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Essien UR, Kim N, Hausmann LRM, Washington DL, Mor MK, Gellad WF, Fine MJ. Facility-Level Variation in Racial Disparities in Anticoagulation for Atrial Fibrillation: The REACH-AF Study. J Gen Intern Med 2024:10.1007/s11606-024-08643-8. [PMID: 38308154 DOI: 10.1007/s11606-024-08643-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 01/17/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Oral anticoagulation reduces stroke risk for patients with atrial fibrillation (AF). Prior research demonstrates lower anticoagulant prescribing in Black than in White individuals but few studies have examined racial differences in facility-level anticoagulant prescribing for AF. OBJECTIVE To assess variation in anticoagulant initiation by race within Veterans Health Administration (VA) facilities. DESIGN Retrospective cohort study. PARTICIPANTS Black and White patients enrolled in the VA with incident AF from 2020 through 2021. MAIN MEASURES The primary outcome was rate of any anticoagulant initiation (i.e., warfarin or direct oral anticoagulant [DOAC]) or any DOAC therapy within 90 days of an AF diagnosis, overall and for Black and White patients at each facility. We also estimated the adjusted Black-White risk difference. KEY RESULTS In 82 VA facilities serving 26,832 Black and White patients, overall unadjusted rates of any anticoagulant therapy ranged from 56.8 to 87.1% across facilities; the corresponding ranges for Black and White patients were 47.6 to 91.3% and 58.2 to 87.1%, respectively. Overall unadjusted rates of DOAC therapy ranged from 55.1 to 85.5% by facility; ranges for Black and White patients were 42.8 to 86.9% and 56.4 to 85.5%, respectively. The adjusted risk difference between Black and White patients ranged from - 29.9 (95% CI, - 54.9 to - 4.8) to 14.2 (95% CI, - 9.1 to 25.0) across facilities for any anticoagulant therapy and from - 28.8 (95% CI, - 58.3 to 0.8) to 15.0 (95% CI, - 8.0 to 38.1) for DOAC therapy. For any anticoagulant therapy there were 3 facilities where prescribing was statistically higher in White than Black patients; for DOAC therapy there were 5 such facilities. CONCLUSIONS In a national cohort of patients with AF, we observed large facility-level variation and adjusted risk differences in any anticoagulant and DOAC initiation, overall and by race. These findings represent a target for local quality improvement in AF care.
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Affiliation(s)
- Utibe R Essien
- HSRD Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA.
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA.
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Donna L Washington
- HSRD Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Frochen S, Wong MS, Neil Steers W, Yuan A, Saliba D, Washington DL. Differential associations of mask mandates on COVID-19 infection and mortality by community social vulnerability. Am J Infect Control 2024; 52:152-158. [PMID: 37343677 PMCID: PMC10278893 DOI: 10.1016/j.ajic.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND The COVID-19 pandemic in the United States has disproportionately impacted communities deemed vulnerable to disease outbreaks. Our objectives were to test (1) whether infection and mortality decreased in counties in the most vulnerable (highest) tercile of the Social Vulnerability Index (SVI), and (2) whether disparities between terciles of SVI were reduced, as the length of mask mandates increased. METHODS Using the New York Times COVID-19 and the Centers for Disease Control and Prevention SVI and mask mandate datasets, we conducted negative binomial regression analyses of county-level COVID-19 cases and deaths from 1/2020-11/2021 on interactions of SVI and mask mandate durations. RESULTS Mask mandates were associated with decreases in mid-SVI cases (IRR: 0.79) and deaths (IRR: 0.90) and high-SVI cases (IRR: 0.89) and deaths (IRR: 0.88). Mandates were associated with the mitigation of infection disparities (Change in IRR: 0.92) and mortality disparities (Change in IRR: 0.85) between low and mid-SVI counties and mortality disparities between low and high-SVI counties (Change in IRR: 0.84). DISCUSSION Mask mandates were associated with reductions in COVID-19 infection and mortality and mitigation of disparities for mid and high-vulnerability communities. CONCLUSIONS Ongoing COVID-19 response efforts may benefit from longer-standing infection control policies, particularly in the most vulnerable communities.
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Affiliation(s)
- Stephen Frochen
- VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), Sepulveda Ambulatory Care Center, North Hills, CA.
| | - Michelle S Wong
- VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), Sepulveda Ambulatory Care Center, North Hills, CA
| | - William Neil Steers
- VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), Sepulveda Ambulatory Care Center, North Hills, CA
| | - Anita Yuan
- VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), Sepulveda Ambulatory Care Center, North Hills, CA
| | - Debra Saliba
- VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), Sepulveda Ambulatory Care Center, North Hills, CA; VA Greater Los Angeles Healthcare system, Geriatric Research, Education and Clinical Center West Los Angeles Campus, Los Angeles, CA; Borun Center, University of California Los Angeles, UCLA Division of Geriatrics, Los Angeles, CA; RAND Health RAND Corporation, Santa Monica, CA
| | - Donna L Washington
- VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), Sepulveda Ambulatory Care Center, North Hills, CA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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Shannon EM, Steers WN, Washington DL. Investigation of the role of perceived access to primary care in mediating and moderating racial and ethnic disparities in chronic disease control in the veterans health administration. Health Serv Res 2024; 59:e14260. [PMID: 37974469 PMCID: PMC10771907 DOI: 10.1111/1475-6773.14260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVE To examine the role of patient-perceived access to primary care in mediating and moderating racial and ethnic disparities in hypertension control and diabetes control among Veterans Health Administration (VA) users. DATA SOURCE AND STUDY SETTING We performed a secondary analysis of national VA user administrative data for fiscal years 2016-2019. STUDY DESIGN Our primary exposure was race or ethnicity and primary outcomes were binary indicators of hypertension control (<140/90 mmHg) and diabetes control (HgbA1c < 9%) among patients with known disease. We used the inverse odds-weighting method to test for mediation and logistic regression with race and ethnicity-by-perceived access interaction product terms to test moderation. All models were adjusted for age, sex, socioeconomic status, rurality, education, self-rated physical and mental health, and comorbidities. DATA COLLECTION/EXTRACTION METHODS We included VA users with hypertension and diabetes control data from the External Peer Review Program who had contemporaneously completed the Survey of Healthcare Experience of Patients-Patient-Centered Medical Home. Hypertension (34,233 patients) and diabetes (23,039 patients) samples were analyzed separately. PRINCIPAL FINDINGS After adjustment, Black patients had significantly lower rates of hypertension control than White patients (75.5% vs. 78.8%, p < 0.01); both Black (81.8%) and Hispanic (80.4%) patients had significantly lower rates of diabetes control than White patients (85.9%, p < 0.01 for both differences). Perceived access was lower among Black, Multi-Race and Native Hawaiian and Other Pacific Islanders compared to White patients in both samples. There was no evidence that perceived access mediated or moderated associations between Black race, Hispanic ethnicity, and hypertension or diabetes control. CONCLUSIONS We observed disparities in hypertension and diabetes control among minoritized patients. There was no evidence that patients' perception of access to primary care mediated or moderated these disparities. Reducing racial and ethnic disparities within VA in hypertension and diabetes control may require interventions beyond those focused on improving patient access.
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Affiliation(s)
- Evan Michael Shannon
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Division of General Internal Medicine and Health Services ResearchUCLA David Geffen School of MedicineLos AngelesCaliforniaUSA
| | - W. Neil Steers
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Division of General Internal Medicine and Health Services ResearchUCLA David Geffen School of MedicineLos AngelesCaliforniaUSA
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Erickson AJ, Ravyts SG, Dzierzewski JM, Carlson GC, Kelly MR, Song Y, McGowan SK, Mitchell MN, Washington DL, Yano EM, Alessi CA, Martin JL. Pain in your day? Get sleep treatment anyway! The role of pain in insomnia treatment efficacy in women veterans. J Sleep Res 2024:e14147. [PMID: 38246598 DOI: 10.1111/jsr.14147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 12/26/2023] [Accepted: 12/29/2023] [Indexed: 01/23/2024]
Abstract
Insomnia and pain disorders are among the most common conditions affecting United States adults and veterans, and their comorbidity can cause detrimental effects to quality of life among other factors. Cognitive behavioural therapy for insomnia and related behavioural therapies are recommended treatments for insomnia, but chronic pain may hinder treatment benefit. Prior research has not addressed how pain impacts the effects of behavioural insomnia treatment in United States women veterans. Using data from a comparative effectiveness clinical trial of two insomnia behavioural treatments (both including sleep restriction, stimulus control, and sleep hygiene education), we examined the impact of pain severity and pain interference on sleep improvements from baseline to post-treatment and 3-month follow-up. We found no significant moderation effects of pain severity or interference in the relationship between treatment phase and sleep outcomes. Findings highlight opportunities for using behavioural sleep interventions in patients, particularly women veterans, with comorbid pain and insomnia, and highlight areas for future research.
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Affiliation(s)
- Alexander J Erickson
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Scott G Ravyts
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Gwendolyn C Carlson
- Department of Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles (UCLA) Geffen School of Medicine, Los Angeles, California, USA
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Monica R Kelly
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Yeonsu Song
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
- School of Nursing, University of California Los Angeles (UCLA), Los Angeles, California, USA
| | - Sarah Kate McGowan
- Department of Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles (UCLA) Geffen School of Medicine, Los Angeles, California, USA
| | - Michael N Mitchell
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Donna L Washington
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Elizabeth M Yano
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Cathy A Alessi
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Jennifer L Martin
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
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Haderlein TP, Hamilton AB, Masheb RM, Mullur R, Lam CA, Washington DL. Racial and Ethnic Variation in Healthcare Utilization Before and During the COVID-19 Pandemic: Differential Effects for Overall Versus Telehealth Care. J Gen Intern Med 2024:10.1007/s11606-023-08592-8. [PMID: 38228985 DOI: 10.1007/s11606-023-08592-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/28/2023] [Indexed: 01/18/2024]
Affiliation(s)
- Taona P Haderlein
- VHA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy (CSHIIP), Greater Los Angeles VA Healthcare System, 11301 Wilshire Blvd, Bldg 206 (151), Los Angeles, CA, 90073, USA.
- Veterans Emergency Management Evaluation Center, U.S Department of Veterans Affairs, North Hills, CA, USA.
| | - Alison B Hamilton
- VHA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy (CSHIIP), Greater Los Angeles VA Healthcare System, 11301 Wilshire Blvd, Bldg 206 (151), Los Angeles, CA, 90073, USA
- Department of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Robin M Masheb
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Rashmi Mullur
- Telehealth Service, VA Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA
- Division of Endocrinology, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | | | - Donna L Washington
- VHA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy (CSHIIP), Greater Los Angeles VA Healthcare System, 11301 Wilshire Blvd, Bldg 206 (151), Los Angeles, CA, 90073, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
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6
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Ravyts SG, Erickson AJ, Washington DL, Yano EM, Carlson GC, Mitchell MN, Kelly M, Alessi CA, McGowan SK, Song Y, Martin JL, Dzierzewski JM. A non-inferiority randomized controlled trial comparing behavioral sleep interventions in women veterans: An examination of pain outcomes. J Psychosom Res 2023; 175:111536. [PMID: 37913677 PMCID: PMC10872669 DOI: 10.1016/j.jpsychores.2023.111536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/13/2023] [Accepted: 10/20/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE Insomnia is known to exacerbate pain symptoms. The purpose of the present study was to compare the secondary effects of cognitive behavioral therapy for insomnia (CBTI) against a novel treatment for insomnia called acceptance and behavioral changes for insomnia (ABC-I) among individuals with comorbid pain. Differences in the potential mechanisms through which these treatments impact pain were also examined. METHODS Data consisted of a secondary analysis from a randomized comparative effectiveness trial of CBT-I and ABC-I among women veterans with insomnia and comorbid pain. Pain outcomes, beliefs about sleep, and psychological flexibility were assessed at baseline, post-treatment, and at three-months follow-up. RESULTS At baseline, 93 women veterans reported comorbid insomnia and pain (mean age = 46.7; 33.3% Black, 24.7% Hispanic/Latina). Both CBT-I (n = 48) and ABC-I (n = 45) were associated with decreased pain intensity (p < .001, Cohen's d = 0.41-0.67) and pain interference (p < .001, Cohen's d = 0.71-0.77) at post-treatment and three-months follow-up, with results indicating that ABC-I was non-inferior to CBT-I for pain improvement. Both conditions were associated with greater psychological flexibility post-treatment, and CBT-I resulted in larger reductions in dysfunctional beliefs about sleep (p = .01, Cohen's d = 0.59). CONCLUSION CBT-I and ABC-I both had positive secondary effects on pain with ABC-I being non-inferior to CBT-I with respect to its impact on pain. The mechanisms of change associated with these treatments may differ with CBT-I leading to greater reductions in dysfunctional beliefs. Hybrid treatments which incorporate an acceptance and commitment approach to both insomnia and pain warrant further examination.
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Affiliation(s)
- Scott G Ravyts
- Johns Hopkins University School of Medicine, Department of Physical Medicine and Rehabilitation.
| | - Alexander J Erickson
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System.
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, United States of America; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, (UCLA), United States of America.
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, United States of America; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, (UCLA), United States of America; Department of Health Policy and Management, UCLA Fielding School of Public Health, United States of America.
| | - Gwendolyn C Carlson
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, United States of America; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, United States of America; Department of Mental Health, VA Greater Los Angeles Healthcare System.
| | - Michael N Mitchell
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System.
| | - Monica Kelly
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, (UCLA), United States of America.
| | - Cathy A Alessi
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, (UCLA), United States of America.
| | - Sarah Kate McGowan
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, United States of America.
| | - Yeonsu Song
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, (UCLA), United States of America; School of Nursing, University of California Los Angeles.
| | - Jennifer L Martin
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, (UCLA), United States of America.
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Shannon EM, Haderlein TP, Neil Steers W, Wong MS, Washington DL. Comparison of Racial and Ethnic Disparities in COVID-19 Mortality Between Veterans Health Administration and US Populations. J Gen Intern Med 2023; 38:3657-3659. [PMID: 37740169 PMCID: PMC10713933 DOI: 10.1007/s11606-023-08430-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023]
Affiliation(s)
- Evan M Shannon
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, CA, USA.
| | - Taona P Haderlein
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA, USA
| | - W Neil Steers
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Michelle S Wong
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
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Pilla SJ, Meza KA, Beach MC, Long JA, Gordon HS, Bates JT, Washington DL, Bokhour BG, Tuepker A, Saha S, Maruthur NM. Assessment and prevention of hypoglycaemia in primary care among U.S. Veterans: a mixed methods study. Lancet Reg Health Am 2023; 28:100641. [PMID: 38076413 PMCID: PMC10701452 DOI: 10.1016/j.lana.2023.100641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 02/12/2024]
Abstract
Background Hypoglycaemia from diabetes treatment causes morbidity and lower quality of life, and prevention should be routinely addressed in clinical visits. Methods This mixed methods study evaluated how primary care providers (PCPs) assess for and prevent hypoglycaemia by analyzing audio-recorded visits from five Veterans Affairs medical centres in the US. Two investigators independently coded visit dialogue to classify discussions of hypoglycaemia history, anticipatory guidance, and adjustments to hypoglycaemia-causing medications according to diabetes guidelines. Findings There were 242 patients (one PCP visit per patient) and 49 PCPs. Two thirds of patients were treated with insulin and 40% with sulfonylureas. Hypoglycaemia history was discussed in 78/242 visits (32%). PCPs provided hypoglycaemia anticipatory guidance in 50 visits (21%) that focused on holding diabetes medications while fasting and carrying glucose tabs; avoiding driving and glucagon were not discussed. Hypoglycaemia-causing medications were de-intensified or adjusted more often (p < 0.001) when the patient reported a history of hypoglycaemia (15/51 visits, 29%) than when the patient reported no hypoglycaemia or it was not discussed (6/191 visits, 3%). Haemoglobin A1c (HbA1c) was not associated with diabetes medication adjustment, and only 5/12 patients (42%) who reported hypoglycaemia with HbA1c <7.0% had medications de-intensified or adjusted. Interpretation PCPs discussed hypoglycaemia in one-third of visits for at-risk patients and provided limited hypoglycaemia anticipatory guidance. De-intensifying or adjusting hypoglycaemia-causing medications did not occur routinely after reported hypoglycaemia with HbA1c <7.0%. Routine hypoglycaemia assessment and provision of diabetes self-management education are needed to achieve guideline-concordant hypoglycaemia prevention. Funding U.S. Department of Veterans Affairs and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
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Affiliation(s)
- Scott J. Pilla
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - Kayla A. Meza
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Mary Catherine Beach
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health, Behavior & Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Judith A. Long
- Corporal Michael J. Cresenz VA Medical Center, Philadelphia, PA, USA
- Division of General Internal Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Howard S. Gordon
- Jesse Brown VA Medical Center, Chicago, IL, USA
- Division of Academic Internal Medicine and Geriatrics, Department of Medicine, University of Illinois Chicago College of Medicine, Chicago, IL, USA
| | - Jeffrey T. Bates
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Donna L. Washington
- VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Barbara G. Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Health Care System, Bedford, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Anais Tuepker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Somnath Saha
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Nisa M. Maruthur
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Carey C, Silvestrini M, Callegari LS, Katon JG, Bossick AS, Doll KM, Christy A, Washington DL, Owens S. "I Wasn't Presented With Options": Perspectives of Black Veterans Receiving Care for Uterine Fibroids in the Veterans Health Administration. Womens Health Issues 2023; 33:652-660. [PMID: 37689493 DOI: 10.1016/j.whi.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 09/11/2023]
Abstract
INTRODUCTION Black women with uterine fibroids experience greater symptom severity and worse treatment outcomes compared with their White counterparts. Black veterans who use Veterans Health Administration (VA) health care experience similar disparities. This study investigated the experiences of Black veterans receiving care for uterine fibroids at VA. METHODS We identified Black veterans aged 18 to 54 years with newly diagnosed symptomatic uterine fibroids between the fiscal years 2010 and 2012 using VA medical record data, and we recruited participants for interviews in 2021. We used purposive sampling by the last recorded fibroid treatment in the data (categorized as hysterectomy, other uterine-sparing treatments, and medication only/no treatment) to ensure diversity of treatment experiences. In-depth semistructured interviews were conducted to gather rich narratives of veterans' uterine fibroid care experiences. Transcribed interviews were analyzed using content analysis. RESULTS Twenty Black veterans completed interviews. Key themes that emerged included the amplified impact of severe fibroid symptoms in male-dominated military culture; the presence of multilevel barriers, from individual to health care system factors, that delayed access to high-quality treatment; insufficient treatments offered; experiences of interpersonal racism and provider bias; and the impact of fertility loss related to fibroids on mental health and intimate relationships. Veterans with positive experiences stressed the importance of finding a trustworthy provider and self-advocacy. CONCLUSIONS System-level interventions, such as race-conscious and person-centered care training, are needed to improve care experiences and outcomes of Black veterans with fibroids.
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Affiliation(s)
- Cathea Carey
- Health Services Research and Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, U.S. Department of Veterans Affairs, VA Puget Sound Healthcare System, Seattle, Washington
| | - Molly Silvestrini
- Health Services Research and Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, U.S. Department of Veterans Affairs, VA Puget Sound Healthcare System, Seattle, Washington
| | - Lisa S Callegari
- Health Services Research and Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, U.S. Department of Veterans Affairs, VA Puget Sound Healthcare System, Seattle, Washington; Department of Health Systems and Population Health, University of Washington, Seattle, Washington; Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington.
| | - Jodie G Katon
- Health Services Research and Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, U.S. Department of Veterans Affairs, VA Puget Sound Healthcare System, Seattle, Washington
| | - Andrew S Bossick
- Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan; Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, East Lansing, Michigan
| | - Kemi M Doll
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington; Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
| | - Alicia Christy
- Women's Health Services, Veterans Administration, U.S. Department of Veterans Affairs, Washington, District of Columbia
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Shanise Owens
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington
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10
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Martin JL, Carlson GC, Kelly MR, Song Y, Mitchell MN, Josephson KR, McGowan SK, Culver NC, Kay M, Erickson A, Saldana KS, May K, Fiorentino L, Alessi CA, Washington DL, Yano EM. Novel treatment based on acceptance and commitment therapy versus cognitive behavioral therapy for insomnia: A randomized comparative effectiveness trial in women veterans. J Consult Clin Psychol 2023; 91:626-639. [PMID: 37535521 PMCID: PMC10592426 DOI: 10.1037/ccp0000836] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
OBJECTIVE This randomized comparative effectiveness trial evaluated a novel insomnia treatment using acceptance and commitment therapy (ACT) among women veterans. Participants received either the acceptance and the behavioral changes to treat insomnia (ABC-I) or cognitive behavioral therapy for insomnia (CBT-I). The primary objectives were to determine whether ABC-I was noninferior to CBT-I in improving sleep and to test whether ABC-I resulted in higher treatment completion and adherence versus CBT-I. METHOD One hundred forty-nine women veterans with insomnia disorder (Mage = 48.0 years) received ABC-I or CBT-I. The main sleep outcomes were Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), and sleep efficiency (SE) by actigraphy (objective) and sleep diary (subjective). Measures were collected at baseline, immediate posttreatment, and 3-month posttreatment follow-up. Treatment completion and adherence were assessed during the interventions. RESULTS Both interventions improved all sleep outcomes from baseline to immediate posttreatment and 3-month posttreatment follow-up. At immediate posttreatment, ABC-I was statically noninferior for sleep diary SE and objective SE, but noninferiority was not statistically confirmed for ISI or PSQI total scores. At 3-month posttreatment follow-up, ABC-I was noninferior for all four of the key outcome variables. There was not a statistically significant difference between the number of participants who discontinued CBT-I (11%) versus ABC-I (18%; p = .248) before completing treatment. ABC-I was superior to CBT-I for some adherence metrics. CONCLUSIONS Overall, ABC-I was similar in effectiveness compared to CBT-I for the treatment of insomnia and may improve adherence to some behavioral elements of treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Jennifer L. Martin
- Geriatric Research, Education and Clinical Center, Veteran Affairs (VA) Greater Los Angeles Healthcare System
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Gwendolyn C. Carlson
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System
| | - Monica R. Kelly
- Geriatric Research, Education and Clinical Center, Veteran Affairs (VA) Greater Los Angeles Healthcare System
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Yeonsu Song
- Geriatric Research, Education and Clinical Center, Veteran Affairs (VA) Greater Los Angeles Healthcare System
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles
- School of Nursing at University of California, Los Angeles
| | - Michael N. Mitchell
- Geriatric Research, Education and Clinical Center, Veteran Affairs (VA) Greater Los Angeles Healthcare System
| | - Karen R. Josephson
- Geriatric Research, Education and Clinical Center, Veteran Affairs (VA) Greater Los Angeles Healthcare System
| | - Sarah Kate McGowan
- Department of Mental Health, VA Greater Los Angeles Healthcare System
- Department of Psychiatry, David Geffen School of Medicine at University of California, Los Angeles
| | - Najwa C. Culver
- Department of Mental Health, VA Greater Los Angeles Healthcare System
| | - Morgan Kay
- Department of Mental Health, VA Greater Los Angeles Healthcare System
| | - Alexander Erickson
- Geriatric Research, Education and Clinical Center, Veteran Affairs (VA) Greater Los Angeles Healthcare System
| | - Katie S. Saldana
- Department of Mental Health, VA Greater Los Angeles Healthcare System
| | - Kimiko May
- Department of Mental Health, VA Greater Los Angeles Healthcare System
| | | | - Cathy A. Alessi
- Geriatric Research, Education and Clinical Center, Veteran Affairs (VA) Greater Los Angeles Healthcare System
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Donna L. Washington
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System
| | - Elizabeth M. Yano
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System
- Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles
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11
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Kosaraju RS, Fonarow GC, Ong MK, Heidenreich PA, Washington DL, Wang X, Ziaeian B. Geographic Variation in the Quality of Heart Failure Care Among U.S. Veterans. JACC Heart Fail 2023; 11:1534-1545. [PMID: 37542510 PMCID: PMC10792103 DOI: 10.1016/j.jchf.2023.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 05/09/2023] [Accepted: 06/05/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND The burden of heart failure is growing. Guideline-directed medical therapies (GDMT) reduce adverse outcomes in heart failure with reduced ejection fraction (HFrEF). Whether there is geographic variation in HFrEF quality of care is not well described. OBJECTIVES This study evaluated variation nationally for prescription of GDMT within the Veterans Health Administration. METHODS A cohort of Veterans with HFrEF had their address linked to hospital referral regions (HRRs). GDMT prescription was defined using pharmacy data between July 1, 2020, and July 1, 2021. Within HRRs, we calculated the percentage of Veterans prescribed GDMT and a composite GDMT z-score. National choropleth maps were created to evaluate prescription variation. Associations between GDMT performance and demographic characteristics were evaluated using linear regression. RESULTS Maps demonstrated significant variation in the HRR composite score and GDMT prescriptions. Within HRRs, the prescription of beta-blockers to Veterans was highest with a median of 80% (IQR: 77.3%-82.2%) followed by angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitors (69.3%; IQR: 66.4%-72.1%), sodium-glucose cotransporter-2 inhibitors (10.3%; IQR: 7.7%-12.8%), mineralocorticoid receptor antagonists (29.2%; IQR: 25.8%-33.9%), and angiotensin receptor-neprilysin inhibitors (12.2%; IQR: 8.6%-15.3%). HRR composite GDMT z-scores were inversely associated with the HRR median Gini coefficient (R = -0.13; P = 0.0218) and the percentage of low-income residents (R = -0.117; P = 0.0413). CONCLUSIONS Wide geographic differences exist for HFrEF care. Targeted strategies may be required to increase GDMT prescription for Veterans in lower-performing regions, including those affected by income inequality and poverty.
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Affiliation(s)
- Revanth S Kosaraju
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. https://twitter.com/revanthsk12
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. https://twitter.com/gcfmd
| | - Michael K Ong
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; Veterans Affairs Health Services Research and Development, Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA; Department of Health Policy and Management, UCLA Jonathan and Karin Fielding School of Public Health, Los Angeles, California, USA. https://twitter.com/michael_ong
| | - Paul A Heidenreich
- Department of Medicine, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA. https://twitter.com/paheidenreich
| | - Donna L Washington
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; Veterans Affairs Health Services Research and Development, Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Xiaoyan Wang
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Boback Ziaeian
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; Veterans Affairs Health Services Research and Development, Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA.
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12
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Breland JY, Tseng CH, Toyama J, Washington DL. Influence of depression on racial and ethnic disparities in diabetes control. BMJ Open Diabetes Res Care 2023; 11:e003612. [PMID: 37989347 PMCID: PMC10660156 DOI: 10.1136/bmjdrc-2023-003612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/30/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION We tested the hypotheses that depression diagnoses influence racial and ethnic disparities in diabetes control and that mental health treatment moderates that relationship. RESEARCH DESIGN AND METHODS We created a national cohort of Veterans Health Administration (VHA) patients with diabetes using administrative data (n=815 067). Cross-sectional linear mixed effects regression models tested the hypothesized indirect effect of depression on poor diabetes control (glycosylated hemoglobin >9%) and tested whether mental health treatment (visits or antidepressant prescriptions) moderated the effect of depression (α=0.05). Results represent the percentage point difference in probability of poor diabetes control. Covariates included primary care visits, sex, age, and VHA facility. RESULTS Overall, 20% of the cohort had poor diabetes control and 22% had depression. Depression was more common among racial and ethnic minoritized groups. The probability of poor diabetes control was higher for most minoritized groups compared with White patients (largest difference: American Indian or Alaska Native patients, 5.2% (95% CI 4.3%, 6.0%)). The absolute value of the proportion of racial and ethnic disparities accounted for by depression ranged from 0.2% (for Hispanic patients) to 2.0% (for Asian patients), with similar effects when accounting for the moderating effect of mental health treatment. Patients with depression and 5+ mental health visits had a lower probability of poor diabetes control compared with those with fewer visits, regardless of antidepressant prescription status. CONCLUSIONS The influence of depression on disparities in diabetes control was small. High rates of depression among people with diabetes, especially among those from racial and ethnic minoritized groups, highlight a need to ensure equitable and coordinated care for both conditions, as the effects of mental health treatment may extend to the control of physical health conditions.
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Affiliation(s)
- Jessica Y Breland
- VA HSR&D Center for Innovation to Implementation, Menlo Park Division (152), VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Chi-Hong Tseng
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine, Los Angeles, California, USA
| | - Joy Toyama
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine, Los Angeles, California, USA
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13
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Moghtaderi I, Kelly MR, Carlson GC, Fung CH, Josephson KR, Song Y, Swistun D, Zhu R, Mitchell M, Lee D, Badr MS, Washington DL, Yano EM, Alessi CA, Zeidler MR, Martin JL. Identifying gaps in clinical evaluation and treatment of sleep-disordered breathing in women veterans. Sleep Breath 2023; 27:1929-1933. [PMID: 36525174 PMCID: PMC10272283 DOI: 10.1007/s11325-022-02765-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/18/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Sleep-disordered breathing (SDB) is a common sleep disorder in veterans; however, limited research exists in women veterans. We sought to estimate patterns of care in terms of evaluation, diagnosis, and treatment among women veterans with factors associated with elevated SDB risk. METHODS Within one VA healthcare system, women identified through electronic health record data as having one or more factors (e.g., age >50 years, hypertension) associated with SDB, completed telephone screening in preparation for an SDB treatment study and answered questions about prior care related to SDB diagnosis and treatment. RESULTS Of 319 women, 111 (35%) reported having completed a diagnostic sleep study in the past, of whom 48 (43%) were diagnosed with SDB. Women who completed a diagnostic study were more likely to have hypertension or obesity. Those who were diagnosed with SDB based on the sleep study were more likely to have hypertension, diabetes, or be ≥50 years old. Of the 40 women who received treatment, 37 (93%) received positive airway pressure therapy. Only 9 (24%) had used positive airway pressure therapy in the prior week. Few women received other treatments such as oral appliances or surgery. CONCLUSIONS Findings support the need for increased attention to identification and management of SDB in women veterans, especially those with conditions associated with elevated SDB risk.
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Affiliation(s)
- Isabel Moghtaderi
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Monica R Kelly
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Gwendolyn C Carlson
- Department of Mental Health, VA Greater Los Angles Healthcare System, Los Angeles, CA, USA
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Constance H Fung
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Karen R Josephson
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Yeonsu Song
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- School of Nursing, University of California, Los Angeles, Los Angeles, CA, USA
| | - Dominika Swistun
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Ruoyan Zhu
- University of Arizona, Phoenix School of Medicine, Phoenix, AZ, USA
| | - Michael Mitchell
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Diane Lee
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - M Safwan Badr
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
- John D. Dingell Veterans Affairs Medical Center, Detroit, MI, USA
| | - Donna L Washington
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Elizabeth M Yano
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
| | - Cathy A Alessi
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Michelle R Zeidler
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Jennifer L Martin
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
- VA Sepulveda Ambulatory Care Center, 16111 Plummer Street (11E), North Hills, CA, 91343, USA.
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14
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Wong MS, Frochen S, Steers WN, Washington DL. Hospital Catchment Areas Characteristics and Geographic Regions Associated With Higher COVID-19 Veterans Health Administration Hospitalization During the Omicron Surge. J Public Health Manag Pract 2023; 29:E198-E207. [PMID: 37104066 PMCID: PMC10363212 DOI: 10.1097/phh.0000000000001745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
CONTEXT Surges in the ongoing coronavirus-19 (COVID-19) pandemic and accompanying increases in hospitalizations continue to strain hospital systems. Identifying hospital-level characteristics associated with COVID-19 hospitalization rates and clusters of hospitalization "hot spots" can help with hospital system planning and resource allocation. OBJECTIVE To identify (1) hospital catchment area-level characteristics associated with higher COVID-19 hospitalization rates and (2) geographic regions with high and low COVID-19 hospitalization rates across catchment areas during COVID-19 Omicron surge (December 20, 2021-April 3, 2022). DESIGN This observational study used Veterans Health Administration (VHA), US Health Resource & Services Administration's Area Health Resources File, and US Census data. We used multivariate regression to identified hospital catchment area-level characteristics associated with COVID-19 hospitalization rates. We used ESRI ArcMap's Getis-Ord Gi* statistic to identify catchment area clusters of hospitalization hot and cold spots. SETTING AND PARTICIPANTS VHA hospital catchment areas in the United States (n = 143). MAIN OUTCOME MEASURES Hospitalization rate. RESULTS Greater COVID-19 hospitalization was associated with serving more high hospitalization risk patients (34.2 hospitalizations/10 000 patients per 10-percentage point increase in high hospitalization risk patients; 95% confidence intervals [CI]: 29.4, 39.0), fewer patients new to VHA during the pandemic (-3.9, 95% CI: -6.2, -1.6), and fewer COVID vaccine-boosted patients (-5.2; 95% CI: -7.9, -2.5).We identified 2 hospitalization cold spots located in the Pacific Northwest and in the Great Lakes regions, and 2 hot spots in the Great Plains and Southeastern US regions. CONCLUSIONS Within VHA's nationally integrated health care system, catchment areas serving a larger high hospitalization risk patient population were associated with more Omicron-related hospitalizations, while serving more patients fully vaccinated and boosted for COVID-19 and new VHA users were associated with lower hospitalization. Hospital and health care system efforts to vaccinate patients, particularly high-risk patients, can potentially safeguard against pandemic surges.Hospitalization hot spots within VHA include states with a high burden of chronic disease in the Great Plains and Southeastern United States.
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Affiliation(s)
- Michelle S Wong
- VA HSR&D Center for the Study of Healthcare
Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare
System, Los Angeles, CA
| | - Stephen Frochen
- VA HSR&D Center for the Study of Healthcare
Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare
System, Los Angeles, CA
| | - W. Neil Steers
- VA HSR&D Center for the Study of Healthcare
Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare
System, Los Angeles, CA
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare
Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare
System, Los Angeles, CA
- Division of General Internal Medicine and Health Services
Research, Department of Medicine, University of California Los Angeles Geffen School
of Medicine, Los Angeles, CA
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15
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Hoggatt KJ, Chawla N, Washington DL, Yano EM. Trends in substance use disorder diagnoses among Veterans, 2009-2019. Am J Addict 2023; 32:393-401. [PMID: 36883297 DOI: 10.1111/ajad.13413] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/11/2023] [Accepted: 02/13/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Substance use disorder (SUD) represents a substantial health burden to US Veterans. We aimed to quantify recent time trends in Veterans' substance-specific disorders using Veterans Health Administration (VA) data. METHODS We identified Veteran VA patients for fiscal years (FY) 2010-2019 (October 1, 2009-September 9, 2019) and extracted patient demographics and diagnoses from electronic health records (~6 million annually). We defined alcohol, cannabis, cocaine, opioid, sedative, and stimulant use disorders with ICD-9 (FY10-FY15) or ICD-10 (FY16-FY19) codes and variables for polysubstance use disorder, drug use disorder (DUD), and SUD. RESULTS Diagnoses for substance-specific disorders (excluding cocaine), polysubstance use disorder, DUD, and SUD increased 2%-13% annually for FY10-FY15. Alcohol, cannabis, and stimulant use disorders increased 4%-18% annually for FY16-FY19, while cocaine, opioid, and sedative use disorders changed by ≤1%. Stimulant and cannabis use disorder diagnoses increased most rapidly, and older Veterans had the largest increases across substances. DISCUSSION AND CONCLUSIONS Rapid increases in cannabis and stimulant use disorder present a treatment challenge and key subgroups (e.g., older adults) may require tailored screening and treatment options. Diagnoses for SUD are increasing among Veterans overall, but there is important heterogeneity by substance and subgroup. Efforts to ensure access to evidence-based treatment for SUD may require greater focus on cannabis and stimulants, particularly for older adults. SCIENTIFIC SIGNIFICANCE These findings represent the first assessment of time trends in substance-specific disorders among Veterans, overall and by age and sex. Notable findings include large increases in diagnoses for cannabis and stimulant use disorder and among older adults.
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Affiliation(s)
- Katherine J Hoggatt
- San Francisco VA Health Care System, Research Division, San Francisco, California, USA
- Department of Medicine, University of California, San Francisco, California, USA
| | - Neetu Chawla
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Research Division, Los Angeles, California, USA
| | - Donna L Washington
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Research Division, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California, USA
| | - Elizabeth M Yano
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Research Division, Los Angeles, California, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
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16
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Katon JG, Bossick A, Carey C, Christy A, Doll K, Gatsby E, Gray KE, Lynch KE, Moy E, Owens S, Washington DL, Callegari LS. Racial Disparities in Uterine Fibroid Treatment Among Veterans Using VA Health Care. Womens Health Issues 2023; 33:405-413. [PMID: 37105835 DOI: 10.1016/j.whi.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 03/10/2023] [Accepted: 03/24/2023] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Uterine fibroids are common, nonmalignant tumors that disproportionately impact Black patients. We aimed to examine Black and White differences in receipt of any treatment and type of first treatment in the Department of Veterans Affairs, including effect modification by severity as approximated by anemia. METHODS We used Department of Veterans Affairs administrative data to identify 5,041 Black and 3,206 White veterans with symptomatic uterine fibroids, identified by International Classification of Diseases, 9th edition, Clinical Modification, codes, between fiscal year 2010 and fiscal year 2012 and followed in the administrative data through fiscal year 2018 for outcomes. Outcomes included receipt of any treatment, hysterectomy as first treatment, and fertility-sparing treatment as first treatment. We stratified all analyses by age (<45, ≥45 years old), used generalized linear models with a log link and Poisson error distribution, included an interaction term between race and anemia, and used recycled predictions to estimate adjusted percentages for outcomes. RESULTS There was evidence of effect modification by anemia for receipt of any treatment but not for any other outcomes. Across age and anemia sub-groups, Black veterans were less likely to receive any treatment than White veterans. Adjusted racial differences were most pronounced among veterans with anemia (<45 years, Black-White difference = -10.3 percentage points; 95% confidence interval, -15.9 to -4.7; ≥45 years, Black-White difference = -20.3 percentage points; 95% confidence interval, -27.8 to -12.7). Across age groups, Black veterans were less likely than White veterans to have hysterectomy and more likely to have a fertility-sparing treatment as their first treatment. CONCLUSIONS We identified significant Black-White disparities in receipt of treatment for symptomatic uterine fibroids. Additional research that centers the experiences of Black veterans with uterine fibroids is needed to inform strategies to eliminate racial disparities in uterine fibroid care.
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Affiliation(s)
- Jodie G Katon
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development (HSR&D), Seattle, Washington; Department of Health Systems and Population Health, University of Washington, Seattle, Washington.
| | - Andrew Bossick
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development (HSR&D), Seattle, Washington; Henry Ford Healthcare System, Detroit, Michigan
| | - Cathea Carey
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development (HSR&D), Seattle, Washington
| | - Alicia Christy
- Office of Women's Health, U.S. Department of Veterans Affairs, Washington, District of Columbia
| | - Kemi Doll
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
| | - Elise Gatsby
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Kristen E Gray
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development (HSR&D), Seattle, Washington; Department of Health Systems and Population Health, University of Washington, Seattle, Washington
| | - Kristine E Lynch
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah; Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ernest Moy
- U.S. Department of Veterans Affairs, Office of Health Equity, Washington, District of Columbia
| | - Shanise Owens
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington
| | - Donna L Washington
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - Lisa S Callegari
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development (HSR&D), Seattle, Washington; Department of Health Systems and Population Health, University of Washington, Seattle, Washington; Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
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17
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Bowersox NW, Browne J, Grau PP, Merrill SL, Haderlein TP, Llorente MD, Washington DL. COVID-19 mortality among veterans with serious mental illness in the veterans health administration. J Psychiatr Res 2023; 163:222-229. [PMID: 37230006 PMCID: PMC10171776 DOI: 10.1016/j.jpsychires.2023.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/31/2023] [Accepted: 05/01/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Persons with serious mental illness (SMI: schizophrenia-spectrum disorders, bipolar disorder) experience increased risk of mortality after contracting COVID-19 based on the results of several international evaluations. However, information about COVID-19 mortality risk among patients with SMI in the Veterans Health Administration (VHA) has been limited, precluding identification of protective factors. The current evaluation was conducted to assess COVID-19 mortality risk among VHA patients with SMI and to evaluate potential protective factors in mitigating mortality risk following a positive COVID-19 diagnosis. METHODS National VHA administrative data was used to identify all patients (N = 52,916) who received a positive COVID-19 test result between March 1, 2020, and September 30, 2020. Mortality risk was assessed by SMI status via bivariate comparisons and multivariate regression analyses. RESULTS In unadjusted analyses, VHA patients with SMI overall and patients with bipolar disorder in particular did not experience increased mortality risk in the 30 days following a positive COVID test, although patients with schizophrenia had increased risk. Within adjusted analyses, patients with schizophrenia remained at increased mortality risk (OR = 1.38), but at reduced levels relative to previous evaluations in other healthcare settings. CONCLUSIONS Within VHA, patients with schizophrenia, but not those with bipolar disorder, experience increased mortality risk in the 30 days following a positive COVID-19 test. Large integrated healthcare settings such as VHA may offer services which may protect against COVID-19 mortality for vulnerable groups such as persons with SMI. Additional work is needed to identify practices which may reduce the risk of COVID-19 mortality among persons with SMI.
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Affiliation(s)
- Nicholas W Bowersox
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington DC, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Julia Browne
- Research Service, VA Providence Healthcare System, Providence, RI, USA; Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Peter P Grau
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington DC, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stephanie L Merrill
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington DC, USA
| | - Taona P Haderlein
- Veterans Health Administration Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, USA; Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, North Hills, CA, USA
| | - Maria D Llorente
- Patient Care Services, Department of Veterans Affairs, Washington DC, USA; Department of Psychiatry, Georgetown University School of Medicine, Washington DC, USA
| | - Donna L Washington
- Veterans Health Administration Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, USA; Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles Geffen School of Medicine, Los Angeles, CA, USA
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18
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Almklov E, Cohen AJ, Russell LE, Mor MK, Fine MJ, Hausmann LRM, Moy E, Washington DL, Jones KT, Long JA, Pittman J. Assessing an electronic self-report method for improving quality of ethnicity and race data in the Veterans Health Administration. JAMIA Open 2023; 6:ooad020. [PMID: 37063405 PMCID: PMC10097454 DOI: 10.1093/jamiaopen/ooad020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/18/2023] [Accepted: 03/29/2023] [Indexed: 04/18/2023] Open
Abstract
Objective Evaluate self-reported electronic screening (eScreening) in a VA Transition Care Management Program (TCM) to improve the accuracy and completeness of administrative ethnicity and race data. Materials and Methods We compared missing, declined, and complete (neither missing nor declined) rates between (1) TCM-eScreening (ethnicity and race entered into electronic tablet directly by patient using eScreening), (2) TCM-EHR (Veteran-completed paper form plus interview, data entered by staff), and (3) Standard-EHR (multiple processes, data entered by staff). The TCM-eScreening (n = 7113) and TCM-EHR groups (n = 7113) included post-9/11 Veterans. Standard-EHR Veterans included all non-TCM Gulf War and post-9/11 Veterans at VA San Diego (n = 92 921). Results Ethnicity: TCM-eScreening had lower rates of missingness than TCM-EHR and Standard-EHR (3.0% vs 5.3% and 8.6%, respectively, P < .05), but higher rates of "decline to answer" (7% vs 0.5% and 1.2%, P < .05). TCM-EHR had higher data completeness than TCM-eScreening and Standard-EHR (94.2% vs 90% and 90.2%, respectively, P < .05). Race: No differences between TCM-eScreening and TCM-EHR for missingness (3.5% vs 3.4%, P > .05) or data completeness (89.9% vs 91%, P > .05). Both had better data completeness than Standard-EHR (P < .05), which despite the lowest rate of "decline to answer" (3%) had the highest missingness (10.3%) and lowest overall completeness (86.6%). There was strong agreement between TCM-eScreening and TCM-EHR for ethnicity (Kappa = .92) and for Asian, Black, and White Veteran race (Kappas = .87 to .97), but lower agreement for American Indian/Alaska Native (Kappa = .59) and Native Hawaiian/Other Pacific Islander (Kappa = .50) Veterans. Conculsions eScreening is a promising method for improving ethnicity and race data accuracy and completeness in VA.
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Affiliation(s)
- Erin Almklov
- Corresponding Author: Erin Almklov, PhD, VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA 92161, USA;
| | - Alicia J Cohen
- VA Center of Innovation in Long Term Services and Supports (LTSS-COIN), VA Providence Healthcare System, Providence, Rhode Island, USA
- Department of Family Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Lauren E Russell
- VHA Office of Health Equity, Washington, District of Columbia, USA
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Biostatistics, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Michael J Fine
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Leslie R M Hausmann
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ernest Moy
- VHA Office of Health Equity, Washington, District of Columbia, USA
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles Geffen School of Medicine, Los Angeles, California, USA
| | - Kenneth T Jones
- VHA Office of Health Equity, Washington, District of Columbia, USA
| | - Judith A Long
- Corporal Michael J. Crescenz VA Medical Center, VA Center for Health Equity Research and Promotion (CHERP), Philadelphia, Pennsylvania, USA
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James Pittman
- VA Center of Excellence for Stress and Mental Health, San Diego, California, USA
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, San Diego, California, USA
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19
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Katon JG, Bossick AS, Tartaglione EV, Enquobahrie DA, Haeger KO, Johnson AM, Ma EW, Savitz D, Shaw JG, Todd-Stenberg J, Yano EM, Washington DL, Christy AY. Assessing Racial Disparities in Access, Use, and Outcomes for Pregnant and Postpartum Veterans and Their Infants in Veterans Health Administration. J Womens Health (Larchmt) 2023; 32:757-766. [PMID: 37186805 DOI: 10.1089/jwh.2022.0507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
Objective: Limited population-based data examines racial disparities among pregnant and postpartum Veterans. Our objective was to determine whether Black/white racial disparities in health care access, use, and Veteran and infant outcomes are present among pregnant and postpartum Veterans and their infants using Veterans Health Administration (VA) care. Methods: The VA National Veteran Pregnancy and Maternity Care Survey included all Veterans with a VA paid live birth between June 2018 and December 2019. Participants could complete the survey online or by telephone. The independent variable was self-reported race. Outcomes included timely initiation of prenatal care, perceived access to timely prenatal care, attendance at a postpartum check-up, receipt of needed mental health care, cesarean section, postpartum rehospitalization, low birthweight, preterm birth, admission to a neonatal intensive care unit, and breastfeeding. Nonresponse weighted general linear models with a log-link were used to examine associations of race with outcomes. Cox regression was used to examine the association of race with duration of breastfeeding. Models adjusted for age, ethnicity, urban versus rural residence, and parity. Results: The analytic sample consisted of 1,220 Veterans (Black n = 916; white n = 304) representing 3,439 weighted responses (Black n = 1,027; white n = 2,412). No racial disparities were detected for health care access or use. Black Veterans were more likely than white Veterans to have a postpartum rehospitalization (RR 1.67, 95% CI: 1.04-2.68) and a low-birthweight infant (RR 1.67, 95% CI: 1.20-2.33). Conclusion: While no racial disparities were detected for health care access and use, we identified disparities in postpartum rehospitalization and low birthweight, underscoring that access is not sufficient for ensuring health equity.
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Affiliation(s)
- Jodie G Katon
- Health Services Research and Development (HSR&D), Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Andrew S Bossick
- Department of Public Health Sciences, Henry Ford Healthcare System, Detroit, Michigan, USA
| | - Erica V Tartaglione
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, HSR&D, Seattle, Washington, USA
| | | | - Kristin O Haeger
- Office of Women's Health, U.S. Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Amanda M Johnson
- Office of Women's Health, U.S. Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Erica W Ma
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, HSR&D, Seattle, Washington, USA
| | - David Savitz
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jonathan G Shaw
- VA Palo Alto Healthcare System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Jeffery Todd-Stenberg
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, HSR&D, Seattle, Washington, USA
| | - Elizabeth M Yano
- Health Services Research and Development (HSR&D), Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
- Jonathan and Karen Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, USA
| | - Donna L Washington
- Health Services Research and Development (HSR&D), Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Alicia Y Christy
- Office of Women's Health, U.S. Department of Veterans Affairs, Washington, District of Columbia, USA
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Vinekar K, Chu K, Tan GJ, Jackson NJ, Washington DL, Cordasco KM. Using Primary Care Geographic Network Adequacy Metrics for VA Obstetric Referrals: a Foundation for Equitable, Timely, and Veteran-Centered Care. J Gen Intern Med 2023:10.1007/s11606-023-08191-7. [PMID: 37340261 DOI: 10.1007/s11606-023-08191-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 03/24/2023] [Indexed: 06/22/2023]
Affiliation(s)
- Kavita Vinekar
- VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, CA, USA.
- Division of Gynecology, Department of Surgery & Perioperative Services, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Department of Obstetrics & Gynecology, University of California Los Angeles (UCLA) David Geffen School of Medicine, Los Angeles, CA, USA.
| | - Karen Chu
- VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, CA, USA
| | - Gracielle J Tan
- VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, CA, USA
| | - Nicholas J Jackson
- VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles (UCLA) David Geffen School of Medicine, Los Angeles, CA, USA
| | - Donna L Washington
- VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, CA, USA
| | - Kristina M Cordasco
- VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, CA, USA
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21
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Faiz J, Essien UR, Washington DL, Ly DP. Racial and Ethnic Differences in Barriers Faced by Medical College Admission Test Examinees and Their Association With Medical School Application and Matriculation. JAMA Health Forum 2023; 4:e230498. [PMID: 37058292 PMCID: PMC10105307 DOI: 10.1001/jamahealthforum.2023.0498] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
Importance There has been disappointing progress in enrollment of medical students from racial and ethnic groups underrepresented in medicine, including American Indian or Alaska Native, Black, and Hispanic students. Barriers that may influence students interested in medicine are understudied. Objective To examine racial and ethnic differences in barriers faced by students taking the Medical College Admission Test (MCAT). Design, Setting, and Participants This cross-sectional study used survey data (surveys administered between January 1, 2015, to December 31, 2018) from MCAT examinees linked with application and matriculation data from the Association of American Medical Colleges. Data analyses were performed from November 1, 2021, to January 31, 2023. Main Variables and Outcomes Main outcomes were medical school application and matriculation. Key independent variables reflected parental educational level, financial and educational barriers, extracurricular opportunities, and interpersonal discrimination. Results The sample included 81 755 MCAT examinees (0.3% American Indian or Alaska Native, 21.3% Asian, 10.1% Black, 8.0% Hispanic, and 60.4% White; 56.9% female). There were racial and ethnic differences in reported barriers. For example, after adjustment for demographic characteristics and examination year, 39.0% (95% CI, 32.3%-45.8%) of American Indian or Alaska Native examinees, 35.1% (95% CI, 34.0%-36.2%) of Black examinees, and 46.6% (95% CI, 45.4%-47.9%) of Hispanic examinees reported having no parent with a college degree compared with 20.4% (95% CI, 20.0%-20.8%) of White examinees. After adjustment for demographic characteristics and examination year, Black examinees (77.8%; 95% CI, 76.9%-78.7%) and Hispanic examinees (71.3%; 95% CI, 70.2%-72.4%) were less likely than White examinees (80.2%; 95% CI, 79.8%-80.5%) to apply to medical school. Black examinees (40.6%; 95% CI, 39.5%-41.7%) and Hispanic examinees (40.2%; 95% CI, 39.0%-41.4%) were also less likely than White examinees (45.0%; 95% CI, 44.6%-45.5%) to matriculate at medical school. Examined barriers were associated with a lower likelihood of medical school application and matriculation (eg, examinees having no parent with a college degree had lower odds of applying [odds ratio, 0.65; 95% CI, 0.61-0.69] and matriculating [odds ratio, 0.63; 95% CI, 0.59-0.66]). Black-White and Hispanic-White disparities in application and matriculation were largely accounted for by differences in these barriers. Conclusions and Relevance In this cross-sectional study of MCAT examinees, American Indian or Alaska Native, Black, and Hispanic students reported lower parental educational levels, greater educational and financial barriers, and greater discouragement from prehealth advisers than White students. These barriers may deter groups underrepresented in medicine from applying to and matriculating at medical school.
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Affiliation(s)
- Jessica Faiz
- National Clinician Scholars Program, Veterans Affairs (VA) Greater Los Angeles Healthcare System and UCLA, Los Angeles, California
| | - Utibe R Essien
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Donna L Washington
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Dan P Ly
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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22
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Wong MS, Brown AF, Washington DL. Inclusion of Race and Ethnicity With Neighborhood Socioeconomic Deprivation When Assessing COVID-19 Hospitalization Risk Among California Veterans Health Administration Users. JAMA Netw Open 2023; 6:e231471. [PMID: 36867407 PMCID: PMC9984969 DOI: 10.1001/jamanetworkopen.2023.1471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
IMPORTANCE Despite complexities of racial and ethnic residential segregation (hereinafter referred to as segregation) and neighborhood socioeconomic deprivation, public health studies, including those on COVID-19 racial and ethnic disparities, often rely on composite neighborhood indices that do not account for residential segregation. OBJECTIVE To examine the associations by race and ethnicity among California's Healthy Places Index (HPI), Black and Hispanic segregation, Social Vulnerability Index (SVI), and COVID-19-related hospitalization. DESIGN, SETTING, AND PARTICIPANTS This cohort study included veterans with positive test results for COVID-19 living in California who used Veterans Health Administration services between March 1, 2020, and October 31, 2021. MAIN OUTCOMES AND MEASURES Rates of COVID-19-related hospitalization among veterans with COVID-19. RESULTS The sample available for analysis included 19 495 veterans with COVID-19 (mean [SD] age, 57.21 [17.68] years), of whom 91.0% were men, 27.7% were Hispanic, 16.1% were non-Hispanic Black, and 45.0% were non-Hispanic White. For Black veterans, living in lower-HPI (ie, less healthy) neighborhoods was associated with higher rates of hospitalization (odds ratio [OR], 1.07 [95% CI, 1.03-1.12]), even after accounting for Black segregation (OR, 1.06 [95% CI, 1.02-1.11]). Among Hispanic veterans, living in lower-HPI neighborhoods was not associated with hospitalization with (OR, 1.04 [95% CI, 0.99-1.09]) and without (OR, 1.03 [95% CI, 1.00-1.08]) Hispanic segregation adjustment. For non-Hispanic White veterans, lower HPI was associated with more frequent hospitalization (OR, 1.03 [95% CI, 1.00-1.06]). The HPI was no longer associated with hospitalization after accounting for Black (OR, 1.02 [95% CI, 0.99-1.05]) or Hispanic (OR, 0.98 [95% CI, 0.95-1.02]) segregation. Hospitalization was higher for White (OR, 4.42 [95% CI, 1.62-12.08]) and Hispanic (OR, 2.90 [95% CI, 1.02-8.23]) veterans living in neighborhoods with greater Black segregation and for White veterans in more Hispanic-segregated neighborhoods (OR, 2.81 [95% CI, 1.96-4.03]), adjusting for HPI. Living in higher SVI (ie, more vulnerable) neighborhoods was associated with greater hospitalization for Black (OR, 1.06 [95% CI, 1.02-1.10]) and non-Hispanic White (OR, 1.04 [95% CI, 1.01-1.06]) veterans. CONCLUSIONS AND RELEVANCE In this cohort study of US veterans with COVID-19, HPI captured neighborhood-level risk for COVID-19-related hospitalization for Black, Hispanic, and White veterans comparably with SVI. These findings have implications for the use of HPI and other composite neighborhood deprivation indices that do not explicitly account for segregation. Understanding associations between place and health requires ensuring composite measures accurately account for multiple aspects of neighborhood deprivation and, importantly, variation by race and ethnicity.
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Affiliation(s)
- Michelle S. Wong
- Veterans Affairs (VA) Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Arleen F. Brown
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles (UCLA)
- Olive View–UCLA Medical Center, Sylmar, California
| | - Donna L. Washington
- Veterans Affairs (VA) Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles (UCLA)
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23
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Cogan AM, Saliba D, Steers WN, Frochen S, Lynch KA, Ganz DA, Washington DL. Provider discussion of health goals and psychosocial needs: Comparing older to younger veteran experience. Health Serv Res 2023; 58 Suppl 1:9-15. [PMID: 36130799 PMCID: PMC9843079 DOI: 10.1111/1475-6773.14054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To examine by age, the veterans' report on whether components of age-friendly health systems were discussed during primary care visits. DATA SOURCES AND STUDY SETTING Veterans Affairs (VA) Survey of Healthcare Experience of Patients from October 2015 to September 2019. STUDY DESIGN Cross-sectional survey of VA users by age group (18-44 years, 45-64 years, 65+ years; N = 1,042,318). We used weighted logistic regression models to evaluate disparities in whether veterans discussed with anyone in their provider's office: health goals, depression symptoms, stress, personal problems, and medications. Models were adjusted for socio-demographic characteristics (sex, socioeconomic status, education, rurality) and comorbidity. DATA COLLECTION/EXTRACTION METHOD Surveys were administered by mail and online. Additional veteran characteristics were extracted from VA administrative data. PRINCIPAL FINDINGS In unadjusted analyses, VA users age 18-44 had a higher (-8.2%; CI: -9.0, -7.3) and users aged 45 to 64 had lower (4.0%; CI: 3.7, 4.3) predicted, probably discussing health goals compared to age 65+. Fewer VA users age 65+ reported discussing depression symptoms, personal problems, and stress than other age groups, whereas more VA users age 65+ discussed medications. Results were unchanged after adjusting for socio-demographics and comorbidity. CONCLUSIONS Delivery of goal-concordant care relies on understanding the needs of individual patients. Lower rates of discussing what matters and mood represent potential missed opportunities to deliver age-friendly care for older veterans.
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Affiliation(s)
- Alison M. Cogan
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
| | - Debra Saliba
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Geriatric Research, Education and Clinical CenterVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Borun CenterUniversity of California Los AngelesLos AngelesCaliforniaUSA
- RAND HealthSanta MonicaCaliforniaUSA
| | - W. Neil Steers
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
| | - Stephen Frochen
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
| | - Kimberly A. Lynch
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- VA Los Angeles and UCLA National Clinician Scholars ProgramVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
| | - David A. Ganz
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Geriatric Research, Education and Clinical CenterVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- David Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- David Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
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Wong MS, Upchurch DM, Steers WN, Haderlein TP, Yuan AT, Washington DL. The Role of Community-Level Factors on Disparities in COVID-19 Infection Among American Indian/Alaska Native Veterans. J Racial Ethn Health Disparities 2022; 9:1861-1872. [PMID: 34491563 PMCID: PMC8422953 DOI: 10.1007/s40615-021-01123-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES American Indian and Alaska Native (AI/AN) communities have been disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic. This study examines whether neighborhood characteristics mediate AI/AN versus White-non-Hispanic Veteran COVID-19 infection disparities, and whether mediation differs based on proximity to reservations. METHODS Using Veteran Health Administration's (VHA) national database of VHA users evaluated for COVID-19 infection (3/1/2020-8/25/2020), we examined whether census tract neighborhood characteristics (percent households overcrowded, without complete plumbing, without kitchen plumbing, and neighborhood socioeconomic status [n-SES]) mediated racial disparities in COVID-19 infection, using inverse odds-weighted logistic models controlling for individual-level characteristics. Using moderated mediation analyses, we assessed whether neighborhood mediating effects on disparities differed for those residing in counties containing/near federally recognized tribal lands (i.e., Contract Health Service Delivery Area [CHSDA] counties) versus not. RESULTS The percent of households without complete plumbing, percent without kitchen plumbing, and n-SES partially mediated AI/AN-White-non-Hispanic COVID-19 infection disparities (accounting for 17-35% of disparity) to a similar extent in CHSDA and non-CHSDA counties. The percent of households without kitchen plumbing had stronger mediating effects for CHSDA than non-CHSDA residents. CONCLUSIONS Neighborhood-level social determinants of health may contribute to the disproportionate COVID-19 infection burden on AI/ANs; differences are exacerbated among AI/ANs living near reservations.
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Affiliation(s)
- Michelle S Wong
- VA HSR&D Center for, the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Dawn M Upchurch
- Department of Community Health Sciences, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - W Neil Steers
- VA HSR&D Center for, the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Taona P Haderlein
- VA HSR&D Center for, the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Anita T Yuan
- VA HSR&D Center for, the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Donna L Washington
- VA HSR&D Center for, the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles Geffen School of Medicine, Los Angeles, CA, USA
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Rose DE, Oishi SM, Farmer MM, Bean-Mayberry B, Canelo I, Washington DL, Yano EM. Association Between Availability of Women's Health Services and Women Veterans' Care Experiences. Womens Health Issues 2022; 32:623-632. [PMID: 36115812 DOI: 10.1016/j.whi.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 07/11/2022] [Accepted: 07/26/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Few studies have focused on determinants of women's ratings of care experiences in primary care. We assessed associations between availability of women's health services and women veterans' ratings of care experiences. METHODS In a cross-sectional analysis, we linked Fiscal Year 2017 (October 1, 2016, to September 30, 2017) survey data from 126 Veterans Health Administration (VA) primary care leaders to 4,254 women veterans' ratings of care from VA's Survey of Health care Experiences of Patients-Patient Centered Medical Home (2017). The dependent variables were ratings of optimal access (appointments, information), care coordination, comprehensiveness (behavioral health assessment), patient-provider communication, and primary care provider. Key independent variables were number of women's health services 1) routinely available all weekday hours (compared with some hours or not available) and 2) available in VA general primary care vs. other arrangements. In multilevel logistic regression models, we adjusted for patient-, facility-, and area-level characteristics. RESULTS A greater number of women's health services routinely available in VA primary care was associated with a higher likelihood of optimal ratings of care coordination (adjusted odds ratio [AOR], 1.06; 95% confidence interval [CI], 1.01-1.10), provider communication (AOR, 1.08; 95% CI, 1.002-1.16), and primary care provider (AOR, 1.07; 95% CI, 1.02-1.13). A greater number of services available in VA primary care was associated with a lower likelihood of optimal ratings for access (AOR, 0.94; 95% CI, 0.88-0.99). CONCLUSION For the most part, routine availability of women's health services in VA primary care clinics enhanced women's health care experiences. These empirical findings offer health care leaders evidence-based approaches for improving women's care experiences.
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Affiliation(s)
- Danielle E Rose
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California.
| | - Sabine M Oishi
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California
| | - Melissa M Farmer
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California
| | - Bevanne Bean-Mayberry
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California; Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California
| | - Ismelda Canelo
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California
| | - Donna L Washington
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California; Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California
| | - Elizabeth M Yano
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California; Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California; Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, California
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Affiliation(s)
- Utibe R Essien
- VA HSR&D Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles Geffen School of Medicine
| | - Michael J Fine
- VA HSR&D Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Friedman S, Shaw JG, Hamilton AB, Vinekar K, Washington DL, Mattocks K, Yano EM, Phibbs CS, Johnson AM, Saechao F, Berg E, Frayne SM. Gynecologist Supply Deserts Across the VA and in the Community. J Gen Intern Med 2022; 37:690-697. [PMID: 36042097 PMCID: PMC9481821 DOI: 10.1007/s11606-022-07591-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 04/01/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND The Veterans Health Administration (VA) refers patients to community providers for specialty services not available on-site. However, community-level specialist shortages may impede access to care. OBJECTIVE Compare gynecologist supply in veterans' county of residence versus at their VA site. DESIGN We identified women veteran VA patients from fiscal year (FY) 2017 administrative data and assessed availability of a VA gynecologist within 50 miles (hereafter called "local") of veterans' VA homesites (per national VA organizational survey data). For the same cohort, we then assessed community-level gynecologist availability; counties with < 2 gynecologists/10,000 women (per the Area Health Resource File) were "inadequate-supply" counties. We examined the proportion of women veterans with local VA gynecologist availability in counties with inadequate versus adequate gynecologist supply, stratified by individual and VA homesite characteristics. Chi-square tests assessed statistical differences. PARTICIPANTS All women veteran FY2017 VA primary care users nationally. MAIN MEASURES Availability of a VA gynecologist within 50 miles of a veteran's VA homesite; county-level "inadequate-supply" of gynecologists. KEY RESULTS Among 407,482 women, 9% were in gynecologist supply deserts (i.e., lacking local VA gynecologist and living in an inadequate-supply county). The sub-populations with the highest proportions in gynecologist supply deserts were rural residents (24%), those who got their primary care at non-VAMC satellite clinics (13%), those who got their care at a site without a women's clinic (13%), and those with American Indian or Alaska Native (12%), or white (12%) race. Among those in inadequate-supply counties, 59.9% had gynecologists at their local VA; however, 40.1% lacked a local VA gynecologist. CONCLUSIONS Most veterans living in inadequate-supply counties had local VA gynecology care, reflecting VA's critical role as a safety net provider. However, for those in gynecologist supply deserts, expanded transportation options, modified staffing models, or tele-gynecology hubs may offer solutions to extend VA gynecology capacity.
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Affiliation(s)
- Sarah Friedman
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA.
- School of Public Health, University of Nevada Reno, Reno, NV, USA.
| | - Jonathan G Shaw
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Alison B Hamilton
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kavita Vinekar
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kristin Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, MA, USA
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ciaran S Phibbs
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
- VA Health Economics Resource Center, Menlo Park, CA, USA
| | | | - Fay Saechao
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Eric Berg
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
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Peltzman T, Rice K, Jones KT, Washington DL, Shiner B. Optimizing Data on Race and Ethnicity for Veterans Affairs Patients. Mil Med 2022; 187:e955-e962. [PMID: 35323934 DOI: 10.1093/milmed/usac066] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/11/2022] [Accepted: 02/25/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Maintaining accurate race and ethnicity data among patients of the Veterans Affairs (VA) healthcare system has historically been a challenge. This work expands on previous efforts to optimize race and ethnicity values by combining multiple VA data sources and exploring race- and ethnicity-specific collation algorithms. MATERIALS AND METHODS We linked VA patient data from 2000 to 2018 with race and ethnicity data from four administrative and electronic health record sources: VA Medical SAS files (MedSAS), Corporate Data Warehouse (CDW), VA Centers for Medicare extracts (CMS), and VA Defense Identity Repository Data (VADIR). To assess the accuracy of each data source, we compared race and ethnicity values to self-reported data from the Survey of Health Experiences of Patients (SHEP). We used Cohen's Kappa to assess overall (holistic) source agreement and positive predictive values (PPV) to determine the accuracy of sources for each race and ethnicity separately. RESULTS Holistic agreement with SHEP data was excellent (K > 0.80 for all sources), while race- and ethnicity-specific agreement varied. All sources were best at identifying White and Black users (average PPV = 0.94, 0.93, respectively). When applied to the full VA user population, both holistic and race-specific algorithms substantially reduced unknown values, as compared to single-source methods. CONCLUSIONS Combining multiple sources to generate race and ethnicity values improves data accuracy among VA patients. Based on the overall agreement with self-reported data, we recommend using non-missing values from sources in the following order to fill in race values-SHEP, CMS, CDW, MedSAS, and VADIR-and in the following order to fill in ethnicity values-SHEP, CDW, MedSAS, VADIR, and CMS.
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Affiliation(s)
- Talya Peltzman
- White River Junction VA Medical Center, White River Junction, VT 05009, USA
| | - Korie Rice
- White River Junction VA Medical Center, White River Junction, VT 05009, USA
| | | | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California Los Angeles Geffen School of Medicine, Los Angeles, CA 90024, USA
| | - Brian Shiner
- White River Junction VA Medical Center, White River Junction, VT 05009, USA
- Geisel School of Medicine at Dartmouth College, Hanover, NH 03755, USA
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Wong MS, Steers WN, Frochen S, Washington DL. Assessment of Exposure to Environmental Toxins and Racial and Ethnic Disparities in COVID-19 Hospitalizations Among US Veterans. JAMA Netw Open 2022; 5:e2224249. [PMID: 35900766 PMCID: PMC9335138 DOI: 10.1001/jamanetworkopen.2022.24249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/12/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Michelle S. Wong
- Veterans Affairs Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - W. Neil Steers
- Veterans Affairs Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Stephen Frochen
- Veterans Affairs Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Donna L. Washington
- Veterans Affairs Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, Department of Medicine, Geffen School of Medicine, University of California, Los Angeles, Los Angeles
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Williams EC, Fletcher OV, Frost MC, Harris AHS, Washington DL, Hoggatt KJ. Comparison of Substance Use Disorder Diagnosis Rates From Electronic Health Record Data With Substance Use Disorder Prevalence Rates Reported in Surveys Across Sociodemographic Groups in the Veterans Health Administration. JAMA Netw Open 2022; 5:e2219651. [PMID: 35771574 PMCID: PMC9247731 DOI: 10.1001/jamanetworkopen.2022.19651] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 05/13/2022] [Indexed: 11/14/2022] Open
Abstract
Importance Substance use disorders (SUDs) are major contributors to morbidity and mortality globally, but they are often underrecognized and underdiagnosed, particularly in some sociodemographic subgroups. Understanding the extent to which clinical diagnoses underestimate these conditions within subgroups is imperative to achieving equitable treatment, regardless of race, ethnicity, gender, or age, and to informing and improving performance monitoring. Objective To compare clinically documented diagnosis rates of alcohol use disorder (AUD), drug use disorder (DUD), and total SUD (AUD and/or DUD) with the prevalence of these disorders as reported in surveys-based on structured, validated diagnostic assessments-across demographic subgroups. Design, Setting, and Participants A telephone-based survey was conducted from January 8, 2018, to April 30, 2019, among 5995 Veterans Health Administration (VHA) outpatients who were randomly sampled from 30 VHA facilities and were 18 years of age or older, could complete the survey in English, and had a valid address and telephone number. Survey data were linked to electronic health record (EHR) data for all participants. Statistical analysis was performed between January 29, 2020, and April 20, 2021. Exposures Demographic subgroups based on self-report: gender (male or female), age (18-34, 35-49, 50-64, 65-74, and ≥75 years), and race and ethnicity (Black non-Hispanic, Hispanic, multiracial, other [Asian or Asian-American, American Indian or Alaskan Native, Native Hawaiian or Pacific Islander, and any other race endorsed by the participant], and White non-Hispanic). Main Outcomes and Measures Survey-based prevalence rates of AUD, DUD, and SUD were assessed using the Mini International Neuropsychiatric Interview, version 7.0, the only validated instrument available at study outset that measured Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria for past 12-month diagnoses. Clinically documented diagnosis rates were measured using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnoses from VHA EHR data. Analyses compared survey-based prevalence rates of AUD, DUD, and SUD with diagnosis rates using sensitivity and specificity and difference-in-difference analysis. All analyses were weighted with survey weights to account for nonresponse. Results Of 5995 participants, 4115 (68.6%) were White non-Hispanic, and 5429 (91.1%) were male; the mean (SD) age was 61.5 (15.3) years. The survey-based prevalence rates of AUD, DUD, and SUD were higher than the diagnosis rates among all patients (AUD, 608 [10.1%] vs 360 [6.0%]; DUD, 282 [4.7%] vs 275 [4.6%]; SUD, 768 [12.8%] vs 515 [8.6%]). Survey-based prevalence rates of AUD and SUD exceeded the diagnosis rates in every demographic subgroup. Gaps between diagnosis rates and survey-based prevalence rates for AUD and SUD were largest among patients aged 18 to 34 years (AUD diagnosis rate, 27 [6.9%; 95% CI, 4.8%-9.9%] vs AUD prevalence rate, 88 [22.4%; 95% CI, 17.3%-28.5%]; SUD diagnosis rate, 41 [10.5%; 95% CI, 8.1%-13.4%] vs SUD prevalence rate, 109 [27.7%; 95% CI, 22.6%-33.3%]) and Hispanic and Latinx patients (AUD diagnosis rate, 31 [7.6%; 95% CI, 5.3%-10.8%] vs AUD prevalence rate, 72 [17.7%; 95% CI, 14.0%-22.1%]; and SUD diagnosis rate, 48 [11.7%; 95% CI, 7.9%-16.9%] vs SUD prevalence rate, 88 [21.6%; 95% CI, 18.0%-25.8%]). For DUD, only patients aged 18 to 34 years had a true prevalence rate that significantly exceeded the diagnosis rate (diagnosis rate, 21 [5.4%; 95% CI, 3.7%-7.8%] vs prevalence rate, 40 [10.1%; 95% CI, 7.2%-14.0%]). Conclusions and Relevance The results of this survey study suggest that existing diagnostic procedures and tools are insufficient to capture SUD prevalence rates, particularly among younger patients and Hispanic and Latinx patients. Clinics and health systems should implement standardized SUD assessments to ensure the provision of equitable care and the optimal identification of underlying conditions for performance monitoring.
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Affiliation(s)
- Emily C. Williams
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle
| | - Olivia V. Fletcher
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Madeline C. Frost
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle
| | - Alex H. S. Harris
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Donna L. Washington
- Veterans Affairs Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California
| | - Katherine J. Hoggatt
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Medicine, University of California, San Francisco
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Haderlein TP, Wong MS, Jones KT, Moy EM, Yuan AH, Washington DL. Racial/Ethnic Variation in Veterans Health Administration COVID-19 Vaccine Uptake. Am J Prev Med 2022; 62:596-601. [PMID: 34782188 PMCID: PMC8529259 DOI: 10.1016/j.amepre.2021.08.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/03/2021] [Accepted: 08/18/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Equitable COVID-19 vaccine access is imperative to mitigating negative COVID-19 impacts among racial/ethnic minorities. U.S. racial/ethnic minorities have lower COVID-19 vaccination rates than Whites despite higher COVID-19 death/case rates. The Veterans Health Administration provides the unique context of a managed care system with few access barriers. This study evaluates race/ethnicity as a predictor of Veterans Health Administration COVID-19 vaccination. METHODS The cohort was composed of Veterans Health Administration outpatient users aged ≥65 years (N=3,474,874). COVID-19 vaccination was assessed between December 14, 2020 and February 23, 2021. Multivariable logistic regressions were conducted, controlling for demographics, medical comorbidity, and influenza vaccination history. Proximity to Indian Health Service Contract Health Service Delivery Areas was tested as a moderator. Data analyses were conducted during 2021. RESULTS Blacks (OR=1.28, 95% CI=1.17, 1.40), Hispanics (OR=1.15, 95% CI=1.05, 1.25), and Asians (OR=1.21, 95% CI=1.02, 1.43) were more likely than Whites to receive Veterans Health Administration COVID-19 vaccinations. American Indian/Alaska Natives were less likely than Whites to receive Veterans Health Administration COVID-19 vaccinations, but only those residing in Contract Health Service Delivery Area counties (OR= 0.58, 95% CI= 0.47, 0.72). Influenza vaccine history positively predicted COVID-19 vaccine uptake (OR= 2.28, 95% CI=2.22, 2.34). CONCLUSIONS In the Veterans Health Administration, compared with the general U.S. population, COVID-19 vaccine receipt is higher among most racial/ethnic minority groups than Whites, suggesting reduced vaccination barriers . The Indian Health Service may provide a safety net for American Indian/Alaska Native populations. Addressing vaccination access barriers in non-Veterans Health Administration settings can potentially reduce racial/ethnic disparities.
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Affiliation(s)
- Taona P Haderlein
- VA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Michelle S Wong
- VA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Kenneth T Jones
- VA Office of Health Equity, Washington, District of Columbia
| | - Ernest M Moy
- VA Office of Health Equity, Washington, District of Columbia
| | - Anita H Yuan
- VA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Donna L Washington
- VA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California.
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Carlson GC, Kelly MR, Mitchell M, Josephson KR, McGowan SK, Culver NC, Kay M, Alessi CA, Fung CH, Washington DL, Hamilton A, Yano EM, Martin JL. Benefits of Cognitive Behavioral Therapy for Insomnia for Women Veterans with and without Probable Post-Traumatic Stress Disorder. Womens Health Issues 2022; 32:194-202. [PMID: 34815139 PMCID: PMC9124441 DOI: 10.1016/j.whi.2021.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 10/02/2021] [Accepted: 10/14/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study compared the benefits of cognitive-behavioral therapy for insomnia for sleep, mental health symptoms, and quality of life (QoL) in a sample of women veterans with and without probable post-traumatic stress disorder (PTSD) comorbid with insomnia disorder. METHODS Seventy-three women veterans (30 with probable PTSD) received a manual-based 5-week cognitive-behavioral therapy for insomnia treatment as part of a behavioral sleep intervention study. Measures were completed at baseline, post-treatment, and 3-month follow-up. Sleep measures included the Insomnia Severity Index, Pittsburgh Sleep Quality Index, sleep efficiency measured by actigraphy, and sleep efficiency and total sleep time measured by sleep diary. Mental health measures included the PTSD Checklist-5, nightmares per week, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7 scale. QoL was measured with the Short Form-12. Linear mixed models compared changes over time across groups. Independent t tests examined PTSD symptom changes in women veterans with probable PTSD. RESULTS Both groups demonstrated improvements across sleep (ps < .001-.040), mental health symptoms (ps < .001), and QoL measures (ps < .001). The probable PTSD group reported greater improvements in diary sleep efficiency (p = .046) and nightmares per week (p = .001) at post-treatment and in total sleep time (p = .029) and nightmares per week (p = .006) at follow-up. Most participants with probable PTSD experienced clinically significant reductions in PTSD symptoms at post-treatment (66.7%) and follow-up (60.0%). Significant reductions in intrusive and arousal/reactivity symptoms were maintained at follow-up. CONCLUSIONS Cognitive-behavioral therapy for insomnia improves insomnia, mental health symptoms, and QoL among women veterans, with greater improvement in those with probable PTSD.
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Affiliation(s)
- Gwendolyn C Carlson
- Department of Mental Health, Veterans Affairs (VA) Greater Los Angles Healthcare System, Los Angeles, California; VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California.
| | - Monica R Kelly
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Michael Mitchell
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Karen R Josephson
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Sarah Kate McGowan
- Department of Mental Health, Veterans Affairs (VA) Greater Los Angles Healthcare System, Los Angeles, California; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Najwa C Culver
- Department of Mental Health, Veterans Affairs (VA) Greater Los Angles Healthcare System, Los Angeles, California
| | - Morgan Kay
- Department of Mental Health, Veterans Affairs (VA) Greater Los Angles Healthcare System, Los Angeles, California
| | - Cathy A Alessi
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Constance H Fung
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Donna L Washington
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Alison Hamilton
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Elizabeth M Yano
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Jennifer L Martin
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
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Chrystal JG, Frayne S, Dyer KE, Moreau JL, Gammage CE, Saechao F, Berg E, Washington DL, Yano EM, Hamilton AB. Women Veterans' Attrition from the VA Health Care System. Womens Health Issues 2022; 32:182-193. [PMID: 34972600 DOI: 10.1016/j.whi.2021.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 11/17/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Patient attrition from the Veterans Health Administration (VA) health care system could undercut its mission to ensure care for eligible veterans. Attrition of women veterans could exacerbate their minority status and impede systemic efforts to provide high-quality care. We obtained women veterans' perspectives on why they left or continued to use VA health care. METHODS A sampling frame of new women veteran VA patients was stratified by those who discontinued (attriters) and those who continued (non-attriters) using VA care. Semistructured interviews were conducted from 2017 to 2018. Transcribed interviews were coded for women's decision-making, contexts, and recommendations related to health care use. RESULTS Fifty-one women veterans (25 attriters and 26 non-attriters) completed interviews. Reasons for attrition included challenging patient care experiences (e.g., provider turnover, claim processing challenges) and the availability of private health insurance. Personal experiences with VA care (e.g., gender-specific care) were impactful in women's decision to use VA. The affordability of VA care was influential for both groups to stay connected to services. More than one-third of women originally categorized as attriters described subsequently reentering or planning to reenter VA care. Suggestions to decrease attrition included increasing outreach, improving access, and continuing to tailor care delivery to women veterans' needs. CONCLUSIONS Understanding the drivers of patients' decisions to use or not use the VA is critical for the development of strategies to improve retention of current patients and optimize health outcomes for veterans. Women veterans described complex reasons why they left or continued using VA, with cost/affordability playing an important role even in considerations of returning to VA after a long hiatus.
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Affiliation(s)
- Joya G Chrystal
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California.
| | - Susan Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, Menlo Park, California; Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Karen E Dyer
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California
| | - Jessica L Moreau
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California
| | - Cynthia E Gammage
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California
| | - Fay Saechao
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, Menlo Park, California
| | - Eric Berg
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, Menlo Park, California
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California; Division of General Internal Medicine and Health Services Research, UCLA, Los Angeles, California
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California; Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, California
| | - Alison B Hamilton
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California; Department of Psychiatry and Biobehavioral Sciences, UCLA Geffen School of Medicine, Semel Institute/NPI, Los Angeles, California
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Upchurch DM, Wong MS, Yuan AH, Haderlein TP, McClendon J, Christy A, Washington DL. COVID-19 Infection in the Veterans Health Administration: Gender-specific Racial and Ethnic Differences. Womens Health Issues 2022; 32:41-50. [PMID: 34702652 PMCID: PMC8486675 DOI: 10.1016/j.whi.2021.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 09/10/2021] [Accepted: 09/27/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Racial/ethnic minoritized groups, women, and economically disadvantaged groups are disproportionately affected by the COVID-19 pandemic. We investigated racial/ethnic differences by gender in correlates of COVID-19 infection among veterans seeking health care services at the Veterans Health Administration. Little is known about gender-specific factors associated with infection among veterans. This study seeks to fill this gap. METHODS The sample was veterans with results from a COVID-19 test (polymerase chain reaction) conducted at Veterans Health Administration facilities between March 1, 2020, and August 5, 2020, and linked to the Centers for Disease Control and Prevention Social Vulnerability Index data (39,223 women and 316,380 men). Bivariate, multivariate logistic, and predicted probability analyses were conducted. All analyses were stratified by gender. RESULTS Similar percentages of women and men tested positive for COVID-19 (9.6% vs. 10.0%). In multivariate analysis, compared with non-Hispanic White women, American Indian/Alaska Native, Black, and Hispanic women all had significantly higher odds of infection. Similar racial/ethnic differences were found for men. Both older men and women (>40 years) had lower odds of infection, but the age cut points differed (40 for women, 55 for men). Men 80 years and older had a higher odds than those aged less than 40 years of age. For men, but not for women, being employed (vs. unemployed) was associated with an increased odds of infection, and having comorbidities was associated with decreased odds. There were significant differences within and across gender-by-race/ethnicity in infection, after adjusting for covariates. CONCLUSIONS American Indian/Alaska Native, Hispanic, and Black women and men veterans are disproportionately impacted by COVID-19 infection. Widespread testing and tracking, education, and outreach regarding COVID-19 mitigation and vaccination efforts are recommended.
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Affiliation(s)
- Dawn M Upchurch
- Department of Community Health Sciences, UCLA Fielding School of Public Health, Los Angeles, California.
| | - Michelle S Wong
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Anita H Yuan
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Taona P Haderlein
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Juliette McClendon
- National Center for PTSD, Women's Health Science Division, VA Boston Health Care System, Boston, Massachusetts; Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Alicia Christy
- Women's Health Services, Veterans Health Administration, Washington, District of Columbia
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California; Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles Geffen School of Medicine, Los Angeles, California
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Casillas A, Rosas LG, Carson SL, Orechwa A, North G, AuYoung M, Kim G, Guereca JA, Ramers CB, Burke NJ, Corchado CG, Aguilar-Gaxiola S, Cheney A, Rabin BA, Stadnick NA, Oswald W, Cabrera A, Sorkin DH, Zaldivar F, Wong W, Yerraguntala AS, Vassar SD, Wright AL, Washington DL, Norris KC, Brown AF. STOP COVID-19 CA: Community engagement to address the disparate impacts of the COVID-19 pandemic in California. Front Health Serv 2022; 2:935297. [PMID: 36925779 PMCID: PMC10012632 DOI: 10.3389/frhs.2022.935297] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 10/10/2022] [Indexed: 12/03/2022]
Abstract
Objective To describe the early activities and lessons of the Share, Trust, Organize, Partner COVID-19 California Alliance (STOP COVID-19 CA), the California awardee of the NIH-funded multi-state Community Engagement Alliance (CEAL) against COVID-19. The Alliance was established to ensure equity in Coronavirus-19 disease (COVID-19) research, clinical practice, and public health for communities most impacted by the COVID-19 pandemic. Study setting The STOP COVID-19 CA Alliance network of 11 universities and affiliated partner community-based organizations (CBOs) across California. Study design Mixed methods evaluation consisting of an analysis of activity (August 2020 to December 2021) detailed in reports submitted by community-academic teams and a survey (August 2021) of academic investigators and affiliated community-based organization (CBO) partners. Data collection We summarized activities from the 11 community-academic teams' progress reports and described results from an online survey of academic investigators and CBO partners in the California Alliance. Principal findings A review of progress reports (n = 256) showed that teams fielded surveys to 11,000 Californians, conducted 133 focus groups, partnered with 29 vaccine/therapeutics clinical trials, and led more than 300 town halls and vaccine events that reached Californians from communities disproportionately impacted by COVID-19. Survey responses from academic investigators and CBO partners emphasized the importance of learning from the successes and challenges of the California Alliance teams' COVID-19 initiatives. Both academic and CBO respondents highlighted the need for streamlined federal and institutional administrative policies, and fiscal practices to promote more effective and timely operations of teams in their efforts to address the numerous underlying health and social disparities that predispose their communities to higher rates of, and poor outcomes from, COVID-19. Conclusions STOP COVID-19 CA represents a new and potentially sustainable statewide community engagement model for addressing health disparities in multiethnic/multicultural and geographically dispersed communities.
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Affiliation(s)
- Alejandra Casillas
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States
| | - Lisa G Rosas
- Department of Epidemiology and Population Health, Stanford School of Medicine, Stanford, CA, United States.,Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford, CA, United States
| | - Savanna L Carson
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States
| | - Allison Orechwa
- Southern California Clinical and Translational Science Institute, University of Southern California, Los Angeles, CA, United States
| | - Gemma North
- Southern California Clinical and Translational Science Institute, University of Southern California, Los Angeles, CA, United States
| | | | - Gloria Kim
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States
| | - Jesus A Guereca
- Laura Rodriguez Research Institute Family Health Centers of San Diego, San Diego, CA, United States
| | - Christian B Ramers
- Division of Infectious Diseases, Department of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Nancy J Burke
- Public Health Department, University of California, Merced, Merced, CA, United States
| | | | - Sergio Aguilar-Gaxiola
- Center for Reducing Health Disparities and Community Engagement Program of the Clinical and Translational Science Center, Department of Internal Medicine, University of California, Davis, Sacramento, CA, United States
| | - Ann Cheney
- Department of Social Medicine Population and Public Health, School of Medicine, University of California, Riverside, Riverside, CA, United States
| | - Borsika A Rabin
- UC San Diego Altman Clinical Translational Research Institute Dissemination and Implementation Science Center, University of California San Diego, La Jolla, CA, United States.,Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, United States
| | - Nicole A Stadnick
- UC San Diego Altman Clinical Translational Research Institute Dissemination and Implementation Science Center, University of California San Diego, La Jolla, CA, United States.,Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA, United States.,Child and Adolescent Services Research Center, San Diego, CA, United States
| | - William Oswald
- The Global Action Research Center, San Diego, CA, United States
| | - Abby Cabrera
- Center for Excellence in Primary Care, Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Dara H Sorkin
- Department of Medicine, Institute for Clinical and Translational Science, University of California, Irvine, Irvine, CA, United States
| | - Frank Zaldivar
- Department of Pediatrics, Susan and Henry Samueli College of Health Sciences, University of California, Irvine, Irvine, CA, United States
| | - Wennie Wong
- Southern California Clinical and Translational Science Institute, University of Southern California, Los Angeles, CA, United States
| | - Anusha S Yerraguntala
- Southern California Clinical and Translational Science Institute, University of Southern California, Los Angeles, CA, United States
| | - Stefanie D Vassar
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States
| | - Aziza Lucas Wright
- Department of Preventive and Social Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, United States.,South Central Prevention Coalition, Los Angeles, CA, United States
| | - Donna L Washington
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States.,VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Keith C Norris
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States
| | - Arleen F Brown
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States.,Olive View Medical Center, Los Angeles County Department of Health Services, Sylmar, CA, United States
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Than CT, Washington DL, Vogt D, Chuang E, Needleman J, Canelo I, Meredith LS, Yano EM. Discontinuity of Women Veterans' Care in Patient-Centered Medical Homes: Does Workforce Gender Sensitivity Matter? Womens Health Issues 2021; 32:173-181. [PMID: 34930639 DOI: 10.1016/j.whi.2021.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 10/15/2021] [Accepted: 11/22/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prior research has found that 25% of women veterans who are new to the Department of Veterans Affairs (VA) health care system discontinue services within 3 years of initial use. Although it has been suggested that providing more gender-sensitive care might improve women veterans' health care experiences, no study has yet documented an empirical relationship between clinic and provider factors associated with the provision of gender-sensitive care and women veterans' care discontinuity. METHODS Surveys of primary care providers (n = 82) and staff members (n = 108) from 12 VA medical centers were linked to administrative data for women veteran patients with at least one primary care visit in 2014 and 2015 (n = 9,958). Patient care discontinuity was operationalized as having no additional primary care visit within 3 years after the patient's baseline visit. Key indicators of gender-sensitive comprehensive primary care included type of medical home (women's health-focused vs. general primary care), workforce gender sensitivity, team functioning, perceived quality of provider/staff communication, leadership support for medical home implementation, and other structural components of care delivery (e.g., chaperone availability). We used logistic regression to assess the association between these indicators and women's care discontinuity, measuring discontinuity for both new and continuing VA users and controlling for patient characteristics. RESULTS Eleven percent of women patients discontinued primary care within 3 years. Poor workforce gender sensitivity (lowest quartile vs. top three quartiles) was significantly associated with higher odds of discontinuity (odds ratio, 1.26; 95% confidence interval, 1.01-1.57); other indicators were not associated with discontinuity. CONCLUSIONS This study is the first to document a relationship between workforce gender sensitivity and women veterans' care continuity. This finding underscores the need for additional attention to enhancing workforce gender sensitivity in VA.
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Affiliation(s)
- Claire T Than
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, California.
| | - Donna L Washington
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine, Geffen School of Medicine, UCLA, Los Angeles, California
| | - Dawne Vogt
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts; Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Emmeline Chuang
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, California
| | - Jack Needleman
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, California
| | - Ismelda Canelo
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Lisa S Meredith
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; RAND Corporation, Santa Monica, California
| | - Elizabeth M Yano
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, California
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Wong MS, Yuan AH, Haderlein TP, Jones KT, Washington DL. Variations by race/ethnicity and time in Covid-19 testing among Veterans Health Administration users with COVID-19 symptoms or exposure. Prev Med Rep 2021; 24:101503. [PMID: 34312589 PMCID: PMC8295495 DOI: 10.1016/j.pmedr.2021.101503] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/10/2021] [Accepted: 07/18/2021] [Indexed: 12/19/2022] Open
Abstract
Racial/ethnic disparities in coronavirus disease 2019 (COVID-19) hospitalization and mortality have emerged in the United States, but less is known about whether similar differences exist in testing, and how this changed as COVID-19 knowledge and policies evolved. We examined racial/ethnic variations in COVID-19 testing over time among veterans who sought care for COVID-19 symptoms or exposure. In the national population of all Veterans who sought Veterans Health Administration (VHA) care for COVID-19 symptoms or exposure (n = 913,806), we conducted multivariate logistic regressions to explore race/ethnicity-by-time period differences in testing from 3/1/2020-11/25/2020, and calculated predicted probabilities by race/ethnicity and time period. Early in the pandemic (3/1/2020-4/6/2020) when testing was limited and there was less awareness of racial/ethnic disparities, non-Hispanic Black, Hispanic, and other non-White racial/ethnic minority Veterans who sought care from VHA for COVID-19 symptoms or exposure were more likely than non-Hispanic White Veterans to receive a COVID-19 test (p < 0.05). In subsequent time periods (4/7/2020-11/25/2020), testing was similar among all racial/ethnic groups. Among Veterans with COVID-19 symptoms or exposure, non-Hispanic Black and Hispanic patients were just as likely, and in some cases, more likely, to receive a COVID-19 test versus non-Hispanic White patients. The United States faced testing shortages at the start of the third wave of the pandemic; additional shortages are likely to emerge as the pandemic continues to peak and ebb. It is important to ensure that racial/ethnic minorities and others at greater risk for infection continue to have access to COVID-19 testing with each of these peaks.
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Affiliation(s)
- Michelle S. Wong
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90073, United States
| | - Anita H. Yuan
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90073, United States
| | - Taona P. Haderlein
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90073, United States
| | - Kenneth T. Jones
- VHA Office of Health Equity, 810 Vermont Ave, NW, Washington, DC 20420, United States
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90073, United States
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles Geffen School of Medicine, 1100 Glendon Ave, Suite 850, Los Angeles, CA 90024, United States
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Haderlein TP, Wong MS, Yuan A, Llorente MD, Washington DL. Association of PTSD with COVID-19 testing and infection in the Veterans Health Administration. J Psychiatr Res 2021; 143:504-507. [PMID: 33261820 PMCID: PMC7682935 DOI: 10.1016/j.jpsychires.2020.11.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/15/2020] [Accepted: 11/18/2020] [Indexed: 12/16/2022]
Abstract
Posttraumatic stress disorder (PTSD) is associated with coronavirus disease 2019 (COVID-19) risk factors, such as hypertension and obesity. Associations between PTSD and COVID-19 outcomes may affect Veterans Health Administration (VA) services, as PTSD occurs at higher rates among veterans than the general population. While previous research has identified the potential for increased PTSD prevalence resulting from COVID-19 as a public health concern, no known research examines the effect of pre-existing PTSD on COVID-19 test-seeking behavior or infection. This study aimed to evaluate pre-existing PTSD as a predictor of COVID-19 testing and test positivity. The sample consisted of 6,721,407 veterans who sought VA care between March 1, 2018 and February 29, 2020. Veterans with a previous PTSD clinical diagnosis were more likely to receive COVID-19 testing than veterans without PTSD. However, among those with available COVID-19 test results (n = 168,032), veterans with a previous PTSD clinical diagnosis were less likely to test positive than veterans without PTSD. Elevated COVID-19 testing rates among veterans with PTSD may reflect increased COVID-19 health concerns and/or hypervigilance. Lower rates of COVID-19 test positivity among veterans with PTSD may reflect increased social isolation, or overrepresentation in the tested population due to higher overall use of VA services. As the COVID-19 pandemic continues, the identification of patient-level psychiatric predictors of testing and test positivity can facilitate the targeted provision of medical and mental health services to individuals in need.
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Affiliation(s)
- Taona P. Haderlein
- VA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Michelle S. Wong
- VA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Anita Yuan
- VA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Maria D. Llorente
- Department of Veterans Affairs, Patient Care Services, Washington, DC, USA,Georgetown University School of Medicine, Department of Psychiatry, Washington, DC, USA
| | - Donna L. Washington
- VA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA,Division of General Internal Medicine and Health Services Research, Department of Medicine, Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA,Corresponding author. 11301 Wilshire Blvd, 111G, Los Angeles, CA, 90073, USA
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Wong MS, Washington DL, Moy E. Researchers Should Consider How Disparities Change Over Time and Space: Lessons from the COVID-19 Pandemic. NAM Perspect 2021; 2021:202108c. [PMID: 34901775 PMCID: PMC8654466 DOI: 10.31478/202108c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
| | - Donna L Washington
- VA Greater Los Angeles Healthcare System and University of California, Los Angeles, David Geffen School of Medicine
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Hoggatt KJ, Harris AHS, Washington DL, Williams EC. Prevalence of substance use and substance-related disorders among US Veterans Health Administration patients. Drug Alcohol Depend 2021; 225:108791. [PMID: 34098384 DOI: 10.1016/j.drugalcdep.2021.108791] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 03/24/2021] [Accepted: 03/29/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Substance use and related disorders are common among US Veterans, but the population burden of has never been directly assessed among Veterans Health Administration (VA) patients. We surveyed VA patients to measure substance use and related disorders in the largest US integrated healthcare system. METHODS We surveyed N = 6000 outpatients from 30 geographically-representative VA healthcare systems. We assessed substance use (lifetime, past 12-month, daily in past 3 months) and past 12-month disorders following DSM-5 criteria and estimated the association with Veteran characteristics (age, gender, race/ethnicity, socioeconomic status, VA utilization). RESULTS Alcohol was the most commonly-reported substance (24% used past 12 months, 11% daily in past 3 months, 10% met criteria for alcohol use disorder), followed by cannabis (42% lifetime use, 12% use in past 12 months, 5% daily use in past 3 months, 3% met criteria for cannabis use disorder). Overall, 5% met criteria for non-alcohol drug use disorder (13% for substance use disorder (SUD)). SUD prevalence was highest for young Veterans and those who were unemployed or otherwise not employed for wages. Past 12-month cannabis use was common, even among older adults (65-74 years: 10%; 75 and older: 2%). CONCLUSIONS Prevalence data are important inputs into decisions around population health monitoring, treatment capacity, and quality measurement strategies. Substance use and SUD are more prevalent than previously reported, and VA may need to screen for non-alcohol drugs to identify patients who need care. More tailored assessment may be needed for cannabis use, high-prevalence subgroups, and older adults.
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Affiliation(s)
- Katherine J Hoggatt
- San Francisco VA Health Care System, 4150 Clement St., San Francisco, CA 94121, USA; University of California, Department of Medicine, 505 Parnassus Ave, San Francisco, CA 94143, USA.
| | - Alexander H S Harris
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA; Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., 111G, Los Angeles, CA 90073, USA; Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, CA, USA.
| | - Emily C Williams
- Center of Innovation for Veteran Centered and Value-Driven Care, VA Puget Sound, 1660 S Columbian Way, S-152 Seattle, WA 98108, USA; Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA.
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Wong MS, Steers WN, Hoggatt KJ, Ziaeian B, Washington DL. Race Differences in Patient Experience by Hispanic Ethnicity Among Veteran Health Administration Users. J Gen Intern Med 2021; 36:1821-1824. [PMID: 32654088 PMCID: PMC8175531 DOI: 10.1007/s11606-020-06023-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/30/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Michelle S Wong
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - W Neil Steers
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Katherine J Hoggatt
- San Francisco VA Healthcare System, San Francisco, CA, USA
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Boback Ziaeian
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Breland JY, Wong MS, Steers WN, Yuan AH, Haderlein TP, Washington DL. BMI and Risk for Severe COVID-19 Among Veterans Health Administration Patients. Obesity (Silver Spring) 2021; 29:825-828. [PMID: 33403755 DOI: 10.1002/oby.23121] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/25/2020] [Accepted: 12/22/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The purpose of this study was to assess associations between BMI and severe coronavirus disease 2019 (COVID-19) outcomes: hospitalization, intensive care unit (ICU) admission, and mortality. A secondary aim was to investigate whether associations varied by age. METHODS The cohort comprised patients in the Veterans Health Administration (VHA) who tested positive for COVID-19 (N = 9,347). For each outcome, we fit piecewise logistic regression models with restricted cubic splines (knots at BMI of 23, 30, and 39), adjusting for age, sex, comorbidities, VHA nursing home residence, and race/ethnicity. Supplemental analyses included age-by-BMI interaction terms (α = 0.05). RESULTS We found evidence of a nonlinear J-curve association between BMI and likelihood of hospitalization and mortality. BMI was associated with increased odds for hospitalization, ICU admission, and mortality among patients with BMI 30 to 39 but decreased odds of hospitalization and mortality for patients with BMI 23 to 30. Patients under age 75 with BMI between 30 and 39 had increased odds for mortality with increasing BMI. CONCLUSIONS Odds for severe outcomes with COVID-19 infection increased with increasing BMI for people with, but not without, obesity. This nonlinear relationship should be tested in future research. COVID-19 public health messages in VHA, and broadly, should incorporate information about risks associated with all classes of obesity, particularly for those under age 75.
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Affiliation(s)
- Jessica Y Breland
- VA Health Services Research and Development Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Michelle S Wong
- VA Health Services Research and Development Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - W Neil Steers
- VA Health Services Research and Development Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Anita H Yuan
- VA Health Services Research and Development Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Taona P Haderlein
- VA Health Services Research and Development Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Donna L Washington
- VA Health Services Research and Development Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
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Wong MS, Haderlein TP, Yuan AH, Moy E, Jones KT, Washington DL. Time Trends in Racial/Ethnic Differences in COVID-19 Infection and Mortality. Int J Environ Res Public Health 2021; 18:4848. [PMID: 34062806 PMCID: PMC8124342 DOI: 10.3390/ijerph18094848] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/22/2021] [Accepted: 04/28/2021] [Indexed: 11/20/2022]
Abstract
Studies documenting coronavirus disease 2019 (COVID-19) racial/ethnic disparities in the United States were limited to data from the initial few months of the pandemic, did not account for changes over time, and focused primarily on Black and Hispanic minority groups. To fill these gaps, we examined time trends in racial/ethnic disparities in COVID-19 infection and mortality. We used the Veteran Health Administration's (VHA) national database of veteran COVID-19 infections over three time periods: 3/1/2020-5/31/2020 (spring); 6/1/2020-8/31/2020 (summer); and 9/1/2020-11/25/2020 (fall). We calculated COVID-19 infection and mortality predicted probabilities from logistic regression models that included time period-by-race/ethnicity interaction terms, and controlled for age, gender, and prior diagnosis of CDC risk factors. Racial/ethnic groups at higher risk for COVID-19 infection and mortality changed over time. American Indian/Alaskan Natives (AI/AN), Blacks, Hispanics, and Native Hawaiians/Other Pacific Islanders experienced higher COVID-19 infections compared to Whites during the summertime. There were mortality disparities for Blacks in springtime, and AI/ANs, Asians, and Hispanics in summertime. Policy makers should consider the dynamic nature of racial/ethnic disparities as the pandemic evolves, and potential effects of risk mitigation and other (e.g., economic) policies on these disparities. Researchers should consider how trends in disparities change over time in other samples.
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Affiliation(s)
- Michelle S. Wong
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System 11301 Wilshire Blvd, Los Angeles, CA 90073, USA; (T.P.H.); (A.H.Y.); (D.L.W.)
| | - Taona P. Haderlein
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System 11301 Wilshire Blvd, Los Angeles, CA 90073, USA; (T.P.H.); (A.H.Y.); (D.L.W.)
| | - Anita H. Yuan
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System 11301 Wilshire Blvd, Los Angeles, CA 90073, USA; (T.P.H.); (A.H.Y.); (D.L.W.)
| | - Ernest Moy
- VHA Office of Health Equity, 810 Vermont Ave NW, Washington, DC 20420, USA; (E.M.); (K.T.J.)
| | - Kenneth T. Jones
- VHA Office of Health Equity, 810 Vermont Ave NW, Washington, DC 20420, USA; (E.M.); (K.T.J.)
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System 11301 Wilshire Blvd, Los Angeles, CA 90073, USA; (T.P.H.); (A.H.Y.); (D.L.W.)
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California Los Angeles Geffen School of Medicine, 1100 Glendon Ave STE 850, Los Angeles, CA 90024, USA
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Martin JL, Carlson G, Kelly M, Fung CH, Song Y, Mitchell MN, Zeidler MR, Josephson KR, Badr MS, Zhu R, Alessi CA, Washington DL, Yano EM. Sleep apnea in women veterans: results of a national survey of VA health care users. J Clin Sleep Med 2021; 17:555-565. [PMID: 33124975 PMCID: PMC7927345 DOI: 10.5664/jcsm.8956] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The goals of this study were to estimate rates of undiagnosed, diagnosed, and treated sleep apnea in women veterans and to identify factors associated with diagnosis and treatment of sleep apnea in this population. METHODS A large nationwide postal survey was sent to a random sample of 4,000 women veterans who had received health care at a Veterans Health Administration (VA) facility in the previous 6 months. A total of 1,498 surveys were completed. Survey items used for the current analyses included: demographics; sleep apnea risk, diagnostic status, and treatment; symptoms of other sleep disorders (eg, insomnia); mental health symptoms; and comorbidities. RESULTS Among responders, 13% of women reported a prior sleep apnea diagnosis. Among women who reported a diagnosis of sleep apnea, 65% reported using positive airway pressure therapy. A sleep apnea diagnosis was associated with older age, higher BMI, non-Hispanic African American/Black racial/ethnic identity, being unemployed, other sleep disorder symptoms (eg, insomnia), depression and post-traumatic stress disorder symptoms, and multimorbidity. Among women without a sleep apnea diagnosis, 43% scored as "high risk" on the STOP (snoring, tiredness, observed apneas, blood pressure) questionnaire. High risk scores were associated with older age, higher BMI, African American/Black identity, other sleep disorder symptoms (eg, insomnia), mental health symptoms, and multimorbidity. Only BMI differed between women using vs not using positive airway pressure therapy. CONCLUSIONS Women veterans with diagnosed sleep apnea were commonly treated with positive airway pressure therapy, which is standard first-line treatment; however, many undiagnosed women were at high risk. Efforts to increase screening, diagnosis, and treatment of sleep apnea in women with comorbid mental and physical health conditions are needed.
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Affiliation(s)
- Jennifer L. Martin
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Gwendolyn Carlson
- Department of Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Monica Kelly
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Constance H. Fung
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Yeonsu Song
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Michael N. Mitchell
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Michelle R. Zeidler
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Karen R. Josephson
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - M. Safwan Badr
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan
| | - Ruoyan Zhu
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
- University of Arizona College of Medicine, Phoenix, Arizona
| | - Cathy A. Alessi
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Donna L. Washington
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Elizabeth M. Yano
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, California
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Carlson GC, Kelly MR, Grinberg AM, Mitchell M, McGowan SK, Culver NC, Kay M, Alessi CA, Washington DL, Yano EM, Martin JL. Insomnia Precipitating Events among Women Veterans: The Impact of Traumatic and Nontraumatic Events on Sleep and Mental Health Symptoms. Behav Sleep Med 2021; 19:672-688. [PMID: 33251855 PMCID: PMC9211746 DOI: 10.1080/15402002.2020.1846537] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE/BACKGROUND The current study describes insomnia precipitating events reported by women Veterans and examines differences in sleep and psychological distress variables in those who endorsed traumatic, nontraumatic, or no insomnia precipitating events. PARTICIPANTS Baseline data were collected from 347 women Veterans enrolled in a behavioral sleep intervention study (NCT02076165). METHODS Participants completed self-report measures of insomnia symptoms, sleep quality, sleep efficiency (SE), nightmare frequency, and depression and posttraumatic stress disorder (PTSD) symptoms; SE was also assessed by wrist actigraphy. Participants responded to 2 open-ended questions assessing stressful life events and health changes that coincided with insomnia symptom onset. Responses were coded as traumatic, nontraumatic, and no events. Analyses of covariance examined the effect of insomnia precipitating event type on sleep and psychological symptom variables after controlling for sociodemographic factors. RESULTS Overall, 25.80% of participants endorsed traumatic events, 65.80% endorsed only nontraumatic events, and 8.41% endorsed no events. Participants who endorsed traumatic events reported more severe insomnia (p = .003), PTSD (p = .001), and depression symptoms (p = .012), and poorer quality of sleep (p = .042) than participants who endorsed no events. Participants who endorsed traumatic events reported more severe PTSD symptoms (p = .004), a longer duration of sleep problems (p = .001), and poorer quality of sleep (p = .039) than participants who endorsed nontraumatic events. Participants who endorsed nontraumatic events reported more severe insomnia (p = .029) and PTSD (p = .049) symptoms than participants who endorsed no events. CONCLUSIONS Trauma as a precipitant for insomnia may be related to higher symptom severity in women Veterans. Implications for treatment engagement and effectiveness remain unstudied.
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Affiliation(s)
- Gwendolyn C. Carlson
- Veterans Affairs (VA) Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Monica R. Kelly
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Austin M. Grinberg
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California,Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Michael Mitchell
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Sarah Kate McGowan
- Department of Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California,Department of Psychiatry, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Najwa C. Culver
- Department of Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Morgan Kay
- Department of Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Cathy A. Alessi
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California,Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Donna L. Washington
- Veterans Affairs (VA) Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California,Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Elizabeth M. Yano
- Veterans Affairs (VA) Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California,Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, California
| | - Jennifer L. Martin
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California,Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, California
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Wong MS, Steers WN, Hoggatt KJ, Ziaeian B, Washington DL. Correction to "Relationship of neighborhood social determinants of health on racial/ethnic mortality disparities in US veterans-Mediation and moderating effects". Health Serv Res 2020; 55:1021. [PMID: 33258131 PMCID: PMC7704465 DOI: 10.1111/1475-6773.13602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Leung LB, Steers WN, Hoggatt KJ, Washington DL. Explaining racial-ethnic differences in hypertension and diabetes control among veterans before and after patient-centered medical home implementation. PLoS One 2020; 15:e0240306. [PMID: 33044984 PMCID: PMC7549758 DOI: 10.1371/journal.pone.0240306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 09/23/2020] [Indexed: 11/18/2022] Open
Abstract
Patient-centered medical homes (PCMH) are primary care delivery models that improve care access and population-level health outcomes, yet they have not been observed to narrow racial-ethnic disparities in the Veteran Health Administration (VHA) or other health systems. We aimed to identify and compare underlying drivers of persistent hypertension and diabetes control differences between non-Hispanic Black (Black) and Hispanic versus non-Hispanic White (White) patients before and after PCMH implementation in the VHA. Among Black and Hispanic versus White VHA primary care patients in 2009 (nhypertension = 26,906; ndiabetes = 21,141) and 2014 (nhypertension = 83,809; ndiabetes = 38,887), we retrospectively examined hypertension control (blood pressure<140/90) and diabetes control (hemoglobin A1c <9) obtained through random chart abstraction of patient health records nationally via VHA's quality monitoring program. We fit linear probability regression models, adjusting for age, gender, comorbidity, and socioeconomic status (SES). Blinder-Oaxaca and Smith-Welch decomposition methods were used to parse out explained and unexplained contributors to health disparity between racial-ethnic groups pre- and post-PCMH implementation. Compared to White patients, hypertension and diabetes control remained significantly lower for Black (-6.2%[0.4%] and -3.1%[0.6%], respectively; p's<0.001) and Hispanic (-1.4%[0.8%] and -4.0%[1.0%], respectively; p's<0.001) patients following VHA PCMH implementation. Most racial-ethnic differences (55.7-92.3%; all p<0.05) were not attributed to age, gender, comorbidity, and SES. The contribution of explained versus unexplained factors did not significantly change over time. While many explanations for persistent racial-ethnic disparities in disease control among veterans exist, our study did not find that it was due to an influx of "sick" or "socioeconomically vulnerable" patients into the VHA following PCMH implementation. Instead, unexplained differences may be due to differential healthcare and community experiences (e.g., discrimination). Understanding underlying pathways leading to health disparities will better inform policy and clinical interventions to improve PCMH care delivery to racial-ethnic minority patients in health systems.
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Affiliation(s)
- Lucinda B. Leung
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy (Health Equity-QUERI National Partnered Evaluation Center), VA Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, United States of America
| | - W. Neil Steers
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy (Health Equity-QUERI National Partnered Evaluation Center), VA Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, United States of America
| | - Katherine J. Hoggatt
- San Francisco VA Health Care System, San Francisco, California, United States of America
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy (Health Equity-QUERI National Partnered Evaluation Center), VA Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, United States of America
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Wong MS, Steers WN, Hoggatt KJ, Ziaeian B, Washington DL. Relationship of neighborhood social determinants of health on racial/ethnic mortality disparities in US veterans-Mediation and moderating effects. Health Serv Res 2020; 55 Suppl 2:851-862. [PMID: 32860253 PMCID: PMC7518818 DOI: 10.1111/1475-6773.13547] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine mediation and moderation of racial/ethnic all-cause mortality disparities among Veteran Health Administration (VHA)-users by neighborhood deprivation and residential segregation. DATA SOURCES Electronic medical records for 10/2008-9/2009 VHA-users linked to National Death Index, 2000 Area Deprivation Index, and 2006-2009 US Census. STUDY DESIGN Racial/ethnic groups included American Indian/Alaskan Native (AI/AN), Asian, non-Hispanic black, Hispanic, Native Hawaiian/Other Pacific Islander, and non-Hispanic white (reference). We measured neighborhood deprivation by Area Deprivation Index, calculated segregation for non-Hispanic black, Hispanic, and AI/AN using the Isolation Index, evaluated mediation using inverse odds-weighted Cox regression models and moderation using Cox regression models testing for neighborhood*race/ethnicity interactions. PRINCIPAL FINDINGS Mortality disparities existed for AI/ANs (HR = 1.07, 95%CI:1.01-1.10) but no other groups after covariate adjustment. Neighborhood deprivation and Hispanic segregation neither mediated nor moderated AI/AN disparities. Non-Hispanic black segregation both mediated and moderated AI/AN disparities. The AI/AN vs. non-Hispanic white disparity was attenuated for AI/ANs living in neighborhoods with greater non-Hispanic black segregation (P = .047). Black segregation's mediating effect was limited to VHA-users living in counties with low black segregation. AI/AN segregation also mediated AI/AN mortality disparities in counties that included or were near AI/AN reservations. CONCLUSIONS Neighborhood characteristics, particularly black and AI/AN residential segregation, may contribute to AI/AN mortality disparities among VHA-users, particularly in communities that were rural, had greater black segregation, or were located on or near AI/AN reservations. This suggests the importance of neighborhood social determinants of health on racial/ethnic mortality disparities. Living near reservations may allow AI/AN VHA-users to maintain cultural and tribal ties, while also providing them with access to economic and other resources. Future research should explore the experiences of AI/ANs living in black communities and underlying mechanisms to identify targets for intervention.
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Affiliation(s)
- Michelle S. Wong
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP)VA Greater Los Angeles Healthcare SystemLos AngelesCAUSA
| | - W. Neil Steers
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP)VA Greater Los Angeles Healthcare SystemLos AngelesCAUSA
| | - Katherine J. Hoggatt
- San Francisco VA Healthcare SystemSan FranciscoCAUSA
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Boback Ziaeian
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP)VA Greater Los Angeles Healthcare SystemLos AngelesCAUSA
- Division of Cardiology, Department of MedicineDavid Geffen School of Medicine at UCLALos AngelesCAUSA
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP)VA Greater Los Angeles Healthcare SystemLos AngelesCAUSA
- Division of General Internal Medicine and Health Services Research, Department of MedicineDavid Geffen School of Medicine at UCLALos AngelesCAUSA
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Zhu R, Carlson G, Kelly M, Song Y, Fung CH, Mitchell MN, Josephson KR, Zeidler MR, Badr MS, Alessi CA, Washington DL, Yano EM, Martin JL. 0581 Characteristics of US Women Veterans with Sleep Apnea: Results of a National Survey of VA Healthcare Users. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Sleep apnea (SA) is the most commonly diagnosed sleep disorder among patients in the US Veterans Administration (VA). The dramatic rise in women receiving VA care makes it essential to understand the presentation and treatment of SA in women Veterans. We performed a nationwide survey about sleep among US women Veterans and compared characteristics of respondents with and without a self-reported history of SA diagnosis and treatment.
Methods
A survey was mailed to a random sample of 4000 women VA healthcare users. The survey included demographics, Insomnia Severity Index (ISI), Patient Health Questionnaire-4 (PHQ-4 depression/anxiety), Primary Care-Post-Traumatic Stress Disorder (PC-PTSD), RLS symptom presence, SA symptoms (snore loudly, observed breathing pauses), diagnosis of SA, and use of PAP therapy (APAP, BPAP, CPAP). We compared women with and without SA, and (among those with SA) women who did and did not use PAP, using Chi-square and t-tests.
Results
1,498 completed surveys were returned (mean age 51.6 years, range 18-105 years, 62% non-Hispanic White). 200 respondents (13.4%) reported diagnosed SA. Women with SA were older (p<.001), likely to be employed (p=.013), more likely to snore loudly (p<.001) and to have breathing pauses while asleep (p<.001). They also had higher ISI (p<.001), were more like to report RLS (p<.001) nightmares (p=.027), and had higher PHQ-4 (p<.001) and PC-PTSD (p<.001) scores. Among women with SA, 130 (65%) used PAP. Loud snorers (p<.001) and those with observed breathing pauses were more likely to use PAP (p<.001).
Conclusion
One in 7 women who receive VA care report diagnosed SA. Women with SA had more mental health symptoms and comorbid sleep problems. Most reported using PAP therapy, although the amount of use is unknown. Those with SA symptoms were more likely to use PAP. Future work is needed to understand barriers to diagnosis and treatment of SA among women Veterans.
Support
Funding: VA Quality Enhancement Research Initiative RRP12-189 (Martin); NIH/NHLBI K24 HL143055 (Martin).
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Affiliation(s)
- R Zhu
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - G Carlson
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - M Kelly
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Y Song
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA
- School of Nursing at the University of California, Los Angeles, Los Angeles, CA
| | - C H Fung
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
| | - M N Mitchell
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - K R Josephson
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - M R Zeidler
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
| | - M S Badr
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI
- John D. DIngell VA Medical Center, Detroit, MI
| | - C A Alessi
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
| | - D L Washington
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - E M Yano
- VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - J L Martin
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
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Carlson GC, Kelly MR, Josephson K, Mitchell M, Fiorentino L, McGowan S, Culver N, Kay M, Alessi C, Washington DL, Yano E, Martin JL. 0467 Benefits of CBT-I for Women Veterans with and without PTSD. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
A quarter of women Veterans (WVs) receiving VA healthcare meet diagnostic criteria for both insomnia disorder and posttraumatic stress disorder (PTSD). Cognitive Behavioral Therapy for Insomnia (CBT-I) is effective at improving sleep among individuals with comorbid psychiatric conditions; however, no studies have examined the impact of CBT-I in women with insomnia plus PTSD. The current analyses examined changes in sleep symptoms, quality of life (QoL), and mental health symptoms from pre- to post-CBT-I in WVs with and without PTSD.
Methods
This was a secondary analysis of 75 WVs with insomnia (32 with probable PTSD), who received CBT-I within a behavioral sleep intervention study (NCT02076165). Measures completed at baseline, posttreatment, and 3-month follow-up included: insomnia severity (Insomnia Severity Index, ISI), sleep quality (Pittsburgh Sleep Quality Index, PSQI), PTSD symptoms (PTSD Checklist-5, PCL-5; probable PTSD=total score ≥33), depressive symptoms (Patient Health Qestionnaire-9, PHQ-9), and mental and physical quality of life (Short Form Health Survey, SF-12). One sample T-tests examined changes in ISI, PSQI, PHQ-9, PCL-5, and SF-12 from baseline to posttreatment and baseline to follow-up. Two samples T-tests compared change scores in ISI, PSQI, PHQ-9, and SF-12 between participants with and without PTSD.
Results
There were significant improvements in ISI (p≤.001), PSQI (p≤.001), PHQ-9 (p≤.001), PCL-5 (p=.001), and SF-12 mental (p≤.001) and physical (p=.03) from baseline to posttreatment and 3-month follow-up (p≤.001-.01). There were no significant change score differences between WVs with and without PTSD from baseline to posttreatment (p=.06-.98) or 3-month follow-up (p=.09-.93).
Conclusion
CBT-I appears to be an effective treatment to improve insomnia symptoms among WVs with and without PTSD, and may reduce psychiatric symptoms as well. These findings suggest WVs with comorbid insomnia and PTSD benefit from CBT-I. The appropriate sequencing of CBT-I and PTSD treatments remains potentially important, but unstudied.
Support
VA/HSR&D IIR-HX002300; NIH/NHLBI K24HL14305; VA Office of Academic Affiliations through the Advanced Fellowship Programs in HSR&D and Women’s Health
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Affiliation(s)
- G C Carlson
- HSR&D Center for the Study Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - M R Kelly
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - K Josephson
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - M Mitchell
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - L Fiorentino
- University of California, San Diego, San Diego, CA
| | - S McGowan
- Department of Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Psychiatry, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | - N Culver
- Department of Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - M Kay
- Department of Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - C Alessi
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | - D L Washington
- HSR&D Center for the Study Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | - E Yano
- HSR&D Center for the Study Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA
| | - J L Martin
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
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