Oral Emergency Contraception Provision in the Veterans Health Administration: a Retrospective Cohort Study.

BACKGROUND: In the USA, oral emergency contraception (EC) use to prevent unintended pregnancy is increasing. Oral EC methods include levonorgestrel (LNG) and ulipristal acetate (UPA), with increased UPA efficacy over LNG in high BMI users and those beyond 3 days post intercourse. The Veterans Health Administration (VHA) provides oral EC at low or no cost, yet prescription-level Veteran data are lacking. OBJECTIVE: To describe oral EC provision in VHA, including method type and Veteran user and prescriber characteristics. DESIGN: A retrospective cohort study using VHA administrative data. PARTICIPANTS: All VHA oral EC prescriptions from January 1, 2016, to December 31, 2020. MAIN MEASURES: We linked Veteran-level sociodemographic and military characteristics and provider-level data with each prescription to identify variables associated with oral EC method. KEY RESULTS: A total of 4280 EC prescriptions (85% LNG) occurred for 3120 unique Veterans over 5 years. While prescriptions remained low annually, the proportion of UPA prescriptions increased from 12 to 19%. Compared to LNG users, UPA users were older (34% vs 25% over age 35 years, p <0.001); more likely to identify as white (57% vs 46%) and non-Hispanic (84% vs 79%) (p <0.001); and more likely to have a BMI ≥ 25 (76% vs 67%, p <0.001). UPA prescriptions originated most frequently from VA Medical Centers (87%) and women's health clinics (76%) compared to community-based or other clinic types. In multivariable regression models, race, ethnicity, BMI ≥30, and prescriber facility type of a VA Medical Center or a women's clinic location were predictive of UPA prescription. CONCLUSIONS: Oral EC provision in VHA remains low, but UPA use is increasing. LNG prescription occurs frequently in high BMI Veterans who would benefit from increased efficacy of UPA. Interventions to expand oral EC access in VHA are essential to ensure Veterans' ability to avert unwanted pregnancies.

Improving Perinatal Mental Health Care for Women Veterans: Description of a Quality Improvement Program.

Purpose We describe results from a quality improvement project undertaken to address perinatal mental healthcare for women veterans. Description This quality improvement project was conducted in a single VA healthcare system between 2012 and 2015 and included screening for depressive symptoms with the Edinburgh Postnatal Depression Scale (EPDS) three times during the perinatal period, a dedicated maternity care coordinator (MCC), an on-site clinical social worker, and an on-site obstetrician/gynecologist (Ob/gyn). Information on prior mental health diagnosis was collected by the MCC or Ob/gyn. The prevalence of perinatal depressive symptoms and receipt of mental healthcare among those with such symptoms are reported by presence of a pre-pregnancy mental health diagnosis. Assessment Of the 199 women who used VA maternity benefits between 2012 and 2015, 56% (n = 111) had at least one pre-pregnancy mental health diagnosis. Compared to those without a pre-pregnancy mental health diagnosis, those with such a diagnosis were more likely to be screened for perinatal depressive symptoms at least once (61.5% vs. 46.8%, p = 0.04). Prevalence of depressive symptoms was 46.7% among those with a pre-pregnancy mental health diagnosis and 19.2% among those without. Among those with a pre-pregnancy mental health diagnosis and depressive symptoms (n = 35), 88% received outpatient mental healthcare and 77% met with the clinical social worker. Among those without a pre-pregnancy mental health diagnosis and depressive symptoms (n = 8), none received outpatient mental healthcare, but 77.8% met with the clinical social worker. Conclusion Improving perinatal mental healthcare for women veterans requires a multidisciplinary approach, including on-site integrated mental healthcare.

Mindfulness-based interventions for military veterans: A systematic review and analysis of the literature.

BACKGROUND: In recent years, mindfulness-based interventions (MBIs) have experienced exponential growth in terms of development, application, and research. However, few studies have examined implementation and efficacy of these interventions in particular populations, such as military Veterans. Such studies are needed as one cannot assume that the literature on MBIs implemented with the general population or other specific populations apply equally well to Veterans. This population is unique regarding professional competencies, military ethos, high degrees of medical comorbidities and barriers to treatment. The aim of this work was to review and summarize the literature over the previous five years (2014-2020) assessing the use of MBIs among military Veterans to guide clinical care and future research. METHODS: Systematic literature review. RESULTS: A total of 88 articles were found. Screening titles and abstracts resulted in 49 articles being excluded. The remaining 39 articles were read in full, and of these, 12 were excluded due to not fully meeting the inclusion criteria. Thus, the present review included a total of 27 articles, 3 of which used qualitative methods and 24 of which used quantitative methods. CONCLUSIONS: MBIs hold promise as complementary adjunctive interventions for Veterans with PTSD and possibly other psychiatric disorders. Currently there are significant gaps in the literature that must be addressed to move the field forward. The main deficiency is, with a few exceptions, the lack of rigorous RCTs. Another major concern is the lack of generalizability to female and non-white Veterans given that the subject samples across all studies reviewed were 85% male and 76% white. At this time, MBSR, PCBMT and MBCT can be recommended as adjunctive complementary interventions for the reduction of PTSD symptoms. Research recommendations to move the field forward are provided.

Patient-centered care and the electronic health record: exploring functionality and gaps.

OBJECTIVE: Healthcare systems have adopted electronic health records (EHRs) to support clinical care. Providing patient-centered care (PCC) is a goal of many healthcare systems. In this study, we sought to explore how existing EHR systems support PCC; defined as understanding the patient as a whole person, building relational connections between the clinician and patient, and supporting patients in health self-management. MATERIALS AND METHODS: We assessed availability of EHR functions consistent with providing PCC including patient goals and preferences, integrated care plans, and contextual and patient-generated data. We surveyed and then interviewed technical representatives and expert clinical users of 6 leading EHR systems. Questions focused on the availability of specific data and functions related to PCC (for technical representatives) and the clinical usefulness of PCC functions (for clinicians) in their EHR. RESULTS: Technical representatives (n = 6) reported that patient communication preferences, personalized indications for medications, and end of life preferences were functions implemented across 6 systems. Clinician users (n = 10) reported moderate usefulness of PCC functions (medians of 2-4 on a 5-pointy -35t scale), suggesting the potential for improvement across systems. Interviews revealed that clinicians do not have a shared conception of PCC. In many cases, data needed to deliver PCC was available in the EHR only in unstructured form. Data systems and functionality to support PCC are under development in these EHRs. DISCUSSION AND CONCLUSION: There are current gaps in PCC functionality in EHRs and opportunities to support the practice of PCC through EHR redesign.

Predictors of patient's intentions to participate in pragmatic clinical trials: An initial exploration.

The Veterans Health Administration is implementing a pragmatic trial research program, called Point of Care Research (POC-R). The purpose of this telephone survey in which respondents were randomized to different framing conditions of the purpose of POC-R was to determine the impact of differing frames of the purpose of POC-R on attitudes towards the program and intentions to participate; and the relative importance of different beliefs and attitudes in discriminating low vs. high intenders to participate in POC-R. The survey addressed veterans' perceptions and attitudes towards POC-R, and their willingness to participate in a pragmatic trial. Overall, respondents felt positively towards POC-R and intended to participate. Differing frames of the purpose of POC-R were not associated with either attitudes (towards the program) or intentions to participate. However, specific beliefs and attitudes toward POC-R program were predictive of intentions to participate.

Mental Status Documentation: Information Quality and Data Processes.

Delirium is a fluctuating disturbance of cognition and/or consciousness associated with poor outcomes. Caring for patients with delirium requires integration of disparate information across clinicians, settings and time. The goal of this project was to characterize the information processes involved in nurses' assessment, documentation, decisionmaking and communication regarding patients' mental status in the inpatient setting. VA nurse managers of medical wards (n=18) were systematically selected across the US. A semi-structured telephone interview focused on current assessment, documentation, and communication processes, as well as clinical and administrative decision-making was conducted, audio-recorded and transcribed. A thematic analytic approach was used. Five themes emerged: 1) Fuzzy Concepts, 2) Grey Data, 3) Process Variability 4) Context is Critical and 5) Goal Conflict. This project describes the vague and variable information processes related to delirium and mental status that undermine effective risk, prevention, identification, communication and mitigation of harm.