS: Informal caregivers of Veterans who suffered a stroke in the preceding 2.5 years were enrolled over an 18-month period. INTERVENTIONS: Intervention participants received RESCUE, a support and problem-solving intervention delivered via telephone and Internet by registered nurses. Attention control participants received active listening with no advice delivered by nurses via telephone. MAIN MEASURES: Feasibility of a larger trial was assessed via recruitment and retention. Acceptability was assessed using an adapted enactment tool and qualitative interviews. Changes in caregiver depressive symptoms and burden were measured by the Center for Epidemiologic Studies Depression Scale and Zarit Burden Interview. The study was not powered for significance testing. RESULTS: Of 340 eligible caregivers, 53 (16%) agreed to participate. Among those enrolled, 51 (96%) completed the study. Caregiver mean age was 60.3 (10.1), 49 (93%) were female and 36 (68%) were white. At baseline, 21 (39%) caregivers had high risk of depression and 18 (33%) had significant burden. Acceptability and enactment tool findings indicated positive participant responses to the intervention. Most rated the amount of sessions the "right amount". Qualitative analysis revealed the intervention was valued by and acceptable to caregivers. CONCLUSIONS: Findings indicate the RESCUE intervention is feasible and acceptable to caregivers and warrants further testing.

Telerehabilitation for Rural Veterans: A Qualitative Assessment of Barriers and Facilitators to Implementation.

PURPOSE: Telerehabilitation (TR) is increasingly being used to meet the rehabilitation needs of individuals living in rural areas. Nevertheless, reports on TR implementation for rural patients remain limited. As part of a broader evaluation, this study investigated barriers and facilitators to the implementation of a national TR program to meet the needs of rural Veterans Health Administration (VHA) patients. METHODS: This study applied a qualitative approach to the RE-AIM framework to investigate barriers and facilitators impacting TR implementation. We conducted in-depth, semi-structured interviews with ten program managers and medical directors within the VHA at three time points during the first 18 months of implementation. Interviews were analyzed using thematic analysis. RESULTS: Three themes were identified describing key cultural, infrastructural and logistical, and environmental barriers impacting the reach, adoption, and implementation of TR. Within the themes, facilitators for TR were also identified to include, allowing providers flexibility in implementing TR, mentorship and development of creative approaches to TR training, overcoming infrastructural and logistical TR barriers through championing, and continuous sharing of lessons learned in a community of practice. DISCUSSION: This study explicates salient barriers and facilitators encountered during the first 18 months of implementation of a TR program within a national healthcare system in the United States. Implementing TR to meet the rehabilitation needs of Veterans in resource-limited rural environments requires creative approaches and flexibility, as well as perseverance and consistent championing in order to overcome cultural challenges. This, in combination with infrastructural challenges, such as lack of broadband, adds greater complexity to meeting the needs of rural patients. This study provides new and in-depth understanding of the processes by which TR is implemented in a large healthcare system and points to practical real-world lessons in implementing TR for rural patients.

Health care workers' perceptions and reported use of respiratory protective equipment: A qualitative analysis.

BACKGROUND: Little is known about health care workers' (HCW) perceptions of, or experiences using, respiratory protective equipment (RPE). We sought to characterize their perceptions and identify reasons underlying inappropriate use. METHODS: We conducted 12 focus groups with nurses and nursing assistants at 4 medical centers. We analyzed the thematic content of 73 discrete "stories" told by focus group participants. RESULTS: We identified 5 story types surrounding RPE use: 1) policies are known and seen during work routines; 2) during protocol lapses, use is reinforced through social norms; 3) clinical experiences sometimes supersede protocol adherence; 4) when risk perception is high, we found concern regarding accessing RPE; and 5) HCWs in emergency departments were viewed as not following protocol because risk was ever-present. DISCUSSION: HCWs were aware of the importance of RPE and protocols for using it, and these supported use when protocol lapses occurred. However, protocol adherence was undermined by clinical experience, perceived risk, and the distinct context of the emergency department where patients continually arrive with incomplete or delayed diagnoses. CONCLUSIONS: Protocols, visual cues, and social norms contribute to a culture of safety. This culture can be undermined when HCWs experience diagnostic uncertainty or they mistrust the protocol and instead rely on their clinical experiences.

Trends in VA Telerehabilitation Patients and Encounters Over Time and by Rurality.

Telerehabilitation fills a need and helps ensure treatment adherence for rural and other veterans who find it difficult to access health care.

A tolerability assessment of new respiratory protective devices developed for health care personnel: A randomized simulated clinical study.

BACKGROUND: U.S. health care personnel (HCP) have reported that some respiratory protective devices (RPD) commonly used in health care have suboptimal tolerability. Between 2012 and 2016, the U.S. National Institute for Occupational Safety and Health, and the Veterans Health Administration collaborated with two respirator manufacturers, Company A and B, to bring new RPD with improved tolerability to the U.S. health care marketplace. The purpose of this study was to compare the tolerability of four new prototype RPD to two models commonly used in U.S. health care delivery. METHODS: A randomized, simulated workplace study was conducted to compare self-reported tolerability of four new prototype RPD (A1, A2, B1, and B2) worn by HCP and two N95 control respirators commonly used in U.S. health care delivery, the 1870 and 1860, manufactured by 3M Corporation. A new survey tool, the Respirator Comfort, Wearing Experience, and Function Instrument (R-COMFI), developed previously in part for the current study, was used as the primary outcome metric. With a maximum total score of 47, lower R-COMFI scores reflected better self-reported tolerability. Poisson regression analyses were used to estimate prototype relative risks compared to controls. RESULTS: Conducted between 2014 and 2015 in two inpatient care rooms at the North Florida/South Georgia Veterans Health System, among 383 participants who enrolled, 335 (87.5%) completed the study. Mean total R-COMFI scores for the 3M 1870, 3M 1860, and prototypes A1, A2, B1, and B2 were 8.26, 9.36, 5.79, 7.70, 6.09, and 5.71, respectively. Compared to the 3M 1870, total R-COMFI unadjusted relative risks (RR) and 95 percent confidence intervals (CI) were A1 (RR 0.70, CI 0.60, 0.82), A2 (RR 0.93, CI 0.82, 1.06), B1 (RR 0.74, CI 0.64, 0.85), and B2 (RR 0.69, CI 0.60, 0.80). Compared to the 3M 1860, prototype total R-COMFI unadjusted RR and 95 percent CI were A1 (RR 0.62, CI 0.53, 0.72), A2 (RR 0.82, CI 0.73, 0.93), B1 (RR 0.65, CI 0.57, 0.74), and B2 (RR 0.61, CI 0.53, 0.70). Similarly, models adjusted for demographic characteristics showed that prototypes A1, B1, and B2 significantly improved tolerability scores compared to both controls, while prototype A2 was significantly improved compared to the 3M 1860. CONCLUSIONS: Compared to the 3M 1870 and 3M 1860, two RPDs commonly used in U.S. health care delivery, tolerability improved for three of four newly developed prototypes in this simulated workplace study. The R-COMFI tool, used in this study to assess tolerability, should be useful for future comparative studies of RPD.

Epidemiology of nontuberculous mycobacterial infections in the U.S. Veterans Health Administration.

OBJECTIVE: We identified patients with non-tuberculous mycobacterial (NTM) disease in the US Veterans Health Administration (VHA), examined the distribution of diseases by NTM species, and explored the association between NTM disease and the frequency of clinic visits and mortality. METHODS: We combined mycobacterial isolate (from natural language processing) with ICD-9-CM diagnoses from VHA data between 2008 and 2012 and then applied modified ATS/IDSA guidelines for NTM diagnosis. We performed validation against a reference standard of chart review. Incidence rates were calculated. Two nested case-control studies (matched by age and location) were used to measure the association between NTM disease and each of 1) the frequency of outpatient clinic visits and 2) mortality, both adjusted by chronic obstructive pulmonary disease (COPD), other structural lung diseases, and immunomodulatory factors. RESULTS: NTM cases were identified with a sensitivity of 94%, a specificity of >99%. The incidence of NTM was 12.6/100k patient-years. COPD was present in 68% of pulmonary NTM. NTM incidence was highest in the southeastern US. Extra-pulmonary NTM rates increased during the study period. The incidence rate ratio of clinic visits in the first year after diagnosis was 1.3 [95%CI 1.34-1.35]. NTM patients had a hazard ratio of mortality of 1.4 [95%CI 1.1-1.9] in the 6 months after NTM identification compared to controls and 1.99 [95%CI 1.8-2.3] thereafter. CONCLUSIONS: In VHA, pulmonary NTM disease is commonly associated with COPD, with the highest rates in the southeastern US. After adjustment, NTM patients had more clinic visits and greater mortality compared to matched patients.

Healthy lifestyles and health-related quality of life among men living with HIV infection.

Although healthy lifestyles are related to improved quality of life in the general population, little is known about the role of healthy lifestyles during HIV infection. The authors examined the relationships between health-promoting behaviors, risk behaviors, stress, and health-related quality of life (HRQOL) among 226 men with HIV infection who were attending three infectious disease clinics. As hypothesized, health-promoting behaviors were positively related and stress was negatively related with most of the HRQOL dimensions. Contrary to the hypothesis, tobacco use, recreational drug use, and unsafe sexual behaviors were not related to the HRQOL dimensions. Hazardous alcohol use was negatively associated with one HRQOL dimension--social functioning. The association of modifiable factors, such as health-promoting behaviors and stress, with HQROL offers opportunities for improving HIV-related health care. Relatively simple, straightforward changes in lifestyles such as eating well, remaining active, and avoiding stressful life events may result in improvements in HRQOL.

Identifying veterans with acute strokes with high-specificity ICD-9 algorithm with VA automated records and Medicare claims data: a more complete picture.

Medicare claims data are available to Department of Veterans Affairs (VA) researchers to identify veterans with acute stroke. Our study sought to (1) ascertain whether additional acute stroke cases are identified with Medicare data and (2) assess the use of VA and Medicare inpatient automated data for assigning the stroke date. The study population was veterans living in Veterans Integrated Service Network 8 with an acute stroke diagnosis during fiscal year 2001. High-sensitivity and high-specificity algorithms were applied to VA data sets and matched with Medicare files. We confirmed acute stroke cases and index dates using the VA Computerized Patient Record System (CPRS). VA data identified 582 veterans with acute stroke, but Medicare claims data identified 201 more such veterans. CPRS confirmed 94% of the VA and 77% of the Medicare cases. The median difference between CPRS and automated index dates was 11 days for VA and 4 days for Medicare data. Use of both VA and Medicare data provides a more complete sample of veterans with acute stroke.

A further investigation of health-related quality of life over time among men with HIV infection in the HAART era.

This is the third study in a line of research which is designed to increase scientific understanding of the predictors of health-related quality of life (HRQOL) among men with HIV infection using data collected in large, prospective cohort study. Building on two prior investigations, this study examined the time-dependent relationships of psychosocial and clinical variables (active coping strategies, social support, CD4 cell count, comorbidity, and duration of HIV infection) and 10 HRQOL dimensions at two time points (baseline and 12 months). Using linear mixed models, we found that most relationships between the psychosocial and clinical variables and HRQOL dimensions were consistent across time. However, there were interactions between time and CD4 cell count and some HRQOL dimensions. Specifically, increased active coping and social support were positively related, whereas more comorbid conditions and longer HIV infection duration were negatively related with multiple HRQOL dimensions at both baseline and 12 months. CD4 cell count was positively associated with emotional well-being at both time points, but the associations between CD4 cell count and five HRQOL dimensions were negative at baseline but positive at 12 months. These findings provide additional support for the recommendation that clinicians and health planners should continually strive to enhance active coping strategies and social support, manage comorbid conditions, and incorporate duration of HIV diagnoses in their treatment plans. Because the relationships between CD4 cell count and HRQOL dimensions varied over time, it is important to recognize that results from laboratory tests (i.e., CD4 cell count) may have differential quality of life implications for patients at various times in their disease trajectories.

Oxidative stress and antioxidant capacity in smoking and nonsmoking men with HIV/acquired immunodeficiency syndrome.

BACKGROUND: Past studies document decreased levels of antioxidants and selenium and increased levels of oxidative stress in people living with HIV/acquired immunodeficiency syndrome (AIDS). Cigarette smoking is another source of oxidative stress. Excessive oxidative stress can induce HIV replication, resulting in disease progression. The purpose of this study was to determine whether subjects with HIV/AIDS who smoke cigarettes have increased oxidative stress and decreased antioxidant status compared with nonsmokers with HIV/AIDS. METHODS: Thirty-one men with HIV/AIDS (adhering to highly active antiretroviral therapy for the previous 3 months) were recruited during regular visits to a Veterans Affairs Medical Center Infectious Disease Clinic in a southeastern US city. Plasma was obtained from a 1-time blood draw for this comparison study. Plasma lipid peroxide (LPO) was used as a marker of oxidative stress. Indicators of antioxidant capacity included plasma glutathione peroxidase (GPx, the functional indicator of selenium status), vitamin C, and antioxidant potential (AOP). RESULTS: Fifteen smokers and 10 nonsmokers with HIV/AIDS were enrolled. Median plasma LPO level was above the normal range of 0-1.3 micromol/L in both nonsmokers (2.5 [0-23.4] micromol/L, median [range]) and smokers (4.0 [0-47.5] micromol/L), but there was no difference between groups. Plasma GPx concentration was significantly lower in smokers (169 [118-295] mumol/min/L) compared with nonsmokers (197 [149-414] micromol/min/L). Vitamin C and AOP levels were not different between groups. CONCLUSIONS: This pilot study suggests that effects of smoking on oxidative stress are not additive, as no striking differences were observed in oxidative stress or antioxidant capacity between clinically stable smoking and nonsmoking men with HIV/AIDS.

Health-related quality of life among men with HIV infection: effects of social support, coping, and depression.

In a prospective cohort study, baseline data were collected on 226 males with HIV infection attending three infectious disease clinics in a southern state. As a result of advances in HIV treatment, understanding the association between psychosocial factors and health-related quality of life has become an important area of study. The purpose of this study was to assess the total effects of social support and coping as well as the direct and indirect effects of these factors through depression on health-related quality of life. Subjects were interviewed and answered the following standardized questionnaires: The HIV Cost and Services Utilization Study tool, Coping with HIV Questionnaire, Social Support Appraisals Scale, and Centers for Epidemiological Studies Depression instrument. Path models with strictly ordered relationships were fitted to study the effects of the psychosocial variables on each quality of life subscale. We found that coping and social support had total effects on some, but not all dimensions of health-related quality of life, whereas depression was associated with all dimensions of health-related quality of life. Furthermore, the effects of both social support and coping were mainly through the intermediate variable, depression. In the era of highly active antiretroviral therapy (HAART), when quality of life issues are of paramount importance, strategies to improve social support, coping, and particularly, depressive symptoms are strongly encouraged.