IL-1 receptor antagonist plus pentoxifylline and zinc for severe alcohol-associated hepatitis.

BACKGROUND AND AIMS: Patients with severe alcohol-associated hepatitis (AH) have high mortality. Corticosteroids improve survival only for 30 days. We targeted inflammation, cellular injury, and gut leakiness in a randomized clinical trial comparing combination therapy to corticosteroids on 180-day survival. APPROACH AND RESULTS: Subjects with a clinical diagnosis of severe AH (Model for End-Stage Liver Disease [MELD] >20, Maddrey discriminant function [MDF] >32) were randomized to receive methylprednisolone (PRED; 28 days) or a combination of anakinra (14 days) plus pentoxifylline (28 days) plus zinc (COMB; 180 days). The primary endpoint was survival at 180 days. The study was designed in 2013, initiated in October 2014, and completed in March 2018. Five hundred patients were screened to randomize 104 subjects with a clinical diagnosis of AH with a MELD score >20. Fifty-three patients were randomized into the COMB and 50 to the PRED treatment; 1 dropped out of the study before randomization. Mean age was 45.3 ± 10.4 years; 60.6% were males, 92.3% White, and mean MELD 25.7 ± 3.9. Kaplan-Meier survival estimate at 180 days was 67.9% in COMB and 56% in PRED (HR = 0.69; p = 0.3001). Survival curves separated by 90 days (COMB, 69.8%; PRED, 58.0%; HR = 0.69; p = 0.28). Survival at 28 days was similar between the COMB (83.4%) and PRED groups (81.2%; HR = 0.91; p = 0.85). There were no unexpected serious adverse events, and incidence of infection was comparable between groups. MELD 20-25 and MELD >26 strata showed nonsignificant treatment effects in favor of COMB. CONCLUSIONS: A combination of anakinra, pentoxifylline plus zinc provides similar survival benefits compared to corticosteroid therapy in severe AH.

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

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

Telemedicine During COVID-19 Response: A Welcome Shift for Younger Female Healthcare Workers.

BACKGROUND: Healthcare workers, especially female employees, have historically been at an increased risk for occupational stress. During the early stages of the COVID-19 pandemic, many healthcare workers shifted to a telework model of care and started working from home (WFH). It is unclear how WFH impacted female healthcare employees' job satisfaction and stress levels. OBJECTIVE: To further understand the impact of WFH on job satisfaction and stress among female healthcare employees. DESIGN: An exploratory survey was utilized. Data was evaluated with generalized linear models and logistic regression. Data was collected March to April 2021, between the third and fourth COVID waves in the U.S.A. PARTICIPANTS: All employees (approximately 1050) within the Veterans Affairs Central Western Massachusetts (VACWM) Healthcare System were invited to participate. We received 220 responses with most (78.6%) respondents identifying as female. MAIN MEASURES: A Work-from-Home Satisfaction Scale and the Professional Quality of Life (ProQOL) Compassion Satisfaction and Burnout Scales. KEY RESULTS: A majority of our participants (> 60%) strongly agreed that WFH during COVID-19 increased their work satisfaction and their ability to feel safe and reduced overall stress levels. Female respondents reported that WFH increased their ability to feel safe, reduced overall stress, and did not interfere with work efficiency when compared to male respondents. Overall, reported burnout was low, with only 32.7% of respondents scoring in the moderate category on the PROQOL burnout scale and no respondents scoring in the high burnout category. CONCLUSIONS: Employees at this VA medical center who had the ability to work from home during the COVID-19 pandemic, particularly younger women, reported less stress, less burnout, and more satisfaction, while maintaining work efficiency and team cohesion. Providing permission to WFH may decrease the added burden that female healthcare workers often experience as they strive to overcome gender gaps and inequalities in the workplace.

Infertility Services for Veterans Enrolled in Veterans Health Administration Care.

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

Evidence-Based Intervention Adaptations Within the Veterans Health Administration: a Scoping Review.

BACKGROUND: Veterans receiving care within the Veterans Health Administration (VA) are a unique population with distinctive cultural traits and healthcare needs compared to the civilian population. Modifications to evidence-based interventions (EBIs) developed outside of the VA may be useful to adapt care to the VA healthcare system context or to specific cultural norms among veterans. We sought to understand how EBIs have been modified for veterans and whether adaptations were feasible and acceptable to veteran populations. METHODS: We conducted a scoping review of EBI adaptations occurring within the VA at any time prior to June 2021. Eligible articles were those where study populations included veterans in VA care, EBIs were clearly defined, and there was a comprehensive description of the EBI adaptation from its original context. Data was summarized by the components of the Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME). FINDINGS: We retrieved 922 abstracts based on our search terms. Following review of titles and abstracts, 49 articles remained for full-text review; eleven of these articles (22%) met all inclusion criteria. EBIs were adapted for mental health (n = 4), access to care and/or care delivery (n = 3), diabetes prevention (n = 2), substance use (n = 2), weight management (n = 1), care specific to cancer survivors (n = 1), and/or to reduce criminal recidivism among veterans (n = 1). All articles used qualitative feedback (e.g., interviews or focus groups) with participants to inform adaptations. The majority of studies (55%) were modified in the pre-implementation, planning, or pilot phases, and all were planned proactive adaptations to EBIs. IMPLICATIONS FOR D&I RESEARCH: The reviewed articles used a variety of methods and frameworks to guide EBI adaptations for veterans receiving VA care. There is an opportunity to continue to expand the use of EBI adaptations to meet the specific needs of veteran populations.

Exploring the Acceptability of Expanded Perinatal Depression Care Practices Among Women Veterans.

BACKGROUND: Veterans receive obstetrical care from community-based providers contracted through the Veterans Health Administration (VA); however, Veterans remain eligible for VA mental healthcare in the perinatal period. To date, few studies have focused specifically on the mental health needs of Veterans during the perinatal period. OBJECTIVE: To examine the acceptability of more comprehensive perinatal mental healthcare screening and treatment in VA care, we explored pregnant and postpartum Veteran perspectives of United States Preventive Services Task Force (USPSTF) recommendations that aim to expand mental health counseling for the prevention and treatment of perinatal depression. DESIGN: Semi-structured interviews with pregnant and postpartum Veterans enrolled in VA care, integrated with quantitative survey data. PARTICIPANTS: Pregnant and postpartum Veterans (n=27) who had delivered infants or were due by February 2020. APPROACH: Framework analysis with an inductive approach was utilized to understand our data, interpret and code our transcripts, and develop themes. KEY RESULTS: Fewer than half (44%) of the women reported seeing a mental health provider at the beginning of their pregnancy. We found that Veterans support USPSTF recommendations in the VA, consider mental healthcare to be very important during the perinatal period, would like better access to mental healthcare resources and peer support networks, and suggest that perinatal depression screening could be more extensive. CONCLUSIONS: These findings support the implementation of more comprehensive perinatal depression prevention policies and practices within VA care. Understanding the real-world feasibility and prevailing barriers to comprehensive perinatal depression care is needed to inform implementation of the USPSTF recommendations or a similar intervention tailored for VA care.

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

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

The impact of military sexual trauma on parent-infant bonding in a sample of perinatal women veterans.

BACKGROUND: The experience of sexual assault and harassment during military service (military sexual trauma [MST]) is associated with increased risk for perinatal and reproductive health problems among women veterans. The objective of this study was to examine the associations between mothers' MST exposure and mother-infant bonding, as well as to examine whether there are any salient sociodemographic or military service characteristics among women veterans with greater impairment to mother-infant bonding, including stress during pregnancy and posttraumatic stress disorder (PTSD) diagnosis. METHODS: This study was a secondary analysis of data collected from prospective, longitudinal study of women veterans using VHA maternity care benefits at 15 VHA medical centers across the US between January 2016 and February 2020. Participants were 697 pregnant veterans using VHA maternity care benefits. RESULTS: MST was associated with higher maternal depression, and higher maternal depression was associated with poorer mother-infant bonding. The effect of MST on bonding was indirect through depression. PTSD diagnosis and life stressors during pregnancy also had significant indirect pathways with bonding through maternal depression. CONCLUSIONS: Results underscore the need for access to high quality and trauma-informed perinatal mental health treatment for women veterans, for education on the unique risks conveyed by MST provided to civilian providers treating this population outside VA, and for further research to understand how to ameliorate the harmful effects of MST on perinatal women veterans and their children.

Understanding VA's Use of and Relationships With Community Care Providers Under the MISSION Act.

BACKGROUND: Congress has enacted 2 major pieces of legislation to improve access to care for Veterans within the Department of Veterans Affairs (VA). As a result, the VA has undergone a major transformation in the way that care is delivered to Veterans with an increased reliance on community-based provider networks. No studies have examined the relationship between VA and contracted community providers. This study examines VA facility directors' perspectives on their successes and challenges building relationships with community providers within the VA Community Care Network (CCN). OBJECTIVES: To understand who VA facilities partner with for community care, highlight areas of greatest need for partnerships in various regions, and identify challenges of working with community providers in the new CCN contract. RESEARCH DESIGN: We conducted a national survey with VA facility directors to explore needs, challenges, and expectations with the CCN. RESULTS: The most common care referred to community providers included physical therapy, chiropractic, orthopedic, ophthalmology, and acupuncture. Open-ended responses focused on 3 topics: (1) Challenges in working with community providers, (2) Strategies to maintain strong relationships with community providers, and (3) Re-engagement with community providers who no longer provide care for Veterans. CONCLUSIONS: VA faces challenges engaging with community providers given problems with timely reimbursement of community providers, low (Medicare) reimbursement rates, and confusing VA rules related to prior authorizations and bundled services. It will be critical to identify strategies to successfully initiate and sustain relationships with community providers.

Racial Differences in the Cesarean Section Rates Among Women Veterans Using Department of Veterans Affairs Community Care.

BACKGROUND: Racial disparities in maternal morbidity and mortality remain a pressing public health problem. Variations in cesarean section (C-section) rates among racial and ethnic groups have been well documented, though reasons for these variations remain unknown. In the Department of Veterans Affairs (VA), nearly half of all women Veterans are of reproductive age and >40% of these women are racial and ethnic minorities. Because the VA does not provide obstetrical services, all obstetrical care is provided by community obstetrical providers under the auspices of the VA Community Care Network. However, little is known regarding the rates and correlates of C-sections among women Veterans receiving community obstetrical care. OBJECTIVE: To examine predictors of C-section deliveries among a cohort of racially diverse pregnant Veterans enrolled in VA care at 15 VA medical facilities nationwide. RESEARCH DESIGN: Cross-sectional analysis of a longitudinal, prospective, multisite, observational cohort study of pregnant, and postpartum Veterans receiving community-based obstetrical care. RESULTS: Overall, 659 Veterans delivered babies during the study period, and 35% of the deliveries were C-sections. Predictors of C-section receipt included being a woman of color [adjusted odds ratio (AOR), 1.76; 95% confidence interval (CI), 1.19-2.60], having an Edinburgh Postnatal Depression Scale score ≥10 (AOR, 1.71; 95% CI, 1.11-2.65), having a higher body mass indexes (AOR, 1.07; 95% CI, 1.04-1.11), and women who were older (AOR, 1.08; 95% CI, 1.03-1.13). There was a substantial racial variation in C-section rates across our 15 study sites, with C-section rates meeting or exceeding 50% for WOC in 8 study sites. CONCLUSIONS: There is substantial racial and geographic variation in C-section rates among pregnant Veterans receiving obstetrical care through VA community care providers. Future research should carefully examine variations in C-sections by the hospital, and which providers and hospitals are included in VA contracts. There should also be an increased focus on the types of providers women Veterans have access to for obstetrical care paid for by the VA and the quality of care delivered by those providers.

Intimate Partner Violence Among Pregnant Veterans: Prevalence, Associated Mental Health Conditions, and Health Care Utilization.

BACKGROUND: Intimate partner violence (IPV) is a prevalent and serious health concern for women veterans, associated with mental and physical health symptoms. The adverse impacts of IPV are exacerbated during pregnancy, with added risks for pregnancy and postpartum outcomes. OBJECTIVE: Identify the scope of IPV among pregnant veterans and associations with health outcomes. DESIGN: Data were obtained from a national retrospective cohort study. PARTICIPANTS: Study participants were 442 pregnant veterans using VHA maternity care benefits. MAIN MEASURES: Mental health history was assessed via self-report measure and chart review; history of IPV and perinatal depression were assessed via brief validated self-report measures. KEY RESULTS: Fourteen percent of the sample reported past-year IPV. Report of past-year IPV was associated with higher self-reported rates of lifetime mental health disorders including depression (p = 0.01), posttraumatic stress disorder (p = 0.02), anxiety disorders (p = 0.05), mood disorders (p = 0.01), bipolar disorder (p = 0.001), and eating disorders (p = 0.003); past-year IPV was also associated with the diagnosis of posttraumatic stress disorder during pregnancy (p = 0.002). Additionally, past-year IPV was associated with higher rates of military sexual trauma (MST; p = 0.03), pregnancy health risk behaviors (i.e., smoking, alcohol, and drug use; p = 0.004), greater number of VHA mental health visits during pregnancy (p = 0.04), and a lower likelihood of seeking social support from a spouse or partner (p < 0.0001). CONCLUSIONS: Results indicate substantial rates of IPV among pregnant veterans, and high rates of mental health conditions which may be exacerbated by MST experience and lower likelihood of seeking social support. Clinicians treating pregnant veterans should screen for and address IPV and mental health treatment needs, and risks should be assessed among pregnant veterans experiencing IPV.

Peripartum depression: Does risk versus diagnostic status impact mother-infant bonding and perceived social support?

BACKGROUND: Peripartum depression (PND) impairs mother-infant boding and perceived social support, yet limited research has examined if women at-risk for PND (AR-PND) also experience impairment. We examined if pregnant women AR-PND, women with PND, and healthy comparison women (HCW) differed in their mother-infant bonding and social support. As PND is highly comorbid with anxiety, we also examined if peripartum anxiety impacted postpartum diagnosis of PND. METHODS: A total of 144 pregnant women AR-PND or euthymic were assessed twice antepartum and twice postpartum. We utilized regression models to examine the impact of PND risk group status and diagnostic status on mother-infant bonding and perceived social support postpartum. We conducted a sensitivity analysis using a generalized estimating equations model to determine if anxiety (Hamilton Anxiety Rating Scale, HAM-A) across all four time points was associated with the postpartum diagnosis of PND. RESULTS: Women AR-PND experienced significantly worse mother-infant bonding compared to HCW (p = .03). Women diagnosed with PND experienced significantly worse mother-infant bonding and social support compared to HCW (p = .001, p = .002, respectively) and to those who were at-risk for but did not develop PND (p = .02, p = .008, respectively). HAM-A severity at each visit was associated with PND diagnosis status, where each increase in HAM-A was associated with 15% increased odds of being diagnosed with PND postpartum. CONCLUSIONS: Both women AR-PND and those with PND experience worse mother-infant bonding. Peripartum anxiety should also be assessed as it represents a marker for later PND.

Exploring the Extent of Perinatal Depression Screening in the Health Records of Veterans.

To investigate adherence by Veterans Affairs (VA) providers to perinatal depression screening clinical practice guidelines (two prenatal and one postpartum screen). Women Veterans who enrolled in a multisite cohort study during pregnancy and delivered newborns between January 1, 2016 and December 31, 2019 were included. VA electronic health record (EHR) and claims data identified the start of pregnancy care, depression screens, and medical history. Prenatal and postpartum telephone surveys collected demographics, pregnancy characteristics, and Edinburgh Postnatal Depression Scale (EPDS) scores. Data from EHRs was combined with telephone survey data to create the analytic dataset (n = 663). Most (93%) Veterans had primary care at the VA during pregnancy; 41% saw a VA mental health provider. Perinatal depression screens were conducted with 43% of Veterans; 13% had both prenatal and postnatal screens. Screened Veterans were less likely to be diagnosed with depression by a VA provider in either the preconception or pregnancy time periods compared to those not screened (11% vs. 24% and 14% vs 23%, respectively). Among unscreened women, 18% scored positive for depression prenatally and 9% postnatally on the EPDS. Less than half of our sample had evidence of depression screening during the perinatal period, despite contact with VA providers. Perinatal Veterans sustaining VA mental health care may account for fewer screens. Lack of screening may hinder connection to VA mental health treatment and referral resources for symptomatic women. VA should ensure Veterans receive perinatal depression screening to mediate the risks of depression on Veterans and their children.

Biomarkers of Macrophage Activation and Immune Danger Signals Predict Clinical Outcomes in Alcoholic Hepatitis.

Although mortality due to acute alcoholic hepatitis (AH) correlates with Model for End-Stage Liver Disease (MELD) scores, biomarkers are critically needed to manage this disease. Increases in inflammatory markers and macrophage activation are associated with acute AH and could be potential biomarkers of clinical events and/or mortality. We enrolled 89 clinically diagnosed AH patients in four US academic medical centers. Plasma from AH patients had a significant increase in gut microbial translocation indicators (endotoxin, bacterial 16S ribosomal DNA) and host response indicators (soluble cluster of differentiation 14 [sCD14] and lipopolysaccharide binding protein [LBP]) compared to controls. Patient MELD score and Glasgow Alcoholic Hepatitis score (GAHS) correlated with endotoxin levels. AH patients also had a significant increase in high mobility group protein 1 (HMGB1), a sterile danger signal molecule, and osteopontin (OPN), a multifunctional phosphoprotein involved in neutrophil activation, compared to controls. Increased levels of OPN positively correlated with increasing MELD score, GAHS, and LBP levels. Consistent with these results, AH patients had significantly increased circulating levels of macrophage activation (sCD163 and sCD206) markers compared to healthy controls, and sCD163 and sCD206 significantly and positively correlated with OPN, HMGB1, and LBP levels as well as with MELD score and GAHS. These findings indicate a connection between microbial translocation, immune cell activation, and AH severity. Plasma sCD14, OPN, sCD163, and sCD206 levels were significantly higher in nonsurvivors than survivors. In multivariate regression models, we identified sCD14, sCD163, and OPN as independent predictors of 90-day mortality, infection, and organ failure development, respectively. Conclusion: Our study suggests that sCD14, LBP, OPN, sCD163, and sCD206 are biomarkers to indicate severity and predict clinical outcomes in AH.

Utilization of deceased organ donors based on HIV, hepatitis B virus, and hepatitis C virus screening test results.

BACKGROUND: Potential deceased organ donors are screened for human immunodeficiency virus (HIV-1), hepatitis B virus (HBV), and hepatitis C virus (HCV) with serologic tests and nucleic acid tests (NATs). The results of these tests on the utilization of donors have not been directly measured. METHODS: Twenty-six organ procurement organizations (OPOs) provided primary HIV, HBV, and HCV screening results and utilization information for donor referrals evaluated from 2004 to 2017. Additional information regarding donor organ utilization was obtained from the Organ Procurement and Transplantation Network database. Data were analyzed using logistic regression. RESULTS: Test results were submitted for 38 166 potential deceased organ donors; 31 (0.1%) were HIV NAT-negative but seropositive, 5.2% were HBV core antibody-positive and NAT-negative, while 1.8% were HCV antibody-positive and NAT-negative. Organ utilization of HBV and/or HCV NAT-negative organs increased over time despite positive antibody status. CONCLUSIONS: Nucleic acid test detected infections in seronegative donors, especially for HCV. The use of NAT for deceased donor screening correlated with increased utilization of donor organs.

Treatment and Management of Depression Symptoms in Pregnant Veterans: Varying Experiences of Mental Health Care in the Prenatal Period.

Depression screening is recommended for all pregnant veterans; however, little is known on how often symptomatic women receive care, how depression treatment presents in practice, and whether women veterans are utilizing treatment during the appreciable perinatal period. Our sample included 142 pregnant veterans from 15 Veterans Health Administration (VA) medical facilities with Edinburgh Postnatal Depression Scale (EPDS) scores ≥10. Sociodemographic characteristics, military service, health utilization, and pregnancy related factors were collected as part of a telephone survey. A majority of our sample (70%) had 1 or more mental health visits or antidepressant prescriptions during pregnancy. Women with a history of depression had more mental health visits and a higher percentage of antidepressant use before and during pregnancy than women without a history of depression. Pregnant women veterans without a history of depression may be less likely to receive care for depression during pregnancy. However, the majority of our veterans showing depression symptoms prenatally had at least one mental health visit or an antidepressant medication fill during their pregnancy window, suggesting that mental health care is readily available for women veterans.

Understanding Maternity Care Coordination for Women Veterans Using an Integrated Care Model Approach.

BACKGROUND: An increasing number of women veterans are using VA maternity benefits for their pregnancies. However, because the VA does not offer obstetrical care, women must seek maternity care from non-VA providers. The growing number of women using non-VA care has increased the importance of understanding how this care is integrated with ongoing VA medical and mental health services and how perceptions of care integration impact healthcare utilization. Therefore, we sought to understand these relationships among a sample of postpartum veterans utilizing VA maternity benefits. METHODS: We fielded a modified version of the Patient Perceptions of Integrated Care survey among a sample of postpartum veterans who had utilized VA maternity benefits for their pregnancies (n = 276). We assessed relationships between perceptions of six domains of patient-reported integrated care, indicating how well-integrated patients perceived the care received from VA and non-VA clinicians, and utilization of mental healthcare following pregnancy. RESULTS: Domain scores were highest for items focused on VA care, including test result communication and VA provider's knowledge of patient's medical conditions. Scores were lower for obstetrician's knowledge of patient's medical history. Women with depressive symptom scores indicative of depression rated test result communication as highly integrated, while women who received mental healthcare following pregnancy had low integrated care ratings for the Support for Medication and Home Health Management domain, indicating a lack of support for mental health conditions following pregnancy. DISCUSSION: Among a group of postpartum veterans, poor ratings of integrated care across some domains were associated with higher rates of mental healthcare use following pregnancy. Further assessment of integrated care by patients may assist VA providers and policymakers in developing systems to ensure integrated care for veterans who receive care outside the VA.