Browsing by Subject "Veterans"

Now showing 1 - 10 of 54
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    A national population-based study of cannabis use and correlates among U.S. veterans prescribed opioids in primary care
    (BMC, 2023-03-17) Zaman, Tauheed; Bravata, Dawn M.; Byers, Amy L.; Krebs, Erin E.; Leonard, Samuel J.; Sandbrink, Friedhelm; Barker, Wylie; Keyhani, Salomeh; Medicine, School of Medicine
    Background: Cannabis is marketed as a treatment for pain. There is limited data on the prevalence of cannabis use and its correlates among Veterans prescribed opioids. Objective: To examine the prevalence and correlates of cannabis use among Veterans prescribed opioids. Design: Cross-sectional study. Participants: Veterans with a urine drug test (UDT) from Primary Care 2014-2018, in 50 states, Washington, D.C., and Puerto Rico. A total of 1,182,779 patients were identified with an opioid prescription within 90 days prior to UDT. Main measures: Annual prevalence of cannabis positive UDT by state. We used multivariable logistic regression to assess associations of demographic factors, mental health conditions, substance use disorders, and pain diagnoses with cannabis positive UDT. Results: Annual prevalence of cannabis positive UDT ranged from 8.5% to 9.7% during the study period, and in 2018 was 18.15% in Washington, D.C. and 10 states with legalized medical and recreational cannabis, 6.1% in Puerto Rico and 25 states with legalized medical cannabis, and 4.5% in non-legal states. Younger age, male sex, being unmarried, and marginal housing were associated with use (p < 0.001). Post-traumatic stress disorder (adjusted odds ratio [AOR] 1.17; 95% confidence interval [CI] 1.13-1.22, p < 0.001), opioid use disorder (AOR 1.14; CI 1.07-1.22, p < 0.001), alcohol use disorder or positive AUDIT-C (AOR 1.34; 95% CI 1.28-1.39, p < 0.001), smoking (AOR 2.58; 95% CI 2.49-2.66, p < 0.001), and other drug use disorders (AOR 1.15; 95% CI 1.03-1.29, p = 0.02) were associated with cannabis use. Positive UDT for amphetamines AOR 1.41; 95% CI 1.26-1.58, p < 0.001), benzodiazepines (AOR 1.41; 95% CI 1.31-1.51, p < 0.001) and cocaine (AOR 2.04; 95% CI 1.75-2.36, p < 0.001) were associated with cannabis positive UDT. Conclusions: Cannabis use among Veterans prescribed opioids varied by state and by legalization status. Veterans with PTSD and substance use disorders were more likely to have cannabis positive UDT. Opioid-prescribed Veterans using cannabis may benefit from screening for these conditions, referral to treatment, and attention to opioid safety.
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    An Investigation of Employment Hope as a Key Factor Influencing Perceptions of Subjective Recovery among Adults with Serious Mental Illness Seeking Community Work
    (MDPI, 2024-03-19) Kukla, Marina; McGuire, Alan B.; Weber, Kenneth C.; Hatfield, Jessi; Henry, Nancy; Kulesza, Eric; Rollins, Angela L.; Psychology, School of Science
    Introduction: Employment is an important contributor to recovery in people with serious mental illness (SMI), yet studies have not explored how subjective elements of employment hope contribute to perceptions of global recovery in this population. Methods: The current study examined the relationship between employment hope and subjective recovery in 276 unemployed adults with SMI participating in a multi-site clinical trial of a cognitive behavioral group intervention tailored toward work and combined with vocational rehabilitation. Participants had diagnoses of schizophrenia spectrum, bipolar, depressive, and posttraumatic stress disorders, and were receiving services at three Veterans Affairs healthcare facilities in the United States. Data were collected at study baseline. Linear regression analysis examined the relationship between employment hope (Short Employment Hope Scale; EHS-14) and subjective recovery (Recovery Assessment Scale; RAS) after controlling for psychiatric symptom severity and mental-health-related burden on daily life. Results: After accounting for covariates, employment hope significantly contributed to the regression model explaining subjective recovery. The overall model of predictor variables explained 52.5% of the variance in recovery. The results further explore the relationships between EHS-14 and RAS subscales. Conclusions: The findings suggest that employment hope is a key intervention target to bolster subjective recovery in this vulnerable population.
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    Art Therapy with Veterans: A Comprehensive Review of the Literature with Recommendations
    (2018) Davis, Heather E.; Misluk, Eileen
    Art therapy has been conducted with military servicemembers and veterans since the beginning of the profession itself. Veterans suffer from a myriad of diagnoses, some of the most prevalent being posttraumatic stress disorder (PTSD), combat trauma, military sexual trauma (MST), complicated grief, substance abuse, anxiety, and depression.Research exists that underscores the unique and vital role art therapy plays in the treatment of these diagnostic concerns; however, no known comprehensive literature review on the topic exists. An integrative, systematic literature review was conducted to gain an understanding of the format, setting, directives, materials, and approaches being used to treat veterans with art therapy. A total of 85 articles and books with a primary focus on art therapy with veterans were organized using the filing method recommended by Garrard(2011). A literature matrix was used to organize26 of the publications for comparison and to identify themes among the content. Themes emerged in all categories of the matrix. Notably, it was shown that 68.6% of the 85 pieces of literature had been published in the last five years. Recommendations for future research were made in response to these themes, such as the need to identify the specific therapeutic factors of art therapy rather than simply its efficacy in comparison to more traditional talk therapy approaches. Finally, opportunities were identified to standardize and streamline the use of art therapy with this population, which would benefit both the clients and the replicability of studies to bolster the generalizability and validity of findings.
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    Assessment of hepatitis C monitoring adherence after viral eradication in veterans with substance use to improve care and surveil reinfection
    (American Association of Psychiatric Pharmacists, 2022-06-10) Stratton, Miranda L.; Ansara, Elayne D.; Ifeachor, Amanda P.; Houck, Kelly K.; Liangpunsakul, Suthat; Binger, Katie J.; Medicine, School of Medicine
    Introduction: Hepatitis C virus (HCV) incidence rates are rising for patients with substance use and/or SUDs. Guidelines provide monitoring recommendations to ensure remission after successful treatment. The study's objective was to identify gaps in follow-up for patients with documented substance use and/or SUD through assessment of adherence to guideline-recommended HCV RNA lab 12 months post-treatment. Methods: Patients treated for HCV through the Veteran Health Indiana Hepatitis C Pharmacy Clinic were retrospectively evaluated. Subjects were categorized based on the provider assigned for follow-up care after 12-week sustained virologic response (SVR12) labs (primary care provider [PCP] or HCV provider). The primary outcome was HCV RNA obtained 11 to 13 months post-treatment. Secondary outcomes were HCV RNA detected post-treatment, substance use, engagement in substance use treatment, and engagement with social work. Results: Two hundred forty-one patients were included in the HCV provider cohort and 139 in the PCP cohort. Forty-one patients did not have a specified clinic for follow-up treatment, and 20 patients did not achieve SVR12. Sixty-one patients (28%) in the HCV provider cohort completed a 12-month HCV RNA within 11 to 13 months post-treatment vs 15 patients (11%) in the PCP cohort (P ≤ .01). One patient had HCV RNA detected post-treatment. Discussion: This study reveals inadequate HCV post-treatment follow-up for patients with substance use and/or SUD. SUD is a chronic disease that requires continued monitoring to prevent complications. Further studies are needed to identify reinfection rates and improvements of care in this population.
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    Assessment of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) Program for Improving Quality of Care for Transient Ischemic Attack: A Nonrandomized Cluster Trial
    (American Medical Association, 2020-09-08) Bravata, Dawn M.; Myers, Laura J.; Perkins, Anthony J.; Zhang, Ying; Miech, Edward J.; Rattray, Nicholas A.; Penney, Lauren S.; Levine, Deborah; Sico, Jason J.; Cheng, Eric M.; Damush, Teresa M.; Medicine, School of Medicine
    Importance Patients with transient ischemic attack (TIA) are at high risk of recurrent vascular events. Timely management can reduce that risk by 70%; however, gaps in TIA quality of care exist. Objective To assess the performance of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) intervention to improve TIA quality of care. Design, Setting, and Participants This nonrandomized cluster trial with matched controls evaluated a multicomponent intervention to improve TIA quality of care at 6 diverse medical centers in 6 geographically diverse states in the US and assessed change over time in quality of care among 36 matched control sites (6 control sites matched to each PREVENT site on TIA patient volume, facility complexity, and quality of care). The study period (defined as the data period) started on August 21, 2015, and extended to May 12, 2019, including 1-year baseline and active implementation periods for each site. The intervention targeted clinical teams caring for patients with TIA. Intervention The quality improvement (QI) intervention included the following 5 components: clinical programs, data feedback, professional education, electronic health record tools, and QI support. Main Outcomes and Measures The primary outcome was the without-fail rate, which was calculated as the proportion of veterans with TIA at a specific facility who received all 7 guideline-recommended processes of care for which they were eligible (ie, anticoagulation for atrial fibrillation, antithrombotic use, brain imaging, carotid artery imaging, high- or moderate-potency statin therapy, hypertension control, and neurological consultation). Generalized mixed-effects models with multilevel hierarchical random effects were constructed to evaluate the intervention associations with the change in the mean without-fail rate from the 1-year baseline period to the 1-year intervention period. Results Six facilities implemented the PREVENT QI intervention, and 36 facilities were identified as matched control sites. The mean (SD) age of patients at baseline was 69.85 (11.19) years at PREVENT sites and 71.66 (11.29) years at matched control sites. Most patients were male (95.1% [154 of 162] at PREVENT sites and 94.6% [920 of 973] at matched control sites at baseline). Among the PREVENT sites, the mean without-fail rate improved substantially from 36.7% (58 of 158 patients) at baseline to 54.0% (95 of 176 patients) during a 1-year implementation period (adjusted odds ratio, 2.10; 95% CI, 1.27-3.48; P = .004). Comparing the change in quality at the PREVENT sites with the matched control sites, the improvement in the mean without-fail rate was greater at the PREVENT sites than at the matched control sites (36.7% [58 of 158 patients] to 54.0% [95 of 176 patients] [17.3% absolute improvement] vs 38.6% [345 of 893 patients] to 41.8% [363 of 869 patients] [3.2% absolute improvement], respectively; absolute difference, 14%; P = .008). Conclusions and Relevance The implementation of this multifaceted program was associated with improved TIA quality of care across the participating sites. The PREVENT QI program is an example of a health care system using QI strategies to improve performance, and may serve as a model for other health systems seeking to provide better care. Trial Registration ClinicalTrials.gov Identifier: NCT02769338 Go to: Introduction Approximately 8500 veterans with transient ischemic attack (TIA) or ischemic stroke are cared for in Department of Veterans Affairs (VA) emergency departments (EDs) or inpatient wards annually in the United States.1 Patients with TIA generally present with transient neurological symptoms of a presumed ischemic cause.2 Patients with TIA are at a high risk of recurrent vascular events3,4,5; however, delivery of timely TIA care can reduce that risk by up to 70%.6,7,8,9 Despite the known benefits of timely TIA care, gaps in TIA quality of care exist in both private-sector US hospitals10 and VA facilities.11,12 In a learning health care system, “clinical informatics, incentives, and culture are aligned to promote continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience.”13(p136) Within a learning health care system, health care teams respond to quality problems by using quality improvement (QI) strategies and systems redesign approaches to improve performance, depending on the complexity and scope of the problem.14 The objective of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) trial was to evaluate a multicomponent QI intervention to improve the quality of TIA care.15 The PREVENT intervention was designed to align with the learning health care system model.13,15
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    Association of a Positive Drug Screening for Cannabis With Mortality and Hospital Visits Among Veterans Affairs Enrollees Prescribed Opioids
    (American Medical Association, 2022-12-01) Keyhani, Salomeh; Leonard, Samuel; Byers, Amy L.; Zaman, Tauheed; Krebs, Erin; Austin, Peter C.; Moss-Vazquez, Tristan; Austin, Charles; Sandbrink, Friedhelm; Bravata, Dawn M.; Medicine, School of Medicine
    Importance: Cannabis has been proposed as a therapeutic with potential opioid-sparing properties in chronic pain, and its use could theoretically be associated with decreased amounts of opioids used and decreased risk of mortality among individuals prescribed opioids. Objective: To examine the risks associated with cannabis use among adults prescribed opioid analgesic medications. Design, setting, and participants: This cohort study was conducted among individuals aged 18 years and older who had urine drug screening in 2014 to 2019 and received any prescription opioid in the prior 90 days or long-term opioid therapy (LTOT), defined as more than 84 days of the prior 90 days, through the Veterans Affairs health system. Data were analyzed from November 2020 through March 2022. Exposures: Biologically verified cannabis use from a urine drug screen. Main outcomes and measures: The main outcomes were 90-day and 180-day all-cause mortality. A composite outcome of all-cause emergency department (ED) visits, all-cause hospitalization, or all-cause mortality was a secondary outcome. Weights based on the propensity score were used to reduce confounding, and hazard ratios [HRs] were estimated using Cox proportional hazards regression models. Analyses were conducted among the overall sample of patients who received any prescription opioid in the prior 90 days and were repeated among those who received LTOT. Analyses were repeated among adults aged 65 years and older. Results: Among 297 620 adults treated with opioids, 30 514 individuals used cannabis (mean [SE] age, 57.8 [10.5] years; 28 784 [94.3%] men) and 267 106 adults did not (mean [SE] age, 62.3 [12.3] years; P < .001; 247 684 [92.7%] men; P < .001). Among all patients, cannabis use was not associated with increased all-cause mortality at 90 days (HR, 1.07; 95% CI, 0.92-1.22) or 180 days (HR, 1.00; 95% CI, 0.90-1.10) but was associated with an increased hazard of the composite outcome at 90 days (HR, 1.05; 95% CI, 1.01-1.07) and 180 days (HR, 1.04; 95% CI, 1.01-1.06). Among 181 096 adults receiving LTOT, cannabis use was not associated with increased risk of all-cause mortality at 90 or 180 days but was associated with an increased hazard of the composite outcome at 90 days (HR, 1.05; 95% CI, 1.02-1.09) and 180 days (HR, 1.05; 95% CI, 1.02-1.09). Among 77 791 adults aged 65 years and older receiving LTOT, cannabis use was associated with increased 90-day mortality (HR, 1.55; 95% CI, 1.17-2.04). Conclusions and relevance: This study found that cannabis use among adults receiving opioid analgesic medications was not associated with any change in mortality risk but was associated with a small increased risk of adverse outcomes and that short-term risks were higher among older adults receiving LTOT.
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    Barriers and facilitators to provide quality TIA care in the Veterans Healthcare Administration
    (American Academy of Neurology, 2017-12-12) Damush, Teresa M.; Miech, Edward J.; Sico, Jason J.; Phipps, Michael S.; Arling, Greg; Ferguson, Jared; Austin, Charles; Myers, Laura; Baye, Fitsum; Luckhurst, Cherie; Keating, Ava B.; Moran, Eileen; Bravata, Dawn M.; Medicine, School of Medicine
    Objective: To identify key barriers and facilitators to the delivery of guideline-based care of patients with TIA in the national Veterans Health Administration (VHA). Methods: We conducted a cross-sectional, observational study of 70 audiotaped interviews of multidisciplinary clinical staff involved in TIA care at 14 VHA hospitals. We de-identified and analyzed all transcribed interviews. We identified emergent themes and patterns of barriers to providing TIA care and of facilitators applied to overcome these barriers. Results: Identified barriers to providing timely acute and follow-up TIA care included difficulties accessing brain imaging, a constantly rotating pool of housestaff, lack of care coordination, resource constraints, and inadequate staff education. Key informants revealed that both stroke nurse coordinators and system-level factors facilitated the provision of TIA care. Few facilities had specific TIA protocols. However, stroke nurse coordinators often expanded upon their role to include TIA. They facilitated TIA care by (1) coordinating patient care across services, communicating across service lines, and educating clinical staff about facility policies and evidence-based practices; (2) tracking individual patients from emergency departments to inpatient settings and to discharge for timely follow-up care; (3) providing and referring TIA patients to risk factor management programs; and (4) performing regular audit and feedback of quality performance data. System-level facilitators included clinical service leadership engagement and use of electronic tools for continuous care across services. Conclusions: The local organization within a health care facility may be targeted to cultivate internal facilitators and a systemic infrastructure to provide evidence-based TIA care.
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    Challenges and Opportunities in Developing an Oncology Clinical Trial Network in the United States Veterans Affairs Health Care System: The VA STARPORT Experience
    (MDPI, 2024-08-21) Solanki, Abhishek A.; Zheng, Kevin; Skipworth, Alicia N.; Robin, Lisa M.; Leparski, Ryan F.; Henry, Elizabeth; Rettig, Matthew; Salama, Joseph K.; Ritter, Timothy; Jones, Jeffrey; Quek, Marcus; Chang, Michael; Block, Alec M.; Welsh, James S.; Kumar, Aryavarta; Chao, Hann-Hsiang; Chen, Albert C.; Shapiro, Ronald; Bitting, Rhonda L.; Kwon, Robert; Stross, William; Puckett, Lindsay; Wong, Yu-Ning; Nickols, Nicholas G.; Carlson, Kimberly; VA STARPORT Investigators Group; Radiation Oncology, School of Medicine
    The United States Veterans Affairs (VA) Health Care System has a strong history of conducting impactful oncology randomized clinical trials (RCTs). We developed a phase II/III RCT to test the use of metastasis-directed therapy in Veterans with oligometastatic prostate cancer (OMPC)-the first VA RCT in OMPC that leverages novel imaging and advanced radiotherapy techniques. To accomplish this, we developed a clinical trial network to conduct the study. In this manuscript, we describe several challenges we encountered in study development/conduct and our strategies to address them, with the goal of helping investigators establish robust study networks to conduct clinical trials. In the study start-up, we encountered challenges in timely site activation, and leveraged project management to maximize efficiency. Additionally, there were several changes in the clinical paradigms in imaging and treatment that led to protocol amendments to ensure maximum equipoise, recruitment, and impact of the study. Specifically, we amended the trial to add de novo OMPC patients (from initially only recurrent OMPC) and expanded the study to allow up to 10 metastases (from initially five). Finally, in order to maintain local study team engagement, we developed initiatives to maximize collaboration and add value to the overall clinical program through study participation.
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    Change Step: Improving Social Support for Women Veterans Through Participatory Design
    (2016) Wessel, Robert; Napier, Pamela; Eby, Chad; Wada, Terri
    This thesis discusses a participatory design project that focused on improving social support for women veterans in Indianapolis, Indiana. Using a series of design research methods to capture the voice of local women veterans, and by visually representing the outcomes of each phase of the project, the participant group and design researcher identified the needs of women veterans, considered existing social supports, and co-created a conceptual model for a social support network. This prototype network aims to make finding support easier, reduce overlap in existing social supports, and foster communication between partner support organizations. It is the first step in integrating social support for Indiana women veterans.