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Nonsuicidal self-injury (NSSI) is a robust predictor of suicide attempts. However, understanding of NSSI and associated treatment utilization among Veterans is limited. Although impairment may be assumed, few studies examine the association between NSSI and psychosocial functioning, a core component of the rehabilitation framework of mental health. In a national survey of Veterans, current NSSI (n = 88) was associated with higher rates of suicidal thoughts and behaviors and more severe psychosocial impairment after adjusting for demographics and probable diagnoses of posttraumatic stress disorder, major depressive disorder, and alcohol use disorder, compared to Veterans without NSSI (n = 979). Only half of Veterans with NSSI were engaged with mental health services, with few appointments attended, suggesting that these Veterans are not receiving treatment interventions. Results underscore the adverse outcomes associated with NSSI. Underutilization of mental health services highlights the importance of screening for NSSI among Veterans to improve psychosocial outcomes. [ABSTRACT FROM AUTHOR]

Background: Empowering Veterans to age in place is a Department of Veterans Affairs priority. Family or unpaid caregivers play an important role in supporting Veterans to achieve this goal. Effectively meeting the needs of Veterans and caregivers requires identifying unmet needs and relevant gaps in resources to address those needs. Methods: Using a modified Socio‐Ecological Model, we developed a prospective longitudinal panel design survey. We randomly selected 20,000 community‐dwelling Veterans enrolled in the Veterans Health Administration (VHA), across five VHA sites. We oversampled Veterans with a higher predicted 2‐year long‐term institutional care (LTIC) risk. Veterans were mailed a packet containing a Veteran survey and a caregiver survey, to be answered by their caregiver if they had one. The Veteran survey assessed the following health‐related domains: physical, mental, social determinants of health, and caregiver assistance. Caregivers completed questions regarding their demographic factors, caregiving activities, impact of caregiving, use of VA and non‐VA services, and caregiver support resources. Follow‐up surveys will be repeated twice at 12‐month intervals for the same respondents. This article describes the HERO CARE survey protocol, content, and response rates. Results: We received responses from 8,056 Veterans and 3,579 caregivers between July 2021 and January 2022, with 95.6% being received via mail. Veteran respondents were mostly males (96.5%), over 65 years of age (94.9%), married (55.0%), Non‐Hispanic White (75.2%), and residing in urban areas (80.7%). Conclusions: This longitudinal survey is unique in its comprehensive assessment of domains relevant to older Veterans stratified by LTIC risk and their caregivers, focusing on social determinants, caregiver support, and the use of caregiver support resources. Survey data will be linked to Centers for Medicare & Medicaid Services and VA data. The results of this study will inform better planning of non‐institutional care services and policy for Veterans and their caregivers. [ABSTRACT FROM AUTHOR]

Objective: The high number of limb injuries among Post-9/11 Veterans and their long-term care pose significant challenges to clinicians. Current follow-up for extremity arterial vascular injury (EVI) is based on guideline-concordant care for treatment of peripheral vascular disease (GCC-PVD), including anticoagulant/antiplatelet or statin therapy and duplex ultrasound. No best practices exist for arterial EVI. Our goal was to determine correlates of GCC-PVD and other care among Post-9/11 Veterans with combat-related arterial EVI.Materials and Methods: We identified Post-9/11 Veterans with arterial EVI who underwent initial limb salvage repair or ligation (e.g., for single-vessel injury) attempt per DoD Trauma Registry validated by chart abstraction. Veterans Health Administration (VHA) data characterized the cohort in the first five years of VHA care. Models predicted (a) GCC-PVD, (b) pain clinic use, (c) mental/behavioral health care, (d) long-term opioid use, and (e) time to complication, controlling for injury severity and type, mental health parameters, and demographics.Results: The 490-Veteran cohort with validated arterial injury was 77% White averaging 25.2 years at injury (range: 18-56). Mechanism of injury was primarily explosive (63%). Veterans had Injury Severity Scores classified as mild (60%), moderate (25%) and severe (15%). Approximately 25% received at least one component of VHA GCC-PVD including 8% arterial ultrasounds, 5% statins, and 11% anticoagulants/antiplatelets; 77% had mental/behavioral healthcare. GCC-PVD, as well as PTSD and substance use disorders, were associated with receipt of mental/behavioral health care. Complications affected 46% of the cohort and were more common among those prescribed 90+ days of opioids or receiving GCC-PVD.Conclusion: Despite injury severity (40% moderate/severe), only 25% of cohort patients received VHA GCC-PVD, and nearly half had complications from their arterial injury. Receiving GCC-PVD appeared to potentiate receiving care for mental and behavioral disorders.Impact: The treatment gap in Veterans with arterial EVI may be due to lack of appropriate guidelines, lack of vascular specialists in VHA or accessing care outside the VHA. Focused study of care options and their outcomes will help define optimal care processes for combat Veterans with arterial EVI. [ABSTRACT FROM AUTHOR]

Purpose: To describe the prevalence of communication disorders in a cohort of 84,377 deployed post-9/11 veterans stratified by blast traumatic brain injury (TBI) exposure. Secondary aim was to evaluate the association between postconcussion symptoms, such as posttraumatic stress disorder, depression, anxiety, insomnia, pain, headache, substance use disorder, and auditory problems, among veterans with and without a communication disorder diagnosis. Method: This is a retrospective study of the prevalence of aphasia, apraxia of speech and dysarthria, cognitivecommunication disorder, fluency, and voice disorders among veterans, stratified by TBI severity and blast status. Data were obtained from the national Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn roster file provided by the Department of Veterans Affairs Office of Public Health and the Veterans Affairs' TBI screening and subsequent comprehensive TBI evaluation. Results: Cognitive-communication disorder was the most prevalent diagnosis, comprising 57.1% of all communication disorder diagnoses, followed by voice disorder (19%) and aphasia (16%). Increased age was significantly associated with higher rates of aphasia, apraxia of speech/dysarthria, and voice disorder. Conclusions: The current study shows that, while the overall total number of communication disorder diagnoses was higher in the blast groups than in the nonblast groups, TBI severity was a more significant risk factor for a diagnosis, with veterans in the more severe groups at a higher risk of being diagnosed with a communication disorder when compared to those with mild TBI and no blast exposure. In order to better inform rehabilitation and clinical management of communication conditions, it is critical to examine the influence of blast and postconcussive symptoms in post-9/ 11 veterans. [ABSTRACT FROM AUTHOR]

Introduction: In the recent conflicts, unprecedented numbers of US service personnel have survived with genitourinary (GU) injury, but few reports have focused on outcomes of these injuries. Outcomes of combat-related GU injury were investigated in wounded US male veterans of Operations Enduring/Iraqi Freedom and New Dawn receiving Veterans Health Administration (VHA) care.Materials and Methods: Department of Defense Trauma Registry (DoDTR) data for male service members injured in theater were linked with VHA electronic health records (EHRs) for veterans who received VHA care at least once from October 2001 through September 2011. Abbreviated Injury Scale scores and International Classification of Diseases-9th Revision-Clinical Modification codes were used to identify GU injuries, severity, and outcomes. Wounded veterans with vs. without GU injury were compared.Results: A total of 12,923 injured veterans were found in both databases; 591 (4.6%) had a GU injury diagnosis in the DoDTR; 18 (3.0% of 591) had a GU injury diagnosis in VHA EHRs. Of the 591 with GU injury, 179 (30.3%) had at least one severe GU injury. The prevalence of both urinary symptoms (6.3% vs. 3.1%; p < 0.0001) and sexual dysfunction (13.5% vs. 7.1%; p < 0.0001) was higher among those with vs. without GU injury, respectively. Traumatic brain injury prevalence was also higher (48.0 % vs. 40.0%; p < 0.0001); post-traumatic stress disorder prevalence was similar between the two groups (51.6% vs. 50.6%).Conclusion: We identified an opportunity to improve the diagnosis and coordination of care for veterans with GU injury. Routine screening and better documentation upon transfer from DoD to VHA care should be implemented to alert multi-specialty care teams to provide care for the urinary, sexual, fertility, and psychological health problems of these patients. [ABSTRACT FROM AUTHOR]

Objectives: To identify and validate trajectories of comorbidity associated with traumatic brain injury in male and female Iraq and Afghanistan war Veterans (IAV). Methods: Derivation and validation cohorts were compiled of IAV who entered the Department of Veterans Affairs (VA) care and received 3 years of VA care between 2002–2011. Chronic disease and comorbidities associated with deployment including TBI were identified using diagnosis codes. A latent class analysis (LCA) of longitudinal comorbidity data was used to identify trajectories of comorbidity. Results: LCA revealed five trajectories that were similar for women and men: (1) Healthy, (2) Chronic Disease, (3) Mental Health, (4) Pain and (5) Polytrauma Clinical Triad (PCT: pain, mental health and TBI). Two additional classes found in men were 6) Minor Chronic and 7) PCT with chronic disease. Among these gender-stratified trajectories, it was found that women were more likely to experience headache (Pain trajectory) and depression (Mental Health trajectory), while men were more likely to experience lower back pain (Pain trajectory) and substance use disorder (Mental Health trajectory). The probability of TBI was highest in the PCT-related trajectories, with significantly lower probabilities in other trajectories. Conclusions: It was found that TBI was most common in PCT-related trajectories, indicating that TBI is commonly comorbid with pain and mental health conditions for both men and women. The relatively young age of this cohort raises important questions regarding how disease burden, including the possibility of neurodegenerative sequelae, will accrue alongside normal age-related decline in individuals with TBI. Additional ‘big data’ methods and a longer observation period may allow the development of predictive models to identify individuals with TBI that are at-risk for adverse outcomes. [ABSTRACT FROM AUTHOR]

U. S. veterans of Iraq and Afghanistan are known to have a high prevalence of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and depression, which are often comorbid and share many symptoms. Attempts to describe this cohort by single diagnoses have limited our understanding of the complex nature of this population. The objective of this study was to identify subgroups of Iraq and Afghanistan veterans (IAVs) with distinct compositions of symptoms associated with TBI, PTSD, and depression. Our cross-sectional, observational study included 303,716 IAVs who received care in the Veterans Health Administration in 2010-2011. Symptoms and conditions were defined using International Classification of Diseases, Ninth Revision codes and symptom-clusters were identified using latent class analysis. We identified seven classes with distinct symptom compositions. One class had low probability of any condition and low health care utilization (HCU) (48 %). Other classes were characterized by high probabilities of mental health comorbidities (14 %); chronic pain and sleep disturbance (20 %); headaches and memory problems (6 %); and auditory problems (2.5 %). Another class had mental health comorbidities and chronic pain (7 %), and the last had high probabilities of most symptoms examined (3 %). These last two classes had the highest likelihood of TBI, PTSD, and depression and were identified as high healthcare utilizers. There are subgroups of IAVs with distinct clusters of symptom that are meaningfully associated with TBI, PTSD, depression, and HCU. Additional studies examining these veteran subgroups could improve our understanding of this complex comorbid patient population. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to examine barriers and facilitators to multimodality chronic pain care among veterans on high-dose opioid analgesics for chronic non-cancer pain. Setting A Veterans Health Administration clinic in San Antonio. Participants Twenty-five veterans taking at least 50 mg morphine equivalent daily oral opioid doses for more than 6 months. Methods Three semi-structured focus groups, each with seven to nine veterans. Interview guide addressed: chronic pain effects on quality of life, attitudes/experiences with multimodality pain care, social support, and interest in peer support. In an iterative process using grounded theory, three reviewers reviewed de-identified transcripts for themes. The theory of planned behavior ( TPB) framework was used to classify barriers and facilitators to multimodal pain management. Main Results The 25 participants had a mean age of 54 years (39-70); 32% were women and 24% non-white. The three TPB dimensions (attitudes, social norms, and perceived behavioral control) were reflected in emergent themes: 1) uncontrollable impact of pain in all aspects of life; 2) reliance on opioids and challenges in obtaining these drugs despite ambivalence about benefits; 3) poor access to and beliefs about non-pharmacologic therapies; 4) frustrations with Department of Veterans Affairs health care; and 5) poor social support and isolation reflected by limited interest in peer support. Conclusions Veterans with chronic pain on long-term opioids hold pervasive attitudes that prevent them from using multimodality pain management options, lack social support and social norms for non-opioid-based pain treatment options, and have poor perceived control due to poor access to multimodality care. [ABSTRACT FROM AUTHOR]

Objectives. We examined the association of posttraumatic stress disorder (PTSD), traumatic brain injury, and chronic pain—the polytrauma clinical triad (PCT)—independently and with other conditions, with suicide-related behavior (SRB) risk among Operation Enduring Freedom (OEF; Afghanistan) and Operation Iraqi Freedom (OIF) veterans. Methods. We used Department of Veterans Affairs (VA) administrative data to identify OEF and OIF veterans receiving VA care in fiscal years 2009–2011; we used International Classification of Diseases, Ninth Revision, Clinical Modification codes to characterize 211 652 cohort members. Descriptive statistics were followed by multinomial logistic regression analyses predicting SRB. Results. Co-occurrence of PCT conditions was associated with significant increase in suicide ideation risk (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.5, 2.4) or attempt and ideation (OR = 2.6; 95% CI = 1.5, 4.6), but did not exceed increased risk with PTSD alone (ideation: OR = 2.3; 95% CI = 2.0, 2.6; attempt: OR = 2.0; 95% CI = 1.4, 2.9; ideation and attempt: OR = 1.8; 95% CI = 1.2, 2.8). Ideation risk was significantly elevated when PTSD was comorbid with depression (OR = 4.2; 95% CI = 3.6, 4.8) or substance abuse (OR = 4.7; 95% CI = 3.9, 5.6). Conclusions. Although PCT was a moderate SRB predictor, interactions among PCT conditions, particularly PTSD, and depression or substance abuse had larger risk increases. ( [ABSTRACT FROM AUTHOR]

Objectives. We evaluated factors associated with suicidal behavior and ideation (SBI) during 3 years of follow-up among 89 995 Veterans Health Administration (VHA) patients who underwent major surgery from October 2005 to September 2006. Methods. We analyzed administrative data using Cox proportional hazards models. SBI was ascertained by International Classification of Disease, 9th Revision codes. Results. African Americans (18% of sample; 16 252)were at an increased risk for SBI (hazard ratio [HR] = 1.21; 95% confidence interval [CI] = 1.10, 1.32), whereas Hispanics were not (HR = 1.10; 95% CI = 0.95, 1.28). Other risk factors included schizophrenia, bipolar disorder, depression, posttraumatic stress disorder, pain disorders, postoperative new-onset depression, and postoperative complications; female gender and married status were protective against SBI. Conclusions. The postoperative period might be a time of heightened risk for SBI among minority patients in the VHA. Tailored monitoring and postoperative management by minority status might be required to achieve care equity. [ABSTRACT FROM AUTHOR]

Objectives To determine the effect of two variables not previously studied in the readmissions literature (frailty-related diagnoses and high-risk medications in the elderly ( HRME)) and one understudied variable (volume of primary care visits in the prior year). Design Retrospective cohort study using data from a study designed to examine outcomes associated with inappropriate prescribing in elderly adults. Setting All Veterans Affairs ( VA) facilities with acute inpatient beds in fiscal year 2006 ( FY06). Participants All veterans aged 65 and older by October 1, 2005, who received VA care at least once per year between October 1, 2004, and September 30, 2006, and were hospitalized at least once during FY06 on a medical or surgical unit. Measurements A generalized linear interactive risk prediction model included demographic and clinical characteristics (mental health and chronic medical conditions, frailty-related diagnoses, number of medications) in FY05; incident HRME in FY06 before index hospitalization or readmission; chronic HRME in FY05; and FY05 emergency department ( ED), hospital, geriatric, palliative, or primary care use. Facility-level variables were complexity, rural versus urban, and FY06 admission rate. Results The mean adjusted readmission rate was 18.3%. The new frailty-related diagnoses variable is a risk factor for readmission in addition to Charlson comorbidity score. Incident HRME use was associated with lower rates of readmission, as were higher numbers of primary care visits in the prior year. Conclusion Frailty-related diagnoses may help to target individuals at higher risk of readmission to receive more-intensive care transition services. HRME use does not help in this targeting. A higher number of face-to-face primary care visits in the prior year, unlike ED and hospital use, correlates with fewer readmissions and may be another avenue for targeting prevention strategies. [ABSTRACT FROM AUTHOR]

Objectives To examine the association between antiepileptic drug ( AED) receipt and suicide-related behavior ( SRB) in older veterans. Design Retrospective database analysis. Setting Veterans Health Administration (VHA) inpatient and outpatient care. Participants Veterans aged 65 and older in 2004 to 2006. Measurements SRB was identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes, and new AED monotherapy was identified using the VHA product variable in pharmacy data. Comorbid conditions and medications were also identified as potential confounders using previously validated algorithms. Cox proportional hazards models controlling for the propensity to receive AEDs examined the association between any AED exposure, specific AEDs, and time to SRB. Results Within the eligible sample of 2.15 million individuals, 332 cases of SRB were found. Overall, 98% of participants were male, and 67% were non-Hispanic white. Affective disorders and severe psychiatric conditions were strongly associated with SRB and were included in the propensity score. AED exposure displayed a significant association with SRB (odds ratio = 4.10, 95% confidence interval ( CI) = 3.85-6.63) after adjusting for propensity to receive AEDs. Stratified analyses found similar results for those with (hazard ratio ( HR) = 4.00, 95% CI = 2.9-5.5) and without ( HR = 4.57, 95% CI = 1.15-18.20) mental health comorbidities. Gabapentin, phenytoin, lamotrigine, levetiracetam, topiramate, and valproate were significantly associated with SRB. Conclusion Exposure to five common AEDs was associated with SRB in older VHA beneficiaries. Given the strong associations between psychiatric comorbidity and SRB, clinicians treating elderly adults should weigh this potential adverse effect into their consideration for treatment of those receiving AEDs. Particular attention should be given to depression and suicidality screening in people prescribed AEDs. [ABSTRACT FROM AUTHOR]

Objectives To describe facility-level variation in two measures of potentially inappropriate prescribing prevalent in Veterans Affairs ( VA) facilities-exposure to high-risk medications in elderly adults ( HRME) and drug-disease interactions ( Rx- DIS)-and to identify facility characteristics associated with high-quality prescribing. Design Cross-sectional. Setting VA Healthcare System. Participants Veterans aged 65 and older with at least one inpatient or outpatient visit in 2005-2006 ( N = 2,023,477; HRME exposure) and a subsample with a history of falls or hip fractures, dementia, or chronic renal failure (n = 305,059; Rx- DIS exposure). Measurements Incident use of any HRME ( iHRME) and incident Rx- DIS ( iRx- DIS) and facility-level rates and facility-level predictors of iHRME and iRx- DIS exposure, adjusting for differences in patient characteristics. Results Overall, 94,692 (4.7%) veterans had iHRME exposure. At the facility level, iHRME exposure ranged from 1.6% at the lowest facility to 12.8% at the highest (median 4.7%). In the subsample, 9,803 (3.2%) veterans had iRx-DIS exposure, with a facility-level range from 1.3% to 5.8% (median 3.2%). In adjusted analyses, veterans seen in facilities with formal geriatric education had lower odds of iHRME (odds ratio ( OR) = 0.86, 95% confidence interval ( CI) = 0.77-0.96) and iRx- DIS ( OR = 0.95, 95% CI = 0.88-1.01). Patients seen in facilities caring for fewer older veterans had greater odds of iHRME ( OR = 1.54, 95% CI = 1.35-1.75) and iRx- DIS exposure ( OR = 1.22, 95% CI = 1.11-1.33). Conclusion Substantial variation in the quality of prescribing for older adults exists across VA facilities, even after adjusting for patient characteristics. Higher-quality prescribing is found in facilities caring for a larger number of older veterans and facilities with formal geriatric education. [ABSTRACT FROM AUTHOR]

The article discusses the development and preliminary validation of a method to assess perceived self-efficacy to complete culturally and age-appropriate life tasks including self-efficacy for life tasks (SELT) among male veterans of Afghanistan and Iraq. It is found that SELT has statistically significant negative correlations with anxiety, depression and being separated from partner.

Objectives To describe the prevalence of unplanned hospitalizations caused by adverse drug reactions ( ADRs) in older veterans and to examine the association between this outcome and polypharmacy after controlling for comorbidities and other patient characteristics. Design Retrospective cohort. Setting Veterans Affairs Medical Centers. Participants Six hundred seventy-eight randomly selected unplanned hospitalizations of older (aged ≥ 65) veterans between October 1, 2003, and September 30, 2006. Measurements Naranjo ADR algorithm, ADR preventability, and polypharmacy (0-4, 5-8, and ≥9 scheduled medications). Results Seventy ADRs involving 113 drugs were found in 68 (10%) hospitalizations of older veterans, of which 25 (36.8%) were preventable. Extrapolating to the population of more than 2.4 million older veterans receiving care during the study period, 8,000 hospitalizations may have been unnecessary. The most common ADRs that occurred were bradycardia (n = 6; beta-blockers, digoxin), hypoglycemia (n = 6; sulfonylureas, insulin), falls (n = 6; antidepressants, angiotensin-converting enzyme inhibitors), and mental status changes (n = 6; anticonvulsants, benzodiazepines). Overall, 44.8% of veterans took nine or more outpatient medications and 35.4% took five to eight. Using multivariable logistic regression and controlling for demographic, health-status, and access-to-care variables, polypharmacy (≥9 and 5-8) was associated with greater risk of ADR-related hospitalization (adjusted odds ratio ( AOR) = 3.90, 95% confidence interval ( CI) = 1.43-10.61 and AOR = 2.85, 95% CI = 1.03-7.85, respectively). Conclusion ADRs, determined using a validated causality algorithm, are a common cause of unplanned hospitalization in older veterans, are frequently preventable, and are associated with polypharmacy. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine the change in use of high-risk medications for the elderly (HRME), as defined by the National Committee on Quality Assurance's Healthcare Effectiveness Data and Information Set (HEDIS) quality measure (HEDIS HRME), by older outpatient veterans over a 3-year period and to identify risk factors for HEDIS HRME exposure overall and for the most commonly used drug classes. DESIGN: Longitudinal retrospective database analysis. SETTING: Outpatient clinics within the Department of Veterans Affairs (VA). PARTICIPANTS: Veterans aged 65 by October 1, 2003, and who received VA care at least once each year until September 30, 2006. MEASUREMENTS: Rates of use of HEDIS HRME overall and according to specific drug classes each year from fiscal year 2004 (FY04) to FY06. RESULTS: In a cohort of 1,567,467, high-risk medication exposure fell from 13.1% to 12.3% between FY04 and FY06 ( P<.001). High-risk antihistamines (e.g., diphenhydramine), opioid analgesics (e.g., propoxyphene), skeletal muscle relaxants (e.g., cyclobenzaprine), psychotropics (e.g., long half-life benzodiazepines), endocrine (e.g., estrogen), and cardiac medications (e.g., short-acting nifedipine) had modest but statistically significant ( P<.001) reductions (range −3.8% to −16.0%); nitrofurantoin demonstrated a statistically significant increase (+36.5%; P<.001). Overall HEDIS HRME exposure was more likely for men, Hispanics, those receiving more medications, those with psychiatric comorbidity, and those without prior geriatric care. Exposure was lower for individuals exempt from copayment. Similar associations were seen between ethnicity, polypharmacy, psychiatric comorbidity, access-to-care factors, and use of individual HEDIS HRME classes. CONCLUSION: HEDIS HRME drug exposure decreased slightly in an integrated healthcare system. Risk factors for exposure were not consistent across drug groups. Future studies should examine whether interventions to further reduce HEDIS HRME use improve health outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify prevalence and risk factors for exposure to drug-disease interactions included in the Healthcare Effectiveness Data and Information Set (HEDIS) Drug-Disease Interaction (Rx-DIS) measure. DESIGN: Cross-sectional retrospective database analysis. SETTING: Outpatient clinics within the Department of Veterans Affairs (VA). PARTICIPANTS: Individuals aged 65 and older who received VA outpatient care between October 1, 2003, and September 30, 2006. MEASUREMENTS: Rx-DIS exposure based on the HEDIS measure was identified in VA patients with dementia, falls, and chronic renal failure using VA pharmacy and administrative databases. Factors associated with Rx-DIS exposure were examined, including demographic, health status, and access-to-care factors, including VA outpatient health services use and copayment status. RESULTS: Of the 305,041 older veterans who met criteria for inclusion, the 1-year prevalence of Rx-DIS exposure was 15.2%; prevalence was 20.2% for dementia, 16.2% for falls, and 8.5% for chronic renal failure. Patients with high disease burden (physical, psychiatric, number of medications) were significantly more likely to have Rx-DIS exposure, regardless of condition. Hispanics and individuals with no copayments were more likely to have Rx-DIS exposure than whites or those with required copayments. There was variation in other predictors based on the type of Rx-DIS. CONCLUSION: The prevalence of Rx-DIS was common in older VA outpatients. Future studies should examine the risk of Rx-DIS exposure on health outcomes using separate analyses for each type of Rx-DIS separately before combining all Rx-DIS into a single measure of exposure. Studies that examine the effectiveness of interventions to reduce Rx-DIS exposure will also be helpful in improving the quality of care for older adults. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine prevalence and resident- and site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants in older Veterans Affairs (VA) Community Living Center (CLC) residents. DESIGN: Longitudinal study. SETTING: One hundred thirty-three VA CLCs. PARTICIPANTS: Three thousand six hundred ninety-two veterans aged 65 and older admitted between January 1, 2004, and June 3, 2005, with long stays (≥90 days). MEASUREMENTS: Prevalence of potential underuse, inappropriate use, and overuse of antidepressants in residents with and without depression (as documented according to International Classification of Diseases, Ninth Revision, Clinical Modification, codes or Depression Rating Scale). RESULTS: Selective serotonin reuptake inhibitors were the most commonly prescribed antidepressant. Of the 877 residents with depression, 25.4% did not receive an antidepressant, suggesting potential underuse. Of residents with depression who received antidepressants, 57.5% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. Of the 2,815 residents who did not have depression, 1,190 (42.3%) were prescribed one or more antidepressants; only 48 (4.0%) of these had a Food and Drug Administration-approved labeled indication, suggesting potential overuse. Overall, only 17.6% of antidepressant use was appropriate (324/1,844). The only consistent resident factor associated with potential underuse and overuse use was taking an antipsychotic without evidence of schizophrenia (underuse: adjusted relative risk ratio (ARRR)=0.56, 95% confidence interval (CI)=0.33-0.94; overuse: adjusted odds ratio=1.52, 95% CI=1.21-1.91). Having moderate to severe pain (ARRR=1.54, 95% CI=1.08-2.20) and the prescribing of an anxiolytic or hypnotic (ARRR=1.33, 95% CI=1.02-1.74) increased the risk of potential inappropriate antidepressant use. CONCLUSION: Potential problems with the use of antidepressants were frequently observed in older U.S. veteran CLC residents. Future studies are needed to examine the true risks and benefits of antidepressant use in CLC and non-VA nursing homes. [ABSTRACT FROM AUTHOR]

Within the Veterans Health Administration (VHA), anthropometric measurements entered into the electronic medical record are stored in local information systems, the national Corporate Data Warehouse (CDW), and in some regional data warehouses. This article describes efforts to examine the quality of weight and height data within the CDW and to compare CDW data with data from warehouses maintained by several of VHA's regional groupings of healthcare facilities (Veterans Integrated Service Networks [VISNs]). We found significantly fewer recorded heights than weights in both the CDW and VISN data sources. In spite of occasional anomalies, the concordance in the number and value of records in the CDW and the VISN warehouses was generally 97% to 99% or greater. Implausible variation in same-day and same-year heights and weights was noted, suggesting measurement or data-entry errors. Our work suggests that the CDW, over time and through validation, has become a generally reliable source of anthropometric data. Researchers should assess the reliability of data contained within any source and apply strategies to minimize the impact of data errors appropriate to their study population. [ABSTRACT FROM AUTHOR]

A letter o the editor is presented which is concerned with the drug choices that are available for older veterans with new onset epilepsy.

Introduction: Chronic pain and post-traumatic stress disorder (PTSD) comorbidity is prevalent among veterans and is associated with increased levels of pain severity and pain-related disability. An improved understanding of the relationship between these co-occurring disorders, in addition to effective integrated treatments, will develop by considering the changes to the PTSD diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The current study examined the relationship between the revised PTSD Checklist for DSM-5 (PCL-5) symptom clusters (i.e., intrusion, avoidance, negative alterations in cognition and mood [NACM], and arousal) and chronic pain measurements (i.e., pain severity, interference, and disability).Materials and Methods: Participants included 103 veterans (ages 26-70, mean = 45.33) participating in a randomized clinical trial examining the efficacy of an interdisciplinary pain management program for chronic musculoskeletal pain. The study was approved by a university system Institutional Review Board and affiliated healthcare system.Results: The participants with a provisional PTSD diagnosis based on PCL-5 responses (N = 76) had significantly greater pain severity, interference, and disability than the participants without a provisional diagnosis (N = 23). Correlations between symptom clusters and pain measurements were mostly significant and positive with varying strengths. The avoidance symptom cluster, however, had relatively weaker correlations with pain measurements and was not significantly associated with the numeric rating scale of pain severity. Path analyses revealed that, after controlling for avoidance symptoms, significant associations remained between NACM and all the pain measurements. After controlling for NACM symptoms, however, there were no significant associations between avoidance symptoms and pain measurements.Conclusion: The current study highlights a need to re-examine the leading theories about the mutual maintenance of these disorders in order to develop effective integrative treatment approaches. PTSD-related avoidance may have a relatively weaker role in co-occurring chronic pain than the other symptom clusters and may have a qualitatively different role than chronic pain-related avoidance. Future research should explore the relationship between the avoidance in PTSD and the avoidance in chronic pain as well as identify which chronic pain measurements are the most useful when examining the relationship between PTSD and chronic pain. The potential impact of trauma-related cognition and mood on chronic pain indicates that this is an important area for intervention and should be considered in the development of integrated treatments for chronic pain and PTSD among veterans. [ABSTRACT FROM AUTHOR]

Objective: To improve urotrauma care by describing veterans' current demographics and needs assessment during transitional care to the Veteran Health Administration (VHA) system.Methods: We utilized our previously identified cohorts obtained from the DoD Trauma Registry data for male service members injured in theater linked with VHA electronic health records. We included veterans who received care at VHA at least once from October 2001 through September 2011 for chart review. We investigate demographics, opportunities for care, combat-related trauma, disability, and associated mental health or urologic conditions specifically at the initial encounter with a VHA healthcare provider.Results: We queried 580 veterans' records in VHA from the linked databases. We idenfied that 141 (24.4%) veterans received addional care outside VHA and 17.1% (n = 99) of charts had insufficient data for injury validation. Reference to the urotrauma was mentioned in 72% of VHA initial visits (n = 416/580). The most common urotrauma occurred to the lower/external genitourinary injury (298, 51%). Of all the veterans identified with genitourinary trauma, approximately 28% (n = 160) were referred for urologic consultation, but only 14% were related to the original urotrauma. Ninety percent (522/580) of service members with urotrauma also had a mental health diagnosis, largely post-traumatic stress disorder (PTSD, 70.8%).Conclusions: The majority of men with urotrauma did have contact with VHA, yet there is no systematic approach to baseline assessment or long-term care strategy. However, only a small proportion of DoD-documented urotrauma requires ongoing care. We identified that coordinating care with mental health pathways (PTSD/traumatic brain injury) may be an opportunity to evaluate the long-term effects of urotrauma. [ABSTRACT FROM AUTHOR]