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BackgroundThere is an increasing burden of cardiovascular disease, including coronary artery disease (CAD) and heart failure (HF), among women Veterans. Clinical practice guidelines recommend multiple pharmacotherapies that can reduce risk of mortality and adverse cardiovascular outcomes.ObjectiveTo determine if there are disparities in the use of guideline-directed medical therapy by gender among Veterans with incident CAD and HF.DesignRetrospective.ParticipantsVeterans (934,504; 87.8% men and 129,469; 12.2% women) returning from Operations Enduring Freedom, Iraqi Freedom, and New Dawn.Main measuresDifferences by gender in the prescription of Class 1, Level of Evidence A guideline-directed medical therapy among patients who developed incident CAD and HF at 30 days, 90 days, and 12 months after diagnosis. For CAD, medications included statins and antiplatelet therapy. For HF, medications included beta-blockers and renin-angiotensin-aldosterone system inhibitors.Key resultsOverall, women developed CAD and HF at a younger average age than men (mean 45.8 vs. 47.7 years, p

Prediabetes affects one-third of U.S. adults. Lifestyle change interventions, such as the Diabetes Prevention Program (DPP), can significantly lower type 2 diabetes risk, but little is known about how the DPP could be best adapted for women. This mixed-methods study assessed the impact of gender-tailoring and modality choice on DPP engagement among women Veterans with prediabetes. Participants were offered women-only groups and either in-person/peer-led or online modalities. Implementation outcomes were assessed using attendance logs, recruitment calls, and semi-structured interviews about patient preferences. Between June 2016 and March 2017, 119 women Veterans enrolled in the DPP (n = 51 in-person, n = 68 online). We conducted 22 interviews between August and September 2016 (n = 10 early-implementation) and March and July 2017 (n = 12 follow-up). Most interviewees preferred women-only groups, citing increased comfort, camaraderie, and mutual understanding of gender-specific barriers to lifestyle change. More women preferred online DPP, and those using this modality participated at higher rates. Most endorsed the importance of modality choice and were satisfied with their selection; however, selection was frequently based on participants' personal circumstances and access barriers and not on a "preferred choice" of two equally accessible options. Patient engagement and program reach can be expanded by tailoring the DPP for population-specific needs.

Background Veterans transitioning to civilian life often have chronic pain from service-related musculoskeletal disorders (MSD) with higher risk for substance misuse. Many seek VA (Department of Veterans Affairs) compensation for MSD. Use of Screening, Brief Intervention, and Referral to Treatment for Pain Management (SBIRT-PM) by VA Post-9/11 Military2VA (M2VA) case managers presents an opportunity to engage these veterans in VA pain care and address substance misuse. Implementation facilitation might help case managers use SBIRT-PM and engage veterans in services to improve outcomes. Design This study is a 2-cohort multisite cluster-randomized hybrid type 2 effectiveness-implementation trial. Within 2 separate cohorts of 14 VA sites each, sites will be allocated to receive an implementation strategy through the use of a constrained randomization procedure: virtual implementation facilitation or training-as-usual. Sites and M2VA case managers will receive the assigned implementation strategy to support use of SBIRT-PM. Recently discharged veterans (n  = 1848) claiming service-connected MSD will be recruited, with case managers blind to veterans' study enrollment. The proportion of participants who receive any SBIRT-PM will be the primary implementation outcome. Veteran participants will complete baseline, 12-week, and 36-week assessments, irrespective of whether case managers conduct SBIRT-PM with them (intent-to-treat). Pain intensity and interference will be the primary clinical outcomes. The study emphasizes pragmatic over explanatory methodological features. Summary This pragmatic trial will examine implementation facilitation versus training-as-usual in implementing SBIRT-PM to promote veteran engagement in nonpharmacological pain services. Using innovative methods to train and support VA case managers in SBIRT-PM, study outcomes could have broad implications for case management systems of care across the VA. [ABSTRACT FROM AUTHOR]

BACKGROUND:The Enhancing Mental and Physical health of Women through Engagement and Retention or EMPOWER program represents a partnership with the US Department of Veterans Health Administration (VA) Health Service Research and Development investigators and the VA Office of Women's Health, National Center for Disease Prevention and Health Promotion, Primary Care-Mental Health Integration Program Office, Women's Mental Health Services, and the Office of Patient Centered Care and Cultural Transformation. EMPOWER includes three projects designed to improve women Veterans' engagement and retention in evidence-based care for high-priority health conditions, i.e., prediabetes, cardiovascular, and mental health. METHODS/DESIGN:The three proposed projects will be conducted in VA primary care clinics that serve women Veterans including general primary care and women's health clinics. The first project is a 1-year quality improvement project targeting diabetes prevention. Two multi-site research implementation studies will focus on cardiovascular risk prevention and collaborative care to address women Veterans' mental health treatment needs respectively. All projects will use the evidence-based Replicating Effective Programs (REP) implementation strategy, enhanced with multi-stakeholder engagement and complexity theory. Mixed methods implementation evaluations will focus on investigating primary implementation outcomes of adoption, acceptability, feasibility, and reach. Program-wide organizational-, provider-, and patient-level measures and tools will be utilized to enhance synergy, productivity, and impact. Both implementation research studies will use a non-randomized stepped wedge design. DISCUSSION:EMPOWER represents a coherent program of women's health implementation research and quality improvement that utilizes cross-project implementation strategies and evaluation methodology. The EMPOWER Quality Enhancement Research Initiative (QUERI) will constitute a major milestone for realizing women Veterans' engagement and empowerment in the VA system. EMPOWER QUERI will be conducted in close partnership with key VA operations partners, such as the VA Office of Women's Health, to disseminate and spread the programs nationally. TRIAL REGISTRATION:The two implementation research studies described in this protocol have been registered as required: Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans: Trial registration NCT02991534 , registered 9 December 2016. Implementation of Tailored Collaborative Care for Women Veterans: Trial registration NCT02950961 , registered 21 October 2016.

IntroductionWomen Veterans may have higher rates of both active and passive tobacco exposure than their civilian counterparts, thereby increasing their risk for lung cancer.Purpose of the studyTo compare differences in active and passive smoking exposure and lung cancer incidence among women Veterans and non-Veterans using prospective data from the Women's Health Initiative (WHI).Design and methodsWe used data from the WHI, which collected longitudinal demographic, clinical, and laboratory data on 161,808 postmenopausal women. We employed linear and multinomial regression and generalized linear models to compare active and passive smoking exposure between Veterans and non-Veterans and Cox proportional hazards models to estimate differences in lung cancer incidence rates.ResultsAfter adjustment, Veterans had 2.54 additional pack years of smoking compared with non-Veterans (95% confidence interval [CI] 1.68, 3.40). Veterans also had a 1% increase in risk of any passive smoking exposure (95% CI 1.00, 1.02) and a 9% increase in risk of any workplace exposure (95% CI 1.07, 1.11) compared with non-Veterans. After adjustment for age and smoking exposures, Veterans did not have a higher risk of lung cancer compared with non-Veterans (relative risk = 1.06 95% CI 0.86, 1.30).ImplicationsWomen Veterans had higher rates of tobacco use and exposure to passive smoking, which were associated with a higher risk for lung cancer compared with non-Veterans. Clinicians who care for Veterans need to be aware that older women Veterans have more exposures to risk factors for lung cancer.

Military sexual trauma (MST) is associated with future intimate partner violence (IPV) experiences among women Veterans. Yet, no studies have examined this relationship among men nor determined whether MST, as a sexual trauma, is more related to sexual IPV than other forms of IPV. Thus, this study examined the associations between MST, and separately military sexual harassment (MSH) and assault (MSA), with both lifetime IPV and past-year IPV (physical, sexual, and emotional) among men and women Veterans. Participants included 1094 Veterans (567 women, 524 men, 3 unknown) from a survey of post-9/11 Veterans enrolled in Veterans Administration healthcare. The survey assessed MST using the VA 2-item screen, past year IPV using the Extended-Hurt Insult Threaten Scream screener, and lifetime IPV using the Traumatic Life Events Questionnaire. Chi-square tests revealed that women Veterans reported higher rates of MST, lifetime IPV, and recent sexual IPV. Men reported higher rates of recent overall IPV and recent psychological IPV. Men and women had equal rates of recent physical IPV. For men, MST was associated with lifetime IPV and recent psychological IPV. Among women, MST was associated with lifetime IPV and all forms of recent IPV, particularly sexual IPV. Moreover, IPV had a stronger relationship to MSA than to MSH. Results indicate that MST is related to IPV for men and women Veterans yet this relationship is stronger for women. Importantly, MSA appears more related to IPV than does MSH, underscoring a need to examine these variables separately in future studies., Author(s): Mark R. Relyea [sup.1] [sup.2] , Galina A. Portnoy [sup.1] [sup.2] , Joan L. Combellick [sup.1] [sup.2] , Cynthia A. Brandt [sup.1] [sup.2] , Sally G. Haskell [sup.1] [sup.2] [...]

Significant research has focused on intimate partner violence (IPV) victimization among women Veterans, yet much less is known about women Veterans' IPV perpetration. Although military sexual trauma (MST) is a predictor of IPV victimization, military sexual assault (MSA), a component of MST, may predict especially adverse consequences for women Veterans. This study examined the unique effects of MSA on IPV victimization of, and perpetration by, women Veterans, and investigated posttraumatic stress disorder (PTSD) symptoms and prior IPV victimization as potential mediators of IPV perpetration. Participants included 187 women Veterans drawn from a larger web-based survey. We assessed the two components of MST (MSA and harassment) at Time 1 (T1), PTSD symptoms at Time 2 (T2), IPV victimization at T2 and Time 3 (T3), and IPV perpetration at T3. MSA predicted multiple subtypes of IPV victimization and perpetration, whereas harassment predicted neither. Those who reported MSA were more likely to experience T3 psychological and sexual IPV victimization, with PTSD symptoms significantly mediating this path. MSA was also directly related to T3 psychological IPV perpetration and indirectly related to physical and sexual IPV perpetration through PTSD symptoms. MSA was directly related to T2 PTSD symptoms while T2 IPV victimization was directly related to T3 IPV perpetration. These findings underscore that women Veterans' IPV perpetration may be in response to their own IPV victimization through self-defense and/or due to their PTSD symptoms. Results support prevention, screening, and treatment for IPV victimization and PTSD symptoms to lower risk of future IPV revictimization and perpetration., Author(s): Galina A. Portnoy [sup.1] [sup.2] , Mark R. Relyea [sup.1] [sup.2] , Amy E. Street [sup.3] [sup.4] , Sally G. Haskell [sup.1] [sup.2] , Katherine M. Iverson [sup.3] [sup.4] [...]

Objective: Veterans are at high risk for eating disorders (EDs), and specifically for atypical anorexia nervosa (atypical AN). The current study aimed to better understand this under‐studied disorder and how it differs from weight loss without ED cognitive features. Method: Secondary analyses were conducted with data from a national study of Veterans (N = 882, 49.4% women). Participants were categorized into four mutually exclusive groups using the Eating Disorder Diagnostic Scale 5: probable atypical AN, a cognitive concerns group (Cog Only), a weight suppressed group (WS Only), and a no ED control group. Adjusted regression models were used to compare groups on measures of eating pathology and mental health. Three weight suppression thresholds (5%, 10%, and 15%) for probable atypical AN were also tested. Results: The sample was comprised of 12% probable atypical AN, 23.6% Cog Only, 16.3% WS Only, and 48.1% Control. The probable atypical AN group was most like the Cog Only group except for higher levels of dietary restraint. Atypical AN fared worse and was least like the Control group followed by the WS Only group. All weight suppression thresholds significantly predicted dietary restraint, with 5% being the best predictor. Discussion: Results found that probable atypical AN is a distinct clinical entity and that the exact weight suppression threshold associated with atypical AN is less important than having any weight suppression. Findings highlight the clinical significance of atypical AN and the importance of gaining a better understanding of how to address this clinical entity. Public significance: Atypical anorexia nervosa is a relatively underexamined but highly prevalent eating disorder in the Veteran population. Results show that ED cognitive features are more closely linked to clinically significant eating pathology and poor mental health than weight suppression alone suggesting that negative thinking about weight gain and appearance, regardless of the presence or severity of weight loss, may signal the need for specialized intervention. [ABSTRACT FROM AUTHOR]