Impact of moral injury and posttraumatic stress disorder on health care utilization and suicidality in rural and urban veterans.

This study explored the impact of moral injury (MI) and posttraumatic stress disorder (PTSD) on health care utilization, mental health complexity, and suicidality in rural and urban veterans. Analyses combined data from the Salt Lake City PTSD Clinic Intake Database and the Department of Veterans Affairs Corporate Data Warehouse. Participants (N = 1,545; Mage = 45.9 years) were predominately male (88.3%) and White (87.8%). Adjusted analyses indicated associations between a 1-unit increase in Moral Injury Events Scale (MIES) score and increased mental health complexity, RR = 1.01, 95% CI [1.01, 1.02], p < .001; psychotropic medication utilization, RR = 1.01, 95% CI [1.01, 1.03], p < .001; VA drug class count, RR = 1.01, 95% CI [1.00, 1.01], p = .030; outpatient utilization, RR = 1.01, 95% CI [1.01, 1.02], p < .001; and mental health outpatient utilization, RR = 1.01, 95% CI [1.00, 1.03], p < .001. For the MIES x PTSD interaction, all associations remained statistically significant with similar estimated effects. However, for rural veterans, this interaction did not significantly affect utilization. Among those with PTSD, a 1-unit MIES increase was associated with an increased risk of suicidality, OR = 1.02, 95% CI [1.01, 1.04], and psychiatric admission, OR = 1.02, 95% CI [1.00, 1.04]. Findings suggest that higher MIES scores predict increased health care utilization and mental health complexity. Further, PTSD combined with higher MIES scores may increase the risk of suicidality and psychiatric admission. Rural veterans with PTSD and higher MIES scores may require additional outreach and intervention.

A scoping review of veteran suicide prevention programs in Native American communities and in the general population.

Suicide is a major public health problem that disproportionately impacts veterans in the general U.S. population. Recent analyses indicate that American Indian and Alaska Native (AI/AN) veterans may be two to three times as likely as non-Hispanic White veterans to experience suicidal ideation. Although suicide prevention programs have been successfully implemented for many at-risk populations, to our knowledge, none have been designed or implemented for AI/AN veterans. To address this gap, we conducted a scoping review of suicide prevention programs with the objective of identifying promising strategies and lessons learned to identify promising practices for preventing suicide among AI/AN veterans. We conducted two parallel literature searches-a review of suicide prevention programs for the general U.S. adult population and AI/AN communities. We rated programs on 16 criteria, covering five domains-best practices in suicide prevention, U.S. Department of Veterans Affairs (VA) Office of Rural Health Promising Practice criteria, cultural fit, care coordination, and outcomes. Our findings indicate that many of the VA evidence-based or best practice programs are available system-wide, but none have been tailored for AI/AN veterans or the communities in which they live. Conversely, we found that many culturally specific programs implemented in AI/AN communities were rarely disseminated beyond tribal land and none were specifically developed for veterans. Based upon these findings, and to advance suicide prevention programs for AI/AN veterans, we propose a suicide prevention model that builds upon existing VA infrastructure to disseminate best practices to AI/AN communities and integrate tribal-specific cultural approaches to suicide prevention. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

"We Got an Invite into the Fortress": VA-Community Partnerships for Meeting Veterans' Healthcare Needs.

Responding to identified needs for increased veterans' access to healthcare, in 2010 the United States Department of Veterans Affairs (VA) launched the Veteran Community Partnership (VCP) initiative to "foster seamless access to, and transitions among, the full continuum of non-institutional extended care and support services in VA and the community". This initiative represents an important effort by VA to promote collaboration with a broad range of community organizations as equal partners in the service of veteran needs. The purpose of the study is an initial assessment of the VCP program. Focus group interviews conducted in six sites in 2015 included 53 representatives of the local VA and community organizations involved with rural and urban VCPs across the US. Interview topics included the experiences and practices of VCP members, perceived benefits and challenges, and the characteristics and dynamics of rural and urban areas served by VCPs. Using a community-oriented conceptual framework, the analyses address VCP processes and preliminary outcomes, including VCP goals and activities, and VCP members' perceptions of their efforts, benefits, challenges, and achievements. The results indicate largely positive perceptions of the VCP initiative and its early outcomes by both community and VA participants. Benefits and challenges vary by rural-urban community context and include resource limitations and the potential for VA dominance of other VCP partners. Although all VCPs identified significant benefits and challenges, time and resource constraints and local organizational dynamics varied by rural and urban context. Significant investments in VCPs will be required to increase their impacts.

Variability in spousal perceptions of caregiving and its relationship to older caregiver health outcomes.

BACKGROUND: The transition to later-life caregiving roles, especially for couples caring for each other, can be rife with ambiguity. The incident discordance in spousal perceptions of one another's role and its relationship to mental health outcomes have not been well-described. OBJECTIVES: (1) To describe the range of daily agreement between older adult spouses' perceptions of care given and care received; (2) to explore associations between caregiving agreement and daily caregiver depression, anxiety, and marital satisfaction; and (3) to evaluate differential effects for male and female caregivers. DESIGN: Cross-sectional, ecological assessment (daily diary). PARTICIPANTS: Sample of 191 couples aged 60-64 (total 5196 daily surveys) drawn from the longitudinal Life and Family Legacies study. MAIN MEASURES: During 2011-2012, spouses independently completed 14 consecutive daily surveys about their mood, marital interactions, and support exchanges. Caregiving agreement was defined as the daily ratio of spouse-reported care received to self-reported care given. Using generalized linear mixed effect modeling, we examined associations between spousal care agreement and outcomes of depression, anxiety, and marital satisfaction. KEY RESULTS: Sample data demonstrated broad variability in spousal agreement, with couples exhibiting substantial disagreement on nearly one-third of couple days (780/2598 days). On days where care was exchanged, higher caregiving agreement was associated with lower caregiver depression (p < 0.01) and anxiety (p < 0.01) in male caregivers, and higher marital satisfaction (p = 0.03) in female caregivers. When care recipients reported receiving more support than their spouse reported giving, these associations did not persist. CONCLUSIONS: Findings suggest that spousal agreement about the amount of care given and received varies broadly and is an important consideration for primary care providers who counsel these patients day-to-day. Furthermore, agreement appears to predict mental health and relationship outcomes and should be further evaluated in this growing population of mid-to-late life adults emerging into caregiving.

COVER to COVER: Connecting Older Veterans (Especially Rural) to Community or Veteran-Eligible Resources.

A demonstration project trained community counselors to become veteran benefits specialists to improve access to benefits for veterans who are unaware of their eligibility.

Veterans as Caregivers: Those Who Continue to Serve.

Provider referrals are effective for connecting caregiving veterans to community-based resources, which can provide necessary support that reduces the caregiving burden.

Supporting Caregivers of Rural Veterans Electronically (SCORE).

BACKGROUND: The increasing prevalence of dementia, including among rural veterans, highlights the improved outcomes possible for caregivers who receive effective support. However, providing these complex interventions in rural areas presents challenges. Internet-based and telephone-based caregiver support can potentially expand access to effective support. METHODS: We designed a multisite intervention for caregivers of veterans with dementia. Caregivers were stratified into 2 cohorts based on their use or nonuse of the Internet. Each cohort was then randomized to either a technology or telephone-delivered support group within each cohort. All groups had a care manager who monitored the 4- to 6-month multicomponent program of assessments, educational content, and skills training. Caregiver outcome measures included burden, anticipatory grief, depression, family conflict, and a desire to institutionalize the care recipient. RESULTS: The majority of comparative effectiveness outcomes were not different between caregivers receiving technology interventions versus those receiving telephone-delivered support. This was true for the 68% of caregivers using home Internet and the 32% nonusers, as well as the 53% rural versus 47% urban caregivers. For experienced Internet users, a meaningful difference in the Marwit Grief Inventory was noted for caregivers receiving Internet versus telephone support, particularly for the Isolation Subscale. CONCLUSION: This study demonstrates the feasibility and acceptability of using a variety of modalities to deliver caregiver support to a group of largely older, rural, spousal caregivers of veterans with dementia. The potential for reducing isolation for caregivers capable of receiving this intervention through the Internet is a promising finding.

Attitudes Toward Telemedicine in Urban, Rural, and Highly Rural Communities.

INTRODUCTION: The rate of telemedicine adoption using interactive video between patient and provider has not met expectations. Technology, regulations, and physician buy-in are cited reasons, but patient acceptance has not received much consideration. We examine attitudes regarding telemedicine to better understand the subjective definitions of its acceptability and utility that shape patients' willingness to use telemedicine. MATERIALS AND METHODS: Using the Montana Health Matters study (a random, statewide survey [n=3,512]), we use latent class analysis to identify groups with similar patterns of attitudes toward telemedicine followed by multinomial logistic regression to estimate predictors of group membership. RESULTS: Although only 5% are amenable to telemedicine regardless of circumstance, 23% would be comfortable if it could be convenient, whereas 29% would be situationally amenable but uncomfortable using telemedicine. Still, a substantial percentage (43%) is unequivocally averse to telemedicine despite the inconvenience of in-person visits. Educational attainment, prior Internet use, and rural residence are main predictors that increase the likelihood of being in an amenable group. CONCLUSIONS: From the patient's perspective, the advantages of reduced travel and convenience are recognized, but questions remain about the equivalence to physician visits. Many people are averse to telemedicine, indicating a perceived incompatibility with patient needs. Only 1.7% of the respondents reported using telemedicine in the previous year; about half were veterans. Hence, few have used telemedicine, and key innovation adoption criteria-trialability and observability-are low. Increased attention to public awareness in the adoption process is needed to increase willingness to embrace telemedicine as a convenient way to obtain quality healthcare services.

The Care Coordination Home Telehealth (CCHT) rural demonstration project: a symptom-based approach for serving older veterans in remote geographical settings.

INTRODUCTION: Innovative healthcare delivery strategies are needed to address the healthcare needs of the 3.5 million older veterans living in US rural areas who face unique healthcare delivery challenges, including transportation barriers, poverty, and limited access to health professions and community-based programs. The care coordination home telehealth (CCHT) rural demonstration project was developed to address the mismatch between the timely identification of patient needs and the care delivered by the traditional disease-oriented institutionally-based healthcare delivery system for older rural veterans. The specific objectives were to: (1) serve as a facilitator of primary care; and (2) provide a portfolio of geriatric care management options to increase early detection of symptoms and to encourage adherence to care plans. METHODS: Participants were recruited based on patterns of high outpatient, inpatient, and emergency care visits; 132 rural older veterans were enrolled. The CCHT applied care management principles to the delivery of healthcare services and used health informatics to facilitate access to evidence-based care. The CCHT's essential components, which were tailored to optimize remote access, included a face-to-face orientation, telephone contact with a designated care coordinator, and daily monitoring sessions using an in-home telehealth device to assess participants' medication usage, compliance, and symptoms, and to provide patient education. RESULTS: One hundred eleven participants successfully installed and connected the telehealth monitoring device in their homes without hands-on assistance, monitored complex medical and psychiatric symptoms, and reported medication compliance remotely. Of the 93 participants who used the device for more than 10 sessions, 88 reported they did not have any difficulty using the device, 86 reported they were satisfied or very satisfied with the device, 73 reported they were likely to continue using the device, and 46 reported improved communication between themselves and their primary healthcare provider. CONCLUSION: Initial utilization and satisfaction evaluation data from this project supports the feasibility of employing a CCHT approach to serve medically-complicated older veterans in rural settings. This approach could also serve as a template for addressing a greater range of healthcare needs among other populations in hard-to-reach settings.

Review of Veterans Health Administration telemedicine interventions.

The Veterans Health Administration (VHA) is a leader in developing and implementing innovative healthcare technology. We review 19 exemplary peer-reviewed articles published between 2000 and 2009 of controlled, VHA-supported telemedicine intervention trials that focused on health outcomes. These trials underscore the role of telemedicine in large managed healthcare organizations in support of (1) chronic disease management, (2) mental health service delivery through in-home monitoring and treatment, and (3) interdisciplinary team functioning through electronic medical record information interchange. Telemedicine is advantageous when ongoing monitoring of patient symptoms is needed, as in chronic disease care (eg, for diabetes) or mental health treatment. Telemedicine appears to enhance patient access to healthcare professionals and provides quick access to patient medical information. The sustainability of telemedicine interventions for the broad spectrum of veteran patient issues and the ongoing technology training of patients and providers are challenges to telemedicine-delivered care.

The role of grief in dementia caregiving.

The literature examining issues of caregiver stress, burden,or depression has focused on the stress-process model of caregiving, which posits that there are characteristics inherent in dementia and in the course of caregiving for a person with dementia that can cause stress in the caregiver's life. A more recent literature has emerged that argues that issues of loss and grief play a significant role ina caregiver's ability to cope with the stressors of caregiving. This article reviews the caregiver stress and grief literatures,and proposes a conceptual model of dementia caregiving that outlines pathways of stress and grief in dementia caregiving. Issues specific to caregiver grief are proposed for future research and intervention design.

A cognitive task analysis of information management strategies in a computerized provider order entry environment.

OBJECTIVE: Computerized Provider Order Entry (CPOE) with electronic documentation, and computerized decision support dramatically changes the information environment of the practicing clinician. Prior work patterns based on paper, verbal exchange, and manual methods are replaced with automated, computerized, and potentially less flexible systems. The objective of this study is to explore the information management strategies that clinicians use in the process of adapting to a CPOE system using cognitive task analysis techniques. DESIGN: Observation and semi-structured interviews were conducted with 88 primary-care clinicians at 10 Veterans Administration Medical Centers. MEASUREMENTS: Interviews were taped, transcribed, and extensively analyzed to identify key information management goals, strategies, and tasks. Tasks were aggregated into groups, common components across tasks were clarified, and underlying goals and strategies identified. RESULTS: Nearly half of the identified tasks were not fully supported by the available technology. Six core components of tasks were identified. Four meta-cognitive information management goals emerged: 1) Relevance Screening; 2) Ensuring Accuracy; 3) Minimizing memory load; and 4) Negotiating Responsibility. Strategies used to support these goals are presented. CONCLUSION: Users develop a wide array of information management strategies that allow them to successfully adapt to new technology. Supporting the ability of users to develop adaptive strategies to support meta-cognitive goals is a key component of a successful system.

Crossing the quality chasm: the role of information technology departments.

Integrating information technology (IT) into medical settings is considered essential to transforming hospitals into 21st-century health care institutions. Yet the role of IT departments in maximizing the effectiveness of information systems is not well understood. This article reports a 3-round Delphi panel of Veterans Administration personnel experienced with provider order entry electronic systems. In round 1, 35 administrative, clinical, and IT personnel answered 10 open-ended questions about IT strategies and structures that best support successful transformation. In round 2, panelists rated item importance and ranked proposed strategies. In round 3, panelists received aggregate feedback and rerated the items. Four domains emerged from round 1: IT organization, IT performance monitoring, user-support activities, and core IT responsibilities (eg, computer security, training). In rounds 2 and 3, IT performance monitoring was rated the most important, closely followed by clinical support. Strategies associated with each domain are identified and discussed.

Perceptions and attitudes about HFE genotyping among college-age adults.

PURPOSE: Examine young adults' attitudes about HFE genotyping. METHODS: 121 college students read about hemochromatosis, transferrin saturation measurement (iron test), and HFE genotyping. Interest in testing and knowledge and attitudes about genetic testing were assessed. Participants were randomly assigned to predict either their response to a positive HFE genotype (genotype group) or a positive iron test (phenotype group). RESULTS: 71% preferred the iron test, but most would undergo either test. Learning risk and early detection/prevention were the most commonly perceived benefits; limited information about health and negative emotional consequences were the most commonly perceived disadvantages. The genotype and phenotype groups did not differ in expected worry, perceived severity, perceived risk, and preventability of organ damage. After reading the description provided, participants answered 78% of knowledge questions correctly. CONCLUSIONS: Young adults view HFE genotyping positively and report few disadvantages, but prefer the iron test for its information about current health. They appear to be receptive to public health screening for hemochromatosis.

Attitudes about and psychosocial outcomes of HFE genotyping for hemochromatosis.

We examined attitudes regarding genetic testing and psychosocial outcomes of HFE genotyping for hemochromatosis. A total of 87 persons with hemochromatosis (patients) (39 women, 48 men), who underwent HFE genotyping, and 50 persons with hypertension (controls) (22 women, 28 men), who had not undergone HFE genotyping, completed a structured interview in which they reported attitudes about benefits and disadvantages of genetic testing and their understanding of genetics and hemochromatosis. Among patients, adherence to treatment for hemochromatosis was assessed. Controls estimated the likelihood of experiencing several potential positive and negative psychosocial outcomes after a positive genetic test. Patients reported their experience pertinent to these outcomes. Patients received information about hemochromatosis when they were diagnosed, and controls read a brief description of hemochromatosis before answering questions. Patients correctly answered 65% of knowledge questions and controls correctly answered 59%. Most participants believed genetic testing is beneficial and described few negative aspects of testing. Controls expected to experience more anxiety, depression, and anger related to a positive genetic test than was reported by patients (p < 0.001). One patient reported discrimination related to the HFE genotype. Most patients were compliant with the iron depletion and maintenance phases of treatment for hemochromatosis. Race, sex, marital status, income, education, barriers to treatment, and knowledge were not significantly associated with adherence to maintenance phlebotomy. We conclude that HFE genotyping appears to be viewed positively and would be generally accepted were it offered as part of a screening program for hemochromatosis. Persons who have not undergone genetic testing may overestimate their emotional responses to a positive test result. In the present hemochromatosis patients, few reported that HFE genotyping was accompanied by negative psychosocial outcomes.

Genetic testing for hemochromatosis: attitudes and acceptability among young and older adults.

Hemochromatosis is a genetic disorder of iron overload common in persons of northern European descent. We examined attitudes about testing for hemochromatosis in 118 young adults (YA) (19.7 years +/- 1.9) and 50 older adults (OA) (58.5 years +/- 13.7). Participants read about hemochromatosis and two related tests: transferrin saturation measurement (iron test) and HFE genotyping (HFE test). Interest in each test and attitudes about genetic testing were assessed. More than 80% of all participants were willing to undergo either test, if offered. A majority preferred the iron test because of the information it provides about current health. A majority of participants identified at least one benefit of genetic testing, with improved health through early detection/prevention being most common. YA were more likely to report disadvantages of genetic testing (p < 0.001) and were more concerned about potential negative psychological effects (p < 0.005). OA were more concerned about potential discrimination (p < 0.0001). These findings suggest that young and older adults view genetic testing as beneficial and would accept HFE testing were it offered as part of a screening program.

Patient compliance with phlebotomy therapy for iron overload associated with hemochromatosis.

OBJECTIVE: The aim of this study was to evaluate patient compliance with phlebotomy therapy of hemochromatosis-associated iron overload. METHODS: We reviewed medical records of white adults with hemochromatosis and iron overload diagnosed during medical care. We defined three elements of compliance: 1) achieving iron depletion (serum ferritin

Interference due to pain following spinal cord injury: important predictors and impact on quality of life.

Two studies were designed to examine important predictors of pain following spinal cord injury (SCI), and the impact of pain on self-reported quality of life (QOL). Pain was defined as "interference in day-to-day activities secondary to pain". In order to determine risk factors associated with the development of pain interference, Study 1 examined the predictive validity of multiple demographic, medical, and QOL variables at year 1 post-SCI to self-reported pain interference 2 years post-injury. Results showed that middle age (30-59-year-olds), lower self-reported mental health, and pain interference at 1 year post-SCI were the most important unique predictors of pain interference 2 years post-SCI. In Study 2, participants were separated into four groups; (1) those pain-free at years 1 and 2, (2) those pain-free at year 1 and in pain at year 2, (3) those in pain at year 1 and pain-free at year 2, and (4) those in pain at years 1 and 2. Results showed that only those experiencing a change in pain interference status reported a change in QOL. More specifically, those developing pain interference (group 2) from year 1 to year 2 reported decreased life satisfaction, physical health, and mental health, whereas, those with resolving pain interference from year 1 to year 2 reported an increase in these same domains. Unexpectedly, change in pain interference status was unrelated to change in self-reported handicap. Implications and future directions are discussed.