Efficacy of the Home-Based Mental Health Evaluation (HOME) Program for Engaging Patients in Care After Hospitalization

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.

Validation of the Expressions of Moral Injury Scale-Military version-Short Form

Military personnel may encounter morally injurious events that lead to emotional, social, and spiritual suffering that transcend and/or overlap with mental health diagnoses (e.g., post-traumatic stress disorder [PTSD]). Advancement of scientific research and potential clinical innovation for moral injury (MI) requires a diversity of measurement approaches. Drawing on results from the bifactor model in Currier et al.'s (2017) psychometric evaluation of the Expressions of Moral Injury Scale-Military version (EMIS-M), this study validated a four-item short form of the instrument with two samples of veterans with a history of war-zone service. Namely, despite the reduced number of items, the EMIS-M-Short Form (SF) yielded favourable internal consistency and comparable levels of convergent validity with theoretically related constructs (e.g., PTSD and struggles with morality and ultimate meaning) as the full-length version. Notwithstanding the possible utility of distinguishing between self- and other-directed forms of MI, factor analytic results further revealed that the EMIS-M-SF was best conceptualized with a unidimensional factorial model that might allow for a general assessment of MI-related outcomes. Overall, these initial results suggest that the EMIS-M-SF may hold promise as a short, reliable, and valid assessment of overall outcomes related to a possible MI.

Action Ethnography of Community Reintegration for Veterans and Military Service Members With Traumatic Brain Injury: Protocol for a Mixed Methods Study

BACKGROUND

Numerous studies of community reintegration (CR) in traumatic brain injury (TBI) have been conducted in civilian populations, but research is limited in veteran and military service member populations. Little is known about how knowledge from civilian studies translates into veterans' experiences and needs. The US Department of Veterans Health Administration (VHA) recognizes the distinctive health care needs of post-9/11 veteran and military service members, particularly with TBI, including the need to bridge health and rehabilitation-related services from acute care and inpatient settings to veteran and military service members' homes and communities to facilitate CR.

OBJECTIVE

The goal of this study is to better understand the experiences of veterans with complicated mild, moderate, or severe TBI; their families; and CR workers as veterans and servicemembers transition to and sustain living in communities. This paper describes the rationale, design, and methods used to reach this goal.

METHODS

This five-year longitudinal mixed methods study uses both a community-engaged research (CEnR) approach and an ethnographic approach. The sample includes 30 veterans and service members with TBI, 13 family caregivers, 11 CR specialists, 16 key stakeholders, and 82 community events. Interviews and observations are coded and analyzed using hierarchical coding schemes and thematic analysis. Analyses include data from surveys, interviews, and participant observations. Content analysis is used to highlight the complex social context of reintegration and to triangulate quantitative data. Egocentric (personal) social network analysis is used to examine the support system a veteran or service member has in place to facilitate reintegration.

RESULTS

Study enrollment and data collection are completed. Data analyses are underway.

CONCLUSIONS

The results of this study may provide a heightened understanding of environmental factors affecting CR in complicated mild, moderate, or severe TBI. Veteran, servicemember and family voices and insights provide VHA clinicians and policy makers with an ecological view of CR that is grounded in the life experiences of veterans, military service members, and families. The results of this study provide a roadmap for designing and testing interventions to maximize CR in a variety of domains. The longitudinal ethnographic approach allows for capturing detailed experiences within the naturalistic context. CEnR allows collaborative assessment of the social context of reintegration with community members.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14170.

Use of the Montreal Cognitive Assessment (MoCA) in a Rural Outreach Program for Military Veterans

The Montreal Cognitive Assessment (MoCA) is a free, easily accessible screener ideal for rural areas where resources are limited. We examined administration and scoring by Veteran Community Outreach Health Workers (VCOHWs); compared positive screening rates using two cutoff scores; and examined predictors of education-adjusted scores in N = 168 rural military Veterans from the Alabama Veteran Rural Health Initiative. Accuracy of administration (95 percent) and scoring (68 percent) was calculated and recommendations are offered. Higher than expected rates of positive screens were observed (40 percent using 24/30 cutoff) in this relatively young (M = 55 years) community-dwelling sample. Age, education, and race but not subjective health predicted differences in domain and total education-adjusted scores on multivariate and univariate tests. This study advances social science research in rural communities by being the first to: (1) examine MoCA scores in a rural, Deep South U.S. sample; and (2) report fidelity administration data for VCOHWs.

Companion Dog Foster Caregiver Program for Older Veterans at the VA Maryland Health Care System: A Feasibility Study

Veterans experience mental health conditions at a disproportionate rate compared to their civilian counterparts, and approximately 60% of older veterans who receive their care through the United States Department of Veterans Affairs (VA) do not meet physical activity (PA) recommendations. We tested the Veterans as Foster Ambassadors program at the VA Maryland Health Care System to examine whether fostering a companion dog would improve PA and function, heart rate variability (HRV), balance, and quality of life (QOL) in older veterans. Participants wore an accelerometer for ≥10 days during each phase (30 day baseline vs. 60 day foster period) to measure daily PA (n = 4). Six-minute walk (6MW) and balance testing (n = 4) and 24 h heart rate (HR) and HRV (n = 2) were determined at baseline and during the foster period. Compared to baseline, there were significant increases in (a) distance during the 6MW, (b) daily steps, and (c) time spent in moderate activity during the foster period. 24 h HR decreased and time- and frequency-domain measures of HRV significantly increased in a veteran with post-traumatic stress disorder during the foster period compared to baseline. All veterans offered positive feedback about the program and indicated that it was beneficial to them. The results from this pilot study provide evidence that fostering a companion dog can improve PA, health, and QOL in older veterans. Future research conducted with a larger sample size to validate the results is warranted.

The Efficacy of Cognitive Processing Therapy for PTSD Related to Military Sexual Trauma in Veterans: A Review

Women currently comprise 12% of the total number of service personnel who have served in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. Presently, 15% of active duty personnel, 17% of National Guard personnel, and 20% of new recruits are female. The number of female veterans utilizing the Veterans Health Administration has more than doubled, from 159,000 to 337,000 from 2000-2011 and is expected to double again within the next decade. Similar overall numbers of female and male service members report experiencing military sexual trauma (MST). Prevalence rates vary by study where 20 to 68% of female service members and 1% to 6% of male service members have experienced MST. Many of these service members subsequently develop mental health issues and are diagnosed with conditions related to MST.Purpose: The purpose of this review was to summarize outcome studies examining Cognitive Processing Therapy (CPT) for the treatment of Post-traumatic Stress Disorder (PTSD) related to Military Sexual Trauma.Methods: The informational databases that were utilized for the current review were ERIC (EBSCO), ERIC (ProQuest), Google Scholar, and PsycINFO. The dates for literature inclusion was from 2010 to March of 2019. The literature search was initiated in March and was terminated in April of 2019.Results: The results indicated that CPT is an effective intervention for the reduction of MST related PTSD symptoms, including negative cognitions, compared to Present-Centered Therapy (PCT). Additionally, at 6-month post-treatment follow-up symptom reduction was stable. Results were mixed for CPT associated with quality of life and exposure to child Sexual abuse (CSA). Veterans who self-identified as African-American and Caucasian female veterans experienced significant reductions in PTSD symptomology with no differences between groups.Discussion: All studies included in the review resulted in significant reductions in PTSD but four of five also suffered from treatment fidelity in the CPT treatment condition. Researchers chose to exclude participant data from the therapists who did not adhere to CPT protocol resulting in a reduction of statistical power in these studies. The final study included in the review administered multiple treatment modalities concurrently.

Medical Therapy Utilization and Long-Term Outcomes Following Percutaneous Coronary Intervention: Five-Year Results From the Veterans Affairs Clinical Assessment, Reporting, and Tracking System Program

BACKGROUND

Optimal medical therapy is endorsed by national guidelines in the management of ischemic heart disease; however, few studies have examined its long-term utilization following percutaneous coronary intervention (PCI) and association with clinical outcomes. We sought to assess longitudinal trends in medical therapy use after PCI and its prognostic significance.

METHODS AND RESULTS

From the Veteran Affairs Clinical Assessment, Reporting, and Tracking System Program, we retrospectively identified 57 900 Veteran's Affairs patients undergoing PCI from January 2005 to May 2014. Using prescription fill dates, the utilization of 4 classes of medical therapy including statins, β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, P2Y12 inhibitors, and their composites were assessed at discharge, 6 months, 1, 3, and 5 years post-PCI. Multivariable Cox regression models were developed to assess the association between medical therapy status and major adverse cardiovascular events, defined as all-cause mortality, rehospitalization for myocardial infarction, rehospitalization for stroke, or repeat revascularization. At discharge following PCI, 58.3% of patients received all 4 classes of medical therapy. Utilization of statins, β-blockers, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers decreased from 89%, 84.9%, and 72.2% on discharge, respectively, to 72.7%, 67.9%, and 57.9% at 5 years. Prescription refills of P2Y12 inhibitors declined from 96.5% on discharge to 28.3% at 5 years, driven by a large decline in P2Y12 inhibitor use after 1 year. Use of each class of medical therapy, and its composite use, was associated with a significant reduction in major adverse cardiovascular events at 5 years, with the largest effect size seen by the use of statins (HR, 0.77; 95% CI, 0.75-0.79; P<0.0001) and P2Y12 inhibitors (HR, 0.82; 95% CI, 0.79-0.85; P<0.0001).

CONCLUSIONS

Consistent declines in medical therapy use following PCI were observed over time, which is associated with worse outcomes. Further efforts are needed to promote long-term adherence to secondary prevention therapies after revascularization.

Correspondence of the Boston Assessment of Traumatic Brain Injury-Lifetime and the VA Comprehensive TBI Evaluation

OBJECTIVE

To compare the diagnosis of positive versus negative for mild traumatic brain injury (mTBI) using the Boston Assessment of TBI-Lifetime (BAT-L), a validated forensic clinical interview used to identify TBI in research, to the diagnosis of mTBI in the clinical polytrauma service using the Comprehensive TBI Evaluation (CTBIE).

PARTICIPANTS

Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans who were enrolled in the Translational Research Center for TBI and Stress Disorders longitudinal cohort study and received a CTBIE at a Veterans Health Administration healthcare facility (n = 104).

MAIN MEASURES

The BAT-L, CTBIE, and Neurobehavioral Symptom Inventory.

RESULTS

There was poor correspondence between the BAT-L and CTBIE mTBI diagnoses (κ = 0.283). The CTBIE showed moderate sensitivity but poor specificity relative to the BAT-L. The agreement did not improve after removing individuals who had failed symptom validity measures, as assessed by the Validity-10 scale of the Neurobehavioral Symptom Inventory.

CONCLUSIONS

This lack of correspondence highlights the difficulties in diagnosing mTBI in Veterans using retrospective self-report. Future work is needed to establish a reliable and valid method for identifying military mTBI both for the care of our Veterans and for appropriate distribution of benefits.

Confirmatory Factor Analysis of the Enriched Life Scale Among US Military Veterans

The Enriched Life Scale (ELS) is a 40-item measure developed by the military veteran service organization, Team Red, White & Blue (RWB), to systematically capture and quantify the lived experiences of military veterans transitioning to civilian life. As Team RWB's mission is to "enrich veterans' lives," veterans who conceived of and co-developed the ELS as a psychometric instrument defined what an "enriched life" would entail. Exploratory factor analysis (EFA) of the ELS revealed a five-factor structure capturing the domains of: physical health, mental health, genuine relationships, sense of purpose, and engaged citizenship. The goal of the current study was to use confirmatory factor analysis to validate the factor structure of the ELS in a sample of veterans not affiliated with Team RWB. We also sought to explore convergent validity with the Military to Civilian Questionnaire, a measure of military to civilian reintegration challenges. Five hundred and twenty-nine veterans participated in the study. We estimated three models, one-factor, four-factor, and five-factor model via maximum likelihood estimation with robust Huber-White standard errors. The five-factor model showed the best fit to the data (RMSEA = 0.05, CFI = 0.90, TLI = 0.90, SRMR = 0.06). Additionally, the five-factor model demonstrated convergent and discriminant validity, as well as internal consistency reliability (genuine relationships, α = 0.90; sense of purpose, α = 0.93; engaged citizenship, α = 0.89; mental health, α = 0.88; and physical health, α = 0.78). Overall, the ELS is a valid and reliable measure of veteran enrichment and could potentially be used in conjunction with diagnostic instruments that capture strain-related transition challenges (to include mental health disorders) to capture post-military service wellbeing.

The impact of military service on the mental health of older UK veterans: A qualitative study

BACKGROUND

There may be ongoing psychological problems associated with military service later in life; yet as the elderly in the general population also suffer from mental health problems, whether such issues can be attributed to military service or are a feature of ageing remains unclear. This study aimed to explore veteran and nonveteran perceptions of the impact of their occupation on their psychological well-being later in life.

METHODS

Twenty-five veterans (≥65 y); 25 nonveterans (≥65 y); 10 veterans with diagnoses of mental health issues (≥65 y); and a close companion of all participants (≥18 y, spouse, child, and close friend) were recruited. Using a qualitative approach, participants completed semistructured qualitative interviews with measures of psychological adjustment used to describe the sample.

RESULTS

Veterans were found to experience higher levels of workplace stress and trauma exposure compared with nonveterans. When such challenges were positively appraised, veterans described increased confidence and resilience. Social support in response to occupational stress was central to veteran and nonveteran well-being, especially for those with mental health problems. Nonetheless, providing support was challenging for close companions, with many feeling overwhelmed and requiring additional guidance from the veteran's clinical care team.

CONCLUSIONS

The findings delineate the impact of occupation on the well-being of older veterans and nonveterans. The results illustrated the psychological support needs and formal guidance desired by veterans, nonveterans, and their families, which could ultimately improve coping of both the individual and family.

Lesbian, Gay, Bisexual, and Transgender Veterans' Experiences of Discrimination in Health Care and Their Relation to Health Outcomes: A Pilot Study Examining the Moderating Role of Provider Communication

Purpose: Lesbian, gay, bisexual, and transgender (LGBT) veterans report discrimination in health care, which may be associated with negative health outcomes/behaviors and has implications for LGBT identity disclosure to providers. Quality provider communication may serve to offset some of the deleterious effects of discrimination; however, no research to date has examined provider communication with respect to health among LGBT patients.

Methods: Participants were 47 LGBT veterans who completed measures related to past health care experiences, experiences of discrimination in health care, perceptions of provider communication, and measures of anxiety, depression, post-traumatic stress disorder symptoms, and alcohol/tobacco use.

Results: The majority of LGBT veterans reported experiencing LGBT-based discrimination in health care, which was associated with higher rates of tobacco use and less comfort in disclosing their LGBT identity to providers. We also found evidence of moderation, such that high-quality provider communication appeared to buffer these associations.

Conclusion: LGBT veterans face unique challenges with respect to receiving appropriate health care. The high frequencies of reported discrimination in health care is problematic and warrants further research and intervention. These results highlight the important role of provider communication, and the potential for quality communication to buffer against certain effects, particularly with respect to tobacco use and LGBT identity disclosure, which is an important protective factor.

Psychometric measurement properties of the world health organization disability assessment schedule 2.0 (WHODAS) evaluated among veterans with mild traumatic brain injury and behavioral health conditions

PURPOSE

Examine the psychometric properties of the World Health Organization Disability Assessment Schedule 2.0 among U.S. Iraq/Afghanistan Veterans with a combination of mild traumatic brain injury and behavioral health conditions using Rasch analysis.

METHODS

307 Veterans were classified as either combat control (n = 141), or one of three clinical groups: mild traumatic brain injury (n = 10), behavioral health conditions (n = 24), or both (n = 128). Data from the three clinical groups were used to establish step and item calibrations serving as anchors when including the control group.

RESULTS

Measurement precision was excellent (person separation reliability = 0.93). Ordering of item calibrations formed a logical hierarchy. Test items were off-target (too easy) for the clinical groups. Principal component analysis indicated unidimensionality although 4/36 items misfit the measurement model. No meaningful differential item functioning was detected. There was a moderate effect size (Hedge's g = 1.64) between the control and clinical groups.

CONCLUSIONS

The World Health Organization Disability Assessment Schedule was suitable for our study sample, distinguishing 4 levels of functional ability. Although items may be easy for some Veterans with mild traumatic brain injury and/or behavioral health conditions, the World Health Organization Disability Assessment Schedule can be used to capture disability information for those with moderate to severe disability.Implications for rehabilitationPersistent functional disability is seen in military and civilian populations with mild traumatic brain injury which often co-occurs with behavioral health conditions.A comprehensive measure of disability is needed to distinguish between levels of disability to inform clinical decisions for individual patients and to detect treatment effects between groups in research.Results of this analysis indicate the World Health Organization Disability Assessment Schedule items are sufficiently unidimensional to evaluate level of disability in the moderate and severe range among persons with mild traumatic brain injury with and without behavioral health conditions.Further examination of the psychometric properties of the World Health Organization.Disability Assessment Schedule is necessary before measurement of disability is recommended for those with less than moderate levels of disability.

Preventing Soldiers' and Veterans' Suicide by Pastoral Counseling and Mental Health Treatment

Suicide prevention for active duty soldiers and veterans is a serious issue in the US, particularly in communities that are home to these populations. A body of research has addressed the prevention of veterans' suicide with therapy and medication. However, few researchers have focused on the role of spirituality and religion in suicide prevention. This paper will address the potential for collaboration between mental health professionals and clergy in the prevention of military-related suicide.

Real-world effectiveness of sofosbuvir/velpatasvir/voxilaprevir in 573 direct-acting antiviral experienced hepatitis C patients

Sofosbuvir/velpatasvir/voxilaprevir (SOF/VEL/VOX) provides a needed hepatitis C virus (HCV) antiviral option for direct-acting antiviral (DAA)-experienced patients. We evaluated the effectiveness of SOF/VEL/VOX for 12 weeks in DAA-experienced patients with genotype 1-4 treated in clinical practice. In this observational cohort analysis from the Veterans Affairs' Clinical Case Registry, 573 DAA-experienced patients initiating SOF/VEL/VOX were included: 490 genotype 1, 20 genotype 2, 51 genotype 3 and 12 genotype 4. Rates of cirrhosis were 32.7%, 30.0%, 49.0% and 58.3%; rates of prior NS5A-experience were 100.0%, 95.0%, 90.2% and 100.0% for genotypes 1-4, respectively. Overall SVR rates were 90.7% (429/473), 90.0% (18/20), 91.3% (42/46) and 100.0% (12/12) for genotypes 1-4, respectively, and were 91.3% (274/300), 88.9% (16/18), 90.2% (37/41) and 100.0% (11/11) for those with prior NS5A + NS5B experience. For genotype 1, SVR rates were similar in patients with prior regimens of ledipasvir/SOF (90.6%, 298/329), elbasvir/grazoprevir (91.2%, 73/80) and ombitasvir/paritaprevir/ritonavir/dasabuvir (90.9%, 70/77). SVR rates in genotype 1, 2 and 3 patients with prior SOF/VEL experience were 78.9% (15/19), 86.7% (13/15) and 84.6% (11/13). In genotype 1-4 patients completing 12 weeks of SOF/VEL/VOX, overall SVR rates were 95.1% (409/430), 89.5% (17/19), 93.3% (42/45) and 100% (12/12). In this diverse real-world cohort of heavily NS5A pretreated patients, SOF/VEL/VOX SVR rates in DAA-experienced patients were high across all genotypes. Genotype 1 patients who had prior experience with the most commonly prescribed NS5A regimens achieved similarly high SVR rates when retreated with SOF/VEL/VOX. For genotypes 1, 2 and 3, patients with prior SOF/VEL experience had lower SVR rates.

Digit Span embedded validity indicators in neurologically-intact veterans

Objective: Embedded validity measures are useful in neuropsychological evaluations but should be updated with new test versions and validated across various samples. This study evaluated Wechsler Adult Intelligence Scale, 4th edition (WAIS-IV) Digit Span validity indicators in post-deployment veterans.Method: Neurologically-intact veterans completed structured diagnostic interviews, the WAIS-IV, the Medical Symptom Validity Test (MSVT), and the b Test as part of a larger study. The Noncredible group included individuals who failed either the MSVT or the b Test. Of the total sample (N = 275), 21.09% failed the MSVT and/or b Test. Diagnostic accuracy was calculated predicting group status across cutoff scores on two Digit Span variables, four Reliable Digit Span (RDS) variables, and two Vocabulary minus Digit Span variables.Results: Digit Span age-corrected scaled score (ACSS) had the highest AUC (.648) of all measures assessed; however, sensitivity at the best cutoff of <7 was only 0.17. Of RDS measures, the Working Memory RDS resulted in the highest AUC (.629), but Enhanced RDS and Alternate RDS produced the highest sensitivities (0.22). Overall, cutoff scores were consistent with other studies, but sensitivities were lower. Vocabulary minus Digit Span measures were not significant.Conclusions: Digit Span ACSS was the strongest predictor of noncredible performance, and outperformed traditional RDS variants. Sensitivity across all validity indicators was low in this research sample, though cutoff scores were congruent with previous research. Although embedded Digit Span validity indicators may be useful, they are not sufficient to replace standalone performance validity tests.

Impact of military service on physical health later in life: a qualitative study of geriatric UK veterans and non-veterans

OBJECTIVES

Military veterans often experience physical health problems in later life; however, it remains unclear whether these problems are due to military service or are a feature of the ageing process. This study aimed to explore veteran and non-veteran perceptions of the impact of their occupation on their physical well-being later in life.

DESIGN

Semi-structured qualitative interviews analysed using thematic analysis.

SETTING

Interviews were conducted face-to-face in participants' homes or via telephone.

PARTICIPANTS

35 veterans (≥65 years), 25 non-veterans (≥65 years) were recruited, as well as a close companion of all participants for triangulation (n=60).

RESULTS

Most veterans reported good physical health later in life which they attributed to the fitness they developed during military service. However, several veterans described challenges in maintaining their desired level of physically activity due to new commitments and limited sports facilities when they left service. Fewer non-veterans had experienced work-related fitness activities or exercise in their civilian jobs. Ongoing physical health difficulties, such as deafness, were perceived to be due to exposure to workplace hazards and appeared more common in veterans compared with non-veterans. Veterans also described greater reluctance than non-veterans to seek medical treatment for physical health difficulties, which could be challenging for close companions who had to provide informal care.

CONCLUSIONS

Military service was largely perceived to be beneficial for physical well-being; although when occupation-related physical health problems were experienced, many veterans were unwilling to seek treatment. These findings may inform clinicians of the needs of older veterans and highlight potential barriers to care.

The Relationship between Suicidal Responses and Traumatic Brain Injury and Severe Insomnia in Active Duty, Veteran, and Civilian Populations

This study examined how a positive traumatic brain injury (TBI) screening and insomnia severity relate to suicidal outcomes across active duty, veteran, and civilian samples. Data were used from 3,993 participants from 19 studies. We conducted a series of analyses by group to identify which significantly differed on the variables of interest. TBI and insomnia each had independent relationships with outcomes over and above the impact of the other factor. Veterans presented as clinically worse across the outcomes. However, the relationship between insomnia and suicidal responses was stronger for active duty military compared to veterans. Continued research on TBIs and insomnia severity across groups will improve quality of care for those at risk of suicide.

Patient Characteristics Associated with Receipt of Prescription Weight-Management Medications Among Veterans Participating in MOVE!

OBJECTIVE

Weight-management medications (WMM) are recommended for the treatment of obesity. This study examined characteristics associated with initial receipt of WMM among eligible veterans in the first year following enrollment in the Veterans Health Administration (VHA) MOVE! behavioral weight-management program.

METHODS

We conducted a retrospective cohort study of VHA patients with obesity or overweight and obesity-related comorbidities who enrolled in MOVE! from October 2013 to September 2016 (N = 153,939). Multivariable logistic regression models estimated predictors of having a filled prescription for WMM and for orlistat.

RESULTS

A total of 1.1% of these veterans received WMM. The most common WMM included orlistat (70.4%), phentermine/topiramate (11.2%), and bupropion/naltrexone (9.7%). Female sex, higher BMI, obstructive sleep apnea, osteoarthritis, depression, lower back pain, and alcohol abuse were associated with greater odds of use of WMM, whereas age over 65 years, Hispanic ethnicity, and required co-payments were associated with lower odds. Among patients receiving WMM, older age, black race, female sex, higher BMI, cardiovascular disease, lower back pain, and congestive heart failure were associated with use of orlistat versus any other WMM.

CONCLUSIONS

Of patients engaged in MOVE! in the VHA, 1.1% received WMM. WMM are underutilized among veterans. Additional research is needed to understand barriers to incorporating WMM into comprehensive obesity treatment plans.

The Impact of Game Outcome on Affect of Military Wheelchair Basketball Players

Participation in physical activity has been shown to improve components of psychological well-being (i.e., affect). Programs such as the Warrior Games have been designed to promote physical activity in wounded military personnel. However, sport competition typically yields a winner and a loser (i.e., game outcome). The experience of a win or a loss may affect how wounded athletes respond to game outcome. Therefore, the purpose of this study was to investigate the affective changes (positive affect, negative affect, tranquility, and fatigue) according to game outcome in a sample of wounded military wheelchair basketball players participating in a weekend tournament. The results indicated that the participants who experienced a win reported significantly higher positive affect and tranquility and significantly lower negative affect than those experiencing a loss. These findings have important implications for wounded veteran athletes, as well as coaches and administrative personnel.

Suicide in Canadian veterans living in Ontario: a retrospective cohort study linking routinely collected data

OBJECTIVES

To compare the risk of death by suicide in male veterans with age-matched civilians.

DESIGN

Retrospective cohort study linking provincial administrative databases between 1990 and 2013 with follow-up complete until death or December 31, 2015.

SETTING

Population-based study in Ontario, Canada.

PARTICIPANTS

Ex-serving Canadian Armed Forces and Royal Canadian Mounted Police veterans living in Ontario who registered for provincial health insurance were included. A civilian comparator group was matched 4:1 on age and sex.

MAIN OUTCOME

Death by suicide was classified using standard cause of death diagnosis codes from a provincial registry of mandatory data collected from death certificates. Fine and Gray sub-distribution hazards regression compared the risk of death by suicide between veterans and civilians. Analyses were adjusted for age, residential region, income, rurality and major physical comorbidities.

RESULTS

20 397 male veterans released to Ontario between 1990 and 2013 and 81 559 age-sex matched civilians were included. 4.2% of veterans died during the study time frame, compared with 6.5% of the civilian cohort. Death by suicide was rare in both cohorts, accounting for 4.6% and 3.6% of veteran and civilian deaths, respectively. After adjustment for confounders, veterans had an 18% lower risk of dying from causes other than suicide (HR 0.82, 95% CI 0.76 to 0.89) and a similar risk of dying by suicide (HR 1.01, 95% CI 0.71 to 1.43), compared with civilians.

CONCLUSIONS

Deaths by suicide were rare in male veterans residing in Ontario. Our findings demonstrate that veterans had a similar risk of suicide-related mortality as an age-matched civilian population. A better understanding of effective suicide prevention as well as clarifying pathways to seeking and receiving mental health supports and services are important areas for future consideration.

Leaving Military Service with a Military Body: Insights for Pastoral Care and Counseling

The significance of the body has emerged as a vital yet neglected element in the transition from military to civilian life. The recognition of a military body enhances the understanding of potential pastoral and counseling needs among veterans beyond the mind and the soul. This article attempts to contribute to further knowledge about this topic, drawing from both theory and empirical research, in an effort to provide insights for pastoral care and counseling.

Telemental health training in the Veterans Administration Puget Sound Health Care System

As a pioneer of training in the field of psychology, the Veterans Affairs (VA) HealthCare System serves as a leader in the training in and provision of Telemental Health (TMH) services in the United States. To meet goals toward continued expansion of these services, the VA TMH training program includes both web-based didactic courses and a skills competency test at a basic level with supervision and consultation in TMH for more advanced training and is available to staff psychologists and psychologist trainees. Despite these efforts, barriers for training in and implementation of TMH occur at the provider, system, and patient level. At the national level, the VA is actively working to resolve these barriers and we share site-specific examples implemented by the VA Puget Sound Health Care System promoting access through TMH team to further address barriers to training and implementation.

A Mobile and Web-Based Self-Directed Complementary and Integrative Health Program for Veterans and Their Partners (Mission Reconnect): Protocol for a Mixed-Methods Randomized Controlled Trial

Background

Complementary and integrative health (CIH) is a viable solution to PTSD and chronic pain. Many veterans believe CIH can be performed only by licensed professionals in a health care setting. Health information technology can bring effective CIH to veterans and their partners.

Objective

This paper describes the rationale, design, and methods of the Mission Reconnect protocol to deliver mobile and Web-based complementary and integrative health programs to veterans and their partners (eg, spouse, significant other, caregiver, or family member).

Methods

This three-site, 4-year mixed-methods randomized controlled trial uses a wait-list control to determine the effects of mobile and Web-based CIH programs for veterans and their partners, or dyads. The study will use two arms (ie, treatment intervention arm and wait-list control arm) in a clinical sample of veterans with comorbid pain and posttraumatic stress disorder, and their partners. The study will evaluate the effectiveness and perceived value of the Mission Reconnect program in relation to physical and psychological symptoms, global health, and social outcomes.

Results

Funding for the study began in November 2018, and we are currently in the process of recruitment screening and data randomization for the study. Primary data collection will begin in May 2019 and continue through May 2021. Projected participants per site will be 76 partners/dyads, for a total of 456 study participants. Anticipated study results will be published in November 2022.

Conclusions

This work highlights innovative delivery of CIH to veterans and their partners for treatment of posttraumatic stress disorder and chronic pain.

Trial Registration

ClinicalTrials.gov NCT03593772; https://clinicaltrials.gov/ct2/show/NCT03593772 (Archived by WebCite at http://www.webcitation.org/77Q2giwtw)

International Registered Report Identifier (IRRID)

PRR1-10.2196/13666

Transitional Care Outcomes in Veterans Receiving Post-Acute Care in a Skilled Nursing Facility

BACKGROUND

As the veteran population ages, more veterans are receiving post-acute care in skilled nursing facilities (SNFs). However, the outcomes of these transitions across Veterans Affairs (VA) and non-VA settings are unclear.

OBJECTIVE

To measure adverse outcomes in veterans transitioning from hospital to SNF in VA and non-VA hospitals and SNFs.

DESIGN

Retrospective observational study using the 2012 to 2014 Residential History File, which concatenates VA, Medicare, and Medicaid data into longitudinal episodes of care for veterans.

SETTING

VA and non-VA hospitals and SNFs in four categories: non-VA SNFs, VA-contracted SNFs, VA Community Living Centers (CLCs), and State Veterans Homes.

PARTICIPANTS

Veterans, aged 65 years or older, who were acutely hospitalized and discharged to an SNF; one transition was randomly selected per patient.

MEASUREMENTS

Adverse "transitional care" outcomes were a composite of hospital readmission, emergency department visit, or mortality within 7 days of hospital discharge.

RESULTS

More than four in five veteran transitions (81.7%) occurred entirely outside the VA system. The overall 7-day outcome rate was 10.7% in the 388 339 veterans included. Adverse outcomes were lowest in VA hospital-CLC transitions (7.5%; 95% confidence interval [CI] = 7.1%-7.8%) and highest in non-VA hospital to VA-contracted nursing home transitions (17.5%; 95% CI = 16.0%-18.9%) in unadjusted analysis. In multivariate analyses adjusted for patient and hospital characteristics, VA hospitals had lower adverse outcome rates than non-VA hospitals (odds ratio [OR] = 0.80; 95% CI = 0.74-0.86). In comparison to VA hospital-VA CLC transitions, non-VA hospital to VA-contracted nursing homes (OR = 2.51; 95% CI = 2.09-3.02) and non-VA hospital to CLC (OR = 2.25; 95% CI = 1.81-2.79) had the highest overall adverse outcome rates.

CONCLUSION

Most veteran hospital-SNF transitions occur outside the VA, although adverse transitional care outcomes are lowest inside the VA. These findings raise important questions about the VA's role as a provider and payer of post-acute care in SNFs. J Am Geriatr Soc 67:1820-1826, 2019.

Freedom From Opioids After Total Knee Arthroplasty

BACKGROUND

In the United States, opioids are commonly prescribed to treat knee pain after total knee arthroplasty (TKA). While surgery leads to decreased pain in most patients, a sizable minority continue to experience severe pain and consume opioids chronically after TKA. We sought to determine the population-level effect of TKA on opioid consumption by detailing the pattern of opioid prescriptions before and after surgery.

METHODS

We retrospectively identified US Veterans Health Administration TKA patients from 2010 to 2015. Outpatient opioid prescriptions were identified from 18 months before to 18 months after surgery, and mean daily opioid doses were calculated. Our primary end point was the achievement of opioid-freedom, defined as a period of at least 6 months without opioids. We compared the percentage of patients who were opioid-free preoperatively to the percentage who were opioid-free 18 months after surgery (no prescriptions after postoperative month 12). We identified factors associated with opioid-freedom.

RESULTS

In a cohort of 33,927 patients, 41% were opioid-free in the month before surgery compared to 54% 18 months after surgery (P < .001). Preoperative freedom from opioids (odds ratio, 4.59; 95% confidence interval, 4.34 to 4.85; P < .001) was more strongly associated with postoperative freedom from opioids than patient medical and social factors.

CONCLUSION

TKA was associated with an increase in postoperative freedom from opioids. Low preoperative dose of opioids was more strongly associated with postoperative opioid-freedom than patient characteristics, suggesting that opioid prescription patterns are a chief driver of opioid use after surgery.

LEVEL OF EVIDENCE III

Retrospective cohort study.

Evaluation of Pharmacist Impact Within an Interdisciplinary Inpatient Heart Failure Consult Service

Background: Heart failure (HF) is highly prevalent in the Veterans Affairs (VA) health care system and the leading cause of hospital discharges in the VA. Despite guideline-specific recommendations of drug therapy, many patients are not on optimal medication regimens. Objective: To examine and quantify pharmacist impact in an interdisciplinary HF consult (IC) service on increasing use of guideline-directed medical therapy (GDMT). The 30-day readmission rates before and after the implementation of an IC service are reported. Methods: This was a single-center retrospective analysis of veterans admitted with a HF diagnosis between August 2008 and August 2015 in 2 distinctive cohorts: pre-IC (August 2008 to November 2011) and IC (November 2011 to August 2015). Results: Four-hundred patients were included, with 200 in each cohort. All-cause readmissions at 30 days were not different between pre-IC and IC groups: 33.5% versus 28.5%, respectively. Secondary outcomes of HF readmission and 1-year mortality were not different between groups. Significant increases in medication use rates were observed from admission to discharge in both cohorts; however, greater increases were observed in the IC group in which the pharmacist role was clearly defined in recommending GDMT optimization, especially in patients with HF with reduced ejection fraction. Conclusion and Relevance: Although the implementation of an IC service did not significantly change 30-day readmission rates, increases in GDMT use are evident with increased pharmacist involvement. Longer-term outcomes associated with this intervention warrant future investigation.

Swallowing Function in Survivors of Oropharyngeal Cancer Is Associated With Advanced T Classification

OBJECTIVES

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is rapidly increasing in the United States. The aim of this study was to characterize the functional status of OPSCC survivors to identify predictors of swallowing dysfunction in this patient population.

METHODS

OPSCC survivors (n = 81) treated at the Michael E. DeBakey Veterans Affairs Medical Center between 2005 and 2015 with at least 2 years of clinical follow-up were reviewed. Functional status was ascertained using (1) gastrostomy and tracheostomy placement and retention, (2) gastrostomy use at last follow-up, (3) patient-reported diet, and (4) modified barium swallow.

RESULTS

Median follow-up duration was 5.6 years; 67% of patients had ≥10-pack-year tobacco exposure; 96% of tumors for which p16 data were available were p16 positive. At last follow-up, 82% of patients reported a regular diet, and only 9 patients required gastrostomy use. Gastrostomy use at last follow-up was higher in patients with T3 and T4 tumors compared with those with T1 and T2 tumors (P = .01). The relationship between T classification and gastrostomy use persisted even when the analysis was limited to p16+ tumors and p16+ tumors with ≥10-pack-year history of tobacco exposure.

CONCLUSIONS

Advanced T classification at presentation is a critical predictor of gastrostomy use in long-term OPSCC survivors irrespective of p16 status or tobacco exposure history.

LEVEL OF EVIDENCE

2b.

Out of sight out of mind: an examination of mental health problems in UK military reservists and veterans

BACKGROUND

Reservists often have different experiences to regular military personnel which may impact their mental health.

AIMS

To investigate the incidence of mental health problems in both active and veteran reservists and determine how this compares to regular service personnel and ex-regular veterans.

METHOD

Five studies which included reservist and/or veteran participants, a validated assessment of mental health problems, and provided primary data were included in the synthesis. Common mental health disorders, post-traumatic stress disorder and alcohol use disorder were examined.

RESULTS

Nondeployed mobilized reservists were significantly less likely to report common mental health disorders than nondeployed regulars. There were no other significant differences between groups. Regardless deployed reservists reported more mental health problems than nondeployed reservists. Similarly, ex-regular deployed veterans were more likely to experience mental health difficulties than nondeployed ex-regular veterans. Notably, a large proportion of non-deployed reservists reported probable alcohol use disorders, indicating that problematic alcohol consumption may not be due to deployment in this group.

CONCLUSION

These results highlight the need for ongoing support for military regular, ex-regular and reservist personnel. Additional research is needed to examine potential risk and protective factors for mental health problems in both deployed and nondeployed reservists. Key points Overall, mobilized deployed reservists were more likely to experience mental health problems than non-deployed reservists. Nondeployed regulars reported significantly more common mental health problems than nondeployed mobilized reservists. Reservists and (ex-)regulars reported similar rates of PTSD. This suggests reservists are vulnerable to developing PTSD following non-combat related trauma that may not lead to PTSD in regulars and this warrants future research. Reservists were less likely to report problematic alcohol consumption compared to regular personnel and ex-regular veterans. The greatest amount of reservist problematic drinking was reported in non-deployed veteran reservists. This indicates problematic alcohol consumption is not deployment related in this group and highlights the need for ongoing formal support for alcohol use disorders in the UK Armed Forces.

Focus on the family: A case example of end-of-life care for an older LGBT veteran

The Department of Veterans Affairs (VA) is likely the largest provider of health care for LGBT persons in US. However, histories of homophobia, stigma, discrimination, and past military policies have all had a lasting impact on the health of LGBT veterans. Effects can be seen across healthcare needs, disparities, access, and utilization for or by LGBT veterans. A case from a VA hospice unit is used to illustrate some challenges and opportunities when providing end-of-life care for an older, lesbian veteran. This veteran had been cared for by her wife who was struggling to meet care needs at home. Over time, it became clear that the wife was emotionally and financially dependent on the veteran, and would be facing many psychosocial and financial challenges when the veteran died. However the wife was reticent to accept referrals for help or services due to past negative experiences with social service agencies related to her sexual orientation. The interdisciplinary team collaborated to care for the veteran's medical needs, and the wife's emotional and psychosocial needs, until after the veteran's death. This case highlights many of the unique needs and challenges that may arise in caring for LGBT veterans and their families at end-of-life.

Suffering for Others While Making Others Suffer: Military Narratives of Sacrifice

Voices from theology seldom participate in a contemporary conversation on military cultures and identities; this article attempts to stimulate this conversation from such a perspective. The article combines a literature review with narratives of sacrifice from real-life cases. It presents a reflective perspective on the formation of military identities with regard to responsibilities and sacrifices. Forgiveness and atonement are discussed as pathways to cultivate growth which can lessen feelings of guilt and regret.

Blast Exposure Impairs Sensory Gating: Evidence from Measures of Acoustic Startle and Auditory Event-Related Potentials

Many military service members and veterans who have been exposed to high-intensity blast waves experience traumatic brain injury (TBI), resulting in chronic auditory deficits despite normal hearing sensitivity. The current study sought to examine the neurological cause of this chronic dysfunction by testing the hypothesis that blast exposure leads to impaired filtering of sensory information at brainstem and early cortical levels. Groups of blast-exposed and non-blast-exposed participants completed self-report measures of auditory and neurobehavioral status, auditory perceptual tasks involving degraded and competing speech stimuli, and physiological measures of sensory gating, including pre-pulse inhibition and habituation of the acoustic startle reflex and electrophysiological assessment of a paired-click sensory gating paradigm. Blast-exposed participants showed significantly reduced habituation to acoustic startle stimuli and impaired filtering of redundant sensory information at the level the auditory cortex. Multiple linear regression analyses revealed that poorer sensory gating at the cortical level was primarily influenced by a diagnosis of TBI, whereas reduced habituation was primarily influenced by a diagnosis of post-traumatic stress disorder. A statistical model was created including cortical sensory gating and habituation to acoustic startle, which strongly predicted performance on a degraded speech task. These results support the hypothesis that blast exposure impairs central auditory processing via impairment of neural mechanisms underlying habituation and sensory gating.

Treatment of military-related post-traumatic stress disorder: challenges, innovations, and the way forward

Post-traumatic stress disorder (PTSD) is one of the common mental disorders in military and veteran populations. Considerable research and clinical opinion has been focused on understanding the relationship between PTSD and military service and the implications for prevention, treatment, and management. This paper examines factors associated with the development of PTSD in this population, considers issues relating to engagement in treatment, and discusses the empirical support for best practice evidence-based treatment. The paper goes on to explore the challenges in those areas, with particular reference to treatment engagement and barriers to care, as well as treatment non-response. The final section addresses innovative solutions to these challenges through improvements in agreed terminology and definitions, strategies to increase engagement, early identification approaches, understanding predictors of treatment outcome, and innovations in treatment. Treatment innovations include enhancing existing treatments, emerging non-trauma-focused interventions, novel pharmacotherapy, personalized medicine approaches, advancing functional outcomes, family intervention and support, and attention to physical health.

Exposure and Response Prevention for Obsessive-Compulsive Disorder: A Case Study of a Veteran With Violent Intrusive Thoughts

Exposure and Response Prevention (ERP) is the gold standard treatment for obsessive-compulsive disorder (OCD); however, few studies have evaluated the use of ERP with veterans. This case study describes ERP and medication treatment of a veteran who experienced violent sexual thoughts, countered by compulsions of focusing on the distressing thought to ensure a negative emotion or reversing the thought to a nonviolent thought or image. The veteran had previously received supportive psychotherapy and medication for depression, anxiety, and sleep difficulties, with poor treatment adherence. Upon reengagement in treatment, the therapist provided ERP in 34 sessions over 14 months, with 15 sessions via video telehealth to home. The patient used the OCD Workbook as a resource throughout treatment. The patient developed a hierarchy of target obsessions and rituals with associated subjective units of distress; completed exposures, beginning with lower-level items; and wrote imaginal scripts. He also received zolpidem for insomnia and venlafaxine for anxiety and depression. His scores on the nine-item Patient Health Questionnaire and Yale Brown Obsessive-Compulsive Scale decreased significantly.

Utilisation of the principles of the Armed Forces Covenant in NHS Trusts and Clinical Commissioning Groups across England: a freedom of information investigation

OBJECTIVES

To determine the extent to which National Health Service (NHS) service providers appoint a named Armed Forces veteran lead or champion, and to explore the commissioning of veteran-specific services by Clinical Commissioning Groups.

DESIGN

A convergent mixed method design was used to improve understanding obtained from the information provided by respondents on their practice. The study comprised two parts: phase 1 involved NHS Trusts, and phase 2 involved Clinical Commissioning Groups.

SETTING

All NHS Trusts and Clinical Commissioning Groups in England were contacted using a freedom of information request.

PARTICIPANTS

All NHS trusts and Clinical Commissioning Groups across England.

INTERVENTIONS

Initially, existing national websites were searched to gather information within the public domain. An audit was carried out, using the Freedom of Information Act (FOIA) 2000 to gather further information.

PRIMARY AND SECONDARY OUTCOME MEASURES

The FOIA 2000 applies to UK Government departments and public authorities, including NHS Trusts in England, Wales and Northern Ireland.

RESULTS

Responses from the freedom of information requests illustrate inconsistencies in relation to adopting the principles of the Armed Forces Covenant. The inconsistencies extend to the practice of appointing an Armed Forces Veteran Lead or an Armed Forces Veteran Champion. There is also evidence to suggest a lack of commitment to and understanding of policy guidance in relation to Clinical Commissioning Group responsibility for commissioning veteran-specific services.

CONCLUSIONS

Findings from this study support the case for making improvements to, and improving the consistency of, commissioning practices for veterans.

Do serving and ex-serving personnel of the UK armed forces seek help for perceived stress, emotional or mental health problems?

Background: UK armed forces personnel are at risk of occupational psychological injury; they are often reluctant to seek help for such problems. Objective: We aimed to examine and describe sources of support, prevalence and associates of help-seeking among UK serving and ex-serving personnel. Method: A total of 1450 participants who self-reported a stress, emotional or mental health problem in the past 3 years were sampled from a health and wellbeing study and subsequently completed a telephone interview comprising measures of mental disorder symptoms, alcohol misuse and help-seeking behaviour. Results: Seven per cent of participants had not sought any help, 55% had accessed medical sources of support (general practitioner or mental health specialist), 46% had received formal non-medical (welfare) support and 86% had used informal support. Gender, age, perceived health, functional impairment, social support, deployment, alcohol and comorbidity impacted upon the choice of help source. Conclusions: This study found that the majority of those with perceived mental health problems sought some form of help, with over half using formal medical sources of support.

Spiritual Care in Nursing Practice in Veteran Health Care

Spiritual care is important in nursing practice, and spiritual well-being and spiritual care are associated with better health. Military veterans, a unique patient population, want spiritual care to cope with chronic conditions. It is unclear whether spiritual care is provided in veteran health care in the United States. This study used a qualitative descriptive method, guided by the Spiritual Care in Nursing Practice (SCNiP) theory, to describe spiritual care in nursing practice and facilitators/barriers in veteran health care. Individual interviews were conducted with 39 registered nurses (RNs) at a U.S. veteran health system. Findings were consistent with the SCNiP theory but revealed additional categorical attributes and processes as it applied to veteran health care. Facilitators that promoted spiritual care include nurse professionalism, collegial support, and available spiritual resources. Barriers included lack of time, task-oriented culture, unclear knowledge of accessing resources, and unclear organization policy in providing spiritual care. Findings further refined the theory.

Moral injury in UK armed forces veterans: a qualitative study

Background: Moral injury has been found to adversely affect US veteran mental health, and the mental health difficulties resulting from moral injury can be particularly challenging to treat. Yet little is known about the impact of moral injury on the well-being of UK armed forces (AF) veterans and how moral injury is currently addressed in treatment. Objective: The aim of this study was to examine UK AF veterans' experiences of moral injury, and the perceptions and challenges faced by clinicians in treating moral injury-related mental health difficulties. Method: Six veterans who reported moral injury exposure and four clinicians who had treated veterans with moral injury were recruited from Combat Stress. Semi-structured qualitative interviews were conducted and data were analysed using thematic analysis. Results: Moral injury was perceived by clinicians to be common in UK AF veterans and, where present, had a considerable negative impact on mental health. Clinicians reported a lack of a manualized approach for treating cases of moral injury and, instead, used a combination of several non-post-traumatic stress disorder (PTSD)-specific therapies. Providing treatment for morally injured veterans could be challenging given the limited number of sessions that clinicians were able to provide. Moreover, moral injury was thought to be poorly understood among UK AF veteran clinical care teams. Conclusion: This study provides some of the first insight into the impact of moral injury on UK AF veteran well-being as well as clinician views of delivering psychological care following moral injury. These findings highlight that moral injury is experienced by UK AF veterans, and further examination of the prevalence of moral injury and whether current treatment approaches are appropriate and efficacious is needed.

Lessons and Outcomes of Mobile Acute Care for Elders Consultation in a Veterans Affairs Medical Center

OBJECTIVE

Describe the implementation and effects of Mobile Acute Care for Elders (MACE) consultation at a Veterans Affairs Medical Center (VAMC).

DESIGN

Retrospective cohort analysis.

INTERVENTION

Veterans aged 65 or older who were admitted to the medicine service between October 1, 2012, and September 30, 2014, were screened for geriatric syndromes via review of medical records within 48 hours of admission. If the screen was positive, the MACE team offered the admitting team a same-day consultation involving comprehensive geriatric assessment and ongoing collaboration with the admitting team and supportive services to implement patient-centric recommendations for geriatric syndromes.

RESULTS

Veterans seen by MACE (n = 421) were compared with those with positive screens but without consultation (n = 372). The two groups did not significantly differ in age, comorbidity, sex, or race. All outcomes (30-day readmission, 30-day mortality, readmission costs) were in the expected direction for patients receiving MACE but did not reach statistical significance. Patients receiving MACE had lower odds of 30-day readmission (11.9% vs 14.8%; odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.54-1.25; p = .360) and 30-day mortality (5.5% vs 8.6%; OR = 0.64; CI = 0.36-1.12; p = .115), and they had lower 30-day readmission costs (MACE $15,502; CI = $12,242-$19,631; comparison = $18,335; CI = $14,641-$22,962; p = .316) than those who did not receive MACE after adjusting for age and Charlson Comorbidity Index.

CONCLUSION

Our MACE consultation model for older veterans with geriatric syndromes leverages the limited supply of clinicians with expertise in geriatrics. Although not statistically significant in this study of 793 subjects, MACE patients had lower odds of 30-day readmission and mortality, and lower readmission costs. J Am Geriatr Soc 67:818-824, 2019.

Guidelines for the Treatment of PTSD Using Clinical EFT (Emotional Freedom Techniques)

Clinical EFT (Emotional Freedom Techniques) is an evidence-based method that combines acupressure with elements drawn from cognitive and exposure therapies. The approach has been validated in more than 100 clinical trials. Its efficacy for post-traumatic stress disorder (PTSD) has been investigated in a variety of demographic groups including war veterans, victims of sexual violence, the spouses of PTSD sufferers, motor accident survivors, prisoners, hospital patients, adolescents, and survivors of natural and human-caused disasters. Meta-analyses of EFT for anxiety, depression, and PTSD indicate treatment effects that exceed those of both psychopharmacology and conventional psychotherapy. Studies of EFT in the treatment of PTSD show that (a) time frames for successful treatment generally range from four to 10 sessions; (b) group therapy sessions are effective; (c) comorbid conditions such as anxiety and depression improve simultaneously; (d) the risk of adverse events is low; (e) treatment produces physiological as well as psychological improvements; (f) patient gains persist over time; (g) the approach is cost-effective; (h) biomarkers such as stress hormones and genes are regulated; and (i) the method can be adapted to online and telemedicine applications. This paper recommends guidelines for the use of EFT in treating PTSD derived from the literature and a detailed practitioner survey. It has been reviewed by the major institutions providing training or supporting research in the method. The guidelines recommend a stepped-care model, with five treatment sessions for subclinical PTSD, 10 sessions for PTSD, and escalation to intensive psychotherapy or psychopharmacology or both for nonresponsive patients and those with developmental trauma. Group therapy, social support, apps, and online and telemedicine methods also contribute to a successful treatment plan.

Examination of Racial Differences in a Posttraumatic Stress Disorder Group Therapy Program for Veterans

Posttraumatic stress disorder (PTSD) is one of the most prevalent mental health diagnoses for veterans. Group therapy can be an effective and efficient means of treating PTSD, yet the literature exploring treatment outcomes for racial minorities is mixed and limited. The present study was an evaluation across racial groups of the PTSD Recovery Program, a manualized group therapy implemented at a Veterans Affairs hospital. Data were collected from male veterans (N = 450) who identified as non-Hispanic White or non-Hispanic African American and participated in a 10-week, combat-related, group therapy program between 2010 and 2014. Participants completed the Posttraumatic Stress Disorder Checklist-Military version (PCL-M) measure at pre-treatment and post-treatment. The Program led to a statistically significant reduction in PCL-M scores (Cohen's d = .64). Symptom reduction occurred regardless of race, with no racial differences in improvement. Racial and ethnic composition of groups was not related to outcomes. The Program was effective regardless of veteran group or provider. Results imply that the PTSD Recovery Program is an effective first-line option to treating non-Hispanic White and non-Hispanic African American veterans with PTSD. Future research should continue to explore the associations between group characteristics and treatment outcomes.

An ecological perspective on implementing environmental control units for veterans with spinal cord injuries and disorders

Purpose: Guided by an ecological perspective, the purpose of this study was to identify multilevel factors that influenced the implementation of environmental control units (ECUs) in Veterans Health Administration (VHA) Spinal Cord Injury/Disorders (SCI/D) Centres.Materials and methods: Mixed methods including an online survey and qualitative interviews of VHA healthcare employees.Results: VHA healthcare employees participated in the online survey (n = 153, 21% participation rate) and semi-structured interview (n = 28; 54% participation rate). About 58.2% of survey respondents indicated that patients admitted to a VHA SCI/D Centre received ECU training. Interview participants reported that patients might benefit from educational materials on using ECUs. About 53.7% of survey respondents indicated that they did not receive ECU training. Interview participants emphasized that more healthcare employees needed to be trained to distribute ECU-related tasks including patient training and troubleshooting problems. The most common challenge was the coordination involved in moving patients out of rooms that were being outfitted with an ECU.Conclusions: Application of an ecological framework highlighted a range of factors at multiple levels that dynamically influence ECU implementation while accounting for the SCI/D care context. Integrating this technology with the care experiences of patients, the workflow of healthcare employees, and the structure of the organization may improve the implementation of ECUs.IMPLICATIONS FOR REHABILITATIONAn environmental control unit (ECU) is an assistive technology device that provides persons with a physical disability (e.g., spinal cord injuries and disorders) increased independence in a home, hospital, or rehabilitation facility setting.An ECU allows a person to access and control appliances like their hospital bed, lights, television, doors, nurse call button, telephone, and computer, thus, decreasing workload on attendants and family members while increasing independence for the user.Application of an ecological framework in this study highlighted a range of factors at multiple levels that dynamically influence ECU implementation while accounting for the SCI/D care context.Integrating this technology with the care experiences of patients, the workflow of healthcare employees, and the structure of the organization may improve the implementation of ECUs in an inpatient setting.

Identifying probable post-traumatic stress disorder: applying supervised machine learning to data from a UK military cohort

BACKGROUND

Early identification of probable post-traumatic stress disorder (PTSD) can lead to early intervention and treatment.

AIMS

This study aimed to evaluate supervised machine learning (ML) classifiers for the identification of probable PTSD in those who are serving, or have recently served in the United Kingdom (UK) Armed Forces.

METHODS

Supervised ML classification techniques were applied to a military cohort of 13,690 serving and ex-serving UK Armed Forces personnel to identify probable PTSD based on self-reported service exposures and a range of validated self-report measures. Data were collected between 2004 and 2009.

RESULTS

The predictive performance of supervised ML classifiers to detect cases of probable PTSD were encouraging when compared to a validated measure, demonstrating a capability of supervised ML to detect the cases of probable PTSD. It was possible to identify which variables contributed to the performance, including alcohol misuse, gender and deployment status. A satisfactory sensitivity was obtained across a range of supervised ML classifiers, but sensitivity was low, indicating a potential for false negative diagnoses.

CONCLUSIONS

Detection of probable PTSD based on self-reported measurement data is feasible, may greatly reduce the burden on public health and improve operational efficiencies by enabling early intervention, before manifestation of symptoms.

War Veterans

Objective: Moral injury may result from perpetration-based and betrayal-based acts that violate deeply held norms; however, researchers and clinicians have little guidance about the moral injury syndrome's specific developmental pathways following morally injurious events. The present study's objective was to examine the direct and indirect pathways proposed in a frequently cited model of moral injury (1) in relation to two types of military-related traumas [experiencing military sexual trauma (MST) and combat exposure]. Methods: Secondary analyses were conducted within a sample of post-9/11 veterans at a Southwestern Veterans Health Care System (N = 310) across two time-points. Structural equation modeling tested the direct and indirect pathways from MST and combat to a PTSD-depression factor via betrayal, perpetration, guilt, and shame. Results: Betrayal accounted for the association between MST and PTSD-depression (β = 0.10, p < 0.01, 95% CI = 0.01 - 0.11) and perpetration accounted for the association between combat and PTSD-depression (β = 0.07, p < 0.05, 95% CI = 0.02 - 0.14). The indirect path from combat to shame to PTSD-depression was significant (β = 0.16, p < 0.01, 95% CI = 0.07 - 0.28) but the path through guilt was not. The specific indirect paths through perpetration or betrayal to shame or guilt were non-significant. Conclusions: Betrayal and perpetration are associated with PTSD-depression following MST and combat. Results suggest multiple pathways of moral injury development following different military traumas and morally injurious events. Implications for moral injury conceptualization and treatment are discussed.

Veterans with Traumatic Brain Injury

Purpose: Traumatic brain injury (TBI) is a signature injury among the U.S. veterans. Hispanic U.S. veterans diagnosed with TBI have been found to have higher risk-adjusted mortality. This study examined the adjusted association of geographic location with all-cause mortality in 114,593 veterans diagnosed with TBI between January 1, 2000 and December 31, 2010, and followed through December 31, 2014. Methods: National Veterans Health Administration (VHA) databases containing administrative data including International Classification of Diseases, 9th Revision (ICD-9) codes, sociodemographic characteristics, and survival were linked. TBI was identified based on ICD-9 codes. Cox proportional hazards regression methods were used to examine the association of time from first TBI ICD-9 code to death with geographic location, after adjustment for TBI severity, race/ethnicity, other sociodemographic characteristics, military factors, and Elixhauser comorbidities. Results: Relative to urban mainland veterans with a median survival of 76.4 months, veterans living in the U.S. territories had a median survival of 69.1 months, whereas rural mainland veterans had a median survival of 77.1 months, and highly rural mainland veterans had a mean survival of 77.6 months. The final model adjusted for race/ethnicity, TBI severity, sociodemographic, military, and comorbidity covariates showed that residing in the U.S. territories was associated with a higher risk of death (hazard ratios=1.24; 95% confidence interval 1.15-1.34) relative to residing on the U.S. mainland. The race/ethnicity disparity previously found for the U.S. veterans diagnosed with TBI seems to be accounted for by living in the U.S. territories. Conclusion: The study shows that among veterans with TBI, mortality rates were higher in those who reside in the U.S. territories, even after adjustment. Previous documented higher mortality among Hispanic veterans seems to be explained by residing in the U.S. territories. The VA has a mission of ensuring equitable treatment of all veterans, and should investigate targeted policies and interventions to improve the survival of the U.S. territory veterans diagnosed with TBI.

Rapid Recovery Total Joint Arthroplasty is Safe, Efficient, and Cost-Effective in the Veterans Administration Setting

BACKGROUND

Institutional pathways in total joint arthroplasty (TJA) have been shown to reduce costs and improve patient care, but questions remain regarding their efficacy in certain populations. We sought to evaluate the comprehensive effect of a rapid recovery perioperative TJA protocol in the Veterans Health Administration (VA) setting.

METHODS

In a VA hospital, a rapid recovery protocol was implemented for all patients undergoing primary total hip or knee arthroplasty. A retrospective chart review was performed comparing pre-protocol (n = 174) and protocol (n = 78) cohorts. Measured outcomes included length of stay (LOS), discharge destination, unplanned readmissions, overall complications, and total cost of healthcare during admission and at 30 and 90 days postoperatively.

RESULTS

After implementation of the protocol, the average LOS decreased from 3.2 to 1.7 days (P < .0001). In the protocol group, there was a 12.3% increase in patients discharging directly home (85.1% vs 97.4%, P = .005). There were lower unplanned readmissions (6.3% vs 3.8%, P = .56) and overall complications (7.5% vs 3.8%, P = .40), but these were not statistically significant. The summative cost of all perioperative healthcare was lower after implementation of the protocol during the inpatient stay ($19,015 vs $21,719, P = .002) and out to 30 days postoperatively ($21,083 vs $23,420, P = .03) and 90 days postoperatively ($24,189 vs $26,514, P = .07).

CONCLUSION

In the VA setting, implementation of a rapid recovery TJA protocol led to decreased LOS, decreased cost of perioperative healthcare, and an increase in patients discharging directly home without increased readmission or complication rates. Such protocols are essential as we transition into an era of value-based arthroplasty.

Hormone therapy, gender affirmation surgery, and their association with recent suicidal ideation and depression symptoms in transgender veterans

BACKGROUND

Access to transition-related medical interventions (TRMIs) for transgender veterans has been the subject of substantial public interest and debate. To better inform these important conversations, the current study investigated whether undergoing hormone or surgical transition intervention(s) relates to the frequency of recent suicidal ideation (SI) and symptoms of depression in transgender veterans.

METHODS

This study included a cross-sectional, national sample of 206 self-identified transgender veterans. They self-reported basic demographics, TRMI history, recent SI, and symptoms of depression through an online survey.

RESULTS

Significantly lower levels of SI experienced in the past year and 2-weeks were seen in veterans with a history of both hormone intervention and surgery on both the chest and genitals in comparison with those who endorsed a history of no medical intervention, history of hormone therapy but no surgical intervention, and those with a history of hormone therapy and surgery on either (but not both) the chest or genitals when controlling for sample demographics (e.g., gender identity and annual income). Indirect effect analyses indicated that lower depressive symptoms experienced in the last 2-weeks mediated the relationship between the history of surgery on both chest and genitals and SI in the last 2-weeks.

CONCLUSIONS

Results indicate the potential protective effect that TRMI may have on symptoms of depression and SI in transgender veterans, particularly when both genitals and chest are affirmed with one's gender identity. Implications for policymakers, providers, and researchers are discussed.

Integrating a mental health clinical pharmacy specialist into the Homeless Patient Aligned Care Teams

Introduction

To address the complex needs of the homeless veteran population, the US Department of Veterans Affairs created the Homeless Patient Aligned Care Team (H-PACT) model. The South Texas Veterans Health Care System has an established H-PACT model, however it does not include a clinical pharmacy specialist in mental health (MH).

Methods

An H-PACT MH pharmacy resident clinic was created and managed by a postgraduate year-2 psychiatric pharmacy resident. Improvements in access to MH care, Veterans Health Administration performance metrics, and estimated cost savings associated with resident interventions were reviewed to evaluate clinic utility.

Results

Over the 6-month clinic time frame, there were a total of 40 patient encounters in which 21 veterans had MH medication evaluation on at least 1 occasion. The average wait time for Veterans previously followed by the H-PACT psychiatrist was approximately 8 weeks. The H-PACT MH pharmacy resident clinic enabled veterans to be evaluated every 4 to 6 weeks. Interventions made by the resident included identification of medication administration errors, medication adjustments, adherence education, reduction in polypharmacy, and referral to other services. Estimated cost savings from clinic interventions totaled $33 613.67.

Discussion

The H-PACT MH pharmacy resident clinic allowed for an improvement in wait time for psychiatric pharmacotherapy follow-up for homeless veterans, with interventions that were associated with significant estimated cost savings.

Care of veterans in a non-veteran health administration hospital: What is the status of nursing practice after continuing education?

AIMS AND OBJECTIVES

To identify how civilian nurses are caring for military veterans following mandatory continuing education on veterans' mental health needs and to describe challenges nurses are facing in provision of that care.

BACKGROUND

Veterans and military personnel experience mental health conditions at a high rate and are increasingly receiving care in civilian healthcare facilities. Nonmilitary providers may not be prepared to address this population's challenging needs. Military culture may influence the presentation of mental health conditions; thus, critical assessment points by nonmilitary medical personnel may be missed. Education is touted internationally as a means to address deficits, but research is lacking to support that statement.

METHODS

Adhering to research reporting guidelines, 115 of a proposed 322 civilian nurses in a tertiary hospital volunteered to complete a one-time online survey that contained quantitative and demographic questions. Forty of 115 nurses went on to complete the qualitative query. Descriptive statistics summarised quantitative results, and constant comparative analysis was applied to qualitative responses for theme identification.

RESULTS

The study was stopped early due to reports of violence from veterans upon nurses. Results showed continuing education did not change documentation of military status. Following mandatory continuing education, civilian nurses continued to describe uncertainty in how to adapt care, on how to interact with veterans and in how to deal with violence.

CONCLUSION

The status of care to veterans remains insufficient, but nurses are asking critical questions on how to update practice. Additional support and research in the clinical setting is needed to promote a safe caring environment.

RELEVANCE TO CLINICAL PRACTICE

Continuing education alone may not advance care of the veteran. A multipronged approach to include mandatory documentation of military status and coaching of providers by those experienced with the military way of life may be used to augment staff preparedness.