Trajectories and Transitions in Service Use Among Older Veterans at High Risk of Long-Term Institutional Care.

BACKGROUND: We aimed to identify combinations of long-term services and supports (LTSS) Veterans use, describe transitions between groups, and identify factors influencing transition. METHODS: We explored LTSS across a continuum from home to institutional care. Analyses included 104,837 Veterans Health Administration (VHA) patients 66 years and older at high-risk of long-term institutional care (LTIC). We conduct latent class and latent transition analyses using VHA and Medicare data from fiscal years 2014 to 2017. We used logistic regression to identify variables associated with transition. RESULTS: We identified 5 latent classes: (1) No Services (11% of sample in 2015); (2) Medicare Services (31%), characterized by using LTSS only in Medicare; (3) VHA-Medicare Care Continuum (19%), including LTSS use in various settings across VHA and Medicare; (4) Personal Care Services (21%), characterized by high probabilities of using VHA homemaker/home health aide or self-directed care; and (5) Home-Centered Interdisciplinary Care (18%), characterized by a high probability of using home-based primary care. Veterans frequently stayed in the same class over the three years (30% to 46% in each class). Having a hip fracture, self-care impairment, or severe ambulatory limitation increased the odds of leaving No Services, and incontinence and dementia increased the odds of entering VHA-Medicare Care Continuum. Results were similar when restricted to Veterans who survived during all 3 years of the study period. CONCLUSIONS: Veterans at high risk of LTIC use a combination of services from across the care continuum and a mix of VHA and Medicare services. Service patterns are relatively stable for 3 years.

Changes in Health Indicators Among Caregivers - United States, 2015-2016 to 2021-2022.

Caregivers provide support to persons who might otherwise require placement in long-term care facilities. Approximately one in five U.S. adults provides care to family members or friends who have a chronic health condition or disability. Promoting the well-being of this large segment of the population is a public health priority as recognized by the 2022 National Strategy to Support Family Caregivers. Although negative associations between caregiving and caregiver health are known, changes in the health status of caregivers over time are not. Data from the 2015-2016 and 2021-2022 Behavioral Risk Factor Surveillance System were analyzed to compare changes in the prevalence of 19 health indicators among cross-sectional samples of caregivers and noncaregivers at different time points. Caregivers experienced improvements in prevalence of four health indicators, whereas six worsened. Some health indicators, such as cigarette smoking, improved for both caregivers and noncaregivers, although smoking prevalence remained higher for caregivers (16.6% versus 11.7%). Prevalence of lifetime depression increased for both groups and remained higher among caregivers (25.6%) than among noncaregivers (18.6%). During 2021-2022, age-adjusted estimates for caregivers were unfavorable for 13 of the 19 health indicators when compared with noncaregivers. Strategies for supporting caregivers are available, and integrating these with existing programs to address mental health and chronic diseases among this population might improve caregiver well-being. For example, many community organizations support caregivers by offering interventions designed to relieve caregiver strain, including skills training, support groups, and care coordination.

Feasibility of training family caregivers of people living with dementia online to deliver life review depression intervention at home.

OBJECTIVES: To alleviate the high prevalence of depressive symptoms and dementia in older Americans (≥65 years), we developed a depression intervention, Caregiver-Provided Life Review (C-PLR), and taught family caregivers life review skills online compared to a synchronous group virtual training, and examined the feasibility and delivery impact (N = 20 dyads). METHOD: In a cross-sectional, mixed-methods dyadic design, we recruited family caregiver-care recipient dyads nationwide, collected the pre- and post-intervention measures on care recipients' depression (primary outcome), life satisfaction, caregivers' burden, caregiving rewards, and dyads' relationship quality (secondary outcomes), and compared them using t-tests. We took fidelity scores to measure caregivers' feasibility of delivering life reviews adhering to the protocol. RESULTS: Care recipients' depressive symptoms declined significantly following the C-PLR intervention (p = 0.034) and caregivers' rewards increased from the pre- to post-period (p = 0.019). Caregivers' qualitative interviews supported the quantitative results that online-trained caregivers' ability to deliver the intervention with high adherence to protocol (15.9 ± 0.27 out of 16) without increasing caregiver burden. CONCLUSION: This pilot study suggested that the C-PLR could make a positive impact on both caregivers' and care recipients' mental health. This innovative, cost-effective, and easily implemented activity can be used by any dyad regardless of whether they have any health-related deficits.

Sex differences in unmet needs between male and female older veterans.

Aging Veterans face complex needs across multiple domains. However, the needs of older female Veterans and the degree to which unmet needs differ by sex are unknown. We analyzed responses to the HERO CARE survey from 7,955 Veterans aged 55 years and older (weighted N = 490,148), 93.9% males and 6.1% females. We evaluated needs and unmet needs across the following domains: activities of daily living (ADLs), instrumental ADLs (IADLs), health management, and social. We calculated weighted estimates and compared sex differences using age-adjusted prevalence ratios. On average, female Veterans were younger, more were Non-Hispanic Black and unmarried. Females and males reported a similar prevalence of problems across all domains. However, compared to males, female Veterans had a lesser prevalence of missed appointments due to transportation (aPR 0.49; 95% CI: 0.26-0.92), housework unmet needs (aPR: 0.44; 95% CI: 0.20-0.97), and medication management unmet needs (aPR: 0.33; 95% CI: 0.11-0.95) but a higher prevalence of healthcare communication unmet needs (aPR: 2.40; 95% CI: 1.13-5.05) and monitoring health conditions unmet needs (aPR: 2.13, 95% CI: 1.08-4.20). Female Veterans' common experience of unmet needs in communicating with their healthcare teams could result in care that is less aligned with their preferences or needs. As the number of older female Veterans grows, these data and additional work to understand sex-specific unmet needs and ways to address them are essential to providing high-quality care for female Veterans.

Caregiver burden and COVID-19: How epilepsy caregivers experienced the pandemic.

INTRODUCTION: Caregivers of adults with epilepsy face unique challenges, yet most studies focus on the impact of epilepsy on those living with the condition, rather than the impact on caregivers. Our objective was to evaluate whether caregivers' pandemic-related changes and experiences - namely those related to their health, healthcare access, and well-being - were associated with their caregiving burden. METHODS: Caregivers of adults with epilepsy (n = 261) were recruited through Qualtrics Panels to participate in an online survey examining health, well-being, COVID-19 experiences, and caregiver burden from October-December, 2020. The burden was measured using the Zarit 12-item measure; the clinically significant burden was defined as a score greater than 16. Adjustments were made to account for burden scores related to exposures of interest. Chi-square tests, t-tests, and generalized linear regression models were used to compare cross-sectional associations between COVID-19 experiences and burden. RESULTS: Over half (57.9%) of caregivers had clinically significant caregiver burden. Most reported increased anxiety (65%), stress (64%), and sense of social isolation (58%) during the pandemic. Many caregivers reported that their sense of control over their life (44%) and their use of healthcare changed (88%) due to COVID-19. In adjusted models, caregivers who reported increased anger, increased anxiety, decreased sense of control, or changes in healthcare utilization during COVID-19 had about twice the odds of having clinically significant caregiver burden compared to caregivers who did not report changes. DISCUSSION: Changes experienced by caregivers of adults with epilepsy during the pandemic were strongly associated with clinically significant levels of caregiver burden. These findings demonstrate the link between mass-level events, such as a pandemic, the burden caregivers of adults with epilepsy may carry, and subsequent psychological outcomes. CONCLUSION: Caregivers of adults with epilepsy may need support to reduce the negative impact of COVID-19-related experiences and should be connected to healthcare and resources that can help alleviate their burden.

COVID-19 pandemic experiences among people with epilepsy: Effect on symptoms of co-occurring health conditions and fear of seizure.

OBJECTIVE: The Coronavirus disease 2019 (COVID-19) pandemic profoundly affected people worldwide, but little is known about how it impacted people with epilepsy (PWE). We examined the associations between COVID-19 stressors and health outcomes including increases in other health symptoms and fear of seizure among PWE. METHODS: This cross-sectional study used data from an online survey that asked about demographic characteristics, health conditions, and potential life stressors during COVID-19. Data were collected from October 30 to December 8, 2020. COVID-19 stressors were anger, anxiety, stress, healthcare access, fear of seeking healthcare, social isolation, sense of control over their lives, and alcohol consumption. A binary variable was created for each of these measures to indicate whether PWEs experienced a negative change versus a neutral or positive change. We used multivariable logistic regression to assess the associations of COVID-19 stressors with primary outcomes: exacerbated co-occurring health conditions and increasing fear of seizure during the pandemic. RESULTS: Of the 260 PWE included in the study, 165 (63.5%) were women; the average age was 38.7 years. During the survey administration period, 79 (30.3%) of the respondents reported exacerbated co-occurring health conditions, and 94 (36.2%) reported an increased fear of seizures. Regression results indicated that the fear of seeking healthcare during COVID-19 was associated with both exacerbated co-occurring health conditions (aOR 1.12; 95%CI 1.01-1.26) and increasing fear of seizure (aOR 2.31; 95%CI 1.14-4.68). Social isolation was associated with exacerbated co-occurring health conditions during COVID-19 (aOR 1.14; 95%CI 1.01-1.29). Reduced access to physical healthcare was associated with increasing fear of seizure (aOR 2.58; 95%CI 1.15-5.78). CONCLUSION: A considerable number of PWE experienced more symptoms of existing health conditions and fear of seizure during the initial year of the pandemic (2020). Fear of seeking healthcare services was associated with both negative outcomes. Assuring access to health care and reducing social isolation could potentially reduce negative outcomes for PWE. It is necessary to provide adequate support for PWE to reduce risks as COVID-19 continues to be a health concern.

Getting back to normal? Identity and role disruptions among adults with Long COVID.

Long COVID is a novel chronic illness with a variety of symptoms that people who have labelled themselves 'long-haulers' experience for an extended duration following a COVID-19 infection. We draw on in-depth interviews conducted in March-April 2021 with 20 working-aged adults in the U.S. who self-identified as long-haulers to understand the consequences for identities. The results demonstrate that Long COVID has important consequences for identities and sense of self. Long-haulers described experiencing three stages of biographical disruptions: realising their illness experience as misaligned with sense of self and embodied, age-based expectations; facing challenges to identities and changes in social roles; and reconciling illness and identity in the context of an uncertain prognosis. It remains unclear how long-haulers will resolve biographical disruptions and identity conflicts, especially as scientific insights about this novel condition emerge. Such outcomes may depend largely on whether Long COVID remains a contested illness or medical knowledge progresses to improve their quality of life. For now, healthcare providers may approach Long COVID holistically to address the identity disruptions that long-haulers face as they manage the consequences of this chronic illness.

Flu Vaccine Uptake in Caregivers and Noncaregivers: Implications for Policy and Practice.

INTRODUCTION: Caregivers are a critical and highly used health care resource. Caregivers may experience adverse health outcomes and practice less self-care, including obtaining vaccinations, while serving in their roles. Influenza (flu) is a common infectious disease responsible for millions of doctor visits, hospitalizations, and approximately 43,000 US deaths annually that can largely be prevented by receiving seasonal vaccinations. We aimed to estimate and compare the prevalence of flu vaccination among caregivers and noncaregivers. We hypothesized that caregivers would have a lower prevalence of flu vaccination than noncaregivers and that sociodemographic variables, health-related variables, and caregiving-specific characteristics would be associated with vaccine uptake. METHODS: We analyzed Behavioral Risk Factor Surveillance System data from 2016 through 2018 on 154,170 respondents from 27 US states and the District of Columbia. We used bivariate analysis to estimate the difference in flu vaccination uptake among caregivers and noncaregivers and logistic regression to estimate differences after adjusting for individuals' characteristics. RESULTS: Logistic regression indicated no significant difference in flu vaccine uptake between caregivers and noncaregivers. Caregiving characteristics such as years in a caregiver role, weekly time spent caregiving, relationship to care recipient, and recipient's risk for flu complications were also nonsignificant. Sociodemographic factors such as marital status, income, health insurance coverage, and race had a significant impact on flu vaccine uptake. CONCLUSION: Although no significant differences in flu vaccine uptake were found between caregivers and noncaregivers, flu vaccine coverage remains low in both groups. Evidence-based programs and policies to improve vaccine coverage in the caregiver and general populations remains a public health priority.

Prevalence and Characteristics of Subjective Cognitive Decline Among Unpaid Caregivers Aged ≥45 Years - 22 States, 2015-2019.

Approximately 20% of U.S. adults are unpaid caregivers (caregivers) (1) who provide support to a family member or friend with a health condition or disability. Although there are benefits to caregiving, it can negatively affect caregivers' physical and mental health (2-4). Much of the assistance caregivers provide, such as administering medications or financial management, relies on cognitive ability, but little is known about caregivers' cognitive functioning. Subjective cognitive decline (SCD), the self-reported experience of worsening or more frequent confusion or memory loss over the past year (5), could affect caregivers' risk for adverse health outcomes and affect the quality of care they provide. CDC analyzed SCD among caregivers aged ≥45 years through a cross-sectional analysis of data from 22 states in the 2015-2019 Behavioral Risk Factor Surveillance System (BRFSS). Among adults aged ≥45 years, SCD was reported by 12.6% of caregivers who provided care to a family member or friend with a health condition or disability in the past 30 days compared with 10.2% of noncaregivers (p<0.001). Caregivers with SCD were more likely to be employed, men, aged 45-64 years, and have chronic health conditions than were noncaregivers with SCD. Caregivers with SCD were more likely to report frequent mental distress, a history of depression, and frequent activity limitations than were caregivers without SCD. SCD among caregivers could adversely affect the quality of care provided to care recipients. Understanding caregivers' cognitive health and the types of care provided is critical to maintaining the health, well-being, and independence of the caregiving dyad. Health care professionals can support patients and their patients' caregivers by increasing awareness among caregivers of the need to monitor their own health. The health care team can work with caregivers to identify potential treatments and access supports that might help them in their caregiving role and compensate for SCD.

Unmet needs for assistance related to subjective cognitive decline among community-dwelling middle-aged and older adults in the US: prevalence and impact on health-related quality of life.

OBJECTIVES: To estimate the prevalence of unmet needs for assistance among middle-aged and older adults with subjective cognitive decline (SCD) in the US and to evaluate whether unmet needs were associated with health-related quality of life (HRQOL). DESIGN: Cross-sectional. SETTING: US - 50 states, District of Columbia, and Puerto Rico. PARTICIPANTS: Community-dwelling adults aged 45 years and older who completed the Cognitive Decline module on the 2015--2018 Behavioral Risk Factor Surveillance System reported experiencing SCD and always, usually, or sometimes needed assistance with day-to-day activities because of SCD (n = 6,568). MEASUREMENTS: We defined SCD as confusion or memory loss that was happening more often or getting worse over the past 12 months. Respondents with SCD were considered to have an unmet need for assistance if they sometimes, rarely, or never got the help they needed with day-to-day activities. We measured three domains of HRQOL: (1) mental (frequent mental distress, ≥14 days of poor mental health in the past 30 days), (2) physical (frequent physical distress, ≥14 days of poor physical health in the past 30 days), and (3) social (SCD always, usually, or sometimes interfered with the ability to work, volunteer, or engage in social activities outside the home). We used log-binomial regression models to estimate prevalence ratios (PRs). All estimates were weighted. RESULTS: In total, 40.2% of people who needed SCD-related assistance reported an unmet need. Among respondents without depression, an unmet need was associated with a higher prevalence of frequent mental distress (PR = 1.55, 95% CI: 1.12-2.13, p = 0.007). Frequent physical distress and social limitations did not differ between people with met and unmet needs. CONCLUSIONS: Middle-aged and older adults with SCD-related needs for assistance frequently did not have those needs met, which could negatively impact their mental health. Interventions to identify and meet the unmet needs among people with SCD may improve HRQOL.

Health Phenotypes and Neurobehavioral Symptom Severity Among Post-9/11 Veterans With Mild Traumatic Brain Injury: A Chronic Effects of Neurotrauma Consortium Study.

OBJECTIVE: To evaluate whether neurobehavioral symptoms differ between groups of veterans with mild traumatic brain injury (mTBI) classified by health characteristics. PARTICIPANTS: A total of 71 934 post-9/11 veterans with mTBI from the Chronic Effects of Neurotrauma Consortium Epidemiology warfighter cohort. DESIGN: Cross-sectional analysis of retrospective cohort. MAIN MEASURES: Health phenotypes identified using latent class analysis of health and function over 5 years. Symptom severity measured using Neurobehavioral Symptom Inventory; domains included vestibular, somatic, cognitive, and affective. RESULTS: Veterans classified as moderately healthy had the lowest symptom burden while the polytrauma phenotype group had the highest. After accounting for sociodemographic and injury characteristics, polytrauma phenotype veterans had about 3 times the odds of reporting severe symptoms in each domain compared with moderately healthy veterans. Those veterans who were initially moderately healthy but whose health declined over time had about twice the odds of severe symptoms as consistently healthier Veterans. The strongest associations were in the affective domain. Compared with the moderately healthy group, veterans in other phenotypes were more likely to report symptoms substantially interfered with their daily lives (odds ratio range: 1.3-2.8). CONCLUSION: Symptom severity and interference varied by phenotype, including between veterans with stable and declining health. Ameliorating severe symptoms, particularly in the affective domain, could improve health trajectories following mTBI.

Characteristics and Health Status of Informal Unpaid Caregivers - 44 States, District of Columbia, and Puerto Rico, 2015-2017.

In 2015, an estimated 17.7 million U.S. persons were informal caregivers who provided substantial services through in-home, unpaid assistance to their family members and friends (1). Caregiving can have many benefits, such as enhancing the bond between caregiver and recipient, but it can also place an emotional and physical strain on caregivers, leading to higher rates of depression, lower quality of life, and poorer overall health (2). As the U.S. population continues to age (3), the need for informal caregivers will likely increase. However, little nationally representative information on prevalence of caregivers is available. This study examined demographic characteristics and health status of informal caregivers from 44 states,* the District of Columbia (DC), and Puerto Rico, based on data from the Behavioral Risk Factor Surveillance System (BRFSS) collected during 2015-2017. Overall, approximately one in five adults reported that they had provided care to a family member or friend in the preceding 30 days. Fifty-eight percent of caregivers were women, and a majority were non-Hispanic white, with at least some college education, and married or living with a partner. Across all states, 19.2% of caregivers reported being in fair or poor health, although significant state-to-state variation occurred. Caregivers provide important support to family members, friends, and the health care system and might compromise their own health to provide this support (1,2). Better understanding of caregivers and the challenges they face could inform implementation of improvements in support systems that could enhance not only the health of the caregiver, but that of the care recipient as well. For example, additional data regarding demographics at the state level might aid in more effective planning and support of caregivers with evidence-based programs and assistance (https://www.cdc.gov/aging/publications/features/caring-for-yourself.html).

Baby Boomers as Caregivers: Results From the Behavioral Risk Factor Surveillance System in 44 States, the District of Columbia, and Puerto Rico, 2015-2017.

INTRODUCTION: Baby boomers, people born from 1946 through 1964, represent a substantial portion of the US population. Generally, baby boomers have more chronic disease and disability than those in the previous generation. Frequently, they also provide informal care to others. The objective of our study was to estimate the prevalence of informal caregiving among baby boomers and compare the health of baby boomer caregivers and noncaregivers. METHODS: Using data from the Behavioral Risk Factor Surveillance System (2015-2017) for 44 states, the District of Columbia, and Puerto Rico, we classified 109,268 baby boomers as caregivers or noncaregivers and compared their general health (poor or fair vs good, very good, or excellent), chronic health conditions, and frequent mental distress (FMD). FMD was defined as 14 days or more of poor mental health in the past month. We used log-binomial regression to calculate prevalence ratios, adjusted for age and sex (aPRs), and to separately estimate aPRs for fair or poor health and FMD or at least one chronic health condition. RESULTS: One in 4 baby boomers (24.2%) were caregivers. In adjusted models, male caregivers had a higher prevalence of fair to poor health than noncaregivers (aPR = 1.17; 95% confidence interval [CI], 1.06-1.29; P = .001). More caregivers than noncaregivers had at least 1 chronic health condition (aPR = 1.10, 95% CI, 1.07-1.13; P < .001) and more often had FMD (aPR = 1.39; 95% CI, 1.26-1.53; P < .001). CONCLUSION: Our study showed these caregivers had more chronic health conditions and more often had FMD than noncaregivers. The health of baby boomer caregivers is a public health priority, as these caregivers might need support to maintain their own physical and mental health.

Inclusive Public Health Preparedness Program to Promote Resilience in Rural Appalachia (2016-2018).

Emergencies range from unexpected injuries to natural disasters. Populations with access and functional needs are more likely than other populations to experience adverse health outcomes during an emergency. The three-county Appalachian District Health Department engaged a collaborative array of community partners to build an all-inclusive, all-hazards emergency plan. Tabletop and full-scale exercises demonstrated the plan's ability to meet the needs of community members with access and functional needs.

Relationship and communication characteristics associated with agreement between heart failure patients and their Carepartners on patient depressive symptoms.

Objectives: Informal caregivers who recognize patients' depressive symptoms can better support self-care and encourage patients to seek treatment. We examined patient-caregiver agreement among patients with heart failure (HF). Our objectives were to (1) identify distinct groups of HF patients and their out-of-home informal caregivers (CarePartners) based on their relationship and communication characteristics, and (2) compare how these groups agree on the patients' depressive symptoms. Method: We used baseline data from a comparative effectiveness trial of a self-care support program for veterans with HF treated in outpatient clinics from 2009-2012. We used a cross-sectional design and latent class analysis (LCA) approach to identify distinct groups of patient-CarePartner dyads (n = 201) based on relationship and communication characteristics then evaluated agreement on patients' depressive symptoms within these groups. Results: The LCA analysis identified four groups: Collaborative (n = 102 dyads, 51%), Avoidant (n = 33 dyads, 16%), Distant (n = 35 dyads, 17%), and Antagonistic (n = 31 dyads, 15%). Dyadic agreement on the patients' depressive symptoms was highest in the Distant (Kappa (κ) = 0.44, r = 0.39) and Collaborative groups (κ = 0.19, r = 0.32), and relatively poor in the Avoidant (κ = -0.20, r = 0.17) and Antagonistic (κ =-0.01, r = 0.004) groups. Patients in Avoidant (61%) and Antagonistic groups (74%) more frequently had depression based on self-report than patients in Collaborative (46%) and Distant (34%) groups. Conclusion: Caregiver relationships in HF tend to be either Collaborative, Avoidant, Distant, or Antagonistic. Patients' depressive symptoms may negatively affect how they communicate with their caregivers. At the same time, improved patient-caregiver communication could enhance dyadic consensus about the patient's depressive symptoms.

The Economic Value of Informal Caregiving for Persons With Dementia: Results From 38 States, the District of Columbia, and Puerto Rico, 2015 and 2016 BRFSS.

OBJECTIVES: To estimate the economic value from a societal perspective of informal caregiving of persons with dementia in 38 states, the District of Columbia, and Puerto Rico. METHODS: Using a cost replacement method and data from the 2015 and 2016 Behavioral Risk Factor Surveillance System caregiver module, the US Bureau of Labor Statistics May 2016 Occupation Profiles, and the US Department of Labor, we estimated the number and economic direct cost of caregiving hours. RESULTS: An estimated 3.2 million dementia caregivers provided more than 4.1 billion hours of care, with an average of 1278 hours per caregiver. The median hourly value of dementia caregiving was $10.28. Overall, we valued these caregiving hours at $41.5 billion, with an average of $13 069 per caregiver. CONCLUSIONS: Caregivers of persons with dementia provide care that has important economic implications. Without these efforts, many people would either not receive needed care or have to pay for that support. Surveillance data can be used to estimate the contributions of informal caregivers and the economic value of the care they provide.

Subjective Cognitive Decline Among Adults Aged ≥45 Years - United States, 2015-2016.

Subjective cognitive decline (SCD) is the self-reported experience of worsening or more frequent confusion or memory loss within the previous 12 months (1,2) and one of the earliest noticeable symptoms of Alzheimer's disease (Alzheimer's), a fatal form of dementia (i.e., a decline in mental abilities severe enough to interfere with everyday life) (1). Alzheimer's is the most common form of dementia, although not all memory loss results from Alzheimer's (3). To examine SCD, CDC analyzed combined data from the 2015 and 2016 Behavioral Risk Factor Surveillance System (BRFSS) surveys. Overall, 11.2% of adults aged ≥45 years reported having SCD, 50.6% of whom reported SCD-related functional limitations. Among persons living alone aged ≥45 years, 13.8% reported SCD; among persons with any chronic disease, 15.2% reported SCD. Adults should discuss confusion or memory loss with a health care professional who can assess cognitive decline and address possible treatments and issues related to chronic disease management, medical care, and caregiving.

Medicare-VHA dual use is associated with poorer chronic wound healing.

Veterans who use Veterans Health Affairs (VHA) have the option of enrolling in and obtaining care from other non-VA sources. Dual system use may improve care by increasing options or it may result in poorer outcomes because of fragmented care. Our objective was to assess whether dual system use of VHA and Medicare for wound care was associated with chronic wound healing. We conducted a retrospective cohort study of 227 Medicare-enrolled VHA users in the Pacific Northwest who had an incident, chronic lower limb wound between October 1, 2006 and September 30, 2007 identified through VHA chart review. All wounds were followed until resolution or for up to one year. Dual system wound care was identified through Medicare claims during follow-up. We used a proportional hazards model to compare wound healing among VHA-exclusive and dual wound care users, using a time-varying measure of dual use and treating amputation and death as competing risks. About 18.1% of subjects were classified as dual wound care users during follow-up. After adjustment using propensity scores, dual use was associated with a significantly lower hazard of wound healing compared to VHA-exclusive use (HR = 0.63, 95%CI: 0.39-0.99, p = 0.047). Hazards for the competing risks, amputation (HR = 4.23, 95% CI: 1.61-11.15, p = 0.003) and death (HR = 3.08, 95%CI: 1.11-8.56, p = 0.031), were significantly higher for dual users compared to VHA-exclusive users. Results were similar in inverse probability of treatment weighted analyses and in sensitivity analyses that excluded veterans enrolled in a Medicare managed care plan and that used a revised wound resolution date based on Medicare claims data, but were not always statistically significant. Overall, dual wound care use was associated with substantially poorer wound healing compared to VHA-exclusive wound care use. VHA may need to design programs or policies that support and improve care coordination for veterans needing chronic wound care.

Weight Change Trajectories After Incident Lower-Limb Amputation.

OBJECTIVE: To characterize weight change after amputation by identifying typical weight trajectories in men with incident lower-limb amputation (LLA) and describing characteristics associated with each trajectory. DESIGN: Retrospective cohort study and analyzed using group-based trajectory modeling. SETTING: Administrative data. PARTICIPANTS: Veterans who were men (N=759), living in the Northwest United States, and who had an incident toe, foot, or leg amputation between 1997 and 2008 and at least 18 months of amputation-free survival thereafter. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Postamputation weight and body mass index change. RESULTS: The mean weight at baseline was 91.6±24 kg (202±53 lb), and average follow-up was 2.4 years. We identified 4 trajectory groups for weight change: weight loss (13%), stable weight (47%), slow weight gain (33%), and rapid weight gain (7%). Men with a toe or foot amputation most frequently were assigned to the stable weight group (58%), whereas men with transtibial or transfemoral amputations were most commonly assigned to the slow weight gain group (42% each). Men who died during follow-up were more likely to be assigned to the weight loss group (24%) than men who did not die (11%). CONCLUSIONS: We identified distinct weight change trajectories that represent heterogeneity in weight change after LLA. An improved understanding of factors predictive of weight gain or loss in people with LLA may help better target rehabilitation and prosthetic prescription. Additional research is needed to fully understand the relation between weight change and health status after amputation.

Evidence-based chronic ulcer care and lower limb outcomes among Pacific Northwest veterans.

Evidence-based ulcer care guidelines detail optimal components of care for treatment of ulcers of different etiologies. We investigated the impact of providing specific evidence-based ulcer treatment components on healing outcomes for lower limb ulcers (LLU) among veterans in the Pacific Northwest. Components of evidence-based ulcer care for venous, arterial, diabetic foot ulcers/neuropathic ulcers were abstracted from medical records. The outcome was ulcer healing. Our analysis assessed the relationship between evidence-based ulcer care by etiology, components of care provided, and healing, while accounting for veteran characteristics. A minority of veterans in all three ulcer-etiology groups received the recommended components of evidence-based care in at least 80% of visits. The likelihood of healing improved when assessment for edema and infection were performed on at least 80% of visits (hazard ratio [HR] = 3.20, p = 0.009 and HR = 3.54, p = 0.006, respectively) in patients with venous ulcers. There was no significant association between frequency of care components provided and healing among patients with arterial ulcers. Among patients with diabetic/neuropathic ulcers, the chance of healing increased 2.5-fold when debridement was performed at 80% of visits (p = 0.03), and doubled when ischemia was assessed at the first visit (p = 0.045). Veterans in the Pacific Northwest did not uniformly receive evidence-based ulcer care. Not all evidence-based ulcer care components were significantly associated with healing. At a minimum, clinicians need to address components of ulcer care associated with improved ulcer healing.