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Cardemil CV, Dahl R, Prill MM, Cates J, Brown S, Perea A, Marconi V, Bell L, Rodriguez-Barradas MC, Rivera-Dominguez G, Beenhouwer D, Poteshkina A, Holodniy M, Lucero-Obusan C, Balachandran N, Hall AJ, Kim L, Langley G. COVID-19-Related Hospitalization Rates and Severe Outcomes Among Veterans From 5 Veterans Affairs Medical Centers: Hospital-Based Surveillance Study. JMIR Public Health Surveill 2021; 7:e24502. [PMID: 33338028 PMCID: PMC7836907 DOI: 10.2196/24502] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/05/2020] [Accepted: 12/14/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND COVID-19 has disproportionately affected older adults and certain racial and ethnic groups in the United States. Data quantifying the disease burden, as well as describing clinical outcomes during hospitalization among these groups, are needed. OBJECTIVE We aimed to describe interim COVID-19 hospitalization rates and severe clinical outcomes by age group and race and ethnicity among US veterans by using a multisite surveillance network. METHODS We implemented a multisite COVID-19 surveillance platform in 5 Veterans Affairs Medical Centers located in Atlanta, Bronx, Houston, Palo Alto, and Los Angeles, collectively serving more than 396,000 patients annually. From February 27 to July 17, 2020, we actively identified inpatient cases with COVID-19 by screening admitted patients and reviewing their laboratory test results. We then manually abstracted the patients' medical charts for demographics, underlying medical conditions, and clinical outcomes. Furthermore, we calculated hospitalization incidence and incidence rate ratios, as well as relative risk for invasive mechanical ventilation, intensive care unit admission, and case fatality rate after adjusting for age, race and ethnicity, and underlying medical conditions. RESULTS We identified 621 laboratory-confirmed, hospitalized COVID-19 cases. The median age of the patients was 70 years, with 65.7% (408/621) aged ≥65 years and 94% (584/621) male. Most COVID-19 diagnoses were among non-Hispanic Black (325/621, 52.3%) veterans, followed by non-Hispanic White (153/621, 24.6%) and Hispanic or Latino (112/621, 18%) veterans. Hospitalization rates were the highest among veterans who were ≥85 years old, Hispanic or Latino, and non-Hispanic Black (430, 317, and 298 per 100,000, respectively). Veterans aged ≥85 years had a 14-fold increased rate of hospitalization compared with those aged 18-29 years (95% CI: 5.7-34.6), whereas Hispanic or Latino and Black veterans had a 4.6- and 4.2-fold increased rate of hospitalization, respectively, compared with non-Hispanic White veterans (95% CI: 3.6-5.9). Overall, 11.6% (72/621) of the patients required invasive mechanical ventilation, 26.6% (165/621) were admitted to the intensive care unit, and 16.9% (105/621) died in the hospital. The adjusted relative risk for invasive mechanical ventilation and admission to the intensive care unit did not differ by age group or race and ethnicity, but veterans aged ≥65 years had a 4.5-fold increased risk of death while hospitalized with COVID-19 compared with those aged <65 years (95% CI: 2.4-8.6). CONCLUSIONS COVID-19 surveillance at the 5 Veterans Affairs Medical Centers across the United States demonstrated higher hospitalization rates and severe outcomes among older veterans, as well as higher hospitalization rates among Hispanic or Latino and non-Hispanic Black veterans than among non-Hispanic White veterans. These findings highlight the need for targeted prevention and timely treatment for veterans, with special attention to older aged, Hispanic or Latino, and non-Hispanic Black veterans.
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Affiliation(s)
- Cristina V Cardemil
- Centers for Disease Control and Prevention, Atlanta, GA, United States.,United States Public Health Service, Rockville, MD, United States
| | - Rebecca Dahl
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Mila M Prill
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Jordan Cates
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Sheldon Brown
- James J. Peters VA Medical Center, New York, NY, United States.,Icahn School of Medicine at Mt. Sinai, New York, NY, United States
| | - Adrienne Perea
- James J. Peters VA Medical Center, New York, NY, United States
| | - Vincent Marconi
- Atlanta VA Medical Center, Atlanta, GA, United States.,Emory University School of Medicine, Atlanta, GA, United States.,Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - LaSara Bell
- Atlanta VA Medical Center, Atlanta, GA, United States
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Department of Medicine, Baylor College of Medicine, Houston, TX, United States.,Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - Gilberto Rivera-Dominguez
- Infectious Diseases Section, Department of Medicine, Baylor College of Medicine, Houston, TX, United States.,Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - David Beenhouwer
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States.,David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | | | - Mark Holodniy
- Public Health Surveillance and Research, Department of Veterans Affairs, Washington, DC, United States.,VA Palo Alto Health Care System, Palo Alto, CA, United States.,Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, United States
| | - Cynthia Lucero-Obusan
- Public Health Surveillance and Research, Department of Veterans Affairs, Washington, DC, United States.,VA Palo Alto Health Care System, Palo Alto, CA, United States
| | - Neha Balachandran
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Aron J Hall
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Lindsay Kim
- Centers for Disease Control and Prevention, Atlanta, GA, United States.,United States Public Health Service, Rockville, MD, United States
| | - Gayle Langley
- Centers for Disease Control and Prevention, Atlanta, GA, United States
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202
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Yank V, Gale RC, Nevedal A, Okwara L, Koenig CJ, Trivedi RB, Dupke NJ, Kabat M, Asch SM. Improving Uptake of a National Web-Based Psychoeducational Workshop for Informal Caregivers of Veterans: Mixed Methods Implementation Evaluation. J Med Internet Res 2021; 23:e16495. [PMID: 33410759 PMCID: PMC7819783 DOI: 10.2196/16495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 07/13/2020] [Accepted: 11/18/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Although web-based psychoeducational programs may be an efficient, accessible, and scalable option for improving participant well-being, they seldom are sustained beyond trial publication. Implementation evaluations may help optimize program uptake, but few are performed. When the US Department of Veterans Affairs (VA) launched the web-based psychoeducational workshop Building Better Caregivers (BBC) for informal caregivers of veterans nationwide in 2013, the workshop did not enroll as many caregivers as anticipated. OBJECTIVE This study aims to identify the strengths and weaknesses of initial implementation, strategies likely to improve workshop uptake, whether the VA adopted these strategies, and whether workshop enrollment changed. METHODS We used mixed methods and the Promoting Action on Research Implementation in Health Services (PARIHS) implementation evaluation framework. In stage 1, we conducted semistructured interviews with caregivers, local staff, and regional and national VA leaders and surveys with caregivers and staff. We collected and analyzed survey and interview data concurrently and integrated the results to identify implementation strengths and weaknesses, and strategies likely to improve workshop uptake. In stage 2, we reinterviewed national leaders to determine whether the VA adopted recommended strategies and used national data to determine whether workshop enrollment changed over time. RESULTS A total of 54 caregivers (n=32, 59%), staff (n=13, 24%), and regional (n=5, 9%) and national (n=4, 7%) leaders were interviewed. We received survey responses from 72% (23/32) of caregivers and 77% (10/13) of local staff. In stage 1, survey and interview results were consistent across multiple PARIHS constructs. Although participants from low-enrollment centers reported fewer implementation strengths and more weaknesses, qualitative themes were consistent across high- and low-enrollment centers, and across caregiver, staff, and leadership respondent groups. Identified strengths included belief in a positive workshop impact and the use of some successful outreach approaches. Implementation weaknesses included missed opportunities to improve outreach and to better support local staff. From these, we identified and recommended new and enhanced implementation strategies-increased investment in outreach and marketing capabilities; tailoring outreach strategies to multiple stakeholder groups; use of campaigns that are personal, repeated, and detailed, and have diverse delivery options; recurrent training and mentoring for new staff; and comprehensive data management and reporting capabilities. In stage 2, we determined that the VA had adopted several of these strategies in 2016. In the 3 years before and after adoption, cumulative BBC enrollment increased from 2139 (2013-2015) to 4030 (2016-2018) caregivers. CONCLUSIONS This study expands the limited implementation science literature on best practices to use when implementing web-based psychoeducational programs. We found that robust outreach and marketing strategies and support for local staff were critical to the implementation success of the BBC workshop. Other health systems may want to deploy these strategies when implementing their web-based programs.
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Affiliation(s)
- Veronica Yank
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Randall C Gale
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States
| | - Andrea Nevedal
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States
| | - Leonore Okwara
- Department of Behavioral and Community Health, University of Maryland, Baltimore, MD, United States
| | - Christopher J Koenig
- Department of Communication Studies, San Francisco State University, San Francisco, CA, United States
| | - Ranak B Trivedi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, United States
| | - Nancy J Dupke
- VA Caregivers Support Program, Department of Veterans Affairs, Washington, DC, United States
| | - Margaret Kabat
- VA Caregivers Support Program, Department of Veterans Affairs, Washington, DC, United States
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States
- Division of Primary Care and Population Health, Stanford University, Palo Alto, CA, United States
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203
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Stika MM, Riordan P, Aaronson A, Herrold AA, Ellison RL, Kletzel S, Drzewiecki M, Evans CT, Mallinson T, High WM, Babcock-Parziale J, Urban A, Pape TLB, Smith B. Cognition and Other Predictors of Functional Disability Among Veterans With Mild Traumatic Brain Injury and Posttraumatic Stress Disorder. J Head Trauma Rehabil 2021; 36:44-55. [PMID: 32898030 PMCID: PMC8916049 DOI: 10.1097/htr.0000000000000611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Limitations in everyday functioning are frequently reported by veterans with a history of mild traumatic brain injury (mTBI) and/or posttraumatic stress disorder (PTSD). Multiple factors are associated with functional disability among veterans, including depression, poor social support, cognition, and substance use. However, the degree to which these factors, particularly cognitive capacities, contribute to functional limitations remains unclear. METHODS We evaluated performance on tests of processing speed, executive functioning, attention, and memory as predictors of functioning on the World Health Organization Disability Assessment Scale (WHODAS) 2.0 in 288 veterans. Participants were placed in one of the following groups: PTSD-only, mTBI-only, mTBI + PTSD, and neither PTSD nor mTBI (deployed control group). Cognitive test performances were evaluated as predictors of WHODAS 2.0 functional ratings in regression models that included demographic variables and a range of mood, behavioral health, and postconcussive symptom ratings. RESULTS Multiple cognitive test performances predicted WHODAS 2.0 scores in the deployed control group, but they generally did not predict functioning in the clinical groups when accounting for demographics, mood, behavioral health, and postconcussive symptoms. CONCLUSIONS In veterans with mTBI and/or PTSD, cognitive test performances are less associated with everyday functioning than mood and postconcussive symptoms.
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Affiliation(s)
- Monica M Stika
- Department of Veterans Affairs (VA), Edward Hines, Jr. VA Hospital: Spinal Cord Injury/Disorder Service (Dr Stika), Mental Health Service Line: Neuropsychology Service (Drs Riordan, Drzewiecki, and Urban) and Psychiatry Service (Dr Aaronson), Research Service (Drs Bender Pape, Herrold, Kletzel, and Ellison), Center of Innovation for Complex Chronic Healthcare (Drs Bender Pape, Herrold, Kletzel, Smith, and Evans), Hines, Illinois; Departments of Psychiatry & Behavioral Sciences (Drs Aaronson and Herrold), Physical Medicine and Rehabilitation (Dr Pape), and Pediatrics (Dr Smith), and Center for Health Services and Outcomes Research, Institute for Public Health and Medicine (Dr Evans), Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Clinical Research and Leadership, The George Washington University, Washington, District of Columbia (Dr Mallinson); Department of Veterans Affairs (VA), New Mexico VA Health Care System, Albuquerque (Dr High); Illinois Institute of Technology (IIT), Chicago (Dr Ellison); and Department of Veterans Affairs (VA), Southern AZ VA Health Care System (3-124), Tucson, Arizona (Dr Babcock-Parziale)
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204
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Bouldin ED, Swan AA, Norman RS, Tate DF, Tumminello C, Amuan ME, Eapen BC, Wang CP, Trevino A, Pugh MJ. Health Phenotypes and Neurobehavioral Symptom Severity Among Post-9/11 Veterans With Mild Traumatic Brain Injury: A Chronic Effects of Neurotrauma Consortium Study. J Head Trauma Rehabil 2021; 36:10-19. [PMID: 32472834 PMCID: PMC10649312 DOI: 10.1097/htr.0000000000000574] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate whether neurobehavioral symptoms differ between groups of veterans with mild traumatic brain injury (mTBI) classified by health characteristics. PARTICIPANTS A total of 71 934 post-9/11 veterans with mTBI from the Chronic Effects of Neurotrauma Consortium Epidemiology warfighter cohort. DESIGN Cross-sectional analysis of retrospective cohort. MAIN MEASURES Health phenotypes identified using latent class analysis of health and function over 5 years. Symptom severity measured using Neurobehavioral Symptom Inventory; domains included vestibular, somatic, cognitive, and affective. RESULTS Veterans classified as moderately healthy had the lowest symptom burden while the polytrauma phenotype group had the highest. After accounting for sociodemographic and injury characteristics, polytrauma phenotype veterans had about 3 times the odds of reporting severe symptoms in each domain compared with moderately healthy veterans. Those veterans who were initially moderately healthy but whose health declined over time had about twice the odds of severe symptoms as consistently healthier Veterans. The strongest associations were in the affective domain. Compared with the moderately healthy group, veterans in other phenotypes were more likely to report symptoms substantially interfered with their daily lives (odds ratio range: 1.3-2.8). CONCLUSION Symptom severity and interference varied by phenotype, including between veterans with stable and declining health. Ameliorating severe symptoms, particularly in the affective domain, could improve health trajectories following mTBI.
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Affiliation(s)
- Erin D Bouldin
- Department of Health and Exercise Science, Appalachian State University, Boone, North Carolina (Dr Bouldin); Department of Psychology, University of Texas at San Antonio (Dr Swan); Speech-Language Pathology Program, School of Health Professions, University of Texas Health Science Center at San Antonio (Dr Norman); George E. Whalen VA Medical Center, Salt Lake City, Utah (Dr Tate); Departments of Neurology (Dr Tate) and Internal Medicine (Dr Pugh), University of Utah School of Medicine, Salt Lake City; Lees-McRae College, Banner Elk, North Carolina (Ms Tumminello); VA Salt Lake City Health Care System, Informatics, Decision-Enhancement, and Analytic Sciences Center, Salt Lake City, Utah (Mss Amuan and Trevino and Dr Pugh); Department of Physical Medicine and Rehabilitation, VA Greater Los Angeles Health Care System, and Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California (Dr Eapen); and Department of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio (Dr Wang)
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205
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Serra MC, Addison O, Giffuni J, Barton-Ort K, Parker E, Katzel L. Changes in Self-Reported Fruit and Vegetable Intake following Nutritional Modification in High Risk Older Veterans. J Nutr Gerontol Geriatr 2021; 40:1-8. [PMID: 33439791 DOI: 10.1080/21551197.2020.1863892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This project aimed to determine the feasibility of implementing a dietary intervention in older Veterans participating in an exercise and health promotion program (Gerofit) and whether this intervention could improve self-reported fruit and vegetable (F&V) intake measured by BRFSS and diet quality measured by visual analog scale (0-10 scale). Participation consisted of optional group and individual counseling with a Registered Dietitian (RD). Out of 50 participants approached to participant in the program, 24 Veterans attended ≥2 group sessions (2.9 ± 2.0 classes, which was 82% of total available sessions). There was a reported trend toward increased daily F&V intake (pre vs. post: 3.4 ± 1.9 vs. 4.1 ± 2.0 servings/day, p = 0.07) and a significant increase in diet quality (4.7 ± 0.5 vs. 5.9 ± 0.4, p= 0.03) from baseline compared to the last attended class. These promising preliminary findings can be used to inform efforts to optimize dietary intake in vulnerable Veteran populations.
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Affiliation(s)
- Monica C Serra
- Division of Geriatrics, Gerontology & Palliative Medicine, The Sam & Ann Barshop Institute for Longevity & Aging Studies, UT Health San Antonio and San Antonio GRECC, South Texas VA Health Care System, San Antonio, Texas, USA
| | - Odessa Addison
- Baltimore VA Medical Center GRECC and VA Maryland Health Care System, Baltimore, Maryland, USA
- Department of Physical Therapy and Rehabilitative Science, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jamie Giffuni
- Baltimore VA Medical Center GRECC and VA Maryland Health Care System, Baltimore, Maryland, USA
| | - Kelly Barton-Ort
- Baltimore VA Medical Center GRECC and VA Maryland Health Care System, Baltimore, Maryland, USA
| | - Elizabeth Parker
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Leslie Katzel
- Baltimore VA Medical Center GRECC and VA Maryland Health Care System, Baltimore, Maryland, USA
- Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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206
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Singh NS, Bogdanov S, Doty B, Haroz E, Girnyk A, Chernobrovkina V, Murray LK, Bass JK, Bolton PA. Experiences of mental health and functioning among conflict-affected populations: A qualitative study with military veterans and displaced persons in Ukraine. Am J Orthopsychiatry 2021; 91:499-513. [PMID: 33900102 PMCID: PMC10015420 DOI: 10.1037/ort0000537] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Objective: This article reports findings from a qualitative study that sought to identify and describe psychosocial and mental health consequences of conflict among internally displaced persons (IDPs) and military veterans in Ukraine. The study was the first phase of a clinical intervention trial and was designed to understand local experiences of mental health problems and function, inform the selection and adaptation of local measures, and guide the modification, and implementation of a psychotherapy intervention that could support conflict-affected persons. Method: Free-list interviews (FLs), key informant interviews (KIIs), and focus group discussions (FDGs) were conducted with IDPs, military veterans, and providers working with these two groups. A total of 227 respondents were interviewed from two study regions in eastern Ukraine-Zaporizhia and Kharkiv-including 136 IDPs and 91 military veterans. Results: Both IDPs and veterans were described as experiencing high levels of psychological stress symptoms, including depression, isolation, anxiety, and intrusive memories. Although IDPs and veterans were exposed to different traumas, they both identified struggles with social adaptation, including feeling isolated and misunderstood by their communities. Both groups also described relational conflict within and outside the family. Social support mechanisms were considered essential for recovery, and positive social interaction was described as a key example of healthy functioning. Conclusion: Findings suggest a need for community-based programming that facilitates social adaptation, supports social network building, and helps engage conflict-affected people into mental health services. Programs that promote greater awareness, interaction, and understanding among the general public, military veterans, and IDPs are also warranted. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Namrita S Singh
- Department of International Health, Johns Hopkins University, Bloomberg School of Public Health
| | - Sergiy Bogdanov
- Center for Mental Health and Psychosocial Support, National University of Kyiv-Mohyla Academy
| | - Benjamin Doty
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health
| | - Emily Haroz
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health
| | - Andriy Girnyk
- Department of Psychology and Pedagogy, National University of Kyiv-Mohyla Academy
| | - Vira Chernobrovkina
- Department of Psychology and Pedagogy, National University of Kyiv-Mohyla Academy
| | - Laura K Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health
| | - Judith K Bass
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health
| | - Paul A Bolton
- Department of International Health, Johns Hopkins University, Bloomberg School of Public Health
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207
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Zalta AK, Tirone V, Orlowska D, Blais RK, Lofgreen A, Klassen B, Held P, Stevens NR, Adkins E, Dent AL. Examining moderators of the relationship between social support and self-reported PTSD symptoms: A meta-analysis. Psychol Bull 2021; 147:33-54. [PMID: 33271023 PMCID: PMC8101258 DOI: 10.1037/bul0000316] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Social support is one of the most robust predictors of posttraumatic stress disorder (PTSD). Yet, little is known about factors that moderate the relationship between social support and PTSD symptom severity. This meta-analysis estimated the overall effect size of the relationship between self-reported social support and PTSD severity and tested meaningful demographic, social support, and trauma characteristics that may moderate this association using both cross-sectional and longitudinal effect sizes. A comprehensive search identified 139 studies with 145 independent cross-sectional effect sizes representing 62,803 individuals and 37 studies with 38 independent longitudinal effect sizes representing 25,792 individuals. Study samples had to comprise trauma-exposed, nonclinical adult populations to be included in the analysis. Cross-sectional and longitudinal analyses revealed a near medium overall effect size (rcross = -.27; 95% CI [-.30, -.24]; rlong = -.25; 95% CI [-.28, -.21]) with a high degree of heterogeneity (cross-sectional I2 = 91.6, longitudinal I2 = 86.5). Both cross-sectional and longitudinal moderator analyses revealed that study samples exposed to natural disasters had a weaker effect size than samples exposed to other trauma types (e.g., combat, interpersonal violence), studies measuring negative social reactions had a larger effect size than studies assessing other types of social support, and veteran samples revealed larger effect sizes than civilian samples. Several other methodological and substantive moderators emerged that revealed a complex relationship between social support and PTSD severity. These findings have important clinical implications for the types of social support interventions that could mitigate PTSD severity. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Alyson K. Zalta
- Department of Psychological Science, University of California, Irvine, Irvine, CA
- Department of Psychiatry & Behavioral Sciences, Rush University Medical Center, Chicago, IL
| | - Vanessa Tirone
- Department of Psychiatry & Behavioral Sciences, Rush University Medical Center, Chicago, IL
| | - Daria Orlowska
- University Libraries, Western Michigan University, Kalamazoo, MI
| | | | - Ashton Lofgreen
- Department of Psychiatry & Behavioral Sciences, Rush University Medical Center, Chicago, IL
| | - Brian Klassen
- Department of Psychiatry & Behavioral Sciences, Rush University Medical Center, Chicago, IL
| | - Philip Held
- Department of Psychiatry & Behavioral Sciences, Rush University Medical Center, Chicago, IL
| | - Natalie R. Stevens
- Department of Psychiatry & Behavioral Sciences, Rush University Medical Center, Chicago, IL
| | - Elizabeth Adkins
- Department of Preventive Medicine, Northwestern University, Chicago, IL
| | - Amy L. Dent
- Department of Psychological Science, University of California, Irvine, Irvine, CA
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208
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Landes SJ, Jegley SM, Kirchner JE, Areno JP, Pitcock JA, Abraham TH, McBain SA, Singh RS, Bollinger MJ, Painter J, Woods JA, Curtis ND, Jones DE, Matarazzo BB, Reger MA, Comtois KA. Adapting Caring Contacts for Veterans in a Department of Veterans Affairs Emergency Department: Results From a Type 2 Hybrid Effectiveness-Implementation Pilot Study. Front Psychiatry 2021; 12:746805. [PMID: 34721114 PMCID: PMC8548725 DOI: 10.3389/fpsyt.2021.746805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 09/13/2021] [Indexed: 12/02/2022] Open
Abstract
Transitions in care, such as discharge from an emergency department (ED), are periods of increased risk for suicide and effective interventions that target these periods are needed. Caring Contacts is an evidence-based suicide prevention intervention that targets transitions, yet it has not been widely implemented. This pilot study adapted Caring Contacts for a Department of Veterans Affairs (VA) ED setting and population, created an implementation toolkit, and piloted implementation and evaluation of effectiveness. To inform adaptation, qualitative interviews were conducted with stakeholders. Data were used by an advisory board comprised of stakeholders, experts, and veterans to make adaptations and develop an implementation planning guide to delineate steps needed to implement. Key decisions about how to adapt Caring Contacts included recipients, author, content, and the schedule for sending. Pilot implementation occurred at one VA ED. Caring Contacts involved sending patients at risk of suicide brief, non-demanding expressions of care. Program evaluation of the pilot used a type 2 hybrid effectiveness-implementation design to both pilot an implementation strategy and evaluate effectiveness of Caring Contacts. Evaluation included qualitative interviews with veteran patients during implementation. VA electronic health records were used to evaluate VA service utilization in the 6-month periods immediately before and after veterans were delivered their first Caring Contact. Hundred and seventy-five veterans were mailed Caring Contacts and the facility continued adoption after the pilot. Participants were positive about the intervention and reported feeling cared about and connected to VA as a result of receiving Caring Contacts. This project developed an implementation planning process that successfully implemented Caring Contacts at one site. This can be used to further implement Caring Contacts at additional VA or community EDs.
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Affiliation(s)
- Sara J Landes
- Behavioral Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,South Central Mental Illness Research Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Susan M Jegley
- Behavioral Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - JoAnn E Kirchner
- Behavioral Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - John P Areno
- South Central VA Health Care Network, Ridgeland, MS, United States
| | - Jeffery A Pitcock
- Behavioral Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Traci H Abraham
- Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Sacha A McBain
- South Central Mental Illness Research Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - R Sonia Singh
- South Central Mental Illness Research Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Mary J Bollinger
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Jacob Painter
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Jack A Woods
- Behavioral Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Nyssa D Curtis
- Behavioral Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Donald E Jones
- Behavioral Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Bridget B Matarazzo
- Rocky Mountain Mental Illness Research Education and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States.,Department of Psychiatry, University of Colorado Anschutz School of Medicine, Aurora, CO, United States
| | - Mark A Reger
- VA Puget Sound Health Care System, Tacoma, WA, United States
| | - Katherine Anne Comtois
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, United States
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209
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Abstract
BACKGROUND Mental health professionals caring for the veteran population are at increased risk for compassion fatigue, burnout, and secondary traumatic stress based on the nature of their work. While mental health professionals may experience positive outcomes from providing compassionate care to veterans, compassion fatigue can lead to instability of the workforce. METHODS A pilot employee wellness program was implemented over a 9-week period, offering a different wellness module weekly during the employee lunch hour. Demographic data were collected pre-program, and mental health employees were surveyed pre- and post-program using an intent to stay scale and the Professional Quality of Life Scale version 5 (ProQOL-5) to measure compassion satisfaction, burn out, and secondary traumatic stress. FINDINGS Pre-program participants (N = 42) reported significant differences in intent to stay in their current position for the next year compared to the post-program group (N = 15). Pre-program participants reported no intent to leave their current position, apply for internal or external positions, or retire in the following year. However, post-program participants reported intent to leave their current positions, apply to internal or external positions, or retire. Pre- and post-program compassion satisfaction scores increased and burnout and secondary traumatic stress scores decreased; these scores were not significantly different between groups. CONCLUSIONS/APPLICATION TO PRACTICE While no significant differences were found between ProQOL-5 subscale scores, the change in participants' scores may indicate some change, potentially as a result of the intervention. This pilot program offered a creative solution to organizations with limited resources to combat occupation-related compassion fatigue.
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210
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Schindler AG, Terry GE, Wolden-Hanson T, Cline M, Park M, Lee J, Yagi M, Meabon JS, Peskind ER, Raskind MM, Phillips PEM, Cook DG. Repetitive Blast Promotes Chronic Aversion to Neutral Cues Encountered in the Peri-Blast Environment. J Neurotrauma 2020; 38:940-948. [PMID: 33138684 DOI: 10.1089/neu.2020.7061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Repetitive mild traumatic brain injury (mTBI) has been called the "signature injury" of military service members in the Iraq and Afghanistan wars and is highly comorbid with post-traumatic stress disorder (PTSD). Correct attribution of adverse blast-induced mTBI and/or PTSD remains challenging. Pre-clinical research using animal models can provide important insight into the mechanisms by which blast produces injury and dysfunction-but only to the degree by which such models reflect the human experience. Avoidance of trauma reminders is a hallmark of PTSD. Here, we sought to understand whether a mouse model of blast reproduces this phenomenon, in addition to blast-induced physical injuries. Drawing on well-established work from the chronic stress and Pavlovian conditioning literature, we hypothesized that even while one is anesthetized during blast exposure, environmental cues encountered in the peri-blast environment could be conditioned to evoke aversion/dysphoria and re-experiencing of traumatic stress. Using a pneumatic shock tube that recapitulates battlefield-relevant open-field blast forces, we provide direct evidence that stress is inherent to repetitive blast exposure, resulting in chronic aversive/dysphoric-like responses to previous blast-paired cues. The results in this report demonstrate that, although both single and repetitive blast exposures produce acute stress responses (weight loss, corticosterone increase), only repetitive blast exposure also results in co-occurring aversive/dysphoric-like stress responses. These results extend appreciation of the highly complex nature of repetitive blast exposure; and lend further support for the potential translational relevance of animal modeling approaches currently used by multiple laboratories aimed at elucidating the mechanisms (both molecular and behavioral) of repetitive blast exposure.
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Affiliation(s)
- Abigail G Schindler
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA.,Graduate Program in Neuroscience, University of Washington, Seattle, Washington, USA.,VA Northwest Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Garth E Terry
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA.,VA Northwest Mental Illness Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Tami Wolden-Hanson
- VA Northwest Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Marcella Cline
- VA Northwest Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Michael Park
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Janet Lee
- VA Northwest Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Mayumi Yagi
- VA Northwest Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - James S Meabon
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA.,VA Northwest Mental Illness Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Elaine R Peskind
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA.,VA Northwest Mental Illness Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Murray M Raskind
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA.,VA Northwest Mental Illness Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Paul E M Phillips
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA.,Graduate Program in Neuroscience, University of Washington, Seattle, Washington, USA.,Department of Pharmacology, University of Washington, Seattle, Washington, USA
| | - David G Cook
- Graduate Program in Neuroscience, University of Washington, Seattle, Washington, USA.,VA Northwest Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA.,Department of Pharmacology, University of Washington, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
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211
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Matarazzo BB, Brenner LA, Wortzel HS, Bahraini NH. Balancing Scientific Evidence, Clinical Expertise, and Patient Preferences: VHA's Suicide Risk Identification Strategy. Psychiatr Serv 2020; 71:1303-1305. [PMID: 32781925 DOI: 10.1176/appi.ps.202000109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Bridget B Matarazzo
- Rocky Mountain Mental Illness Research, Education and Clinical Center, U.S. Department of Veterans Affairs, Aurora, Colorado (all authors); Departments of Psychiatry (all authors), Physical Medicine and Rehabilitation (Brenner, Bahraini), and Neurology (Brenner, Wortzel), University of Colorado School of Medicine, Aurora
| | - Lisa A Brenner
- Rocky Mountain Mental Illness Research, Education and Clinical Center, U.S. Department of Veterans Affairs, Aurora, Colorado (all authors); Departments of Psychiatry (all authors), Physical Medicine and Rehabilitation (Brenner, Bahraini), and Neurology (Brenner, Wortzel), University of Colorado School of Medicine, Aurora
| | - Hal S Wortzel
- Rocky Mountain Mental Illness Research, Education and Clinical Center, U.S. Department of Veterans Affairs, Aurora, Colorado (all authors); Departments of Psychiatry (all authors), Physical Medicine and Rehabilitation (Brenner, Bahraini), and Neurology (Brenner, Wortzel), University of Colorado School of Medicine, Aurora
| | - Nazanin H Bahraini
- Rocky Mountain Mental Illness Research, Education and Clinical Center, U.S. Department of Veterans Affairs, Aurora, Colorado (all authors); Departments of Psychiatry (all authors), Physical Medicine and Rehabilitation (Brenner, Bahraini), and Neurology (Brenner, Wortzel), University of Colorado School of Medicine, Aurora
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212
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Martindale SL, Shura RD, Ord AS, Williams AM, Brearly TW, Miskey HM, Rowland JA. Symptom burden, validity, and cognitive performance in Iraq and Afghanistan veterans. Appl Neuropsychol Adult 2020; 29:1068-1077. [PMID: 33202168 DOI: 10.1080/23279095.2020.1847111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The present study evaluates the complex relationships between symptom burden, validity, and cognition in a sample of Iraq and Afghanistan veterans to identify key characteristic symptoms and validity measures driving cognitive performance. We hypothesized that symptom and performance validity would account for poorer outcomes on cognitive performance beyond psychological symptoms. METHODS Veterans (n = 226) completed a cognitive test battery, Personality Assessment Inventory (PAI), Word Memory Test (WMT), and Miller Forensic Assessment Symptom Test (M-FAST). Partial least squares structural equation modeling (PLS-SEM) modeled the fully-adjusted relationships among PAI subscales, validity, and cognitive performance. RESULTS 23.45% of participants failed validity indices (19.9% WMT; 7.1% M-FAST). PLS-SEM indicated PAI subscales were not directly associated with performance or symptom validity measures, and there were no direct effects between validity performance and cognitive performance. Several PAI subscales were directly associated with measures of verbal abstraction, visual processing, and verbal learning and memory. CONCLUSION Contrary to hypotheses, symptom and performance validity did not account for poorer outcomes on cognitive performance beyond symptom burden in the PLS-SEM model. Results highlight the association between psychiatric symptoms and cognitive performance beyond validity status.
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Affiliation(s)
- Sarah L Martindale
- Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA.,Physiology & Pharmacology Division, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Robert D Shura
- Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA.,Psychiatry & Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Anna S Ord
- Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA
| | - Ann M Williams
- Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA
| | - Timothy W Brearly
- Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA.,Neuropsychology Assessment - Directorate of Behavioral Health (Consultation & Education), Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Holly M Miskey
- Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA.,Psychiatry & Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jared A Rowland
- Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA.,Neurobiology & Anatomy, Wake Forest School of Medicine, Winston-Salem, NC, USA
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213
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Abstract
Telemedicine technology has become essential to healthcare delivery in the COVID-19 era, but concerns remain regarding whether the intimacy and communication that is central to high-quality palliative care will be compromised by the use of this technology. We employed a business model approach to identify the need for system innovation in palliative care, and a quality improvement approach to structure the project. Products from this project included a standard operating procedure for safe use of tablet computers for inpatient palliative care consultations and family visitations; tablet procurement with installation of video telehealth software; and training and education for clinical staff and other stakeholders. We describe a case illustrating the successful use of palliative care telehealth in the care of a COVID-19-positive patient at the end of life. Successful use of video telehealth for palliative care involved overcoming inertia to the development of telehealth infrastructure and learning clinical video telehealth skills; and engaging front-line care staff and family members who were open to a trial of telehealth for communication. Information gleaned from family about the patient as a person helped bedside staff to tailor care toward aspects meaningful to the patient and family and informed best practices to incorporate intimacy into future palliative video consultations and family visit.
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Affiliation(s)
- Katherine C. Ritchey
- Palliative Care and Hospice Service, Geriatrics and Extended Care Service, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Alice Foy
- Palliative Care and Hospice Service, Geriatrics and Extended Care Service, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - Erin McArdel
- Chaplain Service, Palliative Care and Hospice Service, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - David A. Gruenewald
- Palliative Care and Hospice Service, Geriatrics and Extended Care Service, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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214
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Jones C, Smith-MacDonald L, Miguel-Cruz A, Pike A, van Gelderen M, Lentz L, Shiu MY, Tang E, Sawalha J, Greenshaw A, Rhind SG, Fang X, Norbash A, Jetly R, Vermetten E, Brémault-Phillips S. Virtual Reality-Based Treatment for Military Members and Veterans With Combat-Related Posttraumatic Stress Disorder: Protocol for a Multimodular Motion-Assisted Memory Desensitization and Reconsolidation Randomized Controlled Trial. JMIR Res Protoc 2020; 9:e20620. [PMID: 33118957 PMCID: PMC7661230 DOI: 10.2196/20620] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 12/12/2022] Open
Abstract
Background Military members are at elevated risk of operational stress injuries, including posttraumatic stress disorder (PTSD) and moral injury. Although psychotherapy can reduce symptoms, some military members may experience treatment-resistant PTSD. Multimodular motion-assisted memory desensitization and reconsolidation (3MDR) has been introduced as a virtual reality (VR) intervention for military members with PTSD related to military service. The 3MDR intervention incorporates exposure therapy, psychotherapy, eye movement desensitization and reconsolidation, VR, supportive counselling, and treadmill walking. Objective The objective of this study is to investigate whether 3MDR reduces PTSD symptoms among military members with combat-related treatment-resistant PTSD (TR-PTSD); examine the technology acceptance and usability of the Computer Assisted Rehabilitation ENvironment (CAREN) and 3MDR interventions by Canadian Armed Forces service members (CAF-SMs), veterans, 3MDR clinicians, and operators; and evaluate the impact on clinicians and operators of delivering 3MDR. Methods This is a mixed-methods waitlist controlled crossover design randomized controlled trial. Participants include both CAF-SMs and veterans (N=40) aged 18-60 years with combat-related TR-PTSD (unsuccessful experience of at least 2 evidence-based trauma treatments). Participants will also include clinicians and operators (N=12) who have been trained in 3MDR and subsequently utilized this intervention with patients. CAF-SMs and veterans will receive 6 weekly 90-minute 3MDR sessions. Quantitative and qualitative data will be collected at baseline and at 1, 3, and 6 months postintervention. Quantitative data collection will include multiomic biomarkers (ie, blood and salivary proteomic and genomic profiles of neuroendocrine, immune-inflammatory mediators, and microRNA), eye tracking, electroencephalography, and physiological data. Data from outcome measures will capture self-reported symptoms of PTSD, moral injury, resilience, and technology acceptance and usability. Qualitative data will be collected from audiovisual recordings of 3MDR sessions and semistructured interviews. Data analysis will include univariate and multivariate approaches, and thematic analysis of treatment sessions and interviews. Machine learning analysis will be included to develop models for the prediction of diagnosis, symptom severity, and treatment outcomes. Results This study commenced in April 2019 and is planned to conclude in April 2021. Study results will guide the further evolution and utilization of 3MDR for military members with TR-PTSD and will have utility in treating other trauma-affected populations. Conclusions The goal of this study is to utilize qualitative and quantitative primary and secondary outcomes to provide evidence for the effectiveness and feasibility of 3MDR for treating CAF-SMs and veterans with combat-related TR-PTSD. The results will inform a full-scale clinical trial and stimulate development and adaptation of the protocol to mobile VR apps in supervised clinical settings. This study will add to knowledge of the clinical effectiveness of 3MDR, and provide the first comprehensive analysis of biomarkers, technology acceptance and usability, moral injury, resilience, and the experience of clinicians and operators delivering 3MDR. Trial Registration ISRCTN Registry 11264368; http://www.isrctn.com/ISRCTN11264368. International Registered Report Identifier (IRRID) DERR1-10.2196/20620
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Affiliation(s)
- Chelsea Jones
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Lorraine Smith-MacDonald
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Antonio Miguel-Cruz
- Department of Occupational Therapy, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada.,Glenrose Rehabilitation Hospital Research Innovation and Technology (GRRIT), Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - Ashley Pike
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Marieke van Gelderen
- ARQ Centrum'45, Diemen, Netherlands.,Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands
| | - Liana Lentz
- School of Health Studies, Western University, London, ON, Canada
| | - Maria Y Shiu
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON, Canada
| | - Emily Tang
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Jeffrey Sawalha
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Andrew Greenshaw
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Shawn G Rhind
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON, Canada
| | - Xin Fang
- Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Adrian Norbash
- Canadian Forces Health Services, Department of National Defense, Edmonton, AB, Canada
| | - Rakesh Jetly
- Department of Mental Health, Canadian Forces Health Services, Department of National Defense, Ottawa, ON, Canada
| | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands.,Military Mental Health Research, Ministry of Defense, Utrecht, Netherlands.,ARQ National Psychotrauma Centre, Deimen, Netherlands
| | - Suzette Brémault-Phillips
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
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215
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Miller CJ, Shin M, Pugatch M, Kim B. Veteran Perspectives on Care Coordination Between Veterans Affairs and Community Providers: A Qualitative Analysis. J Rural Health 2020; 37:437-446. [PMID: 33085119 DOI: 10.1111/jrh.12526] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate veteran perspectives on challenges in care coordination between US Department of Veterans Affairs (VA) clinics and community providers in rural areas. METHODS We completed qualitative interviews with a geographically diverse sample of 51 veterans who had used both VA and community health care services. Interviews were audio-recorded and transcribed verbatim. We used directed content analysis (informed by previous work with VA and community staff) to elucidate findings, while remaining attentive to emergent themes. RESULTS We report results in 5 key domains related to interorganizational care coordination: organizational mechanisms, organizational culture, relational practices, contextual factors, and the role of the Third-Party Administrators responsible for scheduling and payment for community services. Veterans described successes and challenges in interorganizational coordination across these domains, while also reporting a variety of workarounds and mitigation strategies. CONCLUSIONS Veterans living in rural areas face myriad challenges when using health care services both within and outside of VA. In the absence of strong mechanisms for ensuring coordination and communication between health care providers at different institutions, veterans themselves may carry the primary burden for coordinating their care. Our results suggest the utility of both structural and relational approaches to enhancing interorganizational care coordination in these settings.
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Affiliation(s)
- Christopher J Miller
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Marlena Shin
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
| | - Marianne Pugatch
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts.,Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, California
| | - Bo Kim
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
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216
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Azizoddin DR, Lakin JR, Hauser J, Rynar LZ, Weldon C, Molokie R, Enzinger AC, Payvar S, Martin JL. Meeting the guidelines: Implementing a distress screening intervention for veterans with cancer. Psychooncology 2020; 29:2067-2074. [PMID: 33009712 DOI: 10.1002/pon.5565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/02/2020] [Accepted: 09/29/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Guidelines recommend systematic evaluation of distress screening and referral for cancer patients. Implementation remains a notable gap for cancer centers serving disadvantaged communities. We present the implementation of a distress screening program within a Veterans Affairs hospital oncology clinic, serving a majority African American (AA) male population of low socioeconomic status (SES). METHODS The Coleman Foundation funded this program supporting a palliative care physician and psychologist to implement screening in a phased approach as follows: (1) Organizing key stakeholders, (2) educating clinical staff, (3) delivering distress screening, (4) generating documentation, and (5) implementing clinical action and referral pathways. We utilized validated measures in the "Patient Screening Questions for Supportive Care" screening tool. RESULTS This program was unsuccessful in screening all veterans with cancer; however, we were able to implement 3 years of longitudinal screening. In distress screens from the initial program period (n = 253), patients were primarily males (95.6%) of older age (m = 70, standard deviation = 9.45), AA (76.4%), with various cancers of advanced disease (69%). Males reported moderate psychosocial distress and elevated financial needs. For males with elevated psychosocial distress (n = 63, PHQ-4 ≥3), 36% were previously connected with psychosocial services. Following screening, engagement increased as the majority (77%) established psychosocial care. CONCLUSIONS This screening program had mixed success. Centralized program staff and available supportive care referrals were critical for program implementation. Screening may have increased engagement in social work/mental health services for males of low SES. Screening programs should be tailored to the needs of underserved communities with accessible housing/food subsidies.
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Affiliation(s)
- Desiree R Azizoddin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Hauser
- Section of Palliative Care, Department of Medicine, Jesse Brown VA Medical Center, Chicago, Illinois, USA.,Section of Palliative Care, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lauren Z Rynar
- Department of Psychiatry, Jesse Brown VA Medical Center, Chicago, Illinois, USA.,Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Christine Weldon
- Department of Medicine, Hematology and Oncology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA.,The Center for Business Models in Healthcare, Glencoe, Illinois, USA
| | - Robert Molokie
- Hematology/Medical Oncology, Department of Medicine, Jesse Brown VA Medical Center, Chicago, Illinois, USA.,Department of Hematology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Andrea C Enzinger
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Susan Payvar
- Department of Psychiatry, Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Joanna L Martin
- Section of Palliative Care, Department of Medicine, Jesse Brown VA Medical Center, Chicago, Illinois, USA.,Section of Palliative Care, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
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217
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Pepin MJ, Valencia WM, Bettger JP, Pearson M, Manning KM, Sloane R, Schmader KE, Morey MC. Impact of Supervised Exercise on One-Year Medication Use in Older Veterans with Multiple Morbidities. Gerontol Geriatr Med 2020; 6:2333721420956751. [PMID: 32995368 PMCID: PMC7503003 DOI: 10.1177/2333721420956751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/14/2020] [Indexed: 11/16/2022] Open
Abstract
Exercise is touted as the ideal prescription to treat and prevent many chronic diseases. We examined changes in utilization and cost of medication classes commonly prescribed in the management of chronic conditions following participation in 12-months of supervised exercise within the Veterans Affairs Gerofit program. Gerofit enrolled 480 veterans between 1999 and 2017 with 12-months participation, with 453 having one or more active prescriptions on enrollment. Active prescriptions overall and for five classes of medications were examined. Changes from enrollment to 12 months were calculated, and cost associated with prescriptions filled were used to estimate net cost changes. Active prescriptions were reduced for opioids (77 of 164, 47%), mental health (93 of 221, 42%), cardiac (175 of 391, 45%), diabetes (41 of 166, 25%), and lipid lowering (56 of 253, 22%) agents. Cost estimates resulted in a net savings of $38,400. These findings support the role of supervised exercise as a favorable therapeutic intervention that has impact across chronic conditions.
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Affiliation(s)
| | - Willy M Valencia
- Miami Healthcare System, FL, USA.,University of Miami, Miami, FL, USA
| | | | | | | | - Richard Sloane
- Duke University Medical Center, Durham, NC, USA.,Center for Aging/ OAIC, Duke University, NC USA
| | - Kenneth E Schmader
- VA Health Care System, Durham, NC, USA.,Duke University Medical Center, Durham, NC, USA.,Center for Aging/ OAIC, Duke University, NC USA
| | - Miriam C Morey
- VA Health Care System, Durham, NC, USA.,Duke University Medical Center, Durham, NC, USA.,Center for Aging/ OAIC, Duke University, NC USA
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218
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Jones C, Miguel-Cruz A, Smith-MacDonald L, Cruikshank E, Baghoori D, Kaur Chohan A, Laidlaw A, White A, Cao B, Agyapong V, Burback L, Winkler O, Sevigny PR, Dennett L, Ferguson-Pell M, Greenshaw A, Brémault-Phillips S. Virtual Trauma-Focused Therapy for Military Members, Veterans, and Public Safety Personnel With Posttraumatic Stress Injury: Systematic Scoping Review. JMIR Mhealth Uhealth 2020; 8:e22079. [PMID: 32955456 PMCID: PMC7536597 DOI: 10.2196/22079] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/28/2020] [Accepted: 08/01/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND A necessary shift from in-person to remote delivery of psychotherapy (eg, teletherapy, eHealth, videoconferencing) has occurred because of the COVID-19 pandemic. A corollary benefit is a potential fit in terms of the need for equitable and timely access to mental health services in remote and rural locations. Owing to COVID-19, there may be an increase in the demand for timely, virtual delivery of services among trauma-affected populations, including public safety personnel (PSP; eg, paramedics, police, fire, correctional officers), military members, and veterans. There is a lack of evidence on the question of whether digital delivery of trauma-therapies for military members, veterans, and PSP leads to similar outcomes to in-person delivery. Information on barriers and facilitators and recommendations regarding digital-delivery is also scarce. OBJECTIVE This study aims to evaluate the scope and quality of peer-reviewed literature on psychotherapeutic digital health interventions delivered remotely to military members, veterans, and PSP and synthesize the knowledge of needs, gaps, barriers to, and facilitators for virtual assessment of and virtual interventions for posttraumatic stress injury. METHODS Relevant studies were identified using MEDLINE (Medical Literature Analysis and Retrieval System Online), EMBASE (Excerpta Medica dataBASE), APA (American Psychological Association) PsycINFO, CINAHL (Cumulative Index of Nursing and Allied Health Literature) Plus with Full Text, and Military & Government Collection. For collation, analysis, summarizing, and reporting of results, we used the CASP (Critical Skills Appraisal Program) qualitative checklist, PEDro (Physiotherapy Evidence Database) scale, level of evidence hierarchy, PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews), and narrative synthesis. RESULTS A total of 38 studies were included in this review. Evidence for the effectiveness of digital delivery of prolonged exposure therapy, cognitive processing therapy, behavioral activation treatment with therapeutic exposure to military members, veterans, and PSP was rated level 1a, whereas evidence for cognitive behavioral therapy was conflicting. The narrative synthesis indicated that virtual delivery of these therapies can be as effective as in-person delivery but may reduce stigma and cost while increasing access to therapy. Issues of risk, safety, potential harm (ie, suicidality, enabling avoidance), privacy, security, and the match among the therapist, modality, and patient warrant further consideration. There is a lack of studies on the influences of gender, racial, and cultural factors that may result in differential outcomes, preferences, and/or needs. An investigation into other therapies that may be suitable for digital delivery is needed. CONCLUSIONS Digital delivery of trauma therapies for military members, veterans, and PSP is a critical area for further research. Although promising evidence exists regarding the effectiveness of digital health within these populations, many questions remain, and a cautious approach to more widespread implementation is warranted.
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Affiliation(s)
- Chelsea Jones
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,1 Field Ambulance Physical Rehabilitation Department, Canadian Armed Forces Health Services, Department of National Defense, Edmonton, AB, Canada
| | - Antonio Miguel-Cruz
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Glenrose Rehabilitation Hospital Research Innovation and Technology (GRRIT), Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - Lorraine Smith-MacDonald
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Emily Cruikshank
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Educational Psychology, Faculty of Education, University of Alberta, Edmonton, AB, Canada
| | - Delaram Baghoori
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Rehabilitation Science, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Avneet Kaur Chohan
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Alexa Laidlaw
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Allison White
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Bo Cao
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Vincent Agyapong
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Lisa Burback
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Olga Winkler
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Phillip R Sevigny
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Educational Psychology, Faculty of Education, University of Alberta, Edmonton, AB, Canada
| | - Liz Dennett
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Scott Health Sciences Library, University of Alberta, Edmonton, AB, Canada
| | - Martin Ferguson-Pell
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Rehabilitation Science, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Andrew Greenshaw
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Suzette Brémault-Phillips
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
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Maust DT, Kim HM, Wiechers IR, Ignacio RV, Bohnert ASB, Blow FC. Benzodiazepine Use among Medicare, Commercially Insured, and Veteran Older Adults, 2013-2017. J Am Geriatr Soc 2020; 69:98-105. [PMID: 32951209 DOI: 10.1111/jgs.16825] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Benzodiazepines (BZDs) are widely prescribed to older adults. Although prescribing has declined in the U.S. Department of Veterans Affairs (VA), Medicare introduced BZD coverage in 2013. It is unknown whether declines in the VA have been widespread among older adults in the United States. DESIGN Observational study in traditional fee-for-service Medicare, commercial insurance, and the VA. SETTING United States, 2013-2017. PARTICIPANTS Adults aged 55 and older in traditional Medicare (234,290,693 person-months), commercial insurance (337,827,125 person-months), and the VA (256,590,369 person-months). MEASUREMENTS (1) Change in BZD and BZD-opioid co-prescribing modeled by Poisson regression over time; and (2) standardized ratios of BZD and BZD-opioid co-prescribing, using Medicare as the reference. RESULTS From April 2013 to December 2017, the monthly percentage of adults aged 55 and older who received BZDs fell from 10.4% to 9.3% in Medicare, 6.6% to 6.5% in commercial insurance, and 5.7% to 3.0% in the VA. Monthly BZD-opioid co-prescribing over the same time fell from 4.0% to 3.0% in Medicare, 2.3% to 2.0% in commercial, and 2.2% to .6% for the VA. Age- and sex-adjusted rates of decline for BZD and BZD-opioid co-prescribing were statistically significant for all systems. Annual BZD rate reductions were .98 (Medicare), .99 (commercial), and .87 (VA; P < .001 for all); co-prescribing rate reductions were .95, .99, and .75 (P < .001 for all). Using standardized ratios accounting for demographic and clinical characteristics, both prescribing and co-prescribing were lowest for the VA relative to Medicare (standardized BZD ratio = .40; 95% confidence interval [CI] = .39-.40; standardized BZD-opioid co-prescribing ratio = .35; 95% CI = .35-.35). Prescribing in commercial insurance was also lower (BZD = .65; 95% CI = .65-.65; BZD-opioid co-prescribing = .65; 95% CI = .65-.65). CONCLUSION BZD prescribing has declined much more to older adults receiving care through the VA than Medicare or commercial insurance. Other systems may learn from strategies implemented in the VA.
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Affiliation(s)
- Donovan T Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - H Myra Kim
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.,Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, Michigan
| | - Ilse R Wiechers
- Northeast Program Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, West Haven, Connecticut.,Department of Psychiatry, University of California, San Francisco, San Francisco, California.,Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Rosalinda V Ignacio
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Amy S B Bohnert
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.,Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Frederic C Blow
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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220
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Tucker RP, Pardue-Bourgeois S, Snow A, Bradstreet M, Cerel J. The Relationship Between Suicide-Related Exposure and Personal History of Suicidal Behavior in Transgender and Gender-Diverse Veterans. LGBT Health 2020; 6:335-341. [PMID: 31618166 DOI: 10.1089/lgbt.2019.0120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Purpose: Transgender and gender-diverse (TGD) veterans experience a high prevalence of suicidal thoughts and behaviors (STBs). Within the general U.S. population, suicide-related exposure is an identified risk factor for STBs. This study explores the impact of suicide-related exposure in TGD veterans. Methods: Self-identified TGD veterans (n = 195) completed an online cross-sectional survey that included self-report measures of suicide-related exposures, experience of past-year suicidal ideation (SI), and history of suicide attempt (SA)(s). Results: A considerable number of respondents indicated that they were close to someone who attempted suicide (40.5%) or died by suicide (32.8%). When asked about the gender identity of decedents, 6.7% indicated that at least one individual was TGD and 18.5% indicated knowing at least one close TGD individual who attempted suicide. Exposure to SA and to suicide were both independently related to a history of at least one SA. Neither type of suicide exposure was related to past year SI. Participants exposed to the SA of a close TGD individual were more likely to report past-year SI than those not exposed. Conclusion: TGD veterans may be more vulnerable to suicidal behaviors if suicide-related exposures are experienced. Public health suicide prevention initiatives, both inside and outside of the TGD community, may help to reduce suicide in these veterans.
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Affiliation(s)
- Raymond P Tucker
- Department of Psychology, Louisiana State University, Baton Rouge, Louisiana
| | | | - Annie Snow
- Department of Social Work, University of Kentucky, Lexington, Kentucky
| | - Mike Bradstreet
- Trans Collaborations, Local Advisory Board, Lincoln, Nebraska
| | - Julie Cerel
- Department of Social Work, University of Kentucky, Lexington, Kentucky
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221
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Hadlandsmyth K, Mosher HJ, Bayman EO, Wikle JG, Lund BC. A Typology of New Long-term Opioid Prescribing in the Veterans Health Administration. J Gen Intern Med 2020; 35:2607-2613. [PMID: 32206994 PMCID: PMC7458960 DOI: 10.1007/s11606-020-05749-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/31/2020] [Accepted: 02/14/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Narrow definitions of long-term opioid (LTO) use result in limited knowledge of the full range of LTO prescribing patterns and the rates of these patterns. OBJECTIVE To investigate a model of new LTO prescribing typologies using latent class analysis. DESIGN National administrative data from the VA Corporate Data Warehouse were accessed using the VA Informatics and Computing Infrastructure. Characterization of the typology of initial LTO prescribing was explored using latent class analysis. PARTICIPANTS Veterans initiating LTO during 2016 through the Veteran's Administration Healthcare System (N = 42,230). MAIN MEASURES Opioid receipt as determined by VA prescription data, using the cabinet supply methodology. KEY RESULTS Over one-quarter (27.7%) of the sample fell into the fragmented new long-term prescribing category, 39.8% were characterized by uniform daily new LTO, and the remaining 32.7% were characterized by uniform episodic LTO. Each of these three broad sub-groups also included two additional sub-groups (6 classes total in the model), characterized by the presence or absence of prior opioid prescriptions. CONCLUSIONS New LTO prescribing in the VA includes uniform daily prescribing, uniform episodic prescribing, and fragmented prescribing. Future work is needed to elucidate the safety and efficacy of these prescribing patterns.
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Affiliation(s)
- Katherine Hadlandsmyth
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA.
- Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
| | - Hilary J Mosher
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Emine O Bayman
- University of Iowa, College of Public Health, Iowa City, IA, USA
| | - Justin G Wikle
- Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Brian C Lund
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA
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Holliday R, Borges LM, Stearns-Yoder KA, Hoffberg AS, Brenner LA, Monteith LL. Posttraumatic Stress Disorder, Suicidal Ideation, and Suicidal Self-Directed Violence Among U.S. Military Personnel and Veterans: A Systematic Review of the Literature From 2010 to 2018. Front Psychol 2020; 11:1998. [PMID: 32982838 PMCID: PMC7479813 DOI: 10.3389/fpsyg.2020.01998] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/20/2020] [Indexed: 01/02/2023] Open
Abstract
Rates of suicide and posttraumatic stress disorder remain high among United States military personnel and veterans. Building upon prior work, we conducted a systematic review of research published from 2010 to 2018 regarding: (1) the prevalence of suicidal ideation, suicide attempt, and suicide among United States military personnel and veterans diagnosed with posttraumatic stress disorder; (2) whether posttraumatic stress disorder was associated with suicidal ideation, suicide attempt, and suicide among United States military personnel and veterans. 2,106 titles and abstracts were screened, with 48 articles included. Overall risk of bias was generally high for studies on suicidal ideation or suicide attempt and low for studies on suicide. Across studies, rates of suicidal ideation, suicide attempt, and suicide widely varied based on study methodology and assessment approaches. Findings regarding the association between posttraumatic stress disorder diagnosis with suicidal ideation and suicide were generally mixed, and some studies reported that posttraumatic stress disorder was associated with lower risk for suicide. In contrast, most studies reported significant associations between posttraumatic stress disorder and suicide attempt. These findings suggest complex associations between posttraumatic stress disorder and suicidal ideation, suicide attempt, and suicide, which are likely influenced by other factors (e.g., psychiatric comorbidity). In addition, most samples were comprised of veterans, rather than military personnel. Further research is warranted to elucidate associations between posttraumatic stress disorder and suicidal ideation, suicide attempt, and suicide, including identification of moderators and mediators of this relationship. Addressing this among United States military personnel, by gender, and in relation to different trauma types is also necessary.
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Affiliation(s)
- Ryan Holliday
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Lauren M. Borges
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kelly A. Stearns-Yoder
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, United States
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Adam S. Hoffberg
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, United States
| | - Lisa A. Brenner
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Lindsey L. Monteith
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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223
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Geraci JC, Mobbs M, Edwards ER, Doerries B, Armstrong N, Porcarelli R, Duffy E, Loos CM, Kilby D, Juanamarga J, Cantor G, Sutton L, Sokol Y, Goodman M. Expanded Roles and Recommendations for Stakeholders to Successfully Reintegrate Modern Warriors and Mitigate Suicide Risk. Front Psychol 2020; 11:1907. [PMID: 32973608 PMCID: PMC7471060 DOI: 10.3389/fpsyg.2020.01907] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/10/2020] [Indexed: 11/13/2022] Open
Abstract
This article draws upon the legends of warriors from ancient Greece and other traditions to illuminate the journey of Modern Warriors (MWs) who have served in the United States military over the last century. It then turns to stakeholders that can assist current MWs in their reintegration to civilian life and mitigate suicide risk. Until this point, without an existing and coordinated local, federal, non-profit, and private system, rates of suicide for post-9/11 MWs after leaving the military have greatly increased, especially for young and women MWs. This is due in part to the military satisfying many of MWs’ needs by providing units, leaders, and a mission during the Departure and Initiation stages of the MW journey. However, as MWs exit the military and face the difficult task of reintegration, the absence of units, leaders, and mission leads to deteriorating psychological health and increasing suicide risk. Written primarily by post-9/11 MWs, this article proposes recommendations for stakeholders to better reintegrate MWs and mitigate suicide risk. The authors strive to develop a system that satisfies MWs’ reintegration needs and enables MWs to be well positioned to continue their next ‘mission’ – to serve and improve society.
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Affiliation(s)
- Joseph C Geraci
- Transitioning Servicemember/Veteran and Suicide Prevention Center, VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, The Bronx, NY, United States.,Resilience Center for Veterans and Families, Teachers College, Columbia University, New York City, NY, United States.,Institute for Veterans and Military Families, Syracuse University, Syracuse, NY, United States
| | - Meaghan Mobbs
- Resilience Center for Veterans and Families, Teachers College, Columbia University, New York City, NY, United States
| | - Emily R Edwards
- Transitioning Servicemember/Veteran and Suicide Prevention Center, VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, The Bronx, NY, United States
| | - Bryan Doerries
- Theater of War Productions, New York City, NY, United States
| | - Nicholas Armstrong
- Institute for Veterans and Military Families, Syracuse University, Syracuse, NY, United States
| | | | - Elana Duffy
- Pathfinder.vet, New York City, NY, United States
| | | | - Daniel Kilby
- Transitioning Servicemember/Veteran and Suicide Prevention Center, VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, The Bronx, NY, United States.,Resilience Center for Veterans and Families, Teachers College, Columbia University, New York City, NY, United States
| | - Josephine Juanamarga
- Resilience Center for Veterans and Families, Teachers College, Columbia University, New York City, NY, United States
| | - Gilly Cantor
- Institute for Veterans and Military Families, Syracuse University, Syracuse, NY, United States
| | - Loree Sutton
- NYC Department of Veterans' Services, New York City, NY, United States
| | - Yosef Sokol
- Transitioning Servicemember/Veteran and Suicide Prevention Center, VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, The Bronx, NY, United States
| | - Marianne Goodman
- Transitioning Servicemember/Veteran and Suicide Prevention Center, VISN 2 Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, The Bronx, NY, United States
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224
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Rowland JA, Martindale SL, Shura RD, Miskey HM, Bateman JR, Epstein EL, Stern MJ, Hurley RA, Taber KH. Initial Validation of the Mid-Atlantic Mental Illness Research, Education, and Clinical Center Assessment of Traumatic Brain Injury. J Neurotrauma 2020; 37:1797-1805. [PMID: 32245339 PMCID: PMC9639229 DOI: 10.1089/neu.2019.6972] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
With the increasing prevalence of traumatic brain injury (TBI), the need for reliable and valid methods to evaluate TBI has also increased. The purpose of this study was to establish the validity and reliability of a new comprehensive assessment of TBI, the Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) Assessment of TBI (MMA-TBI). The participants in this study were post-deployment, combat exposed veterans. First, MMA-TBI outcomes were compared with those of independently conducted clinical TBI assessments. Next, MMA-TBI outcomes were compared with those of a different validated TBI measure (the Ohio State University TBI Identification method [OSU-TBI-ID]). Next, four TBI subject matter experts independently evaluated 64 potential TBI events based on both clinical judgment and Veterans Administration/Department of Defense (VA/DoD) Clinical Practice Guidelines. Results of the MMA-TBI algorithm (based on VA/DoD clinical guideline) were compared with those of the subject matter experts. Diagnostic correspondence with independently conducted expert clinical evaluation was 96% for lifetime TBI and 92% for deployment-acquired TBI. Consistency between the MMA-TBI and the OSU-TBI-ID was high (κ = 0.90; Kendall Tau = 0.94). Comparison of MMA-TBI algorithm results with those of subject matter experts was high (κ = 0.97-1.00). The MMA-TBI is the first TBI interview to be validated against an independently conducted clinical TBI assessment. Overall, results demonstrate the MMA-TBI is a highly valid and reliable instrument for determining TBI based on VA/DoD clinical guidelines. These results support the need for application of standardized TBI criteria across all diagnostic contexts.
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Affiliation(s)
- Jared A. Rowland
- Research and Academic Affairs, Salisbury VA Medical Center, Salisbury, North Carolina, USA
- Mid-Atlantic Mental Illness Research Education and Clinical Center, Durham, North Carolina, USA
- Department of Neurobiology and Anatomy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Sarah L. Martindale
- Research and Academic Affairs, Salisbury VA Medical Center, Salisbury, North Carolina, USA
- Mid-Atlantic Mental Illness Research Education and Clinical Center, Durham, North Carolina, USA
- Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Robert D. Shura
- Research and Academic Affairs, Salisbury VA Medical Center, Salisbury, North Carolina, USA
- Mid-Atlantic Mental Illness Research Education and Clinical Center, Durham, North Carolina, USA
- Department of Neurology and Psychiatry, and Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Holly M. Miskey
- Research and Academic Affairs, Salisbury VA Medical Center, Salisbury, North Carolina, USA
- Mid-Atlantic Mental Illness Research Education and Clinical Center, Durham, North Carolina, USA
- Department of Neurology and Psychiatry, and Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - James R. Bateman
- Research and Academic Affairs, Salisbury VA Medical Center, Salisbury, North Carolina, USA
- Mid-Atlantic Mental Illness Research Education and Clinical Center, Durham, North Carolina, USA
- Department of Neurology and Psychiatry, and Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Erica L. Epstein
- Research and Academic Affairs, Salisbury VA Medical Center, Salisbury, North Carolina, USA
- Mid-Atlantic Mental Illness Research Education and Clinical Center, Durham, North Carolina, USA
- Department of Neurology and Psychiatry, and Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mark J. Stern
- Research and Academic Affairs, Salisbury VA Medical Center, Salisbury, North Carolina, USA
- Mid-Atlantic Mental Illness Research Education and Clinical Center, Durham, North Carolina, USA
| | - Robin A. Hurley
- Research and Academic Affairs, Salisbury VA Medical Center, Salisbury, North Carolina, USA
- Mid-Atlantic Mental Illness Research Education and Clinical Center, Durham, North Carolina, USA
- Department of Psychiatry and Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
| | - Katherine H. Taber
- Research and Academic Affairs, Salisbury VA Medical Center, Salisbury, North Carolina, USA
- Mid-Atlantic Mental Illness Research Education and Clinical Center, Durham, North Carolina, USA
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
- Department of Physical Medicine and Rehabilitation, Via College of Osteopathic Medicine, Blacksburg, Virginia, USA
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225
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O'Hare AM, Butler CR, Taylor JS, Wong SPY, Vig EK, Laundry RS, Wachterman MW, Hebert PL, Liu CF, Rios-Burrows N, Richards CA. Thematic Analysis of Hospice Mentions in the Health Records of Veterans with Advanced Kidney Disease. J Am Soc Nephrol 2020; 31:2667-2677. [PMID: 32764141 DOI: 10.1681/asn.2020040473] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 06/29/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Patients with advanced kidney disease are less likely than many patients with other types of serious illness to enroll in hospice. Little is known about real-world clinical decision-making related to hospice for members of this population. METHODS We used a text search tool to conduct a thematic analysis of documentation pertaining to hospice in the electronic medical record system of the Department of Veterans Affairs, for a national sample of 1000 patients with advanced kidney disease between 2004 and 2014 who were followed until October 8, 2019. RESULTS Three dominant themes emerged from our qualitative analysis of the electronic medical records of 340 cohort members with notes containing hospice mentions: (1) hospice and usual care as antithetical care models: clinicians appeared to perceive a sharp demarcation between services that could be provided under hospice versus usual care and were often uncertain about hospice eligibility criteria. This could shape decision-making about hospice and dialysis and made it hard to individualize care; (2) hospice as a last resort: patients often were referred to hospice late in the course of illness and did not so much choose hospice as accept these services after all treatment options had been exhausted; and (3) care complexity: patients' complex care needs at the time of hospice referral could complicate transitions to hospice, stretch the limits of home hospice, and promote continued reliance on the acute care system. CONCLUSIONS Our findings underscore the need to improve transitions to hospice for patients with advanced kidney disease as they approach the end of life.
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Affiliation(s)
- Ann M O'Hare
- Department of Medicine, University of Washington, Seattle, Washington .,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | | | - Janelle S Taylor
- Department of Anthropology, University of Toronto, Toronto, Ontario, Canada
| | - Susan P Y Wong
- Department of Medicine, University of Washington, Seattle, Washington.,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Elizabeth K Vig
- Department of Medicine, University of Washington, Seattle, Washington.,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Ryan S Laundry
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Melissa W Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Paul L Hebert
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
| | - Chuan-Fen Liu
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
| | - Nilka Rios-Burrows
- Chronic Kidney Disease Initiative, Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Claire A Richards
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,School of Nursing, University of Washington, Seattle, Washington
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226
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Mahoney CT, Livingston NA, Wong MM, Rosen RC, Marx BP, Keane TM. Parallel process modeling of posttraumatic stress disorder symptoms and alcohol use severity in returning veterans. Psychol Addict Behav 2020; 34:569-578. [PMID: 32118464 PMCID: PMC9077743 DOI: 10.1037/adb0000569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Posttraumatic stress disorder (PTSD) is associated with higher levels of alcohol use among returning veterans. Persistent PTSD symptoms can predict alcohol use over the span of hours, days, weeks, and months; however, knowledge of the strength of these associations beyond 1 year remains limited. In this study, we examined the 6-year course of co-occurring PTSD and alcohol use to explicate the directional and possible enduring effects of PTSD on alcohol use severity over time. Our study included 1,649 returning veterans (M age = 37.49; SD = 9.88) who completed 4 waves of data collection between 2010 and 2016. We used parallel process modeling to evaluate temporal associations between PTSD symptoms and alcohol use severity across 4 (T1-T4) waves of data collection. PTSD and alcohol use both decreased significantly between T1 and T4 and in tandem with one another. That is, decreases in one were associated with decreases in the other. Further, individuals with higher levels of PTSD symptom severity at T1 reported accelerated rates of change regarding PTSD symptoms and alcohol use over time. Conversely, baseline alcohol use severity did not predict the rate of change in PTSD symptom severity. Our findings provide evidence of a prospective association between PTSD symptoms and alcohol use and highlight the potential for reciprocal associations between them over the span of years. Importantly, our demonstration of the natural course of co-occurring PTSD symptoms and alcohol use suggests further trauma-focused and combined intervention strategies are needed to disrupt this enduring and reciprocal pattern among returning veterans. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
- Colin T. Mahoney
- VA Boston Healthcare System, Boston, MA,National Center for PTSD, Behavioral Science Division, Boston, MA,Department of Psychiatry, Boston University School of Medicine, Boston, MA
| | - Nicholas A. Livingston
- VA Boston Healthcare System, Boston, MA,National Center for PTSD, Behavioral Science Division, Boston, MA,Department of Psychiatry, Boston University School of Medicine, Boston, MA
| | - Maria M. Wong
- Department of Psychology, Idaho State University, Pocatello, ID
| | | | - Brian P. Marx
- VA Boston Healthcare System, Boston, MA,National Center for PTSD, Behavioral Science Division, Boston, MA,Department of Psychiatry, Boston University School of Medicine, Boston, MA
| | - Terence M. Keane
- VA Boston Healthcare System, Boston, MA,National Center for PTSD, Behavioral Science Division, Boston, MA,Department of Psychiatry, Boston University School of Medicine, Boston, MA
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227
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Pajak A. Special Needs of and Promising Solutions for Incarcerated Veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. J Correct Health Care 2020; 26:227-239. [PMID: 32715835 DOI: 10.1177/1078345820938032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Over 2.5 million military service members have been deployed to Iraq and Afghanistan in Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND). Research indicates OEF/OIF/OND veterans, compared to veterans of other service eras, have elevated risks of mental health problems, suicide rates, homelessness, and problems in the criminal justice system. This article reviews the characteristics of, treatment needs of, and emerging criminal justice reentry initiatives for veterans of the Iraq and Afghanistan conflicts.
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228
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Rojas SM, Piccirillo ML, McCann RA, Reger MA, Felker B. An examination of suicidal behaviour among veterans receiving mental-health appointments in person versus clinical video telehealth. J Telemed Telecare 2020; 28:429-435. [PMID: 32692597 DOI: 10.1177/1357633x20942041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The US Department of Veterans Affairs (VA) is a national leader in the implementation of clinical video telehealth (CVT) services. Despite the growth of mental-health services offered via CVT, it is unclear to what extent these services are offered and accessed by veterans with previous suicidal behaviour. METHODS The current quality improvement project examined this question within a local VA health-care system using data from suicide behaviour reports (SBRs), the Veteran Health Administration's official reporting and surveillance system. The frequency of SBRs was compared during two different time points among veterans who received individual mental-health appointments in person only or via CVT during the 2017 calendar year. Among veterans with a SBR, time in days elapsed from their first mental-health appointment to a SBR was examined as a function of treatment modality. RESULTS Results indicated veterans who received in-person treatment only were more likely to present with a SBR six months prior to their first mental-health appointment compared to those who received CVT during the observation period. There were no differences in SBRs during the 12 months after the first appointment or the time from the first appointment to the SBR as a function of treatment modality used. DISCUSSION Although veterans who received in-person mental-health services were more likely to have had a SBR six months prior to treatment, suicide risk throughout the observation period did not differ between groups. Clinical implications that arise from these findings are described in the discussion.
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Affiliation(s)
- Sasha M Rojas
- VA Puget Sound Health Care System, USA.,VISN 20 Clinical Resource Hub, USA
| | - Marilyn L Piccirillo
- VA Puget Sound Health Care System, USA.,Department of Psychological and Brain Sciences, Washington University in St Louis, USA
| | - Russell A McCann
- VA Puget Sound Health Care System, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, USA
| | - Mark A Reger
- VA Puget Sound Health Care System, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, USA
| | - Bradford Felker
- VA Puget Sound Health Care System, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, USA
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229
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Etingen B, Patrianakos J, Wirth M, Hogan TP, Smith BM, Tarlov E, Stroupe KT, Kartje R, Weaver FM. TeleWound Practice Within the Veterans Health Administration: Protocol for a Mixed Methods Program Evaluation. JMIR Res Protoc 2020; 9:e20139. [PMID: 32706742 PMCID: PMC7399961 DOI: 10.2196/20139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Chronic wounds, such as pressure injuries and diabetic foot ulcers, are a significant predictor of mortality. Veterans who reside in rural areas often have difficulty accessing care for their wounds. TeleWound Practice (TWP), a coordinated effort to incorporate telehealth into the provision of specialty care for patients with skin wounds, has the potential to increase access to wound care by allowing veterans to receive this care at nearby outpatient clinics or in their homes. The Veterans Health Administration (VA) is championing the rollout of the TWP, starting with regional implementation. OBJECTIVE This paper aims to describe the protocol for a mixed-methods program evaluation to assess the implementation and outcomes of TWP in VA. METHODS We are conducting a mixed-methods evaluation of 4 VA medical centers and their community-based outpatient clinics that are participating in the initial implementation of the TWP. Data will be collected from veterans, VA health care team members, and other key stakeholders (eg, clinical leadership). We will use qualitative methods (ie, semistructured interviews), site visits, and quantitative methods (ie, surveys, national VA administrative databases) to assess the process and reach of TWP implementation and its impact on veterans' clinical outcomes and travel burdens and costs. RESULTS This program evaluation was funded in October 2019 as a Partnered Evaluation Initiative by the US Department of Veterans Affairs, Diffusion of Excellence Office, and Office of Research and Development, Health Services Research and Development Service, Quality Enhancement Research Initiative Program (PEC 19-310). CONCLUSIONS Evaluation of the TWP will identify barriers and solutions to TeleWound implementation in a small number of sites that can be used to inform successful rollout of the TWP nationally. Our evaluation work will inform future efforts to scale up the TWP across VA and optimize reach of the program to veterans across the nation. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/20139.
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Affiliation(s)
- Bella Etingen
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Jamie Patrianakos
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Marissa Wirth
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Timothy P Hogan
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States.,Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Bridget M Smith
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States.,Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Elizabeth Tarlov
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States.,College of Nursing, University of Illinois at Chicago, Chicago, IL, United States
| | - Kevin T Stroupe
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States.,Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, IL, United States
| | - Rebecca Kartje
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Frances M Weaver
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States.,Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, IL, United States
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230
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Abstract
Moral injury is a term whose popularity has grown in psychology and psychiatry, as well as philosophy, over the last several years. This presents challenges, because these fields use the term in different ways and draw their understanding from different sources, creating the potential for contradiction. This, however, is also an opportunity. Comparison between behavioral sciences and philosophy can help enrich understandings of harms considered not just psychological but moral. To this end, I provide an overview of the more influential writing of moral injury, mapping them into three broad discourses: clinical, juridical-critical, and structural. This overview then leads to a discussion of how comparative engagement among these discourses promises to expand on current theories of moral harm. I argue that such a comparison will demonstrate that more emphasis on structural violence will strengthen current understandings of moral injury, often understood in a more narrow sense to be a result of more direct, physical violence, allowing us to view moral injury as a result of institutional and social violence and injustices.
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231
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Kerr NC, Ashby S, Gerardi SM, Lane SJ. Occupational therapy for military personnel and military veterans experiencing post-traumatic stress disorder: A scoping review. Aust Occup Ther J 2020; 67:479-497. [PMID: 32627215 DOI: 10.1111/1440-1630.12684] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 06/05/2020] [Accepted: 06/07/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION As the rate of post-traumatic stress disorder (PTSD) among military personnel and military veterans continues to rise, occupational therapists are increasingly concerned with the impact of this disorder on health, occupational performance, and quality of life. However, the literature on occupational therapy for military personnel and military veterans with PTSD has not been summarised. METHOD The objective was to identify what is known from the published, peer-reviewed literature, about the services provided by occupational therapists to military personnel and military veterans experiencing PTSD. Arksey and O'Malley's five steps for scoping reviews were utilised. A search of three databases identified 27 articles. RESULTS Of the 27 papers reviewed, 13 papers discussed military personnel, 13 for military veterans, and 1 reported on both populations. Of these 27, 9 research papers provided data to support the efficacy of interventions, whereas 2 papers reported occupational performance issues. Eight opinion and eight service description papers were included. The most commonly mentioned interventions across the reviewed papers were stress and anger, or coping skills (n = 11), returning to duty (n = 9), physical training (n = 7), and sleep hygiene (n = 6). CONCLUSION Occupational therapists provide services to military personnel who are vulnerable to PTSD from combat and operational stress. Rarely did publications address intervention efficacy for military personnel. Additionally, there is a paucity of literature that addresses occupational therapy interventions following transition from military service for veterans with PTSD specific to facilitating reintegration to civilian life. Despite this, occupational therapists are well suited to enable military veterans to build upon their existing strengths, skills, and professional identities to minimise the impact of PTSD on daily life and to reach their full potential.
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Affiliation(s)
- Nathan C Kerr
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
| | - Samantha Ashby
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
| | - Steven M Gerardi
- Occupational Therapy Program, University of St. Augustine for Health Sciences, Austin, TX, USA
| | - Shelly J Lane
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia.,Occupational Therapy, Colorado State University, Fort Collins, CO, USA
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232
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Hausman C, Meffert BN, Mosich MK, Heinz AJ. Impulsivity and Cognitive Flexibility as Neuropsychological Markers for Suicidality: A Multi-Modal Investigation Among Military Veterans with Alcohol Use Disorder and PTSD. Arch Suicide Res 2020; 24:313-326. [PMID: 31248349 PMCID: PMC6954988 DOI: 10.1080/13811118.2019.1635930] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
To examine relations between self-report and behavioral measures of impulsivity and cognitive flexibility with suicidal ideation and self-harm and suicide attempt history. Methods: Eighty-seven military veterans who met DSM-5 diagnostic criteria for alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD) were evaluated for current suicidal ideation and self-harm, suicide attempt history, impulsivity, and cognitive flexibility. Results: Higher levels of self-reported impulsivity were associated with greater suicidal ideation and self-harm and lower behavioral inhibition was associated with greater likelihood of endorsing a suicide attempt. Conclusion: Use of multi-modal assessment of impulsivity and cognitive flexibility may aid in suicide screening and intervention among vulnerable and high-risk populations.
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233
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Abstract
INTRODUCTION The US Department of Veterans Affairs (VA) has developed a homeless patient aligned care team (H-PACT) model to provide clinical outreach to homeless veterans. This model has not been implemented by the VA Sierra Nevada Health Care System; however, a day shelter for homeless veterans does exist. Currently, clinical staff at the shelter consists of licensed clinical social workers. METHODS A half day per week pharmacy clinic was established and managed by a postgraduate year-2 psychiatric pharmacy resident. Data regarding provider and emergency department (ED) visits, psychotropic medication adherence, and interventions made during visits were collected and analyzed to provide support for need of additional clinical staff and the establishment of an H-PACT at the Reno VA. RESULTS Over 5 months, 52 veterans were seen, including some over multiple visits, with a total of 77 encounters. There were an average of 4 visits per clinic day. Total interventions equaled 205 and included medication review, patient education, and adverse drug reaction detection among other interventions. Provider visits and psychotropic medication possession prior to and following clinic visits were tracked. DISCUSSION This pharmacist-managed outpatient clinic provided a comfortable walk-in environment for homeless veterans. The difference in provider visits, medication possession, and ED visits before and after walk-in clinic visits provided clinical significance with 205 documented interventions, and the clinic was well received by veterans.
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Affiliation(s)
- Elizabeth R Haake
- Psychiatric Clinical Pharmacy Specialist, PGY2 Psychiatric Pharmacy Residency Director, Pharmacy Services, Veterans Affairs Sierra Nevada Health Care System, Reno, Nevada
| | - Kelly J Krieger
- Psychiatric Clinical Pharmacy Specialist, PGY2 Psychiatric Pharmacy Residency Director, Pharmacy Services, Veterans Affairs Sierra Nevada Health Care System, Reno, Nevada
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234
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Haun JN, Alman AC, Melillo C, Standifer M, McMahon-Grenz J, Shin M, Lapcevic WA, Patel N, Elwy AR. Using Electronic Data Collection Platforms to Assess Complementary and Integrative Health Patient-Reported Outcomes: Feasibility Project. JMIR Med Inform 2020; 8:e15609. [PMID: 32589163 PMCID: PMC7381258 DOI: 10.2196/15609] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 12/06/2019] [Accepted: 04/27/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The Veteran Administration (VA) Office of Patient-Centered Care and Cultural Transformation is invested in improving veteran health through a whole-person approach while taking advantage of the electronic resources suite available through the VA. Currently, there is no standardized process to collect and integrate electronic patient-reported outcomes (ePROs) of complementary and integrative health (CIH) into clinical care using a web-based survey platform. This quality improvement project enrolled veterans attending CIH appointments within a VA facility and used web-based technologies to collect ePROs. OBJECTIVE This study aimed to (1) determine a practical process for collecting ePROs using patient email services and a web-based survey platform and (2) conduct analyses of survey data using repeated measures to estimate the effects of CIH on patient outcomes. METHODS In total, 100 veterans from one VA facility, comprising 11 cohorts, agreed to participate. The VA patient email services (Secure Messaging) were used to manually send links to a 16-item web-based survey stored on a secure web-based survey storage platform (Qualtrics). Each survey included questions about patient outcomes from CIH programs. Each cohort was sent survey links via Secure Messaging (SM) at 6 time points: weeks 1 through 4, week 8, and week 12. Process evaluation interviews were conducted with five primary care providers to assess barriers and facilitators to using the patient-reported outcome survey in usual care. RESULTS This quality improvement project demonstrated the usability of SM and Qualtrics for ePRO collection. However, SM for ePROs was labor intensive for providers. Descriptive statistics on health competence (2-item Perceived Health Competence Scale), physical and mental health (Patient-Reported Outcomes Measurement Information System Global-10), and stress (4-item Perceived Stress Scale) indicated that scores did not significantly change over time. Survey response rates varied (18/100, 18.0%-42/100, 42.0%) across each of the 12 weekly survey periods. In total, 74 of 100 participants provided ≥1 survey, and 90% (66/74) were female. The majority, 62% (33/53) of participants, who reported the use of any CIH modality, reported the use of two or more unique modalities. Primary care providers highlighted specific challenges with SM and offered solutions regarding staff involvement in survey implementation. CONCLUSIONS This quality improvement project informs our understanding of the processes currently available for using SM and web-based data platforms to collect ePROs. The study results indicate that although it is possible to use SM and web-based survey platforms for ePROs, automating scheduled administration will be necessary to reduce provider burden. The lack of significant change in ePROs may be due to standard measures taking a biomedical approach to wellness. Future work should focus on identifying ideal ePRO processes that would include standardized, whole-person measures of wellness.
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Affiliation(s)
- Jolie N Haun
- Research Service, James A. Haley VA Medical Center, Tampa, FL, United States.,Department of Community & Family Health, College of Public Health, University of South Florida, Tampa, FL, United States
| | - Amy C Alman
- Research Service, James A. Haley VA Medical Center, Tampa, FL, United States.,Department of Public Health, University of South Florida, Tampa, FL, United States
| | - Christine Melillo
- Research Service, James A. Haley VA Medical Center, Tampa, FL, United States
| | - Maisha Standifer
- Research Service, James A. Haley VA Medical Center, Tampa, FL, United States.,Department of Pharmacy Practice, College of Pharmacy, University of South Florida, Tampa, FL, United States
| | - Julie McMahon-Grenz
- Research Service, James A. Haley VA Medical Center, Tampa, FL, United States
| | - Marlena Shin
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, MA, United States
| | - W A Lapcevic
- Research Service, James A. Haley VA Medical Center, Tampa, FL, United States
| | - Nitin Patel
- Performance Improvement and Reporting, VHA Office of Community Care, Department of Veteran Affairs, Washington, DC, United States
| | - A Rani Elwy
- Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Medical Center, Bedford, MA, United States.,Brown University, Providence, RI, United States
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235
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LaMotte AD, Pless Kaiser A, Lee LO, Supelana C, Taft CT, Vasterling JJ. Factors Influencing Family Environment Reporting Concordance Among U.S. War Zone Veterans and Their Partners. Assessment 2020; 28:1459-1470. [PMID: 32486907 DOI: 10.1177/1073191120922619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A key challenge in the assessment of family variables is the discrepancies that arise between reports. Although prior research has observed levels of interpartner agreement on the family environment, no studies have investigated factors that may influence agreement. In this study, war zone veterans (WZVs) and their partners (N = 207 couples) completed assessments of the family environment. We examined interpartner agreement in relation to WZV and partner posttraumatic stress disorder (PTSD) symptoms, WZV time away from home, and family size. More severe WZV PTSD symptoms were associated with greater interpartner agreement on family environment, whereas more severe partner PTSD symptoms were associated with reporting more negative perceptions of the family environment relative to WZV reports. Family size was associated with greater interpartner agreement. Factors associated with concordance in this study should be considered by clinicians and researchers seeking to understand and address reporting discrepancies on the family.
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Affiliation(s)
- Adam D LaMotte
- University of Maryland, Baltimore County, Baltimore MD, USA
| | - Anica Pless Kaiser
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA.,Boston University School of Medicine, Boston, MA, USA.,Psychology Service, VA Boston Healthcare System, Boston, MA, USA
| | - Lewina O Lee
- Boston University School of Medicine, Boston, MA, USA.,Research Service, VA Boston Healthcare System, Boston, MA, USA.,Psychology Service, VA Boston Healthcare System, Boston, MA, USA
| | - Christina Supelana
- Boston University School of Medicine, Boston, MA, USA.,Psychology Service, VA Boston Healthcare System, Boston, MA, USA
| | - Casey T Taft
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA.,Boston University School of Medicine, Boston, MA, USA.,Psychology Service, VA Boston Healthcare System, Boston, MA, USA
| | - Jennifer J Vasterling
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA.,Boston University School of Medicine, Boston, MA, USA.,Psychology Service, VA Boston Healthcare System, Boston, MA, USA
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236
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Levy C, Ersek M, Scott W, Carpenter JG, Kononowech J, Phibbs C, Lowry J, Cohen J, Foglia M. Life-Sustaining Treatment Decisions Initiative: Early Implementation Results of a National Veterans Affairs Program to Honor Veterans' Care Preferences. J Gen Intern Med 2020; 35:1803-1812. [PMID: 32096084 PMCID: PMC7280392 DOI: 10.1007/s11606-020-05697-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 01/31/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND On July 1, 2018, the Veterans Health Administration (VA) National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI). Its goal is to identify, document, and honor LST decisions of seriously ill veterans. Providers document veterans' goals and decisions using a standardized LST template and order set. OBJECTIVE Evaluate the first 7 months of LSTDI implementation and identify predictors of LST template completion. DESIGN Retrospective observational study of clinical and administrative data. We identified all completed LST templates, defined as completion of four required template fields. Templates also include four non-required fields. Results were stratified by risk of hospitalization or death as estimated by the Care Assessment Need (CAN) score. SUBJECTS All veterans with VA utilization between July 1, 2018, and January 31, 2019. MAIN MEASURES Completed LST templates, goals and LST preferences, and predictors of documentation. RESULTS LST templates were documented for 108,145 veterans, and 85% had one or more of the non-required fields completed in addition to the required fields. Approximately half documented a preference for cardiopulmonary resuscitation. Among those who documented specific goals, half wanted to improve or maintain function, independence, and quality of life while 28% had a goal of life prolongation irrespective of risk of hospitalization/death and 45% expressed a goal of comfort. Only 7% expressed a goal of being cured. Predictors of documentation included VA nursing home residence, older age, frailty, and comorbidity, while non-Caucasian race, rural residence, and receipt of care in a lower complexity medical center were predictive of no documentation. CONCLUSIONS LST decisions were documented for veterans at high risk of hospitalization or death. While few expressed a preference for cure, half desire, cardiopulmonary resuscitation. Predictors of documentation were generally consistent with existing literature. Opportunities to reduce observed disparities exist by leveraging available VA resources and programs.
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Affiliation(s)
- Cari Levy
- Department of Veterans Affairs, Rocky Mountain VA Medical Center, Aurora, CO, USA.
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Mary Ersek
- Department of Veterans Affairs, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Joan G Carpenter
- Department of Veterans Affairs, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Jennifer Kononowech
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Jill Lowry
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA
| | - Jennifer Cohen
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA
| | - Marybeth Foglia
- Department of Veterans Affairs, National Center for Ethics in Health Care, Washington, DC, USA
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA
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237
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Miller C, Gurewich D, Garvin L, Pugatch M, Koppelman E, Pendergast J, Harrington K, Clark JA. Veterans Affairs and Rural Community Providers' Perspectives on Interorganizational Care Coordination: A Qualitative Analysis. J Rural Health 2020; 37:417-425. [PMID: 32472724 DOI: 10.1111/jrh.12453] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To investigate challenges in care coordination between US Department of Veterans Affairs (VA) clinics and community providers serving rural veterans. METHODS We completed qualitative interviews in 2017-2018 with a geographically diverse sample of 57 VA and community staff. Interviews were audio-recorded and transcribed verbatim. We used Rapid Qualitative Inquiry (RQI) to guide analyses. RESULTS Results suggested 5 pivotal domains related to interorganizational care coordination at these sites: organizational mechanisms; organizational culture; relational coordination; contextual factors; and the role of the third party administrators charged with management of scheduling and reimbursement of community services through recent legislation. Across these domains, strategies to bridge gaps between organizations (eg, contracts with third party administrators, development of VA-based community care offices, provision of boundary-spanning staff) at times exacerbated coordination challenges. CONCLUSIONS Steps taken to improve interorganizational care coordination between VA and community clinics may inadvertently complicate an already complex process. Our findings emphasize the importance of attending to key contextual barriers in coordinating care for rural veterans, and they illustrate the value of fundamental structural and relational approaches to enhancing such care coordination.
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Affiliation(s)
- Christopher Miller
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Deborah Gurewich
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
| | - Lynn Garvin
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
- Boston University School of Public Health, Boston, Massachusetts
| | - Marianne Pugatch
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
| | - Elisa Koppelman
- Boston University School of Public Health, Boston, Massachusetts
| | - Jacquelyn Pendergast
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
| | - Katharine Harrington
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
| | - Jack A Clark
- Boston University School of Public Health, Boston, Massachusetts
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238
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Leightley D, Pernet D, Velupillai S, Stewart RJ, Mark KM, Opie E, Murphy D, Fear NT, Stevelink SAM. The Development of the Military Service Identification Tool: Identifying Military Veterans in a Clinical Research Database Using Natural Language Processing and Machine Learning. JMIR Med Inform 2020; 8:e15852. [PMID: 32348287 PMCID: PMC7281146 DOI: 10.2196/15852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 12/11/2019] [Accepted: 01/26/2020] [Indexed: 02/07/2023] Open
Abstract
Background Electronic health care records (EHRs) are a rich source of health-related information, with potential for secondary research use. In the United Kingdom, there is no national marker for identifying those who have previously served in the Armed Forces, making analysis of the health and well-being of veterans using EHRs difficult. Objective This study aimed to develop a tool to identify veterans from free-text clinical documents recorded in a psychiatric EHR database. Methods Veterans were manually identified using the South London and Maudsley (SLaM) Biomedical Research Centre Clinical Record Interactive Search—a database holding secondary mental health care electronic records for the SLaM National Health Service Foundation Trust. An iterative approach was taken; first, a structured query language (SQL) method was developed, which was then refined using natural language processing and machine learning to create the Military Service Identification Tool (MSIT) to identify if a patient was a civilian or veteran. Performance, defined as correct classification of veterans compared with incorrect classification, was measured using positive predictive value, negative predictive value, sensitivity, F1 score, and accuracy (otherwise termed Youden Index). Results A gold standard dataset of 6672 free-text clinical documents was manually annotated by human coders. Of these documents, 66.00% (4470/6672) were then used to train the SQL and MSIT approaches and 34.00% (2202/6672) were used for testing the approaches. To develop the MSIT, an iterative 2-stage approach was undertaken. In the first stage, an SQL method was developed to identify veterans using a keyword rule–based approach. This approach obtained an accuracy of 0.93 in correctly predicting civilians and veterans, a positive predictive value of 0.81, a sensitivity of 0.75, and a negative predictive value of 0.95. This method informed the second stage, which was the development of the MSIT using machine learning, which, when tested, obtained an accuracy of 0.97, a positive predictive value of 0.90, a sensitivity of 0.91, and a negative predictive value of 0.98. Conclusions The MSIT has the potential to be used in identifying veterans in the United Kingdom from free-text clinical documents, providing new and unique insights into the health and well-being of this population and their use of mental health care services.
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Affiliation(s)
- Daniel Leightley
- King's Centre for Military Health Research, King's College London, London, United Kingdom
| | - David Pernet
- King's Centre for Military Health Research, King's College London, London, United Kingdom
| | - Sumithra Velupillai
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.,South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Robert J Stewart
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.,South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Katharine M Mark
- King's Centre for Military Health Research, King's College London, London, United Kingdom
| | - Elena Opie
- King's Centre for Military Health Research, King's College London, London, United Kingdom
| | - Dominic Murphy
- King's Centre for Military Health Research, King's College London, London, United Kingdom.,Combat Stress, Letherhead, United Kingdom
| | - Nicola T Fear
- King's Centre for Military Health Research, King's College London, London, United Kingdom.,Academic Department of Military Mental Health, King's College London, London, United Kingdom
| | - Sharon A M Stevelink
- King's Centre for Military Health Research, King's College London, London, United Kingdom.,Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
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239
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Helmer DA, Van Doren WW, Litke DR, Tseng CL, Ho L, Osinubi O, Pasinetti GM. Safety, Tolerability and Efficacy of Dietary Supplementation with Concord Grape Juice in Gulf War Veterans with Gulf War Illness: A Phase I/IIA, Randomized, Double-Blind, Placebo-Controlled Trial. Int J Environ Res Public Health 2020; 17:E3546. [PMID: 32438639 DOI: 10.3390/ijerph17103546] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/11/2020] [Accepted: 05/15/2020] [Indexed: 12/18/2022]
Abstract
Approximately 30 percent of U.S. veterans deployed during the Gulf War (1990–1991) have been diagnosed with Gulf War Illness (GWI), a chronic multi-symptom disorder without widely available specific treatments. We investigated whether the consumption of Concord grape juice (CGJ), rich in anti-inflammatory flavonoids, would be tolerated and safe in individuals with GWI and explored improvement in cognitive function and fatigue. Thirty-six veterans with GWI enrolled in a 24-week randomized, double-blind, Phase I/IIA clinical trial to explore safety, tolerability, and feasibility of 16 ounces daily of commercially available CGJ compared to placebo. Participants completed neurocognitive tests and self-reported surveys at baseline, 12 and 24 weeks. Thirty-one participants (86%) completed the study; no dropouts were related to side effects. Thirty participants (83%) documented ≥80% adherence. There were no statistically significant unadjusted differences between CGJ and placebo groups in change in efficacy measures from baseline to endpoint. We employed general linear regression models controlling for baseline differences between groups which indicated statistically significant improvement in the Halstead Category Test–Russell Revised Version (RCAT) at endpoint in the CGJ group compared to placebo (8.4 points, p = 0.04). Other measures of cognitive functioning did not indicate significant improvements in the adjusted analyses (p-values: 0.09–0.32), nor did the fatigue variable (p = 0.67). CGJ was safe and well-tolerated by veterans with GWI. Our data suggest high tolerability and potential benefit from CGJ in veterans with GWI and can be used to inform future studies of efficacy.
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240
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Gaitens JM, Potter BK, D'Alleyrand JG, Overmann AL, Gochfeld M, Smith DR, Breyer R, McDiarmid MA. The management of embedded metal fragment patients and the role of chelation Therapy: A workshop of the Department of Veterans Affairs-Walter Reed National Medical Center. Am J Ind Med 2020; 63:381-393. [PMID: 32144801 DOI: 10.1002/ajim.23098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/10/2020] [Accepted: 02/21/2020] [Indexed: 01/12/2023]
Abstract
Exposure to retained metal fragments from war-related injuries can result in increased systemic metal concentrations, thereby posing potential health risks to target organs far from the site of injury. Given the large number of veterans who have retained fragments and the lack of clear guidance on how to medically manage these individuals, the Department of Veterans Affairs (VA) convened a meeting of chelation experts and clinicians who care for embedded fragment patients to discuss current practices and provide medical management guidance. Based on this group's clinical expertise and review of published literature, the evidence presented suggests that, at least in the case of lead fragments, short-term chelation therapy may be beneficial for embedded fragment patients experiencing acute symptoms associated with metal toxicity; however, in the absence of clinical symptoms or significantly elevated blood lead concentrations (greater than 80 µg/dL), chelation therapy may offer little to no benefit for individuals with retained fragments and pose greater risks due to remobilization of metals stored in bone and other soft tissues. The combination of periodic biomonitoring to assess metal body burden, longitudinal fragment imaging, and selective fragment removal when metal concentrations approach critical injury thresholds offers a more conservative management approach to caring for patients with embedded fragments.
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Affiliation(s)
- Joanna M. Gaitens
- Department of Veterans Affairs Medical Center Baltimore and Department of MedicineUniversity of Maryland School of MedicineBaltimore Maryland
| | - Benjamin K. Potter
- Department of OrthopaedicsWalter Reed National Military Medical CenterBethesda Maryland
| | | | - Archie L. Overmann
- Department of OrthopaedicsWalter Reed National Military Medical CenterBethesda Maryland
| | - Michael Gochfeld
- Department of Environmental and Occupational Health, Environmental and Occupational Health Sciences InstituteRutgers Robert Wood Johnson Medical SchoolPiscataway New Jersey
| | - Donald R. Smith
- Department of Microbiology and Environmental ToxicologyUniversity of CaliforniaSanta Cruz California
| | - Richard Breyer
- Department of RadiologyBaltimore Veterans Affairs Medical CenterBaltimore Maryland
| | - Melissa A. McDiarmid
- Department of Veterans Affairs Medical Center Baltimore and Department of MedicineUniversity of Maryland School of MedicineBaltimore Maryland
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241
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Groll DL, Ricciardelli R, Carleton RN, Anderson G, Cramm H. A Cross-Sectional Study of the Relationship between Previous Military Experience and Mental Health Disorders in Currently Serving Public Safety Personnel in Canada. Can J Psychiatry 2020; 65:330-337. [PMID: 31830817 PMCID: PMC7265614 DOI: 10.1177/0706743719895341] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE There is an increased incidence of some mental health disorders such as post-traumatic stress disorder (PTSD) in some members of the military and in some public safety personnel (PSP) such as firefighters, police officers, paramedics, and dispatchers. Upon retirement from the armed forces, many individuals go on to second careers as PSP. Individuals with prior military experience may be at even greater risk than nonveterans for developing mental health disorders. The present study was designed to examine the relationship between prior military service and symptoms of mental health disorders in PSP. METHODS This is a cross-sectional, observational study. Data for this study were collected from an anonymous, web-based, self-report survey of PSP in Canada. Invitations to participate were sent to PSP via their professional organizations. Indications of mental disorder(s) and symptom severity were assessed using well-validated self-report screening measures. RESULTS Of the survey respondents who provided this information, 631 (6.8%) had prior armed forces experience; however, not all responses were complete. Ex-military PSP reported significantly more exposure to traumatic events and were approximately 1.5 times more likely to screen positive for indications of PTSD, mood, anxiety, or acute stress disorders and to have contemplated suicide than those without prior armed forces experience. CONCLUSIONS In our study, individuals in PSP with prior service experience in the armed forces were more likely to screen positive for indicators of some mental health disorders. Accordingly, mental health practitioners should inquire about previous service in the armed forces when screening, assessing, and treating PSP.
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Affiliation(s)
| | - Rosemary Ricciardelli
- Memorial University of Newfoundland, Saint John's, Newfoundland and Labrador, Canada
| | | | - Greg Anderson
- Justice Institute of British Columbia, New Westminster, British Columbia, Canada
| | - Heidi Cramm
- Queen's University, Kingston, Ontario, Canada
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242
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Essien UR, Sileanu FE, Zhao X, Liebschutz JM, Thorpe CT, Good CB, Mor MK, Radomski TR, Hausmann LRM, Fine MJ, Gellad WF. Racial/Ethnic Differences in the Medical Treatment of Opioid Use Disorders Within the VA Healthcare System Following Non-Fatal Opioid Overdose. J Gen Intern Med 2020; 35:1537-1544. [PMID: 31965528 PMCID: PMC7210353 DOI: 10.1007/s11606-020-05645-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/30/2019] [Accepted: 01/03/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND After non-fatal opioid overdoses, opioid prescribing patterns are often unchanged and the use of medications for opioid use disorder (MOUDs) remains low. Whether such prescribing differs by race/ethnicity remains unknown. OBJECTIVE To assess the association of race/ethnicity with the prescribing of opioids and MOUDs after a non-fatal opioid overdose. DESIGN Retrospective cohort study. PARTICIPANTS Patients prescribed ≥ 1 opioid from July 1, 2010, to September 30, 2015, with a non-fatal opioid overdose in the Veterans Health Administration (VA). MAIN MEASURES Primary outcomes were the proportion of patients prescribed: (1) any opioid during the 30 days before and after overdose and (2) MOUDs within 30 days after overdose by race and ethnicity. We conducted difference-in-difference analyses using multivariable regression to assess whether the change in opioid prescribing from before to after overdose differed by race/ethnicity. We also used multivariable regression to test whether MOUD prescribing after overdose differed by race/ethnicity. KEY RESULTS Among 16,210 patients with a non-fatal opioid overdose (81.2% were white, 14.3% black, and 4.5% Hispanic), 10,745 (66.3%) patients received an opioid prescription (67.1% white, 61.7% black, and 65.9% Hispanic; p < 0.01) before overdose. After overdose, the frequency of receiving opioids was reduced by 18.3, 16.4, and 20.6 percentage points in whites, blacks, and Hispanics, respectively, with no significant difference-in-difference in opioid prescribing by race/ethnicity (p = 0.23). After overdose, 526 (3.2%) patients received MOUDs (2.9% white, 4.6% black, and 5.5% Hispanic; p < 0.01). Blacks (adjusted OR (aOR) 1.6; 95% CI 1.2, 1.9) and Hispanics (aOR 1.8; 95% CI 1.2, 2.6) had significantly larger odds of receiving MOUDs than white patients. CONCLUSIONS In a national cohort of patients with non-fatal opioid overdose in VA, there were no racial/ethnic differences in changes in opioid prescribing after overdose. Although blacks and Hispanics were more likely than white patients to receive MOUDs in the 30 days after overdose, less than 4% of all groups received such therapy.
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Affiliation(s)
- Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, UPMC Health Plan, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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243
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Burke RE, Canamucio A, Glorioso TJ, Barón AE, Ryskina KL. Variability in Transitional Care Outcomes Across Hospitals Discharging Veterans to Skilled Nursing Facilities. Med Care 2020; 58:301-306. [PMID: 31895308 PMCID: PMC11078064 DOI: 10.1097/mlr.0000000000001282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The period after transition from hospital to skilled nursing facility (SNF) is high-risk, but variability in outcomes related to transitions across hospitals is not well-known. OBJECTIVES Evaluate variability in transitional care outcomes across Veterans Health Administration (VHA) and non-VHA hospitals for Veterans, and identify characteristics of high-performing and low-performing hospitals. RESEARCH DESIGN Retrospective observational study using the 2012-2014 Residential History File, which concatenates VHA, Medicare, and Medicaid data into longitudinal episodes of care for Veterans. SUBJECTS Veterans aged 65 or older who were acutely hospitalized in a VHA or non-VHA hospital and discharged to SNF; 1 transition was randomly selected per patient. MEASURES Adverse "transitional care" outcomes were a composite of hospital readmission, emergency department visit, or mortality within 7 days of hospital discharge. RESULTS Among the 365,942 Veteran transitions from hospital to SNF across 1310 hospitals, the composite outcome rate ranged from 3.3% to 23.2%. In multivariable analysis adjusting for patient characteristics, hospital discharge diagnosis and SNF category, no single hospital characteristic was significantly associated with the 7-day adverse outcomes in either VHA or non-VHA hospitals. Very few high or low-performing hospitals remained in this category across all 3 years. The increased odds of having a 7-day event due to being treated in a low versus high-performing hospital was similar to the odds carried by having an intensive care unit stay during the index admission. CONCLUSIONS While variability in hospital outcomes is significant, unmeasured care processes may play a larger role than currently measured hospital characteristics in explaining outcomes.
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Affiliation(s)
- Robert E. Burke
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VHA Medical Center
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Anne Canamucio
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VHA Medical Center
| | - Thomas J. Glorioso
- Center of Innovation for Veteran-Centered and Value-Driven Care, Denver VHA Medical Center, Denver
| | - Anna E. Barón
- Center of Innovation for Veteran-Centered and Value-Driven Care, Denver VHA Medical Center, Denver
- Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Kira L. Ryskina
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Simonetti JA, Piegari R, Maynard C, Brenner LA, Mori A, Post EP, Nelson K, Trivedi R. Characteristics and Injury Mechanisms of Veteran Primary Care Suicide Decedents with and without Diagnosed Mental Illness. J Gen Intern Med 2020:10.1007/s11606-020-05787-1. [PMID: 32219647 DOI: 10.1007/s11606-020-05787-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/09/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND In the United States, suicide rates are increasing among nearly all age groups. Primary care is a critical setting for suicide prevention, where interventions often rely on identifying mental health conditions as indicators of elevated suicide risk. OBJECTIVE Quantify the proportion of suicide decedents within primary care who had no antecedent mental health or substance use diagnosis. DESIGN Retrospective cohort study. PARTICIPANTS Veterans who received Veterans Health Administration (VHA) primary care any time from 2000 to 2014 and died by suicide before 2015 (n = 27,741). MAIN MEASURES We categorized decedents by whether they had any mental health or substance use diagnosis (yes/no) using ICD-9 codes available from VHA records. We compared sociodemographic, clinical, and suicide mechanism characteristics between groups using chi-square, Student's T, or Wilcoxon tests. RESULTS Forty-five percent of decedents had no mental health or substance use diagnosis. Decedents without such a diagnosis were older (68 vs. 57 years, p < 0.001), and more likely to be male (98.3% vs. 95.8%, p < 0.001), non-Hispanic White (90.6% vs. 87.9%, p < 0.001), married/partnered (50.4% vs. 36.6%, p < 0.001), and without military service-connected disability benefits (72.6% vs. 56.9%, p < 0.001). They were also more likely to die from firearm injury (78.9% vs. 60.7%, p < 0.001). There were statistically significant differences in physical health between groups, but the magnitudes of those differences were small. Decedents without a mental health or substance use diagnosis had significantly shorter durations of enrollment in VHA healthcare, less healthcare utilization in their last year of life, and had little utilization aside from primary care visits. CONCLUSIONS AND RELEVANCE From 2000 to 2014, of nearly thirty thousand VHA primary care patients who died by suicide, almost half had no antecedent mental health or substance use diagnosis. Within VHA primary care settings, suicide risk screening for those with and without such a diagnosis is indicated.
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Affiliation(s)
- Joseph A Simonetti
- Rocky Mountain Mental Illness Research, Education and Clinical Center, Rocky Mountain Regional VA Medical Center, G3-189, 1700 N Wheeling St, Aurora, CO, 80045, USA.
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Health Administration, Washington, D.C., USA.
- Division of Hospital Medicine, University of Colorado Anschutz School of Medicine, Aurora, CO, USA.
| | - Rebecca Piegari
- Department of Veterans Affairs, Clinical Systems Development and Evaluation, Veterans Health Administration, Washington, D.C., USA
| | - Charles Maynard
- VHA Primary Care Analytics Team, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Lisa A Brenner
- Rocky Mountain Mental Illness Research, Education and Clinical Center, Rocky Mountain Regional VA Medical Center, G3-189, 1700 N Wheeling St, Aurora, CO, 80045, USA
- Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, University of Colorado Anschutz School of Medicine, Aurora, CO, USA
| | - Alaina Mori
- VHA Primary Care Analytics Team, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Edward P Post
- VA HSR&D Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Karin Nelson
- VHA Primary Care Analytics Team, VA Puget Sound Healthcare System, Seattle, WA, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
- General Medicine Service, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Ranak Trivedi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral Sciences, Division of Public Mental Health and Population Sciences, Stanford University, Palo Alto, CA, USA
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245
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Gould CE, Loup J, Kuhn E, Beaudreau SA, Ma F, Goldstein MK, Wetherell JL, Zapata AML, Choe P, O'Hara R. Technology use and preferences for mental health self-management interventions among older veterans. Int J Geriatr Psychiatry 2020; 35:321-330. [PMID: 31854029 DOI: 10.1002/gps.5252] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 12/07/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The United States Department of Veterans Affairs offers numerous technology-delivered interventions to self-manage mental health problems. It is unknown, however, what barriers older military veterans face to using these technologies and how willing they would be to use technologies for mental health concerns. METHODS Seventy-seven veterans (Mage = 69.16 years; SD = 7.10) completed interviews in a concurrent mixed methods study. Interviewers asked about technology ownership and described four modalities of delivering self-management interventions: printed materials, DVDs, Internet, and mobile apps. Interviewers obtained feedback about each modality's benefits, barriers, and facilitators. Participants ranked their self-management modalities preferences alone and compared with counseling. Multivariable adjusted logistic regression and qualitative analyses were conducted to investigate the reasons contributing to preferences. RESULTS Most reported owning a computer (84.4%), having home Internet (80.5%), and a smartphone (70.1%). Participants preferred printed materials (35.1%) over mobile apps (28.6%), Internet (24.7%), and DVDs (13.0%). Lower computer proficiency was associated with preferring DVDs; higher proficiency was associated with Internet and mobile interventions. Residing in an urban area was associated with mobile apps. When counseling was an option, 66% identified this as their first preference. Qualitative findings showed veterans' desire for information, training, and provider support with technology. CONCLUSIONS Older veterans reported high technology ownership rates but varied preferences for self-management interventions. Notably, two-thirds preferred some form of technology, which points to the importance of ensuring that providers offer existing technology-delivered interventions to older veterans. Veterans' strong preference for counseling emphasizes the need for human support alongside self-management.
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Affiliation(s)
- Christine E Gould
- Palo Alto Geriatric Research, Education, and Clinical Center (GRECC), VA Palo Alto Health Care System, Palo Alto, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Julia Loup
- Palo Alto Geriatric Research, Education, and Clinical Center (GRECC), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Eric Kuhn
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.,National Center for PTSD, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Sherry A Beaudreau
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.,Sierra Pacific Mental Illness Research Education and Clinical Center (MIRECC), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Flora Ma
- Palo Alto Geriatric Research, Education, and Clinical Center (GRECC), VA Palo Alto Health Care System, Palo Alto, CA, USA.,Pacific Graduate School of Psychology, Palo Alto University, Palo Alto, CA, USA
| | - Mary K Goldstein
- Medical Service, VA Palo Alto Health Care System, Palo Alto, CA, USA.,Stanford University, Center for Primary Care and Outcomes Research (PCOR), Stanford, CA, USA
| | - Julie Loebach Wetherell
- Psychology Service, VA San Diego Healthcare System, San Diego, CA, USA.,Department of Psychiatry, University of California, San Diego, CA, USA
| | - Aimee Marie L Zapata
- Palo Alto Geriatric Research, Education, and Clinical Center (GRECC), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Philip Choe
- Palo Alto Geriatric Research, Education, and Clinical Center (GRECC), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Ruth O'Hara
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.,Sierra Pacific Mental Illness Research Education and Clinical Center (MIRECC), VA Palo Alto Health Care System, Palo Alto, CA, USA
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246
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Hinrichs KLM, Steadman-Wood P, Meyerson JL. ACT Now: The Intersection of Acceptance and Commitment Therapy with Palliative Care in a Veteran with Chronic Suicidal Ideation. Clin Gerontol 2020; 43:126-131. [PMID: 31322060 DOI: 10.1080/07317115.2019.1642974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Suicide rates are increasing in the United States and groups at elevated risk include older adults, veterans, and those with life-limiting illnesses. However, the treatment of suicidality at end-of-life has been little studied. There is emerging evidence that palliative care itself may be protective against suicide and there is some support for the use of Acceptance and Commitment Therapy (ACT) at end-of-life. The overlapping mechanisms of palliative care and ACT are especially well-suited for individuals struggling with suicidality in the context of life-limiting illness.A case from a Veterans Affairs Home-Based Primary Care (HBPC) team is used to illustrate the challenges and opportunities when providing end-of-life care to an older veteran with chronic suicidal ideation. Prior mental health treatment had limited impact on his suicidality. However, with an integrated ACT and palliative care approach, the HBPC team was better able to focus on the veteran's goals. This approach was helpful in reducing suicidal ideation and engaging him in end-of-life decision-making discussions. This case highlights the valuable role of palliative care in suicide prevention and how the addition of ACT can aid in the effective treatment of chronic suicidal ideation at the end-of-life.
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Affiliation(s)
| | - Pamela Steadman-Wood
- Providence VA Medical Center, Providence, USA.,Alpert Medical School Brown University
| | - Jordana L Meyerson
- VA Boston Healthcare System, Boston, USA.,Harvard Medical School.,Boston University School of Medicine, Boston, USA
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247
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Woodard L, Kamdar N, Hundt N, Gordon HS, Hertz B, Amspoker AB, Kiefer L, Mehta P, Odom E, Rajan S, Stone E, Jones L, Naik AD. Empowering patients in chronic care to improve diabetes distress and glycaemic control: Protocol for a hybrid implementation-effectiveness clinical trial. Endocrinol Diabetes Metab 2020; 3:e00099. [PMID: 31922026 PMCID: PMC6947690 DOI: 10.1002/edm2.99] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/23/2019] [Accepted: 10/07/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To evaluate the effectiveness of a collaborative goal-setting intervention (Empowering Patients in Chronic Care [EPIC]) to improve glycaemic control and diabetesrelated distress, and implementation into routine care across multiple primary care clinics. DESIGN Randomized controlled trial comparing the effectiveness of the EPIC intervention with enhanced usual care (EUC) at five clinic sites located in the greater Chicago and Houston areas. We will measure differences in haemoglobin A1c (HbA1c) and diabetes distress scale scores among study arms at post-intervention and maintenance (6 months post-intervention). We will evaluate implementation of the intervention across sites using the RE-AIM framework. We will evaluate reach by comparing the per cent and characteristics of enrolled study participants among all potentially eligible participants in the given clinic population. Adoption is reflected by the characteristics of the involved providers and the number of intervention sessions conducted. Implementation of EPIC will be evaluated by number of sessions delivered, participants' evaluation of group sessions, and evaluation of quality of goal-setting. PATIENTS We randomized 280 participants with equal allocation to EPIC and enhanced usual care (EUC). RESULTS At baseline, the groups were similar with the exception that EUC participants were more likely to have prior diabetes education. At baseline, participants were predominately older men who have poorly controlled diabetes (mean HbA1c = 76 mmol/mol [9.1%]) and moderate levels of diabetes distress (mean DDS = 2.43). CONCLUSIONS This hybrid effectiveness-implementation protocol is designed to accelerate the translation of a patient-centred diabetes care intervention from research to clinical practice.
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Affiliation(s)
- LeChauncy Woodard
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
- Department of MedicineBaylor College of MedicineHoustonTexas
| | - Nipa Kamdar
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
| | - Natalie Hundt
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
- Department of Psychiatry and Behavioral SciencesBaylor College of MedicineHoustonTexas
| | - Howard S. Gordon
- Jesse Brown Veterans Affairs Medical Center and VA Center of Innovation for Complex Chronic HealthcareChicagoIllinois
- Section of Academic Internal MedicineDepartment of MedicineUniversity of Illinois at ChicagoChicagoIllinois
- Institute for Health Research and PolicyUniversity of Illinois at ChicagoChicagoIllinois
| | - Brian Hertz
- Department of Internal MedicineLoyola University ChicagoIllinois
- U.S. Department of Veterans AffairsEdward Hines Jr. VA HospitalHinesIllinois
| | - Amber B. Amspoker
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
- Department of MedicineBaylor College of MedicineHoustonTexas
| | - Lea Kiefer
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
| | - Praveen Mehta
- Jesse Brown Veterans Affairs Medical Center and VA Center of Innovation for Complex Chronic HealthcareChicagoIllinois
| | - Edward Odom
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
| | - Suja Rajan
- University of Texas, School of Public HealthHoustonTexas
| | - Elizabeth Stone
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
- School of Social SciencesBrown CollegeRice UniversityHoustonTexas
| | - Lindsey Jones
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
- U.S. Department of Veterans AffairsEdward Hines Jr. VA HospitalHinesIllinois
- U.S. Department of Veterans AffairsVA Information Resource Center (VIReC)Edward Hines Jr. VA HospitalHinesIllinois
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
- Department of MedicineBaylor College of MedicineHoustonTexas
- Department of Psychiatry and Behavioral SciencesBaylor College of MedicineHoustonTexas
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248
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Abstract
Background: An extensive public health literature associates military service with increased alcohol consumption and problematic drinking. However, few well-controlled population-based studies compare alcohol use among nonveterans and veterans with diverse military service experiences, and no such study examines everyday drinking. Methods: We use population-representative data from the 2010 and 2011 Behavioral Risk Factor Surveillance System and distinguish four groups of men: nonveterans; non-combat veterans without a psychiatric disorder (PD) or traumatic brain injury (TBI); combat veterans without a PD or TBI; and veterans (non-combat and combat combined) with a PD and/or TBI. We estimate hierarchical multivariate logistic regression models of current drinking (N = 21,947) and daily drinking (among current drinkers; N = 11,491). Results from supplemental analyses are discussed. Results: Relative to nonveterans, non-combat veterans with no PD or TBI and veterans with a PD and/or TBI, respectively, but not combat veterans with no PD or TBI, are more likely to be current drinkers. Among current drinkers, non-combat and combat veterans with no PD or TBI, respectively, are less likely than nonveterans to be daily drinkers. Conversely, among current drinkers, veterans with a PD and/or TBI are more likely to be daily drinkers than nonveterans, non-combat veterans with no PD or TBI, and combat veterans with no PD or TBI. Conclusion: We document heterogeneous and countervailing influences of military service experiences on current and daily drinking. Results indicate that harmful military service experience may be associated with an increased risk of current, moderate daily drinking, which may represent a form of self-medication.
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Affiliation(s)
- Andrew S London
- Aging Studies Institute, Syracuse University, Syracuse, NY, USA
| | - Janet M Wilmoth
- Aging Studies Institute, Syracuse University, Syracuse, NY, USA
| | - William J Oliver
- Department of Sociology, Maxwell School of Citizenship and Public Affairs, Syracuse University, Syracuse, NY, USA
| | - Jessica A Hausauer
- Department of Sociology, Maxwell School of Citizenship and Public Affairs, Syracuse University, Syracuse, NY, USA
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249
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Abstract
In 1948, the state of Israel was created as a homeland for the Jewish people after 2,000 years of persecution and deportations in the diaspora. During the past 72 years, its inhabitants have experienced several wars and numerous terrorist attacks. Therefore, the issue of trauma goes beyond academic study, it is part of daily life. These circumstances have, unfortunately, turned Israel into a natural stress laboratory, which has enabled the systematic research of the biopsychosocial effects of traumatic stress on soldiers and civilians. This article reviews the findings of a series of studies that examine (a) the short- and long-term mental health effects of war on combat veterans; (b) the effects of repeated exposure to war on veterans; (c) trajectories of PTSD; and, specifically, (d) reactivation and (e) delayed-onset PTSD. We present the findings of two decades of systematic trauma research, which have followed the ongoing psychopathological effect of war on veterans. In understanding the ripple effects of trauma, it can be seen that veterans do not leave the events of the war behind once they are home; rather, it is with them wherever they go. Consequently, the trauma has a ripple effect that may carry over to veterans' spouses and offspring. The multiple manifestations and trajectories of both acute and chronic trauma will be presented. Clinical ramifications and implications will also be discussed.
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Affiliation(s)
- Zahava Solomon
- Bob Shapell School of Social Work, Tel-Aviv University, Tel-Aviv, Israel.,I-Core Research Center for Mass Trauma, Tel-Aviv University, Tel-Aviv, Israel
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250
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Matarazzo BB, Forster JE, Hostetter TA, Billera M, Adler G, Ganzini LK, Oslin DW, Brenner LA. Efficacy of the Home-Based Mental Health Evaluation (HOME) Program for Engaging Patients in Care After Hospitalization. Psychiatr Serv 2019; 70:1094-1100. [PMID: 31451065 DOI: 10.1176/appi.ps.201900002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The risk of suicide is elevated in the days and weeks after discharge from a psychiatric hospitalization, and lack of treatment engagement posthospitalization is also associated with suicide. The authors sought to determine whether the Home-Based Mental Health Evaluation [HOME] Program is efficacious in helping patients engage in care after psychiatric hospitalization. METHODS This study was a nonrandomized, controlled, two-arm (HOME Program versus enhanced care as usual [E-CARE]) trial that took place at four Department of Veterans Affairs medical centers. Participants (N=302) were patients admitted to a psychiatric inpatient unit. The HOME Program consists of phone- and home-based contacts that include suicide risk assessment, safety planning, and problem-solving around barriers to care. The primary outcome was treatment engagement, as documented in the electronic medical record. RESULTS Veterans in the HOME Program group were 1.33 (95% confidence interval [CI]=1.29-1.37) times more likely to engage in treatment, compared with veterans in the E-CARE group (p<0.001). HOME Program participants were estimated to have attended 55% more individual appointments (95% CI=12%-113%, p=0.02), compared with those in the E-CARE group. The adjusted difference in median time to treatment engagement was 15 days (95% CI=3.5-27.0) such that HOME Program participants engaged in treatment more quickly than participants at the E-CARE sites. CONCLUSIONS Findings suggest that participation in the HOME Program can help individuals at high risk of suicide engage in care after psychiatric hospitalization.
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Affiliation(s)
- Bridget B Matarazzo
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC), U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Forster, Hostetter, Billera, Brenner); Department of Psychiatry (Matarazzo), and Department of Physical Medicine and Rehabilitation (Forster, Brenner), University of Colorado School of Medicine, Aurora; South Central MIRECC, VA, Houston, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Adler); Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Department of Psychiatry, Oregon Health and Science University, Portland (Ganzini); MIRECC, Veterans Integrated Service Network 4, VA, Philadelphia, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - Jeri E Forster
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC), U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Forster, Hostetter, Billera, Brenner); Department of Psychiatry (Matarazzo), and Department of Physical Medicine and Rehabilitation (Forster, Brenner), University of Colorado School of Medicine, Aurora; South Central MIRECC, VA, Houston, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Adler); Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Department of Psychiatry, Oregon Health and Science University, Portland (Ganzini); MIRECC, Veterans Integrated Service Network 4, VA, Philadelphia, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - Trisha A Hostetter
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC), U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Forster, Hostetter, Billera, Brenner); Department of Psychiatry (Matarazzo), and Department of Physical Medicine and Rehabilitation (Forster, Brenner), University of Colorado School of Medicine, Aurora; South Central MIRECC, VA, Houston, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Adler); Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Department of Psychiatry, Oregon Health and Science University, Portland (Ganzini); MIRECC, Veterans Integrated Service Network 4, VA, Philadelphia, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - Melodi Billera
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC), U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Forster, Hostetter, Billera, Brenner); Department of Psychiatry (Matarazzo), and Department of Physical Medicine and Rehabilitation (Forster, Brenner), University of Colorado School of Medicine, Aurora; South Central MIRECC, VA, Houston, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Adler); Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Department of Psychiatry, Oregon Health and Science University, Portland (Ganzini); MIRECC, Veterans Integrated Service Network 4, VA, Philadelphia, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - Geri Adler
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC), U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Forster, Hostetter, Billera, Brenner); Department of Psychiatry (Matarazzo), and Department of Physical Medicine and Rehabilitation (Forster, Brenner), University of Colorado School of Medicine, Aurora; South Central MIRECC, VA, Houston, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Adler); Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Department of Psychiatry, Oregon Health and Science University, Portland (Ganzini); MIRECC, Veterans Integrated Service Network 4, VA, Philadelphia, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - Linda K Ganzini
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC), U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Forster, Hostetter, Billera, Brenner); Department of Psychiatry (Matarazzo), and Department of Physical Medicine and Rehabilitation (Forster, Brenner), University of Colorado School of Medicine, Aurora; South Central MIRECC, VA, Houston, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Adler); Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Department of Psychiatry, Oregon Health and Science University, Portland (Ganzini); MIRECC, Veterans Integrated Service Network 4, VA, Philadelphia, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - David W Oslin
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC), U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Forster, Hostetter, Billera, Brenner); Department of Psychiatry (Matarazzo), and Department of Physical Medicine and Rehabilitation (Forster, Brenner), University of Colorado School of Medicine, Aurora; South Central MIRECC, VA, Houston, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Adler); Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Department of Psychiatry, Oregon Health and Science University, Portland (Ganzini); MIRECC, Veterans Integrated Service Network 4, VA, Philadelphia, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - Lisa A Brenner
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC), U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Forster, Hostetter, Billera, Brenner); Department of Psychiatry (Matarazzo), and Department of Physical Medicine and Rehabilitation (Forster, Brenner), University of Colorado School of Medicine, Aurora; South Central MIRECC, VA, Houston, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Adler); Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Department of Psychiatry, Oregon Health and Science University, Portland (Ganzini); MIRECC, Veterans Integrated Service Network 4, VA, Philadelphia, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
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