Clinical effectiveness and cost-impact after 2 years of a ketogenic diet and virtual coaching intervention for patients with diabetes.

AIM: We previously evaluated the impacts at 5 months of a digitally delivered coaching intervention in which participants are instructed to adhere to a very low carbohydrate, ketogenic diet. With extended follow-up (24 months), we assessed the longer-term effects of this intervention on changes in clinical outcomes, health care utilization and costs associated with outpatient, inpatient and emergency department use in the Veterans Health Administration. MATERIALS AND METHODS: We employed a difference-in-differences model with a waiting list control group to estimate the 24-month change in glycated haemoglobin, body mass index, blood pressure, prescription medication use, health care utilization rates and associated costs. The analysis included 550 people with type 2 diabetes who were overweight or obese and enrolled in the Veterans Health Administration for health care. Data were obtained from electronic health records from 2018 to 2021. RESULTS: The virtual coaching and ketogenic diet intervention was associated with significant reductions in body mass index [-1.56 (SE 0.390)] and total monthly diabetes medication usage [-0.35 (SE 0.054)]. No statistically significant differences in glycated haemoglobin, blood pressure, outpatient visits, inpatient visits, or emergency department visits were observed. The intervention was associated with reductions in per-patient, per-month outpatient spending [-USD286.80 (SE 97.175)] and prescription drug costs (-USD105.40 (SE 30.332)]. CONCLUSIONS: A virtual coaching intervention with a ketogenic diet component offered modest effects on clinical and cost parameters in people with type 2 diabetes and with obesity or overweight. Health care systems should develop methods to assess participant progress and engagement over time if they adopt such interventions, to ensure continued patient engagement and goal achievement.

Differences in adverse outcomes across race and ethnicity among Veterans with similar predicted risks of an overdose or suicide-related event.

OBJECTIVE: To evaluate the degree to which differences in incidence of mortality and serious adverse events exist across patient race and ethnicity among Veterans Health Administration (VHA) patients receiving outpatient opioid prescriptions and who have similar predicted risks of adverse outcomes. Patients were assigned scores via the VHA Stratification Tool for Opioid Risk Mitigation (STORM), a model used to predict the risk of experiencing overdose- or suicide-related health care events or death. Individuals with the highest STORM risk scores are targeted for case review. DESIGN: Retrospective cohort study of high-risk veterans who received an outpatient prescription opioid between 4/2018-3/2019. SETTING: All VHA medical centers. PARTICIPANTS: In total, 84 473 patients whose estimated risk scores were between 0.0420 and 0.0609, the risk scores associated with the top 5%-10% of risk in the STORM development sample. METHODS: We examined the expected probability of mortality and serious adverse events (SAEs; overdose or suicide-related events) given a patient's risk score and race. RESULTS: Given a similar risk score, Black patients were less likely than White patients to have a recorded SAE within 6 months of risk score calculation. Black, Hispanic, and Asian patients were less likely than White patients with similar risk scores to die within 6 months of risk score calculation. Some of the mortality differences were driven by age differences in the composition of racial and ethnic groups in our sample. CONCLUSIONS: Our results suggest that relying on the STORM model to identify patients who may benefit from an interdisciplinary case review may identify patients with clinically meaningful differences in outcome risk across race and ethnicity.

Excess Mortality at Veterans Health Administration Facilities During the COVID-19 Pandemic.

IMPORTANCE: The COVID-19 pandemic resulted in excess mortality among the general US population and at Veterans Health Administration (VHA) facilities. It is critical to understand the characteristics of facilities that experienced the highest and lowest pandemic-related mortality to inform future mitigation efforts. OBJECTIVE: To identify facility-level excess mortality during the pandemic and to correlate these estimates with facility characteristics and community-wide rates of COVID-19 burden. DESIGN: We used pre-pandemic data to estimate mortality risk prediction models using 5-fold cross-validation and Poisson quasi-likelihood regression. We then estimated excess mortality and observed versus expected (O/E) mortality ratios by the VHA facility from March to December 2020. We examined facility-level characteristics by excess mortality quartile. PARTICIPANTS: Overall, there were 11.4 million VHA enrollees during 2016 and 2020. MAIN MEASURES: Facility-level O/E mortality ratios and excess all-cause mortality. RESULT: VHA-enrolled veterans experienced 52,038 excess deaths from March to December 2020, equating to 16.8% excess mortality. Facility-specific rates ranged from -5.5% to +63.7%. Facilities in the lowest quartile for excess mortality experienced fewer COVID-19 deaths (0.7-1.51, P <0.001) and cases (52.0-63.0, P =0.002) per 1,000 population compared with the highest quartile. The highest quartile facilities had more hospital beds (276.7-187.6, P =0.024) and a higher percent change in the share of visits conducted via telehealth from 2019 to 2020 (183%-133%, P <0.008). CONCLUSIONS: There was a large variation in mortality across VHA facilities during the pandemic, which was only partially explained by the local COVID-19 burden. Our work provides a framework for large health care systems to identify changes in facility-level mortality during a public health emergency.

Effect of a Predictive Analytics-Targeted Program in Patients on Opioids: a Stepped-Wedge Cluster Randomized Controlled Trial.

BACKGROUND: Risk of overdose, suicide, and other adverse outcomes are elevated among sub-populations prescribed opioid analgesics. To address this, the Veterans Health Administration (VHA) developed the Stratification Tool for Opioid Risk Mitigation (STORM)-a provider-facing dashboard that utilizes predictive analytics to stratify patients prescribed opioids based on risk for overdose/suicide. OBJECTIVE: To evaluate the impact of the case review mandate on serious adverse events (SAEs) and all-cause mortality among high-risk Veterans. DESIGN: A 23-month stepped-wedge cluster randomized controlled trial in all 140 VHA medical centers between 2018 and 2020. PARTICIPANTS: A total of 44,042 patients actively prescribed opioid analgesics with high STORM risk scores (i.e., percentiles 1% to 5%) for an overdose or suicide-related event. INTERVENTION: A mandate requiring providers to perform case reviews on opioid analgesic-prescribed patients at high risk of overdose/suicide. MAIN MEASURES: Nine serious adverse events (SAEs), case review completion, number of risk mitigation strategies, and all-cause mortality. KEY RESULTS: Mandated review inclusion was associated with a significant decrease in all-cause mortality within 4 months of inclusion (OR: 0.78; 95% CI: 0.65-0.94). There was no detectable effect on SAEs. Stepped-wedge analyses found that mandated review patients were five times more likely to receive a case review than non-mandated patients with similar risk (OR: 5.1; 95% CI: 3.64-7.23) and received more risk mitigation strategies than non-mandated patients (0.498; CI: 0.39-0.61). CONCLUSIONS: Among VHA patients prescribed opioid analgesics, identifying high risk patients and mandating they receive an interdisciplinary case review was associated with a decrease in all-cause mortality. Results suggest that providers can leverage predictive analytic-targeted population health approaches and interdisciplinary collaboration to improve patient outcomes. TRIAL REGISTRATION: ISRCTN16012111.

Impact of Mandated Case Review Policy on Opioid Discontinuation and Mortality Among High-Risk Long-Term Opioid Therapy Patients: The STORM Stepped-Wedge Cluster Randomized Controlled Trial.

BACKGROUND: Although long-term opioid therapy (LTOT) has its own risks, opioid discontinuation could pose harm for high-risk Veterans Health Administration (VHA) patients receiving LTOT. There is limited information on the impact of a mandate requiring providers to perform case reviews on high-risk patients with an active opioid prescription (ie, mandated case review policy) on opioid discontinuation and mortality. METHODS: Our study is a secondary data analysis of a 23-month stepped-wedge cluster randomized controlled trial between April 2018 and March 2020. The study included 10 685 LTOT patients with a predicted risk of a serious adverse event between the top 1% to 5% nationally who entered the risk range between 4/18/2018 and 11/9/2019. We examined whether the mandated case review policy had an impact on opioid discontinuation and mortality for the patients. RESULTS: Among 10 685 LTOT patients (88.2% male; mean [SD] age, 61.1 [11.7] years), 29.1% experienced discontinuation and the mortality rate was 9.5%. Patients under mandated case review had a decreased risk of opioid discontinuation (average marginal effect [AME], -11.16 [95% CI, -15.30 to -7.01] percentage points) and all-cause mortality (AME, -3.31 [95% CI, -5.63 to -1.00] percentage points), relative to patients who were not under the mandate. CONCLUSIONS: The VHA mandated case review policy was associated with lower probability of discontinuation and all-cause mortality for high-risk patients receiving LTOT. Interventions that maintain care engagement while optimizing pain management for high-risk patients may be beneficial for minimizing mortality and other risks associated with discontinuation.

Randomized Policy Evaluation of the Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM).

BACKGROUND: The Veterans Health Administration (VHA) developed a dashboard Stratification Tool for Opioid Risk Mitigation (STROM) to guide clinical practice interventions. VHA released a policy mandating that high-risk patients of an adverse event based on the STORM dashboard are to be reviewed by an interdisciplinary team of clinicians. AIM: Randomized program evaluation to evaluate if patients in the oversight arm had a lower risk of opioid-related serious adverse events (SAEs) or death compared to those in the non-oversight arm. SETTING AND PARTICIPANTS: One-hundred and forty VHA facilities (aka medical centers) were randomly assigned to two groups: oversight and non-oversight arms. VHA patients who were prescribed opioids between April 18, 2018, and November 8, 2019, were included in the cohort. PROGRAM DESCRIPTION: We hypothesized that patients cared for by VHA facilities that received the policy with the oversight accountability language would achieve lower opioid-related SAEs or death. PROGRAM EVALUATION: We did not observe a relationship between the oversight arm and opioid-related SAEs or death. Patients in the non-oversight arm had a significantly higher chance of receiving a case review compared to those in the oversight arm. DISCUSSION: Even though our findings were unexpected, the STORM policy overall was likely successful in focusing the provider's attention on very high-risk patients.

Effectiveness of a ketogenic diet and virtual coaching intervention for patients with diabetes: A difference-in-differences analysis.

AIM: To test the effectiveness of a ketogenic diet and virtual coaching intervention in controlling markers of diabetes care and healthcare utilization. MATERIALS AND METHODS: Using a difference-in-differences analysis with a waiting list control group-a quasi-experimental methodology-we estimated the 5-month change in HbA1c, body mass index, blood pressure, prescription medication use and costs, as well as healthcare utilization. The analysis included 590 patients with diabetes who were also overweight or obese, and who regularly utilize the Veterans Health Administration (VA) for healthcare. We used data from VA electronic health records from 2018 to 2020. RESULTS: The ketogenic diet and virtual coaching intervention was associated with significant reductions in HbA1c (-0.69 [95% CI -1.02, -0.36]), diabetes medication fills (-0.38, [-0.49, -0.26]), body mass index (-1.07, [-1.95, -0.19]), diastolic blood pressure levels (-1.43, [-2.72, -0.14]), outpatient visits (-0.36, [-0.70, -0.02]) and prescription drug costs (-34.54 [-48.56, -20.53]). We found no significant change in emergency department visits (-0.02 [-0.05, 0.01]) or inpatient admissions (-0.01 [-0.02, 0.01]). CONCLUSIONS: This real-world assessment of a virtual coaching and diet programme shows that such an intervention offers short-term benefits on markers of diabetes care and healthcare utilization in patients with diabetes.

Do JUUL and e-cigarette flavours change risk perceptions of adolescents? Evidence from a national survey.

INTRODUCTION: Use of JUULs and e-cigarettes is growing rapidly, particularly among adolescents. Research suggests that flavours may increase the appeal of these products, but little is known about how flavours influence perception. We examined whether youth perceptions about the health risks of JUULs and e-cigarettes vary with flavours. METHODS: We conducted a national survey in 2018 of 1610 high-school students aged 14-18 who had ever heard of either JUULs or e-cigarettes. Respondents were asked to rate the lung cancer risk, the harm of second-hand vapour, potential for addiction and healthiness of differently flavoured JUUL and e-cigarette products. We investigated the relationship among flavour, risk perception and socio-demographic information. RESULTS: We found that risk perceptions for both JUULs and e-cigarettes differ significantly by flavour type. Youths perceive fruit flavours to be less likely to lead to lung cancer (-0.909 (0.065)), have harmful second-hand vapour (-0.933 (0.060)) and be more addictive (1.104 (0.094)) relative to tobacco flavours. Candy, menthol/mint and alcohol flavours show similar patterns of risk association, although the magnitude is slightly smaller than for fruit flavours. CONCLUSIONS: Youths believe that flavours are related to the health risks of both JUULs and e-cigarettes despite the fact that these differences in risk by flavour have not been scientifically or systematically established. A policy concern is that misperceptions based on flavour may result in increased vaping by youths. The findings from this study support the assertion that banning fruit, menthol or mint and sweet flavours could reduce the appeal of JUULs and e-cigarettes to youth, with concomitant health protections.

Factors Associated With Uptake of an Open Access Health Center-Based Mobile Produce Market: A Case for Expanded Eligibility.

BACKGROUND: Health care-based food assistance programs show promise but are underutilized. Strict eligibility requirements and program scheduling may dampen reach and outcomes. OBJECTIVE: To explore factors associated with uptake of a health center-based mobile produce market with no eligibility requirements and few barriers to entry. DESIGN: A cross-sectional analysis of medical record, sociodemographic, environmental, and market attendance data was used. PARTICIPANTS/SETTING: The study sample consisted of 3071 adults (18+ years) who were patients of an urban health center in eastern Massachusetts and registered for the mobile market during the study period of August 2016 to February 2020. MAIN OUTCOME MEASURES: The main outcome measure was monthly market attendance over the study period. STATISTICAL ANALYSES: T-tests and χ2 tests were used to compare market users and never-users. Multiple logistic regression was used to analyze variables associated with market attendance each month. RESULTS: In multiple variable analyses, Supplemental Nutrition Assistance Program enrollment was associated with slightly less frequent monthly market use (odds ratio [OR], 0.989; 95% CI, 0.984-0.994). Day-of, on-site market registration was associated with more frequent monthly use than self-registration on nonmarket days (OR, 1.08; 95% CI, 1.07-1.08). Having a psychiatric or substance use disorder diagnosis was associated with slightly less frequent market attendance (OR, 0.99; 95% CI, 0.98-0.99; and OR, 0.96; 95% CI, 0.95-0.97, respectively) compared with registrants without these diagnoses. CONCLUSIONS: Individual, community-level, and organizational factors are associated with uptake of a free mobile produce market and should be considered when designing programs.

A Qualitative Study of A Health Center-Based Mobile Produce Market.

Healthcare-based food assistance programs have the potential to improve patients' food security, but are underutilized. We conducted a qualitative study of user and staff perceptions of an on-site mobile market at a federally-qualified health center (FQHC). Five themes were identified: 1) financial need drives the decision to use the market, 2) people attend specifically to receive healthy food, 3) users feel a connection to the FQHC, which increases participation, 4) social networks increase usage of the program, and 5) long lines, inclement weather, inaccessibility, and inconsistent marketing and communication are attendance barriers. Findings should inform implementation of future healthcare-based food assistance programs.

Veterans Crisis Line Contacts After the 988 Suicide and Crisis Lifeline Rollout.

INTRODUCTION: This study identifies changes in Veterans Crisis Line (VCL) contact volume following the 988 National Suicide Prevention Hotline rollout, and examines changes in contact volume for self-identified Veterans. METHODS: VCL's Medora database was analyzed from July 2018 to June 2023, fitting linear interrupted time series models to forecast trends after the July 2022 rollout of the 988 Suicide Prevention Hotline. Data analysis was performed from 2023 to 2024. RESULTS: After the 988 rollout, average monthly VCL contact volume increased by 5,388 contacts (8.2%). The number of contacts self-identifying as Veterans increased by 2,739 (6.2%), while the percentage of self-identifying Veteran contacts who could be linked to VHA records declined by 3.8%. CONCLUSIONS: The 988 rollout was associated with increased VCL contact volume and broad changes in the profile of users. This underscores the importance of crisis services in adapting to dynamic user needs and highlights the potential of national suicide prevention initiatives to reach diverse populations.

Caring Letters Sent by a Clinician or Peer to At-Risk Veterans: A Randomized Clinical Trial.

Importance: Caring letters is an evidence-based suicide prevention intervention in acute care settings, but its outcomes among individuals who contact a national crisis line have not previously been evaluated. Objective: To examine the outcomes of the Veterans Crisis Line (VCL) caring letters intervention and determine whether there are differences in outcomes by signatory. Design, Setting, and Participants: This parallel randomized clinical trial compared signatories of caring letters and used an observational design to compare no receipt of caring letters with any caring letters receipt. Participants included veterans who contacted the VCL. Enrollment occurred between June 11, 2020, and June 10, 2021, with 1 year of follow-up. Analyses were completed between July 2022 and August 2023. Intervention: Veterans were randomized to receive 9 caring letters for 1 year from either a clinician or peer veteran signatory. Main Outcomes and Measures: The primary outcome measure was suicide attempt incidence in the 12 months following the index VCL contact. Incidence of Veterans Health Administration (VHA) inpatient, outpatient, and emergency health care use were secondary outcomes. All-cause mortality was an exploratory outcome. Wilcoxon rank-sum tests and χ2 tests were used to assess the differences in outcomes among the treatment and comparison groups. Results: A total of 102 709 veterans (86 942 males [84.65%]; 15 737 females [15.32%]; mean [SD] age, 53.82 [17.35] years) contacted the VCL and were randomized. No association was found among signatory and suicide attempts, secondary outcomes, or all-cause mortality. In the analysis of any receipt of caring letters, there was no evidence of an association between caring letters receipt and suicide attempt incidence. Caring letters receipt was associated with increased VHA health care use (any outpatient: hazard ratio [HR], 1.10; 95% CI, 1.08-1.13; outpatient mental health: HR, 1.19; 95% CI, 1.17-1.22; any inpatient: HR, 1.13; 95% CI, 1.08-1.18; inpatient mental health: HR, 1.14; 95% CI, 1.07-1.21). Caring letters receipt was not associated with all-cause mortality. Conclusions and Relevance: Among VHA patients who contacted the VCL, caring letters were not associated with suicide attempts, but were associated with a higher probability of health care use. No differences in outcomes were identified by signatory. Trial Registration: isrctn.org Identifier: ISRCTN27551361.

Effect of mental health staffing inputs on initiation of care among recently separated Veterans.

OBJECTIVE: To estimate a causal relationship between mental health staffing and time to initiation of mental health care for new patients. DATA SOURCES AND STUDY SETTING: As the largest integrated health care delivery system in the United States, the Veterans Health Administration (VHA) provides a unique setting for isolating the effects of staffing on initiation of mental health care where demand is high and out-of-pocket costs are not a relevant confounder. We use data from the Department of Defense and VHA to obtain patient and facility characteristics and health care use. STUDY DESIGN: To isolate exogenous variation in mental health staffing, we used an instrumental variables approach-two-stage residual inclusion with a discrete time hazard model. Our outcome is time to initiation of mental health care after separation from active duty (first appointment) and our exposure is mental health staffing (standardized clinic time per 1000 VHA enrollees per pay period). DATA COLLECTION/EXTRACTION METHODS: Our cohort consists of all Veterans separating from active duty between July 2014 and September 2017, who were enrolled in the VHA, and had at least one diagnosis of post-traumatic stress disorder, major depressive disorder, and/or substance use disorder in the year prior to separation from active duty (N = 54,209). PRINCIPAL FINDINGS: An increase of 1 standard deviation in mental health staffing results in a higher likelihood of initiating mental health care (adjusted hazard ratio: 3.17, 95% confidence interval: 2.62, 3.84, p < 0.001). Models stratified by tertile of mental health staffing exhibit decreasing returns to scale. CONCLUSIONS: Increases in mental health staffing led to faster initiation of care and are especially beneficial in facilities where staffing is lower, although initiation of care appears capacity-limited everywhere.

A systematic review of the economic value proposition for commercially available nonsurgical weight-loss interventions.

OBJECTIVE: The study aim was to review the economic evaluation literature of commercially available and effective nonsurgical weight-loss interventions to investigate whether there is evidence to support claims of cost-effectiveness (i.e., good value for money) or cost savings (i.e., a positive return on investment). METHODS: Relevant databases were systematically reviewed to identify economic evaluations of commercially available weight-loss products and services shown to result in clinically significant weight loss. Five weight-loss medications (orlistat, liraglutide, naltrexone-bupropion, semaglutide, and phentermine-topiramate), two meal replacement programs (Jenny Craig, Optifast), and one behavioral intervention (Weight Watchers [WW]) that met inclusion criteria were identified. After screening, 32 relevant comparisons of cost-effectiveness or cost savings across 20 studies were identified. RESULTS: Ten of twenty pharmaceutical comparisons showed evidence of cost-effectiveness based on established thresholds. Four of twelve nonpharmaceutical comparisons provided evidence of cost-effectiveness, and five made claims of cost savings. However, methodological concerns cast doubt on the robustness of these claims. CONCLUSIONS: Evidence of cost-effectiveness for commercially available, evidence-based, nonsurgical weight-loss interventions is mixed. There is no evidence for cost-saving weight-loss medications and only weak evidence for behavioral and weight-loss interventions. Results provide a call to action to generate more robust evidence of the economic value proposition for these interventions.

Racial and ethnic disparities in excess mortality among U.S. veterans during the COVID-19 pandemic.

OBJECTIVE: The COVID-19 pandemic disproportionately affected racial and ethnic minorities among the general population in the United States; however, little is known regarding its impact on U.S. military Veterans. In this study, our objectives were to identify the extent to which Veterans experienced increased all-cause mortality during the COVID-19 pandemic, stratified by race and ethnicity. DATA SOURCES: Administrative data from the Veterans Health Administration's Corporate Data Warehouse. STUDY DESIGN: We use pre-pandemic data to estimate mortality risk models using five-fold cross-validation and quasi-Poisson regression. Models were stratified by a combined race-ethnicity variable and included controls for major comorbidities, demographic characteristics, and county fixed effects. DATA COLLECTION: We queried data for all Veterans residing in the 50 states plus Washington D.C. during 2016-2020. Veterans were excluded from analyses if they were missing county of residence or race-ethnicity data. Data were then aggregated to the county-year level and stratified by race-ethnicity. PRINCIPAL FINDINGS: Overall, Veterans' mortality rates were 16% above normal during March-December 2020 which equates to 42,348 excess deaths. However, there was substantial variation by racial and ethnic group. Non-Hispanic White Veterans experienced the smallest relative increase in mortality (17%, 95% CI 11%-24%), while Native American Veterans had the highest increase (40%, 95% CI 17%-73%). Black Veterans (32%, 95% CI 27%-39%) and Hispanic Veterans (26%, 95% CI 17%-36%) had somewhat lower excess mortality, although these changes were significantly higher compared to White Veterans. Disparities were smaller than in the general population. CONCLUSIONS: Minoritized Veterans experienced higher rates excess of mortality during the COVID-19 pandemic compared to White Veterans, though with smaller differences than the general population. This is likely due in part to the long-standing history of structural racism in the United States that has negatively affected the health of minoritized communities via several pathways including health care access, economic, and occupational inequities.

Effect of a Veterans Health Administration mandate to case review patients with opioid prescriptions on mortality among patients with opioid use disorder: a secondary analysis of the STORM randomized control trial.

AIMS: The Veterans Health Administration (VHA) implemented the Stratification Tool for Opioid Risk Mitigation (STORM) to reduce the risk of serious adverse events (SAE) among patients with opioid analgesic prescriptions. VHA facilities were mandated to case review patients identified as high risk by STORM. The aim of this study was to measure the effect of this mandate on all-cause mortality and SAEs among VHA patients newly diagnosed with opioid use disorder (OUD). DESIGN: Secondary analysis of a stepped-wedged cluster randomized controlled trial conducted at all 140 VHA facilities, with facility as the unit of randomization, from 2018 to 2020. SETTING AND PARTICIPANTS: United States VHA facilities were randomized to case review the top 1 or 5% of high-risk patients prescribed opioid analgesics identified by STORM. A total of 28 251 patients were diagnosed with OUD during the trial and were considered control or treatment depending on the status of the facility where they received their OUD diagnosis. Post-hoc analyses among patients who had at least one opioid analgesic prescription in the 90 days prior to diagnosis were conducted and were then stratified by receipt of a prescription in the 90 days following diagnosis to assess the sensitivity of results to opioid discontinuation. MEASUREMENTS: All-cause mortality and opioid-related, drug-related, suicide-related and other SAEs within 90 days of OUD diagnosis. FINDINGS: Mandated case review increased the odds of 90-day mortality [odds ratio (OR) = 1.74, 95% confidence interval (CI) = 1.06, 2.87], but did not significantly change the odds of SAEs. Among patients who received an opioid prescription prior to but not after OUD diagnosis, the odds of all-cause mortality within 90 days was 5.87 (95% CI = 1.85, 18.58) relative to control patients. CONCLUSIONS: Veterans Health Administration patients newly diagnosed with opioid use disorder experienced increased all-cause mortality following expansion of a case review mandate for high-risk patients prescribed opioids.

Healthcare-based food assistance programmes in the United States: a scoping review and typology.

This scoping review aimed to identify the breadth of healthcare-based food assistance programmes in the United States and organize them into a typology of programmes to provide implementation guidance to aspiring food assistance programmers in healthcare settings. We searched PubMed, Cochrane, and CINAHL databases for peer-reviewed articles published between 1 January 2010 and 31 December 2021, and mined reference lists. We used content analysis to extract programmatic details from each intervention and to qualitatively analyse intervention components to develop a typology for healthcare institutions in the United States. Eligible articles included descriptions of patient populations served and programmatic details. Articles were not required to include formal evaluations for inclusion in this scoping review. Our search resulted in 8706 abstracts, which yielded forty-three articles from thirty-five interventions. We identified three distinct programme types: direct food provision, referral, and voucher programmes. Programme type was influenced by programme goals, logistical considerations, such as staffing, food storage or refrigeration space, and existence of willing partner CBOs. Food provision programmes (n 13) were frequently permanent and leveraged partnerships with community-based organisations (CBOs) that provide food. Referral programmes (n 8) connected patients to CBOs for federal or local food assistance enrollment. Voucher programmes (n 14) prioritised provision of fruits and vegetables (n 10) and relied on a variety of clinic staff to refer patients to months-long programmes. Healthcare-based implementers can use this typology to design and maintain programmes that align with the needs of their sites and patient populations.

Effect of mental health staffing inputs on suicide-related events.

OBJECTIVE: To estimate the effects of changes in Veterans Health Administration (VHA) mental health services staffing levels on suicide-related events among a cohort of Veterans. DATA SOURCES: Data were obtained from the VHA Corporate Data Warehouse, the Department of Defense and Veterans Administration Infrastructure for Clinical Intelligence, the VHA survey of enrollees, and customized VHA databases tracking suicide-related events. Geographic variables were obtained from the Area Health Resources Files and the Centers for Medicare and Medicaid Services. STUDY DESIGN: We used an instrumental variables (IV) design with a Heckman correction for non-random partial observability of the use of mental health services. The principal predictor was a measure of provider staffing per 10,000 enrollees. The outcome was the probability of a suicide-related event. DATA COLLECTION/EXTRACTION METHODS: Data were obtained for a cohort of Veterans who recently separated from active service. PRINCIPAL FINDINGS: From 2014 to 2018, the per-pay period probability of a suicide-related event among our cohort was 0.05%. We found that a 1% increase in mental health staffing led to a 1.6 percentage point reduction in suicide-related events. This was driven by the first tertile of staffing, suggesting diminishing returns to scale for mental health staffing. CONCLUSIONS: VHA facilities appear to be staffing-constrained when providing mental health care. Targeted increases in mental health staffing would be likely to reduce suicidality.

County-Level Impact of the COVID-19 Pandemic on Excess Mortality Among U.S. Veterans: A Population-Based Study.

BACKGROUND: As the novel coronavirus (COVID-19) continues to impact the world at large, Veterans of the US Armed Forces are experiencing increases in both COVID-19 and non-COVID-19 mortality. Veterans may be more susceptible to the pandemic than the general population due to their higher comorbidity burdens and older age, but no research has examined if trends in excess mortality differ between these groups. Additionally, individual-level data on demographics, comorbidities, and deaths are provided in near-real time for all enrolees of the Veterans Health Administration (VHA). These data provide a unique opportunity to identify excess mortality throughout 2020 at a subnational level, and to validate these estimates against local COVID-19 burden. METHODS: We queried VHA administrative data on demographics and comorbidities for 11.4 million enrolees during 2016-2020. Pre-pandemic data was used to develop and cross-validate eight mortality prediction models at the county-level including Poisson, Poisson quasi-likelihood, negative binomial, and generalized estimating equations. We then estimated county-level excess Veteran mortality during 2020 and correlated these estimates with local rates of COVID-19 confirmed cases and deaths. FINDINGS: All models demonstrated excellent agreement between observed and predicted mortality during 2016-2019; a Poisson quasi-likelihood with county fixed effects minimized median squared error with a calibration slope of 1.00. Veterans of the U.S. Armed Forces faced an excess mortality rate of 13% in 2020, which corresponds to 50,299 excess deaths. County-level estimates of excess mortality were correlated with both COVID-19 cases (R2=0.77) and deaths per 1,000 population (R2=0.59). INTERPRETATION: We developed sub-national estimates of excess mortality associated with the pandemic and shared our data as a resource for researchers and data journalists. Despite Veterans' greater likelihood of risk factors associated with severe COVID-19 illness, their excess mortality rate was slightly lower than the general population. Consistent access to health care and the rapid expansion of VHA telemedicine during the pandemic may explain this divergence. FUNDING: This work was supported by grants from the Department of Veterans Affairs Quality Enhancement Research Initiative [PEC 16-001]. Dr. Griffith's effort was supported in part by the Agency for Healthcare Research & Quality [K12 HS026395].

Development of the Veterans Crisis Line Caring Letters Suicide Prevention Intervention.

OBJECTIVE: To describe the design, implementation, and plans to evaluate the Veterans Crisis Line (VCL) Caring Letters intervention. DATA SOURCES: Veterans with VCL contact and VHA service utilization. STUDY DESIGN: Caring Letters is an evidence-based post-acute care suicide prevention intervention in which brief messages are mailed to individuals at high risk of suicide repeatedly over time to communicate that people care about them and are concerned for their well-being. An effectiveness-implementation hybrid type 1 trial using the RE-AIM evaluation framework is underway to examine the use of Caring Letters with veterans who contact the VCL. A team of suicide prevention subject matter experts, researchers, and operational partners from the VCL will evaluate the effects of Caring Letters on clinical outcomes and Department of Veterans Affairs - Veterans Health Administration (VHA) clinical utilization rates and examine facilitators and barriers to implementing the Caring Letters campaign. DATA COLLECTION METHODS: Veterans who contact the VCL are linked with national administrative VHA data. Semi-structured interviews were conducted as part of a qualitative formative evaluation. PRINCIPAL FINDINGS: In the first 12 months of the intervention, Caring Letters have been sent to over 100,000 veterans with VCL contact (over 500,000 letters mailed). A formative qualitative evaluation early in implementation revealed a variety of positive veteran perspectives on the intervention. CONCLUSIONS: Partnered program design and evaluation with a high level of stakeholder engagement and participant feedback can result in a rigorous and feasible evaluation plan that improves implementation processes and produces actionable results. The initial results of this evaluation will be used to better inform care in the VHA and, specifically, the VCL.