Sexual and Gender Minority Status and Suicide Mortality: An Explainable Artificial Intelligence Analysis.

Objectives: Suicide risk is elevated in lesbian, gay, bisexual, and transgender (LGBT) individuals. Limited data on LGBT status in healthcare systems hinder our understanding of this risk. This study used natural language processing to extract LGBT status and a deep neural network (DNN) to examine suicidal death risk factors among US Veterans. Methods: Data on 8.8 million veterans with visits between 2010 and 2017 was used. A case-control study was performed, and suicide death risk was analyzed by a DNN. Feature impacts and interactions on the outcome were evaluated. Results: The crude suicide mortality rate was higher in LGBT patients. However, after adjusting for over 200 risk and protective factors, known LGBT status was associated with reduced risk compared to LGBT-Unknown status. Among LGBT patients, black, female, married, and older Veterans have a higher risk, while Veterans of various religions have a lower risk. Conclusion: Our results suggest that disclosed LGBT status is not directly associated with an increase suicide death risk, however, other factors (e.g., depression and anxiety caused by stigma) are associated with suicide death risks.

Blood Pressure Control and Maintenance in a Prospective Cohort of Younger Veterans: Roles of Sex, Race, Ethnicity, and Social Determinants of Health.

Background: Proactive blood pressure (BP) management is particularly beneficial for younger Veterans, who have a greater prevalence and earlier onset of cardiovascular disease than non-Veterans. It is unknown what proportion of younger Veterans achieve and maintain BP control after hypertension onset and if BP control differs by demographics and social deprivation. Methods: Electronic health records were merged from Veterans who enrolled in VA care 10/1/2001-9/30/2017 and met criteria for hypertension - first diagnosis or antihypertensive fill. BP control (140/90 mmHg), was estimated 1, 2, and 5 years post-hypertension documentation, and characterized by sex, race, and ethnicity. Adjusted logistic regressions assessed likelihood of BP control by these demographics and with the Social Deprivation Index (SDI). Results: Overall, 17% patients met criteria for hypertension (n=198,367; 11% of women, median age 41). One year later, 59% of men and 65% of women achieved BP control. After adjustment, women had a 72% greater odds of BP control than men, with minimal change over 5 years. Black adults had a 22% lower odds of BP control than White adults. SDI did not significantly change these results. Conclusions: In the largest study of hypertension in younger Veterans, 41% of men and 35% of women did not have BP control after 1 year, and BP control was consistently better for women through 5 years. Thus, the first year of hypertension management portends future, long-term BP control. As social deprivation did not affect BP control, the VA system may protect against disadvantages observed in the general U.S. population.

A roadmap to artificial intelligence (AI): Methods for designing and building AI ready data to promote fairness.

OBJECTIVES: We evaluated methods for preparing electronic health record data to reduce bias before applying artificial intelligence (AI). METHODS: We created methods for transforming raw data into a data framework for applying machine learning and natural language processing techniques for predicting falls and fractures. Strategies such as inclusion and reporting for multiple races, mixed data sources such as outpatient, inpatient, structured codes, and unstructured notes, and addressing missingness were applied to raw data to promote a reduction in bias. The raw data was carefully curated using validated definitions to create data variables such as age, race, gender, and healthcare utilization. For the formation of these variables, clinical, statistical, and data expertise were used. The research team included a variety of experts with diverse professional and demographic backgrounds to include diverse perspectives. RESULTS: For the prediction of falls, information extracted from radiology reports was converted to a matrix for applying machine learning. The processing of the data resulted in an input of 5,377,673 reports to the machine learning algorithm, out of which 45,304 were flagged as positive and 5,332,369 as negative for falls. Processed data resulted in lower missingness and a better representation of race and diagnosis codes. For fractures, specialized algorithms extracted snippets of text around keywork "femoral" from dual x-ray absorptiometry (DXA) scans to identify femoral neck T-scores that are important for predicting fracture risk. The natural language processing algorithms yielded 98% accuracy and 2% error rate The methods to prepare data for input to artificial intelligence processes are reproducible and can be applied to other studies. CONCLUSION: The life cycle of data from raw to analytic form includes data governance, cleaning, management, and analysis. When applying artificial intelligence methods, input data must be prepared optimally to reduce algorithmic bias, as biased output is harmful. Building AI-ready data frameworks that improve efficiency can contribute to transparency and reproducibility. The roadmap for the application of AI involves applying specialized techniques to input data, some of which are suggested here. This study highlights data curation aspects to be considered when preparing data for the application of artificial intelligence to reduce bias.

Relationship Between Pain and LGBT Status Among Veterans in Care in a Retrospective Cross-Sectional Cohort.

Background: Pain assessment is performed in many healthcare systems, such as the Veterans Health Administration, but prior studies have not assessed whether pain screening varies in sexual and gender minority populations that include individuals who identify as lesbian, gay, bisexual, and/or transgender (LGBT). Objective: The purpose of this study was to evaluate pain screening and reported pain of LGBT Veterans compared to non-LGBT Veterans. Methods: Using a retrospective cross-sectional cohort, data from the Corporate Data Warehouse, a national repository with clinical/administrative data, were analyzed. Veterans were classified as LGBT using natural language processing. We used a robust Poisson model to examine the association between LGBT status and binary outcomes of pain screening, any pain, and persistent pain within one year of entry in the cohort. All models were adjusted for demographics, mental health, substance use, musculoskeletal disorder(s), and number of clinic visits. Results: There were 1,149,486 Veterans (218,154 (19%) classified as LGBT) in our study. Among LGBT Veterans, 94% were screened for pain compared to 89% among those not classified as LGBT (non-LGBT) Veterans. In adjusted models, LGBT Veterans' probability of being screened for pain compared to non-LGBT Veterans was 2.5% higher (95% CI 2.3%, 2.6%); risk of any pain was 2.1% lower (95% CI 1.6%, 2.6%); and there was no significant difference between LGBT and non-LGBT Veterans in persistent pain (RR = 1.00, 95% CI (0.99, 1.01), p = 0.88). Conclusions: In a nationwide sample, LGBT Veterans were more likely to be screened for pain but had lower self-reported pain scores, though adjusted differences were small. It was notable that transgender and Black Veterans reported the greatest pain. Reasons for these findings require further investigation.

Insomnia and Early Incident Atrial Fibrillation: A 16-Year Cohort Study of Younger Men and Women Veterans.

Background There is growing consideration of sleep disturbances and disorders in early cardiovascular risk, including atrial fibrillation (AF). Obstructive sleep apnea confers risk for AF but is highly comorbid with insomnia, another common sleep disorder. We sought to first determine the association of insomnia and early incident AF risk, and second, to determine if AF onset is earlier among those with insomnia. Methods and Results This retrospective analysis used electronic health records from a cohort study of US veterans who were discharged from military service since October 1, 2001 (ie, post-9/11) and received Veterans Health Administration care, 2001 to 2017. Time-varying, multivariate Cox proportional hazard models were used to examine the independent contribution of insomnia diagnosis to AF incidence while serially adjusting for demographics, lifestyle factors, clinical comorbidities including obstructive sleep apnea and psychiatric disorders, and health care utilization. Overall, 1 063 723 post-9/11 veterans (Mean age=28.2 years, 14% women) were followed for 10 years on average. There were 4168 cases of AF (0.42/1000 person-years). Insomnia was associated with a 32% greater adjusted risk of AF (95% CI, 1.21-1.43), and veterans with insomnia showed AF onset up to 2 years earlier. Insomnia-AF associations were similar after accounting for health care utilization (adjusted hazard ratio [aHR], 1.27 [95% CI, 1.17-1.39]), excluding veterans with obstructive sleep apnea (aHR, 1.38 [95% CI, 1.24-1.53]), and among those with a sleep study (aHR, 1.26 [95% CI, 1.07-1.50]). Conclusions In younger adults, insomnia was independently associated with incident AF. Additional studies should determine if this association differs by sex and if behavioral or pharmacological treatment for insomnia attenuates AF risk.

Screening for Intimate Partner Violence Experience and Use in the Veterans Health Administration.

Importance: The practice of screening women for intimate partner violence (IPV) in health care settings has been a critical part of responding to this major public health problem. Yet, IPV prevention would be enhanced with detection efforts that extend beyond screening for IPV experiences to identifying those who use violence in relationships as well. Objective: To determine rates of IPV experiences and use (ie, among perpetrators of IPV) and factors associated with disclosures among adult patients seeking mental health services at the Veterans Health Administration. Design, Setting, and Participants: This cross-sectional study used electronic medical record data drawn from a quality improvement initiative at 5 Veterans Health Administration medical centers conducted between November 2021 and February 2022 to examine IPV disclosures following concurrent screening for IPV experience and use. Participants included patients engaged in mental health services. Data were analyzed in April and May 2023. Exposure: Mental health clinicians were trained to screen for IPV experience and use concurrently and instructed to screen all patients encountered through routine mental health care visits during a 3-month period. Main Outcomes and Measures: Outcomes of interest were past-year prevalence of IPV use and experience, sociodemographic characteristics, and clinical diagnoses among screened patients. Results: A total of 200 patients were offered IPV screening. Of 155 participants (mean [SD] age, 52.45 [15.65] years; 124 [80.0%] men) with completed screenings, 74 (47.7%) denied past-year IPV experience and use, 76 (49.0%) endorsed past-year IPV experience, and 72 (46.4%) endorsed past-year IPV use, including 67 participants (43.2%) who reported IPV experience and use concurrently; only 9 participants (5.8%) endorsed unidirectional IPV experiences and 5 participants (3.2%) endorsed unidirectional IPV use. Patients who reported past-year IPV experience and use were younger than those who denied IPV (experience: mean difference, -7.34 [95% CI, 2.51-12.17] years; use: mean difference, -7.20 [95% CI, 2.40-12.00] years). Patients with a posttraumatic stress disorder diagnosis were more likely to report IPV use (43 patients [59.7%]) than those without a posttraumatic stress disorder diagnosis (29 patients [40.3%]; odds ratio, 2.14; [95% CI, 1.12-4.06]). No other demographic characteristics or clinical diagnoses were associated with IPV use or experience. Conclusions and Relevance: In this cross-sectional study of IPV rates and associated factors, screening for IPV found high rates of both IPV experience and use among patients receiving mental health care. These findings highlight the benefit of screening for IPV experience and use concurrently across gender and age. Additionally, the associations found between PTSD and IPV use underscore the importance of strengthening and developing additional targeted treatment for IPV.

Identifying suicide documentation in clinical notes through zero-shot learning.

Background and Aims: In deep learning, a major difficulty in identifying suicidality and its risk factors in clinical notes is the lack of training samples given the small number of true positive instances among the number of patients screened. This paper describes a novel methodology that identifies suicidality in clinical notes by addressing this data sparsity issue through zero-shot learning. Our general aim was to develop a tool that leveraged zero-shot learning to effectively identify suicidality documentation in all types of clinical notes. Methods: US Veterans Affairs clinical notes served as data. The training data set label was determined using diagnostic codes of suicide attempt and self-harm. We used a base string associated with the target label of suicidality to provide auxiliary information by narrowing the positive training cases to those containing the base string. We trained a deep neural network by mapping the training documents' contents to a semantic space. For comparison, we trained another deep neural network using the identical training data set labels, and bag-of-words features. Results: The zero-shot learning model outperformed the baseline model in terms of area under the curve, sensitivity, specificity, and positive predictive value at multiple probability thresholds. In applying a 0.90 probability threshold, the methodology identified notes documenting suicidality but not associated with a relevant ICD-10-CM code, with 94% accuracy. Conclusion: This method can effectively identify suicidality without manual annotation.

Implementer report: ICD-10 code F44.5 review for functional seizure disorder.

OBJECTIVE: The study aimed to measure the validity of International Classification of Diseases, 10th Edition (ICD-10) code F44.5 for functional seizure disorder (FSD) in the Veterans Affairs Connecticut Healthcare System electronic health record (VA EHR). METHODS: The study used an informatics search tool, a natural language processing algorithm and a chart review to validate FSD coding. RESULTS: The positive predictive value (PPV) for code F44.5 was calculated to be 44%. DISCUSSION: ICD-10 introduced a specific code for FSD to improve coding validity. However, results revealed a meager (44%) PPV for code F44.5. Evaluation of the low diagnostic precision of FSD identified inconsistencies in the ICD-10 and VA EHR systems. CONCLUSION: Information system improvements may increase the precision of diagnostic coding by clinicians. Specifically, the EHR problem list should include commonly used diagnostic codes and an appropriately curated ICD-10 term list for 'seizure disorder,' and a single ICD code for FSD should be classified under neurology and psychiatry.

Intimate partner violence among lesbian, gay, and bisexual veterans.

The present study describes intimate partner violence (IPV) perpetration and victimization alongside theoretically associated variables in a sample of lesbian, gay, and bisexual veterans. We conducted bivariate analyses (chi-square tests and independent t test) to examine whether the frequencies of IPV perpetration and victimization varied by demographic characteristics, military sexual trauma, alcohol use, and mental health symptoms. Out of the 69 lesbian, gay, and bisexual (LGB) veterans who answered the questions on IPV, 16 (23.2%) reported some form of IPV victimization in the past year, and 38 (55.1%) reported past-year perpetration. Among the 43 veterans who reported psychological IPV, roughly half (48.9%) reported bidirectional psychological IPV, 39.5% reported perpetration only, and 11.6% reported victimization only. LGB veterans who reported bidirectional psychological IPV in their relationships were younger and reported greater symptoms of posttraumatic stress disorder symptoms and depression. The results presented here call for universal screening of IPV perpetration and victimization to both accurately assess and ultimately intervene among all veterans. Inclusive interventions are needed for all genders and sexual orientations, specifically interventions that do not adhere to gendered assumptions of perpetrators and victims. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A Roadmap to Artificial Intelligence (AI): Methods for Designing and Building AI ready Data for Women's Health Studies.

Objectives: Evaluating methods for building data frameworks for application of AI in large scale datasets for women's health studies. Methods: We created methods for transforming raw data to a data framework for applying machine learning (ML) and natural language processing (NLP) techniques for predicting falls and fractures. Results: Prediction of falls was higher in women compared to men. Information extracted from radiology reports was converted to a matrix for applying machine learning. For fractures, by applying specialized algorithms, we extracted snippets from dual x-ray absorptiometry (DXA) scans for meaningful terms usable for predicting fracture risk. Discussion: Life cycle of data from raw to analytic form includes data governance, cleaning, management, and analysis. For applying AI, data must be prepared optimally to reduce algorithmic bias. Conclusion: Algorithmic bias is harmful for research using AI methods. Building AI ready data frameworks that improve efficiency can be especially valuable for women's health.

Detection of left ventricular systolic dysfunction from single-lead electrocardiography adapted for portable and wearable devices.

Artificial intelligence (AI) can detect left ventricular systolic dysfunction (LVSD) from electrocardiograms (ECGs). Wearable devices could allow for broad AI-based screening but frequently obtain noisy ECGs. We report a novel strategy that automates the detection of hidden cardiovascular diseases, such as LVSD, adapted for noisy single-lead ECGs obtained on wearable and portable devices. We use 385,601 ECGs for development of a standard and noise-adapted model. For the noise-adapted model, ECGs are augmented during training with random gaussian noise within four distinct frequency ranges, each emulating real-world noise sources. Both models perform comparably on standard ECGs with an AUROC of 0.90. The noise-adapted model performs significantly better on the same test set augmented with four distinct real-world noise recordings at multiple signal-to-noise ratios (SNRs), including noise isolated from a portable device ECG. The standard and noise-adapted models have an AUROC of 0.72 and 0.87, respectively, when evaluated on ECGs augmented with portable ECG device noise at an SNR of 0.5. This approach represents a novel strategy for the development of wearable-adapted tools from clinical ECG repositories.

Detection of Left Ventricular Systolic Dysfunction From Electrocardiographic Images.

BACKGROUND: Left ventricular (LV) systolic dysfunction is associated with a >8-fold increased risk of heart failure and a 2-fold risk of premature death. The use of ECG signals in screening for LV systolic dysfunction is limited by their availability to clinicians. We developed a novel deep learning-based approach that can use ECG images for the screening of LV systolic dysfunction. METHODS: Using 12-lead ECGs plotted in multiple different formats, and corresponding echocardiographic data recorded within 15 days from the Yale New Haven Hospital between 2015 and 2021, we developed a convolutional neural network algorithm to detect an LV ejection fraction <40%. The model was validated within clinical settings at Yale New Haven Hospital and externally on ECG images from Cedars Sinai Medical Center in Los Angeles, CA; Lake Regional Hospital in Osage Beach, MO; Memorial Hermann Southeast Hospital in Houston, TX; and Methodist Cardiology Clinic of San Antonio, TX. In addition, it was validated in the prospective Brazilian Longitudinal Study of Adult Health. Gradient-weighted class activation mapping was used to localize class-discriminating signals on ECG images. RESULTS: Overall, 385 601 ECGs with paired echocardiograms were used for model development. The model demonstrated high discrimination across various ECG image formats and calibrations in internal validation (area under receiving operation characteristics [AUROCs], 0.91; area under precision-recall curve [AUPRC], 0.55); and external sets of ECG images from Cedars Sinai (AUROC, 0.90 and AUPRC, 0.53), outpatient Yale New Haven Hospital clinics (AUROC, 0.94 and AUPRC, 0.77), Lake Regional Hospital (AUROC, 0.90 and AUPRC, 0.88), Memorial Hermann Southeast Hospital (AUROC, 0.91 and AUPRC 0.88), Methodist Cardiology Clinic (AUROC, 0.90 and AUPRC, 0.74), and Brazilian Longitudinal Study of Adult Health cohort (AUROC, 0.95 and AUPRC, 0.45). An ECG suggestive of LV systolic dysfunction portended >27-fold higher odds of LV systolic dysfunction on transthoracic echocardiogram (odds ratio, 27.5 [95% CI, 22.3-33.9] in the held-out set). Class-discriminative patterns localized to the anterior and anteroseptal leads (V2 and V3), corresponding to the left ventricle regardless of the ECG layout. A positive ECG screen in individuals with an LV ejection fraction ≥40% at the time of initial assessment was associated with a 3.9-fold increased risk of developing incident LV systolic dysfunction in the future (hazard ratio, 3.9 [95% CI, 3.3-4.7]; median follow-up, 3.2 years). CONCLUSIONS: We developed and externally validated a deep learning model that identifies LV systolic dysfunction from ECG images. This approach represents an automated and accessible screening strategy for LV systolic dysfunction, particularly in low-resource settings.

Understanding Veterans' intimate partner violence use and patterns of healthcare utilization.

OBJECTIVE: To understand the association between Veterans' healthcare utilization and intimate partner violence (IPV) use (i.e., perpetration) in order to (1) identify conditions comorbid with IPV use and (2) inform clinical settings to target for IPV use screening, intervention, and provider training. DATA SOURCES AND STUDY SETTING: We examined survey data from a national sample of 834 Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) Veterans. STUDY DESIGN: We assessed associations between past-year IPV use and medical treatment, health issues, and use of Veterans Health Administration (VA) and non-VA services using chi-square tests and logistic regression. DATA COLLECTION/EXTRACTION METHODS: Data were derived from the Department of Defense OEF/OIF/OND Roster. Surveys were sent to all women Veterans and a random sample of men from participating study sites. PRINCIPAL FINDINGS: Half (49%) of the Veterans who reported utilizing VA healthcare in the past year indicated using IPV. Q values using a 5% false discovery rate indicated that Veterans who used IPV were more likely than Veterans who did not use IPV to have received treatment for post-traumatic stress disorder (PTSD; 39% vs. 27%), chronic sleep problems (36% vs. 26%), anxiety or depression (44% vs. 36%), severe chronic pain (31% vs. 22%), and stomach or digestive disorders (24% vs. 16%). Veterans who used IPV were also more likely than Veterans who did not use IPV to have received medical treatment in the past year (86% vs. 80%), seen psychiatrists outside VA (39% vs. 20%), and have outpatient healthcare outside VA (49% vs. 41%). IPV use was not related to whether Veterans received care from VA or non-VA providers. CONCLUSIONS: Veterans' IPV use was related to greater utilization of services for mental health, chronic pain, and digestive issues. Future research should examine whether these are risk factors or consequences of IPV use.

Patient Dietary Supplements Use: Do Results from Natural Language Processing of Clinical Notes Agree with Survey Data?

There is widespread use of dietary supplements, some prescribed but many taken without a physician's guidance. There are many potential interactions between supplements and both over-the-counter and prescription medications in ways that are unknown to patients. Structured medical records do not adequately document supplement use; however, unstructured clinical notes often contain extra information on supplements. We studied a group of 377 patients from three healthcare facilities and developed a natural language processing (NLP) tool to detect supplement use. Using surveys of these patients, we investigated the correlation between self-reported supplement use and NLP extractions from the clinical notes. Our model achieved an F1 score of 0.914 for detecting all supplements. Individual supplement detection had a variable correlation with survey responses, ranging from an F1 of 0.83 for calcium to an F1 of 0.39 for folic acid. Our study demonstrated good NLP performance while also finding that self-reported supplement use is not always consistent with the documented use in clinical records.

Personal Health Libraries for People Returning From Incarceration: Protocol for a Qualitative Study.

BACKGROUND: Individuals released from carceral facilities have high rates of hospitalization and death, especially in the weeks immediately after their return to community settings. During this transitional process, individuals leaving incarceration are expected to engage with multiple providers working in separate, complex systems, including health care clinics, social service agencies, community-based organizations, and probation and parole services. This navigation is often complicated by individuals' physical and mental health, literacy and fluency, and socioeconomic status. Personal health information technology, which can help people access and organize their health information, could improve the transition from carceral systems to the community and mitigate health risks upon release. Yet, personal health information technologies have not been designed to meet the needs and preferences of this population nor tested for acceptability or use. OBJECTIVE: The objective of our study is to develop a mobile app to create personal health libraries for individuals returning from incarceration to help bridge the transition from carceral settings to community living. METHODS: Participants were recruited through Transitions Clinic Network clinic encounters and professional networking with justice-involved organizations. We used qualitative research methods to assess the facilitators and barriers to developing and using personal health information technology for individuals returning from incarceration. We conducted individual interviews with people just released from carceral facilities (n=~20) and providers (n=~10) from the local community and carceral facilities involved with the transition for returning community members. We used rigorous rapid qualitative analysis to generate thematic output characterizing the unique circumstances impacting the development and use of personal health information technology for individuals returning from incarceration and to identify content and features for the mobile app based on the preferences and needs of our participants. RESULTS: As of February 2023, we have completed 27 qualitative interviews with individuals recently released from carceral systems (n=20) and stakeholders (n=7) who support justice-involved individuals from various organizations in the community. CONCLUSIONS: We anticipate that the study will characterize the experiences of people transitioning from prison and jails to community settings; describe the information, technology resources, and needs upon reentry to the community; and create potential pathways for fostering engagement with personal health information technology. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/44748.

The Role of Unit and Interpersonal Support in Military Sexual Trauma and Posttraumatic Stress Disorder Symptoms.

Military sexual trauma (MST) is strongly associated with posttraumatic stress disorder (PTSD). Among many potential factors explaining this association are unit and interpersonal support, which have been explored in few studies with veterans who have experienced MST. This project examines unit and interpersonal support as moderators and/or mediators of PTSD symptoms among post-9/11 Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans who experienced MST. MST, unit support, and interpersonal support variables were collected at Time 1 (T1; N = 1,150, 51.4% women), and PTSD symptoms 1 year later at Time 2 (T2; N = 825; 52.3% women). Given gender differences in endorsed MST, models with the full sample (men and women) and women only were examined, while controlling for covariates related to PTSD, and a path model was examined among women veterans. Mediation was supported in the full model and women-only models, with the combination of both mediators demonstrating the strongest mediation effects (full-model: ß = .06, 95% confidence interval [CI] [0.03, 0.10], p < .001; women-only model: ß = .07, [0.03, 0.14], p = .002). Among the women-only model, MST was negatively associated with unit support (ß = -.23, [-0.33, -0.13], p < .001) and interpersonal support (ß = -.16, [-0.27, -0.06], p = .002) and both support types were negatively associated with PTSD symptoms (unit support: ß = -.13, [-0.24, -0.03], p = .014; interpersonal support: ß = -.25, [-0.35, -0.15], p < .001). Moderation was not supported in the full model nor in the women-only model. Experiencing MST is associated with receiving less unit and/or interpersonal support, which in turn is associated with greater PTSD symptoms. More work is needed to understand and improve the impact of unit and community responses to MST on service members who experience MST.

Assessing the contributions of modifiable risk factors to serious falls and fragility fractures among older persons living with HIV.

BACKGROUND: Although 50 years represents middle age among uninfected individuals, studies have shown that persons living with HIV (PWH) begin to demonstrate elevated risk for serious falls and fragility fractures in the sixth decade; the proportions of these outcomes attributable to modifiable factors are unknown. METHODS: We analyzed 21,041 older PWH on antiretroviral therapy (ART) from the Veterans Aging Cohort Study from 01/01/2010 through 09/30/2015. Serious falls were identified by Ecodes and a machine-learning algorithm applied to radiology reports. Fragility fractures (hip, vertebral, and upper arm) were identified using ICD9 codes. Predictors for both models included a serious fall within the past 12 months, body mass index, physiologic frailty (VACS Index 2.0), illicit substance and alcohol use disorders, and measures of multimorbidity and polypharmacy. We separately fit multivariable logistic models to each outcome using generalized estimating equations. From these models, the longitudinal extensions of average attributable fraction (LE-AAF) for modifiable risk factors were estimated. RESULTS: Key risk factors for both outcomes included physiologic frailty (VACS Index 2.0) (serious falls [15%; 95% CI 14%-15%]; fractures [13%; 95% CI 12%-14%]), a serious fall in the past year (serious falls [7%; 95% CI 7%-7%]; fractures [5%; 95% CI 4%-5%]), polypharmacy (serious falls [5%; 95% CI 4%-5%]; fractures [5%; 95% CI 4%-5%]), an opioid prescription in the past month (serious falls [7%; 95% CI 6%-7%]; fractures [9%; 95% CI 8%-9%]), and diagnosis of alcohol use disorder (serious falls [4%; 95% CI 4%-5%]; fractures [8%; 95% CI 7%-8%]). CONCLUSIONS: This study confirms the contributions of risk factors important in the general population to both serious falls and fragility fractures among older PWH. Successful prevention programs for these outcomes should build on existing prevention efforts while including risk factors specific to PWH.

Complementary and Integrative Health Approaches and Pain Care Quality in the Veterans Health Administration Primary Care Setting: A Quasi-Experimental Analysis.

Background: Complementary and integrative health (CIH) approaches have been recommended in national and international clinical guidelines for chronic pain management. We set out to determine whether exposure to CIH approaches is associated with pain care quality (PCQ) in the Veterans Health Administration (VHA) primary care setting. Methods: We followed a cohort of 62,721 Veterans with newly diagnosed musculoskeletal disorders between October 2016 and September 2017 over 1-year. PCQ scores were derived from primary care progress notes using natural language processing. CIH exposure was defined as documentation of acupuncture, chiropractic or massage therapies by providers. Propensity scores (PSs) were used to match one control for each Veteran with CIH exposure. Generalized estimating equations were used to examine associations between CIH exposure and PCQ scores, accounting for potential selection and confounding bias. Results: CIH was documented for 14,114 (22.5%) Veterans over 16,015 primary care clinic visits during the follow-up period. The CIH exposure group and the 1:1 PS-matched control group achieved superior balance on all measured baseline covariates, with standardized differences ranging from 0.000 to 0.045. CIH exposure was associated with an adjusted rate ratio (aRR) of 1.147 (95% confidence interval [CI]: 1.142, 1.151) on PCQ total score (mean: 8.36). Sensitivity analyses using an alternative PCQ scoring algorithm (aRR: 1.155; 95% CI: 1.150-1.160) and redefining CIH exposure by chiropractic alone (aRR: 1.118; 95% CI: 1.110-1.126) derived consistent results. Discussion: Our data suggest that incorporating CIH approaches may reflect higher overall quality of care for patients with musculoskeletal pain seen in primary care settings, supporting VHA initiatives and the Declaration of Astana to build comprehensive, sustainable primary care capacity for pain management. Future investigation is warranted to better understand whether and to what degree the observed association may reflect the therapeutic benefits patients actually received or other factors such as empowering provider-patient education and communication about these approaches.