"You want people to listen to you": Patient experiences of women's healthcare within the Veterans Health Administration.

OBJECTIVE: To identify constructs that are critical in shaping Veterans' experiences with Veterans Health Administration (VA) women's healthcare, including any which have been underexplored or are not included in current VA surveys of patient experience. DATA SOURCES AND STUDY SETTING: From June 2022 to January 2023, we conducted 28 semi-structured interviews with a diverse, national sample of Veterans who use VA women's healthcare. STUDY DESIGN: Using VA data, we divided Veteran VA-users identified as female into four groups stratified by age (dichotomized at age 45) and race/ethnicity (non-Hispanic White vs. all other). We enrolled Veterans continuously from each recruitment strata until thematic saturation was reached. DATA COLLECTION/EXTRACTION METHODS: For this qualitative study, we asked Veterans about past VA healthcare experiences. Interview questions were guided by a priori domains identified from review of the literature, including trust, safety, respect, privacy, communication and discrimination. Analysis occurred concurrently with interviews, using inductive and deductive content analysis. PRINCIPAL FINDINGS: We identified five themes influencing Veterans' experiences of VA women's healthcare: feeling valued and supported, bodily autonomy, discrimination, past military experiences and trauma, and accessible care. Each emergent theme was associated with multiple of the a priori domains we asked about in the interview guide. CONCLUSIONS: Our findings underscore the need for a measure of patient experience tailored to VA women's healthcare. Existing patient experience measures used within VA fail to address several aspects of experience highlighted by our study, including bodily autonomy, the influence of past military experiences and trauma on healthcare, and discrimination. Understanding distinct factors that influence women and gender-diverse Veterans' experiences with VA care is critical to advance efforts by VA to measure and improve the quality and equity of care for all Veterans.

Extracorporeal cardiopulmonary resuscitation outcomes for children with out-of-hospital and emergency department cardiac arrest.

OBJECTIVE: Data suggest extracorporeal cardiopulmonary resuscitation (ECPR) improves survival in adult patients with refractory cardiac arrest; however, ECPR outcomes in pediatric patients with out-of-hospital cardiac arrest (OHCA) is lacking. The primary aim of this study was to characterize pediatric patients who experience OHCA or cardiac arrest in the ED (EDCA). The secondary aim was to examine associations of cardiac arrest and location of ECPR cannulation with mortality. METHODS: We performed a retrospective analysis of the Extracorporeal Life Support Organization registry. We included pediatric patients (age > 28 days to <18 years) who received ECPR for refractory OHCA or EDCA between 2010 and 2019. Patient, cardiac arrest, and ECPR cannulation characteristics were summarized. We examined associations of location of cardiac arrest and ECPR cannulation with in-hospital mortality using multivariable logistic regression. RESULTS: We analyzed data from 140 pediatric patients. 66 patients (47%) experienced OHCA and 74 patients (53%) experienced EDCA. Overall survival to hospital discharge was 31% (20% OHCA survival vs. 41% EDCA survival, p = 0.008). In adjusted analyses, OHCA was associated with 3.9 times greater odds of mortality (95% confidence interval [CI] 1.61, 9.81) when compared to compared to EDCA. The location of ECPR cannulation was not associated with mortality (odds ratio 1.8, 95% CI 0.75, 4.3). CONCLUSIONS: The use of ECPR for pediatric patients with refractory OHCA is associated with poor survival compared to patients with EDCA. Location of ECPR cannulation does not appear to be associated with mortality.

Factors Associated With Use of the Preventive Health Inventory in US Veterans.

Importance: The COVID-19 pandemic caused significant declines in the quality of preventive and chronic disease care. The Veterans Health Administration (VHA) used the Preventive Health Inventory (PHI), a multicomponent care management intervention, to catch up on care disrupted by the pandemic. Objective: To identify key factors associated with PHI use. Design, Setting, and Participants: This cohort study of veterans receiving primary care used administrative data from national VHA primary care clinics for February 1, 2021, through February 1, 2022. Exposure: Patient PHI receipt. Main Outcomes and Measures: The main outcomes were patient, practitioner, and clinic factors associated with PHI receipt. Binomial generalized linear models with fixed effects for clinic were used to analyze factors associated with receipt of PHI. Least absolute shrinkage and selection operator procedures were used for variable selection. Results: A total of 4 358 038 veterans (mean [SD] age, 63.7 [16.0] years; 90% male; 76% non-Hispanic White) formed the study cohort, of whom 389 757 (9%) received the PHI. Veterans who received the PHI had higher mean Care Assessment Need (CAN) scores, which indicate the likelihood of hospitalization or death within 1 year (mean [SD], 51.9 [28.6] vs 47.2 [28.6]; standardized mean difference [SMD], -0.16). They were also more likely to live in urban areas (77% vs 64%; SMD, 0.28) and have a shorter drive distance to primary care (mean [SD], 13.2 [12.4] vs 15.7 [14.6] miles; SMD, 0.19). The mean outpatient use was higher among PHI recipients compared with non-PHI recipients (mean [SD], 18.4 [27.8] vs 15.1 [24.1] visits; SMD, -0.13). In addition, veterans with primary care practitioners with higher caseloads were more likely to receive the PHI (mean [SD], 778 [231] vs 744 [249] patients; SMD, -0.14), and they were more likely to be seen at larger clinics (mean [SD], 9670 [6876] vs 8786 [6892] patients; SMD, -0.13). Prior outpatient use and CAN score were associated with PHI receipt in the final model. Conclusions and Relevance: In this cohort study of the VHA's PHI, patients with higher CAN scores and more outpatient use in the previous year were more likely to receive the PHI. This study identifies potential intervention points to improve care coordination for veterans.

Effect of a Peer Health Coaching Intervention on Clinical Outcomes Among US Veterans With Cardiovascular Risks: The Vet-COACH Randomized Clinical Trial.

Importance: Although cardiovascular disease (CVD) is the leading cause of death in the US, CVD risk factors remain suboptimally controlled. Objective: To test the effectiveness of a home-visit, peer health coaching intervention to improve health outcomes for veterans with multiple CVD risks. Design, Setting, and Participants: This 2-group, unblinded randomized clinical trial, called Vet-COACH (Veteran Peer Coaches Optimizing and Advancing Cardiac Health), used a novel geographic-based method to recruit a racially diverse population of veterans with low income. These veterans were enrolled at the Seattle or American Lake Veterans Health Affairs primary care clinics in Washington state. Veterans with a diagnosis of hypertension with at least 1 blood pressure reading of 150/90 mm Hg or higher in the past year, and 1 other CVD risk factor (current smoker, overweight or obesity, and/or hyperlipidemia), who resided in Census tracts with the highest prevalence of hypertension were eligible to participate. Participants were randomized to the intervention group (n = 134) or control group (n = 130). An intention-to-treat analysis was performed from May 2017 to October 2021. Intervention: Participants in the intervention group received peer health coaching for 12 months with mandatory and optional educational materials, an automatic blood pressure monitor, a scale, a pill organizer, and healthy nutrition tools. Participants in the control group received usual care plus educational materials. Main Outcomes and Measures: The primary outcome was a change in systolic blood pressure (SBP) from baseline to 12-month follow-up. Secondary outcomes included change in health-related quality of life (HRQOL; measured using the 12-item Short Form survey's Mental Component Summary and Physical Component Summary scores), Framingham Risk Score, and overall CVD risk and health care use (hospitalizations, emergency department visits, and outpatient visits). Results: The 264 participants who were randomized (mean [SD] age of 60.6 [9.7] years) were predominantly male (229 [87%]) and 73 (28%) were Black individuals and 103 (44%) reported low annual income (<$40 000 per year). Seven peer health coaches were recruited. No difference was found in change in SBP between the intervention and control groups (-3.32 [95% CI, -6.88 to 0.23] mm Hg vs -0.40 [95% CI, -4.20 to 3.39] mm Hg; adjusted difference in differences, -2.05 [95% CI, -7.00 to 2.55] mm Hg; P = .40). Participants in the intervention vs control group reported greater improvements in mental HRQOL scores (2.19 [95% CI, 0.26-4.12] points vs -1.01 [95% CI, -2.91 to 0.88] points; adjusted difference in differences, 3.64 [95% CI, 0.66-6.63] points; P = .02). No difference was found in physical HRQOL scores, Framingham Risk Scores, and overall CVD risk or health care use. Conclusions and Relevance: This trial found that, although the peer health coaching program did not significantly decrease SBP, participants who received the intervention reported better mental HRQOL compared with the control group. The results suggest that a peer-support model that is integrated into primary care can create opportunities for well-being improvements beyond blood pressure control. Trial Registration: ClinicalTrials.gov Identifier: NCT02697422.

Racial Disparities in Uterine Fibroid Treatment Among Veterans Using VA Health Care.

INTRODUCTION: Uterine fibroids are common, nonmalignant tumors that disproportionately impact Black patients. We aimed to examine Black and White differences in receipt of any treatment and type of first treatment in the Department of Veterans Affairs, including effect modification by severity as approximated by anemia. METHODS: We used Department of Veterans Affairs administrative data to identify 5,041 Black and 3,206 White veterans with symptomatic uterine fibroids, identified by International Classification of Diseases, 9th edition, Clinical Modification, codes, between fiscal year 2010 and fiscal year 2012 and followed in the administrative data through fiscal year 2018 for outcomes. Outcomes included receipt of any treatment, hysterectomy as first treatment, and fertility-sparing treatment as first treatment. We stratified all analyses by age (<45, ≥45 years old), used generalized linear models with a log link and Poisson error distribution, included an interaction term between race and anemia, and used recycled predictions to estimate adjusted percentages for outcomes. RESULTS: There was evidence of effect modification by anemia for receipt of any treatment but not for any other outcomes. Across age and anemia sub-groups, Black veterans were less likely to receive any treatment than White veterans. Adjusted racial differences were most pronounced among veterans with anemia (<45 years, Black-White difference = -10.3 percentage points; 95% confidence interval, -15.9 to -4.7; ≥45 years, Black-White difference = -20.3 percentage points; 95% confidence interval, -27.8 to -12.7). Across age groups, Black veterans were less likely than White veterans to have hysterectomy and more likely to have a fertility-sparing treatment as their first treatment. CONCLUSIONS: We identified significant Black-White disparities in receipt of treatment for symptomatic uterine fibroids. Additional research that centers the experiences of Black veterans with uterine fibroids is needed to inform strategies to eliminate racial disparities in uterine fibroid care.

Changes in Primary Care Quality Associated With Implementation of the Veterans Health Administration Preventive Health Inventory.

Importance: The COVID-19 pandemic caused significant disruptions in primary care delivery. The Veterans Health Administration (VHA) launched the Preventive Health Inventory (PHI) program-a multicomponent care management intervention, including a clinical dashboard and templated electronic health record note-to support primary care in delivering chronic disease care and preventive care that had been delayed by the pandemic. Objectives: To describe patient, clinician, and clinic correlates of PHI use in primary care clinics and to examine associations between PHI adoption and clinical quality measures. Design, Setting, and Participants: This quality improvement study used VHA administrative data from February 1, 2021, through February 28, 2022, from a national cohort of 216 VHA primary care clinics that have implemented the PHI. Participants comprised 829 527 veterans enrolled in primary care in clinics with the highest and lowest decile of PHI use as of February 2021. Exposure: Templated electronic health record note documenting use of the PHI. Main Outcomes and Measures: Diabetes and blood pressure clinical quality measures were the primary outcomes. Interrupted time series models were applied to estimate changes in diabetes and hypertension quality measures associated with PHI implementation. Low vs high PHI use was stratified at the facility level to measure whether systematic differences in uptake were associated with quality. Results: A total of 216 primary clinics caring for 829 527 unique veterans (mean [SD] age, 64.1 [16.9] years; 755 158 of 829 527 [91%] were men) formed the study cohort. Use of the PHI varied considerably across clinics. The clinics in the highest decile of PHI use completed a mean (SD) of 32 997.4 (14 019.3) notes in the electronic health record per 100 000 veterans compared with 56.5 (35.3) notes per 100 000 veterans at the clinics in the lowest decile of use (P < .001). Compared with the clinics with the lowest use of the PHI, clinics with the highest use had a larger mean (SD) clinic size (12 072 [7895] patients vs 5713 [5825] patients; P < .001), were more likely to be urban (91% vs 57%; P < .001), and served more non-Hispanic Black veterans (16% vs 5%; P < .001) and Hispanic veterans (14% vs 4%; P < .001). Staffing did not differ meaningfully between high- and low-use clinics (mean [SD] ratio of full-time equivalent staff to clinician, 3.4 [1.2] vs 3.4 [0.8], respectively; P < .001). After PHI implementation, compared with the clinics with the lowest use, those with the highest use had fewer veterans with a hemoglobin A1c greater than 9% or missing (mean [SD], 6577 [3216] per 100 000 veterans at low-use clinics; 9928 [4236] per 100 000 veterans at high-use clinics), more veterans with an annual hemoglobin A1c measurement (mean [SD], 13 181 [5625] per 100 000 veterans at high-use clinics; 8307 [3539] per 100 000 veterans at low-use clinics), and more veterans with adequate blood pressure control (mean [SD], 20 582 [12 201] per 100 000 veterans at high-use clinics; 12 276 [6850] per 100 000 veterans at low-use clinics). Conclusions and Relevance: This quality improvement study of the implementation of the VHA PHI suggests that higher use of a multicomponent care management intervention was associated with improved quality-of-care metrics. The study also found significant variation in PHI uptake, with higher uptake associated with clinics with more racial and ethnic diversity and larger, urban clinic sites.

"We Are Working Harder, Not Smarter": A Qualitative Inquiry into Care Coordination for Department of Veterans Affairs Mammograms Referred to the Community.

INTRODUCTION: The Department of Veterans Affairs (VA) relies on facilities outside of VA to provide mammograms for most VA patients. Prior work suggests challenges to coordinating some sex-specific services between VA and other health care systems (e.g., gynecologic malignancies, maternity care), but little is known about barriers and facilitators to mammogram care coordination. We sought to describe processes for coordinating mammograms referred outside of VA and to characterize VA staff perspectives on care coordination barriers and facilitators. METHODS: We conducted semistructured interviews with 44 VA staff at 10 VA Medical Centers that refer all mammograms outside of the VA. Respondents included staff across multiple VA departments involved in coordinating mammograms. We used a rapid templated approach to analyze audio-recorded interviews to characterize the coordination processes and identify barriers and facilitators to care coordination. RESULTS: Interviews elucidated a common mammogram care coordination process, with variability in how process steps were achieved. We identified six themes: 1) the process is generally perceived as inefficient, 2) clarity in VA staff roles and responsibilities is essential, 3) internal VA communication facilitates coordination, 4) challenges arise from variability in community provider processes and their limited understanding of VA processes, 5) coordination challenges can negatively impact veterans, and 6) technology holds promise but remains a barrier. CONCLUSIONS: Coordination of mammograms that are referred outside of VA is challenging for staff in multiple VA departments and roles. VA programs should focus on improving communication and role clarity within the VA and better harnessing technology to support coordination efforts.

Gender differences in social support for diabetes self-management: A qualitative study among veterans.

OBJECTIVE: Describe the role of social support in veterans' diabetes self-management and examine gender differences. METHODS: We conducted semi-structured interviews among veterans with diabetes from one Veterans Health Administration Health Care System. Participants described how support persons influenced their diabetes self-management and perspectives on a proposed self-management program incorporating a support person. We used thematic analysis to identify salient themes and examine gender differences. RESULTS: Among 18 women and 18 men, we identified four themes: 1) women felt responsible for their health and the care of others; 2) men shared responsibility for managing their diabetes, with support persons often attempting to correct behaviors (social control); 3) whereas both men and women described receiving instrumental and informational social support, primarily women described emotional support; and 4) some women's self-management efforts were hindered by support persons. Regarding programs incorporating a support person, some participants endorsed including family/friends and some preferred programs including other individuals with diabetes. CONCLUSIONS: Notable gender differences in social support for self-management were observed, with women assuming responsibility for their diabetes and their family's needs and experiencing interpersonal barriers. PRACTICE IMPLICATIONS: Gender differences in the role of support persons in diabetes self-management should inform support-based self-management programs.

A Method to Deliver Automated and Tailored Intervention Content: 24-month Clinical Trial.

BACKGROUND: The use of digital technologies and software allows for new opportunities to communicate and engage with research participants over time. When software is coupled with automation, we can engage with research participants in a reliable and affordable manner. Research Electronic Data Capture (REDCap), a browser-based software, has the capability to send automated text messages. This feature can be used to automate delivery of tailored intervention content to research participants in interventions, offering the potential to reduce costs and improve accessibility and scalability. OBJECTIVE: This study aimed to describe the development and use of 2 REDCap databases to deliver automated intervention content and communication to index participants and their partners (dyads) in a 2-arm, 24-month weight management trial, Partner2Lose. METHODS: Partner2Lose randomized individuals with overweight or obesity and cohabitating with a partner to a weight management intervention alone or with their partner. Two databases were developed to correspond to 2 study phases: one for weight loss initiation and one for weight loss maintenance and reminders. The weight loss initiation database was programmed to send participants (in both arms) and their partners (partner-assisted arm) tailored text messages during months 1-6 of the intervention to reinforce class content and support goal achievement. The weight maintenance and reminder database was programmed to send maintenance-related text messages to each participant (both arms) and their partners (partner-assisted arm) during months 7-18. It was also programmed to send text messages to all participants and partners over the course of the 24-month trial to remind them of group classes, dietary recall and physical activity tracking for assessments, and measurement visits. All text messages were delivered via Twilio and were unidirectional. RESULTS: Five cohorts, comprising 231 couples, were consented and randomized in the Partner2Lose trial. The databases will send 53,518 automated, tailored text messages during the trial, significantly reducing the need for staff to send and manage intervention content over 24 months. The cost of text messaging will be approximately US $450. Thus far, there is a 0.004% known error rate in text message delivery. CONCLUSIONS: Our trial automated the delivery of tailored intervention content and communication using REDCap. The approach described provides a framework that can be used in future behavioral health interventions to create an accessible, reliable, and affordable method for intervention delivery and engagement that requires minimal trial-specific resources and personnel time. TRIAL REGISTRATION: ClinicalTrials.gov NCT03801174; https://clinicaltrials.gov/ct2/show/NCT03801174?term=NCT03801174.

National Veterans Health Administration MOVE! Weight Management Program Participation During the COVID-19 Pandemic.

INTRODUCTION: In response to COVID-19, the Veterans Health Administration (VHA) converted appropriate outpatient visits to virtual care, including MOVE! Weight Management Program for Veterans (MOVE!) visits. Before the pandemic, most veterans participated in MOVE! in person, with several telehealth modalities available. We sought to describe national trends in MOVE! participation during the pandemic (March 2020-January 2021) overall and by modality and to compare participation to prepandemic levels. METHODS: We conducted a national retrospective cohort study of veterans who participated in MOVE! from January 2018 through January 2021. We examined MOVE! participation across VHA aggregated at the national level by month, including the number of visits, participants, and new participants in person and via telehealth, including telephone, clinic-to-clinic synchronous video, anywhere-to-anywhere (eg, provider home to patient home) synchronous video, and remote education and monitoring. We also determined the percentage of all MOVE! visits attributable to each modality and the monthly percentage change in participation during the pandemic compared with monthly averages in prior years. RESULTS: Before March 2020, 20% to 30% of MOVE! was delivered via telehealth, which increased to 90% by April 2020. Early in the pandemic, telephone-delivered MOVE! was the most common modality, but anywhere-to-anywhere synchronous video participation increased over time. Compared with the same months in prior years, total monthly MOVE! participation remained 20% to 40% lower at the end of 2020 and into January 2021. CONCLUSION: The VHA MOVE! program rapidly shifted to telehealth delivery of weight management services in response to the pandemic. However, a gap remained in the number of veterans receiving these services compared with prior years, suggesting potential unmet needs for weight management.

Home Telehealth in the Veterans Health Administration: Trends and Correlates of Length of Enrollment from 2010 to 2017.

BACKGROUND: Home telehealth (HT) programs enable communication and remote monitoring of patient health data between clinician visits, with the goal of improving chronic disease self-management and outcomes. The Veterans Health Administration (VHA) established one of the earliest HT programs in the country in 2003; however, little is known about how these services have been utilized and expanded over the last decade. OBJECTIVE: To describe trends in use of VHA's HT program from 2010 through 2017 and correlates of length of enrollment in HT services. DESIGN: Retrospective observational cohort study. PARTICIPANTS: Patients enrolled in HT between January 1, 2010 and December 31, 2017. MAIN MEASURES: We described the number and characteristics of patients enrolled in HT, including the chronic conditions managed. We also identified length of HT enrollment and examined patient and facility characteristics associated with longer enrollment. KEY RESULTS: The total number of patients enrolled in HT was 402,263. At time of enrollment, half were >65 years old, 91% were male, and 59.3% lived in urban residences. The most common conditions addressed by HT were hypertension (28.8%), obesity (23.9%), and diabetes (17.0%). The median time to disenrollment in HT was 261 days (8.6 months) but varied by chronic condition. In a multivariable Cox proportional hazards model, covariates associated with higher likelihood of staying enrolled were older age, male gender, non-Hispanic Black race/ethnicity, lower neighborhood socioeconomic status, living in a more rural setting, and a greater burden of comorbidities per the Gagne index. CONCLUSIONS: Across 8 years, over 400,000 veterans engaged in HT services for chronic disease management and over half remained in the program for longer than 8 months. Our work provides a real-world evaluation of HT service expansion in the VHA. Additional studies are necessary to identify optimal enrollment duration and patients most likely to benefit from HT services.

Uterine Weight as a Modifier of Black/White Racial Disparities in Minimally Invasive Hysterectomy Among Veterans with Fibroids in the Veterans Health Administration.

Introduction: Uterine fibroids are the most common indication for hysterectomy. Minimally invasive hysterectomy (MIH) confers lower risk of complications and shorter recovery than open surgical procedures; however, it is more challenging to perform with larger fibroids. There are racialized differences in fibroid size and MIH rates. We examined the role of uterine size in black-white differences in MIH among Veterans in the Department of Veterans Affairs (VA). Methods: Using VA clinical and administrative data, we conducted a cross-sectional study among black and white Veterans with fibroids who underwent hysterectomy between 2012 and 2014. We abstracted postoperative uterine weight from pathology reports as a proxy for uterine size. We used a generalized linear model to estimate the association between race and MIH and tested an interaction between race and postoperative uterine weight (≤250 g vs. >250 g). We estimated adjusted marginal effects for racial differences in MIH by postoperative uterine weight. Results: The sample included 732 Veterans (60% black, 40% white). Postoperative uterine weight modified the association of race and MIH (p for interaction=0.05). Black Veterans with postoperative uterine weight ≤250 g had a nearly 12-percentage point decrease in MIH compared to white Veterans (95% CI -23.1 to -0.5), with no difference by race among those with postoperative uterine weight >250 g. Discussion: The racial disparity among Veterans with small fibroids who should be candidates for MIH underscores the role of other determinants beyond uterine size. To eliminate disparities in MIH, research focused on experiences of black Veterans, including pathways to treatment and provider-patient interactions, is needed.

Early pregnancy loss in the emergency department, 2006-2016.

OBJECTIVES: Women experiencing early pregnancy loss (EPL) frequently present to the emergency department (ED), but little is known about who receives EPL care in these settings. We aimed to estimate the proportion of ED visits for EPL-related care and determine characteristics associated with seeking care for EPL in the ED in a national sample. METHODS: We conducted a secondary analysis of the 2006-2016 National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative survey of US ED visits. We identified women ages 15-44 years who presented to the ED for threatened or confirmed EPL based on diagnosis code or chief complaint. We estimated the proportion of ED visits attributable to EPL-related care among all ED visits and among women 15-44 years old. Using multivariable logistic regression, we evaluated patient and visit characteristics associated with receiving EPL-related care versus all other care. RESULTS: The 2006-2016 NHAMCS dataset included 325,037 visits (weighted n = 1,447,144,423), including 82,871 visits among women ages 15-44 years (weighted n = 371,016,125). Of all ED visits for women ages 15-44 years, 2.7% (95% confidence interval, 2.5-2.9) were for EPL-related care. This equates to ≈900,000 visits annually. Compared with women ages 15-44 years presenting to the ED for other reasons, those presenting for EPL-related care were younger and more likely to be Black or Hispanic. CONCLUSIONS: EPL-related care accounts for over 900,000 ED visits in the United States each year. These findings highlight the current burden of EPL visits upon EDs nationally.

Improvements in physical activity and some dietary behaviors in a community health worker-led diabetes self-management intervention for adults with low incomes: results from a randomized controlled trial.

People with low incomes have a disproportionate prevalence of diabetes and its complications and experience many barriers to self-management, which community health workers (CHWs) may help address. We sought to examine the effects of an in-home CHW-led intervention for adults with diabetes and incomes <250% of the federal poverty line on self-management behaviors and test mediators and moderators. From 2010 to 2013, we randomized participants from three Washington State health systems with type 2 diabetes and hemoglobin A1c (HbA1c) ≥ 8% to the CHW intervention (N = 145) or usual care control (N = 142) arms. We examined effects on 12-month self-management: physical activity, dietary behaviors, medication taking, blood glucose monitoring, foot care, and tobacco use. For behaviors with significant intervention-control group differences, we tested mediation by self-efficacy and social support. We also investigated whether intervention-associated changes in behaviors varied by race/ethnicity, gender, and baseline values of HbA1c, diabetes distress, depression, and food insecurity (moderators). Compared to controls, intervention participants engaged in more physical activity and reported better dietary behaviors for some measures (general diet, frequency of skipping meals, and frequency of eating out) at 12-months, but there was no evidence of mediation by self-efficacy or social support. Evidence of moderation was limited: improvements in the frequency of skipping meals were restricted to participants with baseline HbA1c < 10%. Study findings suggest CHWs could be integrated into diabetes care to effectively support lifestyle changes around physical activity and some eating behaviors among adults with low incomes. More research is needed to understand mechanisms of change.

Differences in functional and structural social support among female and male veterans and civilians.

PURPOSE: Social support is an important correlate of health behaviors and outcomes. Studies suggest that veterans have lower social support than civilians, but interpretation is hindered by methodological limitations. Furthermore, little is known about how sex influences veteran-civilian differences. Therefore, we examined veteran-civilian differences in several dimensions of social support and whether differences varied by sex. METHODS: We performed a cross-sectional analysis of the 2012-2013 National Epidemiologic Survey of Alcohol and Related Conditions-III, a nationally representative sample of 34,331 respondents (male veterans = 2569; female veterans = 356). We examined veteran-civilian differences in functional and structural social support using linear regression and variation by sex with interactions. We adjusted for socio-demographics, childhood experiences, and physical and mental health. RESULTS: Compared to civilians, veterans had lower social network diversity scores (difference [diff] = - 0.13, 95% confidence interval [CI] - 0.23, - 0.03). Among women but not men, veterans had smaller social network size (diff = - 2.27, 95% CI - 3.81, - 0.73) than civilians, attributable to differences in religious groups, volunteers, and coworkers. Among men, veterans had lower social network diversity scores than civilians (diff = - 0.13, 95% CI - 0.23, - 0.03); while among women, the difference was similar but did not reach statistical significance (diff = - 0.13, 95% CI - 0.23, 0.09). There was limited evidence of functional social support differences. CONCLUSION: After accounting for factors that influence military entry and social support, veterans reported significantly lower structural social support, which may be attributable to reintegration challenges and geographic mobility. Findings suggest that veterans could benefit from programs to enhance structural social support and improve health outcomes, with female veterans potentially in greatest need.

Concomitant Bilateral Salpingo-Oophorectomy at Hysterectomy: Differences by Race and Menopausal Status in the Veterans Affairs Health Care System, 2007-2014.

Background: Hysterectomy can be performed with concomitant bilateral salpingo-oophorectomy (BSO) to treat symptomatic pathology of the ovary (e.g., endometriosis) or to prevent ovarian cancer. Our objective was to examine the relationship between race and concomitant BSO by menopausal status in the Veterans Affairs (VA) health care system. Methods: This is a longitudinal study utilizing VA administrative data to identify hysterectomies provided or paid for by VA (i.e., source of care) between 2007 and 2014. We defined BSO as removal of both ovaries and fallopian tubes at the time of hysterectomy, identified by International Classification of Diseases-Ninth Revision codes. Covariates included demographic (e.g., ethnicity) and gynecological diagnoses (e.g., endometriosis). We used generalized linear models with a log-link and binomial distribution to estimate associations of race with BSO by menopausal status and source of care. Results: We identified 6,785 Veterans with hysterectomies, including 2,320 with concomitant BSO. Overall, Black Veterans were more likely to be single, obese, and undergo abdominal hysterectomy. After adjustment, premenopausal Black Veterans had a 41% lower odds of BSO than their White counterparts (odds ratio [OR]: 0.59, 95% confidence interval [CI]: 0.51-0.68). Stratifying on source of care, these results remained unchanged (provided: OR: 0.61, 95% CI: 0.52-0.72; paid: OR: 0.58, 95% CI: 0.48-0.71). There was insufficient evidence of an association among postmenopausal Veterans. Conclusions: Premenopausal Black Veterans are less likely to undergo BSO even after adjustment for salient characteristics. Our findings may have implications for equitable gynecological care for Veterans. Additional research is needed to better understand the role of differential preferences or cancer risk in these racial differences.

Association of Depression and Post-Traumatic Stress Disorder with Receipt of Minimally Invasive Hysterectomy for Uterine Fibroids: Findings from the U.S. Department of Veterans Affairs.

BACKGROUND: When hysterectomy is used to treat uterine fibroids, a minimally invasive versus open abdominal approach is preferred. Depression and post-traumatic stress disorder (PTSD) may be associated with surgical mode. We sought to examine whether depression and PTSD are associated with minimally invasive hysterectomy (MIH). METHODS: This was a cross-sectional study of veterans with uterine fibroids undergoing hysterectomy in the Department of Veterans Affairs between 2012 and 2014. Diagnoses and procedures were identified by International Classification of Disease, Ninth Revision, codes. MIH was defined as laparoscopic, vaginal, or robotic-assisted versus open abdominal. A dichotomous variable indicated presence of depression or PTSD. Clinical variables, including uterine size, were abstracted from the medical record. We employed generalized linear models to estimate adjusted percentages and 95% confidence intervals (CIs) of MIH by presence of depression or PTSD and sequentially adjusted for sociodemographic variables and health indicators (model 1), and then gynecologic and reproductive history variables, including uterine size (model 2). RESULTS: We included 770 veterans in our analytic sample. Veterans with depression or PTSD were more likely than those without such diagnoses to have a MIH (49% vs. 42%). Differences were attenuated in model 1 (47% [95% CI, 37%-57%] vs. 43% [95% CI, 34%-52%]) and no longer detectable in model 2 (45% [95% CI, 36%-54%] vs. 44% [95% CI, 36%-52%]). CONCLUSIONS: Veterans with depression or PTSD were more likely that those without to have a MIH, possibly owing to smaller uterine size, suggesting that they may be undergoing hysterectomy earlier in the disease process. Further research is needed to understand whether this reflects high-quality, patient-centered care.

Understanding Variation in Availability and Provision of Minimally Invasive Hysterectomy: A Qualitative Study of Department of Veterans Affairs Gynecologists.

BACKGROUND: Approximately one-half of women undergoing hysterectomy in the Department of Veterans Affairs health care system receive minimally invasive hysterectomies (MIH), with Black women less likely than White women to receive MIH. We sought to characterize gynecologists' perspectives on factors contributing to the availability and provision of MIH and on the role of race/ethnicity in decision making. METHODS: Between October 2017 and January 2018, we conducted 16 in-depth semistructured telephone interviews with Department of Veterans Affairs gynecologists exploring practice characteristics and barriers and facilitators to providing MIH, including clinical and nonclinical characteristics of patients impacting surgical decision making. We identified key themes using simultaneous deductive and inductive thematic analysis. RESULTS: Gynecologists identified provider-, facility-, and patient-level barriers and facilitators to MIH. Provider-level factors included gynecologists' skills and training in MIH, and facility factors included access to qualified surgical assistants, availability of surgical equipment, and operating room resources, particularly time. On the patient level, clinical characteristics, including uterine size, were the most common determinants of surgical approach, but nonclinical factors such as patients' attitudes toward surgery also contributed. Race/ethnicity was identified by a minority of respondents as influencing hysterectomy route through clinical presentation and surgical attitudes. CONCLUSIONS: Given the range of factors identified, efforts to promote MIH in the Department of Veterans Affairs will likely require a multipronged approach that includes support for MIH training, increased access to surgical assistants with MIH skills, and reduced barriers to obtaining equipment. Patient perspectives are needed to more fully capture nonclinical patient-level contributors to MIH and differences in MIH between Black and White Veterans.

Contributors to Racial Disparities in Minimally Invasive Hysterectomy in the US Department of Veterans Affairs.

BACKGROUND: Minimally invasive hysterectomy for fibroids decreases recovery time and risk of postoperative complications compared with abdominal hysterectomy. Within Veterans Affair (VA), black women with uterine fibroids are less likely to receive a minimally invasive hysterectomy than white women. OBJECTIVE: To quantify the contributions of patient, facility, temporal and geographic factors to VA black-white disparity in minimally invasive hysterectomy. RESEARCH DESIGN: A cross-sectional study. SUBJECTS: Veterans with fibroids and hysterectomy performed in VA between October 1, 2012 and September 30, 2015. MEASURES: Hysterectomy mode was defined using ICD-9 codes as minimally invasive (laparoscopic, vaginal, or robotic-assisted) versus abdominal. The authors estimated a logistic regression model with minimally invasive hysterectomy modeled as a function of 4 sets of factors: sociodemographic characteristics other than race, health risk factors, facility, and temporal and geographic factors. Using decomposition techniques, systematically substituting each white woman's characteristics for each black woman's characteristics, then recalculating the predicted probability of minimally invasive hysterectomy for black women for each possible combination of factors, we quantified the contribution of each set of factors to observed disparities in minimally invasive hysterectomy. RESULTS: Among 1255 veterans with fibroids who had a hysterectomy at a VA, 61% of black women and 39% of white women had an abdominal hysterectomy. Our models indicated there were 99 excess abdominal hysterectomies among black women. The majority (n=77) of excess abdominal hysterectomies were unexplained by measured sociodemographic factors beyond race, health risk factors, facility, and temporal or geographic trends. CONCLUSION: Closer examination of the equity of VA gynecology care and ways in which the VA can work to ensure equitable care for all women veterans is necessary.