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CONTEXT: Longitudinal studies examining care for seriously ill patients are needed to understand patients' experience of illness, evaluate interventions, and improve quality of care. Unfortunately, such studies face substantial methodological challenges. OBJECTIVES: This article describes such challenges and the strategies used to overcome them in a successfully implemented palliative care intervention trial for veterans. METHODS: Veterans admitted with a physician-estimated moderate-to-high one-year mortality risk were enrolled and followed up to three years, until death or study completion. Study protocols, procedures, and process data were intermittently analyzed to identify and develop strategies to address issues affecting study enrollment and interview completion rates. RESULTS: Of 561 patients who were eligible, 400 (71%) enrolled in the study; 357 (87%) alive at the end of Month 1 completed interviews; and 254 (88%) alive at Month 6 completed interviews. Of the 208 patients who died during the study and had identified a caregiver, we were able to conduct an after-death interview with 154 (74%) caregivers. A variety of strategies, such as systematic tracking and check-in calls, minimizing respondent burden, and maintaining interviewer-respondent dyads over time, were used to maximize enrollment rates, data collection, and retention. CONCLUSION: These data demonstrate that the use of diverse strategies and flexibility with regard to study protocols can result in successful recruitment, data collection, and retention of participants with serious illness. They thus show that longitudinal research can be successfully implemented with this population to evaluate interventions and examine patient experiences. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine the impact of participation in community-based support groups and human immunodeficiency virus (HIV) viral load on sexual behavior among gay men. METHODS: Using self-administered questionnaires, 46 seropositive support-group participants and 20 seropositive comparison subjects were asked about viral load and frequency of unprotected anal intercourse in 1996 and 1997 following the XI International Conference on AIDS. RESULTS: Support group participants reported less unprotected receptive anal sex at follow-up than did comparison subjects. Overall, study participants with undetectable viral loads reported more unprotected anal intercourse at follow-up than did participants with detectable viral loads. CONCLUSION: Among HIV-seropositive gay men, knowledge of an undetectable viral load may contribute to high-risk sexual-risk behavior. [ABSTRACT FROM AUTHOR]

Background: Previous research has shown that socioeconomic and demographic risk factors in children are additive and lead to increasingly negative impacts on vaccination coverage. The goal of this study is to examine if different combinations of four risk factors (infant sex, birth order, maternal education level, and family wealth status) vary by state among children 12-23 months in India and to determine the impact of ≥ 1 risk factor on differences in state vaccination rates., Methods: Using data from the National Family Health Survey (NFHS) conducted in India between 2005 and 2006 (NFHS-3) and 2015-2016 (NFHS-4), full vaccination of children 12-23 months was examined. Full vaccination was defined as receipt of one dose of bacillus Calmette-Guérin (BCG), three doses of diphtheria-pertussis-tetanus vaccine (DPT) vaccine, three doses of oral polio vaccine (OPV), and one dose of measles-containing vaccine (MCV). Associations between full vaccination and the four risk factors were assessed using logistic regression. Data were analyzed by the state of residence., Results: A total of 60.9% of children 12-23 months were fully vaccinated, in NFHS-4, ranging from 33.9% in Arunachal Pradesh to 91.3% in Punjab. In NFHS-4, the odds of full vaccination across all states were 15% lower among infants with 2 risk factors versus 0 or 1 risk factors (OR: 0.85, 95% CI: 0.80-0.91), and 28% lower among infants with 3 or 4 risk factors versus 0 or 1 risk factor (OR: 0.72, 95% CI: 0.67-0.78). Overall, the absolute difference in the full vaccination coverage in those with > 2 vs < 2 risk factors decreased from -13% in NFHS-3 to -5.6% in NFHS-4, with substantial variation across states., Conclusions: Disparities in full vaccination exist among children 12-23 months experiencing > 1 risk factor. Indian states that are more populous or located in the north were more likely to have greater disparities., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Matthew L. Boulton reports financial support was provided by National Institute on Minority Health and Health Disparities of the National Institutes of Health., (© 2023 The Author(s).)

Measles continues to result in focal outbreaks in India, despite over three decades of universal infant vaccination. The aims of this study were to examine measles immunity in the population of Chandigarh, India, and to compare immunity by vaccination vs. natural infection. In a cross-sectional study of individuals 1-60 years selected from 30 communities within Chandigarh during 2017-2018, measles immunity was assessed using serological surveys. Seropositivity was compared across demographic groups, and by prior history of vaccination and natural history of infection. Among those 1-20 years old, measles seropositivity, and histories of measles vaccination or prior measles diagnosis were separately assessed as outcomes in logistic regression models, with demographic factors as independent variables. Among 1690 participants, 94% were seropositive, and 6% had borderline or negative antibody levels. Of those positive, 30% had prior vaccination, 16% had a history of natural infection, and 54% had an unknown history. Over 50% of individuals among those >20 years old, had unknown history of immunity. In the multivariable regression models, vaccination was more common in younger ages (P < .0001), and in males compared to females (P = .0220), and in those with more education (P < .0001). The majority of the population was seropositive, and seropositivity increased with age. Older age groups were more likely to be protected because of previous natural infection, whereas younger age groups were protected by vaccination. There was inequity in vaccination coverage by gender, and maternal education status.

Background: Falls are a common complication experienced after a stroke and can cause serious detriments to physical health and social mobility, necessitating a dire need for intervention. Among recent advancements, wearable airbag technology has been designed to detect and mitigate fall impact. However, these devices have not been designed nor validated for the stroke population and thus, may inadequately detect falls in individuals with stroke-related motor impairments. To address this gap, we investigated whether population-specific training data and modeling parameters are required to pre-detect falls in a chronic stroke population., Methods: We collected data from a wearable airbag's inertial measurement units (IMUs) from individuals with (n = 20 stroke) and without (n = 15 control) history of stroke while performing a series of falls (842 falls total) and non-falls (961 non-falls total) in a laboratory setting. A leave-one-subject-out crossvalidation was used to compare the performance of two identical machine learned models (adaptive boosting classifier) trained on cohort-dependent data (control or stroke) to pre-detect falls in the stroke cohort., Results: The average performance of the model trained on stroke data (recall = 0.905, precision = 0.900) had statistically significantly better recall (P = 0.0035) than the model trained on control data (recall = 0.800, precision = 0.944), while precision was not statistically significantly different. Stratifying models trained on specific fall types revealed differences in pre-detecting anterior-posterior (AP) falls (stroke-trained model's F 1 -score was 35% higher, P = 0.019). Using activities of daily living as non-falls training data (compared to near-falls) significantly increased the AUC (Area under the receiver operating characteristic) for classifying AP falls for both models (P < 0.04). Preliminary analysis suggests that users with more severe stroke impairments benefit further from a stroke-trained model. The optimal lead time (time interval pre-impact to detect falls) differed between control- and stroke-trained models., Conclusions: These results demonstrate the importance of population sensitivity, non-falls data, and optimal lead time for machine learned pre-impact fall detection specific to stroke. Existing fall mitigation technologies should be challenged to include data of neurologically impaired individuals in model development to adequately detect falls in other high fall risk populations. Trial registration https://clinicaltrials.gov/ct2/show/NCT05076565 ; Unique Identifier: NCT05076565. Retrospectively registered on 13 October 2021., (© 2022. The Author(s).)

Background: The COVID-19 pandemic has changed the way orthopaedics programs are educating and recruiting residents and applicants. With an increased focus on online and virtual programming, there has been an uptick in social media usage by orthopaedics residencies as a means of communicating with applicants. This study investigated the growth in utilization of social media platforms by residency programs since the beginning of the COVID-19 pandemic., Methods: Instagram and Twitter were queried for each orthopaedic surgery residency program. It was determined if each program with a corresponding social media account was created before or after March 1, 2020. The number of posts per month were tabulated for accounts that existed prior to March 1, 2020., Results: 187 orthopaedic surgery residency programs were identified using the AAMC ERAS database. Of these programs, 74 (41.6%) were found to have an Instagram profile, and 50 (26.7%) were found to have a Twitter page. Of the 74 Instagram profiles, 45 were created after March 1, 2020, representing a 155% increase. Of the 50 Twitter pages, 15 were created after March 1, 2020, representing a 43% increase. Instagram accounts that were active before the pandemic had a 96% increase in the number of posts per month, on average, after March 1, 2020., Conclusion: Over one-third of programs are utilizing social media for recruitment purposes. There has been an 155% increase in Instagram and 43% increase in Twitter usage by residency programs since March 1, 2020. Instagram accounts created prior to the pandemic also demonstrated a near doubling of increased utilization after March. This represents a new, cost-effective way to connect with applicants in a time when in-person interactions are limited. Level of Evidence: III., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study., (Copyright © The Iowa Orthopaedic Journal 2021.)

Background/aims: We examined the quality of palliative care received by patients with decompensated cirrhosis using an explicit set of palliative care quality indicators (QIs) for patients with end-stage liver disease (PC-ESLD)., Methods: We identified patients newly diagnosed with decompensated cirrhosis at a single veterans health center and followed up them for 2 years or until death. We piloted measurement of PC-ESLD QIs in all patients confirmed to have ESLD using a chart abstraction tool., Results: Out of 167 patients identified using at least one sampling strategy, 62 were confirmed to meet ESLD criteria with chart abstraction. Ninety-eight percent of veterans in the cohort were male, mean age at diagnosis was 61 years, and 74% were White. The overall QI pass rate was 68% (64% for information care planning QIs and 76% for supportive care QIs). Patients receiving specialty palliative care consultation were more likely to receive information care planning QIs (67% vs. 37%, p = 0.02). The best performing sampling strategy had a sensitivity of 62% and specificity of 60%., Conclusion: Measuring the quality of palliative care for patients with ESLD is feasible in the veteran population. Our single-center data suggest that the quality of palliative care is inadequate in the veteran population with ESLD, though patients offered specialty palliative care consultation and those affected by homelessness, drug, and alcohol abuse may receive better care. Our combination of ICD-9 codes can be used to identify a cohort of patients with ESLD, though better sensitivity and specificity may be needed.

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

Introduction: The Veterans Health Administration (VHA), the largest integrated healthcare delivery system in the United States, is charged with ensuring timely access to high-quality care for veterans during disasters, and supporting national, state, local, and tribal emergency management and homeland security efforts. In 2008, the VHA Office of Public Health (OPH) sponsored the first VHA Emergency Management Research Agenda-setting conference to develop research priorities that address the needs of veterans and to position VHA as a national leader in emergency management by having VHA serve as a "laboratory" for the development of evidence-based emergency management practices., Methods: We focused on four steps: #1: Appraising the emergency management research portfolio of VHA-based researchers; #2: Obtaining systematic information on VHA's role in emergency management and the healthcare needs of veterans during disasters; #3: Based upon gaps between the current research portfolio and the existing evidence base, identifying strategic priorities using a research agenda-setting conference; and #4: Laying the groundwork to foster the conduct of emergency management research within VHA., Results: Identified research priorities included how to prevent and treat behavioral health problems related to a disaster, the efficacy of training programs, crisis communication strategies, workforce resilience, and evacuating veterans from health care facilities. Conclusion: VHA is uniquely situated to answer research questions that cannot be readily addressed in other settings. VHA should partner with other governmental and private entities to build on existing work and establish shared research priorities.

Introduction There have been numerous initiatives by government and private organizations to help hospitals become better prepared for major disasters and public health emergencies. This study reports on efforts by the US Department of Veterans Affairs (VA), Veterans Health Administration, Office of Emergency Management's (OEM) Comprehensive Emergency Management Program (CEMP) to assess the readiness of VA Medical Centers (VAMCs) across the nation. Hypothesis/Problem This study conducts descriptive analyses of preparedness assessments of VAMCs and examines change in hospital readiness over time., Methods: To assess change, quantitative analyses of data from two phases of preparedness assessments (Phase I: 2008-2010; Phase II: 2011-2013) at 137 VAMCs were conducted using 61 unique capabilities assessed during the two phases. The initial five-point Likert-like scale used to rate each capability was collapsed into a dichotomous variable: "not-developed=0" versus "developed=1." To describe changes in preparedness over time, four new categories were created from the Phase I and Phase II dichotomous variables: (1) rated developed in both phases; (2) rated not-developed in Phase I but rated developed in Phase II; (3) rated not-developed in both phases; and (4) rated developed in Phase I but rated not- developed in Phase II., Results: From a total of 61 unique emergency preparedness capabilities, 33 items achieved the desired outcome - they were rated either "developed in both phases" or "became developed" in Phase II for at least 80% of VAMCs. For 14 items, 70%-80% of VAMCs achieved the desired outcome. The remaining 14 items were identified as "low-performing" capabilities, defined as less than 70% of VAMCs achieved the desired outcome., Conclusion: Measuring emergency management capabilities is a necessary first step to improving those capabilities. Furthermore, assessing hospital readiness over time and creating robust hospital readiness assessment tools can help hospitals make informed decisions regarding allocation of resources to ensure patient safety, provide timely access to high-quality patient care, and identify best practices in emergency management during and after disasters. Moreover, with some minor modifications, this comprehensive, all-hazards-based, hospital preparedness assessment tool could be adapted for use beyond the VA. Der-Martirosian C , Radcliff TA , Gable AR , Riopelle D , Hagigi FA , Brewster P , Dobalian A . Assessing hospital disaster readiness over time at the US Department of Veterans Affairs. Prehsop Disaster Med. 2017;32(1):46-57.

Accurate and early prediction of tissue viability is the most significant determinant of tissue flap survival in reconstructive surgery. Perturbation in tissue water content (TWC) is a generic component of the tissue response to such surgeries, and, therefore, may be an important diagnostic target for assessing the extent of flap viability in vivo . We have previously shown that reflective terahertz (THz) imaging, a non-ionizing technique, can generate spatially resolved maps of TWC in superficial soft tissues, such as cornea and wounds, on the order of minutes. Herein, we report the first in vivo pilot study to investigate the utility of reflective THz TWC imaging for early assessment of skin flap viability. We obtained longitudinal visible and reflective THz imagery comparing 3 bipedicled flaps (i.e. survival model) and 3 fully excised flaps (i.e. failure model) in the dorsal skin of rats over a postoperative period of 7 days. While visual differences between both models manifested 48 hr after surgery, statistically significant ( p < 0.05, independent t -test) local differences in TWC contrast were evident in THz flap image sets as early as 24 hr. Excised flaps, histologically confirmed as necrotic, demonstrated a significant, yet localized, reduction in TWC in the flap region compared to non-traumatized skin. In contrast, bipedicled flaps, histologically verified as viable, displayed mostly uniform, unperturbed TWC across the flap tissue. These results indicate the practical potential of THz TWC sensing to accurately predict flap failure 24 hours earlier than clinical examination.

Unlabelled: Introduction Hospitals play a critical role in providing health care in the aftermath of disasters and emergencies. Nonetheless, while multiple tools exist to assess hospital disaster preparedness, existing instruments have not been tested adequately for validity. Hypothesis/Problem This study reports on the development of a preparedness assessment tool for hospitals that are part of the US Department of Veterans Affairs (VA; Washington, DC USA)., Methods: The authors evaluated hospital preparedness in six "Mission Areas" (MAs: Program Management; Incident Management; Safety and Security; Resiliency and Continuity; Medical Surge; and Support to External Requirements), each composed of various observable hospital preparedness capabilities, among 140 VA Medical Centers (VAMCs). This paper reports on two successive assessments (Phase I and Phase II) to assess the MAs' construct validity, or the degree to which component capabilities relate to one another to represent the associated domain successfully. This report describes a two-stage confirmatory factor analysis (CFA) of candidate items for a comprehensive survey implemented to assess emergency preparedness in a hospital setting., Results: The individual CFAs by MA received acceptable fit statistics with some exceptions. Some individual items did not have adequate factor loadings within their hypothesized factor (or MA) and were dropped from the analyses in order to obtain acceptable fit statistics. The Phase II modified tool was better able to assess the pre-determined MAs. For each MA, except for Resiliency and Continuity (MA 4), the CFA confirmed one latent variable. In Phase I, two sub-scales (seven and nine items in each respective sub-scale) and in Phase II, three sub-scales (eight, four, and eight items in each respective sub-scale) were confirmed for MA 4. The MA 4 capabilities comprise multiple sub-domains, and future assessment protocols should consider re-classifying MA 4 into three distinct MAs., Conclusion: The assessments provide a comprehensive and consistent, but flexible, approach for ascertaining health system preparedness. This approach can provide an organization with a clear understanding of areas for improvement and could be adapted into a standard for hospital readiness. Dobalian A , Stein JA , Radcliff TA , Riopelle D , Brewster P , Hagigi F , Der-Martirosian C . Developing valid measures of emergency management capabilities within US Department of Veterans Affairs hospitals. Prehosp Disaster Med. 2016;31(5):475-484.

Background: During an earthquake, vulnerable populations, especially those with chronic conditions, are more susceptible to adverse, event-induced exacerbation of chronic conditions such as limited access to food and water, extreme weather temperatures, and injury. These circumstances merit special attention when health care facilities and organizations prepare for and respond to disasters., Methods: This study explores the relationship between pre-earthquake burden of illness and post earthquake health-related and preparedness factors in the US. Data from a cohort of male veterans who were receiving care at the Sepulveda Veterans Affairs Medical Center (VAMC) in Los Angeles, California USA during the 1994 Northridge earthquake were analyzed., Results: Veterans with one or more chronic conditions were more likely to report pain lasting two or more days, severe mental/emotional stress for more than two weeks, broken/lost medical equipment, having difficulty refilling prescriptions, and being unable to get medical help following the quake compared to veterans without chronic conditions. In terms of personal emergency preparedness, however, there was no association between burden of illness and having enough food or water for at least 24 hours after the earthquake., Conclusion: The relationship that exists between health care providers, including both individual providers and organizations like the US Department of Veterans Affairs (VA), and their vulnerable, chronically-ill patients affords providers the unique opportunity to deliver critical assistance that could make this vulnerable population better prepared to meet their post disaster health-related needs. This can be accomplished through education about preparedness and the provision of easier access to medical supplies. Disaster plans for those who are burdened with chronic conditions should meet their social needs in addition to their psychological and physical needs.

Objective: The effectiveness of local public health systems in emergency management depends on trust from the entire community. However, the failure of some government agencies to respond effectively to several major disasters has had a disproportionate impact on certain groups-racial/ethnic minorities, in particular-that are well-represented in the veteran population. Many veterans belong to multiple vulnerable populations at greater risk of harm during disasters. This study examines confidence that local public health systems will respond fairly to disasters in a diverse sample of US veterans., Methods: This study is an analysis of cross-sectional data on 5955 veterans in the 2009 California Health Interview Survey. Respondents were asked about their confidence that public health systems would respond fairly to their needs in the event of a disaster, regardless of their race/ethnicity or other personal characteristics. Multivariable regression analysis was used to identify variables on respondent characteristics that were independently associated with confidence. The hypothesis was that there would be less confidence in county public health systems among respondents who were racial/ethnic minorities, had less than a college degree, and were of low-income backgrounds., Results: Approximately 79% of veterans were confident that public health systems would respond fairly. The hypothesis was unsupported, with no differences in confidence by race/ethnicity, education, or income. Also, no differences were noted between men and women or between veterans with and without disabilities. However, confidence was associated with continent of birth, age, homeownership, and marital status., Conclusion: If confidence affects veterans’ willingness to accept disaster preparedness communications or to give proper consideration to recommended emergency countermeasures, then local health departments that issue such information to veterans are not likely to encounter barriers by race/ethnicity, income, education, disability status, or gender.

Background: Timely access to healthcare is essential to ensuring optimal health outcomes, and not surprisingly, is at the heart of healthcare reform efforts. While the Veterans Health Administration (VA) has made improved access a priority, women veterans still underutilize VA healthcare relative to men. Eliminating access disparities requires a better understanding of the barriers to care that women veterans' experience., Objective: We examined the association of general and veteran-specific barriers on access to healthcare among women veterans., Design and Participants: Cross-sectional, population-based national telephone survey of 3,611 women veterans., Main Measure: Delayed healthcare or unmet healthcare need in the prior 12 months., Key Results: Of women veterans, 19% had delayed healthcare or unmet need, with higher rates in younger age groups (36%, 29%, 16%, 7%, respectively, in 18-34, 35-49, 50-64, and 65-plus age groups; p < 0.001). Among those delaying or going without care, barriers that varied by age group were: unaffordable healthcare (63% of 18-34 versus 12% of 65-plus age groups); inability to take off from work (39% of those <50); and transportation difficulties (36% of 65-plus). Controlling for age, race/ethnicity, regular source of care, and health status, being uninsured (OR = 6.5; confidence interval [CI] 3.0-14.0), knowledge gaps about VA care (OR = 2.1; 95% CI 1.1-4.0), perception that VA providers are not gender-sensitive (OR = 2.4; CI 1.2-4.7), and military sexual assault history (OR = 2.1; CI 1.1-4.0) predicted delaying or foregoing care, whereas VA use and enrollment priority did not., Conclusions: Both general and veteran-specific factors impact women veterans' access to needed services. Many of the identified access barriers are potentially modifiable through expanded VA healthcare and social services. Health reform efforts should address these barriers for VA nonusers. Efforts are also warranted to improve women veterans' knowledge of availability and affordability of VA healthcare, and to enhance the gender-sensitivity of this care.

Objective: The 1994 earthquake that struck Northridge, California, led to the closure of the Veterans Health Administration Medical Center at Sepulveda. This article examines the earthquake's impact on the mental health of an existing cohort of veterans who had previously used the Sepulveda Veterans Health Administration Medical Center., Methods: From 1 to 3 months after the disaster, trained interviewers made repeated attempts to contact participants by telephone to administer a repeated measures follow-up design survey based on a survey that had been done preearthquake. Postearthquake data were obtained on 1144 of 1800 (64%) male veterans for whom there were previous data. We tested a predictive latent variable path model of the relations between sociodemographic characteristics, predisaster physical and emotional health measures, and postdisaster emotional health and perceived earthquake impact., Results: Perceived earthquake impact was predicted by predisaster emotional distress, functional limitations, and number of health conditions. Postdisaster emotional distress was predicted by preexisting emotional distress and earthquake impact. The regression coefficient from earthquake impact to postearthquake emotional distress was larger than that of the stability coefficient from preearthquake emotional distress. Postearthquake emotional distress also was affected indirectly by preearthquake emotional distress, health conditions, younger age, and lower socioeconomic status., Conclusions: The postdisaster emotional health of veterans who experienced greater earthquake impact would have likely benefited from postdisaster intervention, regardless of their predisaster emotional health. Younger veterans and veterans with generally poor physical and emotional health were more vulnerable to greater postearthquake emotional distress. Veterans of lower socioeconomic status were disproportionately likely to experience more effects of the disaster because they had more predisaster emotional distress, more functional limitations, and a greater number of health conditions. Because many veterans use non-Department of Veterans Affairs (VA) health care providers for at least some of their health needs, future disaster planning for both VA and non-VA providers should incorporate interventions targeted at these groups.

Objectives: Veterans experience a particularly heavy burden with smoking rates higher than the general population, and the smoking prevalence for women Veterans has increased in recent years. We examined differences in smoking prevalence and treatment by gender for Veterans receiving at least some of their care at a VA facility, and examined the degree to which organizational factors may be associated with reductions in gender disparities in smoking cessation treatment., Methods: We merged national organizational-level data focused on primary care (sites = 225) and women's health (sites = 195) with patient-level survey data (n = 15,033 smokers). Organizational measures focused on smoking cessation-specific structure and processes in primary care and women's health. Primary outcomes were patient-reported receipt of smoking cessation treatments-advised to quit, medication recommendation, and other treatment recommendation. We used multi-level, random-intercept logistic regression., Results: In 2007, 29% of women and 23% of men were smokers. Overall, 83% of smokers reported they had been advised to quit, 62% recommended medications, and 60% recommended other treatments. Women were more likely to report being advised to quit (odds ratio, 1.33; 95% confidence interval, 1.07-1.64) but equally likely as men to have medications or other treatment recommended. Organizational factors did not eliminate the gender differences in being advised to quit., Conclusion: Despite having equivalent or higher smoking cessation treatment rates, women Veterans were more likely to smoke than men. With the rapid growth of women entering VA care, the need for effective gender-focused and gender-sensitive smoking cessation care arrangements is critical for the future health of women who have served., (Published by Elsevier Inc.)

Background: Primary care delivery models tailored to women's needs and preferences are associated with higher quality and satisfaction. Therefore, the U.S. Department of Veterans Affairs (VA) recommends adoption of designated providers for women in primary care clinics or women's health centers as the optimal models for women's primary care. We assessed women veterans' ratings of their VA health care quality, gender-related satisfaction, gender appropriateness, and VA provider skills in treating women, in relation to primary care model at VA sites nationwide., Methods: Health care ratings were obtained from VA users in the 2008-2009 National Survey of Women Veterans. VA administrative data identified the site for each respondent's primary care. Facility data identified the site's primary care model for women. We conducted multilevel modeling to compare health care ratings for sites serving 300 or more women veterans who had adopted VA recommendations for women's primary care models (adopter sites), with non-adopter sites, and with small sites serving fewer women veterans, adjusting for patient characteristics., Results: Adopter sites received higher adjusted ratings of gender-related satisfaction and perceptions of VA provider skills than non-adopter and small sites. Adopter sites also received higher adjusted ratings of gender appropriateness than small sites. Adjusted ratings of quality of care did not differ by type of site., Conclusion: VA sites with primary care models tailored to women were rated higher on most dimensions of care. Facilitating establishment of these optimal care models at other sites is one strategy for improving women veterans' experiences with VA care. Research to identify other features of care associated with quality could inform ongoing VA quality transformation efforts., (Published by Elsevier Inc.)

Medical decision making in the context of serious illness ideally involves a patient who understands his or her condition and prognosis and can effectively formulate and communicate his or her care preferences. To understand the relationships among these care processes, we analyzed baseline interview data from veterans enrolled in a randomized controlled trial of a palliative care intervention. Participants were 400 inpatient veterans admitted with a physician-estimated risk of one-year mortality more than 25%; 260 (65%) had cancer as the primary diagnosis. Patients who believed that they had a life-limiting illness (89% of sample) reported that their provider had communicated this to them more frequently than those who did not share that belief (78% vs. 22%, P<0.001). Over half (53%) of the participants reported discussing their care preferences with their providers and 66% reported such discussions with their family; 35% had a living will. In multivariate analysis, greater functional impairment was associated with patients having discussed their care preferences with providers (P<0.05), whereas patient understanding of prognosis (P<0.05), better quality of life (P<0.01), and not being African American (P<0.05) were associated with patients having discussed their care preferences with family; higher education (P<0.001), and not being African American (P<0.01) were associated with having a living will. Patients with poor understanding of prognosis are less likely to discuss care preferences with family members, suggesting the importance of provider communication with patients regarding prognosis. Because functional decline may prompt physicians to discuss prognosis with patients, patients with relatively preserved function may particularly need such communication., ((c) 2010 U.S. Cancer Pain Relief Committee. All rights reserved.)

Formative research findings from 10 focus group interviews on botulism are described. Data were collected from a diverse sample of people throughout the United States in 2003, as part of a collaborative multisite initiative sponsored by the Centers for Disease Control and Prevention to improve communications materials on bioterrorism agents. Focus group guides included questions on knowledge, action, emotions, and information seeking in response to a series of scenarios on a hypothetical terrorist attack using botulinum toxin. Data were collected, transcribed, coded, and analyzed using content domains based on risk and health communications theories. Initial participant responses to scenarios were emotional, changing into immediate health and survival concerns conceptualized as information specific to the agent and event. Knowledge about botulism was low, and participants wanted clear, concise, and actionable messages. Broadcast media, the internet, and community-based sources were cited as sources of information. Findings have implications for botulism preparedness messages and for general public risk communications.

This study describes the prevalence and correlates of physical assaults, threats of assault, and workers' perceptions of safety in selected urban employment settings. Questionnaires were mailed to a random sample of 1,763 persons working at various jobs and sites throughout Los Angeles County. Workers were asked to describe their work environments, their perceptions of personal safety at work, and physical assaults and threats they had experienced. Three percent of the respondents reported being assaulted within the previous year and 14% reported being threatened within the previous 30 days. Younger workers, more educated workers, and those who worked with clients or patients were more likely to report assaults. Approximately one third of those who reported threats or assaults described the perpetrator(s) as clients, patients, or persons in legal custody, and one third described the perpetrator(s) as co-workers or supervisors. Fifty-two percent of the workers reported being concerned about their safety at work.