Factors Related to Prescription Drug Monitoring Program Queries for Veterans Receiving Long-Term Opioid Therapy.

OBJECTIVE: State prescription drug monitoring programs (PDMPs) identify controlled medications dispensed across providers and systems. Department of Veterans Affairs (VA) policy requires electronic health record documentation of PDMP queries at least annually for VA patients receiving controlled medications; however, queries are not uniformly conducted. We examined factors associated with PDMP queries for veterans receiving long-term opioid therapy. METHODS: Veterans with a VA provider who received long-term opioid therapy between August 2015 and August 2016 within a four-state region were identified; 9,879 were due for a PDMP query between August 2016 and February 2017. Likelihood of veterans' PDMP queries during this follow-up period was modeled as a function of patient, provider, and facility characteristics of interest in mixed-effects modified Poisson models estimating relative risk and 95% confidence intervals. Multivariable models controlled for potential confounders identified through the use of directed acyclic graphs. RESULTS: PDMP queries were documented for 62.1% of veterans that were due for a PDMP query. Veterans were more likely to be queried if they were Hispanic or if they received methadone, had average daily milligram morphine equivalents >20, or received urine drug screening during the studied period. Veterans were less likely to be queried if they had a rural address, mail order medication, or cancer diagnosis. Likelihood of PDMP queries was also lower for veterans whose opioid-prescribing provider was an oncologist or working in a low-complexity facility. CONCLUSIONS: Adherence to PDMP query policy within the VA varied by patient, clinician, and facility factors. Mechanisms to standardize the conduct of PDMP queries may be needed.

Veterans Health Administration enrollees' choice of care setting relates to the expansion of care options: Evidence from screening colonoscopies before and after the MISSION Act.

OBJECTIVE: To estimate whether those enrolled in the Veterans Health Administration (VHA) were less likely to use VHA-delivered colorectal cancer screening colonoscopies after the MISSION Act. DATA SOURCES AND STUDY SETTING: Secondary data were collected on VHA-enrolled Veterans from FY2017-FY2021. STUDY DESIGN: This retrospective cross-sectional study measured the volume and share of screening colonoscopies that were VHA-delivered over time and by drive time eligibility-defined as living more than 60 min away from the nearest VHA specialty-care clinic. We used a multivariable logistic regression to adjust for patient and facility factors. DATA EXTRACTION: Data were extracted for VHA enrollees (n = 773,766) who underwent a screening colonoscopy either performed or purchased by the VHA from FY2017-FY2021. PRINCIPAL FINDINGS: In the 9 months after the implementation of the MISSION Act, and before the onset of the Covid-19 pandemic, the average monthly VHA-share of screening colonoscopies decreased by 3 percentage points (pp; 95% confidence interval [CI] = [-4 to -2 pp]) for the non-drive time eligible group and it decreased by 16 pp (95% CI = [-22 to -9 pp]) for the drive time eligible group. The total number of screening colonoscopies did not significantly change in either group during this time period. After adjusting for patient characteristics, a linear time trend, and parent facility fixed effects, implementation of the MISSION Act was associated with a reduction in the probability of a VHA-delivered screening colonoscopy (average marginal effect [AME]: -2.5 pp; 95% CI = [-5.1 to 0.0 pp]) for the non-drive time eligible group. The drive time eligible group (AME: -9.4 pp; 95% CI = [-13.2 to -5.5 pp]) experienced a larger change. CONCLUSIONS: The VHA-share of screening colonoscopies among VHA enrollees fell in the 9 months immediately after the passage of the MISSION Act. This decline was larger for VHA enrollees who were targeted for eligibility due to a longer drive time. These results suggest that the MISSION Act led to more VHA-purchased care among targeted VHA enrollees, though it is unclear whether total utilization increased.

Participation of Veterans Affairs Medical Centers in veteran-centric community-based service navigation networks: A mixed methods study.

OBJECTIVE: To understand the determinants and benefits of cross-sector partnerships between Veterans Affairs Medical Centers (VAMCs) and geographically affiliated AmericaServes Network coordination centers that address Veteran health-related social needs. DATA SOURCES AND SETTING: Semi-structured interviews were conducted with AmericaServes and VAMC staff across seven regional networks. We matched administrative data to calculate the percentage of AmericaServes referrals that were successfully resolved (i.e., requested support was provided) in each network overall and stratified by whether clients were also VAMC patients. STUDY DESIGN: Convergent parallel mixed-methods study guided by Himmelman's Developmental Continuum of Change Strategies (DCCS) for interorganizational collaboration. DATA COLLECTION: Fourteen AmericaServes staff and 17 VAMC staff across seven networks were recruited using snowball sampling and interviewed between October 2021 and April 2022. Rapid qualitative analysis methods were used to characterize the extent and determinants of VAMC participation in networks. PRINCIPAL FINDINGS: On the DCCS continuum of participation, three networks were classified as networking, two as coordinating, one as cooperating, and one as collaborating. Barriers to moving from networking to collaborating included bureaucratic resistance to change, VAMC leadership buy-in, and not having VAMCs staff use the shared technology platform. Facilitators included ongoing communication, a shared mission of serving Veterans, and having designated points-of-contact between organizations. The percentage of referrals that were successfully resolved was lowest in networks engaged in networking (65.3%) and highest in cooperating (85.6%) and collaborating (83.1%) networks. For coordinating, cooperating, and collaborating networks, successfully resolved referrals were more likely among Veterans who were also VAMC patients than among Veterans served only by AmericaServes. CONCLUSIONS: VAMCs participate in AmericaServes Networks at varying levels. When partnerships are more advanced, successful resolution of referrals is more likely, especially among Veterans who are dually served by both organizations. Although challenges to establishing partnerships exist, this study highlights effective strategies to overcome them.

Barriers to accessing pain management services among veterans with bipolar disorder.

OBJECTIVE: To identify barriers veterans with bipolar disorder face to accessing chronic pain management services within a Veterans Affairs (VA) health care system. DATA SOURCES AND STUDY SETTING: Veterans (n = 15) with chronic pain and bipolar disorder and providers (n = 15) working within a mid-Atlantic VA health care system. Data were collected from August 2017-June 2018. STUDY DESIGN: Veteran interviews focused on their chronic pain experiences and treatment, including barriers that arose when trying to access pain management services. Provider interviews focused on whether they address chronic pain with veteran patients and, if so, what considerations arise when addressing pain in veterans with bipolar disorder and other serious mental illnesses. DATA COLLECTION: Veterans were at least 18 years old, had a confirmed bipolar disorder and chronic pain diagnosis, and engaged in outpatient care within the VA health care system. Clinicians provided direct care services to veterans within the same VA. Interviews lasted approximately 60 min and were transcribed and analyzed using a rapid analysis protocol. PRINCIPAL FINDINGS: Four major themes emerged from veteran and provider interviews: siloed care (unintegrated and uncoordinated mental and physical health care), mental health primacy (prioritization of mental health symptoms at expense of physical health symptoms), lagging expectations (unfamiliarity with comprehensive evidence-based pain management options), and provider-patient communication concerns (inefficient communication about pain concerns and treatment options). CONCLUSIONS: Veterans with co-occurring pain and bipolar disorder face unique barriers that compromise equitable access to evidence-based pain treatment. Our findings suggest that educating providers about bipolar disorder and other serious mental illnesses and the benefit of effective non-pharmacological pain interventions for this group may improve care coordination and care quality and reduce access disparities.

Organization of pulmonary hypertension care in non-expert care settings: Lessons learned from a multi-site study.

OBJECTIVE: To examine how select Veterans Health Administration (VA) sites organized care for patients with pulmonary hypertension (PH), with a focus on describing existing practices and identifying unmet needs within the sites. DATA SOURCES AND STUDY SETTING: Semi-structured interviews across seven diverse VA sites. STUDY DESIGN: Qualitative multiple-site study. DATA COLLECTION/EXTRACTION METHODS: We interviewed 54 key informants including pulmonologists, cardiologists, primary care providers, advanced care practitioners, pharmacists, and clinical leaders to assess the structures and processes of PH care delivery. We analyzed transcripts using directed content analysis and constructed site profiles for each site, comparing profiles to existing guidelines for PH expert centers. PRINCIPAL FINDINGS: Sites varied considerably in how they organized PH care, with wide variation in the availability of structures and processes recommended for expert centers, including availability of PH expertise and PH-specific resources, multidisciplinary approach to care, establishment of clear referral pathways, and presence of PH education. Further, participants identified three areas of unmet need not directly addressed within current guidelines, including better integration of pharmacists into multidisciplinary teams, early and routine involvement of palliative care, and improved care coordination efforts. CONCLUSIONS: The rising prevalence of PH and evolution of treatments for common PH subgroups underscore the need to standardize PH care delivery in non-expert care settings to improve care quality and patient outcomes. The insight gained from this study may inform the development of guidance appropriate for care settings outside of expert centers.

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.

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.

From patient outcomes to system change: Evaluating the impact of VHA's implementation of the Whole Health System of Care.

OBJECTIVE: To describe how a partnered evaluation of the Whole Health (WH) system of care-comprised of the WH pathway, clinical care, and well-being programs-produced patient outcomes findings, which informed Veterans Health Administration (VA) policy and system change. DATA SOURCES: Electronic health records (EHR)-based cohort of 1,368,413 patients and a longitudinal survey of Veterans receiving care at 18 WH pilot medical centers. STUDY DESIGN: In partnership with VA operations, we focused the evaluation on the impact of WH services utilization on Veterans' (1) use of opioids and (2) care experiences, care engagement, and well-being. Outcomes were compared between Veterans who did and did not use WH services identified from the EHR. DATA COLLECTION: Pharmacy records and WH service data were obtained from the VA EHR, including WH coaching, peer-led groups, personal health planning, and complementary, integrative health therapies. We surveyed veterans at baseline and 6 months to measure patient-reported outcomes. PRINCIPAL FINDINGS: Opioid use decreased 23% (31.5-6.5) to 38% (60.3-14.4) among WH users depending on level of WH use compared to a secular 11% (12.0-9.9) decrease among Veterans using Conventional Care. Compared to Conventional Care users, WH users reported greater improvements in perceptions of care (SMD = 0.138), engagement in health care (SMD = 0.118) and self-care (SMD = 0.1), life meaning and purpose (SMD = 0.152), pain (SMD = 0.025), and perceived stress (SMD = 0.191). CONCLUSIONS: Evidence developed through this partnership yielded key VA policy changes to increase Veteran access to WH services. Findings formed the foundation of a congressionally mandated report in response to the Comprehensive Addiction and Recovery Act, highlighting the value of WH and complementary, integrative health and well-being programs for Veterans with pain. Findings subsequently informed issuance of an Executive Decision Memo mandating the integration of WH into mental health and primary care across VA, now one lane of modernization for VA.

Continuity of care and health care cost among community-dwelling older adult veterans living with dementia.

OBJECTIVES: To estimate the causal impact of continuity of care (COC) on total, institutional, and noninstitutional cost among community-dwelling older veterans with dementia. DATA SOURCES: Combined Veterans Health Administration (VHA) and Medicare data in Fiscal Years (FYs) 2014-2015. STUDY DESIGN: FY 2014 COC was measured by the Bice-Boxerman Continuity of Care (BBC) index on a 0-1 scale. FY 2015 total combined VHA and Medicare cost, institutional cost of acute inpatient, emergency department [ED], long-/short-stay nursing home, and noninstitutional long-term care (LTC) cost for medical (like skilled-) and social (like unskilled-) services were assessed controlling for covariates. An instrumental variable for COC (change of residence by more than 10 miles) was used to account for unobserved health confounders. DATA COLLECTION: Community-dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (N = 102 073). PRINCIPAL FINDINGS: Mean BBC in FY 2014 was 0.32; mean total cost in FY 2015 was $35 425. A 0.1 higher BBC resulted in (a) $4045 lower total cost; (b) $1597 lower acute inpatient cost, $119 lower ED cost, $4368 lower long-stay nursing home cost; (c) $402 higher noninstitutional medical LTC and $764 higher noninstitutional social LTC cost. BBC had no impact on short-stay nursing home cost. CONCLUSIONS: COC is an effective approach to reducing total health care cost by supporting noninstitutional care and reducing institutional care.

Relative accuracy of social and medical determinants of suicide in electronic health records.

OBJECTIVE: This paper compares the accuracy of predicting suicide from Social Determinants of Health (SDoH) or history of illness. POPULATION STUDIED: 5 313 965 Veterans who at least had two primary care visits between 2008 and 2016. STUDY DESIGN: The dependent variable was suicide or intentional self-injury. The independent variables were 10 495 International Classification of Disease (ICD) Version 9 codes, age, and gender. The ICD codes included 40 V-codes used for measuring SDoH, such as family disruption, family history of substance abuse, lack of education, legal impediments, social isolation, unemployment, and homelessness. The sample was randomly divided into training (90 percent) and validation (10 percent) sets. Area under the receiver operating characteristic (AROC) was used to measure accuracy of predictions in the validation set. PRINCIPAL FINDINGS: Separate analyses were done for inpatient and outpatient codes; the results were similar. In the hospitalized group, the mean age was 67.2 years, and 92.1 percent were male. The mean number of medical diagnostic codes during the study period was 37; and 12.9 percent had at least one SDoH V-code. At least one episode of suicide or intentional self-injury occurred in 1.89 percent of cases. SDoH V-codes, on average, elevated the risk of suicide or intentional self-injury by 24-fold (ranging from 4- to 86-fold). An index of 40 SDoH codes predicted suicide or intentional self-injury with an AROC of 0.64. An index of 10 445 medical diagnoses, without SDoH V-codes, had AROC of 0.77. The combined SDoH and medical diagnoses codes also had AROC of 0.77. CONCLUSION: In predicting suicide or intentional self-harm, SDoH V-codes add negligible information beyond what is already available in medical diagnosis codes. IMPLICATIONS FOR PRACTICE: Policies that affect SDoH (eg, housing policies, resilience training) may not have an impact on suicide rates, if they do not change the underlying medical causes of SDoH.

Comprehensive support of family caregivers: Are there health system cost offsets?

OBJECTIVES: To examine the effect of the Department of Veterans Affairs' (VA) Program of Comprehensive Assistance for Caregivers (PCAFC) on total VA health care costs for Veterans. DATA SOURCES: VA claims. STUDY DESIGN: Using a pre-post cohort design with nonequivalent control group, we estimated the effect of PCAFC on total VA costs up through 6 years. The treatment group included Veterans (n = 32 394) whose caregivers enrolled in PCAFC. The control group included an inverse probability of treatment weighted sample of Veterans whose caregivers were denied PCAFC enrollment (n = 38 402). DATA EXTRACTION: May 2009-September 2017. PRINCIPAL FINDINGS: Total VA costs pre-PCAFC application date were no different between groups. Veterans in PCAFC were estimated to have $13 227 in VA costs in the first 6 months post-PCAFC application, compared to $10 806 for controls. Estimated VA costs for both groups decreased in the first 3 years with a narrowing, but persistent and significant, difference, through 5.5 years. No significant difference in VA health care costs existed at 6 years, approximately $10 000 each, though confidence intervals reflect significant uncertainty in cost differences at 6 years. CONCLUSIONS: Increased costs arose from increased outpatient costs of participants. Sample composition changes may explain lack of significance in cost differences at 6 years because these costs comprise of early appliers to PCAFC. Examining 10-year costs could elucidate whether there are long-term cost offsets from increased engagement in outpatient care.

Guideline-concordant initiation of oral anticoagulant therapy for stroke prevention in older veterans with atrial fibrillation eligible for Medicare Part D.

OBJECTIVE: To characterize the rate of guideline-concordant initiation of oral anticoagulation (OAC) among elderly Veterans with atrial fibrillation (AF) and high stroke risk. DATA SOURCES/STUDY SETTING: Veterans Health Administration (VHA) Corporate Data Warehouse (CDW) linked with Medicare claims 2011-2015. STUDY DESIGN: We identified 6619 elderly, high stroke-risk patients with a new episode of AF initially diagnosed in the VHA during fiscal years 2012-2015. We used logistic regression to estimate marginal effects of associations between patient characteristics and OAC initiation within 90 days of the first AF episode. DATA EXTRACTION METHODS: We identified OACs using generic drug names. We calculated comorbidities and risk scores using diagnosis codes from 1 year of baseline data. PRINCIPAL FINDINGS: Overall, 66.5% of Medicare-eligible Veterans with AF at high risk of stroke initiated an OAC within 90 days. We found lower initiation rates for patients enrolled in Medicare Part D and those ineligible for drug co-payment subsidies. OAC initiation rates increased during the study among VHA-reliant patients but not among dual VHA-Part D enrollees. CONCLUSIONS: One-third of elderly Veterans at risk of stroke are not receiving recommended therapy. Increased coordination between Medicare and VHA providers may lead to improvements in anticoagulation quality and stroke prevention.

Attributable Cost of Dementia: Demonstrating Pitfalls of Ignoring Multiple Health Care System Utilization.

OBJECTIVES: To determine dementia prevalence and costs attributable to dementia using Veterans Health Administration (VHA) data with and without Medicare data. DATA SOURCES: VHA inpatient, outpatient, purchased care and other data and Medicare enrollment, claims, and assessments in fiscal year (FY) 2013. STUDY DESIGN: Analyses were conducted with VHA data alone and with combined VHA and Medicare data. Dementia was identified from a VHA sanctioned list of ICD-9 diagnoses. Attributable cost of dementia was estimated using recycled predictions. DATA COLLECTION: Veterans age 65 and older who used VHA and were enrolled in Traditional Medicare in FY 2013 (1.9 million). PRINCIPAL FINDINGS: VHA records indicated the prevalence of dementia in FY 2013 was 4.8 percent while combined VHA and Medicare data indicated the prevalence was 7.4 percent. Attributable cost of dementia to VHA was, on average, $10,950 per veteran per year (pvpy) using VHA alone and $6,662 pvpy using combined VHA and Medicare data. Combined VHA and Medicare attributable cost of dementia was $11,285 pvpy. Utilization attributed to dementia using VHA data alone was lower for long-term institutionalization and higher for supportive care services than indicated in combined VHA and Medicare data. CONCLUSIONS: Better planning for clinical and cost-efficient care requires VHA and Medicare to share data for veterans with dementia and likely more generally.

Linkage of VA and State Prescription Drug Monitoring Program Data to Examine Concurrent Opioid and Sedative-Hypnotic Prescriptions among Veterans.

OBJECTIVE: To examine the prevalence of concurrent Veterans Health Administration (VA) and non-VA prescriptions for opioids and sedative-hypnotic medications among post-9/11 veterans in Oregon. DATA SOURCES: VA health care and prescription data were probabilistically linked with Oregon Prescription Drug Monitoring Program (PDMP) data. STUDY DESIGN: This retrospective cohort study examined concurrent prescriptions among n = 19,959 post-9/11 veterans, by year (2014-2016) and by patient demographic and clinical characteristics. Veterans were included in the cohort for years in which they received VA outpatient care; those receiving hospice or palliative care were excluded. Concurrent prescriptions were defined as ≥1 days of overlap between outpatient prescriptions for opioids and/or sedative-hypnotics (categorized as benzodiazepines vs. non-benzodiazepines). PRINCIPAL FINDINGS: Among 5,882 veterans who filled opioid or sedative-hypnotic prescriptions at VA pharmacies, 1,036 (17.6 percent) filled concurrent prescriptions from non-VA pharmacies. Within drug class, 15.1, 8.8, and 4.6 percent received concurrent VA and non-VA opioids, benzodiazepines, and non-benzodiazepines, respectively. Veteran demographics and clinical diagnoses were associated with the likelihood of concurrent prescriptions, as was enrollment in the Veterans Choice Program. CONCLUSIONS: A considerable proportion of post-9/11 veterans receiving VA care in Oregon filled concurrent prescriptions for opioids and sedative-hypnotics. Fragmentation of care may contribute to prescription drug overdose risk among veterans.

Development of an Adverse Event Surveillance Model for Outpatient Surgery in the Veterans Health Administration.

OBJECTIVE: Develop and validate a surveillance model to identify outpatient surgical adverse events (AEs) based on previously developed electronic triggers. DATA SOURCES: Veterans Health Administration's Corporate Data Warehouse. STUDY DESIGN: Six surgical AE triggers, including postoperative emergency room visits and hospitalizations, were applied to FY2012-2014 outpatient surgeries (n = 744,355). We randomly sampled trigger-flagged and unflagged cases for nurse chart review to document AEs and measured positive predictive value (PPV) for triggers. Next, we used chart review data to iteratively estimate multilevel logistic regression models to predict the probability of an AE, starting with the six triggers and adding in patient, procedure, and facility characteristics to improve model fit. We validated the final model by applying the coefficients to FY2015 outpatient surgery data (n = 256,690) and reviewing charts for cases at high and moderate probability of an AE. PRINCIPAL FINDINGS: Of 1,730 FY2012-2014 reviewed surgeries, 350 had an AE (20 percent). The final surveillance model c-statistic was 0.81. In FY2015 surgeries with >0.8 predicted probability of an AE (n = 405, 0.15 percent), PPV was 85 percent; in surgeries with a 0.4-0.5 predicted probability of an AE, PPV was 38 percent. CONCLUSIONS: The surveillance model performed well, accurately identifying outpatient surgeries with a high probability of an AE.

Empirical-Based Typology of Health Care Utilization by Medicare Eligible Veterans.

OBJECTIVE: Up to 70 percent of patients who receive care through Veterans Health Administration (VHA) facilities also receive care from non-VA providers. Using applied classification techniques, this study sought to improve understanding of how elderly VA patients use VA services and complementary use of non-VA care. METHODS: The study included 1,721,900 veterans age 65 and older who were enrolled in VA and Medicare during 2013 with at least one VA encounter during 2013. Outpatient and inpatient encounters and medications received in VA were classified, and mutually exclusive patient subsets distinguished by patterns of VA service use were derived empirically using latent class analysis (LCA). Patient characteristics and complementary use of non-VA care were compared by patient subset. RESULTS: Five patterns of VA service use were identified that were distinguished by quantity of VA medical and specialty services, medication complexity, and mental health services. Low VA Medical users tend to be healthier and rely on non-VA services, while High VA users have multiple high cost illnesses and concentrate their care in the VA. CONCLUSIONS: VA patients distinguished by patterns of VA service use differ in illness burden and the use of non-VA services. This information may be useful for framing efforts to optimize access to care and care coordination for elderly VA patients.

Overcoming Challenges to Evidence-Based Policy Development in a Large, Integrated Delivery System.

OBJECTIVE: To describe a new Veterans Health Administration (VHA) program to foster the learning health system paradigm by rigorously evaluating health care initiatives and to report key lessons learned in designing those evaluations. PRINCIPAL FINDINGS: The VHA's Quality Enhancement Research Initiative and its Health Services Research and Development Service are cooperating on several large, randomized program evaluations aimed at improving the care veterans receive and the efficiency with which it is delivered. The evaluations we describe involve collaborative design, outcomes assessment, and implementation science through partnerships between VHA operations and researchers. We review key factors to assess before committing to an evaluation. In addition to traditional design issues (such as ensuring adequate power and availability of data), these include others that are easily overlooked: the stability of intervention financing, means of controlling and commitment to adhering to randomized roll-out, degree of buy-in from key implementation staff, and feasibility of managing multiple veto points for interventions that span several programs, among others. CONCLUSIONS: Successful program implementation and rigorous evaluation require resources, specialized expertise, and careful planning. If the learning health system model is to be sustained, organizations will need dedicated programs to prioritize resources and continuously adapt evaluation designs.

Has Interprofessional Education Changed Learning Preferences? A National Perspective.

OBJECTIVE: To assess how changes in curriculum, accreditation standards, and certification and licensure competencies impacted how medical students and physician residents value interprofessional team and patient-centered care. PRIMARY DATA SOURCE: The Department of Veterans Affairs Learners' Perceptions Survey (2003-2013). The nationally administered survey asked a representative sample of 56,569 U.S. medical students and physician residents, with a comparison group of 78,038 nonphysician trainees, to rate satisfaction with 28 elements, in two overall domains, describing their clinical learning experiences at VA medical centers. STUDY DESIGN: Value preferences were scored as independent adjusted associations between an element (interprofessional team, patient-centered preceptor) and the respective overall domain (clinical learning environment, faculty, and preceptors) relative to a referent element (quality of clinical care, quality of preceptor). PRINCIPAL FINDINGS: Physician trainees valued interprofessional (14 percent vs. 37 percent, p < .001) and patient-centered learning (21 percent vs. 36 percent, p < .001) less than their nonphysician counterparts. Physician preferences for interprofessional learning showed modest increases over time (2.5 percent/year, p < .001), driven mostly by internal medicine and surgery residents. Preferences did not increase with trainees' academic progress. CONCLUSIONS: Despite changes in medical education, physician trainees continue to lag behind their nonphysician counterparts in valuing experience with interprofessional team and patient-centered care.

Determinants of National Guard Mental Health Service Utilization in VA versus Non-VA Settings.

OBJECTIVE: To determine associations between need, enabling, and predisposing factors with mental health service use among National Guard soldiers in the first year following a combat deployment to Iraq or Afghanistan. DATA SOURCES/STUDY SETTING: Primary data were collected between 2011 and 2013 from 1,426 Guard soldiers representing 36 units. STUDY DESIGN: Associations between Guard soldier factors and any mental health service use were assessed using multivariable logistic regression models in a cross-sectional study. Further analysis among service users (N = 405) assessed VA treatment versus treatment in other settings. PRINCIPAL FINDINGS: Fifty-six percent of Guard soldiers meeting cutoffs on symptom scales received mental health services with 81 percent of those reporting care from the VA. Mental health service use was associated with need (mental health screens and physical health) and residing in micropolitan communities. Among service users, predisposing factors (middle age range and female gender) and enabling factors (employment, income above $50,000, and private insurance) were associated with greater non-VA services use. CONCLUSION: Overall service use was strongly associated with need, whereas sector of use (non-VA vs. VA) was insignificantly associated with need but strongly associated with enabling factors. These findings have implications for the recent extension of veteran health coverage to non-VA providers.

Ten-Year Publication Trajectories of Health Services Research Career Development Award Recipients: Collaboration, Awardee Characteristics, and Productivity Correlates.

This study's purpose was to identify distinct publishing trajectories among 442 participants in three prominent mentored health services research career development programs (Veterans Affairs, National Institutes of Health, and Agency for Healthcare Research & Quality) in the 10 years after award receipt and to examine awardee characteristics associated with different trajectories. Curricula vitae (CVs) of researchers receiving awards between 1991 and 2010 were coded for publications, grants, and awardee characteristics. We found that awardees published at constant or increasing rates despite flat or decreasing rates of first-author publications. Senior-author publications rose concurrently with rates of overall publications. Higher overall publication trajectories were associated with receiving more grants, more citations as measured by the h-index, and more authors per article. Lower trajectory groups were older and had a greater proportion of female awardees. Career development awards supported researchers who generally published successfully, but trajectories varied across individual researchers. Researchers' collaborative efforts produced an increasing number of articles, whereas first author articles were written at a more consistent rate. Career development awards in health services research supported the careers of researchers who published at a high rate; future research should further examine reasons for variation in publishing among early career researchers.