Clinicians in the Veterans Health Administration initiate gender-affirming hormone therapy in concordance with clinical guideline recommendations.

Background: Gender-affirming hormone therapy (GAHT) is a common medical intervention sought by transgender and gender diverse (TGD) individuals. Initiating GAHT in accordance with clinical guideline recommendations ensures delivery of high-quality care. However, no prior studies have examined how current GAHT initiation compares to recommended GAHT initiation. Objective: This study assessed guideline concordance around feminizing and masculinizing GAHT initiation in the Veterans Health Administration (VHA). Methods: The sample included 4,676 veterans with a gender identity disorder diagnosis who initiated feminizing (n=3,547) and masculinizing (n=1,129) GAHT between 2007 and 2018 in VHA. Demographics and health conditions on veterans receiving feminizing and masculinizing GAHT were assessed. Proportion of guideline concordant veterans on six VHA guidelines on feminizing and masculinizing GAHT initiation were determined. Results: Compared to veterans receiving masculinizing GAHT, a higher proportion of veterans receiving feminizing GAHT were older (≥60 years: 23.7% vs. 6.3%), White non-Hispanic (83.5% vs. 57.6%), and had a higher number of comorbidities (≥7: 14.0% vs. 10.6%). A higher proportion of veterans receiving masculinizing GAHT were Black non-Hispanic (21.5% vs. 3.5%), had posttraumatic stress disorder (43.0% vs. 33.9%) and positive military sexual trauma (33.5% vs.16.8%; all p-values<0.001) than veterans receiving feminizing GAHT. Among veterans who started feminizing GAHT with estrogen, 97.0% were guideline concordant due to no documentation of contraindication, including venous thromboembolism, breast cancer, stroke, or myocardial infarction. Among veterans who started spironolactone as part of feminizing GAHT, 98.1% were guideline concordant as they had no documentation of contraindication, including hyperkalemia or acute renal failure. Among veterans starting masculinizing GAHT, 90.1% were guideline concordant due to no documentation of contraindications, such as breast or prostate cancer. Hematocrit had been measured in 91.8% of veterans before initiating masculinizing GAHT, with 96.5% not having an elevated hematocrit (>50%) prior to starting masculinizing GAHT. Among veterans initiating feminizing and masculinizing GAHT, 91.2% had documentation of a gender identity disorder diagnosis prior to GAHT initiation. Conclusion: We observed high concordance between current GAHT initiation practices in VHA and guidelines, particularly for feminizing GAHT. Findings suggest that VHA clinicians are initiating feminizing GAHT in concordance with clinical guidelines. Future work should assess guideline concordance on monitoring and management of GAHT in VHA.

Pulmonary vascular disease in Veterans with post-deployment respiratory syndrome.

Exertional dyspnea has been documented in US military personnel after deployment to Iraq and Afghanistan. We studied whether continued exertional dyspnea in this patient population is associated with pulmonary vascular disease (PVD). We performed detailed histomorphometry of pulmonary vasculature in 52 Veterans with biopsy-proven post-deployment respiratory syndrome (PDRS) and then recruited five of these same Veterans with continued exertional dyspnea to undergo a follow-up clinical evaluation, including symptom questionnaire, pulmonary function testing, surface echocardiography, and right heart catheterization (RHC). Morphometric evaluation of pulmonary arteries showed significantly increased intima and media thicknesses, along with collagen deposition (fibrosis), in Veterans with PDRS compared to non-diseased (ND) controls. In addition, pulmonary veins in PDRS showed increased intima and adventitia thicknesses with prominent collagen deposition compared to controls. Of the five Veterans involved in our clinical follow-up study, three had borderline or overt right ventricle (RV) enlargement by echocardiography and evidence of pulmonary hypertension (PH) on RHC. Together, our studies suggest that PVD with predominant venular fibrosis is common in PDRS and development of PH may explain exertional dyspnea and exercise limitation in some Veterans with PDRS.

Development and Validation of Case-Finding Algorithms to Identify Pancreatic Cancer in the Veterans Health Administration.

BACKGROUND: Survival in pancreatic ductal adenocarcinoma (PDAC) remains poor due to late diagnosis. Electronic Health Records (EHRs) can be used to study this rare disease, but validated algorithms to identify PDAC in the United States EHRs do not currently exist. AIMS: To develop and validate an algorithm using Veterans Health Administration (VHA) EHR data for the identification of patients with PDAC. METHODS: We developed two algorithms to identify patients with PDAC in the VHA from 2002 to 2023. The algorithms required diagnosis of exocrine pancreatic cancer in either ≥ 1 or ≥ 2 of the following domains: (i) the VA national cancer registry, (ii) an inpatient encounter, or (iii) an outpatient encounter in an oncology setting. Among individuals identified with ≥ 1 of the above criteria, a random sample of 100 were reviewed by three gastroenterologists to adjudicate PDAC status. We also adjudicated fifty patients not qualifying for either algorithm. These patients died as inpatients and had alkaline phosphatase values within the interquartile range of patients who met ≥ 2 of the above criteria for PDAC. These expert adjudications allowed us to calculate the positive and negative predictive value of the algorithms. RESULTS: Of 10.8 million individuals, 25,533 met ≥ 1 criteria (PPV 83.0%, kappa statistic 0.93) and 13,693 individuals met ≥ 2 criteria (PPV 95.2%, kappa statistic 1.00). The NPV for PDAC was 100%. CONCLUSIONS: An algorithm incorporating readily available EHR data elements to identify patients with PDAC achieved excellent PPV and NPV. This algorithm is likely to enable future epidemiologic studies of PDAC.

Medical Home Implementation and Follow-Up of Cancer-Related Abnormal Test Results in the Veterans Health Administration.

Importance: Lack of timely follow-up of cancer-related abnormal test results can lead to delayed or missed diagnoses, adverse cancer outcomes, and substantial cost burden for patients. Care delivery models, such as the Veterans Affairs' (VA) Patient-Aligned Care Team (PACT), which aim to improve patient-centered care coordination, could potentially also improve timely follow-up of abnormal test results. PACT was implemented nationally in the VA between 2010 and 2012. Objective: To evaluate the long-term association between PACT implementation and timely follow-up of abnormal test results related to the diagnosis of 5 different cancers. Design, Setting, and Participants: This multiyear retrospective cohort study used 14 years of VA data (2006-2019), which were analyzed using panel data-based random-effects linear regressions. The setting included all VA clinics and facilities. The participants were adult patients who underwent diagnostic testing related to 5 different cancers and had abnormal test results. Data extraction and statistical analyses were performed from September 2021 to December 2023. Exposure: Calendar years denoting preperiods and postperiods of PACT implementation, and the PACT Implementation Progress Index Score denoting the extent of implementation in each VA clinic and facility. Main Outcome and Measure: Percentage of potentially missed timely follow-ups of abnormal test results. Results: This study analyzed 6 data sets representing 5 different types of cancers. During the initial years of PACT implementation (2010 to 2013), percentage of potentially missed timely follow-ups decreased between 3 to 7 percentage points for urinalysis suggestive of bladder cancer, 12 to 14 percentage points for mammograms suggestive of breast cancer, 19 to 22 percentage points for fecal tests suggestive of colorectal cancer, and 6 to 13 percentage points for iron deficiency anemia laboratory tests suggestive of colorectal cancer, with no statistically significant changes for α-fetoprotien tests and lung cancer imaging. However, these beneficial reductions were not sustained over time. Better PACT implementation scores were associated with a decrease in potentially missed timely follow-up percentages for urinalysis (0.3-percentage point reduction [95% CI, -0.6 to -0.1] with 1-point increase in the score), and laboratory tests suggestive of iron deficiency anemia (0.5-percentage point reduction [95% CI,-0.8 to -0.2] with 1-point increase in the score). Conclusions and Relevance: This cohort study found that implementation of PACT in the VA was associated with a potential short-term improvement in the quality of follow-up for certain test results. Additional multifaceted sustained interventions to reduce missed test results are required to prevent care delays.

Workforce readiness for pharmacogenomics and key elements for sustainment within the Veterans Health Administration.

Aim: Understanding barriers and facilitators to pharmacogenomics (PGx) implementation and how to structure a clinical program with the Veterans Health Administration (VA). Materials & methods: Healthcare provider (HCP) survey at 20 VA facilities assessing PGx knowledge/acceptance and qualitative interviews to understand how best to design and sustain a national program. Results: 186 (12% response rate) surveyed believed PGx informs drug efficacy (74.7%) and adverse events (71.0%). Low confidence in knowledge (43.0%) and ability to implement (35.4-43.5%). 23 (60.5% response rate) interviewees supported a nationally program to oversee VA education, consultation and IT resources. Prescribing HCPs should be directing local activities. Conclusion: HCPs recognize PGx value but are not prepared to implement. Healthcare systems should build system-wide programs for implementation education and support.

Lung Cancer Survival Trends in the Veterans Health Administration.

INTRODUCTION: Lung cancer survival is improving in the United States. We investigated whether there was a similar trend within the Veterans Health Administration (VHA), the largest integrated healthcare system in the United States. MATERIALS AND METHODS: Data from the Veterans Affairs Central Cancer Registry were analyzed for temporal survival trends using Kaplan-Meier estimates and linear regression. RESULTS: A total number of 54,922 Veterans were identified with lung cancer diagnosed from 2010 to 2017. Histologies were classified as non-small-cell lung cancer (NSCLC) (64.2%), small cell lung cancer (SCLC) (12.9%), and 'other' (22.9%). The proportion with stage I increased from 18.1% to 30.4%, while stage IV decreased from 38.9% to 34.6% (both P < .001). The 3-year overall survival (OS) improved for stage I (58.6% to 68.4%, P < .001), stage II (35.5% to 48.4%, P < .001), stage III (18.7% to 29.4%, P < .001), and stage IV (3.4% to 7.8%, P < .001). For NSCLC, the median OS increased from 12 to 21 months (P < .001), and the 3-year OS increased from 24.1% to 38.3% (P < .001). For SCLC, the median OS remained unchanged (8 to 9 months, P = .10), while the 3-year OS increased from 9.1% to 12.3% (P = .014). Compared to White Veterans, Black Veterans with NSCLC had similar OS (P = .81), and those with SCLC had higher OS (P = .003). CONCLUSION: Lung cancer survival is improving within the VHA. Compared to White Veterans, Black Veterans had similar or higher survival rates. The observed racial equity in outcomes within a geographically and socioeconomically diverse population warrants further investigation to better understand and replicate this achievement in other healthcare systems.

Behavioral weight management use in the Veterans Health Administration: Sociodemographic and health correlates.

INTRODUCTION: Over 40 % of United States Veterans Health Administration (VHA) primary care patients have obesity. Few patients use VHA's flagship weight management program, MOVE! and there is little information on other behavioral weight management program use. METHODS: The national United States cohort included over 1.5 million primary care patients with obesity, age 18-79, based on VHA administrative data. Gender stratified multivariable logistic regression identified correlates of weight management use in the year after a patient's first primary care appointment (alpha of 0.05). Weight management use was defined as MOVE! or nutrition clinic visits. RESULTS: The cohort included 121,235 women and 1,521,547 men with 13 % and 7 % using weight management, respectively. Point estimates for specific correlates of use were similar between women and men, and across programs. Black patients were more likely to use weight management than White patients. Several physical and mental health diagnoses were also associated with increased use, such as sleep apnea and eating disorders. Age and distance from VHA were negatively associated with weight management use. CONCLUSIONS: When assessing multiple types of weight management visits, weight management care in VHA appears to be used more often by some populations at higher risk for obesity. Other groups may need additional outreach, such as those living far from VHA. Future work should focus on outreach and prevention efforts to increase overall use rates. This work could also examine the benefits of tailoring care for populations in greatest need.

Looking back to move forward: Creating a blueprint for success for nurse scientists in the Veterans Health Administration.

AIM: The purpose of this manuscript is to report the findings of a qualitative content analysis of interviews with VA Nurse Scientists about work life experiences, barriers, and facilitators across the enterprise. BACKGROUND: The VA enterprise is widely variable in terms of size, services, research activity, and budget. For this reason, the roles of nurses with a research-focused doctorate are also quite diverse. METHODS: We purposively sampled 18 PhD prepared Nurse Scientists based on a variety geographic locations, titles, and years in the field and who conduct research. We conducted semi-structured interviews over the virtual platform, WebEx. Interviews, averaging 1 h in length, were conducted between April and May 2021. We analyzed interviews using deductive and inductive content analysis. RESULTS: We found five key factors affecting VA Nurse Scientists. Each factor emerged as an important issue influencing whether Nurse Scientists reported being successful, supported, and productive in their research. These include having: 1) mentorship, 2) supportive leadership 3) available resources, 4) respect and understanding from clinical and research colleagues who understand a Nurse Scientist's role in research, and 5) a career pathway. CONCLUSIONS: VA Nurse Scientists are leaders and innovators who generate evidence to improve health outcomes and promote equity in health and health care of Veterans, their families, and caregivers. Results from this project suggest that many Nurse Scientists need additional mentorship, resources, and networks to advance their development, increase their funding success, and maximize the impact of their role, ultimately enhancing care of Veterans and their families.

Association Between a National Behavioral Weight Management Program and Veterans Affairs Health Expenditures.

OBJECTIVE: The association between participation in a behavioral weight intervention and health expenditures has not been well characterized. We compared Veterans Affairs (VA) expenditures of individuals participating in MOVE!, a VA behavioral weight loss program, and matched comparators 2 years before and 2 years after MOVE! initiation. METHODS: Retrospective cohort study of Veterans who had one or more MOVE! visits in 2008-2017 who were matched contemporaneously to up to 3 comparators with overweight or obesity through sequential stratification on an array of patient characteristics, including sex. Baseline patient characteristics were compared between the two cohorts through standardized mean differences. VA expenditures in the 2 years before MOVE! initiation and 2 years after initiation were modeled using generalized estimating equations with a log link and distribution with variance proportional to the standard deviation (gamma). RESULTS: MOVE! participants (n=499,696) and comparators (n=1,336,172) were well-matched, with an average age of 56, average body mass index of 35, and similar total VA expenditures in the fiscal year before MOVE! initiation ($9662 for MOVE! participants and $10,072 for comparators, standardized mean difference=-0.019). MOVE! participants had total expenditures that were statistically lower than matched comparators in the 6 months after initiation but modestly higher in the 6 months to 2 years after initiation, though differences were small in magnitude (1.0%-1.6% differences). CONCLUSIONS: The VA's system-wide behavioral weight intervention did not realize meaningful short-term health care cost savings for participants.

Chlamydial and Gonococcal Infections and Adverse Reproductive Health Conditions Among Patients Assigned Female at Birth in the Veterans Health Administration.

BACKGROUND: Reproductive age female individuals comprise the fastest-growing segment of Veterans Health Administration patients, but little is known about rates of reproductive health outcomes among those with chlamydia or gonorrhea infections. Our aim was to estimate the risk of pelvic inflammatory disease, ectopic pregnancy, infertility, and pelvic pain in female veterans tested for chlamydia or gonorrhea. METHODS: We performed a retrospective cohort analysis of female veterans tested for chlamydia or gonorrhea between January 1, 2010, and December 31, 2020. We calculated rates of pelvic inflammatory disease, ectopic pregnancy, infertility, and pelvic pain per 100,000 person-years and used Cox proportional hazards regression models to estimate the risk of these reproductive health conditions according to infection status after adjustment for age, race, ethnicity, military sexual trauma, mental health diagnoses, and substance use disorder. RESULTS: Of female veterans, 232,614 were tested at least once for chlamydia or gonorrhea, with a total of 1,665,786 person-years of follow-up. Of these, 12,971 had positive chlamydia or gonorrhea results (5.8%, 796 cases per 100,000 person-years). Compared with people who tested negative, those testing positive had double the risk of pelvic inflammatory disease (adjusted hazard ratio [aHR], 1.94; 95% confidence interval [CI], 1.81-2.07), 11% increased risk of infertility (aHR, 1.11; 95% CI, 1.04-1.18), 12% increased risk of pelvic pain (aHR, 1.12; 95% CI, 1.08-1.17), and 21% increased risk of any of these conditions (aHR, 1.21; 95% CI, 1.17-1.25). People with positive chlamydia or gonorrhea testing tended to have an increased risk of ectopic pregnancy (aHR, 1.14; 95% CI, 1.0-1.30). Among those with a positive test result, 2218 people (17.1%) had 1 or more additional positive test results. Compared with those with 1 positive test result, people with more than 1 positive test result had a significantly increased risk of pelvic inflammatory disease (aHR, 1.37; 95% CI, 1.18-1.58), infertility (aHR, 1.20; 95% CI, 1.04-1.39), and pelvic pain (aHR1.16; 95% CI, 1.05-1.28), but not ectopic pregnancy (aHR, 1.09; 95% CI, 0.80-1.47). CONCLUSIONS: Female veterans with positive chlamydia or gonorrhea results experience a significantly higher risk of pelvic inflammatory disease, infertility, and pelvic pain, especially among those with repeat infection.

Assessing trends and variability in outpatient dual testing for chronic kidney disease with urine albumin and serum creatinine, 2009-2018: a retrospective cohort study in the Veterans Health Administration System.

BACKGROUND: Simultaneous urine testing for albumin (UAlb) and serum creatinine (SCr), that is, 'dual testing,' is an accepted quality measure in the management of diabetes. As chronic kidney disease (CKD) is defined by both UAlb and SCr testing, this approach could be more widely adopted in kidney care. OBJECTIVE: We assessed time trends and facility-level variation in the performance of outpatient dual testing in the integrated Veterans Health Administration (VHA) system. DESIGN, SUBJECTS AND MAIN MEASURES: This retrospective cohort study included patients with any inpatient or outpatient visit to the VHA system during the period 2009-2018. Dual testing was defined as UAlb and SCr testing in the outpatient setting within a calendar year. We assessed time trends in dual testing by demographics, comorbidities, high-risk (eg, diabetes) specialty care and facilities. A generalised linear mixed-effects model was applied to explore individual and facility-level predictors of receiving dual testing. KEY RESULTS: We analysed data from approximately 6.9 million veterans per year. Dual testing increased, on average, from 17.4% to 21.2%, but varied substantially among VHA centres (0.3%-43.7% in 2018). Dual testing was strongly associated with diabetes (OR 10.4, 95% CI 10.3 to 10.5, p<0.0001) and not associated with VHA centre complexity level. However, among patients with high-risk conditions including diabetes, <50% received dual testing in any given year. As compared with white veterans, black veterans were less likely to be tested after adjusting for other individual and facility characteristics (OR 0.93, 95% CI 0.92 to 0.93, p<0.0001). CONCLUSIONS: Dual testing for CKD in high-risk specialties is increasing but remains low. This appears primarily due to low rates of testing for albuminuria. Promoting dual testing in high-risk patients will help to improve disease management and patient outcomes.

Predictors of non-fatal suicide attempts among Veterans Health Administration (VHA) patients who experienced military sexual trauma.

OBJECTIVE: Military sexual trauma (MST) has been identified as a risk factor for suicidal behavior. To inform suicide prevention efforts within the Veterans Health Administration (VHA), this study evaluates predictors of non-fatal suicide attempts (NFSAs) among VHA patients who experienced MST. METHODS: For VHA patients in fiscal year (FY) 2019 who previously screened positive for a history of MST, documented NFSAs were assessed. Using multivariable logistic regression, demographic, clinical, and VHA care utilization predictors of NFSAs were assessed. RESULTS: Of the 212,215 VHA patients who screened positive for MST prior to FY 2019 and for whom complete race, service connection, and rurality information was available, 1742 (0.8%) had a documented NFSA in FY 2019. In multivariable logistic regression analyses, total physical and mental health morbidities were not associated with NFSA risk. Predictors of a documented NFSA included specific mental health diagnoses [adjusted odds ratio (aOR) range: 1.28-1.94], receipt of psychotropic medication prescriptions (aOR range: 1.23-2.69) and having a prior year emergency department visit (aOR = 1.32) or inpatient psychiatric admission (aOR = 2.15). CONCLUSIONS: Among VHA patients who experienced MST, specific mental health conditions may increase risk of NFSAs, even after adjustment for overall mental health morbidity. Additionally, indicators of severity of mental health difficulties such as receipt of psychotropic medication prescriptions and inpatient psychiatric admissions are also associated with increased risk above and beyond risk associated with diagnoses. Findings highlight targets for suicide prevention initiatives among this vulnerable group within VHA and may help identify patients who would benefit from additional support.

The impact of informal caregiving on U.S. Veterans Health Administration utilization and expenditures.

Few studies have examined the effect of informal care receipt on health care utilization and expenditures while accounting for the potentially endogenous relationship between informal and formal care, and none have examined these relationships for U.S. Veterans. With rapidly increasing investments in caregiver supports over the past decade, including stipends for caregivers, the U.S. Department of Veterans Affairs (VA) needs to better understand the costs and benefits of informal care provision. Using a unique data linkage between the 1998-2010 Health and Retirement Study and VA administrative data (n = 2083 Veterans with 9511 person-wave observations), we applied instrumental variable techniques to understand the effect of care from an adult child on Veterans' two-year VA utilization and expenditures. We found that informal care decreased overall utilization by 53 percentage points (p < 0.001) and expenditures by $19,977 (p < 0.01). These reductions can be explained by informal care decreasing the probability of inpatient utilization by 17 percentage points (p < 0.001), outpatient utilization by 57 percentage points (p < 0.001), and institutional long-term care by 3 percentage points (p < 0.05). There were no changes in the probability of non-institutional long-term care use, though these expenditures decreased by $882 (p < 0.05). Expenditure decreases were greatest amongst medically complex patients. Our results indicate relative alignment between VA's stipend payments, which are based on replacement cost methods, and the monetary benefits derived through VA cost avoidances due to informal care. For health systems considering similar caregiver stipend payments, our findings suggest that the cost of these programs may be offset by informal care substituting for formal care, particularly for higher need patients.

Health Equity in the Veterans Health Administration From Veterans' Perspectives by Race and Sex.

Importance: Advancing equitable patient-centered care in the Veterans Health Administration (VHA) requires understanding the differential experiences of unique patient groups. Objective: To inform a comprehensive strategy for improving VHA health equity through the comparative qualitative analysis of care experiences at the VHA among veterans of Black and White race and male and female sex. Design, Setting, and Participants: This qualitative study used a technique termed freelisting, an anthropologic technique eliciting responses in list form, at an urban academic VHA medical center from August 2, 2021, to February 9, 2022. Participants included veterans with chronic hypertension. The length of individual lists, item order in those lists, and item frequency across lists were used to calculate a salience score for each item, allowing comparison of salient words and topics within and across different groups. Participants were asked about current perceptions of VHA care, challenges in the past year, virtual care, suggestions for change, and experiences of racism. Data were analyzed from February 10 through September 30, 2022. Main Outcomes and Measures: The Smith salience index, which measures the frequency and rank of each word or phrase, was calculated for each group. Results: Responses from 49 veterans (12 Black men, 12 Black women, 12 White men, and 13 White women) were compared by race (24 Black and 25 White) and sex (24 men and 25 women). The mean (SD) age was 64.5 (9.2) years. Some positive items were salient across race and sex, including "good medical care" and telehealth as a "comfortable/great option," as were some negative items, including "long waits/delays in getting care," "transportation/traffic challenges," and "anxiety/stress/fear." Reporting "no impact" of racism on experiences of VHA health care was salient across race and sex; however, reports of race-related unprofessional treatment and active avoidance of race-related conflict differed by race (present among Black and not White participants). Experiences of interpersonal interactions also diverged. "Impersonal/cursory" telehealth experiences and the need for "more personal/attentive" care were salient among women and Black participants, but not men or White participants, who associated VHA care with courtesy and respect. Conclusions and Relevance: In this qualitative freelist study of veteran experiences, divergent experiences of interpersonal care by race and sex provided insights for improving equitable, patient-centered VHA care. Future research and interventions could focus on identifying differences across broader categories both within and beyond race and sex and bolstering efforts to improve respect and personalized care to diverse veteran populations.

Severe COVID-19 in Vaccinated Adults With Hematologic Cancers in the Veterans Health Administration.

Importance: With SARS-CoV-2 transforming into an endemic disease and with antiviral treatments available, it is important to establish which patients remain at risk of severe COVID-19 despite vaccination. Objective: To quantify the associations of clinical and demographic variables with odds of severe COVID-19 among patients with hematologic cancers. Design, Setting, and Participants: This case-control study included all patients with hematologic malignant neoplasms in the national Veterans Health Administration (VHA) who had documented SARS-CoV-2 infection after vaccination. Groups of patients with severe (cases) vs nonsevere (controls) COVID-19 were compared. Data were collected between January 1, 2020, and April 5, 2023, with data on infection collected between January 1, 2021, and September 30, 2022. All patients with diagnostic codes for hematologic malignant neoplasms who had documented vaccination followed by documented SARS-CoV-2 infection and for whom disease severity could be assessed were included. Data were analyzed from July 28 to December 30, 2023. Exposures: Clinical (comorbidities, predominant viral variant, treatment for malignant neoplasm, booster vaccination, and antiviral treatment) and demographic (age and sex) variables shown in prior studies to be associated with higher or lower rates of severe COVID-19. Comorbidities included Alzheimer disease or dementia, chronic kidney disease, chronic obstructive pulmonary disease, diabetes, heart failure, and peripheral vascular disease. Main Outcome and Measures: The main outcome was severe COVID-19 compared with nonsevere SARS-CoV-2 infection. Severe COVID-19 was defined as death within 28 days, mechanical ventilation, or hospitalization with use of dexamethasone or evidence of hypoxemia or use of supplemental oxygen. Multivariable logistic regression was used to estimate the associations of demographic and clinical variables with the odds of severe COVID-19, expressed as adjusted odds ratios (aORs) with 95% CIs. Results: Among 6122 patients (5844 [95.5%] male, mean [SD] age, 70.89 [11.57] years), 1301 (21.3%) had severe COVID-19. Age (aOR per 1-year increase, 1.05; 95% CI, 1.04-1.06), treatment with antineoplastic or immune-suppressive drugs (eg, in combination with glucocorticoids: aOR, 2.32; 95% CI, 1.93-2.80), and comorbidities (aOR per comorbidity, 1.35; 95% CI, 1.29-1.43) were associated with higher odds of severe disease, whereas booster vaccination was associated with lower odds (aOR, 0.73; 95% CI, 0.62-0.86). After oral antiviral drugs became widely used in March 2022, 20 of 538 patients (3.7%) with SARS-CoV-2 infection during this period had progression to severe COVID-19. Conclusions and Relevance: In this case-control study of patients with hematologic cancers, odds of severe COVID-19 remained high through mid-2022 despite vaccination, especially in patients requiring treatment.

Evaluation of implementation facilitation integrated into a national mentoring programme to improve access to evidence-based psychotherapy for post-traumatic stress disorder within the veterans health administration: a quality improvement report.

Despite the resources dedicated to specialised mental healthcare for patients with post-traumatic stress disorder (PTSD) within the US Veterans Health Administration, evidence-based psychotherapies (EBPs) for PTSD have been underutilised, as evidenced by low EBP reach to patients. A research-operation collaboration evaluated whether implementation facilitation delivered by regional PTSD mentors as part of a national mentoring programme improved EBP reach compared with less-intensive quality improvement interventions. We used a non-equivalent comparison-group design that included all PTSD clinics with low EBP reach at baseline (n=51). Clinics were grouped into one of four quality improvement conditions according to self-selection by regional PTSD mentors: facilitation (n=6), learning collaborative (n=15), mentoring as usual in the regions that had facilitation-target clinics (n=15) and mentoring as usual in other regions (n=15). The primary outcome was EBP reach among therapy patients with PTSD at preintervention baseline and postintervention sustainment periods. We used the ratio of odds ratios (ROR) between the two time periods to evaluate the effectiveness of facilitation compared with the other conditions, adjusting for patient-level and clinic-level confounders. 26 126 veterans with PTSD received psychotherapy in one of 51 low-reach PTSD clinics during preintervention baseline and postintervention sustainment periods. The odds of a patient receiving an EBP increased over time across conditions. The adjusted ORs of a patient receiving an EBP from baseline to sustainment were 1.35-1.69 times larger in clinics that received facilitation compared with the three comparison conditions (adjusted RORs of comparison condition versus facilitation ranged from 0.59 (95% CI 0.47 to 0.75) to 0.74 (95% CI 0.58 to 0.94)). Implementation facilitation can be integrated into a national programme for quality improvement for PTSD specialty care and may be particularly useful when less-intensive approaches are not sufficiently effective.

Impact of Medical Training Programs on Time-to-Fill Physician Vacancies at the Veterans Health Administration.

BACKGROUND: The Department of Veterans Affairs (VA) provides the largest Graduate Medical Education (GME) training platform for health professionals in the United States. Studies on the impact of VA GME programs on physician recruitment were lacking. OBJECTIVES: To examine the impact of the size of residency training programs at a VA facility on the facility's time-to-fill physician vacancies, and whether the impact differs by the socioeconomic deprivation and public school quality of the geographic area. PROJECT DESIGN: We constructed an instrumental variable for training program size by interacting the facility clinicians share with the total training allocation nationally. SUBJECTS: Our evaluation used national data on filled physician vacancies in the VA that were posted between 2020 and 2021. MEASURES: The outcome evaluated was time-to-fill physician vacancies. Our explanatory variable was the facility-year level number of physician residency slots. RESULTS: For positions posted in 2020, an increase of one training slot was significantly associated with a decrease of 1.33 days to fill physician vacancies (95% CI, 0.38-2.28) in facilities in less deprived areas, a decrease of 1.50 days (95% CI, 0.75-2.25) in facilities with better public schools, a decrease of 3.30 days (95% CI, 0.85-5.76) in facilities in both less deprived areas and better public schools. We found similar results for positions posted in 2020 and 2021 when limiting time-to-fill to <500 days. CONCLUSIONS: We found that increasing the size of the residency program at a VA facility could decrease the facility's time-to-fill vacant physician positions in places with less socioeconomic deprivation or better public schools.

Clinical Characteristics, Treatment Patterns, and Outcomes of Patients With Locally Advanced/Metastatic Hepatocellular Carcinoma Treated at the Veterans Health Administration.

PURPOSE: This study retrospectively reviewed the outcomes of patients with advanced hepatocellular carcinoma (HCC) receiving atezolizumab with bevacizumab (A + B) therapy at the Veterans Health Administration (VHA). PATIENTS AND METHODS: Patients with advanced HCC who received first-line systemic therapy with A + B at the VHA between December 1, 2019, and March 1, 2022, were selected from electronic medical records (EMR) using ICD-9 and ICD-10 codes. Abstractors reviewed the EMR of the patients from their index date of A + B initiation until death or their last VHA visit, with the study period ending on January 31, 2023. The chi-square test was used to compare rates, and the Mann-Whitney test was used to compare medians. RESULTS: A total of 332 patients met the study criteria. The median age was 67 years; 99% were male, 63% were non-Hispanic Whites, 26% were Black, and 66% had an Eastern Cooperative Oncology Group performance status of ≥1. 84% had child Pugh score (CPS) class A, 16% had CPS classes B and C, 62% had a grade 2 albumin-bilirubin score, 56% had HCC caused by viral hepatitis, 80% had cirrhosis, and 67% had received prior local therapies. The 6-month progression-free survival (PFS) was 59%, while the 1-year PFS rate was 36%. Overall survival (OS) at 1-year was 52% in our study. CONCLUSION: In real world, despite having similar PFS as the phase III IMbrave 150 trial, our OS at 12 months was lower (52% vs. 67%) because our study included a higher proportion of elderly patients with moderate liver dysfunction and a 40% non-White. This study provided real-world outcomes that differed from the study population in a pivotal trial.

Experiences of oncology researchers in the Veterans Health Administration during the COVID-19 pandemic.

The Veterans Health Administration is chartered "to serve as the primary backup for any health care services needed…in the event of war or national emergency" according to a 1982 Congressional Act. This mission was invoked during the COVID-19 pandemic to divert clinical and research resources. We used an electronic mixed-methods questionnaire constructed using the Theoretical Domains Framework (TDF) and the Capability, Opportunity, and Motivation (COM-B) model for behavior change to study the effects of the pandemic on VHA researchers. The questionnaire was distributed electronically to 118 cancer researchers participating in national VHA collaborations. The questionnaire received 42 responses (36%). Only 36% did not feel that their research focus changed during the pandemic. Only 26% reported prior experience with infectious disease research, and 74% agreed that they gained new research skills. When asked to describe helpful support structures, 29% mentioned local supervisors, mentors, and research staff, 15% cited larger VHA organizations and 18% mentioned remote work. Lack of timely communication and remote work, particularly for individuals with caregiving responsibilities, were limiting factors. Fewer than half felt professionally rewarded for pursuing research related to COVID. This study demonstrated the tremendous effects of the COVID-19 pandemic on research activities of VHA investigators. We identified perceptions of insufficient recognition and lack of professional advancement related to pandemic-era research, yet most reported gaining new research skills. Individualizing the structure of remote work and ensuring clear and timely team communication represent high yield areas for improvement.