Correlates of the Veterans Visiting Emergency Departments in Taiwan: A Comparison Before and After the Coronavirus Disease 2019 Pandemic

BACKGROUND

Taiwan has a substantial number of veterans, but knowledge regarding their emergency department (ED) visits during the coronavirus disease 2019 (COVID-19) pandemic remains limited. This study examined the characteristics of veterans' ED visits during Taiwan's COVID-19 epidemic.

METHODS

This was a cross-sectional study conducted at the ED of a large veteran medical center located in Taipei, Taiwan, from May 2018 to October 2021. We analyzed the numbers and features of visits in summer and autumn according to the first wave of the COVID-19 epidemic in Taiwan in 2021.

RESULTS

Medical institutions were positively associated with veteran status. Emergency department complaints of trauma (adjusted odds ratio [AOR] = 1.15, 95% CI: 1.06-1.25; summer P < .01) and chest pain/tightness (AOR = 1.65, 95% CI: 1.45-1.87; summer P < .01; AOR = 1.4, 95% CI: 1.26-1.55; P < .01) were associated with increased odds of being a veteran. Triage levels above 2 were positively associated with veteran status in the autumn model (AOR = 1.14, 95% CI: 1.07-1.22; P < .01). Patients hospitalized after ED visits were associated with reduced odds of veteran status (P < .01). Those who spent a long time in the ED were more likely to be veterans than those who spent a shorter time in the ED (P < .01). Veterans were less likely to visit the ED regardless of the time frame of the study period (P < .01), except during the COVID-19 outbreak in the autumn (2019-2020).

CONCLUSIONS

The distinctions in ED visits highlighted the individuality of veterans' medical needs. Our findings suggest that the veteran medical system can add to the focus on improving senior-friendly care, fall prevention, quality of life of institutionalized veterans, access for homeless veterans, and care for ambulatory care-sensitive conditions.

Refining the Implementation of a Hub-and-Spoke Model for TelePain Through Qualitative Inquiry

The hub-and-spoke telehealth model leverages centrally located providers who utilize telehealth technology to bring specialized care to medically underserved areas. This model has the potential to promote equitable access to healthcare. However, few studies address how to facilitate the adoption and implementation of hub-and-spoke telehealth. We examined spoke site providers' experiences with TelePain, a national hub-and-spoke model of interdisciplinary chronic pain care, with a focus on improving future implementation. We conducted semi-structured individual interviews (20-45 min) with 27 VA spoke site providers via teleconferencing between August 2020 and February 2021. Interview transcripts were coded in Atlas.ti 8.0 using deductive (identified a priori and used to build the interview guide) and inductive (emerging) codes. Our analysis identified the following themes stressed by the spoke sites: (1) spoke sites needed to envision how TelePain services would work at their site before deciding to adopt; (2) TelePain implementation needed to fit into local existing care processes; (3) hub sites needed to understand spoke sites' context (e.g., via needs assessment) to tailor the services accordingly, and (4) hub-and-spoke sites needed to establish bidirectional communication. Our findings provide a practical guide to improve future rollout of hub-and-spoke telehealth models. Recommendations focus on the role of the hub site in promoting program adoption by (1) developing a clear and detailed marketing plan and (2) considering how the program can be adapted to fit the local spoke site context. To improve implementation, hub-and-spoke sites must establish ongoing and consistent bidirectional communication; this is particularly critical in the everchanging post-peak pandemic healthcare system. An important next step is the development of recommendations and guidelines for implementing hub-and-spoke telehealth, as well as examining pain outcomes for patients touched by this program.

"There's a huge benefit just to know that someone cares:" a qualitative examination of rural veterans' experiences with TelePain

BACKGROUND

Veterans in the United States are at an increased risk of chronic pain and have higher reported pain prevalence and severity than nonveterans. This qualitative study aims to examine veterans' perspectives on the acceptability of receiving pain care through TelePain, a telehealth program implemented by the Veterans Health Administration (VA) that offers specialty pain care to rural veterans in their homes or in a video conferencing room at a nearby outpatient clinic.

METHODS

The VA electronic health record was used to identify patients who were referred to TelePain from rural clinics located in Washington, Oregon, and Alaska between 12/01/2019 and 03/31/2020. The study team completed 16 semi-structured interviews with rural veterans about their experiences with TelePain. After interview transcripts were recorded digitally and transcribed, Atlas.ti was used to organize data and facilitate qualitative coding. Interview transcripts were analyzed using thematic analysis.

RESULTS

Veterans reported general satisfaction with receiving pain care through telehealth and valued having supportive, knowledgeable providers who provided useful information and resources. In addition, veterans appreciated the convenience of telehealth. Barriers to care included problems with program follow-up, negative perceptions of mental health care for pain, and preference for in-person care. Although some patients suggested that telehealth audio and video could be improved, most patients did not have any significant problems with telehealth technology.

CONCLUSIONS

In this sample of rural veterans who used TelePain, many reported satisfaction with the program and positive experiences with providers. Targets for quality improvement include streamlining the program's referral and scheduling process and improving patient motivation to engage in psychological pain treatments. Results indicate that delivering pain services over telehealth is an acceptable modality for this patient population.

Bringing chronic-pain care to rural veterans: A telehealth pilot program description

Opioid-related harms disproportionately affect rural communities. Recent research-based policy changes have called for reductions in opioid prescribing and substitution of safe and effective alternatives to opioids for treating chronic pain, but such alternatives are often difficult to access in rural areas. Telehealth services can help address this disparity by bringing evidence-based, biopsychosocial chronic-pain services to rural and underserved patients with chronic pain. This article describes a 2-year pilot project for delivering chronic-pain care by pain specialists from central hubs at Veterans Health Administration (VA) medical centers to spokes at VA community-based outpatient clinics (CBOCs). The VA Puget Sound Pain Telehealth pilot program offered pain education classes, cognitive-behavioral therapy groups, opioid-safety education, and acupuncture education. The program delivered 501 encounters to patients from 1 hub to 4 CBOC spoke sites from 2016 to 2018, and supported training, administration, equipment acquisition, and grant-writing. The quality-improvement project was rolled out using existing local resources. We present initial findings about the patients who utilized Pain Telehealth, share lessons learned, and discuss future directions for expansion. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The associations between suicidality and mental health factors and pain interference in veterans being referred to primary care mental health integration

In veterans being referred to a primary care-mental health integration (PCMHI) program, the Behavioral Health Laboratory, we sought to identify correlates of suicidal ideation severity and suicide attempts using the ideation-to-action framework among pain interference, psychiatric disorders, and treatment factors. Veterans (n = 17,176) referred to the Behavioral Health Laboratory received a structured assessment that included past-year suicidal thoughts and behaviors, psychiatric symptoms, substance use, psychotropic medication use, and mental health treatment utilization. Nearly 50% of participants reported at least passive suicidal ideation. While psychiatric symptoms differentiated passive ideators, active ideators, and suicide attempters from non-suicide ideators, there were no significant differences among active ideators and attempters. Additionally, attempters differed from passive ideators in terms of drug use, mental health treatment, psychotropic medication use, mania, and psychosis. Pain interference was significantly associated with suicidal ideation severity in bivariate analyses, but not for the adjusted analyses. PCMHI is a setting seeing a high rate of suicidal ideation and may serve as a critical setting to implement suicide prevention efforts.

Gender Differences in the Prevalence of Fibromyalgia and in Concomitant Medical and Psychiatric Disorders: A National Veterans Health Administration Study

BACKGROUND

Fibromyalgia is a poorly understood, chronically disabling pain syndrome. While research has focused on its clinical presentation and treatment, less is known about fibromyalgia's clinical epidemiology in real-world healthcare systems. Gender differences have been difficult to study because relatively few males are diagnosed with fibromyalgia.

METHODS

Veterans Health Administration (VHA) patients diagnosed with fibromyalgia nationwide in FY 2012 were compared to Veterans with other pain diagnoses on sociodemographic characteristics, medical and psychiatric diagnoses, health service use, and opioid and psychotropic prescription fills. Additional analyses compared characteristics of men and women diagnosed with fibromyalgia. Risk ratios and Cohen's d were used for bivariate comparisons, followed by logistic regression analyses to identify independent factors associated with a diagnosis of fibromyalgia in the VHA.

RESULTS

Altogether, 77,087 of 2,216,621 Veterans with pain diagnoses (3.48%) were diagnosed with fibromyalgia. They were more likely to be female, younger than patients with other pain conditions, more likely to have multiple psychiatric comorbidities and other types of pain, and used more medical outpatient services. Women diagnosed with fibromyalgia were younger and more likely to have headaches, connective tissue diseases (CTD), and psychiatric comorbidities, while men had more comorbid medical conditions.

CONCLUSIONS

In this large, predominantly older male sample of Veterans with pain diagnoses, those with fibromyalgia were far more likely to be women. Gender comparisons showed women with fibromyalgia were more likely to be diagnosed with psychiatric disorders and CTD, while males were more likely to be diagnosed with medical conditions. Fibromyalgia shows a striking, gender-dependent picture of multimorbidity, which should be considered in treatment.