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The Risk Analysis Index (RAI) has emerged as the most thoroughly validated and flexible assessment of surgical frailty, proven feasible for at-scale bedside screening and available in a suite of tools, that effectively risk stratifies patients across a wide variety of clinical contexts and data sources. This user guide provides a definitive summary of the RAI's theoretical model, historical development, validation, statistical performance, and clinical interpretation, placing the RAI in context with other frailty assessments and emphasizing some of its advantages. Detailed instructions are provided for each RAI variant, along with a systematic review of existing RAI-related literature., (Published by Elsevier Inc.)

Importance: The Veterans Health Administration (VHA) reports multiple indicators of hospital surgical performance, including hospital risk-standardized 30-day readmission rates (RSRRs). Currently, most routinely reported measures do not include readmissions that occur outside VHA hospitals. The impact of readmissions outside the VHA on hospital RSRR is not known., Objective: To measure the impact of including non-VHA readmissions on VHA hospital performance rankings for 30-day readmission., Design, Setting, and Participants: This retrospective cohort study included patients aged at least 65 years from 2013 to 2019 from the Veterans Affairs Surgical Quality Improvement Program linked to patient-level data from the VHA and Medicare. Data were limited to patients with VHA and Medicare enrollment during the year prior to surgery. Data were analyzed from November 2023 through July 2024., Main Outcomes and Measures: The main outcome was readmissions to acute care VHA or non-VHA hospitals within 30 days of discharge. VHA hospital-level RSRRs were estimated using separate generalized linear mixed-effects risk adjustment models that alternatively included VHA-only or VHA plus non-VHA readmissions. VHA hospitals were then stratified into quintiles based on RSRRs derived using VHA-only or VHA plus non-VHA readmissions. Changes in hospital performance quintiles with the addition of non-VHA readmissions were calculated, and characteristics of VHA hospitals most impacted by including non-VHA readmissions were evaluated., Results: The eligible cohort included 108 265 patients (mean [SD] age, 72.2 [6.5] years; 105 661 [97.6%] male) who underwent surgery in 104 VHA hospitals. The combined readmission rate was 14.0%. The proportion of readmissions occurring outside the VHA ranged from 0% to 55.3% across the 104 VHA hospitals (median, 20.9%). Using VHA and non-VHA readmissions, 24 VHA hospitals (23.1%) improved performance and 23 hospitals (22.1%) worsened performance, defined as a decrease or increase, respectively, of 1 or more RSRR quintiles. Improvements in hospital performance rank were associated with larger surgical volume (-7.48; 95% CI, -11.33 to 03.64; P < .001), urban location, greater surgical complexity (-9.86; 95% CI, -16.61 to -3.11; P = .005), and lower proportion of readmissions outside the VHA (-8.15; 95% CI, -12.75 to -3.55; P < .001)., Conclusions and Relevance: In this cohort study, VHA hospitals whose readmission performance metric improved by including non-VHA readmissions had higher patient volume, higher complexity, and lower proportion of care outside the VHA. Thus, improving continuity of care may have a paradoxical effect of worsening VHA performance metrics.

Introduction: Nursing home (NH) residents with limited life expectancy (LLE) who are intensely treated for hyperlipidemia, hypertension, or diabetes may benefit from deprescribing., Objective: This study sought to describe NH clinician and family caregiver perspectives on key influences on deprescribing decisions for chronic disease medications in NH residents near the end of life., Methods: We recruited family caregivers of veterans who recently died in a Veterans Affairs (VA) NH, known as community living centers (CLCs), and CLC healthcare clinicians (physicians, nurse practitioners, physician assistants, pharmacists, registered nurses). Respondents completed semi-structured interviews about their experiences with deprescribing statin, antihypertensive, and antidiabetic medications for residents near end of life. We conducted thematic analysis of interview transcripts to identify key themes regarding influences on deprescribing decisions., Results: Thirteen family caregivers and 13 clinicians completed interviews. Key themes included (1) clinicians and caregivers both prefer to minimize drug burden; (2) clinical factors strongly influence deprescribing of chronic disease medications, with differences in how clinicians and caregivers weigh specific factors; (3) caregivers trust and rely on clinicians to make deprescribing decisions; (4) clinicians perceive caregiver involvement and buy-in as essential to deprescribing decisions, which requires time and effort to obtain; and (5) clinicians perceive conflicting care from other clinicians as a barrier to deprescribing., Conclusions: Findings suggest a need for efforts to encourage communication with and education for family caregivers of residents with LLE about deprescribing, and to foster better collaboration among clinicians in CLC and non-CLC settings., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Research is limited about whether and to what extent registered sex offenders (RSOs) face an increased risk of housing instability. The intersection of RSO and housing instability is particularly salient for veterans as there are disproportionately higher rates of veterans among both RSOs and homeless populations. This study assessed the relationship between RSO status and risk of housing instability and homelessness among military veterans. We matched a list of 373,774 RSOs obtained from publicly available sex offender registries in 19 states with a cohort of 5.9 million veterans who responded to a brief screening for housing instability administered throughout the Veterans Health Administration between 2012 and 2016. Logistic regression estimated adjusted odds of any housing instability and homelessness among veterans identified as RSOs. Veterans identified as RSOs had 1.81 (95% confidence interval [CI] 1.46-2.25) and 2.97 (95% CI 1.67-5.17) times greater odds of reporting any housing instability and homelessness, respectively, than non-RSOs. Findings represent some of the strongest evidence to date for the high risk of housing instability and homelessness among RSOs, suggesting a clear gap in policy and programmatic responses to their unique housing needs. Evidence-based alternative approaches to residence restriction laws may reduce recidivism and protect public safety.