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Objective To evaluate race and gender variations in complementary and alternative medicine (CAM) use for knee osteoarthritis (OA) (unadjusted and adjusted for demographic and clinical factors). Methods A secondary analysis of cross‐sectional data was conducted. The sample included Veterans Affairs patients 50 years of age or older with symptomatic knee OA. Current use of various CAM therapies was assessed at baseline. Logistic regression models were used to compare race and gender differences in the use of specific CAMs. Results The sample included 517 participants (52.2% identified as African American [AA]; 27.1% identified as female). After adjusting for demographic and clinical factors, AA participants, compared with white participants, were less likely to use joint supplements (odds ratio [OR]: 0.53; 95% confidence interval [CI], 0.31‐0.90]); yoga, tai chi, or pilates (OR: 0.39; 95% CI: 0.19‐0.77); and chiropractic care (OR: 0.51; 95% CI: 0.26‐1.00). However, they were more likely to participate in spiritual activities (OR: 2.02; 95% CI: 1.39‐2.94). Women, compared with men, were more likely to use herbs (OR: 2.42; 95% CI: 1.41‐4.14); yoga, tai chi, or pilates (OR: 2.09; 95% CI: 1.04‐4.19); acupuncture, acupressure, or massage (OR: 2.45; 95% CI: 1.28‐4.67); and spiritual activities (OR: 1.68; 95% CI: 1.09‐2.60). The interactive effects of race and gender were significant in the use of herbs (P = 0.008); yoga, tai chi, or pilates (P = 0.011); acupuncture, acupressure or massage (P = 0.038); and spiritual activities (P < 0.001). Conclusion There are race and gender differences in the use of various CAMs for OA. As benefits and limitations of CAM therapies vary, clinicians must be aware of these differences.

As many health systems have been working to become high-reliability organizations (HROs), health equity has been largely absent from discussions and applications of HRO principles. This is a serious oversight. Disparities in health and health care represent systematic failures to achieve reliable outcomes for certain groups. Acceptance of disparities is antithetical to the essential HRO goal of "zero harm." We propose adding Equity to HROs in the most literal sense by designating it as a key component and achieving High Equity Reliability Organizations. We describe how equity should be a crucial element of all 5 HRO core concepts: sensitivity to operations, preoccupation with failure, deference to expertise, resilience, and reluctance to simplify.

Supplemental Digital Content is available in the text., Background: On April 23, 2014, US media outlets broadcast reports of excessive wait times and “secret” waitlists at some Veterans Affairs (VA) hospitals, precipitating legislation to increase Veterans’ access to private sector health care. Objective: The aims were to assess changes in Veterans’ distrust in the VA health care system before and after the media coverage and explore sex and racial/ethnic differences in the temporal patterns. Methods: Veterans completed semistructured interviews on health care satisfaction from June 2013 to January 2015, including a validated scale of health system distrust (range: 1–5). We used linear splines with knots at 90-day intervals to assess changes in distrust before and after April 23, 2014 (“day 0”) in linear mixed models. To explore sex and racial/ethnic differences in temporal patterns, we stratified models by sex and tested for interactions of race/ethnicity with time. Results: For women (n=600), distrust scores (mean=2.09) increased by 0.45 in days 0–90 (P

Objective Opioid specialty clinics have emerged as an approach for mitigating the risks associated with opioid therapies. Many opioid specialty clinics within the Department of Veterans Affairs (VA) have been described in the extant literature, yet veterans’ experiences of these remain absent. This research study was undertaken to describe veterans’ responses (e.g., knowledge, attitudes, and beliefs) toward being evaluated in an opioid specialty clinic. Design Qualitative descriptive research study. Setting A VA medical center in the northeast United States. Subjects Twenty veterans were interviewed between December 2017 and May 2018. Methods Veterans’ characteristics were extracted from the VA’s electronic health record and analyzed with descriptive statistics. Qualitative data about veterans’ experiences with the opioid specialty clinic were collected via semistructured interviews (in person or via telephone) and were analyzed with qualitative content analysis. Results Most participants were older, non-Hispanic or non-Latino white men. Generally, veterans had positive experiences in the opioid specialty clinic. However, there was wide variation in their understanding of the purpose of the clinic, who staffed the clinic, and why they had been referred to the clinic. Conclusions For veterans prescribed opioid therapies, this clinic served as an adjunct service for ensuring appropriate and safe prescribing. Data from this study can be used to inform interventions to promote veterans’ understanding across the total opioid safety clinic experience—referral, actual visit, and follow-up.

Objective The objective of this study was to evaluate how patient knowledge and beliefs regarding nonsteroidal anti‐inflammatory drugs (NSAIDs) may influence the use of NSAIDs for osteoarthritis (OA). Methods Surveys of 334 adults with knee and/or hip OA were analyzed in this cross‐sectional study. Familiarity with and perceptions of benefits/risks of NSAID use were measured to assess associations with the use of prescription and nonprescription oral NSAIDs. Multinomial logistic regression models were adjusted for sociodemographic and clinical variables. Results In this sample, 35.9% and 35.6% reported use of oral prescription and nonprescription‐only NSAIDs, respectively. Hispanic participants, compared with non‐Hispanic White participants, had lower perceived benefit (P = 0.005) and risk (P = 0.001) of prescription NSAIDs. The following were associated with prescription NSAID use instead of no NSAID use: having family/friends who used prescription (relative risk ratio [RRR] 3.91; 95% confidence interval [CI] 2.05‐7.47) and over‐the‐counter (OTC) (RRR 3.10; 95% CI 1.65‐5.83) NSAIDs for OA, understanding the consequences of using both prescription (RRR 3.50; 95% CI 1.79‐6.86) and OTC (RRR 2.80; 95% CI 1.39‐5.65) NSAIDs, higher perceived benefit of both prescription (RRR 2.51; 95% CI 1.71‐3.66) and OTC (RRR 1.44; 95% CI 1.01‐2.06) NSAIDs, and lower perceived risk of both types of NSAIDs (prescription: RRR 0.63 [95% CI 0.46‐0.87]; OTC: RRR 0.53 [95% CI 0.37‐0.75]). Similar results were found when we assessed the relationship between these variables and OTC NSAID use versus no oral NSAID use. Conclusion Adults with knee and/or hip OA were more likely to use NSAIDs if they were more familiar with, had an increased perceived benefit of, and had a decreased perceived risk of these drugs. Patients’ perceptions and beliefs about NSAIDs should be evaluated when considering them for treatment.

African Americans are more likely than members of other racial groups to report perceived discrimination in health care settings, and discrimination is linked to depression. Using data from a randomized controlled trial of pain coping skills training (PCST) for African Americans with osteoarthritis (N=164), we evaluated the interaction between discrimination experiences and experimental condition (PCST or control group) in linear regression models predicting depressive symptoms. There was a significant interaction between personal discrimination and experimental condition on depressive symptoms (interaction term coefficient: b=-3.2, 95% CI [- 6.4, - .02], p=.05). Discrimination was associated with depressive symptoms among those in the control group but not among those who received PCST. Participation in a PCST intervention may have reduced the association between discrimination experiences and depressive symptoms among participants in this sample. Future research should explore whether interventions aimed at teaching coping skills may be effective in ameliorating the harmful mental health effects of perceived discrimination.

Objective: To identify sociodemographic profiles of patients prescribed high-dose opioids . Design: Cross-sectional cohort study. Setting/Patients: Veterans dually-enrolled in Veterans Health Administration and Medicare Part D, with ≥ 1 opioid prescription in 2012. Main Outcome Measures: We identified five patient-level demographic characteristics and 12 community variables reflective of region, socioeconomic deprivation, safety, and internet connectivity. Our outcome was the proportion of veterans receiving >120 morphine milligram equivalents (MME) for ≥ 90 consecutive days, a Pharmacy Quality Alliance measure of chronic high-dose opioid prescribing. We used classification and regression tree (CART) methods to identify risk of chronic high-dose opioid prescribing for sociodemographic subgroups. Results: Overall, 17,271 (3.3 percent) of 525,716 dually enrolled veterans were prescribed chronic high-dose opioids. CART analyses identified 35 subgroups using four sociodemographic and five community-level measures, with high-dose opioid prescribing ranging from 0.28 percent to 12.1 percent. The subgroup (n = 16,302) with highest frequency of the outcome included veterans who were with disability, age 18-64 years, white or other race, and lived in the Western Census region. The subgroup (n = 14,835) with the lowest frequency of the outcome included veterans who were without disability, did not receive Medicare Part D Low Income Subsidy, were >85 years old, and lived in communities within the second and sixth to tenth deciles of community public assistance. Conclusions: Using CART analyses with sociodemographic and community-level variables only, we identified subgroups of veterans with a 43-fold difference in chronic high-dose opioid prescriptions. Interactions among disability, age, race/ ethnicity, and region should be considered when identifying high-risk subgroups in large populations.

Our objective was to determine if there are ethnic differences in the use of over-the-counter (OTC) and prescription oral nonsteroidal anti-inflammatory drugs (NSAIDs) and if observed ethnic differences persist after adjustment for sociodemographic and clinical factors.Knee and hip osteoarthritis study participants were identified. Surveys were administered to collect sociodemographics, clinical information, and oral treatment methods for arthritis. Multivariable logistic regression models were created using a fully conditional method.Hispanics (n = 130), compared to non-Hispanic whites (n = 204), were less likely to have a high school education (26.9% vs 63.2%, P0.001), less likely to have private medical insurance (P0.001), and more likely to have worse health (P = 0.004). OTC oral NSAID use was less common (52.9% vs 66.3%, P = 0.019), whereas prescription oral NSAID use was more common (43.4% vs 31.7%, P = 0.042) among Hispanics than non-Hispanic whites in the last 6 months. The ethnic difference in using an OTC NSAID instead of not using any oral NSAID was attenuated and no longer significant when adjusted for age, sex, education, and medical insurance (odds ratio [OR] 0.54 [95% confidence interval [CI]: 0.28-1.02]). The odds of using a prescription instead of an OTC NSAID remained significantly higher among Hispanics than non-Hispanic whites when adjusted for the same variables (odds ratio 2.17 [95% confidence interval: 1.16-4.05]).Among patients with osteoarthritis, OTC NSAIDs were less commonly used but prescription NSAIDs were more commonly used by Hispanics than non-Hispanic whites. Sociodemographic factors partially mediate ethnic differences in the use of oral NSAIDs.

Objective To examine the relationship between body mass index (BMI) and pain intensity among veterans with musculoskeletal disorder diagnoses (MSDs; nontraumatic joint disorder; osteoarthritis; low back, back, and neck pain). Setting Administrative and electronic health record data from the Veterans Health Administration (VHA). Subjects A national cohort of US military veterans with MSDs in VHA care during 2001–2012 (N = 1,759,338). Methods These cross-sectional data were analyzed using hurdle negative binomial models of pain intensity as a function of BMI, adjusted for comorbidities and demographics. Results The sample had a mean age of 59.4, 95% were male, 77% were white/Non-Hispanic, 79% were overweight or obese, and 42% reported no pain at index MSD diagnosis. Overall, there was a J-shaped relationship between BMI and pain (nadir = 27 kg/m2), with the severely obese (BMI ≥ 40 kg/m2) being most likely to report any pain (OR vs normal weight = 1.23, 95% confidence interval = 1.21–1.26). The association between BMI and pain varied by MSD, with a stronger relationship in the osteoarthritis group and a less pronounced relationship in the back and low back pain groups. Conclusions There was a high prevalence of overweight/obesity among veterans with MSD. High levels of BMI (>27 kg/m2) were associated with increased odds of pain, most markedly among veterans with osteoarthritis.

BACKGROUND: Experiences of discrimination are associated with poor health behaviors and outcomes. Understanding discrimination in health care informs interventions to improve health care experiences. OBJECTIVE: Describe the prevalence of, and variables associated with, perceived gender-based discrimination in the Veterans Affairs (VA) Healthcare System among women Veterans. DESIGN: A cross-sectional, telephone-based survey of a random na- tional sample of young female Veterans. PARTICIPANTS: Female VA primary care patients aged 18–45 years. MAIN MEASURES: The primary outcome was perceived gender-based discrimination in VA health care. Logistic and linear regression models were used to determine associations between any perceived discrim- ination and cumulative perceived discrimination with patient and health service characteristics. KEY RESULTS: Among 2294 women Veterans, 33.7% perceived gender- based discrimination in VA. Perceiving gender-based discrimination was associated with medical illness [adjusted odds ratio (aOR)=1.67, 95% confidence interval (CI)=1.34, 2.08], mental illness (aOR=2.06, 95% CI=1.57, 2.69), and military sexual trauma (aOR=2.65, 95% CI= 2.11, 3.32). Receiving most health care from the same VA provider (aOR=0.73, 95% CI=0.57, 0.94) and receiving care at a VA site with a women’s health clinic (aOR=0.76, 95% CI=0.61, 0.95) were associated with reduced odds of any perceived gender-based discrim- ination. Among those who perceived gender-based discrimination (n=733), perceived discrimination scores were higher among women with increased age, medical illness, or history of military sexual trauma and lower among those who saw the same VA provider for most medical care. CONCLUSIONS: One third of women Veterans perceived gender-based discrimination in VA. Obtaining most medical care from the same VA provider and having a women’s health clinic at one’s VA were associated with less perceived discrimination.

Background:Racial and ethnic disparities in anticoagulation exist in atrial fibrillation management in Medicare and the Veterans Health Administration, but the influence of dual Veterans Health Administration and Medicare enrollment is unclear. We compared anticoagulant initiation by race and ethnicity in dually enrolled patients and assessed the role of Medicare part D enrollment on anticoagulation disparities.Methods:We identified patients with incident atrial fibrillation (2014–2018) dually enrolled in Veterans Health Administration and Medicare. We assessed any anticoagulant initiation (warfarin or direct-acting oral anticoagulants [DOACs]) within 90 days of atrial fibrillation diagnosis and DOAC use among anticoagulant initiators. We modeled anticoagulant initiation, adjusting for patient, provider, and facility factors, including main effects for race and ethnicity and Medicare part D enrollment and an interaction term for these variables.Results:In 43 789 patients, 8.9% were Black, 3.6% Hispanic, and 87.5% White; 10.9% participated in Medicare part D. Overall, 29 680 (67.8%) patients initiated any anticoagulant, of whom 17 568 (59.2%) initiated DOACs. Lower proportions of Black (65.2%) than Hispanic (67.6%) or White (68.0%) patients initiated any anticoagulant (P=0.001) and, lower proportions of Black (56.3%) and Hispanic (55.9%) than White (59.6%) patients (P=0.001) initiated DOACs. Compared with White patients, Black patients had significantly lower initiation of any anticoagulant (adjusted odds ratio, 0.89 [95% CI, 0.82–0.97]). The adjusted odds ratios for DOAC initiation were significantly lower for Black (0.72 [95% CI, 0.65–0.81]) and Hispanic (0.84 [95% CI, 0.70–1.00]) than White patients. The interaction between race and ethnicity and Medicare part D enrollment was nonsignificant for any anticoagulant (P=0.99) and DOAC (P=0.27) therapies.Conclusions:In dually enrolled Veterans Health Administration and Medicare patients with atrial fibrillation, Black patients were less likely to initiate any anticoagulant, and Black and Hispanic patients were less likely to initiate DOACs. Medicare part D enrollment did not moderate the associations between race and ethnicity and anticoagulant therapies.

Objective This observational cohort study included patients of Black and White race and non-Hispanic ethnicity with end-stage knee osteoarthritis who were scheduled to receive total knee arthroplasty (TKA) surgery. We examined whether there are race differences in (1) use of physical therapy (PT) across all post-acute settings and (2) patient-reported physical function following TKA. Methods We collected pre- and post-operative physical function data and post-operative rehabilitation data on 104 Black and White individuals undergoing TKA. Regression analyses and independent samples t-tests were used to explore the predictive value of race on post-operative functional outcome and compare PT utilization within each post-acute setting and across all post-acute rehabilitation settings. Results Total PT received was similar between White and Black participants, but there were significant race differences in PT utilization within specific settings. Race did not significantly predict function after TKA, but Black participants had slightly lower self-reported function both before and after surgery than White participants. Conclusion This is the first study to examine both PT utilization and functional outcomes in a sample of individuals undergoing TKA, and results indicate differences in where post-operative PT is received between Black and White patients.

Key Points Question Among patients with atrial fibrillation treated in the Veterans Health Administration system, are there racial/ethnic differences in the initiation of anticoagulation therapy? Findings In this cohort study of a nationally retrospective cohort of 111 666 patients with atrial fibrillation treated from 2014 to 2018, Black and Asian patients were less likely to initiate any anticoagulation therapy. Among initiators, Black, Hispanic, and American Indian/Alaska Native patients were less likely to initiate direct oral anticoagulants. Meaning In the Veterans Health Administration system, a national, integrated health system with improved access to medications through a uniform national drug formulary, racial and ethnic disparities appear to persist in atrial fibrillation management., This cohort study uses data from the Veterans Health Administration system to compare rates of initiation of anticoagulant therapy by race/ethnicity., Importance Atrial fibrillation is a common cardiac rhythm disturbance causing substantial morbidity and mortality that disproportionately affects racial/ethnic minority groups. Anticoagulation reduces stroke risk in atrial fibrillation, yet studies show it is underprescribed in racial/ethnic minority patients. Objective To compare initiation of anticoagulant therapy by race/ethnicity for patients in the Veterans Health Administration (VA) system with atrial fibrillation. Design, Setting, and Participants This retrospective cohort study included 111 666 patients within the VA system with incident atrial fibrillation between January 1, 2014, and December 31, 2018. Data were analyzed between December 1, 2019, and March 31, 2020. Exposures Any anticoagulation was defined as receipt of warfarin or direct-acting oral anticoagulants, apixaban, dabigatran, edoxaban, or rivaroxaban. Main Outcomes and Measures Initiation of any anticoagulation (or direct-acting oral anticoagulant therapy in those who initiated any anticoagulation) was examined within 90 days of an index atrial fibrillation diagnosis. Results Our final cohort comprised 111 666 patients (109 386 men [98.0%] and 95 493 White patients [85.5%]; mean [SD] age, 72.9 [10.4] years). A total of 69 590 patients (62.3%) initiated any anticoagulant therapy, varying 10.5 percentage points by race/ethnicity (P

Objective To determine the extent of ethnic differences in the use of exercise for therapy and identify relevant modifiable determinants of exercise use among patients with knee/hip osteoarthritis (OA). Methods Knee/hip OA study participants were identified. Surveys were administered to collect patient sociodemographic and clinical information, and beliefs and attitudes about providers and treatments. Final multivariable logistic regression models were created using a fully conditional method. Results Hispanic participants (n = 130), compared to non-Hispanic participants (n = 232), were less likely to have private medical insurance (9.2% versus 31.0%) or to report having excellent/very good health (40.7% versus 52.6%). They were also less likely to report using exercise for OA treatment in the last 6 months (56% versus 73%; P = 0.003). When adjusted for age and disease severity, the difference in exercise use among ethnicities remained significant (odds ratio [OR] 0.59 [95% confidence interval (95% CI) 0.36-0.99]). In a multivariable logistic regression model designed to determine the most important determinants of exercise use for OA treatment, in the last 6 months the following were all associated with exercise use: having knee instead of hip OA (OR 2.83 [95% CI 1.51-5.29]), having family/friends who exercise (OR 3.20 [95% CI 1.76-5.84]), having a good understanding of what happens after exercise (OR 2.19 [95 CI 1.15-4.19]), and higher perceived benefit of exercise (OR 2.24 [95% CI 1.64-3.04]). Conclusion Among patients with knee/hip OA, Hispanics were less likely to exercise for OA treatment. Increased knowledge about the benefits of exercise for treatment and improved familiarity with exercise as treatment for OA may increase exercise use.

Background Few studies have assessed prescription opioid supply preceding death in individuals dying from unintentional prescription opioid overdoses, or described the characteristics of these individuals, particularly among Veterans. Objectives To describe the history of prescription opioid supply preceding prescription opioid overdose death among Veterans. Methods In a national cohort of Veterans who filled ≥1 opioid prescriptions from the Veterans Health Administration (VA) or Medicare Part D during 2008–2013, we identified deaths from unintentional or undetermined-intent prescription opioid overdoses in 2012–2013. We captured opioid prescriptions using both linked VA and Part D data, and VA data only. Results Among 1181 decedents, 643 (54.4%) had prescription opioid supply on the day of death, and 735 (62.2%) within 30 days based on linked data, compared to 40.1% and 46.7%, respectively, using VA data alone. Decedents with prescription opioid supply were significantly older and less likely to have alcohol or illicit drugs as co-occurring substances involved in the overdose. Using linked data, 241 (20.4%) decedents lacked prescription opioid supply within a year of death. Conclusions Many VA patients who die from prescription opioid overdose receive opioid prescriptions outside VA or not at all. It is important to supplement VA with non-VA data to more accurately measure prescription opioid exposure and improve opioid medication safety.

BACKGROUND: The 2014 Veterans Access, Choice and Accountability Act (i.e., “Choice”) allows eligible Veterans to receive covered health care outside the Veterans Affairs (VA) Healthcare System. The initial implementation of Choice was challenging, and use was limited in the first year. OBJECTIVE: To assess satisfaction with Choice, and identify reasons for satisfaction and dissatisfaction during its early implementation. DESIGN AND PARTICIPANTS: Semi-structured telephone interviews from July to September 2015 with Choice-eligible Veterans from 25 VA facilities across the USA. MAIN MEASURES: Satisfaction was assessed with 5-point Likert scales and open-ended questions. We compared ratings of satisfaction with Choice and VA health care, and identified reasons for satisfaction/dissatisfaction with Choice in a thematic analysis of open-ended qualitative data. RESULTS: Of 195 participants, 35 had not attempted to use Choice; 43 attempted but had not received Choice care (i.e., attempted only); and 117 attempted and received Choice care. Among those who attempted only, a smaller percentage were somewhat/very satisfied with Choice than with VA health care (17.9% and 71.8%, p

Objective: To characterize primary care physicians’ (PCPs’) perceptions of the reasons patients receive opioid medications from both VA and non-VA healthcare systems. Design: Qualitative. Setting: Department of Veterans Affairs (VA). Participants: Forty-two VA PCPs who prescribed opioids to at least 15 patients and who practiced in Massachusetts, Illinois, or Pennsylvania. Methods: Thirty-minute, semistructured telephone interviews were conducted in 2016, addressing topics regarding PCPs’ experiences and perspectives on patients who use both VA and non-VA healthcare systems to obtain prescription opioids. The analysis focused on two questions: attributes that PCPs believe characterize dual-use patients and reasons that PCPs believe patients obtain opioids from both VA and non-VA sources. Results: PCPs identified multiple attributes of, and reasons for, patients obtaining opioid medications from both VA and non-VA healthcare systems, including pain issues, opioid misuse, having healthcare managed through multiple healthcare systems, and transferring care between systems. More than half of the PCPs identified addiction and diversion as key attributes and reasons why patients obtain prescription opioids from multiple sources. PCPs also identified several behavioral and psychological factors as attributes of these patients. Conclusions: PCPs within the VA have varying perceptions of patients obtaining opioid medications from multiple healthcare systems, with pain complaints and opioid misuse as the primary themes. This knowledge about PCPs’ perceptions can be incorporated into interventions to better manage pain and prescription opioid use by VA patients.

The United States is facing an opioid crisis in which overdose is the leading cause of injury death—misuse of opioids constitutes the vast majority of those deaths. In 2016 alone, over 42,000 people died from opioid overdose, an increase of 27% from the prior year. Deployment of the Stratification Tool for Opioid Risk Mitigation (STORM), a clinical decision support tool to improve opioid safety, is one response by the Veterans Health Administration (VHA) to the opioid crisis. STORM identifies VHA patients at very high risk of opioid-related adverse events and lists potential risk mitigation strategies. Deployment of STORM also helps VHA meet certain requirements of the Comprehensive Addiction and Recovery Act of 2016. In alignment with the VHA's learning health care system initiative, a multidisciplinary team designed a randomized evaluation of a policy approach to mandating case reviews of very-high-risk patients identified by STORM and the impacts of patient inclusion versus exclusion in mandated STORM case reviews using a stepped-wedge design. The STORM evaluation involves drafting the policy notice, shepherding it through the VHA approval process, and implementing the cluster randomized design. This mixed-methods evaluation includes (1) a qualitative assessment of medical center implementation strategies with the aim of understanding of how STORM is incorporated into practice, and (2) quantitative analyses of the relations between policy mandates and STORM inclusion on opioid-related adverse events. The findings from this synergistic research design will yield critical insights for VHA leadership to refine opioid prescribing-related policy and practice.

ObjectiveWhile opioids are known to cause unintended adverse effects, they are being utilized by a number of patients with osteoarthritis (OA). The aim of this study was to evaluate the association of patient familiarity and perceptions regarding efficacy and risks with opioid medication use for OA.MethodsA total of 362 adults with knee and/or hip OA were surveyed in this cross-sectional study. Patients’ familiarity with and perceptions of benefits/risks of opioid medications were measured to evaluate potential associations with the utilization of opioid medications for OA within the last 6 months. Logistic regression models were adjusted for sociodemographic and clinical variables.ResultsIn this sample, 28.7% (100/349) reported use of an opioid medication for OA-related symptoms in the last 6 months. Those who were on an opioid medication, compared to those who were not, were younger (mean age 62.5 vs 64.8 yrs), were more likely to have a high school education or lower (48.0% vs 35.3%), and had higher mean depression (Patient Health Questionnaire [PHQ]-8 7.2 vs 4.9) and OA-related pain (Western Ontario and McMaster Universities Arthritis Index [WOMAC] 54.8 vs 46.8) scores. After adjustment for sociodemographic and clinical variables, the following were associated with opioid medication use: higher perception of medication benefit (OR 1.68, 95% CI 1.18–2.41), lower perception of medication risk (OR 0.67, 95% CI 0.51–0.88), and having family or friends who received the medication for OA (OR 3.88, 95% CI 1.88–8.02).ConclusionAmong adults with knee/hip OA, opioid use was associated with being familiar with the treatment, as well as believing that the medication was beneficial and low-risk.

Background: Atrial fibrillation (AF) affects nearly 1 million patients in VA, with morbidity and mortality disproportionately affecting racial/ethnic minorities. Anticoagulation reduces stroke risk in AF, yet warfarin and direct oral anticoagulants (DOACs) are underused in minorities. We compared anticoagulant initiation by race/ethnicity for patients with AF in VA—which facilitates access to medications through a uniform drug formulary. Methods: Using the VA Corporate Data Warehouse, we identified patients from 1/1/2014 - 12/31/2018 with an AF diagnosis and a confirmatory diagnosis ≦180 days of their index AF diagnosis. We excluded patients with an AF diagnosis or anticoagulant therapy in the 2 years prior to their index AF diagnosis, as well as those with valvular heart disease, who died within 180 days of AF diagnosis, or had missing or “other” race/ethnicity. We categorized our independent variable as non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic. Our primary outcome was receipt of any anticoagulant ≦180 days of AF diagnosis as well as the type of anticoagulant (warfarin, DOAC) initiated. We used logistic regression to compare outcomes by race/ethnicity, adjusting for year of diagnosis, stroke risk with CHADS2VA2Sc score, renal disease, region and rurality. Results: We identified 148,062 patients with incident AF: 8.6% were NHB, 3.4% Hispanic. Overall, NHBs (57.7%) and Hispanics (58.4%) were less likely than NHWs (61.4%) to initiate any anticoagulant therapy (p Conclusions: In a national cohort of AF in VA, we identified significant racial/ethnic disparities in anticoagulant initiation, driven by growing disparities in DOAC initiation. Understanding these differences is essential to ensuring equitable AF care in the largest U.S. integrated health care system.

OBJECTIVE Perceived discrimination is associated with chronic pain and depression and contributes to racial health disparities. In a cohort of older adult veterans with osteoarthritis (OA), our objective was to examine how membership in multiple socially disadvantaged groups (cumulative disadvantage) was associated with perceived discrimination, pain, and depression. We also tested whether perceived discrimination mediated the association of cumulative disadvantage with depression and pain. METHODS We analyzed baseline data from 270 African American veterans and 247 White veterans enrolled in a randomized controlled trial testing a psychological intervention for chronic pain at 2 Department of Veterans Affairs medical centers. Participants were age ≥50 years and self-reported symptomatic knee OA. Measures included the Everyday Discrimination Scale, the Patient Health Questionnaire Depression Scale, the Western Ontario and McMaster Universities Osteoarthritis Index pain subscale, and demographic variables. Cumulative disadvantage was defined as the number of socially disadvantaged groups to which each participant belonged (i.e., self-reported female sex, African American race, annual income of

Background While patients with substance use disorders (SUDs) are thought to encounter poor primary care experiences, the perspectives of patients with opioid use disorder (OUD), specifically, are unknown. This study compares the primary care experiences of patients with OUD, other SUDs and no SUD in the Veterans Health Administration. Methods The sample included Veterans who responded to the national Patient-Centered Medical Home Survey of Healthcare Experiences of Patients, 2013–2015. Respondents included 3554 patients with OUD, 36,175 with other SUDs, and 756,386 with no SUD; 742 OUD-diagnosed patients received buprenorphine. Multivariable multinomial logistic regressions estimated differences in the probability of reporting positive and negative experiences (0–100 scale) for patients with OUD, compared to patients with other SUDs and no SUD, and for OUD-diagnosed patients treated versus not treated with buprenorphine. Results Of all domains, patients with OUD reported the least positive experiences with access (31%) and medication decision-making (35%), and the most negative experiences with self-management support (35%) and provider communication (23%). Compared to the other groups, patients diagnosed with OUD reported fewer positive and/or more negative experiences with access, communication, office staff, provider ratings, comprehensiveness, care coordination, and self-management support (adjusted risk differences[aRDs] range from |2.9| to |7.0|). Among OUD-diagnosed patients, buprenorphine was associated with more positive experiences with comprehensiveness (aRD = 8.3) and self-management support (aRD = 7.1), and less negative experiences with care coordination (aRD = −4.9) and medication shared decision-making (aRD = −5.4). Conclusions In a national sample, patients diagnosed with OUD encounter less positive and more negative experiences than other primary care patients, including those with other SUDs. Buprenorphine treatment relates positively to experiences with care comprehensiveness, medication decisions, and care coordination. As stakeholders encourage more primary care providers to manage OUD, it will be important for healthcare systems to attend to patient access and experiences with care in these settings.

Background In 2018, the Department of Veterans Affairs (VA) issued Notice 2018-08 requiring facilities to complete “case reviews” for Veterans identified in the Stratification Tool for Opioid Risk Mitigation (STORM) dashboard as high risk for adverse outcomes among patients prescribed opioids. Half of the facilities were randomly assigned to a Notice version including additional oversight. We evaluated implementation strategies used, whether strategies differed by randomization arm, and which strategies were associated with case review completion rates. Methods Facility points of contact completed a survey assessing their facility’s use of 68 implementation strategies based on the Expert Recommendations for Implementing Change taxonomy. We collected respondent demographic information, facility-level characteristics, and case review completion rates (percentage of high-risk patients who received a case review). We used Kruskal-Wallis tests and negative binomial regression to assess strategy use and factors associated with case reviews. Results Contacts at 89 of 140 facilities completed the survey (64%) and reported using a median of 23 (IQR 16–31) strategies. The median case review completion rate was 71% (IQR 48–95%). Neither the number or types of strategies nor completion rates differed by randomization arm. The most common strategies were using the STORM dashboard (97%), working with local opinion leaders (80%), and recruiting local partners (80%). Characteristics associated with case review completion rates included respondents being ≤ 35 years old (incidence rate ratio, IRR 1.35, 95% CI 1.09–1.67) and having < 5 years in their primary role (IRR 1.23; 95% CI 1.01–1.51), and facilities having more prior academic detailing around pain and opioid safety (IRR 1.40, 95% CI 1.12–1.75). Controlling for these characteristics, implementation strategies associated with higher completion rates included (1) monitoring and adjusting practices (adjusted IRR (AIRR) 1.40, 95% CI 1.11–1.77), (2) identifying adaptations while maintaining core components (AIRR 1.28, 95% CI 1.03–1.60), (3) conducting initial training (AIRR 1.16, 95% CI 1.02–1.50), and (4) regularly sharing lessons learned (AIRR 1.32, 95% CI 1.09–1.59). Conclusions In this national evaluation of strategies used to implement case reviews of patients at high risk of opioid-related adverse events, point of contact age and tenure in the current role, prior pain-related academic detailing at the facility, and four specific implementation strategies were associated with case review completion rates, while randomization to additional centralized oversight was not. Trial registration This project is registered at the ISRCTN Registry with number ISRCTN16012111. The trial was first registered on May 3, 2017.

BackgroundHealthcare experiences associated with perceived racial/ethnic discrimination among patients are poorly understood.ObjectiveIdentify domains of patient dissatisfaction associated with perceived racial/ethnic discrimination among patients with pain.DesignSemi-structured telephone surveys completed in 2013-2015.ParticipantsWhite, African American, and Latino participants who reported receiving pain management from 25 Veterans Affairs (VA) Medical Centers.Main measuresSurveys included open-ended questions about healthcare satisfaction/dissatisfaction and a measure of perceived racial/ethnic-based discrimination while seeking VA healthcare. Binary indicators for ten qualitative domains of dissatisfaction were derived from open-ended questions. We used multilevel models to identify dissatisfaction domains associated with perceived discrimination, adjusting for patient characteristics and site. Within domains associated with discrimination, we identified the most frequent codes and examined whether patients primarily referenced clinical or non-clinical staff in their experiences.Key resultsOverall, 622 participants (30.4% White, 37.8% African American, 31.8% Latino; 57.4% female; mean age = 53.4) reported a median discrimination score of 1.0 (IQR: 1.0-1.3) on a scale of 1 to 5; 233 (37.5%) perceived any racial/ethnic discrimination in healthcare. Individually, 7 of 10 qualitative domains were significantly associated with perceived discrimination: dissatisfaction with care quality, facilities, continuity of care, interactions with staff, staff demeanor, unresolved pain, and pharmacy services (psConclusionNegative interpersonal experiences and unresolved pain are strong correlates of perceived racial/ethnic discrimination among patients with pain. Future studies should test whether interventions targeting these domains reduce patient perceptions of racial/ethnic discrimination in healthcare.

Osteoarthritis (OA), also known as osteoarthrosis, is the most prevalent form of joint pathology. It is attributed to diverse causes like joint injury, obesity, aging, and genetic predisposition. The result is the degeneration of the articular cartilage, the subchondral bone, and the entire joint organ. The articular cartilage destruction, typical of OA, is associated with joint space narrowing and periarticular hypertrophic changes. Chronic knee pain significantly affects quality of life (1). People suffering from OA are often confused about the management of their condition. Healthcare professionals must provide support and clear advice on the possible ways to regulate symptoms like pain and decreased physical function, which have an impact on self-efficacy and social engagement.

BACKGROUND Clinical guidelines recommend cardioverter defibrillator implantation for patients with heart failure and reduced ejection fraction. Despite this, women and minorities have been less likely to receive implantable cardioverter-defibrillator (ICD) therapy than white men. We examined race and sex differences in ICD implantation in a recent cohort. METHODS Using cross-sectional, retrospective analyses, we mined our health system's outpatient electronic medical records to assess age, race, sex, medications, and comorbidities for patients aged ≥18 years with ejection fraction ≤ 35% during 2014. While adjusting for confounding variables such as medications, age, and comorbidities, we conducted a multivariable logistic regression assessing whether racial and sex differences in ICD therapy persist. RESULTS Among 5,156 outpatients with ejection fraction ≤35%, 1,681 (32.6%) patients had an ICD present at the time of their index outpatient visit in 2014. Women were less likely to have an ICD than men (25.0% vs 36.3%, P

BACKGROUND Homeless patients describe poor experiences with primary care. In 2012, the Veterans Health Administration (VHA) implemented homeless-tailored primary care teams (Homeless Patient Aligned Care Team, HPACTs) that could improve the primary care experience for homeless patients. OBJECTIVE To assess differences in primary care experiences between homeless and nonhomeless Veterans receiving care in VHA facilities that had HPACTs available (HPACT facilities) and in VHA facilities lacking HPACTs (non-HPACT facilities). RESEARCH DESIGN We used multivariable multinomial regressions to estimate homeless versus nonhomeless patient differences in primary care experiences (categorized as negative/moderate/positive) reported on a national VHA survey. We compared the homeless versus nonhomeless risk differences (RDs) in reporting negative or positive experiences in 25 HPACT facilities versus 485 non-HPACT facilities. SUBJECTS Survey respondents from non-HPACT facilities (homeless: n=10,148; nonhomeless: n=309,779) and HPACT facilities (homeless: n=2022; nonhomeless: n=20,941). MEASURES Negative and positive experiences with access, communication, office staff, provider rating, comprehensiveness, coordination, shared decision-making, and self-management support. RESULTS In non-HPACT facilities, homeless patients reported more negative and fewer positive experiences than nonhomeless patients. However, these patterns of homeless versus nonhomeless differences were reversed in HPACT facilities for the domains of communication (positive experience RDs in non-HPACT versus HPACT facilities=-2.0 and 2.0, respectively); comprehensiveness (negative RDs=2.1 and -2.3), shared decision-making (negative RDs=1.2 and -1.8), and self-management support (negative RDs=0.1 and -4.5; positive RDs=0.5 and 8.0). CONCLUSIONS VHA facilities with HPACT programs appear to offer a better primary care experience for homeless versus nonhomeless Veterans, reversing the pattern of relatively poor primary care experiences often associated with homelessness.

BACKGROUND: Managing depression in primary care settings has increased with the rise of integrated models of care, such as patient-centered medical homes (PCMHs). The relationship between patient experience in PCMH settings and receipt of depression treatment is unknown. OBJECTIVE: In a large sample of Veterans diagnosed with depression, we examined whether positive PCMH experiences predicted subsequent initiation or continuation of treatment for depression. DESIGN AND PARTICIPANTS: We conducted a lagged cross-sectional study of depression treatment among Veterans with depression diagnoses (n = 27,362) in the years before (Y1) and after (Y2) they completed the Veterans Health Administration’s national 2013 PCMH Survey of Healthcare Experiences of Patients. MAIN MEASURES: We assessed patient experiences in four domains, each categorized as positive/moderate/negative. Depression treatment, determined from administrative records, was defined annually as 90 days of antidepressant medications or six psychotherapy visits. Multivariable logistic regressions measured associations between PCMH experiences and receipt of depression treatment in Y2, accounting for treatment in Y1. KEY RESULTS: Among those who did not receive depression treatment in Y1 (n = 4613), positive experiences in three domains (comprehensiveness, shared decision-making, self-management support) predicted greater initiation of treatment in Y2. Among those who received depression treatment in Y1 (n = 22,749), positive or moderate experiences in four domains (comprehensiveness, care coordination, medication decision-making, self-management support) predicted greater continuation of treatment in Y2. CONCLUSIONS: In a national PCMH setting, patient experiences with integrated care, including care coordination, comprehensiveness, involvement in shared decision-making, and self-management support predicted patients’ subsequent initiation and continuation of depression treatment over time—a relationship that could affect physical and mental health outcomes. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-018-4522-7) contains supplementary material, which is available to authorized users.

Oxide and nitride thin-films of Ti, Hf, and Si serve numerous applications owing to the diverse range of their material properties. It is therefore imperative to have proper control over these properties during materials processing. Ion-surface interactions during plasma processing techniques can influence the properties of a growing film. In this work, we investigated the effects of controlling ion characteristics (energy, dose) on the properties of the aforementioned materials during plasma-enhanced atomic layer deposition (PEALD) on planar and 3D substrate topographies. We used a 200 mm remote PEALD system equipped with substrate biasing to control the energy and dose of ions by varying the magnitude and duration of the applied bias, respectively, during plasma exposure. Implementing substrate biasing in these forms enhanced PEALD process capability by providing two additional parameters for tuning a wide range of material properties. Below the regimes of ion-induced degradation, enhancing ion energies with substrate biasing during PEALD increased the refractive index and mass density of TiOx and HfOx and enabled control over their crystalline properties. PEALD of these oxides with substrate biasing at 150 °C led to the formation of crystalline material at the low temperature, which would otherwise yield amorphous films for deposition without biasing. Enhanced ion energies drastically reduced the resistivity of conductive TiNx and HfNx films. Furthermore, biasing during PEALD enabled the residual stress of these materials to be altered from tensile to compressive. The properties of SiOx were slightly improved whereas those of SiNx were degraded as a function of substrate biasing. PEALD on 3D trench nanostructures with biasing induced differing film properties at different regions of the 3D substrate. On the basis of the results presented herein, prospects afforded by the implementation of this technique during PEALD, such as enabling new routes for topographically selective deposition on 3D substrates, are discussed.

BACKGROUND: The Department of Veterans Affairs (VA) has implemented robust strategies to monitor prescription opioid dispensing, but these strategies have not accounted for opioids prescribed by non-VA providers. State-based prescription drug monitoring programs (PDMPs) are a potential tool to identify VA patients’ receipt of opioids from non-VA prescribers, and recent legislation requires their use within VA. OBJECTIVE: To evaluate VA physicians’ perspectives and experiences regarding use of PDMPs to monitor Veterans’ receipt of opioids from non-VA prescribers. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: Forty-two VA primary care physicians who prescribed opioids to 15 or more Veterans in 2015. We sampled physicians from two states with PDMPs (Massachusetts and Illinois) and one without prescriber access to a PDMP at the time of the interviews (Pennsylvania). APPROACH: From February to August 2016, we conducted semi-structured telephone interviews that addressed the following topics regarding PDMPs: overall experiences, barriers to optimal use, and facilitators to improve use. KEY RESULTS: VA physicians broadly supported use of PDMPs or desired access to one, while exhibiting varying patterns of PDMP use dictated by state laws and their clinical judgment. Physicians noted administrative burdens and incomplete or unavailable prescribing data as key barriers to PDMP use. To facilitate use, physicians endorsed (1) linking PDMPs with the VA electronic health record, (2) using templated notes to document PDMP use, and (3) delegating routine PDMP queries to ancillary staff. CONCLUSIONS: Despite the time and administrative burdens associated with their use, VA physicians in our study broadly supported PDMPs. The application of our findings to ongoing PDMP implementation efforts may strengthen PDMP use both within and outside VA and improve the safe prescribing of opioids. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-018-4374-1) contains supplementary material, which is available to authorized users.

Knee osteoarthritis is a painful, disabling condition that disproportionately affects African Americans. Existing arthritis treatments yield small to moderate improvements in pain and have not been effective at reducing racial disparities in the management of pain. The biopsychosocial model of pain and evidence from the positive psychology literature, suggest that increasing positive psychological skills (e.g., gratitude, kindness) could improve pain and functioning and reduce disparities in osteoarthritis pain management. Activities to cultivate positive psychological skills have been developed and validated; however, they have not been tested in patients with osteoarthritis, their effects on racial differences in health outcomes have not been examined, and evidence of their effects on health outcomes in patients with other chronic illnesses is of limited quality. In this article we describe the rationale and design of Staying Positive with Arthritis (SPA) study, a randomized controlled trial in which 180 African American and 180 White primary care patients with chronic pain from knee osteoarthritis will be randomized to a 6-week program of either positive skill-building activities or neutral control activities. The primary outcomes will be self-reported pain and functioning as measured by the WOMAC Osteoarthritis Index. We will assess these primary outcomes and potential, exploratory psychosocial mediating variables at an in-person baseline visit and by telephone at 1, 3, and 6 months following completion of the assigned program. If effective, the SPA program would be a novel, theoretically-informed psychosocial intervention to improve quality and equity of care in the management of chronic pain from osteoarthritis.

Highlights Patient-reported outcomes (PRO) in atrial fibrillation (AF) differ by sex. We compared general and disease-specific PRO in women and men with AF. Comorbidity, treatment, and social factors did not change differences. Modification of such factors by sex also did not change differences in PRO. Sex-specific assessment of PRO is essential to improve how women experience AF., Background Women have worse patient-reported outcomes in atrial fibrillation (AF) than men, but the reasons remain poorly understood. We investigated how comorbid conditions, treatment, social factors, and their modification by sex would attenuate sex-specific differences in patient-reported outcomes in AF. Methods In a cohort with prevalent AF we measured patient-reported outcomes with the Short-Form-12 (SF-12, an 8-domain quality of life measure), and the AF Effect on QualiTy of Life (AFEQT), an instrument specific to AF, both with range 0-100 and higher scores indicating superior outcomes. We examined sex-specific differences in patient-reported outcomes in multivariable-adjusted regression analyses incorporating demographics, comorbid conditions, treatment, social factors, and their sex-based modification. Results In 339 individuals (age 72±10, 45% women), women (vs. men) reported worse physical functioning on the SF-12 (49.7±39.0 versus 65.0±34.0), social functioning (69.8±31.8 versus 79.7±25.8), and mental health (67.4±20.2 versus 75.0±18.6). These differences were attenuated with adjustment for comorbid conditions and depression. Women had worse composite AFEQT scores (73.8±18.4 versus 78.5±16.6) and symptoms and treatment scores than men with differences remaining significant after multivariable adjustment. There were not significant interactions by sex and the array of covariates when examining differences in patient-reported outcomes between women and men. Conclusions We identified sex-specific differences in patient-reported outcomes assessed with general and AF-specific measures. Compared to men, women with AF reported worse overall health-related quality of life, even after consideration of both relevant covariates and their modification by sex. Our research indicates the importance of consideration of sex-based inequities when evaluating patient-reported outcomes in AF.

Background: Health disparities are differences in health or health care between groups based on social, economic, and/or environmental disadvantage. Disparity research often follows 3 steps: detecting (phase 1), understanding (phase 2), and reducing (phase 3), disparities. Although disparities have narrowed over time, many remain. Objectives: We argue that implementation science could enhance disparities research by broadening the scope of phase 2 studies and offering rigorous methods to test disparity-reducing implementation strategies in phase 3 studies. Methods: We briefly review the focus of phase 2 and phase 3 disparities research. We then provide a decision tree and case examples to illustrate how implementation science frameworks and research designs could further enhance disparity research. Results: Most health disparities research emphasizes patient and provider factors as predominant mechanisms underlying disparities. Applying implementation science frameworks like the Consolidated Framework for Implementation Research could help disparities research widen its scope in phase 2 studies and, in turn, develop broader disparities-reducing implementation strategies in phase 3 studies. Many phase 3 studies of disparity-reducing implementation strategies are similar to case studies, whose designs are not able to fully test causality. Implementation science research designs offer rigorous methods that could accelerate the pace at which equity is achieved in real-world practice. Conclusions: Disparities can be considered a “special case” of implementation challenges—when evidence-based clinical interventions are delivered to, and received by, vulnerable populations at lower rates. Bringing together health disparities research and implementation science could advance equity more than either could achieve on their own.

Objective Osteoarthritis is a leading cause of disability for which there is no cure. Psychosocial-oriented treatments are underexplored. We developed and tested an intervention to build positive psychological skills (e.g., gratitude) to reduce osteoarthritis symptom severity, including pain and functioning, and to improve psychosocial well-being in patients with knee or hip osteoarthritis. Design Two-arm randomized design with six-month follow-up. Setting An academic Veterans Affairs Medical Center. Subjects Patients aged 50 years or older with knee or hip osteoarthritis and pain ratings of 4 or higher. Methods Patients (N = 42) were randomized to a six-week program containing positive skill-building activities or neutral control activities tailored to the patient population. Adherence was assessed by telephone each week. We assessed osteoarthritis symptom severity (WOMAC Osteoarthritis Index) and measures of well-being (positive affect, negative affect, and life satisfaction) at baseline and by telephone one, three, and six months after the program ended. We used linear mixed models to examine changes over time. Results The majority (64%) of patients completed more than 80% of their weekly activities. Patients in the positive (vs neutral) program reported significantly more improvement over time in osteoarthritis symptom severity (P = 0.02, Cohen's d = 0.86), negative affect (P = 0.03, Cohen's d = 0.50), and life satisfaction (P = 0.02, Cohen's d = 0.36). Conclusions The study successfully engaged patients with knee or hip osteoarthritis in a six-week intervention to build positive psychological skills. Improving osteoarthritis symptom severity and measures of psychosocial well-being, the intervention shows promise as a tool for chronic pain management.

Objectives To assess in Veterans with spinal cord injury (SCI) or amputated limb (AL) the following: (1) patient demographics, medical factors, cultural and psychosocial characteristic by race; (2) wheelchair quality by race; and (3) the independent associations of patient race and the other factors with wheelchair quality. Design Cross-sectional cohort study. Setting Three Department of Veterans Affairs (VA) medical centers affiliated with academic medical centers. Participants Eligible participants were Veterans with SCI or ALs (N=516); 482 of them completed the interview. Analyses were restricted to white and African American participants. Because there was no variation in wheelchair quality among AL patients (n=42), they were excluded from all but descriptive analyses, leading to a final sample size of 421. Interventions Not applicable. Main Outcome Measure Wheelchair quality as defined by the Medicare Healthcare Common Procedure Coding System. Results We found race differences in many of our variables, but not in quality for manual (odds ratio [OR]=.67; 95% confidence interval [CI], .33–1.36) or power (OR=.82; 95% CI, .51–1.34) wheelchairs. Several factors including age (OR=.96; 95% CI, .93–.99) and income (OR=3.78; 95% CI, 1.43–9.97) were associated with wheelchair quality. There were no significant associations of cultural or psychosocial factors with wheelchair quality. Conclusions Although there were no racial differences in wheelchair quality, we found a significant association of older age and lower income with poorer wheelchair quality among Veterans. Efforts are needed to raise awareness of such disparities among VA wheelchair providers and to take steps to eliminate these disparities in prescription practice across VA sites.

Background and objectivesThe general population and most physicians have implicit racial bias against black adults. Pediatricians also have implicit bias against black adults, albeit less than other specialties. There is no published research on the implicit racial attitudes of pediatricians or other physicians toward children. Our objectives were to compare implicit racial bias toward adults versus children among resident physicians working in a pediatric emergency department, and to assess whether bias varied by specialty (pediatrics, emergency medicine, or other), gender, race, age, and year of training.MethodsWe measured implicit racial bias of residents before a pediatric emergency department shift using the Adult and Child Race Implicit Association Tests (IATs). Generalized linear models compared Adult and Child IAT scores and determined the association of participant demographics with Adult and Child IAT scores.ResultsAmong 91 residents, we found moderate pro-white/anti-black bias on both the Adult (mean=0.49, standard deviation=0.34) and Child Race IAT (mean=0.55, standard deviation=0.37). There was no significant difference between Adult and Child Race IAT scores (difference=0.06, P=.15). Implicit bias was not associated with resident demographic characteristics, including specialty.ConclusionsThis is the first study demonstrating that resident physicians have implicit racial bias against black children, similar to levels of bias against black adults. Bias in our study did not vary by resident demographic characteristics, including specialty, suggesting that pediatric residents are as susceptible as other physicians to implicit bias. Future studies are needed to explore how physicians' implicit attitudes toward parents and children may impact inequities in pediatric health care.

Background Compared to White patients in the United States, Black patients have a higher prevalence of hypertension and more severe forms of this condition. Objective To decrease racial disparities in blood pressure (BP) control among Black veterans with severe hypertension within a regional network of Veterans Affairs Medical Centers (VAMCs). Methods Health system leaders, clinicians, and health services researchers collaborated on a 12-month quality improvement (QI) project to: (1) examine project implementation and the QI strategies used to improve BP control and (2) assess the effect of the initiative on Black-White differences in BP control among veterans with severe hypertension. Results Within 9 participating VAMCs, the most frequently used QI strategies involved provider education (n=9), provider audit and feedback (n=8), and health care team change (n=7). Among 141,124 veterans with a diagnosis of hypertension, 9,913 had severe hypertension [2,533 (25.6%) Black and 7380 (74.4%) White]. Over the course of the project, the proportion of Black veterans with severe hypertension decreased from 7.5% to 6.6% (p=.002) and the racial difference in proportions for this condition decreased 0.9 percentage points, from 2.9% to 2.0% (p=.01). Conclusions A multicenter, equity-focused QI project in VA reduced the proportion of Black veterans with severe hypertension and ameliorated observed racial disparities for this condition. Embedding health services researchers within a QI team facilitated an evaluation of the processes and effectiveness of our initiative, providing a successful model for QI within a learning health care system.

Objective Treating chronic low back pain (CLBP) with spine-focused interventions is common, potentially dangerous, and often ineffective. This preliminary trial tests the feasibility and efficacy of caring for CLBP in older adults as a geriatric syndrome in Aging Back Clinics (ABC). Design Randomized controlled trial. Setting Outpatient clinics of two VA Medical Centers. Subjects Fifty-five English-speaking veterans aged 60–89 with CLBP and no red flags for serious underlying illness, prior back surgery, dementia, impaired communication, or uncontrolled psychiatric illness. Methods Participants were randomized to ABC care or usual care (UC) and followed for six months. ABC care included 1) a structured history and physical examination to identify pain contributors, 2) structured participant education, 3) collaborative decision-making, and 4) care guided by condition-specific algorithms. Primary outcomes were low back pain severity (0–10 current and seven-day average/worst pain) and pain-related disability (Roland Morris). Secondary outcomes included the SF-12 and health care utilization. Results ABC participants experienced significantly greater reduction in seven-day average (–1.22 points, P = 0.023) and worst pain (–1.70 points, P = 0.003) and SF-12 interference with social activities (50.0 vs 11.5%, P = 0.0030) at six months. ABC participants were less likely to take muscle relaxants (16.7 vs 42.3%, P = 0.0481). Descriptively, UC participants were more likely to experience pain-related emergency room visits (45.8% vs 30.8%) and to be exposed to non-COX2 nonsteroidal anti-inflammatory drugs (73.1% vs 54.2%). Conclusions These preliminary data suggest that ABC care for older veterans with CLBP is feasible and may reduce pain and exposure to other potential morbidity.

Objective Sleep and pain-related experiences are consistently associated, but the pathways linking these experiences are not well understood. We evaluated whether pain catastrophizing and arthritis self-efficacy mediate the association between sleep disturbance and osteoarthritis (OA) symptom severity in patients with knee OA. Methods We analyzed cross-sectional baseline data collected from Veterans Affairs (VA) patients enrolled in a clinical trial examining the effectiveness of a positive psychology intervention in managing pain from knee OA. Participants indicated how often in the past two weeks they were bothered by trouble falling asleep, staying asleep, or sleeping too much. We used validated scales to assess the primary outcome (OA symptom severity) and potential mediators (arthritis self-efficacy and pain catastrophizing). To test the proposed mediation model, we used parallel multiple mediation analyses with bootstrapping, controlling for sociodemographic and clinical characteristics with bivariate associations with OA symptom severity. Results The sample included 517 patients (Mage = 64 years, 72.9% male, 52.2% African American). On average, participants reported experiencing sleep disturbance at least several days in the past two weeks (M = 1.41, SD = 1.18) and reported moderate OA symptom severity (M = 48.22, SD = 16.36). More frequent sleep disturbance was associated with higher OA symptom severity directly (b = 3.08, P Conclusions Pain catastrophizing and arthritis self-efficacy partially mediated the association between sleep disturbance and OA symptom severity. Behavioral interventions that address pain catastrophizing and/or self-efficacy may buffer the association between sleep disturbance and OA symptom severity.

BACKGROUND: Patient engagement is a key tenet of patient-centered care and is associated with many positive health outcomes. To improve resources for patient engagement, we created a web-based, interactive patient engagement toolkit to improve patient engagement in primary care across the Veterans Health Administration (VHA). OBJECTIVE: To use the knowledge translation (KT) framework to evaluate the dissemination and implementation of a patient engagement toolkit at facilities across one region in the VHA. DESIGN: Using a mixed-methods approach, this process evaluation involved phone monitoring via semi-structured interviews and group meetings, during which we explored barriers and facilitators to KT. Outcomes were assessed using a structured rubric and existing patient satisfaction measures. PARTICIPANTS: We enlisted implementers at 40 VHA facilities primarily serving Pennsylvania, New Jersey, and Delaware to implement patient engagement practices at their sites. Sites were randomly assigned into a high or low coaching group to assess whether external support influenced implementation. KEY RESULTS: Sites with high rubric scores employed and possessed several elements across the KT trajectory from identification of the problem to sustainment of knowledge use. Key factors for successful implementation and dissemination included implementer engagement, organizational support, and strong collaborators. The most frequently cited barriers included short staffing, time availability, lack of buy-in, and issues with leadership. Successful implementers experienced just as many barriers, but leveraged facilitators to overcome obstacles. While sites that received more coaching did not have different outcomes, they were more likely to revisit the toolkit and indicated that they felt more accountable to local personnel. CONCLUSIONS: Because leveraging available resources is a key component of successful implementation, future toolkits should highlight the type of facilitators necessary for successful implementation of toolkit content in healthcare settings. The ability to tailor interventions to local context is critical for overcoming barriers faced in most healthcare settings.

The opioid crisis has highlighted the importance of improving patients’ access to behavioral treatments for chronic pain and addiction. What is not known is if patients are interested in receiving these treatments. In this cross-sectional study, over 1000 participants with chronic pain were surveyed using an anonymous online questionnaire on Amazon Mechanical Turk (Mturk) to investigate participants’ use of and interest in pharmacological and behavioral treatments for chronic pain and addiction. Participants also indicated whether their doctor had recommended these treatments. The majority of participants reported using medication for their pain (83.19%) and that their doctor recommended medication (85.05%), whereas fewer participants reported using (67.45%) and being recommended to (62.82%) behavioral treatments. We found 63.67% of participants screened positive for possible opioid misuse; those who screened positive were more interested in receiving behavioral treatments than those who did not screen positive. Participants who received treatment recommendations were more likely to be interested in receiving those treatments as compared to participants who did not. The results suggest that recommendations for behavioral treatments and interest in those treatments are related. Results also suggest that patients endorsing behaviors consistent with opioid misuse are interested in behavioral treatments. Perspective: This study provides information around chronic pain patients’ treatment interests, treatment receipt, and recommendation receipt for behavioral pain management and addiction treatment. This study could help facilitate communication between patients and doctors regarding available treatments for chronic pain and pain treatment-related addiction problems.

BACKGROUND: There is systemic undercoding of medical comorbidities within administrative claims in the Department of Veterans Affairs (VA). This leads to bias when applying claims-based risk adjustment indices to compare outcomes between VA and non-VA settings. Our objective was to compare the accuracy of a medication-based risk adjustment index (RxRisk-VM) to diagnostic claims-based indices for predicting mortality. METHODS: We modified the RxRisk-V index (RxRisk-VM) by incorporating VA and Medicare pharmacy and durable medical equipment claims in Veterans dually-enrolled in VA and Medicare in 2012. Using the concordance (C) statistic, we compared its accuracy in predicting 1 and 3-year all-cause mortality to the following models: demographics only, demographics plus prescription count, or demographics plus a diagnostic claims-based risk index (e.g., Charlson, Elixhauser, or Gagne). We also compared models containing demographics, RxRisk-VM, and a claims-based index. RESULTS: In our cohort of 271,184 dually-enrolled Veterans (mean age=70.5 years, 96.1% male, 81.7% non-Hispanic white), RxRisk-VM (C=0.773) exhibited greater accuracy in predicting 1-year mortality than demographics only (C=0.716) or prescription counts (C=0.744), but was less accurate than the Charlson (C=0.794), Elixhauser (C=0.80), or Gagne (C=0.810) indices (all P

Background In 2012, select Veterans Health Administration (VHA) facilities implemented a homeless-tailored medical home model, called Homeless Patient Aligned Care Teams (H-PACT), to improve care processes and outcomes for homeless Veterans. Objective The main aim of this study was to determine whether H-PACT offers a better patient experience than standard VHA primary care. Research design We used multivariable logistic regressions to estimate differences in the probability of reporting positive primary care experiences on a national survey. Subjects Homeless-experienced survey respondents enrolled in H-PACT (n=251) or standard primary care in facilities with H-PACT available (n=1527) and facilities without H-PACT (n=10,079). Measures Patient experiences in 8 domains from the Consumer Assessment of Healthcare Provider and Systems surveys. Domain scores were categorized as positive versus nonpositive. Results H-PACT patients were less likely than standard primary care patients to be female, have 4-year college degrees, or to have served in recent military conflicts; they received more primary care visits and social services. H-PACT patients were more likely than standard primary care patients in the same facilities to report positive experiences with access [adjusted risk difference (RD)=17.4], communication (RD=13.9), office staff (RD=13.1), provider ratings (RD=11.0), and comprehensiveness (RD=9.3). Standard primary care patients in facilities with H-PACT available were more likely than those from facilities without H-PACT to report positive experiences with communication (RD=4.7) and self-management support (RD=4.6). Conclusions Patient-centered medical homes designed to address the social determinants of health offer a better care experience for homeless patients, when compared with standard primary care approaches. The lessons learned from H-PACT can be applied throughout VHA and to other health care settings.

e24124 Background: The aims of this study were to examine; the predictors of perceived stress; and the associations between perceived stress and tumor growth and development of metastases as well as the mediational role of inflammatory biomarkers. Methods: This study is prospective in design. A battery of questionnaires, including a sociodemographic characteristic and the Perceived Stress Scale, was collected at baseline from patients diagnosed with solid tumors at various stages of treatment. Disease progression was measured over a 12-month period. Poverty threshold was determined using the U.S. Department of Health & Human Services 2020 poverty guidelines. Computerized tomography and Magnetic Resonance Imaging scans were assessed for disease progression between baseline and 12 months using Response Evaluation Criteria in Solid Tumors. Blood was collected and serum levels of IL-2, IL-1a, IL-1b, TNF-a, IL-6, and IL-8 were assessed. The predictors of stress include sociodemographic and disease specific characteristics. Primary outcomes were tumor growth and development of metastases. Descriptive statistics, correlations, and ordinal and linear regression were performed to assess the aims. Results: Of 159 patients diagnosed with cancer, 47.8% were male, mean age was 62.97 (SD = 10.35), 89.3% were Caucasian, and 13.8% met poverty guidelines. Significant predictors of stress were age (b=-.151, p=0.029, 95% C.I.=-2.86-.016) and income below the poverty threshold (b= 5.615, p=0.007, 95% C.I.=1.596-9.635). Gender was the only sociodemographic and disease specific factor significantly associated with disease progression. After adjusting for gender, greater perceived stress was associated with tumor growth and development of metastases (p =0.029), accounting for 33.3% of the variance. Circulating cytokines were significantly related to disease progression [IL-1a, p=0.020; IL-1b, p=0.011; IL-6, p

BACKGROUND Patient-Centered Medical Homes (PCMH) may be effective in managing care for racial/ethnic minorities with mental health and/or substance use disorders (MHSUDs). How such patients experience care in PCMH settings is relatively unknown.

Objectives The emergency department (ED) is characterized by stressors (e.g., fatigue, stress, time pressure, and complex decision-making) that can pose challenges to delivering high-quality, equitable care. Although it has been suggested that characteristics of the ED may exacerbate reliance on cognitive heuristics, no research has directly investigated whether stressors in the ED impact physician racial bias, a common heuristic. We seek to determine if physicians have different levels of implicit racial bias post-ED shift versus preshift and to examine associations between demographics and cognitive stressors with bias. Methods This repeated-measures study of resident physicians in a pediatric ED used electronic pre- and postshift assessments of implicit racial bias, demographics, and cognitive stressors. Implicit bias was measured using the Race Implicit Association Test (IAT). Linear regression models compared differences in IAT scores pre- to postshift and determined associations between participant demographics and cognitive stressors with postshift IAT and pre- to postshift difference scores. Results Participants (n = 91) displayed moderate prowhite/antiblack bias on preshift (mean ± SD = 0.50 ± 0.34, d = 1.48) and postshift (mean ± SD = 0.55 ± 0.39, d = 1.40) IAT scores. Overall, IAT scores did not differ preshift to postshift (mean increase = 0.05, 95% CI = –0.02 to 0.14, d = 0.13). Subanalyses revealed increased pre- to postshift bias among participants working when the ED was more overcrowded (mean increase = 0.09, 95% CI = 0.01 to 0.17, d = 0.24) and among those caring for >10 patients (mean increase = 0.17, 95% CI = 0.05 to 0.27, d = 0.47). Residents' demographics (including specialty), fatigue, busyness, stressfulness, and number of shifts were not associated with postshift IAT or difference scores. In multivariable models, ED overcrowding was associated with greater postshift bias (coefficient = 0.11 per 1 unit of NEDOCS score, SE = 0.05, 95% CI = 0.00 to 0.21). Conclusions While resident implicit bias remained stable overall preshift to postshift, cognitive stressors (overcrowding and patient load) were associated with increased implicit bias. Physicians in the ED should be aware of how cognitive stressors may exacerbate implicit racial bias.

Background Overlapping use of opioids and benzodiazepines is associated with increased risk for overdose. Veterans receiving medications concurrently from the U.S. Department of Veterans Affairs (VA) and Medicare may be at higher risk for such overlap. Objective To assess the association between dual use of VA and Medicare drug benefits and receipt of overlapping opioid and benzodiazepine prescriptions. Design Cross-sectional. Setting VA and Medicare. Participants All veterans enrolled in VA and Medicare Part D who filled at least 2 opioid prescriptions in 2013 (n = 368 891). Measurements Outcomes were the proportion of patients with a Pharmacy Quality Alliance (PQA) measure of opioid-benzodiazepine overlap (≥2 filled prescriptions for benzodiazepines with ≥30 days of overlap with opioids) and the proportion of patients with high-dose opioid-benzodiazepine overlap (≥30 days of overlap with a daily opioid dose >120 morphine milligram equivalents). Augmented inverse probability weighting regression was used to compare these measures by prescription drug source: VA only, Medicare only, or VA and Medicare (dual use). Results Of 368 891 eligible veterans, 18.3% received prescriptions from the VA only, 30.3% from Medicare only, and 51.4% from both VA and Medicare. The proportion with PQA opioid-benzodiazepine overlap was larger for the dual-use group than the VA-only group (23.1% vs. 17.3%; adjusted risk ratio [aRR], 1.27 [95% CI, 1.24 to 1.30]) and Medicare-only group (23.1% vs. 16.5%; aRR, 1.12 [CI, 1.10 to 1.14]). The proportion with high-dose overlap was also larger for the dual-use group than the VA-only group (4.7% vs. 2.3%; aRR, 2.23 [CI, 2.10 to 2.36]) and Medicare-only group (4.7% vs. 2.9%; aRR, 1.06 [CI, 1.02 to 1.11]). Limitation Data are from 2013 and cannot capture medications purchased without insurance; unmeasured confounding may remain in this cross-sectional study. Conclusion Among a national cohort of veterans dually enrolled in VA and Medicare, receiving prescriptions from both sources was associated with greater risk for receiving potentially unsafe overlapping prescriptions for opioids and benzodiazepines. Primary Funding Source U.S. Department of Veterans Affairs.

Key Points Question Is positive psychology effective as a treatment for chronic arthritis pain and does it reduce race disparities in pain management? Findings In this randomized clinical trial involving 360 Veterans Affairs patients with chronic pain from osteoarthritis, a 6-week telephone-administered positive psychological intervention did not improve pain or functional difficulty vs a control program. No difference by race was found in the effect of the intervention. Meaning A telephone-administered positive psychological intervention was not associated with improvement in chronic pain or functional difficulty from osteoarthritis for either white or African American patients., Importance Positive psychological interventions for improving health have received increasing attention recently. Evidence on the impact of such interventions on pain, and racial disparities in pain, is limited. Objective To assess the effects of a positive psychological intervention on pain and functional difficulty in veterans with knee osteoarthritis. Design, Setting, and Participants The Staying Positive With Arthritis Study is a large, double-blinded randomized clinical trial powered to detect race differences in self-reported pain in response to a positive psychological intervention compared with a neutral control intervention. Data were collected from 2 urban Veterans Affairs medical centers. Participants included non-Hispanic white and non-Hispanic African American patients aged 50 years or older with a diagnosis of osteoarthritis. Mailings were sent to 5111 patients meeting these criteria, of whom 839 were fully screened, 488 were eligible, and 360 were randomized. Enrollment lasted from July 8, 2015, to February 1, 2017, with follow-up through September 6, 2017. Interventions The intervention comprised a 6-week series of evidence-based activities to build positive psychological skills (eg, gratitude and kindness). The control program comprised similarly structured neutral activities. Programs were delivered via workbook and weekly telephone calls with interventionists. Main Outcomes and Measures The primary outcomes were self-reported pain and functional difficulty measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; range 0-100). Secondary outcomes included affect balance and life satisfaction. Results The sample included 180 non-Hispanic white patients and 180 non-Hispanic African American patients (mean [SD] age, 64.2 [8.8] years; 76.4% were male). Mean (SD) baseline scores for WOMAC pain and functional difficulty were 48.8 (17.6) and 46.8 (18.1), respectively. Although both decreased significantly over time (pain: χ23 = 49.50, P, This randomized clinical trial assesses the effects of a positive psychological intervention on pain and functional difficulty vs a control program in veterans with knee osteoarthritis and evaluates whether this management varies by race.

OBJECTIVE: Determine modifiable social and psychological health factors that are associated with use of oral opioid and non-opioid medications for OA. METHODS: Patients were categorized based on use of the following oral medications: opioids (with/without other oral analgesic treatments), non-opioid analgesics, and no oral analgesic treatment. We used multinomial logistic regression models to estimate adjusted relative risk ratios (RRRs) of using an opioid or a non-opioid analgesic (vs. no oral analgesic treatment), comparing patients by levels of social support (Medical Outcomes Study scale), health literacy (“How confident are you filling out medical forms by yourself?”), and depressive symptoms (Patient Health Questionnaire-8). Models were adjusted for demographic and clinical characteristics. RESULTS: In this sample (mean age 64.2 years, 23.6% women), 30.6% (n=110) reported taking opioid analgesics for OA, 54.2% (n=195) reported non-opioid use, and 15.3% (n=55) reported no oral analgesic use. Opioid users had lower mean social support scores (10.0 vs. 10.5 vs. 11.9, p=0.007) and were more likely to have moderate-severe depressive symptoms (42.7% vs. 24.1% vs. 14.5%, p