Alcohol-Related Care Among Veterans With Unhealthy Alcohol Use: The Role of Long-term Opioid Therapy Receipt.

OBJECTIVES: Long-term opioid therapy (LTOT) is potentially dangerous among patients with unhealthy alcohol use because of possible adverse interactions. We examined receipt of alcohol-related care among patients with unhealthy alcohol use receiving LTOT and without opioid receipt. METHODS: We use data collected from 2009 to 2017 in the Women Veterans Cohort Study, a national cohort of Veterans engaged in Veterans Health Administration care. We included patients who screened positive for unhealthy alcohol use (score ≥5) using the Alcohol Use Disorder Identification Consumption questionnaire. Our primary exposure was LTOT (receipt of prescribed opioids for ≥90 days) versus no opioid receipt at the time of the first positive Alcohol Use Disorder Identification Consumption. Our primary outcome was receipt of brief intervention within 14 days of positive alcohol screen. Unadjusted and 4 adjusted modified Poisson regression models assessed prevalence and relative rates (RRs) of outcomes. RESULTS: Among eligible veterans, 6222 of 113,628 (5.5%) received LTOT at screening. Among patients receiving LTOT, 67.5% (95% confidence interval [CI], 66.3%-68.6%) had a documented brief intervention within 14 days of positive screen, compared with 70.1% (95% CI, 69.8%-70.4%) among patients without opioid receipt (RR, 0.96; 95% CI, 0.95-0.98; P < 0.001). Within adjusted models, the rate of brief intervention among patients receiving LTOT remained lower than patients without opioid receipt. CONCLUSIONS: Among patients with unhealthy alcohol use, patients receiving LTOT had significantly lower rates of brief intervention receipt compared with those without opioid receipt, and they should be a focus for interventions to improve alcohol-related care and safer opioid prescribing.

Racial, Ethnic, and Rural Disparities in US Veteran COVID-19 Vaccine Rates.

Background: Race, ethnicity, and rurality-related disparities in coronavirus disease 2019 (COVID-19) vaccine uptake have been documented in the United States (US). Objective: We determined whether these disparities existed among patients at the Department of Veterans Affairs (VA), the largest healthcare system in the US. Design Settings Participants Measurements: Using VA Corporate Data Warehouse data, we included 5,871,438 patients (9.4% women) with at least one primary care visit in 2019 in a retrospective cohort study. Each patient was assigned a single race/ethnicity, which were mutually exclusive, self-reported categories. Rurality was based on 2019 home address at the zip code level. Our primary outcome was time-to-first COVID-19 vaccination between December 15, 2020-June 15, 2021. Additional covariates included age (in years), sex, geographic region (North Atlantic, Midwest, Southeast, Pacific, Continental), smoking status (current, former, never), Charlson Comorbidity Index (based on ≥1 inpatient or two outpatient ICD codes), service connection (any/none, using standardized VA-cutoffs for disability compensation), and influenza vaccination in 2019-2020 (yes/no). Results: Compared with unvaccinated patients, those vaccinated (n=3,238,532; 55.2%) were older (mean age in years vaccinated=66.3, (standard deviation=14.4) vs. unvaccinated=57.7, (18.0), p<.0001)). They were more likely to identify as Black (18.2% vs. 16.1%, p<.0001), Hispanic (7.0% vs. 6.6% p<.0001), or Asian American/Pacific Islander (AA/PI) (2.0% vs. 1.7%, P<.0001). In addition, they were more likely to reside in urban settings (68.0% vs. 62.8, p<.0001). Relative to non-Hispanic White urban Veterans, the reference group for race/ethnicity-urban/rural hazard ratios reported, all urban race/ethnicity groups were associated with increased likelihood for vaccination except American Indian/Alaskan Native (AI/AN) groups. Urban Black groups were 12% more likely (Hazard Ratio (HR)=1.12 [CI 1.12-1.13]) and rural Black groups were 6% more likely to receive a first vaccination (HR=1.06 [1.05-1.06]) relative to white urban groups. Urban Hispanic, AA/PI and Mixed groups were more likely to receive vaccination while rural members of these groups were less likely (Hispanic: Urban HR=1.17 [1.16-1.18], Rural HR=0.98 [0.97-0.99]; AA/PI: Urban HR=1.22 [1.21-1.23], Rural HR=0.86 [0.84-0.88]). Rural White Veterans were 21% less likely to receive an initial vaccine compared with urban White Veterans (HR=0.79 [0.78-0.79]). AI/AN groups were less likely to receive vaccination regardless of rurality: Urban HR=0.93 [0.91-0.95]; AI/AN-Rural HR=0.76 [0.74-0.78]. Conclusions: Urban Black, Hispanic, and AA/PI Veterans were more likely than their urban White counterparts to receive a first vaccination; all rural race/ethnicity groups except Black patients had lower likelihood for vaccination compared with urban White patients. A better understanding of disparities and rural outreach will inform equitable vaccine distribution.

Characteristics Associated with Spirometry Guideline Adherence in VA Patients Hospitalized with Chronic Obstructive Pulmonary Disease.

BACKGROUND: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends at least annual spirometry for patients with chronic obstructive pulmonary disease (COPD). Since spirometry acquisition is variable in clinical practice, identifying characteristics associated with annual spirometry may inform strategies to improve care for patients with COPD. METHODS: We included veterans hospitalized for COPD at Veterans Health Administration (VHA) facilities from 10/2012 to 09/2015. Our primary outcome was spirometry within 1 year of COPD hospitalization. Patient demographics, health factors, and comorbidities as well as practice and geographic variables were identified using Corporate Data Warehouse; provider characteristics were obtained from the Survey of Healthcare Experiences of Patients. We used logistic regression with a random intercept to account for potential clustering within facilities. RESULTS: Spirometry was completed 1 year before or after hospitalization for 20,683/38,148 (54.2%) veterans across 114 facilities. Patients with spirometry were younger, (mean=67.2 years (standard deviation (SD)=9.3) vs. 69.4 (10.3)), more likely non-white (21.3% vs. 19.7%), and more likely to have comorbidities (p<0.0001 for asthma, depression, and post-traumatic stress disorder). Pulmonary clinic visit was most strongly associated with spirometry (odds ratio (OR)=3.14 [95% confidence interval 2.99-3.30]). There was no association for facility complexity. In a secondary analysis including provider-level data (3862 patients), results were largely unchanged. There was no association between primary care provider age, gender, or type (physician vs. advanced practice registered nurse vs. physician assistant) and spirometry. CONCLUSION: In a cohort of high-risk COPD patients, just over half completed spirometry within 1 year of hospitalization. Pulmonary clinic visit was most strongly associated with 1-year spirometry, though provider variables were not. Spirometry completion for high-risk COPD patients remains suboptimal and strategies to improve post-hospitalization care for patients not seen in pulmonary clinic should be developed to ensure guideline concordant care.

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.

Perceived Pain and Smoking Interrelations Among Veterans with Chronic Pain Enrolled in a Smoking Cessation Trial.

INTRODUCTION: The Pain and Smoking Inventory (PSI) measures patients' perceived interrelations of their pain and smoking behavior, and it comprises three conceptually distinct domains: smoking to cope with pain (PSI-Cope), pain as a motivator of smoking (PSI-Motivate), and pain as a barrier to cessation (PSI-Barrier). Associations between PSI scores and pain interference and self-efficacy to quit smoking, two measures that can affect cessation outcomes, remain unclear. METHODS: We conducted a secondary analysis of baseline data from 371 veterans with chronic pain (88% male, Medianage =60) enrolled in a randomized smoking cessation trial. We used sequential multivariate regression models to examine associations between the three PSI domains and pain interference / self-efficacy. RESULTS: Of 371 veterans who completed baseline surveys, 88% were male, with a median age of 60 years. PSI-Motivate scores were positively associated with pain interference (beta [B]: 0.18, 95% confidence interval [CI]: 0.02 to 0.34). PSI-Barrier subscores were negatively associated with self-efficacy (B: -0.23, 95% CI: -0.36 to -0.10). CONCLUSION: Findings suggest that individuals who hold maladaptive perceptions of pain-smoking interrelations could be more likely to endorse higher pain interference and lower self-efficacy-two established predictors of cessation outcomes. Moreover, each PSI subscale demonstrated unique relationships with the dependent variables, and our results provided support for a three-factor structure. These findings further demonstrate that the PSI comprises three conceptually and empirically distinct domains; future research should evaluate the clinical utility of assessing each domain in relation to cessation outcomes.

Coordinating women's preventive health care for rural veterans.

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

Pain and smoking study (PASS): A comparative effectiveness trial of smoking cessation counseling for veterans with chronic pain.

INTRODUCTION: Smoking is associated with greater pain intensity and pain-related functional interference in people with chronic pain. Interventions that teach smokers with chronic pain how to apply adaptive coping strategies to promote both smoking cessation and pain self-management may be effective. METHODS: The Pain and Smoking Study (PASS) is a randomized clinical trial of a telephone-delivered, cognitive behavioral intervention among Veterans with chronic pain who smoke cigarettes. PASS participants are randomized to a standard telephone counseling intervention that includes five sessions focusing on motivational interviewing, craving and relapse management, rewards, and nicotine replacement therapy versus the same components with the addition of a cognitive behavioral intervention for pain management. Participants are assessed at baseline, 6, and 12 months. The primary outcome is smoking cessation. RESULTS: The 371 participants are 88% male, a median age of 60 years old (range 24-82), and smoke a median of 15 cigarettes per day. Participants are mainly white (61%), unemployed (70%), 33% had a high school degree or less, and report their overall health as "Fair" (40%) to "Poor" (11%). Overall, pain was moderately high (mean pain intensity in past week = 5.2 (Standard Deviation (SD) = 1.6) and mean pain interference = 5.5 (SD = 2.2)). Pain-related anxiety was high (mean = 47.0 (SD = 22.2)) and self-efficacy was low (mean = 3.8 (SD = 1.6)). CONCLUSIONS: PASS utilizes an innovative smoking and pain intervention to promote smoking cessation among Veterans with chronic pain. Baseline characteristics reflect a socioeconomically vulnerable population with a high burden of mental health comorbidities.

I smoke to cope with pain: patients' perspectives on the link between cigarette smoking and pain.

BACKGROUND: For people with chronic pain, cigarette smoking is associated with greater pain intensity and impairment. Researchers have hypothesized a reciprocal relationship in which pain and smoking exacerbate each other, resulting in greater pain and increased smoking. This study aimed to qualitatively examine patient perspectives on this association. METHODS: A retrospective thematic analysis of smoking cessation counseling notes for 136 veterans in the Pain and Smoking Study, a tailored smoking cessation trial, was conducted. A validated codebook was applied to each counseling note by four independent coders using Atlas.ti (Atlas.ti, Berlin, Germany). Coders participated in a consensus-forming exercise with salient themes validated among the wider research team. KEY RESULTS: Participants averaged 60 years of age (range 28-77 years) and were 9% female. The median number of cigarettes smoked per day was 15, with a mean pain intensity score in the last week (from 0-10) of 5.1. While not all patients acknowledged a connection between pain and smoking, we found that (1) pain motivates smoking and helps manage pain-related distress, as a coping strategy and through cognitive distraction, and (2) pain motivates smoking but smoking does not offer pain relief. Concerns about managing pain without smoking was identified as a notable barrier to cessation. CONCLUSION: Many patients with chronic pain who smoke readily identified pain as a motivator of their smoking behavior and are reluctant to quit for this reason. Integrated interventions for smokers with pain should address these perceptions and expectancies and promote uptake of more adaptive self-management strategies for pain.

Pain intensity and pain medication prescription patterns in Veterans with heart failure and back pain.

BACKGROUND: Pain and heart failure are highly comorbid. OBJECTIVES: The purpose of this study was to examine differences in pain intensity and pain medication prescriptions among Veterans with comorbid heart failure and pain and those with pain alone. METHODS: The Musculoskeletal Disorder (MSD) cohort includes 5,237,763 Veteran diagnosed with a musculoskeletal disorder between 2000 and 2013. Veterans with comorbid heart failure and back pain (heart failure+, n = 3,950, Mage = 70.5 ± 12) were compared to those with back pain alone (heart failure-, n = 165,290, Mage = 52.1 ± 17.5). RESULTS: In multivariate adjusted models, heart failure+ was associated with a higher likelihood of moderate/severe pain (OR = 1.12; 95% CI 1.04-1.21), a higher likelihood of opioids (OR = 1.63; CI = 1.52-1.75) and/or gabapentin prescriptions (OR = 1.18; CI = 1.02-1.36), but a lower likelihood of NSAID prescriptions (OR = 0.57; CI = 0.50-0.66). CONCLUSIONS: Comorbid cardiovascular and pain conditions present a challenge in clinical management that warrants further study.

Factors Associated With Quitting Smoking During Pregnancy Among Women Veterans.

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

Predictors of prenatal smoking among US women veterans.

This study investigated prevalence and factors associated with prenatal smoking among US women veterans using cross-sectional data from a cohort study of veterans from recent wars utilizing Veterans Health Administration primary care (N = 6190). Among the participants, 747 (12.0%) were current smokers and 1039 (16.8%) were former smokers. Multivariable logistic regression indicated that White race, substance use disorder, and posttraumatic stress disorder were associated with increased likelihood of smoking during pregnancy. Conversely, being married and officer rank were associated with decreased likelihood of prenatal smoking. Findings suggest a need for empirical testing of interventions to address perinatal smoking, substance use, and mental health.

Obstructive Sleep Apnea and Pain Intensity in Young Adults.

Rationale: Prior research studies on the association of obstructive sleep apnea (OSA) and pain intensity have examined older patients; there is a need to understand the relationship between OSA and pain intensity among younger adults.Objectives: To examine whether young adults with diagnosed OSA are more likely to report higher pain intensity compared with those without OSA.Methods: We conducted a cross-sectional analysis of a cohort study of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans who had at least one visit to a Veterans Health Administration primary care clinic between 2001 and 2014. OSA was identified using one inpatient or two outpatient International Classification of Diseases, Ninth Revision codes from electronic medical records. Average pain intensity (based on the self-reported 0-10 numeric rating scale over a 12-month period) was categorized as no pain/mild (0-3; no pain) and moderate/severe (4-10; significant pain). Covariates included age, sex, education, race, mental health diagnoses, headache diagnoses, pain diagnoses, hypertension, diabetes, body mass index, and smoking status. Multivariate logistic regression models were used, and multiple imputation was performed to generate values for missing variables.Results: We identified 858,226 young adults (mean age 30 yr [SD = 7]), of whom 91,244 (10.6%) had a diagnosis of OSA and 238,587 (27.8%) reported moderate/severe pain for the 12-month average. with young adults without OSA, those with OSA were more likely to report moderate/severe pain intensity (adjusted odds ratio, 1.09; 95% confidence interval, 1.08-1.11) even after controlling for covariates.Conclusions: We found that young adults with OSA have greater odds of comorbid moderate/severe pain. Because of the high prevalence of chronic pain in younger adults, this study highlights the need to understand the impact of OSA diagnosis and treatment on pain intensity. Future work is needed to determine the role of effective OSA treatment on pain intensity over time in these young adults.

Factors Associated With Posttraumatic Stress Disorder Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care.

OBJECTIVES: Post-traumatic stress disorder (PTSD) is thought to complicate pain management outcomes, which is consistent with the impact of other psychosocial factors in the biopsychosocial model of pain. This study aimed to identify patient sociodemographic and clinical characteristics associated with PTSD prevalence among veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who received Veterans Affairs (VA) chiropractic care. METHODS: A cross-sectional analysis of electronic health record data from a national cohort study of OEF/OIF/OND veterans with at least 1 visit to a VA chiropractic clinic from 2001 to 2014 was performed. The primary outcome measure was a prior PTSD diagnosis. Variables including sex, race, age, body mass index, pain intensity, alcohol and substance use disorders, and smoking status were examined in association with PTSD diagnosis using logistic regression. RESULTS: We identified 14,025 OEF/OIF/OND veterans with at least 1 VA chiropractic visit, with a mean age of 38 years and 54.2% having a diagnosis of PTSD. Male sex (adjusted odds ratio [OR] = 1.23, 95% CI = 1.11-1.37), younger age (OR = 0.99, CI = 0.98-0.99), moderate-to-severe pain intensity (numerical rating scale ≥ 4) (OR = 1.72, CI = 1.59-1.87), body mass index ≥ 30 (OR = 1.34, CI = 1.24-1.45), current smoking (OR = 1.32, CI = 1.20-1.44), and having an alcohol or substance use disorder (OR = 4.51, CI = 4.01-5.08) were significantly associated with a higher likelihood of PTSD diagnosis. CONCLUSION: Post-traumatic stress disorder is a common comorbidity among OEF/OIF/OND veterans receiving VA chiropractic care and is significantly associated with several patient characteristics. Recognition of these factors is important for the appropriate diagnosis and management of veterans with PTSD seeking chiropractic treatment for pain conditions.

Associations between obstructive sleep apnea and prescribed opioids among veterans.

ABSTRACT: Sleep disruption caused by obstructive sleep apnea (OSA) may be associated with hyperalgesia and may contribute to poor pain control and use of prescription opioids. However, the relationship between OSA and opioid prescription is not well described. We examine this association using cross-sectional data from a national cohort of veterans from recent wars enrolled from October 1, 2001 to October 7, 2014. The primary outcome was the relative risk ratio (RRR) of receiving opioid prescriptions for acute (<90 days/year) and chronic (≥90 days/year) durations compared with no opioid prescriptions. The primary exposure was a diagnosis of OSA. We used multinomial logistic regression to control for factors that may affect diagnosis of OSA or receipt of opioid prescriptions. Of the 1,149,874 patients (mean age 38.0 ± 9.6 years) assessed, 88.1% had no opioid prescriptions, 9.4% had acute prescriptions, and 2.5% had chronic prescriptions. Ten percent had a diagnosis of OSA. Patients with OSA were more likely to be older, male, nonwhite, obese, current or former smokers, have higher pain intensity, and have medical and psychiatric comorbidities. Controlling for these differences, patients with OSA were more likely to receive acute (RRR 2.02 [95% confidence interval 1.98-2.06]) or chronic (RRR 2.15 [2.09-2.22]) opioids. Further dividing opioid categories by high vs low dosage did not yield substantially different results. Obstructive sleep apnea is associated with a two-fold likelihood of being prescribed opioids for pain. Clinicians should consider incorporating OSA treatment into multimodal pain management strategies; OSA as a target for pain management should be further studied.

Underutilization of Pulmonary Function Testing in Veterans Hospitalized for Chronic Obstructive Pulmonary Disease Exacerbation: Who are We Missing?

Pulmonary function testing (PFT) is required to diagnose chronic obstructive pulmonary disease (COPD) but is completed for only 30-50% of patients with the disease. We determined patient factors associated with decreased likelihood for PFT acquisition (i.e. underutilization) in the United States Veterans Affairs (VA) health care system.We performed a retrospective analysis of Veterans who survived a VA-based COPD hospitalization between 2012 and 2015. COPD was identified using International Classification of Disease (ICD)-9 codes. Our primary outcome was PFT acquisition, using Current Procedural Terminology (CPT) codes any time prior to the index hospitalization. We compared patients with and without PFTs and used logistic regression to identify associations with PFT underutilization.Of the 48,888 Veterans included, 78% underwent PFTs prior to hospitalization. Patients without PFTs were younger and more likely to be: women (4.2% vs. 3.6%; p = 0.01), nonwhite (22% vs. 19%; p < 0.0001), and current smokers (66% vs 61%; p < 0.0001). PFT acquisition was less likely in Veterans with alcohol and drug use disorders. Using logistic regression, Veterans who were women (Odds Ratio (OR) = 1.17 [95% confidence limit 1.03-1.32]), nonwhite (OR 1.12 [1.06-1.20]), and with a history of alcohol (OR = 1.07 [1.00-1.14]) or drug use disorders (OR = 1.15 [1.06-1.24]) were less likely to undergo PFTs.Though most Veterans hospitalized for COPD had PFTs prior to admission, PFTs are underutilized in Veterans who are: women, younger, nonwhite, and have alcohol or drug use disorders. These groups may be "at-risk" for delayed diagnosis or substandard COPD quality care.

Native Joint Septic Arthritis: Comparison of Outcomes with Medical and Surgical Management.

OBJECTIVE: To determine whether there are differences in the outcomes of native joint septic arthritis (SA) in adults, based on medical versus surgical management. METHODS: A 10-year retrospective single-center study was conducted of patients admitted to a tertiary care hospital between January 1, 2006 and December 31, 2015 with a diagnosis of SA to compare outcomes based on the management approach taken: medical (bedside closed-needle joint aspiration) versus surgical (arthrotomy/arthroscopy). Evaluated outcomes included joint recovery, time to recovery, length of stay, disposition to home versus rehabilitation unit, recurrence of SA in the same joint, and mortality. RESULTS: Of 118 confirmed cases of SA, 48 were in prosthetic joints and 70 were in native joints, and 61 met our inclusion criteria. Forty-one (67%) patients received surgery, and 20 (33%) received closed-needle aspiration. There was no statistically significant difference in long-term outcomes between the two groups at 12 months. Patients managed medically were more likely to experience full recovery at 3 months and were less likely to need short-term rehabilitation. CONCLUSIONS: Medical management with closed-needle aspiration may be an adequate approach to the treatment of native joint infections.

Sex Differences in Veterans Admitted to the Hospital for Chronic Obstructive Pulmonary Disease Exacerbation.

Rationale: As chronic obstructive pulmonary disease (COPD) prevalence in women has outpaced that in men, COPD-related hospitalization and mortality are now higher in women. Presentation, evaluation, and treatment of COPD differ between women and men. Despite higher smoking rates in Veterans, little work has characterized differences in Veterans with COPD by sex. Objectives: To determine risk factors for 30-day readmission among Veterans hospitalized for COPD exacerbations and how they differed by sex. Methods: We performed a retrospective observational analysis of Veterans receiving primary care in Veterans Health Affairs facilities. We included Veterans Administration-based hospitalizations for Veterans with a COPD exacerbation (identified by International Classification of Disease, Ninth Revision codes) who survived to discharge between fiscal years 2012 and 2015. Primary outcome was 30-day readmission. Predictors ascertained before hospitalization included smoking status (current, former, never), pulmonary function testing, pulmonary medication prescriptions, and medical and psychiatric comorbidities (identified by International Classification of Disease, ninth revision codes). We created combined and sex-stratified multivariate logistic regression models to identify associations with 30-day readmission. Results: Our sample included 48,888 Veterans (4% women). Compared with men, women Veterans were younger, more likely to be nonwhite, and differed in smoking status. Women were more likely to have asthma, drug use, and several psychiatric comorbidities. Before hospitalization, women were less likely to have pulmonary function testing (76% vs. 78%; P = 0.01) or be treated with antimuscarinic (43% vs. 48%) or combined long-acting bronchodilator/inhaled corticosteroid (61% vs. 64%) inhalers. Women were more likely to receive nicotine-replacement therapy (all P < 0.01). Women had shorter length of stay (median days, 2 vs. 3; P = 0.04) and lower 30-day readmission rate (20% vs. 22%; P = 0.01). In adjusted models including both sexes, age, antimuscarinic use, comorbidities, and diagnosis of drug or alcohol use were associated with readmission; there was no association with sex and readmission risk. In models stratified by sex, associations were similar between women and men. Conclusions: This study suggests differences between women and men hospitalized for COPD regarding presentation, evaluation, and management. Readmission is strongly influenced by comorbidities, suggesting individualized and comprehensive case management may reduce readmission risk for women and men with COPD.

Dual Use of Department of Veterans Affairs and Medicare Benefits on High-Risk Opioid Prescriptions in Veterans Aged 65 Years and Older: Insights from the VA Musculoskeletal Disorders Cohort.

OBJECTIVE: To examine the association of dual use of both Veterans Health Administration (VHA) and Medicare benefits with high-risk opioid prescriptions among Veterans aged 65 years and older with a musculoskeletal disorder diagnosis. DATA SOURCES/STUDY SETTING: Data were obtained from the VA Musculoskeletal Disorder (MSD) cohort and national Medicare claims data from 2008 to 2010. STUDY DESIGN: We conducted a retrospective analysis of Veterans enrolled in Medicare to examine the association of dual use with long-term opioid use (>90 days of prescription opioids/year) and overlapping opioid prescriptions. Multivariable logistic regression was performed adjusting for demographic and clinical characteristics. DATA COLLECTION/EXTRACTION METHODS: We identified 21,111 Veterans enrolled in Medicare who entered the MSD cohort in 2008 and received an opioid prescription in 2010. We linked VHA data with Medicare claims data to identify opioid prescriptions for these Veterans in 2010. PRINCIPAL FINDINGS: As compared to Veterans who used only VHA or Medicare, Veterans with dual use of VHA and Medicare were significantly more likely to be prescribed long-term opioid therapy (OR = 4.61 (95 percent CI 4.05-5.25) and were also found to have higher median number of opioid prescriptions and higher odds of overlapping opioid prescriptions in 1 year. Patients reporting moderate-to-severe pain, non-white-race/ethnicity, and higher scoring on the Charlson comorbidity index had significantly higher odds of long-term opioid prescriptions. CONCLUSIONS: Among Veterans aged 65 years or older, dual use of both VHA and Medicare was associated with higher odds of long-term opioid therapy. Our findings suggest there may be benefit to combining VHA and non-VHA electronic health record data to minimize exposure to high-risk opioid prescribing.

A Brief, Integrated, Telephone-Based Intervention for Veterans Who Smoke and Have Chronic Pain: A Feasibility Study.

Objective: High rates of co-occurring smoking and chronic pain are observed in the veteran population. Individuals who smoke and have chronic pain report lower self-efficacy to quit and are less successful in their attempts. Design: In this pilot study, we assess the feasibility of a telephone-delivered intervention designed to integrate evidence-based smoking cessation and pain management components in a way that allows patients to understand the interplay between the two while attempting to have them build off each other and develop coping skills to address both concerns. Patients: Study participants (N = 7) were veterans who received primary care in the VA Healthcare System and reported current smoking and a worst pain intensity score of 4 or greater. Intervention: A five-session telephone intervention was delivered over eight weeks. Participants completed a survey at baseline and 10-week follow-up. Outcome Measures: Feasibility was assessed by examining engagement with the intervention. Results: Four out of seven participants completed all five sessions. Two out of seven veterans reported quitting smoking, and five out of seven reported clinically meaningful improvements in pain intensity and functional interference. Conclusions: Insights gained from this study were used to modify an intervention being examined in a randomized controlled trial to test its effectiveness on both smoking and pain outcomes.

Variation in National Opioid Prescribing Patterns Following Surgery for Kidney Stones.

Background: Opioid misuse is a significant public health problem. As initial exposures to opioids are frequently encountered through the management of postoperative pain, we examined patterns of opioid prescribing following surgical treatment for nephrolithiasis. Methods: We identified patients with nephrolithiasis in the national Women Veterans Cohort Study (WVCS) who were treated surgically by diagnosis and procedure codes. Using standard conversion factors, we calculated the morphine milligram equivalent (MME) dose prescribed. We used descriptive statistics to characterize opioid prescription across management strategy and multivariable regression to examine clinical and demographic characteristics associated with dispensed dose. Results: We identified 22,609 patients diagnosed with kidney stones during 1999-2014, 1,976 of whom were treated surgically and 1,582 (80.1%) of whom received an opioid prescription. The median age was 39 years, and 1,366 (90%) were male; 1,314 (86.3%) were treated with ureteroscopy, 172 (11.3%) with extracorporeal shockwave lithotripsy, and 36 (2.4%) with percutaneous nephrolithotomy. The median number of days supplied per opioid prescription (interquartile range) was 10 (5-14), and patients were dispensed a median of 180 (140-300) MME. A total of 6.4% of patients received ≥50 MME/d. On multivariable analysis, comorbid diagnosis of post-traumatic stress disorder (PTSD) was associated with higher total dispensed dose, whereas surgery type was not. Conclusions: We observed substantial variation in opioid prescribing following surgical treatment of nephrolithiasis. Although type of surgical intervention did not impact opioid dosing, patients with a diagnosis of PTSD were more likely to receive higher doses. This work can inform efforts to improve the safety and efficacy of postoperative opioid prescribing.