Search

Whether patients receive guideline-concordant opioid therapy (OT) is largely unknown and may vary based on provider and patient characteristics. We assessed the extent to which human immunodeficiency virus (HIV)-infected and uninfected patients initiating long-term (≥90 days) OT received care concordant with American Pain Society/American Academy of Pain Medicine and Department of Veterans Affairs/Department of Defense guidelines by measuring receipt of 17 indicators during the first 6 months of OT. Of 20,753 patients, HIV-infected patients (n = 6,604) were more likely than uninfected patients to receive a primary care provider visit within 1 month (52.0% vs 30.9%) and 6 months (90.7% vs 73.7%) and urine drug tests within 1 month (14.8% vs 11.5%) and 6 months (19.5% vs 15.4%; all P < .001). HIV-infected patients were also more likely to receive OT concurrent with sedatives (24.6% vs 19.6%) and a current substance use disorder (21.6% vs 17.2%). Among both patient groups, only modest changes in guideline concordance were observed over time: urine drug tests and OT concurrent with current substance use disorders increased, whereas sedative coprescriptions decreased (all P s for trend <.001). Over a 10-year period, on average, patients received no more than 40% of recommended care. OT guideline–concordant care is rare in primary care, varies by patient/provider characteristics, and has undergone few changes over time. Perspective The promulgation of OT clinical guidelines has not resulted in substantive changes over time in OT management, which falls well short of the standard recommended by leading medical societies. Strategies are needed to increase the provision of OT guideline–concordant care for all patients. [ABSTRACT FROM AUTHOR]

Advanced hepatic fibrosis was present with nonhazardous alcohol consumption and increased with higher alcohol use categories across groups stratified by HIV and chronic hepatitis C virus (HCV) status. All alcohol use categories were strongly associated with advanced hepatic fibrosis in HIV/HCV-coinfected patients.Background. It is unclear if the risk of liver disease associated with different levels of alcohol consumption is higher for patients infected with human immunodeficiency virus (HIV) or chronic hepatitis C virus (HCV). We evaluated associations between alcohol use categories and advanced hepatic fibrosis, by HIV and chronic HCV status.Methods. We performed a cross-sectional study among participants in the Veterans Aging Cohort Study who reported alcohol consumption at enrollment (701 HIV/HCV-coinfected; 1410 HIV-monoinfected; 296 HCV-monoinfected; 1158 HIV/HCV-uninfected). Alcohol use category was determined by the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) questionnaire and alcohol-related diagnoses and was classified as nonhazardous drinking, hazardous/binge drinking, or alcohol-related diagnosis. Advanced hepatic fibrosis was defined by FIB-4 index >3.25.Results. Within each HIV/HCV group, the prevalence of advanced hepatic fibrosis increased as alcohol use category increased. For each alcohol use category, advanced hepatic fibrosis was more common among HIV-infected than uninfected (nonhazardous: 6.7% vs 1.4%; hazardous/binge: 9.5% vs 3.0%; alcohol-related diagnosis: 19.0% vs 8.6%; P < .01) and chronic HCV-infected than uninfected (nonhazardous: 13.6% vs 2.5%; hazardous/binge: 18.2% vs 3.1%; alcohol-related diagnosis: 22.1% vs 6.5%; P < .01) participants. Strong associations with advanced hepatic fibrosis (adjusted odds ratio [95% confidence interval]) were observed among HIV/HCV-coinfected patients with nonhazardous drinking (14.2 [5.91–34.0]), hazardous/binge drinking (18.9 [7.98–44.8]), and alcohol-related diagnoses (25.2 [10.6–59.7]) compared with uninfected nonhazardous drinkers.Conclusions. Advanced hepatic fibrosis was present at low levels of alcohol consumption, increased with higher alcohol use categories, and was more prevalent among HIV-infected and chronic HCV-infected patients than uninfected individuals. All alcohol use categories were strongly associated with advanced hepatic fibrosis in HIV/HCV-coinfected patients. [ABSTRACT FROM AUTHOR]

Objective Chronic pain is a significant concern for the Veterans Health Administration ( VHA), with chronic pain conditions among those most frequently reported by Operation Enduring Freedom ( OEF)/ Operation Iraqi Freedom ( OIF)/ Operation New Dawn ( OND) veterans. The current study examined VHA electronic medical record data to examine variation in demographics and high prevalence and high impact medical and mental health conditions in order to characterize the differences between patients with persistent pain and no pain. Design A conservative operational definition of chronic or 'persistent pain' based on multiple indicators of pain (i.e., pain intensity ratings, prescription opioids, pain clinic visits, International Classification of Diseases, Ninth Revision codes) was employed. Analyses included the entire roster of longitudinal clinical data on OEF/ OIF/ OND veterans who used VHA care to compare those with persistent pain with those with no clinical evidence of pain. Results Results of logistic regression models suggest that sex, race, education, military variables, body mass index ( BMI), traumatic brain injury ( TBI), and mental health conditions, but not age, reliably discriminate the two groups. Those with persistent pain were more likely to be Black, female, on active duty, enlisted, Army service members, have a high school education or less, and have diagnoses of mood disorders, post-traumatic stress disorder, substance use disorders, anxiety disorders, TBI, and have a BMI consistent with overweight and obesity. Conclusions The operational definition of chronic pain used in this study may have research implications for examining predictors of incident and chronic pain. These data have important clinical implications in that addressing comorbid conditions of persistent pain may improve adaptive coping and functioning in these patients. [ABSTRACT FROM AUTHOR]

Objectives: The VACS Index is highly predictive of all-cause mortality among HIV infected individuals within the first few years of combination antiretroviral therapy (cART). However, its accuracy among highly treatment experienced individuals and its responsiveness to treatment interventions have yet to be evaluated. We compared the accuracy and responsiveness of the VACS Index with a Restricted Index of age and traditional HIV biomarkers among patients enrolled in the OPTIMA study. Methods: Using data from 324/339 (96%) patients in OPTIMA, we evaluated associations between indices and mortality using Kaplan-Meier estimates, proportional hazards models, Harrel’s C-statistic and net reclassification improvement (NRI). We also determined the association between study interventions and risk scores over time, and change in score and mortality. Results: Both the Restricted Index (c = 0.70) and VACS Index (c = 0.74) predicted mortality from baseline, but discrimination was improved with the VACS Index (NRI = 23%). Change in score from baseline to 48 weeks was more strongly associated with survival for the VACS Index than the Restricted Index with respective hazard ratios of 0.26 (95% CI 0.14–0.49) and 0.39(95% CI 0.22–0.70) among the 25% most improved scores, and 2.08 (95% CI 1.27–3.38) and 1.51 (95%CI 0.90–2.53) for the 25% least improved scores. Conclusions: The VACS Index predicts all-cause mortality more accurately among multi-drug resistant, treatment experienced individuals and is more responsive to changes in risk associated with treatment intervention than an index restricted to age and HIV biomarkers. The VACS Index holds promise as an intermediate outcome for intervention research. [ABSTRACT FROM AUTHOR]

Frailty, as measured by the Veterans Aging Cohort Study Index, is an important predictor of fragility fracture in the context of established fracture risk factors. Anemia and increasing age drive this association in a male veteran population.Background. The Veterans Aging Cohort Study (VACS) Index is associated with all-cause mortality in individuals infected with human immunodeficiency virus (HIV). It is also associated with markers of inflammation and may thus reflect physiologic frailty. This analysis explores the association between physiologic frailty, as assessed by the VACS Index, and fragility fracture.Methods. HIV-infected men from VACS were included. We identified hip, vertebral, and upper arm fractures using ICD-9-CM codes. We used Cox regression models to assess fragility fracture risk factors including the VACS Index, its components (age, hepatitis C status, FIB-4 score, estimated glomerular filtration rate, hemoglobin, HIV RNA, CD4 count), and previously identified risk factors for fragility fractures.Results. We included 40 115 HIV-infected male Veterans. They experienced 588 first fragility fractures over 6.0 ± 3.9 years. The VACS Index score (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.11–1.19), white race (HR, 1.92; 95% CI, 1.63–2.28), body mass index (HR, 0.94; 95% CI, .92–.96), alcohol-related diagnoses (HR, 1.65; 95% CI, 1.26–2.17), cerebrovascular disease (HR, 1.95; 95% CI, 1.14–3.33), proton pump inhibitor use (HR, 1.87; 95% CI, 1.54–2.27), and protease inhibitor use (HR, 1.25; 95% CI, 1.04–1.50) were associated with fracture risk. Components of the VACS Index score most strongly associated with fracture risk were age (HR, 1.40; 95% CI, 1.27–1.54), log HIV RNA (HR, 0.91; 95% CI, .88–.94), and hemoglobin level (HR, 0.82; 95% CI, .78–.86).Conclusions. Frailty, as measured by the VACS Index, is an important predictor of fragility fractures among HIV-infected male Veterans. [ABSTRACT FROM AUTHOR]

Background: HIV infection has been associated with an increased risk of fragility fracture. We explored whether or not this increased risk persisted in HIV infected and uninfected men when controlling for traditional fragility fracture risk factors. Methodology/Principal Findings: Cox regression models were used to assess the association of HIV infection with the risk for incident hip, vertebral, or upper arm fracture in male Veterans enrolled in the Veterans Aging Cohort Study Virtual Cohort (VACS-VC). We calculated adjusted hazard ratios comparing HIV status and controlling for demographics and other established risk factors. The sample consisted of 119,318 men, 33% of whom were HIV infected (34% aged 50 years or older at baseline, and 55% black or Hispanic). Median body mass index (BMI) was lower in HIV infected compared with uninfected men (25 vs. 28 kg/m²; p<0.0001). Unadjusted risk for fracture was higher among HIV infected compared with uninfected men [HR: 1.32 (95% CI: 1.20, 1.47)]. After adjusting for demographics, comorbid disease, smoking and alcohol abuse, HIV infection remained associated with an increased fracture risk [HR: 1.24 (95% CI: 1.11, 1.39)]. However, adjusting for BMI attenuated this association [HR: 1.10 (95% CI: 0.97, 1.25)]. The only HIV-specific factor associated with fragility fracture was current protease inhibitor use [HR: 1.41 (95% CI: 1.16, 1.70)]. Conclusions/Significance: HIV infection is associated with fragility fracture risk. This risk is attenuated by BMI. [ABSTRACT FROM AUTHOR]

Background: The number of women serving in the United States military increased during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), leading to a subsequent surge in new women Veterans seeking health care services from the Veterans Administration (VA). The objective of this study was to examine gender differences among OEF/OIF Veterans in utilization of VA outpatient health care services. Methods: Our retrospective cohort consisted of 1,620 OEF/OIF Veterans (240 women and 1380 men) who enrolled for outpatient healthcare at a single VA facility. We collected demographic data and information on military service and VA utilization from VA electronic medical records. To assess gender differences we used two models: use versus nonuse of services (logistic regression) and intensity of use among users (negative binomial regression). Results: In our sample, women were more likely to be younger, single, and non-white than men. Women were more likely to utilize outpatient care services (odds ratio [OR] = 1.47, 95% confidence interval [CI]:1.09, 1.98), but once care was initiated, frequency of visits over time (intensity) did not differ by gender (incident rate ratio [IRR] = 1.07; 95% CI: 0.90, 1.27). Conclusion: Recently discharged OEF/OIF women Veterans were more likely to seek VA health care than men Veterans. But the intensity of use was similar between women and men VA care users. As more women use VA health care, prospective studies exploring gender differences in types of services utilized, health outcomes, and factors associated with satisfaction will be required. [ABSTRACT FROM AUTHOR]

Background: Complementary and integrative health (CIH) approaches have been recommended in national and international clinical guidelines for chronic pain management. We set out to determine whether exposure to CIH approaches is associated with pain care quality (PCQ) in the Veterans Health Administration (VHA) primary care setting. Methods: We followed a cohort of 62,721 Veterans with newly diagnosed musculoskeletal disorders between October 2016 and September 2017 over 1-year. PCQ scores were derived from primary care progress notes using natural language processing. CIH exposure was defined as documentation of acupuncture, chiropractic or massage therapies by providers. Propensity scores (PSs) were used to match one control for each Veteran with CIH exposure. Generalized estimating equations were used to examine associations between CIH exposure and PCQ scores, accounting for potential selection and confounding bias. Results: CIH was documented for 14,114 (22.5%) Veterans over 16,015 primary care clinic visits during the follow-up period. The CIH exposure group and the 1:1 PS-matched control group achieved superior balance on all measured baseline covariates, with standardized differences ranging from 0.000 to 0.045. CIH exposure was associated with an adjusted rate ratio (aRR) of 1.147 (95% confidence interval [CI]: 1.142, 1.151) on PCQ total score (mean: 8.36). Sensitivity analyses using an alternative PCQ scoring algorithm (aRR: 1.155; 95% CI: 1.150–1.160) and redefining CIH exposure by chiropractic alone (aRR: 1.118; 95% CI: 1.110–1.126) derived consistent results. Discussion: Our data suggest that incorporating CIH approaches may reflect higher overall quality of care for patients with musculoskeletal pain seen in primary care settings, supporting VHA initiatives and the Declaration of Astana to build comprehensive, sustainable primary care capacity for pain management. Future investigation is warranted to better understand whether and to what degree the observed association may reflect the therapeutic benefits patients actually received or other factors such as empowering provider-patient education and communication about these approaches. [ABSTRACT FROM AUTHOR]

Deep neural network (DNN) is a powerful technology that is being utilized by a growing number and range of research projects, including disease risk prediction models. One of the key strengths of DNN is its ability to model non-linear relationships, which include covariate interactions. We developed a novel method called interaction scores for measuring the covariate interactions captured by DNN models. As the method is model-agnostic, it can also be applied to other types of machine learning models. It is designed to be a generalization of the coefficient of the interaction term in a logistic regression; hence, its values are easily interpretable. The interaction score can be calculated at both an individual level and population level. The individual-level score provides an individualized explanation for covariate interactions. We applied this method to two simulated datasets and a real-world clinical dataset on Alzheimer's disease and related dementia (ADRD). We also applied two existing interaction measurement methods to those datasets for comparison. The results on the simulated datasets showed that the interaction score method can explain the underlying interaction effects, there are strong correlations between the population-level interaction scores and the ground truth values, and the individual-level interaction scores vary when the interaction was designed to be non-uniform. Another validation of our new method is that the interactions discovered from the ADRD data included both known and novel relationships. [ABSTRACT FROM AUTHOR]

Abstract: The lack of a reliable approach to assess quality of pain care hinders quality improvement initiatives. Rule-based natural language processing algorithms were used to extract pain care quality (PCQ) indicators from documents of Veterans Health Administration primary care providers for veterans diagnosed within the past year with musculoskeletal disorders with moderate-to-severe pain intensity across 2 time periods 2013 to 2014 (fiscal year [FY] 2013) and 2017 to 2018 (FY 2017). Patterns of documentation of PCQ indicators for 64,444 veterans and 124,408 unique visits (FY 2013) and 63,427 veterans and 146,507 visits (FY 2017) are described. The most commonly documented PCQ indicators in each cohort were presence of pain, etiology or source, and site of pain (greater than 90% of progress notes), while least commonly documented were sensation, what makes pain better or worse, and pain's impact on function (documented in fewer than 50%). A PCQ indicator score (maximum = 12) was calculated for each visit in FY 2013 (mean = 7.8, SD = 1.9) and FY 2017 (mean = 8.3, SD = 2.3) by adding one point for every indicator documented. Standardized Cronbach alpha for total PCQ scores was 0.74 in the most recent data (FY 2017). The mean PCQ indicator scores across patient characteristics and types of healthcare facilities were highly stable. Estimates of the frequency of documentation of PCQ indicators have face validity and encourage further evaluation of the reliability, validity, and utility of the measure. A reliable measure of PCQ fills an important scientific knowledge and practice gap. [ABSTRACT FROM AUTHOR]

Introduction: Presence of a firearm is associated with increased risk of violence and suicide. United States military veterans are at disproportionate risk of suicide. Routine healthcare provider screening of firearm access may prompt counseling on safe storage and handling of firearms. The objective of this study was to determine the frequency with which Veterans Health Administration (VHA) healthcare providers document firearm access in electronic health record (EHR) clinical notes, and whether this varied by patient characteristics. Methods: The study sample is a post-9-11 cohort of veterans in their first year of VHA care, with at least one outpatient care visit between 2012-2017 (N = 762,953). Demographic data, veteran military service characteristics, and clinical comorbidities were obtained from VHA EHR. We extracted clinical notes for outpatient visits to primary, urgent, or emergency clinics (total 105,316,004). Natural language processing and machine learning (ML) approaches were used to identify documentation of firearm access. A taxonomy of firearm terms was identified and manually annotated with text anchored by these terms, and then trained the ML algorithm. The random-forest algorithm achieved 81.9% accuracy in identifying documentation of firearm access. Results: The proportion of patients with EHR-documented access to one or more firearms during their first year of care in the VHA was relatively low and varied by patient characteristics. Men had significantly higher documentation of firearms than women (9.8% vs 7.1%; P < .001) and veterans >50 years old had the lowest (6.5%). Among veterans with any firearm term present, only 24.4% were classified as positive for access to a firearm (24.7% of men and 20.9% of women). Conclusion: Natural language processing can identify documentation of access to firearms in clinical notes with acceptable accuracy, but there is a need for investigation into facilitators and barriers for providers and veterans to improve a systemwide process of firearm access screening. Screening, regardless of race/ ethnicity, gender, and age, provides additional opportunities to protect veterans from self-harm and violence. [ABSTRACT FROM AUTHOR]

We examined the effectiveness and safety of a walking program offered as part of cognitive behavioral therapy for chronic pain (CBT-CP). Participants were randomized to 10 weeks of CBT-CP, delivered either in person or by interactive voice response. Participants reported pedometer-measured step counts daily throughout treatment and received a weekly goal to increase their steps by 10% over the prior week's average. Walking-related adverse events (AEs) were assessed weekly. Participants (n = 125) were primarily male (72%), and white (80%) with longstanding pain (median: 11 years). There was no significant difference between treatment groups in rate of change in daily steps, but there was a significant increase in steps from baseline to treatment termination in the combined study sample (1648 steps (95% CI 1063–2225)). Participants classified as active doubled. AEs were mostly minor and temporary. Treatment was effective and safe whether the program was delivered in-person or remotely. Trial registration number: clinicaltrials.gov identifier: NCT01025752. [ABSTRACT FROM AUTHOR]

Co-morbidity between medical and psychiatric conditions is commonly considered between individual pairs of conditions. However, an important alternative is to consider all conditions as part of a co-morbidity network, which encompasses all interactions between patients and a healthcare system. Analysis of co-morbidity networks could detect and quantify general tendencies not observed by smaller-scale studies. Here, we investigate the comorbidity network derived fromlongitudinal healthcare records from approximately 1 million United States military veterans, a population disproportionately impacted by psychiatric morbidity and psychological trauma. Network analyses revealed marked and heterogenous patterns of co-morbidity, including a multi-scale community structure composed of groups of commonly co-morbid conditions. Psychiatric conditions including posttraumatic stress disorder were strong predictors of future medical morbidity. Neurological conditions and conditions associated with chronic pain were particularly highly co-morbid with psychiatric conditions. Across conditions, the degree of co-morbidity was positively associated with mortality. Co-morbidity was modified by biological sex and could be used to predict future diagnostic status, with out-of-sample prediction accuracy of 90-92%. Understanding complex patterns of disease co-morbidity has the potential to lead to improved designs of systems of care and the development of targeted interventions that consider the broader context of mental and physical health. [ABSTRACT FROM AUTHOR]

Background: We compared male and female American veterans with schizophrenia or bipolar disorder regarding clinical characteristics associated with lifetime suicidal ideation and behavior. Subsequent mortality, including death by suicide, was also assessed.Methods: Data from questionnaires and face-to-face evaluations were collected during 2011-2014 from 8,049 male and 1,290 female veterans with schizophrenia or bipolar disorder. In addition to comparing male-female characteristics, Cox regression models-adjusted for demographic information, medical-psychiatric comorbidities, and self-reported suicidal ideation and behavior-were used to examine gender differences in associations of putative risk factors with suicide-specific and all-cause mortality during up to six years of follow-up.Results: Women overall were younger, more likely to report a history of suicidal behavior, less likely to be substance abusers, and had lower overall mortality during follow-up. Among women only, psychiatric comorbidity was paradoxically associated with lower all-cause mortality (hazard ratio [HR]=0.53, 95% CI, 0.29-0.96, p = 0.037 for 1 disorder vs. none; HR=0.44, 95% CI, 0.25-0.77, p = 0.004 for ≥2 disorders vs. none). Suicide-specific mortality involved relatively few events, but crude rates were an order of magnitude higher than in the U.S. general and overall veteran populations.Limitations: Incomplete cause-of-death information and low statistical power for male-female comparisons regarding mortality.Conclusions: Female veterans with SMI differed from females in the general population by having a higher risk of suicide attempts. They also had more lifetime suicide attempts than male veterans with same diagnoses. These differences should inform public policy and clinical planning. [ABSTRACT FROM AUTHOR]

Introduction: Infrequent use of and poor retention on evidence-based medications for alcohol use disorder (MAUD) represent a treatment gap, particularly among people living with HIV (PLWH). We examined predictors of MAUD initiation and retention across HIV status.Methods: From Veterans Aging Cohort Study (VACS) data, we identified new alcohol use disorder (AUD) diagnoses from 1998 to 2015 among 163,339 individuals (50,826 PLWH and 112,573 uninfected, matched by age, sex, and facility). MAUD initiation was defined as a prescription fill for naltrexone, acamprosate or disulfiram within 30 days of a new diagnosis. Among those who initiated, retention was defined as filling medication for ≥80% of days over the following six months. We used multivariable logistic regression to assess patient- and facility-level predictors of AUD medication initiation across HIV status.Results: Among 10,603 PLWH and 24,424 uninfected individuals with at least one AUD episode, 359 (1.0%) initiated MAUD and 49 (0.14%) were retained. The prevalence of initiation was lower among PLWH than those without HIV (adjusted odds ratio [AOR] 0.66, 95% confidence interval [CI] 0.51-0.85). Older age (for PLWH: AOR 0.78, 95% CI 0.61-0.99; for uninfected: AOR 0.70, 95% CI 0.61-0.80) and black race (for PLWH: AOR 0.63, 95% CI 0.0.49-0.1.00; for uninfected: AOR 0.63, 95% CI 0.48-0.83), were associated with decreased odds of initiation for both groups. The low frequency of retention precluded multivariable analyses for retention.Conclusions: For PLWH and uninfected individuals, targeted implementation strategies to expand MAUD are needed, particularly for specific subpopulations (e.g. black PLWH). [ABSTRACT FROM AUTHOR]

Objective: To examine the association of dual use of both Veterans Health Administration (VHA) and Medicare benefits with high-risk opioid prescriptions among Veterans aged 65 years and older with a musculoskeletal disorder diagnosis.Data Sources/study Setting: Data were obtained from the VA Musculoskeletal Disorder (MSD) cohort and national Medicare claims data from 2008 to 2010.Study Design: We conducted a retrospective analysis of Veterans enrolled in Medicare to examine the association of dual use with long-term opioid use (>90 days of prescription opioids/year) and overlapping opioid prescriptions. Multivariable logistic regression was performed adjusting for demographic and clinical characteristics.Data Collection/extraction Methods: We identified 21,111 Veterans enrolled in Medicare who entered the MSD cohort in 2008 and received an opioid prescription in 2010. We linked VHA data with Medicare claims data to identify opioid prescriptions for these Veterans in 2010.Principal Findings: As compared to Veterans who used only VHA or Medicare, Veterans with dual use of VHA and Medicare were significantly more likely to be prescribed long-term opioid therapy (OR = 4.61 (95 percent CI 4.05-5.25) and were also found to have higher median number of opioid prescriptions and higher odds of overlapping opioid prescriptions in 1 year. Patients reporting moderate-to-severe pain, non-white-race/ethnicity, and higher scoring on the Charlson comorbidity index had significantly higher odds of long-term opioid prescriptions.Conclusions: Among Veterans aged 65 years or older, dual use of both VHA and Medicare was associated with higher odds of long-term opioid therapy. Our findings suggest there may be benefit to combining VHA and non-VHA electronic health record data to minimize exposure to high-risk opioid prescribing. [ABSTRACT FROM AUTHOR]

Background: Veterans are disproportionately affected by overweight/obesity and growing evidence suggests that post-deployment is a critical period of accelerated weight gain.Objective: We explored the relationship between posttraumatic stress disorder (PTSD) diagnosis, gender, and post-deployment weight trajectories among U.S. Operations Iraqi Freedom, Enduring Freedom, and New Dawn veterans.Design: We used Veterans Affairs electronic health record data from 248,089 veterans (87% men) who, after their last deployment, had at least one medical visit between October 2001 and January 2009 and more than one BMI recorded through September 2010. We analyzed repeated BMI measurements using linear mixed models, with demographics, PTSD and other relevant psychiatric diagnoses as predictors.Results: At the first recorded BMI, veterans' median age was 29, and 59% of women and 77% of men were overweight/obese. They had a median of 6 BMI measurements during a median follow-up of 2.4 years. Controlling for potential confounders, women with a PTSD diagnosis had a yearly BMI growth rate of 0.11 kg/m2 (95% CI 0.09 to 0.13, p < 0.001) higher than women without PTSD. For men, the corresponding PTSD effect was also significant, but slightly lower: 0.07 kg/m2 ((95% CI 0.05 to 0.09, p < 0.001); women-men difference: 0.03 (95% CI 0.01 to 0.06) kg/m2, p = 0.006).Conclusions: The post-deployment period is critical for weight gain, particularly for veterans diagnosed with PTSD and women veterans with PTSD. Efforts are needed to engage post-deployment veterans in weight management services, and to determine whether tailored recruitment/treatment interventions will reduce disparities for veterans with PTSD. [ABSTRACT FROM AUTHOR]

Background Studies suggest that women may be at greater risk for developing chronic pain and pain-related disability. Methods Because musculoskeletal disorders (MSD) are the most frequently endorsed painful conditions among veterans, we sought to characterize gender differences in sociodemographic and clinical correlates among veterans upon entry into Veterans Health Administration's Musculoskeletal Disorders Cohort ( n = 4,128,008). Results Women were more likely to be younger, Black, unmarried, and veterans of recent conflicts. In analyses adjusted for gender differences in sociodemographics, women were more likely to have diagnoses of fibromyalgia, temporomandibular disorders, and neck pain. Almost one in five women (19.4%) had more than one MSD diagnosis, compared with 15.7% of men; this higher risk of MSD multimorbidity remained in adjusted analyses. Adjusting for sociodemographics, women with MSD were more likely to have migraine headache and depressive, anxiety, and bipolar disorders. Women had lower odds of cardiovascular diseases, substance use disorders, and several MSDs, including back pain conditions. Men were more likely to report “no pain” on the pain intensity Numeric Rating Scale, whereas more women (41%) than men (34%) reported moderate to severe pain (Numeric Rating Scale 4+). Conclusions Because women veterans are more likely to have conditions such as fibromyalgia and mental health conditions, along with greater pain intensity in the setting of MSD, women-specific pain services may be needed. [ABSTRACT FROM AUTHOR]

Purpose: For patients receiving long-term opioid therapy (LtOT), the impact of guideline-concordant care on important clinical outcomes--notably mortality--is largely unknown, even among patients with a high comorbidity and mortality burden (e.g., HIV-infected patients). Our objective was to determine the association between receipt of guideline-concordant LtOT and 1-year all-cause mortality.Methods: Among HIV-infected and uninfected patients initiating LtOT between 2000 and 2010 through the Department of Veterans Affairs, we used Cox regression with time-updated covariates and propensity-score matched analyses to examine the association between receipt of guideline-concordant care and 1-year all-cause mortality.Results: Of 17,044 patients initiating LtOT between 2000 and 2010, 1048 patients (6%) died during 1 year of follow-up. Patients receiving psychotherapeutic co-interventions (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.51-0.75; P < 0.001) or physical rehabilitative therapies (HR 0.81; 95% CI 0.67-0.98; P = 0.03) had a decreased risk of all-cause mortality compared to patients not receiving these services, whereas patients prescribed benzodiazepines concurrent with opioids had a higher risk of mortality (HR 1.39; 95% CI 1.12-1.66; P < 0.001). Among patients with a current substance use disorder (SUD), those receiving SUD treatment had a lower risk of mortality than untreated patients (HR 0.47; 95% CI 0.32-0.68; P = < 0.001). No association was found between all-cause mortality and primary care visits (HR 1.12; 95% CI 0.90-1.26; P = 0.32) or urine drug testing (HR 0.96; 95% CI 0.78-1.17; P = 0.67).Conclusions: Providers should use caution in initiating LtOT in conjunction with benzodiazepines and untreated SUDs. Patients receiving LtOT may benefit from multi-modal treatment that addresses chronic pain and its associated comorbidities across multiple disciplines. [ABSTRACT FROM AUTHOR]

Abstract: Background: We sought to determine the prevalence and correlates of suicidal ideation (SI) among Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans following the Department of Veterans Affairs′ (VA) 2007 implementation of required brief SI assessments for veterans who screen positive for depression and post-traumatic stress disorder. Methods: We retrospectively identified OEF/OIF veterans screened for depression using the Patient Health Questionnaire (PHQ-2) between April 2008 and September 2009 at three geographically-distinct VA Medical Centers′ primary care or mental health clinics. Veteran responses to a two-item risk assessment tool (VA Pocket Card) or PHQ-9 9th item, administered following a positive depression screen (PHQ-2≥3), were determined using manual chart review. Generalized estimating equations were used to calculate adjusted odds ratios for demographic and clinical correlates of positive SI assessments. Results: Of 1340 OEF/OIF veterans with positive depression screens, 32.4% reported SI. In multivariate models, odds of SI were lower for non-Hispanic white veterans (AOR=0.68) and greater for those with PHQ-2≥5 (AOR=1.87), depression (AOR=1.45), bipolar disorder/schizophrenia (AOR=2.84), and 2 or ≥3 diagnoses (AORs=1.59 and 2.49, respectively). Limitations: Study findings may not be generalizable to non-veteran patient populations and the study does not address the reliability and validity of tools employed for brief suicidal ideation assessment. Conclusions: SI is common among OEF/OIF veterans who receive VA care, perhaps more so among non-white veterans. Targeting veterans with higher PHQ-2 scores for SI assessment should be considered to reduce patient and administrative burden. [Copyright &y& Elsevier]

• 14.7–16.5% Veterans without mental health diagnosis report recent suicidal ideation. • MST is reported by 27.9% and 2.9% of these women and men, respectively. • RR of MST on SI: 1.65 (95% CI 1.35, 2.00) in women, 1.49 (95% CI 1.26, 1.75) in men. Sexual trauma is a suicide risk factor. While military sexual trauma (MST) is frequently associated with suicidal ideation (SI) in women and men veterans who served in recent conflicts, less is known about MST's relationship to SI in veterans who have no documented mental health concerns. Of the 1.1 million post-9/11 veterans enrolled in the Veterans Healthcare Administration (VHA) we examined 41,658 (12.3% women, 87.7% men) without evidence of mental health diagnosis or treatment and who were screened for MST and SI using the standard VHA clinical reminders between 2008 and 2013. Relative risk estimates were generated using separate models for women and men. MST was reported by 27.9% of women and 2.9% of men; SI by 14.7% and 16.5%, respectively. The adjusted relative risk of MST on SI was 1.65 (95% CI 1.35, 2.00) in women, and 1.49 (95% CI 1.26, 1.75) in men. In this sample of veterans without evidence of mental health diagnosis or treatment, MST was associated with a high risk of SI in both genders. Positive MST screening should prompt SI screening and risk management if indicated, and further study of barriers to mental healthcare among MST survivors at risk for suicide is warranted. [ABSTRACT FROM AUTHOR]

Guideline concordant opioid therapy is a key part of the concerted effort to address the opioid crisis in the United States. The study aimed to compare the rates of guideline concordant care between veterans who solely used VA services (mono users) and veterans who used both VA services and community care (dual-system users). We used electronic health record data from the Washington DC and Baltimore VA Medical Centers from 2015 to 2019. We provided descriptive statistics as well as generalized estimating equations models to find associations between mono vs. dual-system users and each guideline outcome, controlling for demographic factors and comorbid conditions. The study found that overall rates of guideline concordant care were high in both mono and dual-system users with over 90% adherence rates for the majority of recommendations. However, there were variations in adherence to specific guidelines, with urine drug screening at initiation being the least commonly followed recommendation (8.9% of mono-user opioid initiators and 11.2% of dual-user initiators). This study also found that there was no consistent pattern of higher guideline adherence in mono vs. dual-system users but did show that through the course of this study (2015-2019) overall rates of guideline concordance increased. Future research will explore additional guideline recommendations and potential coordination issues among dual-system users., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: High suicide rates are documented among persons with bipolar disorder diagnoses and pain diagnoses, but few studies have examined the association of pain with suicide mortality in individuals with comorbid pain and bipolar disorders. This study assessed the association of pain screening and pain severity with suicide mortality among veterans with comorbid bipolar and musculoskeletal disorder (MSD) diagnoses., Methods: A retrospective cohort study was conducted on 168,021 patients within the Veterans Health Administration (VHA) who received an MSD diagnosis from 2000 to 2015 and had a bipolar disorder diagnosis. Pain severity, comorbidities, demographics, and suicide mortality were extracted from VHA databases. Poisson regression examined relative risk of suicide by the presence pain screening and pain severity ratings., Results: Pain was assessed in 72.73 % of veterans. Suicide risk was greater in those not assessed (0.98 % versus 0.77 % in assessed group). However, this result did not persist after adjusting for covariates (RR = 1.06). Among those assessed, higher suicide risk was associated with moderate (RR = 1.10), severe pain (RR = 1.06), and no pain (reference) relative to mild pain (RR = 0.99). Major depression, substance use disorders, and prescribed opioids and benzodiazepines increased risk., Limitations: Data were obtained from medical records; diagnoses were not confirmed via formal assessment, and no information was available on actual medication use or purpose. Over 25 % of the sample were missing pain severity ratings, which could have affected results., Conclusions: Suicide risk factors among persons with bipolar disorder are complex and multifactorial. Providers should prioritize suicide prevention efforts following new onset or worsening pain., Competing Interests: Declaration of competing interest All authors have no conflicts of interest to declare., (Published by Elsevier B.V.)

To examine whether complementary and integrative health approaches mitigate opioid prescriptions for pain and whether the relationship differs by post-dramatic stress disorder (PTSD) diagnosis, we followed 1,993,455 Veterans with musculoskeletal disorders during 2005-2017 using Veterans Healthcare Administration electronic health records. Complementary and integrative health (CIH) approaches were defined as ≥ 1 primary care visits for meditation, Yoga, and acupuncture etc using natural language processing. Opioid prescriptions were ascertained from pharmacy dispensing records. A propensity score was estimated and used to match one control Veteran to each CIH recipient. Over the 2-year follow-up period after the index diagnosis, 140,902 (7.1 %) Veterans received ≥ 1 modalities. Among the matched analytic sample (272,296 Veterans), the likelihood of dispensing opioid prescriptions was significantly lower for Veterans in the CIH group than their controls [adjusted hazard ratio (aHR), 0.45 (95 % Confidence Intervals (CI): 0.44-0.46)]. The association did not differ between Veterans with [aHR: 0.46 (95 % CI: 0.45-0.47)] and without [aHR: 0.44 (95 % CI: 0.43-0.45)] PTSD. In sensitivity analyses, the exposure group had 3.82 (95 % CI: 3.76-3.87) months longer restricted mean survival time to opioid initiation, 2 % (95 % CI: 4 %-1 %) lower morphine equivalent and 17 % lower total days' supply (95 % CI: 18 %-16 %). The relationship remains significant but was attenuated after eliminating waiting time for the exposure group (aHR, 0.63 (95 % CI: 0.62-0.64)). These observations suggest that CIH approaches may help reduce opioid prescriptions for Veterans with musculoskeletal disorders and related pain. The impact of the timing of receiving such approaches warrants further investigation. PERSPECTIVE: This article presents a quasi-experimental investigation into potential benefit of complementary and integrative health approaches (CIH) on de-prescribing opioids. The findings may potentially help clinicians who are seeking non-pharmacological alternative options to manage patient pain and opioid dependence"., Competing Interests: Declaration of Competing Interest The authors have no financial interests/personal relationships which may be considered as potential competing interests to declare., (Copyright © 2024 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine the associations of two measures of minority stress, non-affirmation minority stress and internalized transphobia, with subjective cognitive decline (SCD) among transgender and gender diverse (TGD) veterans., Method: We administered a cross-sectional survey from September 2022 to July 2023 to TGD veterans. The final analytic sample included 3,152 TGD veterans aged ≥45 years. We used a generalized linear model with quasi-Poisson distribution to calculate prevalence ratios (PR) and 95% confidence intervals (CIs) measuring the relationship between non-affirmation minority stress and internalized transphobia and past-year SCD., Results: The mean age was 61.3 years (SD = 9.7) and the majority (70%) identified as trans women or women. Overall, 27.2% ( n  = 857) reported SCD. Adjusted models revealed that TGD veterans who reported experiencing non-affirmation minority stress or internalized transphobia had greater risk of past-year SCD compared to those who did not report either stressor (aPR: 1.09, 95% CI: 1.04-1.15; aPR: 1.19, 95% CI: 1.12-1.27)., Conclusion: Our findings demonstrate that proximal and distal processes of stigma are associated with SCD among TGD veterans and underscore the need for addressing multiple types of discrimination. Above all, these results indicate the lasting sequelae of transphobia and need for systemic changes to prioritize the safety and welfare of TGD people.

Objective: People with HIV (PWH) are at an increased risk of suicide and death from unintentional causes compared with people living without HIV. Broadening the categorization of death from suicide to self-injurious unnatural death (SIUD) may better identify a more complete set of modifiable risk factors that could be targeted for prevention efforts among PWH., Design: We conducted a nested case-control study using data from the Veterans Aging Cohort Study (VACS), a longitudinal, observational cohort of Veterans from 2006-2015. A total of 5036 Veterans with HIV, of whom 461 died by SIUD, were included in the sample., Methods: SIUD was defined using the International Classification of Disease 10 th revision cause of death codes. Cases ( n  = 461) included individuals who died by SIUD (intentional, unintentional, and undetermined causes of death). Controls ( n  = 4575) were selected using incidence density sampling, matching on date of birth ± 1 year, race, sex, and HIV status. SIUD and suicide was estimated using conditional logistic regression., Results: A previous suicide attempt, a diagnosis of an affective disorder, recent use of benzodiazepines, psychiatric hospitalization, and living in the western US significantly increased the risk of suicide and SIUD. Risk factors that appear more important for SIUD than for suicide included a drug use disorder, alcohol use disorder, Hepatitis C, VACS Index 2.0, current smoking, and high pain levels (7-10)., Conclusion: Limiting studies to known suicides obscures the larger public health burden of excess deaths from self-injurious behavior. Our findings demonstrate the benefit of expanding the focus to SIUD for the identification of modifiable risk factors that could be targeted for treatment., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The present study describes intimate partner violence (IPV) perpetration and victimization alongside theoretically associated variables in a sample of lesbian, gay, and bisexual veterans. We conducted bivariate analyses (chi-square tests and independent t test) to examine whether the frequencies of IPV perpetration and victimization varied by demographic characteristics, military sexual trauma, alcohol use, and mental health symptoms. Out of the 69 lesbian, gay, and bisexual (LGB) veterans who answered the questions on IPV, 16 (23.2%) reported some form of IPV victimization in the past year, and 38 (55.1%) reported past-year perpetration. Among the 43 veterans who reported psychological IPV, roughly half (48.9%) reported bidirectional psychological IPV, 39.5% reported perpetration only, and 11.6% reported victimization only. LGB veterans who reported bidirectional psychological IPV in their relationships were younger and reported greater symptoms of posttraumatic stress disorder symptoms and depression. The results presented here call for universal screening of IPV perpetration and victimization to both accurately assess and ultimately intervene among all veterans. Inclusive interventions are needed for all genders and sexual orientations, specifically interventions that do not adhere to gendered assumptions of perpetrators and victims. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objectives: Suicide risk is elevated in lesbian, gay, bisexual, and transgender (LGBT) individuals. Limited data on LGBT status in healthcare systems hinder our understanding of this risk. This study used natural language processing to extract LGBT status and a deep neural network (DNN) to examine suicidal death risk factors among US Veterans. Methods: Data on 8.8 million veterans with visits between 2010 and 2017 was used. A case-control study was performed, and suicide death risk was analyzed by a DNN. Feature impacts and interactions on the outcome were evaluated. Results: The crude suicide mortality rate was higher in LGBT patients. However, after adjusting for over 200 risk and protective factors, known LGBT status was associated with reduced risk compared to LGBT-Unknown status. Among LGBT patients, black, female, married, and older Veterans have a higher risk, while Veterans of various religions have a lower risk. Conclusion: Our results suggest that disclosed LGBT status is not directly associated with an increase suicide death risk, however, other factors (e.g., depression and anxiety caused by stigma) are associated with suicide death risks., Competing Interests: The authors declare that they do not have any conflicts of interest., (Copyright © 2024 Yin, Workman, Blosnich, Brandt, Skanderson, Shao, Goulet and Zeng-Treitler.)

Affecting an estimated 88 million Americans, prediabetes increases the risk for developing type 2 diabetes mellitus (T2DM), and independently, cardiovascular disease, retinopathy, nephropathy, and neuropathy. Nevertheless, little is known about the use of metformin for diabetes prevention among patients in the Veterans Health Administration, the largest integrated healthcare system in the U.S. This is a retrospective observational cohort study of the proportion of Veterans with incident prediabetes who were prescribed metformin at the Veterans Health Administration from October 2010 to September 2019. Among 1,059,605 Veterans with incident prediabetes, 12,009 (1.1%) were prescribed metformin during an average 3.4 years of observation after diagnosis. Metformin prescribing was marginally higher (1.6%) among those with body mass index (BMI) ≥35 kg/m 2 , age <60 years, HbA 1c ≥6.0%, or those with a history of gestational diabetes, all subgroups at a higher risk for progression to T2DM. In a multivariable model, metformin was more likely to be prescribed for those with BMI ≥35 kg/m 2 incidence rate ratio [IRR] 2.6 [95% confidence intervals (CI): 2.1-3.3], female sex IRR, 2.4 [95% CI: 1.8-3.3], HbA 1c ≥6% IRR, 1.93 [95% CI: 1.5-2.4], age <60 years IRR, 1.7 [95% CI: 1.3-2.3], hypertriglyceridemia IRR, 1.5 [95% CI: 1.2-1.9], hypertension IRR, 1.5 [95% CI: 1.1-2.1], Major Depressive Disorder IRR, 1.5 [95% CI: 1.1-2.0], or schizophrenia IRR, 2.1 [95% CI: 1.2-3.8]. Over 20% of Veterans with prediabetes attended a comprehensive structured lifestyle modification clinic or program. Among Veterans with prediabetes, metformin was prescribed to 1.1% overall, a proportion that marginally increased to 1.6% in the subset of individuals at highest risk for progression to T2DM., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The rate of suicide among people with HIV (PWH) remains elevated compared to the general population. The aim of the study was to examine the association between a broad range of risk factors, HIV-specific risk factors, and suicide. We conducted a nested case-control study using data from the Veterans Aging Cohort Study (VACS) between 2006 and 2015. The risk of suicide was estimated using conditional logistic regression and models were stratified by HIV status. Most risk factors associated with suicide were similar between PWH and people without HIV; these included affective disorders, use of benzodiazepines, and mental health treatment. Among PWH, HIV-specific risk factors were not associated with suicide. A multiplicative interaction was observed between a diagnosis of HIV and a previous suicide attempt. Among PWH, a high prevalence of psychiatric, substance use disorders and multimorbidity contribute to the risk of suicide., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Pain assessment is performed in many healthcare systems, such as the Veterans Health Administration, but prior studies have not assessed whether pain screening varies in sexual and gender minority populations that include individuals who identify as lesbian, gay, bisexual, and/or transgender (LGBT)., Objective: The purpose of this study was to evaluate pain screening and reported pain of LGBT Veterans compared to non-LGBT Veterans., Methods: Using a retrospective cross-sectional cohort, data from the Corporate Data Warehouse, a national repository with clinical/administrative data, were analyzed. Veterans were classified as LGBT using natural language processing. We used a robust Poisson model to examine the association between LGBT status and binary outcomes of pain screening, any pain, and persistent pain within one year of entry in the cohort. All models were adjusted for demographics, mental health, substance use, musculoskeletal disorder(s), and number of clinic visits., Results: There were 1,149,486 Veterans (218,154 (19%) classified as LGBT) in our study. Among LGBT Veterans, 94% were screened for pain compared to 89% among those not classified as LGBT (non-LGBT) Veterans. In adjusted models, LGBT Veterans' probability of being screened for pain compared to non-LGBT Veterans was 2.5% higher (95% CI 2.3%, 2.6%); risk of any pain was 2.1% lower (95% CI 1.6%, 2.6%); and there was no significant difference between LGBT and non-LGBT Veterans in persistent pain (RR = 1.00, 95% CI (0.99, 1.01), p = 0.88)., Conclusions: In a nationwide sample, LGBT Veterans were more likely to be screened for pain but had lower self-reported pain scores, though adjusted differences were small. It was notable that transgender and Black Veterans reported the greatest pain. Reasons for these findings require further investigation., Competing Interests: Dr T Elizabeth Workman reports grants from US Department of Veterans Affairs, during the conduct of the study. The authors report no other conflicts of interest in this work., (© 2023 Gordon et al.)

Background and Aims: In deep learning, a major difficulty in identifying suicidality and its risk factors in clinical notes is the lack of training samples given the small number of true positive instances among the number of patients screened. This paper describes a novel methodology that identifies suicidality in clinical notes by addressing this data sparsity issue through zero-shot learning. Our general aim was to develop a tool that leveraged zero-shot learning to effectively identify suicidality documentation in all types of clinical notes., Methods: US Veterans Affairs clinical notes served as data. The training data set label was determined using diagnostic codes of suicide attempt and self-harm. We used a base string associated with the target label of suicidality to provide auxiliary information by narrowing the positive training cases to those containing the base string. We trained a deep neural network by mapping the training documents' contents to a semantic space. For comparison, we trained another deep neural network using the identical training data set labels, and bag-of-words features., Results: The zero-shot learning model outperformed the baseline model in terms of area under the curve, sensitivity, specificity, and positive predictive value at multiple probability thresholds. In applying a 0.90 probability threshold, the methodology identified notes documenting suicidality but not associated with a relevant ICD-10-CM code, with 94% accuracy., Conclusion: This method can effectively identify suicidality without manual annotation., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors. Health Science Reports published by Wiley Periodicals LLC.)