Ask and Ask Again: Repeated Screening for Smoking Increases Likelihood of Prescription for Cessation Treatment Among Women Veterans.

BACKGROUND: Preventive screening at the point of care can increase desired clinical outcomes. However, the impact of repeated screening for tobacco use on receiving smoking cessation treatment among women Veteran population has not been documented. OBJECTIVE: To examine screening for tobacco use using clinical reminders and the association between the number of screenings and prescription for cessation treatment. DESIGN: A retrospective analysis using data from a 5-year implementation trial for cardiovascular risk identification conducted between December 2016 and March 2020. SUBJECTS: Women patients who had at least one primary care visit with a women's health provider during the study period at five primary care clinics in the Veterans Affairs (VA) Healthcare System. MEASURES: The outcome is prescription of pharmacotherapy or referral to behavioral counseling for smoking cessation on or after the screening date. The exposure is the number of screenings for tobacco use from the trial and the annual VA national clinical reminders during the study period. RESULTS: Of 6009 eligible patients, 5788 (96.3%) were screened at least once for tobacco use over five calendar years, and 2784 of those screened (48.1%) were reported as current and former smokers. Among current and former smokers, 709 (25.5%) received a prescription and/or referral for smoking cessation. In the adjusted model, the average predicted probability of prescription and/or referral for smoking cessation was 13.7% among current and former smokers screened once over 5 years, 18.6% among screened twice, 26.5% among screened thrice, 32.9% among screened four times, and 41.7% among screened five or six times. CONCLUSIONS: Repeated screening was associated with higher predicted probabilities of being prescribed smoking cessation treatment.

Adherence to the Use of Home Telehealth Technologies and Emergency Room Visits in Veterans with Heart Failure.

Background: Prior studies have posited poor patient adherence to remote patient monitoring as the reason for observed lack of benefits. Introduction: The purpose of this study was to examine the relationship between average adherence to the daily use of home telehealth (HT) and emergency room (ER) visits in Veterans with heart failure. Materials and Methods: This was a retrospective study using administrative data of Veterans with heart failure enrolled in Veterans Affairs (VA) HT Program in the first half of 2014. Zero-inflated negative binomial regression was used to determine which predictors affect the probability of having an ER visit and the number of ER visits. Results: The final sample size was 3,449 with most being white and male. There were fewer ER visits after HT enrollment (mean ± standard deviation of 1.85 ± 2.8) compared with the year before (2.2 ± 3.4). Patient adherence was not significantly associated with ER visits. Age and being from a racial minority group (not white or black) and belonging to a large HT program were associated with having an ER visit. Being in poorer health was associated with higher expected count of ER visits. Discussion: Subgroups of patients (e.g., with depression, sicker, or from a racial minority group) may benefit from added interventions to decrease ER use. Conclusions: This study found that adherence was not associated with ER visits. Reasons other than adherence should be considered when looking at ER use in patients with heart failure enrolled in remote patient monitoring programs.

Why patients stop using their home telehealth technologies over time: Predictors of discontinuation in Veterans with heart failure.

BACKGROUND: Daily use of home telehealth (HT) technologies decreases over time. Barriers to continued use are unclear. PURPOSE: To examine predictors of drop-out from HT in Veterans with heart failure. METHODS: Data for Veterans with heart failure enrolled in the Veterans Affairs HT Program were analyzed using a mixed effects Cox regression model to determine risk of dropping-out over a 1-year period. FINDINGS: Older (hazard ratio [HR] 1.01), sicker (prior hospital readmission [HR 1.39]), higher probability of hospital admission/death [HR 1.23], functional impairments [1.14]) and white Veterans (compared to black; HR 1.41) had higher risk of drop-out in HT Programs. Users of VA's online patient portal (HR 0.90) had lower risk of drop-out. DISCUSSION: Older and sicker patients are at most risk of stopping HT use, yet use of a patient portal shows promise in improving continued use. Interventions targeting patients at high risk for HT discontinuation are needed to promote ongoing engagement.

Tailoring an evidence-based lifestyle intervention to meet the needs of women Veterans with prediabetes.

Prediabetes affects one-third of U.S. adults. Lifestyle change interventions, such as the Diabetes Prevention Program (DPP), can significantly lower type 2 diabetes risk, but little is known about how the DPP could be best adapted for women. This mixed-methods study assessed the impact of gender-tailoring and modality choice on DPP engagement among women Veterans with prediabetes. Participants were offered women-only groups and either in-person/peer-led or online modalities. Implementation outcomes were assessed using attendance logs, recruitment calls, and semi-structured interviews about patient preferences. Between June 2016 and March 2017, 119 women Veterans enrolled in the DPP (n = 51 in-person, n = 68 online). We conducted 22 interviews between August and September 2016 (n = 10 early-implementation) and March and July 2017 (n = 12 follow-up). Most interviewees preferred women-only groups, citing increased comfort, camaraderie, and mutual understanding of gender-specific barriers to lifestyle change. More women preferred online DPP, and those using this modality participated at higher rates. Most endorsed the importance of modality choice and were satisfied with their selection; however, selection was frequently based on participants' personal circumstances and access barriers and not on a "preferred choice" of two equally accessible options. Patient engagement and program reach can be expanded by tailoring the DPP for population-specific needs.

Home Telehealth Technologies for Heart Failure: An Examination of Adherence Among Veterans.

The current retrospective cohort study uses Department of Veterans Affairs (VA) clinical and facility data of Veterans with heart failure enrolled in the VA Home Tele-health (HT) Program. General estimating equations with facility as a covariate were used to model percent average adherence at 1, 3, 6, and 12 months post-enrollment. Most HT patients were White, male, and of older age (mean = 71 years). Average adherence increased the longer patients remained in the HT program. Number of weekly reports of HT use, not having depression, and being of older age were all associated with higher adherence. Compared to White Veterans, Black and other non-White Veterans had lower adherence. These findings identify subgroups of patients (e.g., those with depression, of younger age, non-White) that may benefit from additional efforts to improve adherence to HT technologies. [Journal of Gerontological Nursing, 46(7), 26-34.].

Periodic reflections: a method of guided discussions for documenting implementation phenomena.

BACKGROUND: Ethnography has been proposed as a valuable method for understanding how implementation occurs within dynamic healthcare contexts, yet this method can be time-intensive and challenging to operationalize in pragmatic implementation. The current study describes an ethnographically-informed method of guided discussions developed for use by a multi-project national implementation program. METHODS: The EMPOWER QUERI is conducting three projects to implement innovative care models in VA women's health for high-priority health concerns - prediabetes, cardiovascular risk, and mental health - utilizing the Replicating Effective Programs (REP) implementation strategy enhanced with stakeholder engagement and complexity science. Drawing on tenets of ethnographic research, we developed a lightly-structured method of guided "periodic reflections" to aid in documenting implementation phenomena over time. Reflections are completed as 30-60 min telephone discussions with implementation team members at monthly or bi-monthly intervals, led by a member of the implementation core. Discussion notes are coded to reflect key domains of interest and emergent themes, and can be analyzed singly or in triangulation with other qualitative and quantitative assessments to inform evaluation and implementation activities. RESULTS: Thirty structured reflections were completed across the three projects during a 15-month period spanning pre-implementation, implementation, and sustainment activities. Reflections provide detailed, near-real-time information on projects' dynamic implementation context, including characteristics of implementation settings and changes in the local or national environment, adaptations to the intervention and implementation plan, and implementation team sensemaking and learning. Reflections also provide an opportunity for implementation teams to engage in recurring reflection and problem-solving. CONCLUSIONS: To implement new, complex interventions into dynamic organizations, we must better understand the implementation process as it unfolds in real time. Ethnography is well suited to this task, but few approaches exist to aid in integrating ethnographic insights into implementation research. Periodic reflections show potential as a straightforward and low-burden method for documenting events across the life cycle of an implementation effort. They offer an effective means for capturing information on context, unfolding process and sensemaking, unexpected events, and diverse viewpoints, illustrating their value for use as part of an ethnographically-minded implementation approach. TRIAL REGISTRATION: The two implementation research studies described in this article have been registered as required: Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans (NCT02991534); and Implementation of Tailored Collaborative Care for Women Veterans (NCT02950961).

Depression Quality of Care: Measuring Quality over Time Using VA Electronic Medical Record Data.

BACKGROUND: The Veterans Health Administration (VA) has invested substantially in evidence-based mental health care. Yet no electronic performance measures for assessing the level at which the population of Veterans with depression receive appropriate care have proven robust enough to support rigorous evaluation of the VA's depression initiatives. OBJECTIVE: Our objectives were to develop prototype longitudinal electronic population-based measures of depression care quality, validate the measures using expert panel judgment by VA and non-VA experts, and examine detection, follow-up and treatment rates over a decade (2000-2010). We describe our development methodology and the challenges to creating measures that capture the longitudinal course of clinical care from detection to treatment. DESIGN AND PARTICIPANTS: Data come from the National Patient Care Database and Pharmacy Benefits Management Database for primary care patients from 1999 to 2011, from nine Veteran Integrated Service Networks. MEASURES: We developed four population-based quality metrics for depression care that incorporate a 6-month look back and 1-year follow-up: detection of a new episode of depression, 84 and 180 day follow-up, and minimum appropriate treatment 1-year post detection. Expert panel techniques were used to evaluate the measure development methodology and results. Key challenges to creating valid longitudinal measures are discussed. KEY RESULTS: Over the decade, the rates for detection of new episodes of depression remained stable at 7-8 %. Follow-up at 84 and 180 days were 37 % and 45 % in 2000 and increased to 56 % and 63 % by 2010. Minimum appropriate treatment remained relatively stable over the decade (82-84 %). CONCLUSIONS: The development of valid longitudinal, population-based quality measures for depression care is a complex process with numerous challenges. If the full spectrum of care from detection to follow-up and treatment is not captured, performance measures could actually mask the clinical areas in need of quality improvement efforts.

Application of a nonrandomized stepped wedge design to evaluate an evidence-based quality improvement intervention: a proof of concept using simulated data on patient-centered medical homes.

BACKGROUND: Stepped wedge designs have gained recognition as a method for rigorously assessing implementation of evidence-based quality improvement interventions (QIIs) across multiple healthcare sites. In theory, this design uses random assignment of sites to successive QII implementation start dates based on a timeline determined by evaluators. However, in practice, QII timing is often controlled more by site readiness. We propose an alternate version of the stepped wedge design that does not assume the randomized timing of implementation while retaining the method's analytic advantages and applying to a broader set of evaluations. To test the feasibility of a nonrandomized stepped wedge design, we developed simulated data on patient care experiences and on QII implementation that had the structures and features of the expected data from a planned QII. We then applied the design in anticipation of performing an actual QII evaluation. METHODS: We used simulated data on 108,000 patients to model nonrandomized stepped wedge results from QII implementation across nine primary care sites over 12 quarters. The outcome we simulated was change in a single self-administered question on access to care used by Veterans Health Administration (VA), based in the United States, as part of its quarterly patient ratings of quality of care. Our main predictors were QII exposure and time. Based on study hypotheses, we assigned values of 4 to 11 % for improvement in access when sites were first exposed to implementation and 1 to 3 % improvement in each ensuing time period thereafter when sites continued with implementation. We included site-level (practice size) and respondent-level (gender, race/ethnicity) characteristics that might account for nonrandomized timing in site implementation of the QII. We analyzed the resulting data as a repeated cross-sectional model using HLM 7 with a three-level hierarchical data structure and an ordinal outcome. Levels in the data structure included patient ratings, timing of adoption of the QII, and primary care site. RESULTS: We were able to demonstrate a statistically significant improvement in adoption of the QII, as postulated in our simulation. The linear time trend while sites were in the control state was not significant, also as expected in the real life scenario of the example QII. CONCLUSIONS: We concluded that the nonrandomized stepped wedge design was feasible within the parameters of our planned QII with its data structure and content. Our statistical approach may be applicable to similar evaluations.

Assessment of the healthcare needs and barriers to VA use experienced by women veterans: findings from the national survey of women Veterans.

BACKGROUND: Prior regional studies of women Veterans identified barriers to Veterans Affairs (VA) healthcare use. However, these studies do not reflect the demographic profile of women Veterans nationally, recent advances in VA women's healthcare, and the national context of expanded healthcare alternatives. OBJECTIVE: To characterize health, VA perceptions, barriers, healthcare delivery preferences, and reasons for VA or non-VA healthcare use in a national women Veteran sample. METHODS: Cross-sectional, population-based 2008-2009 National Survey of Women Veterans (n=3611). RESULTS: VA users had worse physical and mental health than non-VA-only users and healthcare nonusers. Older women Veterans had worse physical health, whereas younger groups had worse mental health. Healthcare use was highest for dual users, followed by VA-only users, but did not differ by age group. Healthcare nonusers were most likely to lack a regular source for healthcare. Perceptions of VA care quality and sex-appropriateness were highest for VA-only, followed by dual, then non-VA-only users. VA perceptions were guided by personal experience for 90% of VA users, versus media or other secondhand sources for 70% of other groups. Non-VA-only users and healthcare nonusers had more knowledge gaps about VA and misperceptions about VA eligibility and services; non-VA-only users more likely encountered VA enrollment barriers. CONCLUSIONS: Many nonusers had healthcare needs that were not met. Positive VA perceptions by women with first-hand VA experience, contrasted with VA knowledge gaps by those without such exposure, suggests the need for more education about available VA healthcare services. VA planning should account for mental health needs and healthcare use by younger women Veterans.

Clinician advice to quit smoking among seniors.

OBJECTIVE: Little smoking research in the past 20years includes persons 50 and older; herein we describe patterns of clinician cessation advice to US seniors, including variation by Medicare beneficiary characteristics. METHOD: In 2012-4, we analyzed 2010 Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data from Medicare beneficiaries over age 64 (n=346,674). We estimated smoking rates and the proportion of smokers whose clinicians encouraged cessation. RESULTS: 12% of male and 8% of female respondents aged 65 and older smoke. The rate decreases with age (14% of 65-69, 3% of 85+) and education (12-15% with no high school degree, 5-6% with BA+). Rates are highest among American Indian/Alaskan Native (16%), multiracial (14%), and African-American (13%) seniors, and in the Southeast (14%). Only 51% of smokers say they receive cessation advice "always" or "usually" at doctor visits, with advice more often given to the young, those in low-smoking regions, Asians, and women. For all results cited p<0.05. CONCLUSIONS: Smoking cessation advice to seniors is variable. Providers may focus on groups or areas in which smoking is less common or when they are most comfortable giving advice. More consistent interventions are needed, including cessation advice from clinicians.

Challenges facing primary care practices aiming to implement patient-centered medical homes.

BACKGROUND: While the potential of patient-centered medical homes (PCMH) is promising, little is known empirically about the frontline challenges that primary care (PC) leaders face before making the decision to implement PCMH, let alone in making it a reality. OBJECTIVE: Prior to the design and implementation of the Veterans Health Administration's (VA) national PCMH model--Patient Aligned Care Teams (PACT)--we identified the top challenges faced by PC directors and examined the organizational and area level factors that influenced those challenges. DESIGN AND PARTICIPANTS: A national cross-sectional key informant organizational survey was fielded to the census of PC directors at VA medical centers and large community-based outpatient clinics (final sample n = 229 sites). MAIN MEASURES: PC directors were asked to rate the degree to which they faced 48 management challenges in eight PCMH-related domains (access, preventive care, chronic diseases requiring care in PC, challenging medical conditions, mental health/substance abuse, special populations, PC coordination of care, and clinical informatics). Responses were dichotomized as moderately-to-extremely challenging versus somewhat-slightly-not at all challenging. Items were rank ordered; chi square or regression techniques were used to examine variations in facility size, type, urban/rural location, and region. KEY RESULTS: On average, VA PC directors reported 16 moderate-to-extreme challenges, and the top 20 challenges spanned all eight PCMH domains. Four of the top 20 challenges, including the top two challenges, were from the clinical informatics domain. Management of chronic non-malignant pain requiring opiate therapy was the third most reported challenge nationwide. Significant organizational and area level variations in reported challenges were found especially for care coordination. CONCLUSIONS: Better understanding of PC challenges ahead of PCMH implementation provides important context for strategic planning and redesign efforts. As a national healthcare system, the VA provides a unique opportunity to examine organizational and area determinants relevant to other PCMH models.

Factors Associated with Delayed Care Among Women Veterans Actively Engaged in Primary Care.

Background: Delaying needed medical care contributes to greater health risks and higher long-term medical costs. Women Veterans with complex medical and mental health needs face increased barriers to timely care access. Objectives: In a sample of women Veterans with recent engagement in Veterans Administration (VA) primary care, we aimed to compare characteristics of women Veterans who delayed care in the past 6 months with those who did not and examine factors associated with self-reported delayed care. Our study aims to inform interventions focused on eliminating health care access disparities among women Veterans. Materials and Methods: An innovation to improve women Veterans' engagement and retention in evidence-based health care for cardiovascular (CV) risk reduction (CV Toolkit) was implemented across five primary care sites within the VA. Women Veterans who were exposed to at least one CV Toolkit component participated in a mailed survey (n = 253). We used multivariate logistic regression to model factors associated with delaying care, including trust in VA providers, positive mental health screening (i.e., positive screen for either depression or anxiety), traumatic experience, self-rated health, and age. Results: Women with any mental health symptoms (odds ratio [OR] 2.42, 95% confidence interval [CI]: 1.23-4.74) and women who had experienced a traumatic event (OR 2.61, 95%CI: 1.11-6.14) were significantly more likely to report delaying care. Conclusions: Our study identified high rates of delayed care-over one-third of respondents-among women Veterans with recent primary care engagement. Mental health symptoms were the most common reported reason for delay among those who delayed care. Clinical Trial registration: NCT02991534.

The Rapid Implementation Feedback (RIF) report: real-time synthesis of qualitative data for proactive implementation planning and tailoring.

BACKGROUND: Qualitative methods are a critical tool for enhancing implementation planning and tailoring, yet rapid turn-around of qualitative insights can be challenging in large implementation trials. The Department of Veterans Affairs-funded EMPOWER 2.0 Quality Enhancement Research Initiative (QUERI) is conducting a hybrid type 3 effectiveness-implementation trial comparing the impact of Replicating Effective Programs (REP) and Evidence-Based Quality Improvement (EBQI) as strategies for implementing three evidence-based practices (EBPs) for women Veterans. We describe the development of the Rapid Implementation Feedback (RIF) report, a pragmatic, team-based approach for the rapid synthesis of qualitative data to aid implementation planning and tailoring, as well as findings from a process evaluation of adopting the RIF report within the EMPOWER 2.0 QUERI. METHODS: Trained qualitative staff conducted 125 semi-structured pre-implementation interviews with frontline staff, providers, and leadership across 16 VA sites between October 2021 and October 2022. High-priority topic domains informed by the updated Consolidated Framework for Implementation Research were selected in dialogue between EMPOWER 2.0 implementation and evaluation teams, and relevant key points were summarized for each interview to produce a structured RIF report, with emergent findings about each site highlighted in weekly written and verbal communications. Process evaluation was conducted to assess EMPOWER 2.0 team experiences with the RIF report across pre-implementation data collection and synthesis and implementation planning and tailoring. RESULTS: Weekly RIF updates supported continuous EMPOWER 2.0 team communication around key findings, particularly questions and concerns raised by participating sites related to the three EBPs. Introducing the RIF report into team processes enhanced: team communication; quality and rigor of qualitative data; sensemaking around emergent challenges; understanding of site readiness; and tailoring of REP and EBQI implementation strategies. RIF report findings have facilitated rapid tailoring of implementation planning and rollout, supporting increased responsiveness to sites' needs and concerns. CONCLUSIONS: The RIF report provides a structured strategy for distillation of time-sensitive findings, continuous team communication amid a complex multi-site implementation effort, and effective tailoring of implementation rollout in real-time. Use of the RIF report may also support trust-building by enhancing responsiveness to sites during pre- and early implementation. TRIAL REGISTRATION: Enhancing Mental and Physical Health of Women Veterans (NCT05050266); https://clinicaltrials.gov/study/NCT05050266?term=EMPOWER%202.0&rank=1 Date of registration: 09/09/2021.

Racial/ethnic differences in cardiovascular risk factors among women veterans.

BACKGROUND: Heart disease is the leading cause of death for women in the United States, accounting for 24.5 % of all deaths among women. Earlier research has demonstrated racial/ethnic differences in prevalence of cardiovascular (CVD) risk factors. OBJECTIVE: To empirically examine the prevalence of CVD risk factors among a national sample of women Veterans by race/ethnicity, providing the first portrait of women Veterans' cardiovascular care needs. DESIGN AND PARTICIPANTS: Cross-sectional, national population-based telephone survey of 3,611 women Veterans. MEASUREMENTS: Women Veterans were queried about presence of diabetes, hypertension, obesity, tobacco use and physical activity. Four racial/ethnic categories were created: Hispanic, Non-Hispanic White (White), Non-Hispanic Black (Black), and Other. Logistic regressions were conducted for each risk factor to test for racial/ethnic differences, controlling for age (under 40 vs. 40 and over). KEY RESULTS: Racial/ethnic differences in CVD risk factors persisted after adjusting for age. Black women Veterans were more likely to report a diagnosis of diabetes (OR: 2.58, 95 % CI: 1.07, 6.21) or hypertension (OR: 2.31, 95 % CI: 1.10, 4.83) and be obese (OR: 2.06, 95 % CI: 1.05, 3.91) than White women Veterans. Hispanic women Veterans were more likely than White women Veterans to report diabetes (OR: 4.20, 95 % CI: 1.15, 15.39) and daily smoking (OR: 3.38, 95 % CI: 1.01, 11.30), but less likely to report a hypertension diagnosis (OR 0.21, 95% CI: 0.07, 0.64) or to be obese (OR: 0.39, 95 % CI: 0.18, 0.81). CONCLUSIONS: Among women Veterans, CVD risks vary by race/ethnicity. Black women Veterans consistently face higher CVD risk compared to White women Veterans, while results are mixed for Hispanic women Veterans.

Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) 2.0 QUERI: study protocol for a cluster-randomized hybrid type 3 effectiveness-implementation trial.

BACKGROUND: Women Veterans are the fastest-growing segment of Veterans Health Administration (VA) users. The VA has invested heavily in delivering care for women Veterans that is effective, comprehensive, and gender-tailored. However, gender disparities persist in cardiovascular (CV) and diabetes risk factor control, and the rate of perinatal depression among women Veterans is higher than that among civilian women. Challenges such as distance, rurality, negative perception of VA, discrimination (e.g., toward sexual and/or gender minority individuals), and harassment on VA grounds can further impede women's regular use of VA care. Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) 2.0 builds on work to date by expanding access to evidence-based, telehealth preventive and mental health services for women Veterans with high-priority health conditions in rural and urban-isolation areas. METHODS: EMPOWER 2.0 will evaluate two implementation strategies, Replicating Effective Practices (REP) and Evidence-Based Quality Improvement (EBQI), in supporting the implementation and sustainment of three evidence-based interventions (Virtual Diabetes Prevention Program; Telephone Lifestyle Coaching Program; and Reach Out, Stay Strong Essentials) focused on preventive and mental health care for women Veterans. We will conduct a mixed-methods implementation evaluation using a cluster-randomized hybrid type 3 effectiveness-implementation trial design to compare the effectiveness of REP and EBQI on improved access to and rates of engagement in telehealth preventive lifestyle and mental health services. Other outcomes of interest include (a) VA performance metrics for telehealth care delivery and related clinical outcomes; (b) progression along the Stages of Implementation Completion; (c) adaptation, sensemaking, and experiences of implementation among multilevel stakeholders; and (d) cost and return on investment. We will also generate implementation playbooks for program partners to support scale-up and spread of these and future evidence-based women's health programs and policies. DISCUSSION: EMPOWER 2.0 provides a model for mixed-methods hybrid type 3 effectiveness-implementation trial design incorporating evaluation of performance metrics, implementation progress, stakeholder experience, and cost and return on investment, with the ultimate goal of improving access to evidence-based preventive and mental telehealth services for women Veterans with high-priority health conditions. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05050266 . Registered on 20 September 2021.

Racial, Ethnic, and Rural Disparities in US Veteran COVID-19 Vaccine Rates.

Background: Race, ethnicity, and rurality-related disparities in coronavirus disease 2019 (COVID-19) vaccine uptake have been documented in the United States (US). Objective: We determined whether these disparities existed among patients at the Department of Veterans Affairs (VA), the largest healthcare system in the US. Design Settings Participants Measurements: Using VA Corporate Data Warehouse data, we included 5,871,438 patients (9.4% women) with at least one primary care visit in 2019 in a retrospective cohort study. Each patient was assigned a single race/ethnicity, which were mutually exclusive, self-reported categories. Rurality was based on 2019 home address at the zip code level. Our primary outcome was time-to-first COVID-19 vaccination between December 15, 2020-June 15, 2021. Additional covariates included age (in years), sex, geographic region (North Atlantic, Midwest, Southeast, Pacific, Continental), smoking status (current, former, never), Charlson Comorbidity Index (based on ≥1 inpatient or two outpatient ICD codes), service connection (any/none, using standardized VA-cutoffs for disability compensation), and influenza vaccination in 2019-2020 (yes/no). Results: Compared with unvaccinated patients, those vaccinated (n=3,238,532; 55.2%) were older (mean age in years vaccinated=66.3, (standard deviation=14.4) vs. unvaccinated=57.7, (18.0), p<.0001)). They were more likely to identify as Black (18.2% vs. 16.1%, p<.0001), Hispanic (7.0% vs. 6.6% p<.0001), or Asian American/Pacific Islander (AA/PI) (2.0% vs. 1.7%, P<.0001). In addition, they were more likely to reside in urban settings (68.0% vs. 62.8, p<.0001). Relative to non-Hispanic White urban Veterans, the reference group for race/ethnicity-urban/rural hazard ratios reported, all urban race/ethnicity groups were associated with increased likelihood for vaccination except American Indian/Alaskan Native (AI/AN) groups. Urban Black groups were 12% more likely (Hazard Ratio (HR)=1.12 [CI 1.12-1.13]) and rural Black groups were 6% more likely to receive a first vaccination (HR=1.06 [1.05-1.06]) relative to white urban groups. Urban Hispanic, AA/PI and Mixed groups were more likely to receive vaccination while rural members of these groups were less likely (Hispanic: Urban HR=1.17 [1.16-1.18], Rural HR=0.98 [0.97-0.99]; AA/PI: Urban HR=1.22 [1.21-1.23], Rural HR=0.86 [0.84-0.88]). Rural White Veterans were 21% less likely to receive an initial vaccine compared with urban White Veterans (HR=0.79 [0.78-0.79]). AI/AN groups were less likely to receive vaccination regardless of rurality: Urban HR=0.93 [0.91-0.95]; AI/AN-Rural HR=0.76 [0.74-0.78]. Conclusions: Urban Black, Hispanic, and AA/PI Veterans were more likely than their urban White counterparts to receive a first vaccination; all rural race/ethnicity groups except Black patients had lower likelihood for vaccination compared with urban White patients. A better understanding of disparities and rural outreach will inform equitable vaccine distribution.

Cardiovascular Risk Screening among Women Veterans: Identifying Provider and Patient Barriers and Facilitators to Develop a Clinical Toolkit.

INTRODUCTION: Cardiovascular (CV) disease is the leading cause of death among women in the United States, making CV risk screening and management a women's health priority. Objectives were to elicit barriers and facilitators to CV risk identification and reduction among women veterans, and iteratively cocreate clinical tools to identify CV risk factors and promote goal-setting for lifestyle changes. METHODS: We conducted three exploratory focus groups with 21 Veterans Health Administration primary care team members and piloted patient CV screeners with brief interviews with 19 patients from two Veterans Health Administration women's clinics to inform toolkit development. We then conducted two focus groups and one interview for feedback from a total of 12 staff on the proposed toolkit components. Transcripts were summarized, and a matrix analysis was used to synthesize qualitative findings. RESULTS: Provider-identified barriers included difficulties disseminating CV information in clinic, limited patient knowledge, and lack of organized resources for provider communication and available referrals. Women's complex health needs were notable challenges to CV risk reduction. Facilitators included having a single place to track patient CV risks (e.g., an electronic template note), a patient screening worksheet, and aids to complete referrals. Patient-identified barriers included difficulties balancing health, finances, and physical and mental health concerns. Facilitators included resources for accountability and gender-specific information about CV risks and complications. Providers requested easy, accessible tools in the electronic record with gender-specific CV data and resources linked. Patients requested lifestyle change supports, including trustworthy sources vetted by providers. CONCLUSIONS: Iteratively eliciting end-users' perspectives is critical to developing user-friendly, clinically relevant tools. CV risk reduction among women veterans will require multilevel tools and resources that meet providers' and women's needs.

Implementing clinical decision support for reducing women Veterans' cardiovascular risk in VA: A mixed-method, longitudinal study of context, adaptation, and uptake.

Evaluations of clinical decision support (CDS) implementation often struggle to measure and explain heterogeneity in uptake over time and across settings, and to account for the impact of context and adaptation on implementation success. In 2017-2020, the EMPOWER QUERI implemented a cardiovascular toolkit using a computerized template aimed at reducing women Veterans' cardiovascular risk across five Veterans Healthcare Administration (VA) sites, using an enhanced Replicating Effective Programs (REP) implementation approach. In this study, we used longitudinal joint displays of qualitative and quantitative findings to explore (1) how contextual factors emerged across sites, (2) how the template and implementation strategies were adapted in response to contextual factors, and (3) how contextual factors and adaptations coincided with template uptake across sites and over time. We identified site structure, staffing changes, relational authority of champions, and external leadership as important contextual factors. These factors gave rise to adaptations such as splitting the template into multiple parts, pairing the template with a computerized reminder, conducting academic detailing, creating cheat sheets, and using small-scale pilot testing. All five sites exhibited variability in utilization over the months of implementation, though later sites exhibited higher template utilization immediately post-launch, possibly reflecting a "preloading" of adaptations from previous sites. These findings underscore the importance of adaptive approaches to implementation, with intentional shifts in intervention and strategy to meet the needs of individual sites, as well as the value of integrating mixed-method data sources in conducting longitudinal evaluation of implementation efforts.

Racial Differences in Nontraditional Risk Factors Associated with Cardiovascular Conditions in Pregnancy Among U.S. Women Veterans.

Background: Pregnancy-related cardiovascular (CV) conditions are important predictors of future cardiovascular disease (CVD). Nontraditional factors, such as depression and chronic stress, have been associated with CVD, but their role in pregnancy-related CVD conditions (pCVD) remains unknown. To determine the association between nontraditional factors and CV conditions in pregnancy, and to explore if this risk varies by race. Methods: Using data from a prospective study of pregnant women within the veterans affairs health system (COMFORT study), we described the prevalence of nontraditional factors (e.g., depression, post-traumatic stress disorder [PTSD], chronic stress) and used logistic regression to determine the association between nontraditional factors and pregnancy-related CV conditions (pre-eclampsia/eclampsia, gestational hypertension, gestation diabetes, or preterm delivery). Analyses were then stratified by race. Results: Among 706 enrollees, 26% had pregnancy-related CV conditions. These women had significantly higher rates of depression (62% vs. 45%, p < 0.01), anxiety (50% vs. 37%, p = 0.01), PTSD (44% vs. 29%, p < 0.01), and high stress levels before pregnancy (22% vs. 16%, p = 0.05) compared with women with normal pregnancies. Overall, these factors were not associated with increased adjusted odds of pCVD. Overall, Black women had disproportionately higher rates of prepregnancy hypertension compared with White women (22% vs. 6%, p < 0.01). Conclusions: Women Veterans with pCVD are a high-risk group for future CVD, with disproportionately high rates of depression, anxiety, PTSD, and chronic stress. Racial disparities exist in pregnancy-related CV risk factors, which may further compound existing racial disparities in CVD among women Veterans.

Association Between Availability of Women's Health Services and Women Veterans' Care Experiences.

INTRODUCTION: Few studies have focused on determinants of women's ratings of care experiences in primary care. We assessed associations between availability of women's health services and women veterans' ratings of care experiences. METHODS: In a cross-sectional analysis, we linked Fiscal Year (FY) 2017 (October 1, 2016, to September 30, 2017) survey data from 126 Veterans Health Administration (VA) primary care leaders to 4,254 women veterans' ratings of care from VA's Survey of Healthcare Experiences of Patients-Patient Centered Medical Home (FY 2017). The dependent variables were ratings of optimal access (appointments, information), care coordination, comprehensiveness (behavioral health assessment), patient-provider communication, and primary care provider. Key independent variables were number of women's health services 1) routinely available all weekday hours (compared with some hours or not available) and 2) available in VA general primary care vs. other arrangements. In multilevel logistic regression models, we adjusted for patient-, facility-, and area-level characteristics. RESULTS: A greater number of women's health services routinely available in VA primary care was associated with a higher likelihood of optimal ratings of care coordination (adjusted odds ratio [AOR], 1.06; 95% confidence interval [CI], 1.01-1.10), provider communication (AOR, 1.08; 95% CI, 1.002-1.16), and primary care provider (AOR, 1.07; 95% CI, 1.02-1.13). A greater number of services available in VA primary care was associated with a lower likelihood of optimal ratings for access (AOR, 0.94; 95% CI, 0.88-0.99). CONCLUSION: For the most part, routine availability of women's health services in VA primary care clinics enhanced women's healthcare experiences. These empirical findings offer healthcare leaders evidence-based approaches for improving women's care experiences.