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1.
BMC Health Serv Res ; 21(1): 899, 2021 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-34470648

RESUMO

BACKGROUND: Hypertension is a major preventable risk factor for cardiovascular disease. Occupational factors such as having served or serving in armed forces may be associated with hypertension. This study aimed to assess the prevalence and factors associated with hypertension among veterans of the Indian Gorkha army living in western Nepal. METHODS: A community-based cross-sectional study was conducted among the veterans living in the Pokhara metropolitan city. Data on blood pressure (BP), anthropometric measurements, and behavioral factors were collected by face-to-face interviews using the World Health Organization's non-communicable disease risk factor surveillance (STEPS) tool. Hypertension was defined as systolic blood pressure (BP) ≥ 140 mm Hg and/or diastolic BP of ≥ 90 mm Hg or currently on antihypertensive medication. RESULTS: The age-adjusted prevalence of hypertension was 66.2 % among the study participants (317). Mean systolic and diastolic blood pressure was 144.5 mmHg (± 18.3) and 89.3mmHg (± 16.0), respectively. Among the hypertensive participants, 67 % were aware of their disease, 90 % of them were under treatment, and 14 % of the individuals who received treatment had their hypertension under control. The proportion of smokers was 12.9 % and alcohol drinker was 86.1 %. One-fourth (25.9 %) of the participants had a family history of hypertension. Veterans aged 55-64 years had higher odds (AOR: 5.3; 95 % CI: 1.8-15.9; p = 0.003) of being associated with hypertension as compared to 35-44 years. Being a current alcohol drinker (AOR: 2.5; 95 % CI: 1.4-4.5; p = 0.003), overweight (AOR: 1.9; 95 % CI: 1.0-3.5; p = 0.04), obese (AOR: 3.1; 95 % CI: 1.1-8.3; p = 0.03) and family history of hypertension (AOR: 2.9; 95 % CI: 1.5-5.8; p = 0.002) were independently associated with hypertension. CONCLUSIONS: Hypertension was prevalent in retired Nepal veterans. Hypertension was associated with a number of modifiable lifestyle and behavioral factors. Our findings suggest the need for screening, education and management of Nepal veterans for hypertension.


Assuntos
Hipertensão , Veteranos , Estudos Transversais , Humanos , Hipertensão/epidemiologia , Nepal/epidemiologia , Prevalência , Fatores de Risco
2.
Trials ; 22(1): 594, 2021 Sep 06.
Artigo em Inglês | MEDLINE | ID: mdl-34488824

RESUMO

BACKGROUND: Post-traumatic stress disorder (PTSD) is a significant public health problem, affecting approximately 7% of the general population and 13-18% of the combat Veteran population. The first study using acupuncture for PTSD in a civilian population showed large pre- to post-treatment effects for an empirically developed verum protocol, which was equivalent to group cognitive behavior therapy and superior to a wait-list control. The primary objective of this study is to determine both clinical and biological effects of verum acupuncture for combat-related PTSD in treatment-seeking US Veterans. METHODS: This is a two-arm, parallel-group, prospective randomized placebo-controlled clinical trial. The experimental condition is verum acupuncture and the placebo control is sham (minimal) acupuncture in 1-h sessions, twice a week for 12 weeks. Ninety subjects will provide adequate power and will be allocated to group by an adaptive randomization procedure. The primary outcome is change in PTSD symptom severity from pre- to post-treatment. The secondary biological outcome is change from pre- to post-treatment in psychophysiological response, startle by electromyographic (EMG) eyeblink. Assessments will be conducted at pre-, mid-, post-, and 1-month post-treatment, blind to group allocation. Intent-to-treat analyses will be conducted. DISCUSSION: The study results will be definitive because both clinical and biological outcomes will be assessed and correlated. Issues such as the number needed for recruitment and improvement, use of sham acupuncture, choice of biological measure, and future research need will be discussed. TRIAL REGISTRATION: ClinicalTrials.gov NCT02869646 . Registered on 17 August 2016.


Assuntos
Terapia por Acupuntura , Transtornos de Estresse Pós-Traumáticos , Veteranos , Terapia por Acupuntura/efeitos adversos , Humanos , Estudos Prospectivos , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Transtornos de Estresse Pós-Traumáticos/terapia , Resultado do Tratamento
3.
Am J Epidemiol ; 190(9): 1928-1934, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-34467408

RESUMO

We sought to operationalize and validate data-driven approaches for identifying transgender individuals in the Veterans Health Administration (VHA) of the US Department of Veterans Affairs (VA) through a retrospective analysis using VA administrative data from 2006-2018. Besides diagnoses of gender identity disorder (GID), a combination of non-GID data elements was used to identify potentially transgender veterans, including 1) an International Classification of Diseases (Ninth or Tenth Revision) code of endocrine disorder, unspecified or not otherwise specified; 2) receipt of sex hormones not associated with the sex documented in the veteran's records (gender-affirming hormone therapy); and 3) a change in the veteran's administratively recorded sex. Both GID and non-GID data elements were applied to a sample of 13,233,529 veterans utilizing the VHA of the VA between January 2006 and December 2018. We identified 10,769 potentially transgender veterans. Based on a high positive predictive value for GID-coded veterans (83%, 95% confidence interval: 77, 89) versus non-GID-coded veterans (2%, 95% confidence interval: 1, 11) from chart review validation, the final analytical sample comprised only veterans with a GID diagnosis code (n = 9,608). In the absence of self-identified gender identity, findings suggest that relying entirely on GID diagnosis codes is the most reliable approach for identifying transgender individuals in the VHA of the VA.


Assuntos
Disforia de Gênero/epidemiologia , Pessoas Transgênero/estatística & dados numéricos , Transexualidade/epidemiologia , Saúde dos Veteranos/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Adulto , Idoso , Feminino , Disforia de Gênero/diagnóstico , Humanos , Classificação Internacional de Doenças , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Procedimentos de Readequação Sexual/estatística & dados numéricos , Transexualidade/diagnóstico , Estados Unidos/epidemiologia
4.
Medicine (Baltimore) ; 100(35): e27068, 2021 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-34477140

RESUMO

ABSTRACT: Many veterans have negative views about the service connection claims process for posttraumatic stress disorder (PTSD), which likely impacts willingness to file service connection claims, re-file claims, and use Veterans Healthcare Administration care. Nevertheless, veterans have reported that PTSD claims are important to them for the financial benefits, validation of prior experience and harm, and self-other issues such as pleasing a significant other. It is unknown if reported attitudes are specific to PTSD claimants or if they would be similar to those submitting claims for other disorders, such as musculoskeletal disorders. Therefore, the purpose of this study was to compare attitudes and beliefs about service connection processes between veterans submitting service connection claims for PTSD and musculoskeletal disorders.Participants were Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans filing service connection claims for PTSD (n = 218) or musculoskeletal disorder (n = 257) who completed a modified Disability Application Appraisal Inventory. This secondary data analysis using multiple regression models tested the effect of demographics, clinical characteristics, and claim type on 5 Disability Application Appraisal Inventory subscales: Knowledge about service connection claims, Negative Expectations about the process, and importance of Financial Benefits, importance of Validation of veteran's experience/condition, and importance of Self-Other attitudes.The PTSD group assigned significantly less importance to financial benefits than the musculoskeletal disorder group. In addition, the subset of the PTSD group without depression had significantly more Negative Expectations than musculoskeletal disorder claimants without depression. Negative Expectations did not differ between the PTSD and musculoskeletal disorder groups with depression. Depression was significantly positively associated with Negative Expectations, importance of Financial Benefits, and importance of Validation.Most perceptions around seeking service connection are not specific to PTSD claimants. Depression is associated with having negative expectations about service connection claims and motivations to file claims. Addressing depression and negative expectations during the compensation and pension process might help veterans at this important point of contact with Veterans Healthcare Administration services.


Assuntos
Atitude Frente a Saúde , Doenças Musculoesqueléticas/psicologia , Transtornos de Estresse Pós-Traumáticos/psicologia , Ajuda a Veteranos Incapacitados/normas , Veteranos/estatística & dados numéricos , Adulto , Pessoas com Deficiência/estatística & dados numéricos , Feminino , Humanos , Masculino , Análise Multivariada , Doenças Musculoesqueléticas/complicações , Transtornos de Estresse Pós-Traumáticos/complicações , Inquéritos e Questionários , Estados Unidos , United States Department of Veterans Affairs/organização & administração , United States Department of Veterans Affairs/estatística & dados numéricos , Ajuda a Veteranos Incapacitados/estatística & dados numéricos
6.
BMJ Open ; 11(8): e047369, 2021 08 16.
Artigo em Inglês | MEDLINE | ID: mdl-34400452

RESUMO

OBJECTIVES: To investigate the temporal trends of 30-day mortality and hospitalisation in US Veterans with COVID-19 and 30-day mortality in hospitalised veterans with COVID-19 and to decompose the contribution of changes in the underlying characteristics of affected populations to these temporal changes. DESIGN: Observational cohort study. SETTING: US Department of Veterans Affairs. PARTICIPANTS: 49 238 US veterans with a positive COVID-19 test between 20 March 2020 and 19 September 2020; and 9428 US veterans hospitalised with a positive COVID-19 test during the same period. OUTCOME MEASURES: 30-day mortality rate and hospitalisation rate. RESULTS: Between 20 March 2020 and 19 September 2020 and in COVID-19 positive individuals, 30-day mortality rate dropped by 9.2% from 13.6% to 4.4%; hospitalisation rate dropped by 16.8% from 33.8% to 17.0%. In hospitalised COVID-19 individuals, 30-day mortality rate dropped by 12.7% from 23.5% to 10.8%. Among COVID-19 positive individuals, decomposition analyses suggested that changes in demographic, health and contextual characteristics, COVID-19 testing capacity, and hospital occupancy rates accounted for 40.2% and 33.3% of the decline in 30-day mortality and hospitalisation, respectively. Changes in the underlying characteristics of hospitalised COVID-19 individuals accounted for 29.9% of the decline in 30-day mortality. CONCLUSION: Between March and September 2020, changes in demographic and health characteristics of people infected with COVID-19 contributed measurably to the substantial decline in 30-day mortality and hospitalisation.


Assuntos
COVID-19 , Veteranos , Teste para COVID-19 , Estudos de Coortes , Hospitalização , Humanos , SARS-CoV-2 , Estados Unidos/epidemiologia
7.
Artigo em Russo | MEDLINE | ID: mdl-34380298

RESUMO

The problem of combatants' rehabilitation in the modern world is relevant for medicine in all countries. The forms of care are inpatient, sanatorium, outpatient and polyclinic. The choice of a specific program for a combatant is based on the compilation of a personalized target map with the measurement of the functional index measurements that allow assigning patients to relevant correction groups. Three variants of programs for the combatants' rehabilitation are proposed. Each one considers such components as a regimen and drug therapy. Psychotherapy plays an important role. The volume and tasks of psychotherapeutic influences are determined taking into account the mechanisms of the disease development and the psychological state of the patient. In the process of psychotherapy, various techniques and methods are used (psychodynamic, humanistic, cognitive-behavioral). Along with traditional psychotherapeutic techniques, psychophysiological trainings using the principle of biofeedback are used. An urgent component of the rehabilitation of veterans is carrying out correctional work with their family members. An important place is given to the rehabilitation of victims' family members - work with acute grief, life crisis, and catastrophic experiences. Preserving and restoring the health of war veterans is not only a medical but also a social problem.


Assuntos
Transtornos de Estresse Pós-Traumáticos , Veteranos , Humanos , Psicoterapia , Transtornos de Estresse Pós-Traumáticos/terapia
8.
BMC Med Res Methodol ; 21(1): 167, 2021 08 16.
Artigo em Inglês | MEDLINE | ID: mdl-34399689

RESUMO

BACKGROUND: Few definitive guidelines exist for rigorous large-scale prospective evaluation of nonrandomized programs and policies that require longitudinal primary data collection. In Veterans Affairs (VA) we identified a need to understand the impact of a geriatrics primary care model (referred to as GeriPACT); however, randomization of patients to GeriPACT vs. a traditional PACT was not feasible because GeriPACT has been rolled out nationally, and the decision to transition from PACT to GeriPACT is made jointly by a patient and provider. We describe our study design used to evaluate the comparative effectiveness of GeriPACT compared to a traditional primary care model (referred to as PACT) on patient experience and quality of care metrics. METHODS: We used prospective matching to guide enrollment of GeriPACT-PACT patient dyads across 57 VA Medical Centers. First, we identified matches based an array of administratively derived characteristics using a combination of coarsened exact and distance function matching on 11 identified key variables that may function as confounders. Once a GeriPACT patient was enrolled, matched PACT patients were then contacted for recruitment using pre-assigned priority categories based on the distance function; if eligible and consented, patients were enrolled and followed with telephone surveys for 18 months. RESULTS: We successfully enrolled 275 matched dyads in near real-time, with a median time of 7 days between enrolling a GeriPACT patient and a closely matched PACT patient. Standardized mean differences of < 0.2 among nearly all baseline variables indicates excellent baseline covariate balance. Exceptional balance on survey-collected baseline covariates not available at the time of matching suggests our procedure successfully controlled many known, but administratively unobserved, drivers of entrance to GeriPACT. CONCLUSIONS: We present an important process to prospectively evaluate the effects of different treatments when randomization is infeasible and provide guidance to researchers who may be interested in implementing a similar approach. Rich matching variables from the pre-treatment period that reflect treatment assignment mechanisms create a high quality comparison group from which to recruit. This design harnesses the power of national administrative data coupled with collection of patient reported outcomes, enabling rigorous evaluation of non-randomized programs or policies.


Assuntos
Geriatria , Veteranos , Humanos , Atenção Primária à Saúde , Inquéritos e Questionários , Estados Unidos , United States Department of Veterans Affairs
10.
Artigo em Inglês | MEDLINE | ID: mdl-34444321

RESUMO

The objective was to examine insomnia and insomnia-related care within a regional network of Department of Veterans Affairs (VA) facilities since the VA roll-out of cognitive behavioral therapy for insomnia (CBT-I) in 2011. A retrospective analysis of VA electronic health records (EHR) data from 2011 to 2019 was conducted. The annual and overall prevalence of four insomnia indicators was measured: diagnoses, medications, consultations for assessment/treatment, and participation in CBT-I. Also examined were sociodemographic and clinical differences among veterans with and without an insomnia indicator, as well as differences among the four individual insomnia indicators. The sample included 439,887 veterans, with 17% identified by one of the four indicators; medications was most common (15%), followed by diagnoses (6%), consults (1.5%), and CBT-I (0.6%). Trends over time included increasing yearly rates for diagnoses, consults, and CBT-I, and decreasing rates for medications. Significant differences were identified between the sociodemographic and clinical variables across indicators. An evaluation of a large sample of veterans identified that prescription sleep medications remain the best way to identify veterans with insomnia. Furthermore, insomnia continues to be under-diagnosed, per VA EHR data, which may have implications for treatment consistent with clinical practice guidelines and may negatively impact veteran health.


Assuntos
Terapia Cognitivo-Comportamental , Distúrbios do Início e da Manutenção do Sono , Veteranos , Registros Eletrônicos de Saúde , Humanos , Estudos Retrospectivos , Distúrbios do Início e da Manutenção do Sono/epidemiologia , Distúrbios do Início e da Manutenção do Sono/terapia , Estados Unidos/epidemiologia
11.
BMJ Open ; 11(8): e049815, 2021 08 27.
Artigo em Inglês | MEDLINE | ID: mdl-34452965

RESUMO

OBJECTIVE: To investigate the impact of the COVID-19 pandemic on the health and well-being of UK ex-service personnel (veterans) before and during the pandemic, and to assess associations of COVID-19 experiences and stressors with mental health, alcohol use and loneliness. DESIGN: An additional wave of data was collected from a longitudinal cohort study of the UK Armed Forces. SETTING: Online survey June-September 2020. PARTICIPANTS: Cohort members were included if they had completed a questionnaire at phase 3 of the King's Centre for Military Health Research health and well-being study (2014-2016), had left the Armed Forces after regular service, were living in the UK, had consented to follow-up and provided a valid email address. Invitation emails were sent to N=3547 with a 44% response rate (n=1562). PRIMARY OUTCOME MEASURES: Common mental health disorders (CMDs) (measured using the General Health Questionnaire, 12 items-cut-off ≥4), hazardous alcohol use (measured using the Alcohol Use Disorder Identification Test, 10 items-cut off ≥8) and loneliness (University of California, Los Angeles, Loneliness Scale- 3 items-cut-off ≥6). RESULTS: Veterans reported a statistically significant decrease in hazardous drinking of 48.5% to 27.6%, while CMD remained stable (non-statistically significant increase of 24.5% to 26.1%). 27.4% of veterans reported feelings of loneliness. The COVID-19 stressors of reporting difficulties with family/social relationships, boredom and difficulties with health were statistically significantly associated with CMD, hazardous drinking and loneliness, even after adjustment for previous mental health/hazardous alcohol use. CONCLUSIONS: Our study suggests a COVID-19 impact on veterans' mental health, alcohol use and loneliness, particularly for those experiencing difficulties with family relationships. Veterans experienced the pandemic in similar ways to the general population and in some cases may have responded in resilient ways. While stable levels of CMD and reduction in alcohol use are positive, there remains a group of veterans who may need mental health and alcohol treatment services.


Assuntos
COVID-19 , Veteranos , Estudos de Coortes , Humanos , Estudos Longitudinais , Saúde Mental , Pandemias , SARS-CoV-2 , Reino Unido/epidemiologia
12.
Artigo em Inglês | MEDLINE | ID: mdl-34444083

RESUMO

Responding to identified needs for increased veterans' access to healthcare, in 2010 the United States Department of Veterans Affairs (VA) launched the Veteran Community Partnership (VCP) initiative to "foster seamless access to, and transitions among, the full continuum of non-institutional extended care and support services in VA and the community". This initiative represents an important effort by VA to promote collaboration with a broad range of community organizations as equal partners in the service of veteran needs. The purpose of the study is an initial assessment of the VCP program. Focus group interviews conducted in six sites in 2015 included 53 representatives of the local VA and community organizations involved with rural and urban VCPs across the US. Interview topics included the experiences and practices of VCP members, perceived benefits and challenges, and the characteristics and dynamics of rural and urban areas served by VCPs. Using a community-oriented conceptual framework, the analyses address VCP processes and preliminary outcomes, including VCP goals and activities, and VCP members' perceptions of their efforts, benefits, challenges, and achievements. The results indicate largely positive perceptions of the VCP initiative and its early outcomes by both community and VA participants. Benefits and challenges vary by rural-urban community context and include resource limitations and the potential for VA dominance of other VCP partners. Although all VCPs identified significant benefits and challenges, time and resource constraints and local organizational dynamics varied by rural and urban context. Significant investments in VCPs will be required to increase their impacts.


Assuntos
Veteranos , Instalações de Saúde , Acesso aos Serviços de Saúde , Humanos , População Rural , Estados Unidos , United States Department of Veterans Affairs
13.
Mo Med ; 118(4): 387-392, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34373676

RESUMO

One of the cornerstones of treatment after acute coronary syndromes is cardiac rehabilitation (CR). However, traditional CR remains underused in the United States due to comorbidities and geographical limitations. To evaluate feasibility and safety of our individually tailored CR program, we evaluated twelve weeks of tele-monitored home-based arm ergometer and weight training exercises in seven Veterans. Prior to beginning our CR program, all Veterans underwent an arm ergometer stress test and training in the proper techniques for arm exercises and weight training. Seattle Angina Questionnaire (SAQ) and the MacNew Heart Disease Health-related Quality of Life (MacNew) questionnaire were administered at the beginning and conclusion of the program. Six patients completed the study. One withdrew due to generalized weakness. There were no adverse events during the study period. There was a perceived improvement in heart disease related global (4.47 to 4.61), physical, emotional, and social well-being by the MacNew questionnaire. The SAQ showed improvement in physical limitation, angina frequency, treatment satisfaction, and overall quality of life (36.1 to 51.7) after completion of our tailored CR program. There was a decrease in average blood pressure and patients were able to exercise seven minutes longer and workload increased eight additional watts. This pilot study demonstrates the safety and feasibility of a home-based arm cardiac rehabilitation program. These tailored programs may improve quality of life in coronary artery disease patients with disabilities.


Assuntos
Reabilitação Cardíaca , Pessoas com Deficiência , Veteranos , Braço , Terapia por Exercício , Humanos , Projetos Piloto , Qualidade de Vida , Estados Unidos
14.
Nurse Educ ; 46(5): E108-E112, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34435762

RESUMO

BACKGROUND: Despite the Joining Forces initiative and recently published veteran care competencies, nursing students and graduates are often unprepared to care for veterans who have unique service-connected illnesses and injuries. PURPOSE: The purpose was to evaluate identified content gaps in prelicensure nursing textbooks with the veteran care competencies knowledge, skills, and attitude (KSA) domains. METHODS: A secondary qualitative analysis was conducted of veteran content in prelicensure nursing textbooks. RESULTS: The skills and attitude domains of veteran care competencies were poorly addressed in nursing textbooks. Overall, the knowledge domain was adequately covered; however, most had limited connection with veterans and veteran care. Competency-focused recommendations for expanding and enhancing veteran content, KSAs, and teaching strategies are offered. CONCLUSIONS: Prelicensure textbooks met the knowledge domain for each veteran competency. Overcoming content gaps needed to achieve requisite skills and attitudes requires interaction with veterans through clinical immersion experiences in various care settings.


Assuntos
Bacharelado em Enfermagem , Estudantes de Enfermagem , Veteranos , Competência Clínica , Humanos , Pesquisa em Educação de Enfermagem
15.
Gene ; 803: 145898, 2021 Nov 30.
Artigo em Inglês | MEDLINE | ID: mdl-34391864

RESUMO

Chronic inflammation is a key factor in symptomology and comorbidities of post-traumatic stress disorder (PTSD). Levels of a proinflammatory marker, C-reactive protein (CRP) are increased in individuals with PTSD but it is not clear if this is due to trauma exposure or PTSD. Our study aimed to assess the relationship between serum CRP levels, CRP SNPs, methylation, mRNA expression and PTSD in a homogenous trauma exposed Australian Vietnam veteran cohort. We hypothesized that decreased DNA methylation would be associated with increased gene expression and increased peripheral CRP levels in PTSD patients and that this would be independent of trauma. Participants were 299 Vietnam veterans who had all been exposed to trauma and approximately half were diagnosed with PTSD. We observed higher levels of serum CRP in the PTSD group compared to the non-PTSD group but after controlling for BMI and triglycerides the association did not remain significant. No association was found between CRP SNPs and PTSD or CRP levels. Absent in Melanoma 2 (AIM2) which is a mediator of inflammatory response and a determinant of CRP levels was analysed for DNA methylation and mRNA expression. We observed a trend level association between PTSD and AIM2 methylation after controlling for age, smoking, triglycerides, BMI and cell types. There was no significant interaction between PTSD and CRP levels on AIM2 methylation after controlling for covariates. We observed that as AIM2 methylation levels decreased, AIM2 mRNA expression increased. Elevated CRP levels were associated with AIM2 mRNA in the trauma exposed cohort but there was no significant interaction effect with PTSD. Our results could not confirm that CRP is a marker of PTSD independent of trauma in this group of older veterans. CRP may be a broad marker of disease risk, or a marker of PTSD in younger cohorts than those in this study.


Assuntos
Proteína C-Reativa/genética , Metilação de DNA , Proteínas de Ligação a DNA/genética , Proteínas do Tecido Nervoso/sangue , Proteínas do Tecido Nervoso/genética , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Veteranos/psicologia , Idoso , Austrália , Estudos de Casos e Controles , Epigênese Genética , Estudos de Associação Genética , Humanos , Masculino , Polimorfismo de Nucleotídeo Único , Transtornos de Estresse Pós-Traumáticos/sangue , Transtornos de Estresse Pós-Traumáticos/genética , Regulação para Cima , Guerra do Vietnã
16.
Am J Prev Med ; 61(3): 357-368, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34419233

RESUMO

INTRODUCTION: Unsheltered homelessness is a strongly debated public issue. The study objective is to identify personal and community characteristics associated with unsheltered homelessness in veterans and to test for interactions between these characteristics. METHODS: In a 2018 national survey of U.S. veterans with homeless experiences; investigators assessed unsheltered time; psychosocial characteristics; and community measures of shelter access, weather, and rental affordability. Associations between these characteristics and unsheltered status were tested in July-August 2020. This study also tested whether the count of personal risk factors interacted with community characteristics in predicting unsheltered status. RESULTS: Among 5,406 veterans, 481 (8.9%) reported ≥7 nights unsheltered over 6 months. This group was more likely to report criminal justice history, poor social support, medical and drug problems, financial hardship, and being unmarried. Their communities had poorer shelter access and warmer temperatures. The likelihood of unsheltered experience rose with risk factor count from 2.0% (0-1) to 8.4% (2-3) and to 24.2% (4-11). Interaction tests showed that the increase was greater for communities with warmer weather and higher rents (p<0.05). CONCLUSIONS: Among veterans experiencing homelessness, unsheltered experiences correlate with individual and community risk factors. Communities wishing to address unsheltered homelessness will need to consider action at both levels.


Assuntos
Pessoas em Situação de Rua , Veteranos , Habitação , Humanos , Fatores de Risco , Apoio Social
17.
Artigo em Inglês | MEDLINE | ID: mdl-34444232

RESUMO

BACKGROUND: We performed an observational Veterans Health Administration cohort analysis to assess how risk factors affect 30-day mortality in SARS-CoV-2-infected subjects relative to those uninfected. While the risk factors for coronavirus disease 2019 (COVID-19) have been extensively studied, these have been seldom compared with uninfected referents. METHODS: We analyzed 341,166 White/Black male veterans tested for SARS-CoV-2 from March 1 to September 10, 2020. The relative risk of 30-day mortality was computed for age, race, ethnicity, BMI, smoking status, and alcohol use disorder in infected and uninfected subjects separately. The difference in relative risk was then evaluated between infected and uninfected subjects. All the analyses were performed considering clinical confounders. RESULTS: In this cohort, 7% were SARS-CoV-2-positive. Age >60 and overweight/obesity were associated with a dose-related increased mortality risk among infected patients relative to those uninfected. In contrast, relative to never smoking, current smoking was associated with a decreased mortality among infected and an increased mortality in uninfected, yielding a reduced mortality risk among infected relative to uninfected. Alcohol use disorder was also associated with decreased mortality risk in infected relative to the uninfected. CONCLUSIONS: Age, BMI, smoking, and alcohol use disorder affect 30-day mortality in SARS-CoV-2-infected subjects differently from uninfected referents. Advanced age and overweight/obesity were associated with increased mortality risk among infected men, while current smoking and alcohol use disorder were associated with lower mortality risk among infected men, when compared with those uninfected.


Assuntos
COVID-19 , Veteranos , Grupos Étnicos , Humanos , Masculino , Fatores de Risco , SARS-CoV-2
18.
Health Aff (Millwood) ; 40(8): 1312-1320, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34339235

RESUMO

The Department of Veterans Affairs (VA) both delivers health care in its own facilities and, increasingly, purchases care for veterans in the community. Policy makers, administrators, health care providers, and veterans frequently face decisions about which services should be delivered versus purchased by the VA. Comparisons of quality across settings are essential if veterans are to receive care that is consistently accessible, patient centered, effective, and safe. We compared risk-adjusted major postoperative complication rates for total knee arthroplasties that were delivered in VA facilities versus purchased from community providers. Overall, adjusted complication rates were significantly lower for arthroplasties delivered by the VA compared with those that were purchased. However, hospital-level comparisons revealed five locations where VA-purchased care outperformed VA-delivered care. As the amount of VA-purchased care continues to increase under the Veterans Access, Choice, and Accountability Act of 2014 and the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, these results support VA monitoring of overall and local comparative hospital performance to improve the quality of the care that the VA delivers while ensuring optimal outcomes in VA-purchased care.


Assuntos
Artroplastia do Joelho , Veteranos , Artroplastia do Joelho/efeitos adversos , Procedimentos Cirúrgicos Eletivos , Hospitais de Veteranos , Humanos , Estados Unidos , United States Department of Veterans Affairs
19.
BMC Health Serv Res ; 21(1): 797, 2021 Aug 11.
Artigo em Inglês | MEDLINE | ID: mdl-34380495

RESUMO

BACKGROUND: While the Veterans Health Administration (VHA) MOVE! weight management program is effective in helping patients lose weight and is available at every VHA medical center across the United States, reaching patients to engage them in treatment remains a challenge. Facility-based MOVE! programs vary in structures, processes of programming, and levels of reach, with no single factor explaining variation in reach. Configurational analysis, based on Boolean algebra and set theory, represents a mathematical approach to data analysis well-suited for discerning how conditions interact and identifying multiple pathways leading to the same outcome. We applied configurational analysis to identify facility-level obesity treatment program arrangements that directly linked to higher reach. METHODS: A national survey was fielded in March 2017 to elicit information about more than 75 different components of obesity treatment programming in all VHA medical centers. This survey data was linked to reach scores available through administrative data. Reach scores were calculated by dividing the total number of Veterans who are candidates for obesity treatment by the number of "new" MOVE! visits in 2017 for each program and then multiplied by 1000. Programs with the top 40 % highest reach scores (n = 51) were compared to those in the lowest 40 % (n = 51). Configurational analysis was applied to identify specific combinations of conditions linked to reach rates. RESULTS: One hundred twenty-seven MOVE! program representatives responded to the survey and had complete reach data. The final solution consisted of 5 distinct pathways comprising combinations of program components related to pharmacotherapy, bariatric surgery, and comprehensive lifestyle intervention; 3 of the 5 pathways depended on the size/complexity of medical center. The 5 pathways explained 78 % (40/51) of the facilities in the higher-reach group with 85 % consistency (40/47). CONCLUSIONS: Specific combinations of facility-level conditions identified through configurational analysis uniquely distinguished facilities with higher reach from those with lower reach. Solutions demonstrated the importance of how local context plus specific program components linked together to account for a key implementation outcome. These findings will guide system recommendations about optimal program structures to maximize reach to patients who would benefit from obesity treatment such as the MOVE!


Assuntos
United States Department of Veterans Affairs , Veteranos , Humanos , Estilo de Vida , Obesidade/prevenção & controle , Estados Unidos , Saúde dos Veteranos
20.
BMC Health Serv Res ; 21(1): 809, 2021 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-34384398

RESUMO

BACKGROUND: The scope of care coordination in VA primary care increased with the launch of the Veterans Choice Act, which aimed to increase access through greater use of non-VA Community Care. These changes may have overburdened already busy providers with additional administrative tasks, contributing to provider burnout. Our objective was to understand the role of challenges with care coordination in burnout. We analyzed relationships between care coordination challenges with Community Care reported by VA primary care providers (PCPs) and VA PCP burnout. METHODS: Our cross-sectional survey contained five questions about challenges with care coordination. We assessed whether care coordination challenges were associated with two measures of provider burnout, adjusted for provider and facility characteristics. Models were also adjusted for survey nonresponse and clustered by facility. Trainee and executive respondents were excluded. 1,543 PCPs in 129 VA facilities nationwide responded to our survey (13 % response rate). RESULTS: 51 % of our sample reported some level of burnout overall, and 46 % reported feeling burned out at least once a week. PCPs were more likely to be burned out overall if they reported more than average challenges with care coordination (odds ratio [OR] 2.04, 95 % confidence interval [CI] 1.58 to 2.63). These challenges include managing patients with outside prescriptions or obtaining outside tests or records. CONCLUSIONS: VA primary care providers who reported greater than average care coordination challenges were more likely to be burned out. Interventions to improve care coordination could help improve VA provider experience.


Assuntos
Esgotamento Profissional , Veteranos , Esgotamento Profissional/epidemiologia , Estudos Transversais , Pessoal de Saúde , Humanos , Atenção Primária à Saúde , Estados Unidos/epidemiologia , United States Department of Veterans Affairs
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