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

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

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

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

Introduction Equitable coronavirus disease 2019 (COVID-19) vaccine access is imperative to addressing disproportionate negative impacts of COVID-19 among racial/ethnic minorities. U.S. racial/ethnic minorities have lower COVID-19 vaccination rates than Whites despite higher COVID-19 death/case rates. The Veterans Health Administration (VA) COVID-19 vaccine rollout provides the unique context of a managed care system with few access barriers. This study aims to evaluate race/ethnicity as a predictor of VA COVID-19 vaccination. Methods The cohort comprised Veteran VA outpatient users aged ≥65 years (N=3,474,874). COVID-19 vaccination was assessed between December 14, 2020 and February 23, 2021 via procedure codes. Multivariable logistic regressions clustered by VA facility were conducted, controlling for demographics, medical comorbidity, and influenza vaccination history. Based on reports of high COVID-19 vaccine uptake among American Indian/Alaska Natives (AI/ANs), proximity to Indian Health Service Contract Health Service Delivery Areas was tested as a moderating variable. Data analyses were conducted during 2021. Results Blacks (OR=1.28, 95% CI=1.17, 1.40), Hispanics (OR=1.15, 95% CI=1.05, 1.25), and Asians (OR=1.21, 95% CI=1.02, 1.43) were more likely than Whites to receive VA COVID-19 vaccinations. AI/ANs were less likely than Whites to receive VA COVID-19 vaccinations, but only those residing in Contract Health Service Delivery Area counties (OR= 0.58, 95% CI= 0.47, 0.72). Influenza vaccine history positively predicted COVID-19 vaccine uptake (OR= 2.28, 95% CI=2.22, 2.34). Conclusions In the VA, compared with the general U.S. population, COVID-19 vaccine receipt is higher among most racial/ethnic minority groups than Whites, suggesting reduced vaccination barriers compared with non-VA care. The Indian Health Service may provide a safety net effective at reaching AI/AN populations. Addressing vaccination access barriers in non-VA settings can potentially reduce racial/ethnic disparities.

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

Introduction: Certain complementary and integrative health (CIH) approaches have increasingly gained attention as evidence-based nonpharmacological options for pain, mental health, and well-being. ...

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

Purpose Racial/ethnic minoritized groups, women, and economically disadvantaged groups are disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic. We investigated racial/ethnic differences by gender in correlates of COVID-19 infection among veterans seeking health care services at the Veterans Health Administration. Little is known about gender-specific factors associated with infection among veterans. This study seeks to fill this gap. Methods The sample was veterans with results from a COVID-19 test (polymerase chain reaction) conducted at Veterans Health Administration facilities between March 1, 2020, and August 5, 2020, and linked to the Centers for Disease Control and Prevention Social Vulnerability Index data (39,223 women and 316,380 men). Bivariate, multivariate logistic, and predicted probability analyses were conducted. All analyses were stratified by gender. Results Similar percentages of women and men tested positive for COVID-19 (9.6% vs. 10.0%). In multivariate analysis, compared with non-Hispanic White women, American Indian/Alaskan Native, Black, and Hispanic women all had significantly higher odds of infection. Similar racial/ethnic differences were found for men. Both older men and women (>40 years) had lower odds of infection, but the age cut points differed (40 for women, 55 for men). Men 80 years and older had a higher odds than those aged less than 40 years of age. For men, but not for women, being employed (vs. unemployed) was associated with an increased odds of infection, and having comorbidities was associated with decreased odds. There were significant differences within and across gender-by-race/ethnicity in infection, after adjusting for covariates. Conclusions American Indian/Alaska Native, Hispanic, and Black women and men veterans are disproportionately impacted by COVID-19 infection. Widespread testing and tracking, education, and outreach regarding COVID-19 mitigation and vaccination efforts are recommended.

Racial/ethnic disparities in coronavirus disease 2019 (COVID-19) hospitalization and mortality have emerged in the United States, but less is known about whether similar differences exist in testing, and how this changed as COVID-19 knowledge and policies evolved. We examined racial/ethnic variations in COVID-19 testing over time among veterans who sought care for COVID-19 symptoms or exposure. In the national population of all Veterans who sought Veterans Health Administration (VHA) care for COVID-19 symptoms or exposure (n = 913,806), we conducted multivariate logistic regressions to explore race/ethnicity-by-time period differences in testing from 3/1/2020–11/25/2020, and calculated predicted probabilities by race/ethnicity and time period. Early in the pandemic (3/1/2020–4/6/2020) when testing was limited and there was less awareness of racial/ethnic disparities, non-Hispanic Black, Hispanic, and other non-White racial/ethnic minority Veterans who sought care from VHA for COVID-19 symptoms or exposure were more likely than non-Hispanic White Veterans to receive a COVID-19 test (p

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

Aim To describe the presence and operationalisation of organisational strategies to support implementation of pressure ulcer prevention programmes across acute care hospitals in a large, integrated health-care system. Background Comprehensive pressure ulcer programmes include nursing interventions such as use of a risk assessment tool and organisational strategies such as policies and performance monitoring to embed these interventions into routine care. The current literature provides little detail about strategies used to implement pressure ulcer prevention programmes. Methods Data were collected by an e-mail survey to all chief nursing officers in Veterans Health Administration acute care hospitals. Descriptive and bivariate statistics were used to summarise survey responses and evaluate relationships between some variables. Results Organisational strategies that support implementation of a pressure ulcer prevention programme (policy, committee, staff education, wound care specialists, and use of performance data) were reported at high levels. Considerable variations were noted in how these strategies were operationalised within individual hospitals. Conclusion Organisational strategies to support implementation of pressure ulcer preventive programmes are often not optimally operationalised to achieve consistent, sustainable performance. Implications for nursing management The results of the present study highlight the role and influence of nurse leaders on pressure ulcer prevention program implementation.

The US Department of Housing and Urban Development (HUD)-VA Supportive Housing (VASH) program-the VA's Housing First effort-is central to efforts to end Veteran homelessness. Yet, little is known about health care utilization patterns associated with achieving HUD-VASH housing.We compare health service utilization at the VA Greater Los Angeles among: (1) formerly homeless Veterans housed through HUD-VASH (HUD-VASH Veterans); (2) currently homeless Veterans; (3) housed, low-income Veterans not in HUD-VASH; and (4) housed, not low-income Veterans.We performed a secondary database analysis of Veterans (n=62,459) who received VA Greater Los Angeles care between October 1, 2010 and September 30, 2011. We described medical/surgical and mental health utilization [inpatient, outpatient, and emergency department (ED)]. We controlled for demographics, need, and primary care use in regression analyses of utilization data by housing and income status.HUD-VASH Veterans had more inpatient, outpatient, and ED use than currently homeless Veterans. Adjusting for demographics and need, HUD-VASH Veterans and the low-income housed Veterans had similar likelihoods of medical/surgical inpatient and outpatient utilization, compared with the housed, not low-income group. Adjusting first for demographics and need (model 1), then also for primary care use (model 2), HUD-VASH Veterans had the greatest decrease in incident rates of specialty medical/surgical, mental health, and ED care from models 1 to 2, becoming similar to the currently homeless, compared with the housed, not low-income group.Our findings suggest that currently homeless Veterans underuse health care relative to housed Veterans. HUD-VASH may address this disparity by providing housing and linkages to primary care.