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BACKGROUND: Veterans Health Administration (VHA) databases are used extensively to study racial/ethnic disparities; however, these databases may not capture all care received by VHA patients. OBJECTIVES: We examined the extent to which accounting for non-VHA care changed conclusions about racial/ethnic disparities for VHA patients with diabetes. METHODS: Using a cross-sectional observational study, we analyzed a national sample of noninstitutionalized Hispanic (n = 5931), black (n = 24,670), and white (n = 149,222) VHA patients with diabetes who were at least 65 years of age for receipt of annual HbA1c testing, low-density lipoprotein (LDL) cholesterol testing, or eye examination from VHA and Medicare administrative files. RESULTS: In VHA alone data, adjusting for patient characteristics, Hispanic and black patients were as likely as white patients to receive HbA1c testing (odds ratio 1.06 [95% confidence interval 0.99-1.13] and 1.04 [1.00-1.07], respectively), and more likely to receive eye examinations (1.31 [1.24-1.38] and 1.33 [1.29-1.37], respectively). Hispanic patients were equally likely (1.01 [0.95-1.07]) and black patients were less likely (0.81 [0.79-0.84]) to receive LDL testing versus white patients. In VHA plus Medicare data, Hispanic and black patients were less likely than white patients to receive HbA1c (0.76 [0.71-0.82] and 0.83 [0.80-0.87], respectively) and LDL testing (0.84 [0.79-0.90] and 0.70 [0.68-0.72], respectively), and equally likely to receive eye examinations (0.91 [0.86-0.96]) and 0.98 [0.95-1.01]), respectively). Accounting for VHA facility had little effect on results. CONCLUSIONS: Restricting to VHA data masks racial/ethnic disparities in care of VHA patients. VHA researchers must be aware and supplement VHA data with other sources whenever possible. [ABSTRACT FROM AUTHOR]

Medical providers often fail to treat depression. We examined whether treatment is more aggressive in a setting with accessible mental health resources, the Veterans Health Administration (VA). VA and non-VA primary care physicians and medical specialists viewed a videotape vignette portraying a patient meeting criteria for major depression and then answered interviewer-administered questions about management. We found that 24% of VA versus 15% of non-VA physicians would initiate guideline-recommended treatment (antidepressants or mental health referral, or both) (P = .09). Among those who identified depression as likely, 42% of VA versus 19% of non-VA physicians would treat (P = .002): 23% versus 3% recommended mental health referral (P < .001) and 21% versus 17% an antidepressant (P = .67). Although many patients with major depression may not receive guideline-recommended management, VA physicians do initiate mental health referral more often than do non-VA physicians. Access to mental health services may prove valuable in the campaign to increase physician adherence to depression clinical guidelines. [ABSTRACT FROM AUTHOR]

Background: Posttraumatic stress disorder (PTSD) is associated with incident diabetes. However, past studies have often included predominantly male samples, despite important sex and gender differences in diabetes. To address this limitation, this study examined the association between PTSD and diabetes in older Veteran women, a population with a high burden of PTSD. Materials and Methods: Data were collected from 4,105 women ( M age = 67.4 years), participating in the Health of Vietnam-Era Veteran Women's Study (HealthViEWS; Department of Veterans Affairs Cooperative Studies Program #579). Participants completed self-report measures of demographics, health conditions, and health behaviors. Information on military service was obtained through service records. A structured clinical interview was conducted by telephone to assess current and lifetime PTSD and other mental health disorders. Weighted descriptive and logistic regression analyses were used to examine associations between PTSD and diabetes. Results: The prevalence of diabetes was 28.4% among women with current full PTSD compared to 23.4%, 17.6%, and 17.5% for current subthreshold, remitted, and no PTSD. In unadjusted analyses, women with current full and subthreshold PTSD were 1.87 [1.49; 2.33] and 1.44 [1.11; 1.85] times more likely to have diabetes compared to women with no PTSD. Remitted PTSD was not associated with increased odds of diabetes. Effects were attenuated but remained significant after adjustment for relevant covariates. Conclusions: Vietnam-era women with current PTSD, including subthreshold symptoms, had a greater likelihood of diabetes compared to women without PTSD. These findings suggest that women with PTSD may benefit from increased diabetes prevention efforts.

Objective: This analysis explored relationships between mental health symptoms and conditions and cognitive function in a cohort of Vietnam-era women veterans from the Health of Vietnam Era Veteran Women's Study (HealthViEWS). Methods: Vietnam-era women veterans completed a mail survey assessing self-reported symptom severity of posttraumatic stress disorder (PTSD) and depression. A telephone-based structured interview assessed mental health conditions and cognitive function (telephone interview for cognitive status [TICS]). Participants were categorized using a TICS threshold of ≤29 to designate possible cognitive impairment versus nonimpaired. Separate logistic regression models were used to determine associations between possible cognitive impairment and each self-reported and interviewer-rated assessment of PTSD and depression while adjusting for age, education, race, marital status, and wartime service location. Results: The sample consisted of 4,077 women veterans who were ≥60 years old and completed the TICS. Of these women, 7.20% were categorized with possible cognitive impairment. Logistic regression models indicated that self-reported PTSD and depression symptom severity were each significantly associated with higher odds of possible cognitive impairment (adjusted odds ratios [aOR]: 1.03 [95% confidence interval [CI]: 1.02-1.04] and 1.07 [95% CI: 1.04-1.09], respectively). Women veterans with a probable diagnosis of depression had higher odds of possible cognitive impairment compared to those without depression (aOR: 1.61 [95% CI: 1.07-2.42]). No association was found for probable diagnosis of PTSD. Conclusions: Although further examination remains necessary, results suggest that Vietnam-era women veterans with self-reported PTSD and depression symptom severity or a probable diagnosis of depression may benefit from screening of cognitive function to inform clinical care.

Competing Interests: Declaration of competing interest The authors have no competing interest to declare.

Context/objective: Excess weight has the potential to carry a substantial physical and emotional burden. A better understanding of perceived consequences of excess weight may facilitate the development of patient-centered programs and interventions to promote weight management efforts in persons with spinal cord injury (SCI). The study objective was to describe consequences of excess weight from the personal perspectives of individuals with SCI., Design: Descriptive qualitative design using in-depth semi-structured interviews and thematic analysis., Setting: Veterans Health Administration (VHA) SCI System of Care., Participants: Individuals with SCI (n-33)., Outcome Measures: Key themes from thematic analysis., Results: Participants were male (61%), ranged from 29 to 84 years of age, and about half had tetraplegia (55%). Five themes were identified that demonstrate negative consequences of excess weight experienced by individuals with SCI, including: (1) physical health conditions (including chronic conditions and SCI secondary conditions), (2) physical symptoms (such as pain, discomfort, and fatigue), (3) movement challenges, (4) appearance-related concerns, and (5) emotional impacts., Conclusions: Carrying excess weight is concerning to individuals with SCI and in terms of consequences such onset or exacerbation of chronic conditions, SCI secondary conditions, physical symptoms, e.g. pain, movement impairment (including hampered mobility, difficult transfers and self-care), image/appearance concerns ( e.g. body image, clothing misfit), and negative emotions ( e.g. unhappy, sad, depressed). Our findings may inform SCI healthcare providers about the consequences of excess weight as experienced by individuals with SCI, highlighting what matters most to persons with SCI and guiding a patient-centered approach to weight management in this population.

Introduction: Over 40 % of United States Veterans Health Administration (VHA) primary care patients have obesity. Few patients use VHA's flagship weight management program, MOVE! and there is little information on other behavioral weight management program use., Methods: The national United States cohort included over 1.5 million primary care patients with obesity, age 18-79, based on VHA administrative data. Gender stratified multivariable logistic regression identified correlates of weight management use in the year after a patient's first primary care appointment (alpha of 0.05). Weight management use was defined as MOVE! or nutrition clinic visits., Results: The cohort included 121,235 women and 1,521,547 men with 13 % and 7 % using weight management, respectively. Point estimates for specific correlates of use were similar between women and men, and across programs. Black patients were more likely to use weight management than White patients. Several physical and mental health diagnoses were also associated with increased use, such as sleep apnea and eating disorders. Age and distance from VHA were negatively associated with weight management use., Conclusions: When assessing multiple types of weight management visits, weight management care in VHA appears to be used more often by some populations at higher risk for obesity. Other groups may need additional outreach, such as those living far from VHA. Future work should focus on outreach and prevention efforts to increase overall use rates. This work could also examine the benefits of tailoring care for populations in greatest need., Competing Interests: Declaration of competing interest All authors declare that they have no conflicts of interest., (Published by Elsevier Ltd.)

Purpose/objective: Nutrition knowledge, beliefs, and behaviors have important implications for managing and preventing chronic and injury-related secondary conditions in persons with spinal cord injuries and disorders (SCI/D). Yet, the unique dietary and nutritional needs and recommendations specific to individuals with SCI/D and their eating beliefs and behaviors have been understudied. Aim is to describe nutrition and eating beliefs and behaviors from the perspectives of individuals with SCI/D., Research Method/design: Descriptive qualitative design using in-depth semistructured interviews with a national sample of veterans with SCI/D ( n = 33). Audio-recorded and transcribed verbatim transcripts were coded and analyzed using thematic analysis., Results: Participants were male (61%), aged 29-84 years, and 55% had tetraplegia. Five key themes were identified: extreme fasting/caloric restriction, perceived healthy eating behaviors, perceived unhealthy eating behaviors, modified eating behaviors due to SCI/D-related symptoms, and food/preparation choices based on abilities/independence and access., Conclusions/implications: Nutrition among veterans with SCI/D may be impacted by many factors, such as nutrition knowledge and beliefs/behaviors about "healthy" and "unhealthy" nutrition, fasting, caloric restriction, imbalanced intake of macro- and micronutrients, overconsumption relative to energy needs, injury-related secondary complications, postinjury body composition and function changes, impairments related to satiety and hunger signals, and difficulty in obtaining and preparing food. Study findings provide many areas that would benefit from intervention. Findings can be used to inform ideal nutrition and healthy eating beliefs and behaviors which are important because nutritional inadequacies can lead to diet-related diseases, may exacerbate SCI secondary conditions, and lead to poor overall health. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Purpose: We sought to describe factors influencing reduced rates of obesity screening for patients with spinal cord injury (SCI) in the United States Veterans Health Administration (VA) and to foster potential solutions., Materials and Methods: Semi-structured interviews with healthcare providers and patients with SCI who were recruited nationally from diverse VAs. We performed rapid qualitative analysis using content analysis of interview data., Results: There were 36 providers and 37 patients. We identified provider, patient, and system level barriers to obesity screening for individuals with SCI. Overarching barriers involved provider and patient perceptions that obesity screening is a low priority compared to other health conditions, and body mass index is of low utility. Other obesity screening barriers were related to measuring weight (i.e., insufficient equipment, unknown wheelchair weight, staffing shortages, measurement errors, reduced access to annual screening, insufficient time, patient preference not to be weighed) and measuring height (i.e., insufficient guidance and equipment to this population, measurement errors)., Conclusions: Barriers to obesity screenings exist for patients with SCI receiving care in VA. Healthcare provider and patient interviews suggest possible solutions, including standardizing height and weight measurement processes, ensuring equipment availability in clinics, clarifying guidelines, and offering support to providers and patients.IMPLICATIONS FOR REHABILITATIONIndividuals with spinal cord injury (SCI) have higher rates of obesity, but are often overlooked for annual obesity screening, even in clinic settings designed to care for individuals with SCI.Results may help tailor guidelines/education for healthcare and rehabilitation providers offering them guidance for improving obesity screening for individuals with SCI by standardizing weight and height measurement and documentation. To facilitate this, findings highlight the need for resources, such as ensuring clinics have necessary equipment, and increasing patient access to support and equipment.Improving the provision of obesity screening for individuals with SCI is necessary to improve health outcomes and patient satisfaction with care.

Background: Almost 40% of Veterans Health Administration (VHA) users have obesity. VHA's national weight management program is associated with weight loss and improved health. However, while 94% of eligible VHA users are offered weight management programs, <8% use them. We developed EMBER - a novel, Motivational Interviewing-based, self-help tool - with the goal of Enhancing Motivation for Better Engagement and Reach for weight management. EMBER is not a weight management program; instead it engages people in existing programs by informing and guiding choices about weight management., Methods: The EMBER Trial is a randomized hybrid type 1 effectiveness implementation trial. Participants are Palo Alto or Houston VA Health Care System users with obesity who have not used a VHA weight management program in the past two years (target N = 470). Participants are randomly assigned to EMBER or an information-only control condition, after which they receive materials on paper or digitally, per their preference. The trial's primary goal is to determine whether participants randomized to EMBER are more likely to have any weight management engagement at two-month follow-up compared to those in the control condition. Secondary outcomes include 6-month retention in weight management, weight management behaviors, weight loss, quality of life, and implementation outcomes (e.g., reach, appropriateness)., Conclusion: EMBER is the first self-directed, Motivational Interviewing-based intervention designed to increase weight management program engagement. The study takes a low-touch, population health approach that could be modified for other programs if effective. The Hybrid Type 1 design will ensure results can be scaled and sustained., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Inc.)

Introduction: Application of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate workforce education and training programs targeting clinical health care staff has received relatively little attention. This paper aims to contribute to this area with RE-AIM findings from a women's health-focused workforce training program implemented by the U.S. Department of Veterans Affairs (VA). Over the past two decades, the rapid expansion of the women Veteran population in VA has necessitated a quick response to meet clinical demand. To address this health care need, the VA Offices of Rural Health (ORH) and Women's Health (OWH) partnered to deploy a primary care workforce development initiative for Rural Providers and Nurses-the Rural Women's Health Mini-Residency (Rural WH-MR)-to train VA clinicians in rural locations in skills for the care of women Veterans. Here we assess the applicability of RE-AIM as an evaluation framework in this context., Methods: We evaluated the Rural WH-MR, relying on a primarily quantitative approach, rooted in RE-AIM. It included longitudinal and cross-sectional measurements from multiple quantitative and qualitative data sources to develop selected metrics. Data collection instruments consisted of pre-, post-, and follow-up training surveys, course evaluations, existing VA databases, and implementation reports. We developed metrics for and assessed each RE-AIM component by combining data from multiple instruments and then triangulating findings., Results: Results from the Rural WH-MR program for fiscal years 2018-2020 indicate that RE-AIM provides an instructive evaluation framework for a rural workforce training program, particularly in eliciting clarity between measures of Reach vs. Adoption and focusing attention on both provider- and patient-level outcomes., Discussion: We describe evaluation metric development and barriers to and facilitators of utilizing RE-AIM as an evaluation framework for a provider- and nurse-facing intervention such as this workforce training program. We also reflect upon RE-AIM benefits for highlighting process and outcomes indicators of a training program's success and lessons learned for evaluating rural workforce development innovations. Several of our observations have implications for training and evaluation approaches in rural areas with more limited access to health care services., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Golden, Sanders and Frayne.)

Background: The Common Sense Model provides a framework to understand health beliefs and behaviors. It includes illness representations comprised of five domains (identity, cause, consequences, timeline, and control/cure). While widely used, it is rarely applied to obesity, yet could explain self-management decisions and inform treatments. This study answered the question, what are patients' illness representations of obesity?; and examined the Common Sense Model's utility in the context of obesity., Methods: Twenty-four participants with obesity completed semi-structured phone interviews (12 women, 12 men). Directed content analysis of transcripts/notes was used to understand obesity illness representations across the five illness domains. Potential differences by gender and race/ethnicity were assessed., Results: Participants did not use clinical terms to discuss weight. Participants' experiences across domains were interconnected. Most described interacting life systems as causing weight problems and used negative consequences of obesity to identify it as a health threat. The control/cure of obesity was discussed within every domain. Participants focused on health and appearance consequences (the former most salient to older, the latter most salient to younger adults). Weight-related timelines were generally chronic. Women more often described negative illness representations and episodic causes (e.g., pregnancy). No patterns were identified by race/ethnicity., Conclusions: The Common Sense Model is useful in the context of obesity. Obesity illness representations highlighted complex causes and consequences of obesity and its management. To improve weight-related care, researchers and clinicians should focus on these beliefs in relation to preferred labels for obesity, obesity's most salient consequences, and ways of monitoring change., (© 2022. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Background: Pregnant veterans with post-traumatic stress disorder (PTSD) are at increased risk for spontaneous preterm birth, yet the underlying reasons are unclear. We examined factors associated with spontaneous preterm birth among pregnant veterans with active PTSD., Methods: This was an observational study of births from administrative databases reimbursed by the Veterans Health Association (VA) between 2005 and 2015. Singleton livebirths among veterans with active PTSD within 12 months prior to childbirth were included. The primary outcome was spontaneous preterm birth. Maternal demographics, psychiatric history, and pregnancy complications were evaluated as exposures. Covariates significant on bivariate analysis, as well as age and race/ethnicity as a social construct, were included in multivariable logistic regression to identify factors associated with spontaneous preterm birth. Additional analyses stratified significant covariates by the presence of active concurrent depression and explored interactions between antidepressant use and preeclampsia., Results: Of 3,242 eligible births to veterans with active PTSD, 249 (7.7%) were spontaneous preterm births. The majority of veterans with active PTSD (79.1%) received some type of mental health treatment, and active concurrent depression was prevalent (61.4%). Preeclampsia/eclampsia (adjusted odds ratio [aOR] 3.30, 95% confidence interval [CI] 1.67-6.54) and ≥6 antidepressant medication dispensations within 12 months prior to childbirth (aOR 1.89, 95% CI 1.29-2.77) were associated with spontaneous preterm birth. No evidence of interaction was seen between antidepressant use and preeclampsia on spontaneous preterm birth (p=0.39). Findings were similar when stratified by active concurrent depression., Conclusion: Among veterans with active PTSD, preeclampsia/eclampsia and ≥6 antidepressant dispensations were associated with spontaneous preterm birth. While the results do not imply that people should discontinue needed antidepressants during pregnancy in veterans with PTSD, research into these factors might inform preterm birth prevention strategies for this high-risk population., Competing Interests: DISCLOSURE: The authors report no conflict of interest.

Purpose/objective: To explore the impact of the COVID-19 pandemic as experienced and reported by individuals living with a spinal cord injury (SCI)., Research Method/design: Descriptive qualitative design using in-depth semistructured interviews with individuals with SCI ( n = 33) followed by thematic analysis., Results: Three main themes described impacts of the COVID-19 pandemic. (a) Impact on health care use; subthemes elaborated that this was attributable to in-person health care facility restrictions or individual decisions to delay care. Individuals with SCI experienced lapses in primary and SCI-specialty care, rehabilitation/therapy services, and home care, but some made use of telehealth services. (b) Impact on weight and/or weight management lifestyle behaviors; subthemes discussed that engagement in physical activity declined because of fitness center closures, recreational activity cancellations, and safety precautions limiting community-based and outdoor activities. The pandemic disrupted participants' independence in purchasing and making preferred food selections which impacted healthy eating. Participants ate due to boredom, at nonmealtimes, and consumed unhealthy foods during the pandemic. (c) Impact on psychosocial factors; included subthemes noting reduced social interactions, social participation, and ability to pursue pastimes with family, friends, and groups they belonged to. The pandemic also triggered emotional reactions such as worry, fear, doubt, demotivation, and feelings of social isolation., Conclusions: Our findings highlight the magnitude of consequences faced by individuals with SCI when restrictions to health care, healthy lifestyle endeavors, and social participation occurred during the COVID-19 pandemic. Findings may inform SCI health care providers on what is needed in response to future public health or natural disaster crises. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Background: The prevalence of obesity and comorbidities is high in the population with spinal cord injury (SCI). We sought to determine the effect of SCI on the functional form of the relationship between body mass index (BMI) and risk of developing nonalcoholic fatty liver disease (NAFLD), and assess whether SCI-specific mapping of BMI to risk of developing NAFLD is needed., Methods: Longitudinal cohort study comparing Veterans Health Administration patients with a diagnosis of SCI to a 1:2 matched control group without SCI. The relationship between BMI and development of NAFLD at any time was assessed with propensity score matched Cox regression models; NAFLD development at 10-year with a propensity score matched logistic model. The positive predictive value of developing NAFLD at 10 years was calculated for BMI 19-45 kg/m 2 ., Results: 14,890 individuals with SCI met study inclusion criteria, and 29,780 Non-SCI individuals in matched control group. Overall, 9.2% in SCI group and 7.3% in Non-SCI group developed NAFLD during the study period. A logistic model assessing the relationship between BMI and the probability of developing a diagnosis of NAFLD demonstrated that the probability of developing disease increased as BMI increased in both cohorts. The probability was significantly higher in the SCI cohort at each BMI threshold ( p  < 0.01), and increased at a higher rate compared with the Non-SCI cohort as BMI increased 19-45 kg/m 2 . Positive predictive value for developing a diagnosis of NAFLD was higher in the SCI group for any given BMI threshold from 19 kg/m 2 to BMI 45 kg/m 2 ., Conclusions: The probability of developing NAFLD is greater in individuals with SCI than without SCI, at every BMI level 19 kg/m 2 to 45 kg/m 2 . Individuals with SCI may warrant a higher level of suspicion and closer screening for NAFLD. The association of SCI and BMI is not linear., Competing Interests: The contents do not represent the views of the VA or the United States Government. The authors have no conflicts of interest to disclose., (© 2022 The Authors. Obesity Science & Practice published by World Obesity and The Obesity Society and John Wiley & Sons Ltd. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Background: The Veterans Health Administration (VA) refers patients to community providers for specialty services not available on-site. However, community-level specialist shortages may impede access to care., Objective: Compare gynecologist supply in veterans' county of residence versus at their VA site., Design: We identified women veteran VA patients from fiscal year (FY) 2017 administrative data and assessed availability of a VA gynecologist within 50 miles (hereafter called "local") of veterans' VA homesites (per national VA organizational survey data). For the same cohort, we then assessed community-level gynecologist availability; counties with < 2 gynecologists/10,000 women (per the Area Health Resource File) were "inadequate-supply" counties. We examined the proportion of women veterans with local VA gynecologist availability in counties with inadequate versus adequate gynecologist supply, stratified by individual and VA homesite characteristics. Chi-square tests assessed statistical differences., Participants: All women veteran FY2017 VA primary care users nationally., Main Measures: Availability of a VA gynecologist within 50 miles of a veteran's VA homesite; county-level "inadequate-supply" of gynecologists., Key Results: Among 407,482 women, 9% were in gynecologist supply deserts (i.e., lacking local VA gynecologist and living in an inadequate-supply county). The sub-populations with the highest proportions in gynecologist supply deserts were rural residents (24%), those who got their primary care at non-VAMC satellite clinics (13%), those who got their care at a site without a women's clinic (13%), and those with American Indian or Alaska Native (12%), or white (12%) race. Among those in inadequate-supply counties, 59.9% had gynecologists at their local VA; however, 40.1% lacked a local VA gynecologist., Conclusions: Most veterans living in inadequate-supply counties had local VA gynecology care, reflecting VA's critical role as a safety net provider. However, for those in gynecologist supply deserts, expanded transportation options, modified staffing models, or tele-gynecology hubs may offer solutions to extend VA gynecology capacity., (© 2022. The Author(s).)

Introduction: The increasing number of women Veterans receiving health care from the Veterans Health Administration (VHA) has spurred the need for more women's health primary care providers (PCPs) and nurses, including in rural areas nationwide. Here we report on the implementation of a women's health rural workforce training program, demonstrate initial evidence of its effectiveness within VHA as a Learning Health System, and present lessons learned and implications for other workforce training programs., Methods: The Women's Health Primary Care Mini-Residency for Rural Providers and Nurses (Rural WH-MR) is a mobile VHA training initiative adapted from a national training model. The Rural WH-MR uses asynchronous blended learning paired with in-person hands-on instruction delivered directly at rural VHA sites. Mixed methods evaluation using quantitative data, qualitative interviews, and observational feedback assessed the program's implementation feasibility, fidelity, acceptability, and appropriateness. Longitudinal survey data were used to assess the initial program impact via changes in participating PCP and nurse knowledge, attitudes, practices, and skills (KAPS)., Results: Inclusive of the pilot and fiscal years 2018 and 2019 Rural WH-MR trainings, 181 PCPs, and 320 nurses were trained through 56 training events nationwide. Cumulative survey data using 5-point measures showed high participant satisfaction, achievement of program-specific objectives, and usefulness of training activities to the rural practice of both PCPs and nurses. Both a pre-training and 6-month-follow-up survey were completed by 52 PCPs (32.9%) and 93 nurses (32.2%) and revealed significant sustained improvements in 18 out of 22 KAPS ( p  < 0.01-0.03) areas assessed for PCPs and all 17 KAPS ( p  < 0.01) areas assessed for nurses., Conclusions: This adapted training program benefitted VHA's rural clinical workforce thereby contributing to the VHA goal of increasing the numbers of rural women Veterans with access to PCPs and nurses with women's health expertise., Competing Interests: None of the authors have relevant commercial associations that might pose a conflict of interest., (Published 2022. This article is a U.S. Government work and is in the public domain in the USA. Learning Health Systems published by Wiley Periodicals LLC on behalf of University of Michigan.)

Background: Meaningful engagement of patients in health research has the potential to increase research impact and foster patient trust in healthcare. For the past decade, the Veterans Health Administration (VA) has invested in increasing Veteran engagement in research., Objective: We sought the perspectives of women Veterans, VA women's health primary care providers (WH-PCPs), and administrators on barriers to and facilitators of health research engagement among women Veterans, the fastest growing subgroup of VA users., Design: Semi-structured qualitative telephone interviews were conducted from October 2016 to April 2018., Participants: Women Veterans (N=31), WH-PCPs (N=22), and administrators (N=6) were enrolled across five VA Women's Health Practice-Based Research Network sites., Approach: Interviews were audio-recorded and transcribed. Consensus-based coding was conducted by two expert analysts., Key Results: All participants endorsed the importance of increasing patient engagement in women's health research. Women Veterans expressed altruistic motives as a personal determinant for research engagement, and interest in driving women's health research forward as a stakeholder or research partner. Challenges to engagement included lack of awareness about opportunities, distrust of research, competing priorities, and confidentiality concerns. Suggestions to increase engagement include utilizing VA's patient-facing portals of the electronic health record for outreach, facilitating "warm hand-offs" between researchers and clinic staff, developing an accessible research registry, and communicating the potential research impact for Veterans., Conclusions: Participants expressed support for increasing women Veterans' engagement in women's health research and identified feasible ways to foster and implement engagement of women Veterans. Given the unique healthcare needs of women Veterans, engaging them in research could translate to improved care, especially for future generations. Knowledge about how to improve women Veterans' research engagement can inform future VA policy and practice for more meaningful interventions and infrastructure., (© 2021. The Author(s).)

Introduction: Individuals with spinal cord injury (SCI) are vulnerable to obesity. Annual obesity screening using body mass index (BMI) is the standard of care mandated by US Veterans Health Administration (VHA) guidelines. Our objective was to determine the rates, variability, and predictors of guideline-concordant annual screening for obesity, given potential challenges of height and weight measurements in individuals with SCI., Methods: This is a cross-sectional retrospective study using US national VA databases. We identified all VHA patients with chronic SCI in the fiscal year (FY) 2019, their treating facility and frequency of recorded height and weight. We applied mixed-effects logistic regression models to assess associations between annual BMI screening and patient- and facility-level characteristics., Results: Of 20,978 individuals with chronic SCI in VHA in FY19, guideline-concordant annual BMI screening was lacking in 37.9%. Accounting for facility-level factors (geographic region, SCI facility type, volume of patients with SCI treated at the facility), a mixed-effects logistic regression model demonstrated that lack of annual obesity screening was significantly associated with older patient age (p < 0.001) and fewer outpatient encounters (p < 0.001) but not other patient-level factors such as sex, race, level of injury, or rurality. The rate of obesity screening among different facilities within VHA varied widely from 11.1% to 75.7%., Conclusion: A large proportion of persons with SCI receiving care in VHA do not receive guideline-concordant annual obesity screening, an especially acute problem in some facilities. Older patients with fewer outpatient encounters are more likely to be missed. To inform the design of interventions to improve identification and documentation of obesity, further study is needed to assess potential barriers to obesity screening in the population with SCI., (© 2022 The Author(s). Published by S. Karger AG, Basel.)

Introduction: Pregnancy presents an opportunity to engage veterans in health care. Guidelines recommend primary care follow-up in the year postpartum, but loss to follow-up is common, poorly quantified, and especially important for those with gestational diabetes (GDM) and hypertension. Racial maternal inequities are well-documented and might be exacerbated by differential postpartum care. This study explores variation in postpartum re-engagement in U.S. Department of Veteran Affairs health care system (VA) primary care to identify potential racial/ethnic inequities in this care transition., Methods: We conducted a complete case analysis of the 2005-2014 national VA birth cohort (n = 18,414), and subcohorts of veterans with GDM (n = 1,253) and hypertensive disorders of pregnancy (HDP; n = 2,052) using VA-reimbursed discharge claims and outpatient data. Outcomes included incidence of any VA primary care visit in the postpartum year; in age-adjusted logistic regression, we explored race/ethnicity as a primary predictor., Results: In the year after a VA-covered birth, the proportion of veterans with one or more primary care visit was 53.8% overall, and slightly higher in the GDM (56.0%) and HDP (57.4%) subcohorts. In adjusted models, the odds of VA primary care follow-up were significantly lower for Black/African American (odds ratio, 0.87; 95% confidence interval, 0.81-0.93), Asian (odds ratio, 0.76; 95% confidence interval, 0.61-0.95), and Hawaiian/other Pacific Islander (odds ratio, 0.73; 95% confidence interval, 0.55-0.96) veterans, compared with White veterans. Among the subcohorts with GDM or HDP, there were no significant associations between primary care and race/ethnicity., Conclusions: One-half of veterans re-engage in VA primary care after childbirth, with significant racial differences in this care transition. Re-engagement for those with the common pregnancy complications of HDP and GDM is only slightly higher, and less than 60%. The potential for innovations such as VA maternity care coordinators to address such gaps merits attention., (Published by Elsevier Inc.)

Purpose: In 2017, Veterans Health Administration (VA) launched a social marketing and training campaign to address harassment of women veterans at VA health care facilities. We assessed women veterans' experiences of harassment, reported perpetrators of harassment, and perceptions of VA in 2017 (before campaign launch) and 2018 (1 year after campaign implementation)., Methods: We administered surveys to women veterans attending primary care appointments (2017, n = 1,300; 2018, n = 1,711). Participants reported whether they experienced sexual harassment (e.g., catcalls) and gender harassment (e.g., questioning women's veteran status) from patients and/or staff at VA in the past 6 months. They also indicated whether they felt welcome, felt safe, and believed the VA is working to address harassment. We compared variables in 2017 versus 2018 with χ 2 analyses, adjusting for facility-level clustering., Results: There were no significant differences in percentages of participants reporting sexual harassment (20% vs. 17%) or gender harassment (11% vs. 11%) in 2017 versus 2018. Men veterans were the most frequently named perpetrators, but participants also reported harassment from staff. Participant beliefs that VA is working to address harassment significantly improved from 2017 to 2018 (52% vs. 57%; p = .05)., Conclusions: One year after campaign launch, women veterans continued to experience harassment while accessing VA health care services. Findings confirm that ongoing efforts to address and monitor both staff- and patient-perpetrated harassment are essential. Results have implications for future anti-harassment intervention design and implementation and highlight additional opportunities for investigation., (Published by Elsevier Inc.)

Background: Approximately half of all women with anginal symptoms and/or signs of ischemia and no obstructive coronary artery disease (INOCA) referred for coronary angiography have elevated risk for major adverse cardiac events (MACE), poor quality of life and resource consumption. Yet, guidelines focus on symptom management while clinical practice typically advocates only reassurance. Pilot studies of INOCA subjects suggest benefit with intensive medical therapy (IMT) that includes high-intensity statins and angiotensin converting enzyme inhibitors (ACE-I) or receptor blockers (ARB) to provide the rationale for a randomized pragmatic trial to limit MACE., Methods: The Women's IschemiA TRial to Reduce Events In Non-ObstRuctive CAD is a multicenter, prospective, randomized, blinded outcome evaluation (PROBE design) of a pragmatic strategy of IMT vs usual care (UC) in 4,422 symptomatic women with INOCA (NCT03417388) in approximately 70 United States sites. The hypothesis is that IMT will reduce the primary outcome of first occurrence of MACE by 20% vs. UC at ∼2.5 year followup. Secondary outcomes include quality of life, time to return to "duty"/work, healthcare utilization, angina, cardiovascular death and individual primary outcome components over 3 years follow-up. The study utilizes web-based data capture, e-consents, single IRB and centralized pharmacy distribution of strategy medications directly to patients' homes to reduce site and patient burden. A biorepository will collect blood samples to assess potential mechanisms., Conclusions: The results of this trial will provide important data necessary to inform guidelines regarding how best to manage this growing and challenging population of women with INOCA., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Key insights: A: Addressing a complex problem like harassment in VA medical facilities requires committed, engaged collaboration at multiple levels of the organization. B: Timely feedback of initial research findings to operations partners enabled rapid and more responsive development of new programs and policies. C: Our research-clinical partnership has enabled us to pursue targeted change from the outset, while incorporating real-time findings from embedded researchers working to develop a comprehensive understanding of the problem., (Published by Elsevier Inc.)

Background: We tested the capacity of the 60-site VA Women's Health Practice-Based Research Network (WH-PBRN), embedded within VA, to employ a multisite card study to collect women Veterans' perspectives about Complementary and Integrative Health (CIH) and to rapidly return findings to participating sites and partnered national policy-makers in support of a Learning Health System (LHS) wherein evidence generation informs ongoing improvement., Methods: VA primary care clinic clerks and nurses distributed anonymous surveys (patient feedback forms) at clinics for up to two weeks in fiscal year 2017, asking about CIH behavior and preferred delivery methods. We examined the project's feasibility, representativeness, acceptability, and impact via a tracking system, national administrative data, debriefing notes, and three surveys of WH-PBRN Site Leads., Results: Twenty geographically diverse and largely representative VA Medical Centers and 11 Community-Based Outpatient Clinics volunteered to participate. Over six months, N = 1191 women Veterans responded (median 57; range 8-151 per site). In under three months, we returned local findings benchmarked against multisite findings to all participating sites and summary findings to national VA partners. Sites and partners disseminated results to clinical and leadership stakeholders, who then applied results as warranted., Conclusions: VA effectively mobilized an embedded PBRN to implement a timely, representative, acceptable and impactful operations project., Implications: Card studies by PBRNs within large, national healthcare systems can provide rapid feedback to participating sites and national leaders to guide policies, programs, and practices., Level of Evidence: Self-selected respondents could have biased results., (Published by Elsevier Inc.)

Background: When an experienced provider opts to leave a healthcare workforce (attrition), there are significant costs, both direct and indirect. Turnover of healthcare providers is underreported and understudied, despite evidence that it negatively impacts care delivery and negatively impacts working conditions for remaining providers. In the Veterans Affairs (VA) healthcare system, attrition of women's health primary care providers (WH-PCPs) threatens a specially trained workforce; it is unknown what factors contribute to, or protect against, their attrition., Objective: Based on evidence that clinic environment, adequate support resources, and workload affect provider burnout and intent to leave, we explored if such clinic characteristics predict attrition of WH-PCPs in the VA, to identify protective factors., Design: This analysis drew on two waves of existing national VA survey data to examine predictors of WH-PCP attrition, via logistic regression., Participants: All 2,259 providers from 140 facilities VA-wide who were WH-PCPs on September 30, 2016., Main Measures: The dependent variable was WH-PCP attrition in the following year. Candidate predictors were clinic environment (working in: a comprehensive women's health center, a limited women's health clinic, a general primary care clinic, or multiple clinic environments), availability of co-located specialty support resources (mental health, social work, clinical pharmacy), provider characteristics (gender, professional degree), and clinic workload (clinic sessions per week)., Key Results: Working exclusively in a comprehensive women's health center uniquely predicted significantly lower risk of WH-PCP attrition (adjusted odds ratio 0.40; CI 0.19-0.86)., Conclusions: A comprehensive women's health center clinical context may promote retention of this specially trained primary care workforce. Exploring potential mechanisms-e.g., shared mission, appropriate support to meet patients' needs, or a cohesive team environment-may inform broader efforts to retain front-line providers.

Purpose: Women veterans are a rapidly increasing subset of the Veterans Affairs (VA) patient population but remain a numerical minority. Men veteran-dominated health care settings pose unique considerations for providing care to women veterans in a comfortable and welcoming environment. We analyzed patient suggestions on how to make the VA more welcoming to women., Methods: We surveyed a convenience sample of women veteran patients who visited 1 of 26 VA locations in August and September of 2017. Women veterans were invited to complete brief anonymous questionnaires that included questions about harassment experiences and feeling welcome at the VA, and an open-ended question about suggestions to make the VA more welcoming to women. We analyzed data from the open-ended question using the constant comparison method., Results: Among respondents (N = 1,303), 85% felt welcome at the VA. Overall, 29% answered the open-ended prompt for a total of 490 distinct responses: 260 comments and 230 suggestions. Comments included praise for the VA (67%) and stories about feeling uncomfortable or harassed in the VA (26%). Suggestions included those related to VA staff (31%), the environment of care (18%), additional resources for women veterans (18%), clinical services for women veterans (15%), changing men veterans' behavior toward women veterans at the VA (5%), and making the treatment of women and men the same (5%)., Conclusions: Although most women veterans felt welcome in the VA, patient-centered suggestions offer opportunities for making the VA more welcoming to women. Soliciting patient suggestions and increasing awareness of how feeling welcome is experienced by patients are first steps to health care settings becoming more inclusive., (Published by Elsevier Inc.)

Objective: The objective was to compare differences in body mass index (BMI) calculated with self-reported versus clinically measured pre-conception data from women veterans in California., Methods: Veterans Health Administration (VHA) and California state birth certificate data were used to develop a cohort of women who gave birth from 2007-2012 and had VHA data available to calculate BMI ( N = 1,326 mothers, 1,473 births). Weighted Kappa statistics assessed concordance between self-reported and measured BMI. A linear mixed-effects model with maximum likelihood estimation, adjusted for mother as a random effect, assessed correlates of differences in BMI., Results: Mean BMI was in the overweight range based on self-reported (26.2 kg/m 2 , SD: 5.2) and measured (26.8 kg/m 2 , SD: 5.2) data. Weighted Kappa statistics indicated good agreement between self-reported and measured BMI (0.73, 95% CI: 0.70, 0.76). Compared to the normal weight group, groups with overweight or obesity were significantly more likely to have lower BMIs when calculated using self-reported versus measured heights and weights, in unadjusted and adjusted models. The finding was pronounced for class 3 obesity, which was associated with a BMI underestimation of 6.4 kg/m 2 ., Conclusions: Epidemiologic research that guides the clinical care of pregnant women should account for potential under-estimation of BMI in heavier women, and perform direct measurement where feasible., Competing Interests: The authors declare no conflict of interest., (Published 2020. This article is a U.S. Government work and is in the public domain in the USA. Obesity Science & Practice published by World Obesity and The Obesity Society and John Wiley & Sons Ltd.)

Objective: The goal was to examine psychiatric diagnosis rates among a national cohort of primary care patients with and without obesity., Methods: The cohort was derived from national Veterans Health Administration data (women, N=342,262; men, N=4,524,787). Sex-stratified descriptive statistics characterized psychiatric diagnosis rates. Chi-square tests determined whether diagnosis rates differed by obesity status (α=0.001)., Results: Rates of any psychiatric diagnosis were higher among women than among men and among people with obesity versus without obesity (women, 53.9% vs. 50.4%; men, 37.9% vs. 35.2%). Depression and posttraumatic stress disorder diagnosis rates were higher for people with obesity, and substance use disorder diagnosis rates were lower for people with obesity. Anxiety diagnosis rates were slightly lower among women with obesity versus women without obesity., Conclusions: Programs simultaneously addressing weight management and mental health could address the psychiatric comorbidities observed among people with obesity. Women are most likely to need these services.

Objective: The effect of stress exposures and mental health sequelae on health-related outcomes is understudied among older women veterans. We examined a) the impact of wartime stress exposures on later-life functioning and disability in Vietnam-era women veterans and b) the extent to which mental health conditions known to be associated with stress-posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD)-are associated with additional later-life functioning and disability., Methods: Data were collected in 2011 to 2012 using a mail survey and telephone interview of 4219 women veterans who were active duty during the Vietnam Era. Health functioning was assessed using the Veterans RAND 36-Item Health Survey, and disability was assessed using the World Health Organization Disability Assessment Schedule 2.0. Wartime exposures were assessed using the Women's War-Zone Stressor Scale-Revised; the Composite International Diagnostic Interview, version 3.0 was used to assess PTSD, MDD, and GAD., Results: Several wartime stress exposures-including job-related pressures, dealing with death, and sexual discrimination and harassment-were associated with worse later-life health (β ranges, -0.04 to -0.26 for functioning, 0.05 to 0.30 for disability). Current PTSD was linked with lower health functioning (physical, β = -0.06; mental, β = -0.15) and greater disability (β = 0.14). Current MDD and GAD were also associated with lower mental health functioning (MDD, β = -0.29; GAD, β = -0.10) and greater disability (MDD, β = 0.16; GAD, β = 0.06)., Conclusions: Results underscore the importance of detection and treatment of the potential long-term effects of wartime stressors and mental health conditions among women veterans.

Objectives: We analyzed long-term differences in incident diabetes associated with military service in a warzone among women who served during the Vietnam War era., Methods: For HealthViEWS, the largest later-life study of women Vietnam War-era U.S. veterans, a population-based retrospective cohort who served during 1965-1973 completed a health interview in 2011-2012. This cohort included women deployed to Vietnam, near Vietnam, or who served primarily in the United States. We hypothesized a warzone exposure gradient: Vietnam (highest exposure), near Vietnam, and the United States (lowest exposure). We used an extended Cox regression to test for differences in incident diabetes by location of wartime service., Results: Of 4,503 women in the analysis, 17.7% developed diabetes. Adjusting for demographics and military service characteristics, hazard of incident diabetes was significantly lower initially in the Vietnam group compared with the U.S. group (hazard ratio, 0.33; 95% confidence interval, 0.15-0.69). However, lower diabetes hazard in the Vietnam group was not constant over time; rather, hazard accumulated faster over time in the Vietnam group compared with the U.S. group (hazard ratio, 1.38; 95% confidence interval, 1.11-1.72). No significant difference in diabetes hazard was found between the near Vietnam and U.S. groups. Older age during military service, minority race/ethnicity, and lower military rank were associated with a higher diabetes hazard., Conclusions: Women deployed to a warzone might have protective health factors that lower risk for diabetes early in their military career, but delivery systems for long-term health should consider that a lower risk for chronic diseases like diabetes can wane quickly in the decades that follow warzone service., (Published by Elsevier Inc.)

Background: In the U.S. civilian population, sex differences have been identified in cardiovascular health; these differences have been used to inform care. Our objective is to determine if the same sex differences are present in Veterans who use the Department of Veterans Affairs (VA) Health Care System given the additional stressors associated with military service. Materials and Methods: Cardiovascular disease (CVD) risk factors and conditions among women and men Veterans using VA in fiscal year (FY) 2014 were identified through the presence of International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes in VA administrative records. ICD-9-CM codes were grouped into conditions; prevalence was examined by gender overall, by age, and by race/ethnicity. Results: Within the FY 2014 cohort of VA Veteran patients included in this analysis, 7.1% ( n  = 412,901) were women and 92.9% were men ( n  = 5,376,749). Compared with men, women in this cohort were younger and more ethnically diverse. Overall, women were less likely to have traditional CVD risk factors, but more likely to have a nontraditional CVD risk factor (depression) compared with men. Women had higher odds of chest pain/angina (adjusted odds ratio [AOR] 1.03, confidence interval [95% CI] 1.02-1.05), palpitations (AOR 2.04; 95% CI 1.98-2.10), and valvular disease (AOR 1.05; 95% CI 1.02-1.08), but lower odds of coronary artery disease (AOR 0.29; 95% CI 0.29-0.30), acute MI (AOR 0.46; 95% CI 0.43-0.49), and heart failure (AOR 0.55; 95% CI 0.53-0.56) compared with men, overall. Conclusions: In age-adjusted comparisons, sex differences in the prevalence of CVD risk factors and conditions among the VA Veteran patient population was similar in that seen in the civilian population with a few exceptions.

Background: Obesity is highly stigmatized, especially for women, and therefore may negatively affect health care experiences. Past findings on the relationship between obesity and health care experiences are mixed, perhaps because few studies examine relationships by gender and obesity class. Our objective was to evaluate whether women and men with more severe obesity report worse health care experiences related to Veterans Health Administration (VA) care., Methods: Health care experiences (self-management support, mental health assessments, office staff courtesy, communication with providers) and overall provider ratings were assessed with the 2014 VA Survey of Health Care Experiences of Patients. Using multiple regression analyses (n = 13,462 women, n = 268,180 men), we assessed associations among obesity classes, health care experiences, and overall provider ratings, adjusting for sociodemographic, health, and primary care use characteristics., Results: The greatest differences in health care experiences between patients with and without obesity were in self-management support experiences, which were more favorable among women and men of all obesity classes. There were gender differences in associations between obesity and mental health assessments: for men, but not women, those in any obesity class gave higher ratings than those without obesity. For most other health care experiences and provider ratings, men with obesity reported slightly less favorable experiences than those without. There was no consistent pattern for women., Conclusions: It is promising that VA patients with obesity report more self-management support, given the behavior change required for weight management. Lower health care experience and provider ratings among men with obesity suggest a need to further investigate possible obesity-related stigma in VA primary care., (Published by Elsevier Inc.)

Purpose: To assess disparities in primary care experiences for patients with a substance use disorder (SUD) diagnosis. Methods: We assessed differences in Veterans Health Administration (VA) primary care patients' experiences using data from the 2014 outpatient VA Patient-Centered Medical Home Survey of Healthcare Experiences of Patients (SHEP; N =286,026). We obtained patient demographics and diagnoses from VA electronic medical record data. Results: Patients with an SUD diagnosis reported worse experiences for 8 of 12 SHEP measures, including access, provider communication, and information received ( p <0.05). Conclusion: Targeted strategies may be needed to ensure patients with SUD have favorable primary care experiences., Competing Interests: No competing financial interests exist.

Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran.

Purpose: Equal-access health care systems such as the Veterans Health Administration (VHA) reduce financial and nonfinancial barriers to care. It is unknown if such systems mitigate racial/ethnic mortality disparities, such as those well documented in the broader U.S. population. We examined racial/ethnic mortality disparities among VHA health care users, and compared racial/ethnic disparities in VHA and U.S. general populations. Methods: Linking VHA records for an October 2008 to September 2009 national VHA user cohort, and National Death Index records, we assessed all-cause, cancer, and cardiovascular-related mortality through December 2011. We calculated age-, sex-, and comorbidity-adjusted mortality hazard ratios. We computed sex-stratified, age-standardized mortality risk ratios for VHA and U.S. populations, then compared racial/ethnic disparities between the populations. Results: Among VHA users, American Indian/Alaskan Natives (AI/ANs) had higher adjusted all-cause mortality, whereas non-Hispanic Blacks had higher cause-specific mortality versus non-Hispanic Whites. Asians, Hispanics, and Native Hawaiian/Other Pacific Islanders had similar, or lower all-cause and cause-specific mortality versus non-Hispanic Whites. Mortality disparities were evident in non-Hispanic-Black men compared with non-Hispanic White men in both VHA and U.S. populations for all-cause, cardiovascular, and cancer (cause-specific) mortality, but disparities were smaller in VHA. VHA non-Hispanic Black women did not experience the all-cause and cause-specific mortality disparity present for U.S. non-Hispanic Black women. Disparities in all-cause and cancer mortality existed in VHA but not in U.S. population AI/AN men. Conclusion: Patterns in racial/ethnic disparities differed between VHA and U.S. populations, with fewer disparities within VHAs equal-access system. Equal-access health care may partially address racial/ethnic mortality disparities, but other nonhealth care factors should also be explored., Competing Interests: No competing financial interests exist.

Objective: To describe variation in payer and outcomes in Veterans' births., Data/setting: Secondary data analyses of deliveries in California, 2000-2012., Study Design: We performed a retrospective, population-based study of all live births to Veterans (confirmed via U.S. Department of Veterans Affairs (VA) enrollment records), to identify payer and variations in outcomes among: (1) Veterans using VA coverage and (2) Veteran vs. all other births. We calculated odds ratios (aOR) adjusted for age, race, ethnicity, education, and obstetric demographics., Methods: We anonymously linked VA administrative data for all female VA enrollees with California birth records., Principal Findings: From 2000 to 2012, we identified 17,495 births to Veterans. VA covered 8.6 percent (1,508), Medicaid 17.3 percent, and Private insurance 47.6 percent. Veterans who relied on VA health coverage had more preeclampsia (aOR 1.4, CI 1.0-1.8) and more cesarean births (aOR 1.2, CI 1.0-1.3), and, despite similar prematurity, trended toward more neonatal intensive care (NICU) admissions (aOR 1.2, CI 1.0-1.4) compared to Veterans using other (non-Medicaid) coverage. Overall, Veterans' birth outcomes (all-payer) mirrored California's birth outcomes, with the exception of excess NICU care (aOR 1.15, CI 1.1-1.2)., Conclusions: VA covers a higher risk fraction of Veterans' births, justifying maternal care coordination and attention to the maternal-fetal impacts of Veterans' comorbidities., (© Health Research and Educational Trust.)

Background: Evidence-Based Quality Improvement (EBQI) is a systematic, multilevel approach to implementing research evidence into clinical settings. Little is known about EBQI effectiveness in the context of Practice-Based Research Networks (PBRNs), which are themselves designed to foster practice-based change. We evaluated EBQI implementation in a PBRN setting to determine the extent to which the PBRN infrastructure added value., Methods: We conducted a four-site cluster randomized trial of an EBQI approach to tailoring an evidence-based gender awareness curriculum in the VA Women’s Health PBRN (WH-PBRN). After curriculum implementation, site teams identified impacts of the WH-PBRN context on EBQI processes using qualitative methods, including a formal review of project call minutes, post-project debriefing calls, and structured site team input. WH-PBRN site feedback was mapped to the Replicating Effective Programs implementation phases: pre-condition, pre-implementation, implementation, and maintenance/evolution., Results: The pre-condition phase benefited from the existing WH-PBRN research-clinician relationships to facilitate stakeholder engagement and build project buy-in at local sites. During pre-implementation, differences across WH-PBRN sites offered variations in local tailoring of EBQI elements. The WH-PBRN Coordinating Center helped resolve process complexities stemming from local resource differences and the sharing of mid-project adaptations during implementation. Local efforts were amplified in the maintenance phase by WH-PBRN dissemination of findings., Conclusions: The PBRN strengthened multi-site EBQI activities across all implementation phases., Implications: PBRNs contribute to the uptake of evidence into everyday practice, and may serve as an important component of the future implementation of evidence-based initiatives. Level of evidence: V., (Published by Elsevier Inc.)

Background: Little is known about medical morbidity among women Vietnam-era veterans, or the long-term physical health problems associated with their service. This study assessed agreement comparing data on physical health conditions from self-report and medical records from a population-based cohort of women Vietnam-era Veterans from the Health of Vietnam Era Women's Study (HealthViEWS)., Materials and Methods: Women Vietnam-era veterans (n = 4219) self-completed a survey and interview on common medical conditions. A subsample (n = 900) were contacted to provide permission to obtain medical records from as many as three of their providers. Medical record reviews were conducted using a standardized checklist. Agreement and kappa (agreement beyond chance) were calculated for physical health condition groups., Results: Of the 900, 449 had medical records returned, and of those, 412 had complete surveys/interviews. The most commonly reported conditions based on self-report or medical record review included hypertension, hyperlipidemia, or arthritis. Kappa scores between self-reported conditions and medical record documentation were 0.75-0.91 for hypertension, diabetes, most cancers, and neurological conditions, but lower (k = 0.29-0.55) for cardiovascular diseases, musculoskeletal, and gastrointestinal conditions. Generally, agreement did not significantly vary by different sociodemographic groups., Conclusions: There was relatively high agreement for physical health conditions when self-report was compared with medical record review. As more women are increasingly represented in the military and more veterans in general seek care outside the Veterans Health Administration, accurate measurement of physical health conditions among population-based samples is crucial.

There are gender-specific variations in the epidemiology and clinical course of hepatitis C virus (HCV) infection. However, few long-term longitudinal studies have examined trends in the incidence and prevalence of serious liver complications among women compared with men with HCV infection. We used the Veterans Administration Corporate Data Warehouse to identify all veterans with positive HCV viraemia from January 2000 to December 2013. We calculated gender-specific annual incidence and prevalence rates of cirrhosis, decompensated cirrhosis and hepatocellular cancer (HCC) adjusting for age, diabetes, HIV and alcohol use. We also calculated the average annual per cent change (AAPC) for each outcome by gender using piecewise linear regression in the Joinpoint software. We identified 264 409 HCV-infected veterans during 2000-2013, of whom 7162 (2.7%) were women. There were statistically significant increases over time in the incidence rates of cirrhosis, decompensated cirrhosis and HCC for both men and women. The annual-adjusted incidence rates of cirrhosis, decompensated cirrhosis and HCC were higher in men than women for all study years. However, these complications increased at a similar rate in both groups. Specifically, the AAPC for cirrhosis was 13.1 and 15.2, while it was 15.6 and 16.9 for decompensated cirrhosis and 21.0 and 25.3 for HCC in men and women, respectively (all test of parallelism not significant). The results were similar in the prevalence analyses, although AAPCs were slightly smaller for each outcome. In conclusion, we found an ongoing upward trend in the incidence and prevalence of HCV complications in this cohort of HCV-infected women. This increase in cirrhosis complications in women with active HCV infection is similar to those in men. With cure from HCV now becoming a reality, most of the projected burden of HCV is potentially preventable. However, benefits of HCV treatment will need to extend to all patients in order to stem the rising tide of HCV complications., (Published 2017. This article is a U.S. Government work and is in the public domain in the USA.)

Purpose: Few wartime experiences scales capture unique issues related to women's service, address their military roles, or have been validated with women. The Women's Wartime Stressor Scale was developed for use with women who served during the Vietnam era, primarily as nurses in Vietnam. We revised this measure by modifying existing items, adding new items, and revising response formats to create a scale less nursing specific and nondeployment specific, and conducted a preliminary assessment of the revised scale., Methods: The Women's Wartime Exposure Scale-Revised (WWES-R) was included in a mail survey as part of the U.S. Department of Veterans Affairs Health of Vietnam-Era Women's Study (HealthViEWS) study. Construct and criterion validity, and internal consistency, were assessed with a sample of 4,839 women veterans using exploratory factor analysis, analysis of variance, and multiple linear regression., Results: Six wartime experience factors consistent with previous research were identified and scales were created based on salient item loadings. Compared with women serving in the United States, women serving in Vietnam had higher mean scores on all scales, and nurses had significantly higher scores on three scales than non-nurses., Conclusions: Evaluation of the WWES-R suggests service and/or deployment location and service in a military health care versus a non-health care role may predict women veterans' reports of certain wartime experiences. Further psychometric evaluation of the WWES-R is recommended with later era veterans and through comparisons to other wartime exposure measures., (Published by Elsevier Inc.)

Patient-centered medical homes are widely promoted as a primary care delivery model that achieves better patient outcomes. It is unknown if their benefits extend equally to all racial/ethnic groups. In 2010 the Veterans Health Administration, part of the Department of Veterans Affairs (VA), began implementing patient-centered medical homes nationwide. In 2009 significant disparities in hypertension or diabetes control were present for most racial/ethnic groups, compared with whites. In 2014 hypertension disparities were similar for blacks, had become smaller but remained significant for Hispanics, and were no longer significant for multiracial veterans, whereas disparities had become significant for American Indians/Alaska Natives and Native Hawaiians/other Pacific Islanders. By contrast, in 2014 diabetes disparities were similar for American Indians/Alaska Natives, blacks, and Hispanics, and were no longer significant for Native Hawaiians/other Pacific Islanders. We found that the modest benefits of the VA's implementation of patient-centered medical homes were offset by competing multifactorial external, health system, provider, and patient factors, such as increased patient volume. To promote health equity, health care innovations such as patient-centered medical homes should incorporate tailored strategies that account for determinants of racial/ethnic variations. Evaluations of patient-centered medical homes should monitor outcomes for racial/ethnic groups., (Project HOPE—The People-to-People Health Foundation, Inc.)

Objective: To evaluate warfarin prescription, quality of international normalised ratio (INR) monitoring and of INR control in patients with atrial fibrillation (AF) and chronic kidney disease (CKD)., Methods: We performed a retrospective cohort study of patients with newly diagnosed AF in the Veterans Administration (VA) healthcare system. We evaluated anticoagulation prescription, INR monitoring intensity and time in and outside INR therapeutic range (TTR) stratified by CKD., Results: Of 123 188 patients with newly diagnosed AF, use of warfarin decreased with increasing severity of CKD (57.2%-46.4%), although it was higher among patients on dialysis (62.3%). Although INR monitoring intensity was similar across CKD strata, the proportion with TTR≥60% decreased with CKD severity, with only 21% of patients on dialysis achieving TTR≥60%. After multivariate adjustment, the magnitude of TTR reduction increased with CKD severity. Patients on dialysis had the highest time markedly out of range with INR <1.5 or >3.5 (30%); 12% of INR time was >3.5, and low TTR persisted for up to 3 years., Conclusions: There is a wide variation in anticoagulation prescription based on CKD severity. Patients with moderate-to-severe CKD, including dialysis, have substantially reduced TTR, despite comparable INR monitoring intensity. These findings have implications for more intensive warfarin management strategies in CKD or alternative therapies such as direct oral anticoagulants., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Prior work shows that Post-traumatic Stress Disorder (PTSD) predicts an increased risk of preterm birth, but the causal pathway(s) are uncertain. We evaluate the associations between PTSD and antepartum complications to explore how PTSD's pathophysiology impacts pregnancy., Methods: This retrospective cohort analysis of all Veterans Health Administration (VA)-covered deliveries from 2000-12 used the data of VA clinical and administration. Mothers with current PTSD were identified using the ICD-9 diagnostic codes (i.e. code present during the antepartum year), as were those with historical PTSD. Medical and administrative data were used to identify the relevant obstetric diagnoses, demographics and health, and military deployment history. We used Poisson regression with robust error variance to derive the adjusted relative risk estimates (RR) for the association of PTSD with five clinically relevant antepartum complications [gestational diabetes (GDM), preeclampsia, gestational hypertension, growth restriction, and abruption]. Secondary outcomes included proxies for obstetric complexity (repeat hospitalisation, prolonged delivery hospitalisation, and caesarean delivery)., Results: Of the 15 986 singleton deliveries, 2977 (19%) were in mothers with PTSD diagnoses (1880 (12%) current PTSD). Mothers with the complication GDM were 4.9% and those with preeclampsia were 4.6% of all births. After adjustment, a current PTSD diagnosis (reference = no PTSD) was associated with an increased risk of GDM (RR 1.4, 95% confidence interval (CI) 1.2, 1.7) and preeclampsia (RR 1.3, 95% CI 1.1, 1.6). PTSD also predicted prolonged (>4 day) delivery hospitalisation (RR 1.2, 95% CI 1.01, 1.4), and repeat hospitalisations (RR 1.4, 95% CI 1.2, 1.6), but not caesarean delivery., Conclusions: The observed association of PTSD with GDM and preeclampsia is consistent with our nascent understanding of PTSD as a disruptor of neuroendocrine and cardiovascular health., (© 2017 John Wiley & Sons Ltd.)

Background: Most US adults are overweight or obese. Understanding differences in obesity prevalence across subpopulations could facilitate the development and dissemination of weight management services., Objectives: To inform Veterans Health Administration (VHA) weight management initiatives, we describe obesity prevalence among subpopulations of VHA patients., Design: Cross-sectional descriptive analyses of fiscal year 2014 (FY2014) national VHA administrative and clinical data, stratified by gender. Differences ≥5% higher than the population mean were considered clinically significant., Participants: Veteran VHA primary care patients with a valid weight within ±365 days of their first FY2014 primary care visit, and a valid height (98% of primary care patients)., Main Measures: We used VHA vital signs data to ascertain height and weight and calculate body mass index, and VHA outpatient, inpatient, and fee basis data to identify sociodemographic- and comorbidity-based subpopulations., Key Results: Among nearly five million primary care patients (347,112 women, 4,567,096 men), obesity prevalence was 41% (women 44%, men 41%), and overweight prevalence was 37% (women 31%, men 38%). Across the VHA's 140 facilities, obesity prevalence ranged from 28% to 49%. Among gender-stratified subpopulations, obesity prevalence was high among veterans under age 65 (age 18-44: women 40%, men 46%; age 45-64: women 49%, men 48%). Obesity prevalence varied across racial/ethnic and comorbidity subpopulations, with high obesity prevalence among black women (51%), women with schizophrenia (56%), and women and men with diabetes (68%, 56%)., Conclusions: Overweight and obesity are common among veterans served by the VHA. VHA's weight management initiatives have the potential to avert long-term morbidity arising from obesity-related conditions. High-risk groups-such as black women veterans, women veterans with schizophrenia, younger veterans, and Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native veterans-may require particular attention to ensure that systems improvement efforts at the population level do not inadvertently increase health disparities.

Background: Provision of bariatric surgery in the Veterans Health Administration must account for obese veterans' co-morbidity burden and the geographically dispersed location of patients relative to Veterans Affairs (VA) bariatric centers., Objectives: To evaluate a collaborative, integrated, interdisciplinary bariatric team of surgeons, bariatricians, psychologists, dieticians, and physical therapists working in a hub-and-spokes care model, for pre- and post-bariatric surgery assessment and management., Methods: This is a description of an interdisciplinary clinic and bariatric program at a VA healthcare system and a report on program evaluation findings. Retrospective data of a prospective database was abstracted. For program evaluation, we abstracted charts to characterize patient data and conducted a patient survey., Results: Since 2009, 181 veterans have undergone bariatric surgery. Referrals came from 7 western U.S. states. Mean preoperative body mass index was 46 kg/m 2 (maximum 71). Mean age was 53 years, with 33% aged>60 years; 79% were male. Medical co-morbidity included diabetes (70%), hypertension (85%), and lower back or extremity joint pain (84%). A psychiatric diagnosis was present in 58%. At 12 months, follow-up was 81% and percent excess body mass index loss was 50.5%. Among 54 sequential clinic patients completing anonymous surveys, overall satisfaction with the interdisciplinary team approach and improved quality of life were high (98% and 94%, respectively)., Conclusion: The integrated, interdisciplinary team approach using a hub-and-spokes model is well suited to the VA bariatric surgery population, with its heavy burden of medical and mental health co-morbidity and its system of geographically dispersed patients receiving treatment at specialty centers. As the VA seeks to expand the use of bariatric surgery as an option for obese veterans, interdisciplinary models crafted to address case complexity, care coordination, and long-term outcomes should be part of policy planning efforts., (Published by Elsevier Inc.)

The Veterans Health Administration (VA) Health Care for Reentry Veterans (HCRV) program links veterans exiting prison with treatment. Among veterans served by HCRV, national VA clinical data were used to describe contact with VA health care, and mental health and substance use disorder diagnoses and treatment use. Of veterans seen for an HCRV outreach visit, 56 % had contact with VA health care. Prevalence of mental health disorders was 57 %; of whom 77 % entered mental health treatment within a month of diagnosis. Prevalence of substance use disorders was 49 %; of whom 37 % entered substance use disorder treatment within a month of diagnosis. For veterans exiting prison, increasing access to VA health care, especially for rural veterans, and for substance use disorder treatment, are important quality improvement targets.

Warfarin prevents stroke and prolongs survival in patients with atrial fibrillation and flutter (AF, collectively) but can cause hemorrhage. The time in international normalized ratio (INR) therapeutic range (TTR) mediates stroke reduction and bleeding risk. This study sought to determine the relation between baseline stroke, bleeding risk, and TTR. Using data from The Retrospective Evaluation and Assessment of Therapies in Atrial Fibrillation (TREAT-AF) retrospective cohort study, national Veterans Health Administration records were used to identify patients with newly diagnosed AF from 2003 to 2012 and subsequent initiation of warfarin. Baseline stroke and bleeding risk was determined by calculating CHA 2 DS 2 -VASc and HAS-BLED scores, respectively. Main outcomes were first-year and long-term TTR and INR monitoring rate. In 167,190 patients, the proportion of patients with TTR (>65%) decreased across increasing strata of CHA 2 DS 2 -VASc and HAS-BLED. After covariate adjustment, odds of achieving TTR >65% were significantly associated with high CHA 2 DS 2 -VASc or HAS-BLED score. INR monitoring rate was similar across risk strata. In conclusion, increased baseline stroke and bleeding risk is associated with poor INR control, despite similar rates of INR monitoring. These findings may paradoxically limit warfarin's efficacy and safety in high-risk patients and may explain observed increased bleeding and stroke rates in this cohort., (Published by Elsevier Inc.)