Differential associations of mask mandates on COVID-19 infection and mortality by community social vulnerability.

BACKGROUND: The COVID-19 pandemic in the United States has disproportionately impacted communities deemed vulnerable to disease outbreaks. Our objectives were to test (1) whether infection and mortality decreased in counties in the most vulnerable (highest) tercile of the Social Vulnerability Index (SVI), and (2) whether disparities between terciles of SVI were reduced, as the length of mask mandates increased. METHODS: Using the New York Times COVID-19 and the Centers for Disease Control and Prevention SVI and mask mandate datasets, we conducted negative binomial regression analyses of county-level COVID-19 cases and deaths from 1/2020-11/2021 on interactions of SVI and mask mandate durations. RESULTS: Mask mandates were associated with decreases in mid-SVI cases (IRR: 0.79) and deaths (IRR: 0.90) and high-SVI cases (IRR: 0.89) and deaths (IRR: 0.88). Mandates were associated with the mitigation of infection disparities (Change in IRR: 0.92) and mortality disparities (Change in IRR: 0.85) between low and mid-SVI counties and mortality disparities between low and high-SVI counties (Change in IRR: 0.84). DISCUSSION: Mask mandates were associated with reductions in COVID-19 infection and mortality and mitigation of disparities for mid and high-vulnerability communities. CONCLUSIONS: Ongoing COVID-19 response efforts may benefit from longer-standing infection control policies, particularly in the most vulnerable communities.

Veteran knowledge, perceptions, and receipt of care following visits to VA emergency departments for ambulatory care sensitive conditions.

OBJECTIVE: Receipt of follow-up care after emergency department (ED) visits for chronic ambulatory care sensitive conditions (ACSCs)-asthma, chronic obstructive pulmonary disease, heart failure, diabetes, and/or hypertension-is crucial. We assessed Veterans' follow-up care knowledge, perceptions, and receipt of care after visits to Veterans Health Administration (VA) EDs for chronic ACSCs. METHODS: Using explanatory sequential mixed methods, we interviewed Veterans with follow-up care needs after ACSC-related ED visits, and manually reviewed ED notes, abstracting interviewees' documented follow-up needs and care received. RESULTS: We interviewed and reviewed ED notes of 35 Veterans, 12-27 (mean 19) days after ED visits. Follow-up care was completely received/scheduled in 20, partially received/scheduled in eight, and not received in seven Veterans. Among those who received care, it was received within specified time frames half the time. However, interviewees often did not recall these time frames or reported them to be longer than specified in the ED notes. Veterans who had not yet received or scheduled follow-up care commonly did not recall follow-up care instructions, believed that they did not need this care since they were not currently having symptoms, or thought that such care would be difficult to obtain due to appointment unavailability and/or difficulties communicating with follow-up care providers. Among the 28 Veterans in whom all or some follow-up care had been received/scheduled, for 25 cases VA staff reached out to the Veteran or the appointment was scheduled prior to or during the ED visit. CONCLUSIONS: VA should prioritize implementing processes for EDs to efficiently communicate Veterans' needs to follow-up care providers and systems for reaching out to Veterans and/or arranging for care prior to Veterans leaving the ED. VA should also enhance practices using multimodal approaches for educating Veterans about recommended ED follow-up care and improve mechanisms for Veterans to communicate with follow-up care providers.

Veterans' Use of Telehealth for Veterans Health Administration Community Care Urgent Care During the Early COVID-19 Pandemic.

BACKGROUND: Since the onset of the COVID-19 pandemic, telehealth has been an option for Veterans receiving urgent care through Veterans Health Administration Community Care (CC). OBJECTIVE: We assessed use, arrangements, Veteran decision-making, and experiences with CC urgent care delivered via telehealth. DESIGN: Convergent parallel mixed methods, combining multivariable regression analyses of claims data with semistructured Veteran interviews. SUBJECTS: Veterans residing in the Western United States and Hawaii, with CC urgent care claims March 1 to September 30, 2020. KEY RESULTS: In comparison to having in-person only visits, having a telehealth-only visit was more likely for Veterans who were non-Hispanic Black, were urban-dwelling, lived further from the clinic used, had a COVID-related visit, and did not require an in-person procedure. Predictors of having both telehealth and in-person (compared with in-person only) visits were other (non-White, non-Black) non-Hispanic race/ethnicity, urban-dwelling status, living further from the clinic used, and having had a COVID-related visit. Care arrangements varied widely; telephone-only care was common. Veteran decisions about using telehealth were driven by limitations in in-person care availability and COVID-related concerns. Veterans receiving care via telehealth generally reported high satisfaction. CONCLUSIONS: CC urgent care via telehealth played an important role in providing Veterans with care access early in the COVID-19 pandemic. Use of telehealth differed by Veteran characteristics; lack of in-person care availability was a driver. Future work should assess for changes in telehealth use with pandemic progression, geographic differences, and impact on care quality, care coordination, outcomes, and costs to ensure Veterans' optimal and equitable access to care.

Effect of the STRIDE fall injury prevention intervention on falls, fall injuries, and health-related quality of life.

BACKGROUND: Falls are common in older adults and can lead to severe injuries. The Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) trial cluster-randomized 86 primary care practices across 10 health systems to a multifactorial intervention to prevent fall injuries, delivered by registered nurses trained as falls care managers, or enhanced usual care. STRIDE enrolled 5451 community-dwelling older adults age ≥70 at increased fall injury risk. METHODS: We assessed fall-related outcomes via telephone interviews of participants (or proxies) every 4 months. At baseline, 12 and 24 months, we assessed health-related quality of life (HRQOL) using the EQ-5D-5L and EQ-VAS. We used Poisson models to assess intervention effects on falls, fall-related fractures, fall injuries leading to hospital admission, and fall injuries leading to medical attention. We used hierarchical longitudinal linear models to assess HRQOL. RESULTS: For recurrent event models, intervention versus control incidence rate ratios were 0.97 (95% confidence interval [CI], 0.93-1.00; p = 0.048) for falls, 0.93 (95% CI, 0.80-1.08; p = 0.337) for self-reported fractures, 0.89 (95% CI, 0.73-1.07; p = 0.205) for adjudicated fractures, 0.91 (95% CI, 0.77-1.07; p = 0.263) for falls leading to hospital admission, and 0.97 (95% CI, 0.89-1.06; p = 0.477) for falls leading to medical attention. Similar effect sizes (non-significant) were obtained for dichotomous outcomes (e.g., participants with ≥1 events). The difference in least square mean change over time in EQ-5D-5L (intervention minus control) was 0.009 (95% CI, -0.002 to 0.019; p = 0.106) at 12 months and 0.005 (95% CI, -0.006 to 0.015; p = 0.384) at 24 months. CONCLUSIONS: Across a standard set of outcomes typically reported in fall prevention studies, we observed modest improvements, one of which was statistically significant. Future work should focus on patient-, practice-, and organization-level operational strategies to increase the real-world effectiveness of interventions, and improving the ability to detect small but potentially meaningful clinical effects. CLINICALTRIALS: gov identifier: NCT02475850.

Patients' needs following emergency care for ambulatory care-sensitive conditions.

OBJECTIVES: Poor coordination across care transitions for patients with chronic ambulatory care-sensitive conditions (ACSCs) leads to adverse clinical outcomes. Veterans are at high risk for post-emergency department (ED) adverse outcomes, but the care needs of patients leaving the ED after "treat-and-release" visits are poorly characterized. To inform intervention development and implementation, we assessed for medication changes and follow-up care needs among patients with treat-and-release Veterans Affairs (VA) ED visits for chronic ACSCs. STUDY DESIGN: Retrospective, observational study. METHODS: We identified treat-and-release ED visits at the Greater Los Angeles VA (10/1/2017-6/30/2018) with diagnostic codes (in any position) for the ACSCs of asthma, chronic obstructive pulmonary disease, heart failure, diabetes, and/or hypertension. For 249 randomly selected visits, a trained nurse abstractor reviewed the ED notes using a structured abstraction tool. RESULTS: Most of the patients (91%) were male; the median (IQR) age was 67 (58-73) years. In 128 (51%) visits, a medication change was recommended; a new medication was prescribed in 109 (44%), changed in 24 (10%), and stopped in 7 (3%) visits. One or more follow-up care needs were specified in 165 (66%) visits; 55 (22%) specified 2 needs, and 13 (5%) specified 3 or more needs. The 2 most common follow-up care needs were symptom check (41%) and potential medication adjustments post ED (21%). CONCLUSIONS: More than half of patients with treat-and-release ED visits for chronic ACSCs have recommended medication changes, and two-thirds have at least 1 follow-up care need. This information offers potential foci for testing interventions to improve care coordination for patients with ACSCs who are released from the ED.

COVID-19 Infection in the Veterans Health Administration: Gender-specific Racial and Ethnic Differences.

PURPOSE: Racial/ethnic minoritized groups, women, and economically disadvantaged groups are disproportionately affected by the COVID-19 pandemic. We investigated racial/ethnic differences by gender in correlates of COVID-19 infection among veterans seeking health care services at the Veterans Health Administration. Little is known about gender-specific factors associated with infection among veterans. This study seeks to fill this gap. METHODS: The sample was veterans with results from a COVID-19 test (polymerase chain reaction) conducted at Veterans Health Administration facilities between March 1, 2020, and August 5, 2020, and linked to the Centers for Disease Control and Prevention Social Vulnerability Index data (39,223 women and 316,380 men). Bivariate, multivariate logistic, and predicted probability analyses were conducted. All analyses were stratified by gender. RESULTS: Similar percentages of women and men tested positive for COVID-19 (9.6% vs. 10.0%). In multivariate analysis, compared with non-Hispanic White women, American Indian/Alaska Native, Black, and Hispanic women all had significantly higher odds of infection. Similar racial/ethnic differences were found for men. Both older men and women (>40 years) had lower odds of infection, but the age cut points differed (40 for women, 55 for men). Men 80 years and older had a higher odds than those aged less than 40 years of age. For men, but not for women, being employed (vs. unemployed) was associated with an increased odds of infection, and having comorbidities was associated with decreased odds. There were significant differences within and across gender-by-race/ethnicity in infection, after adjusting for covariates. CONCLUSIONS: American Indian/Alaska Native, Hispanic, and Black women and men veterans are disproportionately impacted by COVID-19 infection. Widespread testing and tracking, education, and outreach regarding COVID-19 mitigation and vaccination efforts are recommended.

The Role of Community-Level Factors on Disparities in COVID-19 Infection Among American Indian/Alaska Native Veterans.

OBJECTIVES: American Indian and Alaska Native (AI/AN) communities have been disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic. This study examines whether neighborhood characteristics mediate AI/AN versus White-non-Hispanic Veteran COVID-19 infection disparities, and whether mediation differs based on proximity to reservations. METHODS: Using Veteran Health Administration's (VHA) national database of VHA users evaluated for COVID-19 infection (3/1/2020-8/25/2020), we examined whether census tract neighborhood characteristics (percent households overcrowded, without complete plumbing, without kitchen plumbing, and neighborhood socioeconomic status [n-SES]) mediated racial disparities in COVID-19 infection, using inverse odds-weighted logistic models controlling for individual-level characteristics. Using moderated mediation analyses, we assessed whether neighborhood mediating effects on disparities differed for those residing in counties containing/near federally recognized tribal lands (i.e., Contract Health Service Delivery Area [CHSDA] counties) versus not. RESULTS: The percent of households without complete plumbing, percent without kitchen plumbing, and n-SES partially mediated AI/AN-White-non-Hispanic COVID-19 infection disparities (accounting for 17-35% of disparity) to a similar extent in CHSDA and non-CHSDA counties. The percent of households without kitchen plumbing had stronger mediating effects for CHSDA than non-CHSDA residents. CONCLUSIONS: Neighborhood-level social determinants of health may contribute to the disproportionate COVID-19 infection burden on AI/ANs; differences are exacerbated among AI/ANs living near reservations.

Racial/Ethnic Variation in Veterans Health Administration COVID-19 Vaccine Uptake.

INTRODUCTION: Equitable COVID-19 vaccine access is imperative to mitigating negative COVID-19 impacts among racial/ethnic minorities. U.S. racial/ethnic minorities have lower COVID-19 vaccination rates than Whites despite higher COVID-19 death/case rates. The Veterans Health Administration provides the unique context of a managed care system with few access barriers. This study evaluates race/ethnicity as a predictor of Veterans Health Administration COVID-19 vaccination. METHODS: The cohort was composed of Veterans Health Administration outpatient users aged ≥65 years (N=3,474,874). COVID-19 vaccination was assessed between December 14, 2020 and February 23, 2021. Multivariable logistic regressions were conducted, controlling for demographics, medical comorbidity, and influenza vaccination history. Proximity to Indian Health Service Contract Health Service Delivery Areas was tested as a moderator. Data analyses were conducted during 2021. RESULTS: Blacks (OR=1.28, 95% CI=1.17, 1.40), Hispanics (OR=1.15, 95% CI=1.05, 1.25), and Asians (OR=1.21, 95% CI=1.02, 1.43) were more likely than Whites to receive Veterans Health Administration COVID-19 vaccinations. American Indian/Alaska Natives were less likely than Whites to receive Veterans Health Administration COVID-19 vaccinations, but only those residing in Contract Health Service Delivery Area counties (OR= 0.58, 95% CI= 0.47, 0.72). Influenza vaccine history positively predicted COVID-19 vaccine uptake (OR= 2.28, 95% CI=2.22, 2.34). CONCLUSIONS: In the Veterans Health Administration, compared with the general U.S. population, COVID-19 vaccine receipt is higher among most racial/ethnic minority groups than Whites, suggesting reduced vaccination barriers . The Indian Health Service may provide a safety net for American Indian/Alaska Native populations. Addressing vaccination access barriers in non-Veterans Health Administration settings can potentially reduce racial/ethnic disparities.

Variations by race/ethnicity and time in Covid-19 testing among Veterans Health Administration users with COVID-19 symptoms or exposure.

Racial/ethnic disparities in coronavirus disease 2019 (COVID-19) hospitalization and mortality have emerged in the United States, but less is known about whether similar differences exist in testing, and how this changed as COVID-19 knowledge and policies evolved. We examined racial/ethnic variations in COVID-19 testing over time among veterans who sought care for COVID-19 symptoms or exposure. In the national population of all Veterans who sought Veterans Health Administration (VHA) care for COVID-19 symptoms or exposure (n = 913,806), we conducted multivariate logistic regressions to explore race/ethnicity-by-time period differences in testing from 3/1/2020-11/25/2020, and calculated predicted probabilities by race/ethnicity and time period. Early in the pandemic (3/1/2020-4/6/2020) when testing was limited and there was less awareness of racial/ethnic disparities, non-Hispanic Black, Hispanic, and other non-White racial/ethnic minority Veterans who sought care from VHA for COVID-19 symptoms or exposure were more likely than non-Hispanic White Veterans to receive a COVID-19 test (p < 0.05). In subsequent time periods (4/7/2020-11/25/2020), testing was similar among all racial/ethnic groups. Among Veterans with COVID-19 symptoms or exposure, non-Hispanic Black and Hispanic patients were just as likely, and in some cases, more likely, to receive a COVID-19 test versus non-Hispanic White patients. The United States faced testing shortages at the start of the third wave of the pandemic; additional shortages are likely to emerge as the pandemic continues to peak and ebb. It is important to ensure that racial/ethnic minorities and others at greater risk for infection continue to have access to COVID-19 testing with each of these peaks.

Time Trends in Racial/Ethnic Differences in COVID-19 Infection and Mortality.

Studies documenting coronavirus disease 2019 (COVID-19) racial/ethnic disparities in the United States were limited to data from the initial few months of the pandemic, did not account for changes over time, and focused primarily on Black and Hispanic minority groups. To fill these gaps, we examined time trends in racial/ethnic disparities in COVID-19 infection and mortality. We used the Veteran Health Administration's (VHA) national database of veteran COVID-19 infections over three time periods: 3/1/2020-5/31/2020 (spring); 6/1/2020-8/31/2020 (summer); and 9/1/2020-11/25/2020 (fall). We calculated COVID-19 infection and mortality predicted probabilities from logistic regression models that included time period-by-race/ethnicity interaction terms, and controlled for age, gender, and prior diagnosis of CDC risk factors. Racial/ethnic groups at higher risk for COVID-19 infection and mortality changed over time. American Indian/Alaskan Natives (AI/AN), Blacks, Hispanics, and Native Hawaiians/Other Pacific Islanders experienced higher COVID-19 infections compared to Whites during the summertime. There were mortality disparities for Blacks in springtime, and AI/ANs, Asians, and Hispanics in summertime. Policy makers should consider the dynamic nature of racial/ethnic disparities as the pandemic evolves, and potential effects of risk mitigation and other (e.g., economic) policies on these disparities. Researchers should consider how trends in disparities change over time in other samples.

Complementary and Integrative Health Approaches Offered in the Veterans Health Administration: Results of a National Organizational Survey.

Introduction: Certain complementary and integrative health (CIH) approaches have increasingly gained attention as evidence-based nonpharmacological options for pain, mental health, and well-being. The Veterans Health Administration (VA) has been at the forefront of providing CIH approaches for years, and the 2016 Comprehensive Addiction and Recovery Act mandated the VA expand its provision of CIH approaches. Objective/Design: To conduct a national organizational survey to document aspects of CIH approach implementation from August 2017 to July 2018 at the VA. Participants: CIH program leads at VA medical centers and community-based outpatient clinics (n = 196) representing 289 sites participated. Measures: Delivery of 27 CIH and other nonpharmacologic approaches was measured, including types of departments and providers, visit format, geographic variations, and implementation challenges. Results: Respondents reported offering a total of 1,568 CIH programs nationally. Sites offered an average of five approaches (range 1-23), and 63 sites offered 10 or more approaches. Relaxation techniques, mindfulness, guided imagery, yoga, and meditation were the top five most frequently offered. The most approaches were offered in physical medicine and rehabilitation, primary care, and within integrative/whole health programs, and VA non-Doctor of Medicine clinical staff were the most common type of CIH provider. Only 13% of sites reported offering CIH approaches through telehealth at the time. Geographically, southwestern sites offered the smallest number of approaches. Implementation challenges included insufficient staffing, funding, and space, hiring/credentialing, positioning CIH as a priority, and high patient demand. Conclusions: The provision of CIH approaches was widespread at the VA in 2017-2018, with over half of responding sites offering five or more approaches. As patients seek nonpharmacologic options to address their pain, anxiety, depression, and well-being, the nation's largest integrated health care system is well-positioned to meet that demand. Providing these therapies might not only increase patient satisfaction but also their health and well-being with limited to no adverse events.

BMI and Risk for Severe COVID-19 Among Veterans Health Administration Patients.

OBJECTIVE: The purpose of this study was to assess associations between BMI and severe coronavirus disease 2019 (COVID-19) outcomes: hospitalization, intensive care unit (ICU) admission, and mortality. A secondary aim was to investigate whether associations varied by age. METHODS: The cohort comprised patients in the Veterans Health Administration (VHA) who tested positive for COVID-19 (N = 9,347). For each outcome, we fit piecewise logistic regression models with restricted cubic splines (knots at BMI of 23, 30, and 39), adjusting for age, sex, comorbidities, VHA nursing home residence, and race/ethnicity. Supplemental analyses included age-by-BMI interaction terms (α = 0.05). RESULTS: We found evidence of a nonlinear J-curve association between BMI and likelihood of hospitalization and mortality. BMI was associated with increased odds for hospitalization, ICU admission, and mortality among patients with BMI 30 to 39 but decreased odds of hospitalization and mortality for patients with BMI 23 to 30. Patients under age 75 with BMI between 30 and 39 had increased odds for mortality with increasing BMI. CONCLUSIONS: Odds for severe outcomes with COVID-19 infection increased with increasing BMI for people with, but not without, obesity. This nonlinear relationship should be tested in future research. COVID-19 public health messages in VHA, and broadly, should incorporate information about risks associated with all classes of obesity, particularly for those under age 75.

Association of PTSD with COVID-19 testing and infection in the Veterans Health Administration.

Posttraumatic stress disorder (PTSD) is associated with coronavirus disease 2019 (COVID-19) risk factors, such as hypertension and obesity. Associations between PTSD and COVID-19 outcomes may affect Veterans Health Administration (VA) services, as PTSD occurs at higher rates among veterans than the general population. While previous research has identified the potential for increased PTSD prevalence resulting from COVID-19 as a public health concern, no known research examines the effect of pre-existing PTSD on COVID-19 test-seeking behavior or infection. This study aimed to evaluate pre-existing PTSD as a predictor of COVID-19 testing and test positivity. The sample consisted of 6,721,407 veterans who sought VA care between March 1, 2018 and February 29, 2020. Veterans with a previous PTSD clinical diagnosis were more likely to receive COVID-19 testing than veterans without PTSD. However, among those with available COVID-19 test results (n = 168,032), veterans with a previous PTSD clinical diagnosis were less likely to test positive than veterans without PTSD. Elevated COVID-19 testing rates among veterans with PTSD may reflect increased COVID-19 health concerns and/or hypervigilance. Lower rates of COVID-19 test positivity among veterans with PTSD may reflect increased social isolation, or overrepresentation in the tested population due to higher overall use of VA services. As the COVID-19 pandemic continues, the identification of patient-level psychiatric predictors of testing and test positivity can facilitate the targeted provision of medical and mental health services to individuals in need.

The use of complementary and integrative health approaches for chronic musculoskeletal pain in younger US Veterans: An economic evaluation.

OBJECTIVES: To estimate the cost-effectiveness to the US Veterans Health Administration (VA) of the use of complementary and integrative health (CIH) approaches by younger Veterans with chronic musculoskeletal disorder (MSD) pain. PERSPECTIVE: VA healthcare system. METHODS: We used a propensity score-adjusted hierarchical linear modeling (HLM), and 2010-2013 VA administrative data to estimate differences in VA healthcare costs, pain intensity (0-10 numerical rating scale), and opioid use between CIH users and nonusers. We identified CIH use in Veterans' medical records through Current Procedural Terminology, VA workload tracking, and provider-type codes. RESULTS: We identified 30,634 younger Veterans with chronic MSD pain as using CIH and 195,424 with no CIH use. CIH users differed from nonusers across all baseline covariates except the Charlson comorbidity index. They also differed on annual pre-CIH-start healthcare costs ($10,729 versus $5,818), pain (4.33 versus 3.76), and opioid use (66.6% versus 54.0%). The HLM results indicated lower annual healthcare costs (-$637; 95% CI: -$1,023, -$247), lower pain (-0.34; -0.40, -0.27), and slightly higher (less than a percentage point) opioid use (0.8; 0.6, 0.9) for CIH users in the year after CIH start. Sensitivity analyses indicated similar results for three most-used CIH approaches (acupuncture, chiropractic care, and massage), but higher costs for those with eight or more CIH visits. CONCLUSIONS: On average CIH use appears associated with lower healthcare costs and pain and slightly higher opioid use in this population of younger Veterans with chronic musculoskeletal pain. Given the VA's growing interest in the use of CIH, further, more detailed analyses of its impacts are warranted.

Veterans Health Administration Primary Care Provider Adherence to Prescribing Guidelines for Systemic Hormone Therapy in Menopausal Women.

BACKGROUND: Systemic hormone therapy (HT) is effective for treating menopausal symptoms but also confers risks. Therefore, experts have developed clinical guidelines for its use. PURPOSE: We assessed primary care guideline adherence in prescribing systemic HT, and associations between adherence and provider characteristics, in four Veterans Health Administration (VA) facilities. METHODS: We abstracted medical records associated with new and renewal systemic HT prescriptions examining adherence to guidelines for documenting indications and contraindications; prescribing appropriate dosages; and prescribing progesterone. RESULTS: Average guideline adherence was 58%. Among new prescriptions, 74% documented a guideline-adherent indication and 28% documented absence of contraindications. Among renewals, 39% documented a guideline-adherent indication. In prescribing an appropriate dose, 45% of new prescriptions were guideline-adherent. Among renewal prescriptions with conjugated equine estrogen doses ≥0.625 mg or equivalent, 16% documented the dosing rationale. Among 116 prescriptions for systemic estrogen in women with a uterus, progesterone was not prescribed in 8. CONCLUSIONS: Guideline adherence in prescribing systemic HT was low among VA primary care providers. Failures to coprescribe progesterone put women at increased risk for endometrial cancer. IMPLICATIONS: Intervention development is urgently needed to improve guideline adherence among primary care prescribers of systemic HT for menopause. Similar assessments should be conducted in community settings.

Guideline Adherence of Veterans Health Administration Primary Care for Abnormal Uterine Bleeding.

BACKGROUND: Abnormal uterine bleeding (AUB) is common among primary care patients. We assessed the extent to which Veterans Health Administration (VA) primary care patients with AUB are receiving guideline-adherent primary care. METHODS: We identified women with AUB presenting to primary care providers across four VA health care systems from June 2013 to September 2015. We performed a structured abstraction of electronic medical record data for 15 indicators of guideline-adherent AUB care. We determined whether documented care was guideline-adherent and compared adherence of care by primary care providers by VA Designated Women's Health Provider status and by volume of clinical encounters with women veterans. RESULTS: Across 305 episodes of AUB, 53% of the care was guideline adherent. There was high adherence with documenting menopausal status (98%), ordering diagnostic studies and referrals for postmenopausal women (92%), and documenting bleeding patterns (87%). There was lower adherence with documenting whether there was active bleeding (55%), performing thyroid testing (47%), performing a pelvic examination (42%), ordering diagnostic studies and referrals in younger women with increased endometrial cancer risk (40%), assessing for pregnancy (32%), assessing for cervical motion, uterine, or adnexal tenderness in patients with intrauterine devices (30%), and assessing for elevated endometrial cancer risk (6%). There were no significant differences in overall guideline adherence between primary care providers who were, versus were not, VA Designated Women's Health Providers, or by provider volume of encounters with women veterans. CONCLUSIONS: VA primary care has high guideline adherence when caring for postmenopausal women with AUB. Quality improvement and educational initiatives are needed to improve primary care for AUB in younger women veterans.

Use of Complementary and Integrated Health: A Retrospective Analysis of U.S. Veterans with Chronic Musculoskeletal Pain Nationally.

OBJECTIVE: To partially address the opioid crisis, some complementary and integrative health (CIH) therapies are now recommended for chronic musculoskeletal pain, a common condition presented in primary care. As such, health care systems are increasingly offering CIH therapies, and the Veterans Health Administration (VHA), the nation's largest integrated health care system, has been at the forefront of this movement. However, little is known about the uptake of CIH among patients with chronic musculoskeletal pain. As such, we conducted the first study of the use of a variety of nonherbal CIH therapies among a large patient population having chronic musculoskeletal pain. MATERIALS AND METHODS: We examined the frequency and predictors of CIH therapy use using administrative data for a large retrospective cohort of younger veterans with chronic musculoskeletal pain using the VHA between 2010 and 2013 (n = 530,216). We conducted a 2-year effort to determine use of nine types of CIH by using both natural language processing data mining methods and administrative and CPT4 codes. We defined chronic musculoskeletal pain as: (1) having 2+ visits with musculoskeletal diagnosis codes likely to represent chronic pain separated by 30-365 days or (2) 2+ visits with musculoskeletal diagnosis codes within 90 days and with 2+ numeric rating scale pain scores ≥4 at 2+ visits within 90 days. RESULTS: More than a quarter (27%) of younger veterans with chronic musculoskeletal pain used any CIH therapy, 15% used meditation, 7% yoga, 6% acupuncture, 5% chiropractic, 4% guided imagery, 3% biofeedback, 2% t'ai chi, 2% massage, and 0.2% hypnosis. Use of any CIH therapy was more likely among women, single patients, patients with three of the six pain conditions, or patients with any of the six pain comorbid conditions. CONCLUSIONS: Patients appear willing to use CIH approaches, given that 27% used some type. However, low rates of some specific CIH suggest the potential to augment CIH use.

Gender Differences in Use of Complementary and Integrative Health by U.S. Military Veterans with Chronic Musculoskeletal Pain.

AIMS: The Veterans Health Administration promotes evidence-based complementary and integrative health (CIH) therapies as nonpharmacologic approaches for chronic pain. We aimed to examine CIH use by gender among veterans with chronic musculoskeletal pain, and variations in gender differences by race/ethnicity and age. METHODS: We conducted a secondary analysis of electronic health records provided by all women (n = 79,537) and men (n = 389,269) veterans age 18 to 54 years with chronic musculoskeletal pain who received Veterans Health Administration-provided care between 2010 and 2013. Using gender-stratified multivariate binary logistic regression, we examined predictors of CIH use, tested a race/ethnicity-by-age interaction term, and conducted pairwise comparisons of predicted probabilities. RESULTS: Among veterans with chronic musculoskeletal pain, more women than men use CIH (36% vs. 26%), with rates ranging from 25% to 42% among women and 15% to 29% among men, depending on race/ethnicity and age. Among women, patients under age 44 who were Hispanic, White, or patients of other race/ethnicities are similarly likely to use CIH; in contrast, Black women, regardless of age, are least likely to use CIH. Among men, White and Black patients, and especially Black men under age 44, are less likely to use CIH than men of Hispanic or other racial/ethnic identities. CONCLUSIONS: Women veteran patients with chronic musculoskeletal pain are more likely than men to use CIH therapies, with variations in CIH use rates by race/ethnicity and age. Tailoring CIH therapy engagement efforts to be sensitive to gender, race/ethnicity, and age could reduce differential CIH use and thereby help to diminish existing health disparities among veterans.

What Patients and Providers Want to Know About Complementary and Integrative Health Therapies.

OBJECTIVES: We conducted a quality improvement project to determine (1) what information providers and patients most wanted to learn about complementary and integrative health (CIH) therapies and (2) in what format they wanted to receive this information. The overall aim was to develop educational materials to facilitate the CIH therapy decision-making processes. DESIGN: We used mixed methods to iteratively pilot test and revise provider and patient educational materials on yoga and meditation. We conducted semistructured interviews with 11 medical providers and held seven focus groups and used feedback forms with 52 outpatients. We iteratively developed and tested three versions of both provider and patient materials. Activities were conducted at four Veterans Administration medical facilities (two large medical centers and two outpatient clinics). RESULTS: Patients want educational materials with clearly stated basic information about: (1) what mindfulness and yoga are, (2) what a yoga/meditation class entails and how classes can be modified to suit different abilities, (3) key benefits to health and wellness, and (4) how to find classes at the hospital/clinic. Diverse media (videos, handouts, pocket guides) appealed to different Veterans. Videos should depict patients speaking to patients and demonstrating the CIH therapy. Written materials should be one to three pages with colors, and images and messages targeting a variety of patients. Providers wanted a concise (one-page) sheet in black and white font with no images listing the scientific evidence for CIH therapies from high-impact journals, organized by either type of CIH or health condition to use during patient encounters, and including practical information about how to refer patients. CONCLUSIONS: Providers and patients want to learn more about CIH therapies, but want the information in succinct, targeted formats. The information learned and materials developed in this study can be used by others to educate patients and providers on CIH therapies.