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Objective Evaluate self-reported electronic screening (eScreening) in a VA Transition Care Management Program (TCM) to improve the accuracy and completeness of administrative ethnicity and race data. Materials and Methods We compared missing, declined, and complete (neither missing nor declined) rates between (1) TCM-eScreening (ethnicity and race entered into electronic tablet directly by patient using eScreening), (2) TCM-EHR (Veteran-completed paper form plus interview, data entered by staff), and (3) Standard-EHR (multiple processes, data entered by staff). The TCM-eScreening (n = 7113) and TCM-EHR groups (n = 7113) included post-9/11 Veterans. Standard-EHR Veterans included all non-TCM Gulf War and post-9/11 Veterans at VA San Diego (n = 92 921). Results Ethnicity: TCM-eScreening had lower rates of missingness than TCM-EHR and Standard-EHR (3.0% vs 5.3% and 8.6%, respectively, P .05) or data completeness (89.9% vs 91%, P > .05). Both had better data completeness than Standard-EHR (P Conculsions eScreening is a promising method for improving ethnicity and race data accuracy and completeness in VA.

Background Most states have recently passed laws requiring prescribers to use prescription drug monitoring programs (PDMPs) before prescribing opioid medications. The impact of these mandates on discontinuing chronic opioid therapy among Veterans managed in the Veterans Health Administration (VA) is unknown. We assess the association between the earliest of these laws and discontinuation of chronic opioid therapy in Veterans receiving VA health care. Methods We conducted a comparative interrupted time-series study in the 5 states mandating PDMP use before August 2013 (Ohio, West Virginia, Kentucky, New Mexico, and Tennessee), adjusting for trends in the 17 neighboring control states without such mandates. We modeled 25 months of prescribing for each state centered on the month the mandate became effective. We included Veterans prescribed long-term outpatient opioid therapy (305 of the preceding 365 d). Our outcomes were discontinuation of chronic opioid therapy (primary outcome) and the average daily quantity of opioids per Veteran over the following 6 months (secondary outcome). Results We included 250 monthly cohorts with 225,665 unique Veterans and 3.4 million Veteran-months. Baseline discontinuation rates before the PDMP mandates were 0.4%-2.7% per month. Kentucky saw a discontinuation increase of 1 absolute percentage point following its PDMP mandate which decreased over time. The other 4 states had no significant association between their mandates and change in opioid discontinuation. There was no evidence of decreasing opioid quantities following PDMP mandates. Conclusion We did not find consistent evidence that state laws mandating provider PDMP use were associated with the discontinuation of chronic opioid therapy within the VA for the time period studied.

Background and objectives Many kidney transplant recipients enrolled in the Veterans Health Administration are also enrolled in Medicare and eligible to receive both Veterans Health Administration and private sector care. Where these patients receive transplant care and its association with mortality are unknown. Design, setting, participants, & measurements We conducted a retrospective cohort study of veterans who underwent kidney transplantation between 2008 and 2016 and were dually enrolled in Veterans Health Administration and Medicare at the time of surgery. We categorized patients on the basis of the source of transplant-related care (i.e., outpatient transplant visits, immunosuppressive medication prescriptions, calcineurin inhibitor measurements) delivered during the first year after transplantation defined as Veterans Health Administration only, Medicare only (i.e., outside Veterans Health Administration using Medicare), or dual care (mixed use of Veterans Health Administration and Medicare). Using multivariable Cox regression, we examined the independent association of post-transplant care source with mortality at 5 years after kidney transplantation. Results Among 6206 dually enrolled veterans, 975 (16%) underwent transplantation at a Veterans Health Administration hospital and 5231 (84%) at a non–Veterans Health Administration hospital using Medicare. Post-transplant care was received by 752 patients (12%) through Veterans Health Administration only, 2092 (34%) through Medicare only, and 3362 (54%) through dual care. Compared with patients who were Veterans Health Administration only, 5-year mortality was significantly higher among patients who were Medicare only (adjusted hazard ratio, 2.2; 95% confidence interval, 1.5 to 3.1) and patients who were dual care (adjusted hazard ratio, 1.5; 95% confidence interval, 1.1 to 2.1). Conclusions Most dually enrolled veterans underwent transplantation at a non–Veterans Health Administration transplant center using Medicare, yet many relied on Veterans Health Administration for some or all of their post-transplant care. Veterans who received Veterans Health Administration–only post-transplant care had the lowest 5-year mortality.

Objective: To identify sociodemographic profiles of patients prescribed high-dose opioids . Design: Cross-sectional cohort study. Setting/Patients: Veterans dually-enrolled in Veterans Health Administration and Medicare Part D, with ≥ 1 opioid prescription in 2012. Main Outcome Measures: We identified five patient-level demographic characteristics and 12 community variables reflective of region, socioeconomic deprivation, safety, and internet connectivity. Our outcome was the proportion of veterans receiving >120 morphine milligram equivalents (MME) for ≥ 90 consecutive days, a Pharmacy Quality Alliance measure of chronic high-dose opioid prescribing. We used classification and regression tree (CART) methods to identify risk of chronic high-dose opioid prescribing for sociodemographic subgroups. Results: Overall, 17,271 (3.3 percent) of 525,716 dually enrolled veterans were prescribed chronic high-dose opioids. CART analyses identified 35 subgroups using four sociodemographic and five community-level measures, with high-dose opioid prescribing ranging from 0.28 percent to 12.1 percent. The subgroup (n = 16,302) with highest frequency of the outcome included veterans who were with disability, age 18-64 years, white or other race, and lived in the Western Census region. The subgroup (n = 14,835) with the lowest frequency of the outcome included veterans who were without disability, did not receive Medicare Part D Low Income Subsidy, were >85 years old, and lived in communities within the second and sixth to tenth deciles of community public assistance. Conclusions: Using CART analyses with sociodemographic and community-level variables only, we identified subgroups of veterans with a 43-fold difference in chronic high-dose opioid prescriptions. Interactions among disability, age, race/ ethnicity, and region should be considered when identifying high-risk subgroups in large populations.

Background Patients with diabetes (PWD) often experience diabetes distress which is associated with worse self-management and glycemic control. In contrast, PWD who receive support from family and friends (supporters) have better diabetes outcomes. Purpose To examine the associations of PWD diabetes distress and supporters’ distress about PWDs’ diabetes with supporters’ roles and PWD cardiometabolic outcomes. Methods We used baseline data from 239 adults with Type 2 diabetes and their supporters participating in a longitudinal trial. PWD and supporter diabetes distress (high vs. low) were determined using the Problem Areas in Diabetes Scale-5. Outcomes included PWD-reported help from supporters with self-care activities, supporter-reported strain, PWD metabolic outcomes (glycemic control [HbA1c], systolic blood pressure [SBP], and non-HDL cholesterol) and 5 and 10 year risk of cardiac event (calculated using the United Kingdom Prospective Diabetes Study algorithm). Results PWDs with high diabetes distress were more likely to report that their supporters helped with taking medications, coordinating medical care, and home glucose testing (p’s < .05), but not more likely to report help with diet or exercise. High supporter distress was associated with greater supporter strain (p < .001). High supporter diabetes distress was associated with higher PWD HbA1c (p = .045), non-HDL cholesterol (p = .011), and 5 (p = .002) and 10 year (p = .001) cardiac risk. Conclusions Adults with high diabetes distress report more supporter help with medically focused self-management but not with diet and exercise. Supporter distress about PWD diabetes was consistently associated with worse outcomes. PWD diabetes distress had mixed associations with their diabetes outcomes.

BACKGROUND/OBJECTIVES Geriatric guidelines recommend against statin use in older adults with limited life expectancy (LLE) or advanced dementia (AD). This study examined resident and facility factors predicting statin discontinuation after nursing home (NH) admission in veterans with LLE/AD taking statins for secondary prevention. DESIGN Retrospective cohort study of Veterans Affairs (VA) bar code medication administration records, Minimum Data Set (MDS) assessments, and utilization records linked to Medicare claims. SETTING VA NHs, known as community living centers (CLCs). PARTICIPANTS Veterans aged 65 and older with coronary artery disease, stroke, or diabetes mellitus, type II, admitted in fiscal years 2009 to 2015, who met criteria for LLE/AD on their admission MDS and received statins in the week after admission (n = 13,110). MEASUREMENTS Residents were followed until statin discontinuation (ie, gap in statin use ≥14 days), death, or censoring due to discharge, day 91 of the stay, or end of the study period. Competing risk models assessed cumulative incidence and predictors of discontinuation, stratified by whether the resident had their end-of-life (EOL) status designated or used hospice at admission. RESULTS Overall cumulative incidence of statin discontinuation was 31% (95% confidence interval [CI] = 30%-32%) by day 91, and it was markedly higher in those with (52%; 95% CI = 50%-55%) vs without (25%; 95% CI = 24%-26%) EOL designation/hospice. In patients with EOL designation/hospice (n = 2,374), obesity, congestive heart failure, and admission from nonhospital settings predicted decreased likelihood of discontinuation; AD, dependency in activities of daily living, greater number of medications, and geographic region predicted increased likelihood of discontinuation. In patients without EOL designation/hospice (n = 10,736), older age and several specific markers of poor prognosis predicted greater discontinuation, whereas obesity/overweight predicted decreased discontinuation. CONCLUSION Most veterans with LLE/AD taking statins for secondary prevention do not discontinue statins following CLC admission. Designating residents as EOL status, hospice use, and individual clinical factors indicating poor prognosis may prompt deprescribing.

Background: We sought to compare associations of contraceptive preferences, beliefs, self-efficacy, and knowledge with use of sterilization versus other methods of contraception. Materials and Methods: This is a secondary analysis of a telephone-based survey of a nationally representative sample of women Veterans not desiring future pregnancy. Contraceptive method used at last sex was categorized as female sterilization, long-acting reversible contraception (LARC), short-acting methods, or nonprescription methods/no method. Multinomial regression models were performed to compare the association between independent variables (contraceptive preferences, beliefs, self-efficacy, and knowledge) and use of sterilization versus other contraceptive methods. Results: Six hundred twelve women Veterans aged 18–44 years who were sexually active with men, had no history of hysterectomy or infertility, did not desire future pregnancy, and were not using male sterilization as their method of contraception were surveyed. A total of 208 women Veterans reported using female sterilization (34.0%). While method effectiveness was rated as extremely important by the majority of participants, there was no association between perceiving method effectiveness as extremely important and method selected in adjusted multinomial models. Women Veterans were more likely to use sterilization compared to hormonal methods of contraception if they reported that lack of hormones was an extremely important contraceptive method characteristic (aRRR 3.69, 95% CI 1.94–7.03). Women Veterans who strongly agreed with the belief that birth control decisions are mainly a woman's responsibility were less likely to use sterilization compared to LARC (aRRR 0.54, 95% CI 0.29–0.98). Conclusion: Associations between contraceptive preferences, beliefs, self-efficacy, and knowledge and use of sterilization in a population of women Veterans not desiring future pregnancy are complex, and decisions may not solely be driven by desire to select a highly effective method.

BACKGROUND: Experiences of discrimination are associated with poor health behaviors and outcomes. Understanding discrimination in health care informs interventions to improve health care experiences. OBJECTIVE: Describe the prevalence of, and variables associated with, perceived gender-based discrimination in the Veterans Affairs (VA) Healthcare System among women Veterans. DESIGN: A cross-sectional, telephone-based survey of a random na- tional sample of young female Veterans. PARTICIPANTS: Female VA primary care patients aged 18–45 years. MAIN MEASURES: The primary outcome was perceived gender-based discrimination in VA health care. Logistic and linear regression models were used to determine associations between any perceived discrim- ination and cumulative perceived discrimination with patient and health service characteristics. KEY RESULTS: Among 2294 women Veterans, 33.7% perceived gender- based discrimination in VA. Perceiving gender-based discrimination was associated with medical illness [adjusted odds ratio (aOR)=1.67, 95% confidence interval (CI)=1.34, 2.08], mental illness (aOR=2.06, 95% CI=1.57, 2.69), and military sexual trauma (aOR=2.65, 95% CI= 2.11, 3.32). Receiving most health care from the same VA provider (aOR=0.73, 95% CI=0.57, 0.94) and receiving care at a VA site with a women’s health clinic (aOR=0.76, 95% CI=0.61, 0.95) were associated with reduced odds of any perceived gender-based discrim- ination. Among those who perceived gender-based discrimination (n=733), perceived discrimination scores were higher among women with increased age, medical illness, or history of military sexual trauma and lower among those who saw the same VA provider for most medical care. CONCLUSIONS: One third of women Veterans perceived gender-based discrimination in VA. Obtaining most medical care from the same VA provider and having a women’s health clinic at one’s VA were associated with less perceived discrimination.

Background Elder abuse (EA) is common and has devastating health consequences yet is not systematically assessed or documented in most health systems, limiting efforts to target health care-based interventions. Our objective was to examine sociodemographic and medical characteristics associated with documented referrals for EA assessment or services in a national U.S. health care system. Methods We conducted a national case–control study in U.S. Veterans Health Administration facilities of primary care (PC)-engaged Veterans age ≥60 years who were evaluated by social work (SW) for EA-related concerns between 2010 and 2018. Cases were matched 1:5 to controls with a PC visit within 60 days of the matched case SW encounter. We examined the association of patient sociodemographic and health factors with receipt of EA services in unadjusted and adjusted models. Results Of 5 567 664 Veterans meeting eligibility criteria during the study period, 15 752 (0.3%) received services for EA (cases). Cases were mean age 74, and 54% unmarried. In adjusted logistic regression models (adjusted odds ratio; 95% confidence interval), age ≥ 85 (3.56 vs age 60–64; 3.24–3.91), female sex (1.96; 1.76–2.21), child as next-of-kin (1.70 vs spouse; 1.57–1.85), lower neighborhood socioeconomic status (1.18 per higher quartile; 1.15–1.21), dementia diagnosis (3.01; 2.77–3.28), and receiving a VA pension (1.34; 1.23–1.46) were associated with receiving EA services. Conclusion In the largest cohort of patients receiving EA-related health care services studied to date, this study identified novel factors associated with clinical suspicion of EA that can be used to inform improvements in health care-based EA surveillance and detection.

Background:Racial and ethnic disparities in anticoagulation exist in atrial fibrillation management in Medicare and the Veterans Health Administration, but the influence of dual Veterans Health Administration and Medicare enrollment is unclear. We compared anticoagulant initiation by race and ethnicity in dually enrolled patients and assessed the role of Medicare part D enrollment on anticoagulation disparities.Methods:We identified patients with incident atrial fibrillation (2014–2018) dually enrolled in Veterans Health Administration and Medicare. We assessed any anticoagulant initiation (warfarin or direct-acting oral anticoagulants [DOACs]) within 90 days of atrial fibrillation diagnosis and DOAC use among anticoagulant initiators. We modeled anticoagulant initiation, adjusting for patient, provider, and facility factors, including main effects for race and ethnicity and Medicare part D enrollment and an interaction term for these variables.Results:In 43 789 patients, 8.9% were Black, 3.6% Hispanic, and 87.5% White; 10.9% participated in Medicare part D. Overall, 29 680 (67.8%) patients initiated any anticoagulant, of whom 17 568 (59.2%) initiated DOACs. Lower proportions of Black (65.2%) than Hispanic (67.6%) or White (68.0%) patients initiated any anticoagulant (P=0.001) and, lower proportions of Black (56.3%) and Hispanic (55.9%) than White (59.6%) patients (P=0.001) initiated DOACs. Compared with White patients, Black patients had significantly lower initiation of any anticoagulant (adjusted odds ratio, 0.89 [95% CI, 0.82–0.97]). The adjusted odds ratios for DOAC initiation were significantly lower for Black (0.72 [95% CI, 0.65–0.81]) and Hispanic (0.84 [95% CI, 0.70–1.00]) than White patients. The interaction between race and ethnicity and Medicare part D enrollment was nonsignificant for any anticoagulant (P=0.99) and DOAC (P=0.27) therapies.Conclusions:In dually enrolled Veterans Health Administration and Medicare patients with atrial fibrillation, Black patients were less likely to initiate any anticoagulant, and Black and Hispanic patients were less likely to initiate DOACs. Medicare part D enrollment did not moderate the associations between race and ethnicity and anticoagulant therapies.

OBJECTIVE Guidelines advocate against tight glycemic control in older nursing home (NH) residents with advanced dementia (AD) or limited life expectancy (LLE). We evaluated the effect of deintensifying diabetes medications with regard to all-cause emergency department (ED) visits, hospitalizations, and death in NH residents with LLE/AD and tight glycemic control. RESEARCH DESIGN AND METHODS We conducted a national retrospective cohort study of 2,082 newly admitted nonhospice veteran NH residents with LLE/AD potentially overtreated for diabetes (HbA1c ≤7.5% and one or more diabetes medications) in fiscal years 2009–2015. Diabetes treatment deintensification (dose decrease or discontinuation of a noninsulin agent or stopping insulin sustained ≥7 days) was identified within 30 days after HbA1c measurement. To adjust for confounding, we used entropy weights to balance covariates between NH residents who deintensified versus continued medications. We used the Aalen-Johansen estimator to calculate the 60-day cumulative incidence and risk ratios (RRs) for ED or hospital visits and deaths. RESULTS Diabetes medications were deintensified for 27% of residents. In the subsequent 60 days, 28.5% of all residents were transferred to the ED or acute hospital setting for any cause and 3.9% died. After entropy weighting, deintensifying was not associated with 60-day all-cause ED visits or hospitalizations (RR 0.99 [95% CI 0.84, 1.18]) or 60-day mortality (1.52 [0.89, 2.81]). CONCLUSIONS Among NH residents with LLE/AD who may be inappropriately overtreated with tight glycemic control, deintensification of diabetes medications was not associated with increased risk of 60-day all-cause ED visits, hospitalization, or death.

Key Points Question Among patients with atrial fibrillation treated in the Veterans Health Administration system, are there racial/ethnic differences in the initiation of anticoagulation therapy? Findings In this cohort study of a nationally retrospective cohort of 111 666 patients with atrial fibrillation treated from 2014 to 2018, Black and Asian patients were less likely to initiate any anticoagulation therapy. Among initiators, Black, Hispanic, and American Indian/Alaska Native patients were less likely to initiate direct oral anticoagulants. Meaning In the Veterans Health Administration system, a national, integrated health system with improved access to medications through a uniform national drug formulary, racial and ethnic disparities appear to persist in atrial fibrillation management., This cohort study uses data from the Veterans Health Administration system to compare rates of initiation of anticoagulant therapy by race/ethnicity., Importance Atrial fibrillation is a common cardiac rhythm disturbance causing substantial morbidity and mortality that disproportionately affects racial/ethnic minority groups. Anticoagulation reduces stroke risk in atrial fibrillation, yet studies show it is underprescribed in racial/ethnic minority patients. Objective To compare initiation of anticoagulant therapy by race/ethnicity for patients in the Veterans Health Administration (VA) system with atrial fibrillation. Design, Setting, and Participants This retrospective cohort study included 111 666 patients within the VA system with incident atrial fibrillation between January 1, 2014, and December 31, 2018. Data were analyzed between December 1, 2019, and March 31, 2020. Exposures Any anticoagulation was defined as receipt of warfarin or direct-acting oral anticoagulants, apixaban, dabigatran, edoxaban, or rivaroxaban. Main Outcomes and Measures Initiation of any anticoagulation (or direct-acting oral anticoagulant therapy in those who initiated any anticoagulation) was examined within 90 days of an index atrial fibrillation diagnosis. Results Our final cohort comprised 111 666 patients (109 386 men [98.0%] and 95 493 White patients [85.5%]; mean [SD] age, 72.9 [10.4] years). A total of 69 590 patients (62.3%) initiated any anticoagulant therapy, varying 10.5 percentage points by race/ethnicity (P

CONTEXT: Women may be at risk for unintended pregnancy if they forgo contraception or use ineffective methods because they erroneously believe they are unlikely to conceive. However, the relationship between perceived susceptibility to pregnancy and contraceptive use is not fully understood. METHODS: Data collected in 2014–2016 for the Examining Contraceptive Use and Unmet Needs study were used to examine perceived susceptibility to pregnancy among 969 women veterans aged 20–45 who were at risk for unintended pregnancy and received primary care through the U.S. Veterans Administration system. Multivariable logistic regression was used to identify associations between perceived susceptibility to pregnancy (perceived likelihood during one year of unprotected intercourse) and use of any contraceptive at last sex. Multinomial regression models were used to examine method effectiveness among women who used a contraceptive at last sex. RESULTS: Forty percent of women perceived their susceptibility to pregnancy to be low. Compared with women with high perceived susceptibility to pregnancy, those with low perceived susceptibility were less likely to have used any contraceptive at last sex (86% vs. 96%; adjusted odds ratio, 0.2). Among contraceptive users, women with low perceived susceptibility were less likely than those with high perceived susceptibility to have used a highly effective method (26% vs. 34%; adjusted relative risk ratio, 0.6) or moderately effective method (34% vs. 39%; 0.6) at last sex. CONCLUSIONS: Identifying and addressing fertility misperceptions among women with low perceived susceptibility to pregnancy could help promote informed decision making about contraception and reduce the risk of unintended pregnancy.

Background Few studies have assessed prescription opioid supply preceding death in individuals dying from unintentional prescription opioid overdoses, or described the characteristics of these individuals, particularly among Veterans. Objectives To describe the history of prescription opioid supply preceding prescription opioid overdose death among Veterans. Methods In a national cohort of Veterans who filled ≥1 opioid prescriptions from the Veterans Health Administration (VA) or Medicare Part D during 2008–2013, we identified deaths from unintentional or undetermined-intent prescription opioid overdoses in 2012–2013. We captured opioid prescriptions using both linked VA and Part D data, and VA data only. Results Among 1181 decedents, 643 (54.4%) had prescription opioid supply on the day of death, and 735 (62.2%) within 30 days based on linked data, compared to 40.1% and 46.7%, respectively, using VA data alone. Decedents with prescription opioid supply were significantly older and less likely to have alcohol or illicit drugs as co-occurring substances involved in the overdose. Using linked data, 241 (20.4%) decedents lacked prescription opioid supply within a year of death. Conclusions Many VA patients who die from prescription opioid overdose receive opioid prescriptions outside VA or not at all. It is important to supplement VA with non-VA data to more accurately measure prescription opioid exposure and improve opioid medication safety.

Introduction: Homeless individuals, overrepresented by Veterans, are more likely to have chronic medical conditions and comorbidities. They receive less medical care and have poor health outcomes, though remain understudied. Atrial fibrillation (AF), the most common cardiovascular rhythm disorder, is managed largely through anticoagulation. Direct-acting oral anticoagulants (DOACs) have been shown superior to warfarin anticoagulation in efficacy, safety, and adherence, though costlier. Hypothesis: Homeless Veterans receive a worse standard of care for AF than non-homeless Veterans in terms of initiation of any anticoagulation therapy, and in prescription of DOACs vs warfarin among those who began therapy. Methods: We studied 181,982 Veterans with incident, non-valvular AF in the Veterans Affairs Healthcare system from 2010-2018 who were not previously anticoagulated. Those who died or entered hospice were excluded. We classified Veterans who had experienced homelessness in the 2 years prior to their AF diagnosis using ICD-9/10 diagnosis codes and through VA homeless services use. We used logistic regression to examine the odds of initiation of any, DOAC, or warfarin anticoagulation. Models were adjusted for sociodemographic characteristics (year, age, race, CHA2DS2-VASc stroke risk score, HAS-BLED bleeding risk score, renal disease, BMI) and provider factors (e.g. specialty, had a patient seen a cardiologist within 90 days of their diagnosis). Facility type was modeled as a random effect. Results: Most of our cohort were male (178,400, 98%) and White (155,142, 85.6%). The homeless population of 6,472 was overrepresented by Black patients (1,574, 24.5%) and presented with AF at a younger age. The likelihood of being anticoagulated was lower in all populations before 2014. Having a BMI less than 25, liver disease, or bleeding concerns decreased the likelihood of being anticoagulated, while patients with renal disease were less likely to be prescribed DOACs. Black and Hispanic patients were less likely to be prescribed DOACs, regardless of homelessness status. We found the adjusted odds ratio (aOR) of initiating any anticoagulant therapy for homeless Veterans was 0.71 (95% CI 0.67 - 0.75). Among those who initiated anticoagulation, homeless individuals were less likely than non-homeless Veterans to initiate DOACs (aOR 0.88, 95% CI 0.80-0.96). Conclusions: In a nationwide cohort of Veterans with AF, we found that homeless Veterans were less likely to initiate any anticoagulation, especially more effective DOAC therapy. These findings persisted after adjusting for sociodemographic and clinical factors within an integrated health system with broad access to medical treatment through a uniform drug formulary. Future research must examine and address systematic biases to ensure high quality and equitable care for the most vulnerable populations, including homeless Veterans.

Background: Atrial Fibrillation (AF) is the most common heart rhythm disorder in the US and is treated with anticoagulation to mediate patients’ increased risk of ischemic stroke and death. Direct-acting oral anticoagulants (DOACs) are associated with better patient outcomes than warfarin, but prior studies show disparities in DOAC prescription. AF patients with low socioeconomic status (SES) have an increased risk of AF incidence, adverse outcomes, and mortality. Despite SES disparities in AF outcomes and prescribed medications, the impact of neighborhood SES (ADI) on AF management is unclear. We hypothesized that in comparison to patients with high ADI (e.g. the most disadvantaged), those with low ADI will be more likely to initiate any oral anticoagulants (OACs) and will be more likely to initiate DOACs. Methods: We conducted a retrospective observational study using national data from the Veterans Health Administration (VA) of newly diagnosed AF patients. Our independent variable was ADI, a marker of SES incorporating income, education, employment etc. Our model assessed numerous baseline patient, provider, and system-level covariates. We grouped patients into ADI quintiles, with Q1 being the lowest ADI (e.g., the least disadvantaged) and Q5 being the highest ADI, and used Q5 as a reference value. We used mixed effects logistic regression models, with site as a random effect, to determine the adjusted odds of initiating any OACs and of initiating DOACs by ADI quintile. Results: In our final cohort including 111,666 patients, 10,9386 (98.0%) were male and 2280 (2.0%) were female. The overall mean age at diagnosis was 72.86 (SD 10.4). Patients had the following medical comorbidities: Congestive heart failure: 18212, (16.3%); Hypertension: 84944, (76.1%); Diabetes: 70673, (63.3%); Vascular Disease: 46599, (41.7%). The ADI quintiles included the following patients: Q1: 21570, (20.3%); Q2: 21032, (19.8%); Q3: 21439, (20.2%); Q4: 20974, (19.8%); Q5: 21215, (20.0%). There was no significant difference in the odds of initiating any OAC between ADI quintiles compared to Q5 (Q1: adjusted odds ratio [95% CI], 0.95 [ 0.9, 1.01]; p=0.11). Among patients initiating DOAC, there was a significant association between low ADI and higher odds of initiating DOAC (Q1: 1.39 [1.29, 1.50]); (Q2: 1.18 [1.10, 1.27]); (Q3: 1.13 [1.06, 1.20]); (Q4: 1.09 [1.02, 1.16]). Each ADI quintile had a significantly higher odds of initiating DOACs compared to the highest ADI quintile. Conclusions: Patients with lower ADI are significantly more likely to be prescribed DOACs compared to patients with the highest levels of ADI. We found no significant difference in initiation of any OAC between ADI quintiles, which may result from high Warfarin utilization in the VA compared to the general population. Our data suggests that differences in neighborhood deprivation contribute to disparities in the prescribing DOACs in the VA.

Introduction Among adults with Type 2 diabetes, low health literacy (HL) is a risk factor for negative health outcomes. Support from family and friends can improve adults' self-management and health-related outcomes. We examined whether supporters provided unique help to adults with diabetes and low HL and whether HL was associated with adults' perception of supporter helpfulness. Methods We used cross-sectional baseline survey data from 239 adult patients with diabetes enrolled in a randomized controlled trial with a support person. Patients reported level of supporter involvement with self-management roles. HL among patients and supporters was assessed using a validated HL screening tool. Patient perception of supporter helpfulness was assessed with a single item. We used multivariable logistic regression to examine associations of patient and supporter HL levels with supporter roles and patients' perception of supporter helpfulness. Results Patients with low HL were more likely to have a supporter with low HL (39% vs. 26%, p = .04). Patients with low HL had higher odds of receiving supporter help with calling health care providers (adjusted odds ratio [AOR] = 2.09, 95% CI [1.00, 4.39]), remembering medical appointments (AOR = 2.24, 95% CI [1.07, 4.69]), and giving directions when blood sugars were low (AOR = 2.51, 95% CI [1.20, 5.37]). Neither patient nor supporter HL was significantly associated with patients' perception of supporter helpfulness. Discussion Adults with diabetes and low HL reported more supporter involvement with specific self-management tasks than patients with adequate HL. Providers could consider targeted involvement of supporters to assist patients with chronic diseases and low HL, although they should be aware that supporters may be challenged by low HL. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

We evaluated the effectiveness of an intervention for patient-family dyads aimed at improving diabetes self-management and outcomes for adults with T2DM (AWD) at risk for complications. AWD were randomized with a family supporter to an intervention vs. usual care for 12 months. The intervention provided dyads: one health coaching session, biweekly automated phone calls to prompt action plans on new diabetes health concerns, coaching calls to prepare for medical visits, and medical visit summaries. 239 AWD-supporter dyads were enrolled at two Veterans Health Administration sites. AWD eligibility criteria included baseline HbA1c>8% or systolic blood pressure (SBP)>150mmHg. Intention-to-treat analyses of changes in outcomes were adjusted for baseline outcome levels, patient-supporter cohabitation, and patients’ baseline insulin use. 96% of dyads had complete 12-month outcome data. Enrolled patients were on average 60±9 years old and had HbA1c levels of 8.5±1.6% and SBP 140mmHg (IQR 128,150). 70% lived with their supporter. Over 12 months, Patient Activation Measure scores (pre-specified primary outcome) increased significantly more in the intervention group (intervention effect +2.6 points (95%CI 0.005, 5.149). There were no statistically significant differences by arm in diabetes-specific cardiac risk score, HbA1c, or SBP change. Patient self-reported adherence to healthy eating increased significantly more in the intervention group (intervention effect +0.7 days/week (95% CI 0.2, 1.2) but not for other self-management behaviors. 97% of patients and 94% of supporters in the intervention group agreed they would recommend the program to others. This family supporter-patient dyadic intervention successfully increased patient activation and one health behavior but not physiologic outcomes over a 12 month period. Improving sustained engagement of family supporters in care of diabetes for adults is feasible and could serve as an additional source of support for diabetes care. Disclosure A. Rosland: None. J. Piette: None. R.B. Trivedi: None. A.A. Lee: None. S.C. Stoll: None. M.K. Mor: None. D. Obrosky: None. E.A. Kerr: Advisory Panel; Self; Bind Insurance. M. Heisler: None. Funding Health Services Research and Development (IIR 14–074-1); Michigan Center for Diabetes Translational Research (5P60-DK09292); Michigan Claude D. Pepper Older Americans Independence Center (AG-024824); VA Ann Arbor Center for Clinical Management Research

Many adults with DM have a family supporter (FS) involved in their care. Informal support has been linked with better DM management and outcomes. We evaluated the effect of a patient and FS engagement intervention on FS roles in DM care, and the impact of those roles on HbA1c. Two-hundred and thirty-nine adult Veterans with type 2 DM and a FS were randomized to intervention vs. usual care for 12 months. Intervention dyads received one coaching session, biweekly automated calls to prompt action planning on new DM concerns, coaching calls to prepare for clinic visits, and summaries of primary care visits and DM complication risk. All models were controlled for baseline HbA1c, age, sex, insulin use, and FS cohabitation with patient. Over 12 months, participants in the intervention group were more likely to have increased involvement in several FS roles, including: deciding when to contact healthcare providers about concerns (AOR 2.080, 95% CI 1.137,3.804), remembering to go to appointments (AOR 2.852, 95% CI 1.503, 5.412), take (1.853, 95% CI 1.001, 3.428) and refill (AOR 2.193, 1.196, 4.019) medications, and perform (AOR 2.615, 95% CI 1.405, 4.867) and review (AOR 2.822, 95% CI 1.506, 5.290) home testing. Changes in help navigating the healthcare system, and encouraging healthy eating and exercise were not different by intervention arm. Help remembering to take medications at baseline was associated with 0.457% increase in HbA1c over 12 months (95% CI 0.107, 0.807, p=0.011), and no support roles were significantly associated with HbA1c decrease. In conclusion, this intervention increased FS involvement in diabetes-specific self-management, with less impact on general lifestyle support. Patients with support for taking medication prior to the intervention had significant subsequent increases in HbA1c. This may indicate family are recognizing which patients have challenges with medication taking, but need more training to effectively help improve subsequent patient outcomes. Disclosure M. Zupa: None. M. Heisler: None. J. Piette: None. R.B. Trivedi: None. S.C. Stoll: None. D. Obrosky: None. E.Z. Lovelace: None. M.K. Mor: None. A. Rosland: None. Funding VA Health Services Research and Development (IIR 14–074-1); Michigan Center for Diabetes Translational Research (5P60-DK09292); Michigan Claude D. Pepper Older Americans Independence Center (AG-024824); VA Ann Arbor Center for Clinical Management Research; University of Pittsburgh (5T32DK007052-45)

Background: Atrial fibrillation (AF) affects nearly 1 million patients in VA, with morbidity and mortality disproportionately affecting racial/ethnic minorities. Anticoagulation reduces stroke risk in AF, yet warfarin and direct oral anticoagulants (DOACs) are underused in minorities. We compared anticoagulant initiation by race/ethnicity for patients with AF in VA—which facilitates access to medications through a uniform drug formulary. Methods: Using the VA Corporate Data Warehouse, we identified patients from 1/1/2014 - 12/31/2018 with an AF diagnosis and a confirmatory diagnosis ≦180 days of their index AF diagnosis. We excluded patients with an AF diagnosis or anticoagulant therapy in the 2 years prior to their index AF diagnosis, as well as those with valvular heart disease, who died within 180 days of AF diagnosis, or had missing or “other” race/ethnicity. We categorized our independent variable as non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic. Our primary outcome was receipt of any anticoagulant ≦180 days of AF diagnosis as well as the type of anticoagulant (warfarin, DOAC) initiated. We used logistic regression to compare outcomes by race/ethnicity, adjusting for year of diagnosis, stroke risk with CHADS2VA2Sc score, renal disease, region and rurality. Results: We identified 148,062 patients with incident AF: 8.6% were NHB, 3.4% Hispanic. Overall, NHBs (57.7%) and Hispanics (58.4%) were less likely than NHWs (61.4%) to initiate any anticoagulant therapy (p Conclusions: In a national cohort of AF in VA, we identified significant racial/ethnic disparities in anticoagulant initiation, driven by growing disparities in DOAC initiation. Understanding these differences is essential to ensuring equitable AF care in the largest U.S. integrated health care system.

Nearly half of all pregnancies in the United States each year are unintended, with the highest rates observed among non-Hispanic black and Hispanic women. Little is known about whether variations in unintended pregnancy and contraceptive use across racial and ethnic groups persist among women veteran Veterans Affairs users who have more universal access than other populations to health care and contraceptive services.The objectives of this study were to identify a history of unintended pregnancy and describe patterns of contraceptive use across racial and ethnic groups among women veterans accessing Veterans Affairs primary care.Cross-sectional data from a national random sample of women veterans (n = 2302) aged 18-44 years who had accessed Veterans Affairs primary care in the previous 12 month were used to assess a history of unintended pregnancy (pregnancies reported as either unwanted or having occurred too soon). Any contraceptive use at last sex (both prescription and nonprescription methods) and prescription contraceptive use at last sex were assessed in the subset of women (n = 1341) identified as being at risk for unintended pregnancy. Prescription contraceptive methods include long-acting reversible contraceptive methods (intrauterine devices and subdermal implants), hormonal methods (pill, patch, ring, and injection), and female or male sterilization; nonprescription methods include barrier methods (eg, condoms, diaphragm), fertility-awareness methods, and withdrawal. Multivariable logistic regression models were used to examine the relationship between race/ethnicity with unintended pregnancy and contraceptive use at last sex.Overall, 94.4% of women veterans at risk of unintended pregnancy used any method of contraception at last sex. Intrauterine devices (18.9%), female surgical sterilization (16.9%), and birth control pills (15.9%) were the 3 most frequently used methods across the sample. Intrauterine devices were the most frequently used method for Hispanic, non-Hispanic white, and other non-Hispanic women, while female surgical sterilization was the most frequently used method among non-Hispanic black women. In adjusted models, Hispanic women (adjusted odds ratio, 1.60, 95% confidence interval, 1.15-2.21) and non-Hispanic black women (adjusted odds ratio, 1.84, 95% confidence interval, 1.44-2.36) were significantly more likely than non-Hispanic white women to report any history of unintended pregnancy. In the subcohort of 1341 women at risk of unintended pregnancy, there were no significant racial/ethnic differences in use of any contraception at last sex. However, significant differences were observed in the use of prescription methods at last sex. Hispanic women (adjusted odds ratio, 0.51, 95% confidence interval, 0.35-0.75) and non-Hispanic black women (adjusted odds ratio, 0.69, 95% confidence interval, 0.51-0.95) were significantly less likely than non-Hispanic white women to have used prescription contraception at last sex.Significant racial and ethnic differences exist in unintended pregnancy and contraceptive use among women veterans using Veterans Affairs care, suggesting the need for interventions to address potential disparities. Improving access to and delivery of patient-centered reproductive goals assessment and contraceptive counseling that can address knowledge gaps while respectfully considering individual patient preferences is needed to support women veterans' decision making and ensure equitable reproductive health services across Veterans Affairs.

Background While patients with substance use disorders (SUDs) are thought to encounter poor primary care experiences, the perspectives of patients with opioid use disorder (OUD), specifically, are unknown. This study compares the primary care experiences of patients with OUD, other SUDs and no SUD in the Veterans Health Administration. Methods The sample included Veterans who responded to the national Patient-Centered Medical Home Survey of Healthcare Experiences of Patients, 2013–2015. Respondents included 3554 patients with OUD, 36,175 with other SUDs, and 756,386 with no SUD; 742 OUD-diagnosed patients received buprenorphine. Multivariable multinomial logistic regressions estimated differences in the probability of reporting positive and negative experiences (0–100 scale) for patients with OUD, compared to patients with other SUDs and no SUD, and for OUD-diagnosed patients treated versus not treated with buprenorphine. Results Of all domains, patients with OUD reported the least positive experiences with access (31%) and medication decision-making (35%), and the most negative experiences with self-management support (35%) and provider communication (23%). Compared to the other groups, patients diagnosed with OUD reported fewer positive and/or more negative experiences with access, communication, office staff, provider ratings, comprehensiveness, care coordination, and self-management support (adjusted risk differences[aRDs] range from |2.9| to |7.0|). Among OUD-diagnosed patients, buprenorphine was associated with more positive experiences with comprehensiveness (aRD = 8.3) and self-management support (aRD = 7.1), and less negative experiences with care coordination (aRD = −4.9) and medication shared decision-making (aRD = −5.4). Conclusions In a national sample, patients diagnosed with OUD encounter less positive and more negative experiences than other primary care patients, including those with other SUDs. Buprenorphine treatment relates positively to experiences with care comprehensiveness, medication decisions, and care coordination. As stakeholders encourage more primary care providers to manage OUD, it will be important for healthcare systems to attend to patient access and experiences with care in these settings.

Objectives Continuation of aspirin for secondary prevention in persons with limited life expectancy (LLE) is controversial. We sought to determine the incidence and predictors of aspirin discontinuation in veterans with LLE and/or advanced dementia (LLE/AD) who were taking aspirin for secondary prevention at nursing home admission, stratified by whether their limited prognosis (LP) was explicitly documented at admission. Design Retrospective cohort study using linked Veterans Affairs (VA) and Medicare clinical/administrative data and Minimum Data Set resident assessments. Setting All VA nursing homes (referred to as community living centers [CLCs]) in the United States. Participants Older (≥65 y) CLC residents with LLE/AD, admitted for 7 days or longer in fiscal years 2009 to 2015, who had a history of coronary artery disease and/or stroke/transient ischemic attack, and used aspirin within the first week of CLC admission (n = 13 844). Measurements The primary dependent variable was aspirin discontinuation within the first 90 days after CLC admission, defined as 14 consecutive days of no aspirin receipt. Independent variables included an indicator for explicit documentation of LP, sociodemographics, environment of care characteristics, cardiovascular risk factors, bleeding risk factors, individual markers of poor prognosis (eg, cancer, weight loss), and facility characteristics. Fine and Gray subdistribution hazard models with death as a competing risk were used to assess predictors of discontinuation. Results Cumulative incidence of aspirin discontinuation was 27% (95% confidence interval [CI] = 26%-28%) in the full sample, 34% (95% CI = 33%-36%) in residents with explicit documentation of LP, and 24% (95% CI = 23%-25%) in residents with no such documentation. The associations of independent variables with aspirin discontinuation differed in residents with vs without explicit LP documentation at admission. Conclusion Just over one-quarter of patients discontinued aspirin, possibly reflecting the unclear role of aspirin in end of life among prescribers. Future research should compare outcomes of aspirin deprescribing in this population. J Am Geriatr Soc 68:725-735, 2020.

Background In 2018, the Department of Veterans Affairs (VA) issued Notice 2018-08 requiring facilities to complete “case reviews” for Veterans identified in the Stratification Tool for Opioid Risk Mitigation (STORM) dashboard as high risk for adverse outcomes among patients prescribed opioids. Half of the facilities were randomly assigned to a Notice version including additional oversight. We evaluated implementation strategies used, whether strategies differed by randomization arm, and which strategies were associated with case review completion rates. Methods Facility points of contact completed a survey assessing their facility’s use of 68 implementation strategies based on the Expert Recommendations for Implementing Change taxonomy. We collected respondent demographic information, facility-level characteristics, and case review completion rates (percentage of high-risk patients who received a case review). We used Kruskal-Wallis tests and negative binomial regression to assess strategy use and factors associated with case reviews. Results Contacts at 89 of 140 facilities completed the survey (64%) and reported using a median of 23 (IQR 16–31) strategies. The median case review completion rate was 71% (IQR 48–95%). Neither the number or types of strategies nor completion rates differed by randomization arm. The most common strategies were using the STORM dashboard (97%), working with local opinion leaders (80%), and recruiting local partners (80%). Characteristics associated with case review completion rates included respondents being ≤ 35 years old (incidence rate ratio, IRR 1.35, 95% CI 1.09–1.67) and having < 5 years in their primary role (IRR 1.23; 95% CI 1.01–1.51), and facilities having more prior academic detailing around pain and opioid safety (IRR 1.40, 95% CI 1.12–1.75). Controlling for these characteristics, implementation strategies associated with higher completion rates included (1) monitoring and adjusting practices (adjusted IRR (AIRR) 1.40, 95% CI 1.11–1.77), (2) identifying adaptations while maintaining core components (AIRR 1.28, 95% CI 1.03–1.60), (3) conducting initial training (AIRR 1.16, 95% CI 1.02–1.50), and (4) regularly sharing lessons learned (AIRR 1.32, 95% CI 1.09–1.59). Conclusions In this national evaluation of strategies used to implement case reviews of patients at high risk of opioid-related adverse events, point of contact age and tenure in the current role, prior pain-related academic detailing at the facility, and four specific implementation strategies were associated with case review completion rates, while randomization to additional centralized oversight was not. Trial registration This project is registered at the ISRCTN Registry with number ISRCTN16012111. The trial was first registered on May 3, 2017.

Background Women veterans who use the Veterans Affairs Healthcare System theoretically have access to the full range of contraceptive methods. This study explores match between currently used and self-reported “ideal” methods as a potential marker of contraceptive access and preference matching. Methods This mixed methods study uses data from a nationally representative survey of reproductive-aged women veterans who use the Veterans Affairs Healthcare System for primary care, including 979 participants at risk of unintended pregnancy. Women reported all contraceptive methods used in the past month and were asked, “If you could choose any method of contraception or birth control to prevent pregnancy, what would be your ideal choice?” and selected a single “ideal” method. If applicable, participants were additionally asked, “Why aren't you currently using this method of contraception?” We used adjusted logistic regression to identify patient-, provider-, and system-level factors associated with ideal–current method match. We qualitatively analyzed open-ended responses about reasons for ideal method nonuse. Results Overall, 58% were currently using their ideal method; match was greatest among women selecting an IUD as ideal (73%). Non-White race/ethnicity (adjusted odds ratio, 0.68; 95% confidence interval, 0.52–0.89) and mental illness (adjusted odds ratio, 0.69; 95% confidence interval, 0.52–0.92) were negatively associated with ideal–current match in adjusted analyses; the presence of a gynecologist at the primary care site was associated with an increased odds of match (adjusted odds ratio, 1.35; 95% confidence interval, 1.03–1.75). Modifiable barriers to ideal method use were cited by 23% of women, including access issues, cost concerns, and provider-level barriers; 79% of responses included nonmodifiable reasons for mismatch including relationship factors and pregnancy plans incongruent with ideal method use, suggesting limitations of our measure based on differential interpretation of the word “ideal.” Conclusions Many women veterans are not currently using the contraceptive method they consider ideal. Results emphasize the complexity of contraceptive method selection and of measuring contraceptive preference matching.

Background Although pregnancy intention is strongly associated with contraceptive use, little is known about the interaction between pregnancy intention and attitude, or how they jointly affect contraceptive use. Methods Cross-sectional data from a national survey of women veterans who receive care within the Veterans Affairs Healthcare System were used to examine relationships among pregnancy intention (in next year, in >1 year, never, not sure), attitude toward hypothetical pregnancy (worst thing, neutral, best thing), and contraceptive use among women at risk for unintended pregnancy. Bivariate and multivariable analyses assessed associations between pregnancy intention and attitude, both separately and jointly, with contraceptive use. Multinomial regression assessed the relationship of intention and attitude with contraceptive method effectiveness. Results Among 858 women at risk of unintended pregnancy, bivariate analysis demonstrated that pregnancy intention and attitude were associated, but not perfectly aligned. In logistic regression models including both variables, intention of never versus in next year (adjusted odds ratio [aOR], 2.78; 95% confidence interval [CI], 1.34–5.75) and attitude of worst thing versus best thing (aOR, 2.86; 95% CI, 1.42–5.74) were each positively associated with contraception use. Among women using contraception, intention of never (aOR, 3.17; 95% CI, 1.33–7.59) and attitude of worst thing (OR, 2.09; 95% CI, 1.05–4.17) were associated with use of highly effective (e.g., intrauterine devices and implants) versus least effective (e.g., barrier) methods. Conclusions These findings support prior research suggesting that pregnancy intention alone does not fully explain contraceptive behaviors and imply that attitude toward pregnancy plays an important role in shaping contraceptive use independent of pregnancy intentions.

Objective To evaluate the effect of dual use of VA/Medicare Part D drug benefits on antihypertensive medication supply in older Veterans with dementia. Data sources/study setting National, linked 2007-2010 Veterans Affairs (VA) and Medicare utilization and prescription records for 50,763 dementia patients with hypertension. Study design We used inverse probability of treatment (IPT)-weighted multinomial logistic regression to examine the association of dual prescription use with undersupply and oversupply of antihypertensives. Data collection/extraction methods Veterans Affairs and Part D prescription records were used to classify patients as VA-only, Part D-only, or dual VA/Part D users of antihypertensives and summarize their antihypertensive medication supply in 2010: (1) appropriate supply of all prescribed antihypertensive classes, (2) undersupply of ≥1 class with no oversupply of another class, (3) oversupply of ≥1 class with no undersupply, or (4) both undersupply and oversupply. Principal findings Dual prescription users were more likely than VA-only users to have undersupply only (aOR = 1.28; 95 percent CI = 1.18-1.39), oversupply only (aOR = 2.38; 95 percent CI = 2.15-2.64), and concurrent under- and oversupply (aOR = 2.89; 95 percent CI = 2.53-3.29), versus appropriate supply of all classes. Conclusions Obtaining antihypertensives through both VA and Part D was associated with increased antihypertensive under- and oversupply. Efforts to understand how best to coordinate dual-system prescription use are critically needed.

Background and objectives It is unknown whether iodinated contrast causes kidney parenchymal damage. Biomarkers that are more specific to nephron injury than serum creatinine may provide insight into whether contrast-associated AKI reflects tubular damage. We assessed the association between biomarker changes after contrast angiography with contrast-associated AKI and 90-day major adverse kidney events and death. Design, setting, participants, & measurements We conducted a longitudinal analysis of participants from the biomarker substudy of the Prevention of Serious Adverse Events following Angiography trial. We measured injury (kidney injury molecule-1, neutrophil gelatinase-associated lipocalin, IL-18) and repair (monocyte chemoattractant protein-1, uromodulin, YKL-40) proteins from plasma and urine samples at baseline and 2–4 hours postangiography. We assessed the associations between absolute changes and relative ratios of biomarkers with contrast-associated AKI and 90-day major adverse kidney events and death. Results Participants (n=922) were predominately men (97%) with diabetes (82%). Mean age was 70±8 years, and eGFR was 48±13 ml/min per 1.73 m2; 73 (8%) and 60 (7%) participants experienced contrast-associated AKI and 90-day major adverse kidney events and death, respectively. No postangiography urine biomarkers were associated with contrast-associated AKI. Postangiography plasma kidney injury molecule-1 and IL-18 were significantly higher in participants with contrast-associated AKI compared with those who did not develop contrast-associated AKI: 428 (248, 745) versus 306 (179, 567) mg/dl; P=0.04 and 325 (247, 422) versus 280 (212, 366) mg/dl; P=0.009, respectively. The majority of patients did not experience an increase in urine or plasma biomarkers. Absolute changes in plasma IL-18 were comparable in participants with contrast-associated AKI (−30 [−71, −9] mg/dl) and those without contrast-associated AKI (−27 [−53, −10] mg/dl; P=0.62). Relative ratios of plasma IL-18 were also comparable in participants with contrast-associated AKI (0.91; 0.86, 0.97) and those without contrast-associated AKI (0.91; 0.85, 0.96; P=0.54). Conclusions The lack of significant differences in the absolute changes and relative ratios of injury and repair biomarkers by contrast-associated AKI status suggests that the majority of mild contrast-associated AKI cases may be driven by hemodynamic changes at the kidney.

BACKGROUND Homeless patients describe poor experiences with primary care. In 2012, the Veterans Health Administration (VHA) implemented homeless-tailored primary care teams (Homeless Patient Aligned Care Team, HPACTs) that could improve the primary care experience for homeless patients. OBJECTIVE To assess differences in primary care experiences between homeless and nonhomeless Veterans receiving care in VHA facilities that had HPACTs available (HPACT facilities) and in VHA facilities lacking HPACTs (non-HPACT facilities). RESEARCH DESIGN We used multivariable multinomial regressions to estimate homeless versus nonhomeless patient differences in primary care experiences (categorized as negative/moderate/positive) reported on a national VHA survey. We compared the homeless versus nonhomeless risk differences (RDs) in reporting negative or positive experiences in 25 HPACT facilities versus 485 non-HPACT facilities. SUBJECTS Survey respondents from non-HPACT facilities (homeless: n=10,148; nonhomeless: n=309,779) and HPACT facilities (homeless: n=2022; nonhomeless: n=20,941). MEASURES Negative and positive experiences with access, communication, office staff, provider rating, comprehensiveness, coordination, shared decision-making, and self-management support. RESULTS In non-HPACT facilities, homeless patients reported more negative and fewer positive experiences than nonhomeless patients. However, these patterns of homeless versus nonhomeless differences were reversed in HPACT facilities for the domains of communication (positive experience RDs in non-HPACT versus HPACT facilities=-2.0 and 2.0, respectively); comprehensiveness (negative RDs=2.1 and -2.3), shared decision-making (negative RDs=1.2 and -1.8), and self-management support (negative RDs=0.1 and -4.5; positive RDs=0.5 and 8.0). CONCLUSIONS VHA facilities with HPACT programs appear to offer a better primary care experience for homeless versus nonhomeless Veterans, reversing the pattern of relatively poor primary care experiences often associated with homelessness.

BACKGROUND: Managing depression in primary care settings has increased with the rise of integrated models of care, such as patient-centered medical homes (PCMHs). The relationship between patient experience in PCMH settings and receipt of depression treatment is unknown. OBJECTIVE: In a large sample of Veterans diagnosed with depression, we examined whether positive PCMH experiences predicted subsequent initiation or continuation of treatment for depression. DESIGN AND PARTICIPANTS: We conducted a lagged cross-sectional study of depression treatment among Veterans with depression diagnoses (n = 27,362) in the years before (Y1) and after (Y2) they completed the Veterans Health Administration’s national 2013 PCMH Survey of Healthcare Experiences of Patients. MAIN MEASURES: We assessed patient experiences in four domains, each categorized as positive/moderate/negative. Depression treatment, determined from administrative records, was defined annually as 90 days of antidepressant medications or six psychotherapy visits. Multivariable logistic regressions measured associations between PCMH experiences and receipt of depression treatment in Y2, accounting for treatment in Y1. KEY RESULTS: Among those who did not receive depression treatment in Y1 (n = 4613), positive experiences in three domains (comprehensiveness, shared decision-making, self-management support) predicted greater initiation of treatment in Y2. Among those who received depression treatment in Y1 (n = 22,749), positive or moderate experiences in four domains (comprehensiveness, care coordination, medication decision-making, self-management support) predicted greater continuation of treatment in Y2. CONCLUSIONS: In a national PCMH setting, patient experiences with integrated care, including care coordination, comprehensiveness, involvement in shared decision-making, and self-management support predicted patients’ subsequent initiation and continuation of depression treatment over time—a relationship that could affect physical and mental health outcomes. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-018-4522-7) contains supplementary material, which is available to authorized users.

Veterans commonly receive care from both Veterans Health Administration (VA) and non-VA sources (i.e., dual use). A major challenge in comparing health outcomes between dual users and VA-predominant users is applying an accurate method of risk adjustment. To determine how different comorbidity indices affect the association between patterns of dual use and health outcomes. Retrospective cohort. A total of 316,775 community-dwelling Veterans (≥65 years) with type 2 diabetes who were enrolled in VA and fee-for-service Medicare from 2008 to 2010. We determined the associations between dual use and death or diabetes-related hospitalization in FY 2010 using multivariable models incorporating claims-based (Elixhauser) or medication-based (RxRisk-V) risk adjustment. Dual use was classified using four previously identified groups of health services users: 1) VA-predominant, 2) VA + Medicare visits and labs, 3) VA + Medicare test strips, and 4) VA + Medicare medications. Controlling for Elixhauser comorbidities, dual-use groups 2–4 had significantly decreased odds of death or hospitalization compared to VA-predominant users. Controlling for RxRisk-V comorbidities, groups 2–4 had increased odds of death compared to VA-predominant users, but variable odds of hospitalization, with group 2 having increased odds (OR 1.06, CI 1.04–1.09), while groups 3 (OR 0.96, CI 0.94–0.99) and 4 (OR 0.93, CI 0.89–0.97) had decreased odds. The method of risk adjustment drastically influences the direction of effect in health outcomes among dual users of VA and Medicare. These findings underscore the need for standardized and reliable risk adjustment methods that are not susceptible to measurement differences across different health systems.

Background Little is known about contraceptive care for the growing population of women veterans who receive care in the Veterans Administration (VA) healthcare system.

Introduction Racial/ethnic disparities exist in the Veterans Health Administration (VHA), despite financial barriers to care being largely mitigated and Veterans Administration’s (VA) organizational commitment to health equity. Accurately identifying minority veterans is critical to monitoring progress toward equity as the VHA treats an increasingly racially and ethnically diverse veteran population. Although the VHA’s completeness of race and ethnicity data is generally better than its public sector and private counterparts, the accuracy of the race and ethnicity in the various databases available to VHA is variable, as is the accuracy in identifying specific minority groups. The purpose of this article was to develop an algorithm for constructing race and ethnicity variables from data sources available to VHA researchers, to present demographic differences cross the data sources, and to apply the algorithm to one study year. Materials and Methods We used existing VHA survey data from the Survey of Healthcare Experiences of Patients (SHEP) and three commonly used administrative databases from 2003 to 2015: the VA Corporate Data Warehouse (CDW), VA Defense Identity Repository (VADIR), and Medicare. Using measures of agreement such as sensitivity, specificity, positive and negative predictive values, and Cohen kappa, we compared self-reported race and ethnicity from the SHEP and each of the other data sources. Based on these results, we propose an algorithm for combining data on race and ethnicity from these datasets. We included VHA patients who completed a SHEP and had race/ethnicity recorded in CDW, VADIR, and/or Medicare. Results Agreement between SHEP and other sources was high for Whites and Blacks and substantially lower for other minority groups. The CDW demonstrated better agreement than VADIR or Medicare. Conclusions We developed an algorithm of data source precedence in the VHA that improves the accuracy of the identification of historically under-identified minorities: (1) SHEP, (2) CDW, (3) Department of Defense’s VADIR, and (4) Medicare.

Background Compared to White patients in the United States, Black patients have a higher prevalence of hypertension and more severe forms of this condition. Objective To decrease racial disparities in blood pressure (BP) control among Black veterans with severe hypertension within a regional network of Veterans Affairs Medical Centers (VAMCs). Methods Health system leaders, clinicians, and health services researchers collaborated on a 12-month quality improvement (QI) project to: (1) examine project implementation and the QI strategies used to improve BP control and (2) assess the effect of the initiative on Black-White differences in BP control among veterans with severe hypertension. Results Within 9 participating VAMCs, the most frequently used QI strategies involved provider education (n=9), provider audit and feedback (n=8), and health care team change (n=7). Among 141,124 veterans with a diagnosis of hypertension, 9,913 had severe hypertension [2,533 (25.6%) Black and 7380 (74.4%) White]. Over the course of the project, the proportion of Black veterans with severe hypertension decreased from 7.5% to 6.6% (p=.002) and the racial difference in proportions for this condition decreased 0.9 percentage points, from 2.9% to 2.0% (p=.01). Conclusions A multicenter, equity-focused QI project in VA reduced the proportion of Black veterans with severe hypertension and ameliorated observed racial disparities for this condition. Embedding health services researchers within a QI team facilitated an evaluation of the processes and effectiveness of our initiative, providing a successful model for QI within a learning health care system.

Rationale & Objective The PRESERVE trial used a 2 × 2 factorial design to compare intravenous saline solution with intravenous sodium bicarbonate solution and oral N-acetylcysteine with placebo for the prevention of 90-day major adverse kidney events and death (MAKE-D) and contrast-associated acute kidney injury (CA-AKI) among patients with chronic kidney disease undergoing angiography. In this ancillary study, we evaluated the predictive capacities of preangiography injury and repair proteins in urine and plasma for MAKE-D, CA-AKI, and their impact on trial design. Study Design Longitudinal analysis. Setting & Participants A subset of participants from the PRESERVE trial. Exposures Injury (KIM-1, NGAL, and IL-18) and repair (MCP-1, UMOD, and YKL-40) proteins in urine and plasma 1 to 2 hours preangiography. Outcomes MAKE-D and CA-AKI. Analytical Approach We analyzed the associations of preangiography biomarkers with MAKE-D and with CA-AKI. We evaluated whether the biomarker levels could enrich the MAKE-D event rate and improve future clinical trial efficiency through an online biomarker prognostic enrichment tool available at prognosticenrichment.com. Results We measured plasma biomarkers in 916 participants and urine biomarkers in 797 participants. After adjusting for urinary albumin-creatinine ratio and baseline estimated glomerular filtration rate, preangiography levels of 4 plasma (KIM-1, NGAL, UMOD, and YKL-40) and 3 urine (NGAL, IL-18, and YKL-40) biomarkers were associated with MAKE-D. Only plasma KIM-1 level was significantly associated with CA-AKI after adjustment. Biomarker levels provided modest discriminatory capacity for MAKE-D. Screening patients using the 50th percentile of preangiography plasma KIM-1 or YKL-40 levels would have reduced the required sample size by 30% (∼2,000 participants). Limitations Evaluation of prognostic enrichment does not account for changing trial costs, time needed to screen patients, or loss to follow-up. Most participants were male, limiting the generalizability of our findings. Conclusions Preangiography levels of injury and repair biomarkers modestly predict the development of MAKE-D and can be used to improve the efficiency of future CA-AKI trials.

Many adults with diabetes have family or friend ‘supporters’ involved in their care. Adult-supporter dyads were recruited to a trial comparing usual care to a 12-month program to engage and train supporters. Potentially eligible patients with T2DM and either HbA1c>8% or high systolic BP were identified via medical records. Patients randomized to the program received biweekly automated calls prompting reports on diabetes status, with tailored feedback to patients and supporters. Before primary care appointments, health coaches conducted a ‘visit prep call’ to improve dyad engagement in the visit. We examined patient characteristics predicting enrollment, and patient, supporter, and call characteristics predicting visit prep and automated call completion via separate multi-level regression models. Of 1119 contacted, 239 dyads (21%) enrolled. Patient predictors of enrollment included younger age (M=60y enrolled vs. 62 not, p In conclusion, high BP predicted enrollment and engagement in a dyadic-based diabetes program more than high HbA1c. Programs emphasizing the importance of BP in preventing diabetes complications may increase participant engagement. Disclosure S.C. Stoll: None. J. Piette: None. R.B. Trivedi: None. A.A. Lee: None. D. Obrosky: None. M.K. Mor: Stock/Shareholder; Spouse/Partner; AbbVie Inc. M. Heisler: None. A. Rosland: None. Funding U.S. Department of Veterans Affairs (IIR 14–074-1); Michigan Center for Diabetes Translational Research (NIDDK5P60-DK09292); Michigan Claude D. Pepper Older Americans Independence Center (NIA AG-024824)

Background: It is unknown whether family members or friends (‘supporters’) tailor their assistance to the unique needs of patients with diabetes and low HL. Methods: Surveys were conducted among 239 VA healthcare system patients with type 2 diabetes who were 30-70 years old, had A1c>8% or high blood pressure, did not have dementia or need help with basic activities of daily living, and had an unpaid supporter who was involved in their care. Patients reported the frequency of supporter involvement with diabetes management roles (e.g., help filling medications). HL was assessed using two items from the well-validated Chew scale: 1) How often do you have problems learning about medical conditions because of difficulty understanding written information (0=none of the time, 4=all of the time), and 2) How confident are you filling out medical forms by yourself (0=extremely, 4=not at all). Those responding ‘3’ (somewhat) or greater were designated as low health literacy. Logistic regression models were used to identify the independent association between patient HL and types of supporter assistance. Findings: Patients with low HL were significantly more likely than patients with adequate HL to have a supporter with low HL (32% vs. 18% of supporters, p=0.02). Low patient HL was significantly associated with higher odds of supporters helping with: deciding when to call doctor (AOR=2.21, 95% CI: 1.10-4.42); remembering medical appointments (AOR=2.48, 95% CI: 1.24-4.98); navigating the health system (AOR=2.67, 95% CI: 1.34-5.32); and attending medical appointments with patient (AOR=2.11, 95% CI: 1.11-3.96). Patient HL was not associated with whether supporters helped with filling or taking medications, or managing diet and exercise. Conclusion: Supporters of patients with low HL were more likely to have low HL themselves, and to help patients with care coordination and equally likely to help with carrying out diabetes medication and lifestyle behaviors compared to patients with adequate HL. Disclosure B. Fields: None. A.A. Lee: None. J. Piette: None. R.B. Trivedi: None. D. Obrosky: None. M.K. Mor: Stock/Shareholder; Spouse/Partner; AbbVie Inc. M. Heisler: None. A. Rosland: None. Funding U.S. Department of Veterans Affairs (IIR 14–074-1); Michigan Center for Diabetes Translational Research (NIDDK5P60-DK09292); Michigan Claude D. Pepper Older Americans Independence Center (NIA AG-024824)

Objectives The objective of this study is to understand patient-, provider- and system-level factors associated with long-acting reversible contraception (LARC) use among women Veterans and with receipt of LARC methods within the Veterans Affairs (VA) system. Study design We analyzed data from a national telephone-based survey of 2302 women ages 18–44 receiving primary care in VA. Multivariable regression was used to examine adjusted associations of participant-reported patient-, provider- and facility-level factors with LARC use and within-VA receipt of LARC among women Veterans. Results Among 987 women Veterans at risk of unintended pregnancy, 294 (30%) reported using LARC, 65% of whom had received their method within VA. Higher LARC use was observed among women who were multiparous vs. nulliparous [adjusted odds ratio (aOR)=1.52; 95% confidence interval (CI)=1.04–2.22] and did not desire future pregnancies (aOR=1.88; 95% CI=1.31–2.68). Although overall LARC uptake was not associated with any provider- or facility-level factors, receipt of these methods within VA was associated with receiving both general and gender-specific health care by a single provider (aOR=2.81; 95% CI=1.20–6.61) and with receiving care within a women's health clinic (aOR=2.54; 95% CI=1.17–5.50). Conclusions While patient-level factors were more strongly correlated with use of LARC, provider- and system-level factors influence whether women received these methods within VA. Implications This study of patient-, provider- and system-level correlates of LARC use in VA, the country's largest integrated healthcare system, highlights that women Veterans share similar patient-level factors associated with LARC use as the general population and that continuity with providers and comprehensive women's health services can facilitate LARC access.

BACKGROUND: There is systemic undercoding of medical comorbidities within administrative claims in the Department of Veterans Affairs (VA). This leads to bias when applying claims-based risk adjustment indices to compare outcomes between VA and non-VA settings. Our objective was to compare the accuracy of a medication-based risk adjustment index (RxRisk-VM) to diagnostic claims-based indices for predicting mortality. METHODS: We modified the RxRisk-V index (RxRisk-VM) by incorporating VA and Medicare pharmacy and durable medical equipment claims in Veterans dually-enrolled in VA and Medicare in 2012. Using the concordance (C) statistic, we compared its accuracy in predicting 1 and 3-year all-cause mortality to the following models: demographics only, demographics plus prescription count, or demographics plus a diagnostic claims-based risk index (e.g., Charlson, Elixhauser, or Gagne). We also compared models containing demographics, RxRisk-VM, and a claims-based index. RESULTS: In our cohort of 271,184 dually-enrolled Veterans (mean age=70.5 years, 96.1% male, 81.7% non-Hispanic white), RxRisk-VM (C=0.773) exhibited greater accuracy in predicting 1-year mortality than demographics only (C=0.716) or prescription counts (C=0.744), but was less accurate than the Charlson (C=0.794), Elixhauser (C=0.80), or Gagne (C=0.810) indices (all P

Background In 2012, select Veterans Health Administration (VHA) facilities implemented a homeless-tailored medical home model, called Homeless Patient Aligned Care Teams (H-PACT), to improve care processes and outcomes for homeless Veterans. Objective The main aim of this study was to determine whether H-PACT offers a better patient experience than standard VHA primary care. Research design We used multivariable logistic regressions to estimate differences in the probability of reporting positive primary care experiences on a national survey. Subjects Homeless-experienced survey respondents enrolled in H-PACT (n=251) or standard primary care in facilities with H-PACT available (n=1527) and facilities without H-PACT (n=10,079). Measures Patient experiences in 8 domains from the Consumer Assessment of Healthcare Provider and Systems surveys. Domain scores were categorized as positive versus nonpositive. Results H-PACT patients were less likely than standard primary care patients to be female, have 4-year college degrees, or to have served in recent military conflicts; they received more primary care visits and social services. H-PACT patients were more likely than standard primary care patients in the same facilities to report positive experiences with access [adjusted risk difference (RD)=17.4], communication (RD=13.9), office staff (RD=13.1), provider ratings (RD=11.0), and comprehensiveness (RD=9.3). Standard primary care patients in facilities with H-PACT available were more likely than those from facilities without H-PACT to report positive experiences with communication (RD=4.7) and self-management support (RD=4.6). Conclusions Patient-centered medical homes designed to address the social determinants of health offer a better care experience for homeless patients, when compared with standard primary care approaches. The lessons learned from H-PACT can be applied throughout VHA and to other health care settings.

BACKGROUND Patient-Centered Medical Homes (PCMH) may be effective in managing care for racial/ethnic minorities with mental health and/or substance use disorders (MHSUDs). How such patients experience care in PCMH settings is relatively unknown.